Socioeconomic position and use of healthcare in the last year of life: A systematic review and meta-analysis

Abstract

Background Low socioeconomic position (SEP) is recognized as a risk factor for worse health outcomes. How socioeconomic factors influence end-of-life care, and the magnitude of their effect, is not understood. This review aimed to synthesise and quantify the associations between measures of SEP and use of healthcare in the last year of life. Methods and findings MEDLINE, EMBASE, PsycINFO, CINAHL, and ASSIA databases were searched without language restrictions from inception to 1 February 2019. We included empirical observational studies from high-income countries reporting an association between SEP (e.g., income, education, occupation, private medical insurance status, housing tenure, housing quality, or area-based deprivation) and place of death, plus use of acute care, specialist and nonspecialist end-of-life care, advance care planning, and quality of care in the last year of life. Methodological quality was evaluated using the Newcastle-Ottawa Quality Assessment Scale (NOS). The overall strength and direction of associations was summarised, and where sufficient comparable data were available, adjusted odds ratios (ORs) were pooled and dose-response meta-regression performed. A total of 209 studies were included (mean NOS quality score of 4.8); 112 high- to medium-quality observational studies were used in the meta-synthesis and meta-analysis (53.5% from North America, 31.0% from Europe, 8.5% from Australia, and 7.0% from Asia). Compared to people living in the least deprived neighbourhoods, people living in the most deprived neighbourhoods were more likely to die in hospital versus home (OR 1.30, 95% CI 1.23–1.38, p < 0.001), to receive acute hospital-based care in the last 3 months of life (OR 1.16, 95% CI 1.08–1.25, p < 0.001), and to not receive specialist palliative care (OR 1.13, 95% CI 1.07–1.19, p < 0.001). For every quintile increase in area deprivation, hospital versus home death was more likely (OR 1.07, 95% CI 1.05–1.08, p < 0.001), and not receiving specialist palliative care was more likely (OR 1.03, 95% CI 1.02–1.05, p < 0.001). Compared to the most educated (qualifications or years of education completed), the least educated people were more likely to not receive specialist palliative care (OR 1.26, 95% CI 1.07–1.49, p = 0.005). The observational nature of the studies included and the focus on high-income countries limit the conclusions of this review. Conclusions In high-income countries, low SEP is a risk factor for hospital death as well as other indicators of potentially poor-quality end-of-life care, with evidence of a dose response indicating that inequality persists across the social stratum. These findings should stimulate widespread efforts to reduce socioeconomic inequality towards the end of life.

Sociodemographic and clinical factors for non-hospital deaths among cancer patients: A nationwide population-based cohort study

“…US, Canada and Europe suggesting that low socioeconomic position is a risk factor for hospital deaths. [37] We hypothesize that within Singapore's healthcare system, early transfers to LTC or hospice were taking place for low SES patients when they lose the ability to self-care, resulting in higher proportions of death within these institutions. [53] While palliative care services are routinely provided within hospices, many LTC facilities are still unable to provide good quality palliative care services due to manpower and resource constraints and lack of training [40] Palliative care provision has to be strengthened within LTC to meet the needs of the socially disadvantaged who are more likely to die in such facilities.…”

“…[6,7,36] PLOS ONE While a recent systematic review concluded that low socioeconomic status increased the odds of hospital deaths, this conclusion was weaker for Asian countries due to a lack of published studies within this region. [37] To the best of our knowledge, local literature defining cancer specific risk factors for hospital deaths is also currently lacking; and remains critical in future identification of patients with unmet needs.…”

Impact of socioeconomic status on end-of-life costs: a systematic review and meta-analysis

“…The end-of-life (EOL) period not only represents a period of high health care use, unmeasured differences in medical need across patient populations are also thought to be attenuated in the terminal years by virtue of the fact that all such patients die. Differences in EOL expenditures according to SES may represent variations in access to medical care, and yield insights in health care seeking behaviours, location of care, medical decision-making, and health care resource allocation [10]. As health care expenditure increases rapidly in the time close to death, understanding SES inequalities at EOL is necessary for future health care planning to reduce such social inequalities [11][12][13].…”

End-of-life experience for older adults in Ireland: results from the Irish longitudinal study on ageing (TILDA)

“…People living and dying with serious medical illness experience poor outcomes and high costs in systems originally designed to provide acute, episodic care [1], and are growing in number due to demographic change [2]. The burden of poor experience falls disproportionately on those of low socioeconomic status [3] and equity gaps are also growing as the population ages [4]. Research studies to inform improvement efforts face challenges [5].…”