Abstract
BackgroundThere is growing evidence of socioeconomic inequality in palliative and end-of-life care, yet our understanding of the causes of this inequality and how to address it is lacking. In the context of an ageing and increasingly unequal society, understanding the patterns and determinants of socioeconomic inequality in palliative and end-of-life care is essential for informing ways to deliver care more equitably.
Aim
To investigate patterns and determinants of socioeconomic inequality in palliative and end-of-life care for older adults, and to explore potential mediating factors of the relationship between socioeconomic position and patterns of care towards the end of life.
Methods
This thesis investigates socioeconomic inequality in palliative and end-of-life care using three secondary analysis studies:
i) Systematic review and meta-analysis of existing evidence on the association between socioeconomic position and service use and outcomes in the last year of life, including place of death, hospital admissions in the last three months of life, and access to specialist palliative care.
ii) Secondary analysis of data from the English Longitudinal Study of Ageing (ELSA) using mediation analysis to estimate the direct effect of wealth and education (exposures) on place of death and frequent hospital admissions in the last two years of life (outcomes), and the indirect effects via health and function, access to services and social support (mediators).
iii) Secondary analysis of routinely collected clinical data to analyse the relationship between area-based deprivation and the symptoms and concerns of hospital inpatients referred to specialist palliative care, using data from a validated patient centred outcome measure, the Integrated Palliative Care Outcome Scale (IPOS).
Results
Based on 112 high-to-medium quality studies, the systematic review and meta-analysis found consistent evidence that in high income countries, people with low socioeconomic position were more likely to die in hospital versus home/hospice (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). The dose-response analysis found that for a 1 quintile increase in area-based deprivation the log-odds of dying in hospital versus home increased by 1.07 (95% CI 1.05–1.08, p < 0.001), and the log-odds of not receiving specialist palliative care increased by 1.03 (95% CI 1.02–1.05, p < 0.001). The review also found no studies investigating the causes of socioeconomic inequality in palliative and end-of-life care, and no high or medium quality studies using validated patient centred outcome measures to investigate inequality. The secondary analysis of ELSA and of the routinely collected clinical data address these gaps.
The mediation analysis using ELSA included 737 participants (median age 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). The analysis of clinical data on the symptoms and concerns of palliative patients included data on 7,860 patients (median age 82 years (IQR 74-89) found that patients living in more deprived areas had a higher burden from practical and communication concerns. The predicted mean score for practical and communication concerns for the most deprived group was 5.38 (95% CI 5.10, 5.65) compared to 4.82 (95% CI 4.62, 5.02) for the least deprived (higher scores are worse). Area deprivation was not associated with physical or emotional symptoms.
Conclusions
The systematic review and meta-analysis provide consistent evidence that low socioeconomic position is a risk factor for death in hospital as well as other service-level indicators of potentially poor-quality end-of-life care and demonstrates consistent evidence of a socioeconomic gradient for death in hospital and access to specialist palliative care. The mediation analysis identifies for the first time, that worse health and function may cause people with lower wealth to have more hospital admissions. This challenges behavioural explanations and highlights the importance of socioeconomically driven health differences in explaining different patterns of hospital use towards the end of life. For hospital inpatients seen by palliative care, the findings suggest that one way to reduce inequalities could be to target resources at addressing the practical and communication concerns of patients who live in more deprived areas.
The findings identify several implications for policy, practice and research including, the need to: monitor inequalities and to use this data to inform service delivery; evaluate interventions for unequal effects across social groups; and raise awareness among the public and health care professionals about socioeconomic inequality in palliative and end-of-life care. Methodologically, the thesis provides the first example of a mediation analysis used to study causes of inequality in palliative and end-of-life care and demonstrates novel use of existing longitudinal cohort study data and routinely collected patient centred outcomes data.
| Date of Award | 1 Jun 2023 |
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| Original language | English |
| Awarding Institution |
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| Supervisor | Katherine Sleeman (Supervisor), Fliss Murtagh (Supervisor) & Matthew Maddocks (Supervisor) |