Place of Death and Density of Homecare Resources: A Nationwide Study in Japan

Abstract

Background Although more than half of the population of Japan wants to spend their last days at home, approximately only 10% are able to do so. This study examined the associations between death at home and healthcare facility density by municipality based on the analysis of nationwide observed data in Japan. Methods We used data on deaths at home and healthcare resources in municipalities across Japan for the fiscal years 2014 and 2017. The proportions of deaths at home by municipality were used as the dependent variable, while healthcare resources (e.g., hospital density) divided by the population of older people in each municipality and municipality-level income were used as independent variables. We applied a fixed-effects regression analysis to examine the association of healthcare resources and municipality-level income with death at home. Results Clinics providing home medical care and facilities providing visiting nursing services were positively associated with death at home, with coefficients (95% confidence intervals) of 2.14 (1.12 to 3.15) and 2.19 (0.99 to 3.39), respectively. Stratified analysis showed that these associations were observed in higher income-level municipalities but not in lower income-level municipalities. Conclusion Municipalities with a higher density of home care services had higher rates of death at home, whereas municipalities with a higher density of hospitals had lower rates. We recommend the development of policy that allows hospitals to be converted into home care providers so that more people can spend time in peace at home at the end of their lives.

Municipal Characteristics of In-Home Death Among Care-Dependent Older Japanese Adults

“…Previous ecological studies [14][15][16][17][18] have reported a positive association between good access to in-home services provided by physicians, nurses, and care workers and in-home death. By contrast, high accessibility to hospital beds and LTC facilities has been associated with a lower likelihood of in-home death (as we found in the current study).…”

“…By contrast, high accessibility to hospital beds and LTC facilities has been associated with a lower likelihood of in-home death (as we found in the current study). [15][16][17][18] Although it is possible that some patients substitute one service for another (eg, some patients might be forced to die at home when there is insufficient local hospital bed supply), our interpretation is that there are more patients who miss out on dying at home because of an insufficient supply of physicians and care workers who are able to provide domiciliary end-of-life care. Because Japan has far more hospital beds per capita than other high-income countries, people may spend more of their final days in hospitals.…”

“…In previous studies, 2,5,[12][13][14][15][16][17][18][19] both individual and regional factors associated with the place of death have been reported. At the individual level, in-home deaths have been associated with personal preferences for in-home death; older age; female sex; low functional status; cancer diagnoses or nonacute diseases; and a history of use of in-home services, day services, and short-stay services at the end of life, as well as the presence of informal caregivers.…”

“…By contrast, numbers of hospitals and nursing home beds per population have been inversely correlated with in-home death. 2,12,[15][16][17][18] Furthermore, substantial geographic variation persists in the proportion of in-home deaths across Japanese municipalities, according to the mapping by Morioka et al 16 In Japan, local governments are organized at 2 levels: prefectures and municipalities.…”

“…At the individual level, in-home deaths have been associated with personal preferences for in-home death; older age; female sex; low functional status; cancer diagnoses or nonacute diseases; and a history of use of in-home services, day services, and short-stay services at the end of life, as well as the presence of informal caregivers. 2 , 5 , 12 , 13 In ecological studies, 2 , 12 , 14 , 15 , 16 , 17 , 18 , 19 in-home death has been associated with higher access to clinics or agencies delivering in-home services provided by physicians, nurses, and care workers, as well as day services provided by care workers. By contrast, numbers of hospitals and nursing home beds per population have been inversely correlated with in-home death.…”