What socio-economic factors determine place of death for people with life-limiting illness? A systematic review and appraisal of methodological rigour

Abstract

Background: Socio-economic factors play important roles in place of death. However, up-to-date knowledge on socio-economic determinants for place of death is warranted including analysis of collinearity between socio-economic determinants. Aim: To examine associations between socio-economic determinants (social class, deprivation level in area of residence, income, education, occupation, urbanisation) and place of death among adult patients with life-limiting illnesses. Furthermore, to describe how these factors are operationalised and examined for collinearity. Design: A systematic review was performed (PROSPERO, record: CRD42018091218) and quality was assessed using the Newcastle–Ottawa Scale. Data sources: A comprehensive search of PubMed, Embase, CINAHL, Scopus and PsycINFO was conducted for studies published from 1 January 2008 until the date of the search (23 March 2018) in English or Scandinavian languages. Results: Of the 1599 unique citations identified, 34 studies were eligible. Dying at home was to a high degree associated with better financial situation and living in rural areas. Furthermore, hospital death was associated with a high level of deprivation in the area of residence and being employed. Regarding educational level, we found mixed and inconclusive results. Conclusion: Inequalities concerning place of death were found, and attention towards socio-economic inequality concerning place of death is necessary, especially in patients with a poor financial status, patients living in deprived and metropolitan areas and patients who are employed. Furthermore, we found a low degree of assessment for collinearity and adjustment of socio-economic variables. These issues should be considered in planning of future studies of socio-economic determinants for place of death.

Socioeconomic inequalities in the place of death in urban small areas of three Mediterranean cities

“…Regarding the excesses of deaths in hospital vs. home, significantly higher values were observed in the most deprived CT, especially in respiratory disease, Alzheimer's disease, malignant neoplasm, heart disease, and other non-palliative causes. In all cases, an association was observed between living in areas with greater deprivation and probability of dying in hospital, as indicated by previous studies [11,19,31,32]. This is an important result since death at home is usually considered an indicator of the quality of palliative care services [3,10].…”

“…In addition, recent studies have also explored the relationship between place of death and aggregate indicators of socioeconomic deprivation [11,19] with the areas of greatest deprivation being those with the highest hospital mortality rates. Furthermore, various studies seem to indicate that social differences have a lesser effect on the place of death when measured at the individual level (for example, educational level) than when measured at the aggregate level (commonly by means of deprivation at the area level) [19].…”

“…In addition, recent studies have also explored the relationship between place of death and aggregate indicators of socioeconomic deprivation [11,19] with the areas of greatest deprivation being those with the highest hospital mortality rates. Furthermore, various studies seem to indicate that social differences have a lesser effect on the place of death when measured at the individual level (for example, educational level) than when measured at the aggregate level (commonly by means of deprivation at the area level) [19]. In this regard, an adequate instrument to measure inequalities is a deprivation index (DI), like those used in the MEDEA and INEQ-CITIES studies on social inequalities and risk of death [20][21][22], that combine a set of indicators such as the percentages of unemployed, temporary workers, low educational level of different population groups, or manual workers and allow classifying small geographic areas according to their level of socioeconomic deprivation [23].…”

Relationship between the place of living and mortality in patients with advanced heart failure

“…The approach to the end of life could be culturally different in a rural setting compared to an urban one. A recent systematic review oriented to analyse the socio-economic factors determining the place of death found that dying at home was associated with living in rural areas but, potential causes remain unsolved [32]. Mean survival time among patients who died in our study was slightly higher among the urban ones.…”

Effect of the Place of Living on Mortality in Patients with Advanced Heart Failure

“…The decision to die at home allows patients to maintain control over their lives. The approach to the end of life is culturally different in a rural setting compared to an urban one 33 . For instance, rural patients could be more in favor of dying at home and not prolonging their lives through hospitalizations and aggressive interventions.…”