Socioeconomic position and use of hospital-based care towards the end of life: a mediation analysis using the English Longitudinal Study of Ageing

Abstract

Background Many patients prefer to avoid hospital-based care towards the end of life, yet hospitalisation is common and more likely for people with low socioeconomic position. The reasons underlying this socioeconomic inequality are not well understood. This study investigated health, service access, and social support as potential mediating pathways between socioeconomic position and receipt of hospital-based care towards the end of life. Methods For this observational cohort study, we included deceased participants from the nationally representative English Longitudinal Study of Ageing of people aged 50 years or older in England. We used a multiple mediation model with age-adjusted and gender-adjusted probit regression to estimate the direct effect of socioeconomic position (measured by wealth and education) on death in hospital and three or more hospital admissions in the last 2 years of life, and the indirect effects of socioeconomic position via three mediators: health and function, access to health-care services, and social support. Findings 737 participants were included (314 [42•6%] female, 423 [57•4%] male), with a median age at death of 78 years (IQR 71-85). For death in hospital, higher wealth had a direct negative effect (probit coefficient-0•16, 95% CI-0•25 to-0•06), which was not mediated by any of the pathways tested. For frequent hospital admissions, health and function mediated the effect of wealth (-0•04,-0•08 to-0•01), accounting for 34•6% of the total negative effect of higher wealth (-0•13,-0•23 to-0•02). Higher wealth was associated with better health and function (0•25, 0•18 to 0•33). Education was associated with the outcomes only indirectly via wealth. Interpretation Our findings suggest that worse health and function could partly explain why people with lower wealth have more hospital admissions, highlighting the importance of socioeconomically driven health differences in explaining patterns of hospital use towards the end of life. The findings should raise awareness about the related risk factors of low wealth and worse health for patients approaching the end of life, and strengthen calls for resource allocation to be made on the basis of health need and socioeconomic profile.

Place of death and phenomenon of going home to die in Chinese adults: A prospective cohort study

“…GHTD between URRBMI and UEBMI beneficiaries during the study period. A recently published study reported socioeconomic factors were associated with inequalities in EOL care utilization [33]. As shown in our data, the demographic and socioeconomic factors were different between URRBMI and UEBMI beneficiaries, but the association of HI schemes with GHTD attenuated and remained significant after adjusted relevant factors, suggesting that the difference in the proportion of GHTD between URRBMI and UEBMI beneficiaries might be partially explained by differences in demographic and socioeconomic factors.…”

“…A recently published study reported socioeconomic factors were associated with inequalities in EOL care utilization. 33 As shown in our data, the demographic and socioeconomic factors were different between URRBMI and UEBMI beneficiaries, but the association of HI schemes with GHTD attenuated and remained significant after adjusted relevant factors, suggesting that the difference in the proportion of GHTD between URRBMI and UEBMI beneficiaries might be partially explained by differences in demographic and socioeconomic factors. For URRBMI beneficiaries, who are already at a socioeconomic disadvantage compared with their UEBMI counterparts, less comprehensive service coverage and lack of financial protections might further aggravate the inequalities in EOL care utilization.…”

Exploring socioeconomic inequities in access to palliative and end-of-life care in the UK: a narrative synthesis

“…This is because of the diversity in individual patients’ preferences for dying at home [ 34 ], challenging the assumption that all deaths in hospital indicate poor access to care. More recent evidence suggests that increasing use of hospital services at the end of life by people in a more disadvantaged socioeconomic position is partly explained by poor health [ 14 ], suggesting reasons beyond access to care may influence the likelihood of dying in hospital.…”

“…Most research on socioeconomic inequities in accessing palliative and end-of-life care examines differences in receipt of care, often indicating an association between socioeconomic disadvantage and a lower likelihood of receiving specialist palliative care [ 10 – 13 ]. Conversely, use of hospital-based care in the last year of life tends to be higher for those in a more disadvantaged socioeconomic position, with poorer health likely accounting for some of this use [ 8 , 14 , 15 ]. However, receipt of care is only one component to accessing care.…”

Disparities in healthcare expenditures according to economic status in cancer patients undergoing end-of-life care

“…Whilst other previous studies revealed similar patterns [ 23 ], others showed an inverse relationship between socioeconomic status and healthcare expenditures at end-of-life [ 24 ]. The findings are understandable considering that individuals belonging to lower socioeconomic commonly report worse health and functioning, which can lead to more frequent use of hospitalization services at end-of-life [ 25 ]. As no financial barriers exist to access services under the English National Health Service (NHS), differences in costs may be a reflection of poorer management rather than financial barriers [ 24 ].…”