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Poor people have worse end-of-life care

Low socioeconomic position raises risk of hospital death, and not having specialist palliative care

Louise Prime

Wednesday, 24 April 2019

People in low socioeconomic groups generally receive poorer quality end-of-life care than those in higher socioeconomic groups, at least in high-income countries, UK-led research has shown. The authors of the study, in PLoS Medicine, said the planning and provision of end-of-life care services should consider socioeconomic position (SEP) in local populations – and they called for all research into care received towards the end of life to account for SEP, and for end-of-life care interventions to be analysed for their different effects across the social strata.

The research team, led from the Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation at King’s College London, pointed out that although low SEP is recognised as a risk factor for worse health outcomes, until now its influence on end-of-life care, and the magnitude of any effect, has not been understood. They conducted a systematic review and meta-analysis to identify and quantify existing evidence on the association between SEP and use of healthcare in the last year of life – including place of death, use of acute care use, use of specialist palliative care and non-specialist end-of-life care, use of advance care planning, and quality of care.


Their analysis of 209 studies (53.5% from North America, 31.0% from Europe, 8.5% from Australia, and 7.0% from Asia) revealed consistent evidence that low SEP increases the odds of hospital versus home death and of using acute care services in the last three months of life, and it also reduces the odds of using specialist palliative care in the last year of life.

Compared with people living in the least deprived neighbourhoods, people living in the most deprived neighbourhoods were significantly more likely to die in hospital than at home (odds ratio, OR 1.30, to receive acute hospital-based care in the last three months of life (OR 1.16), and to not receive specialist palliative care (OR 1.13). For every quintile increase in area deprivation, hospital versus home death was significantly more likely (OR 1.07), and not receiving specialist palliative care was more likely (OR 1.03). Compared with 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).

The study authors also noted that research in this area often poorly accounts for SEP, being dominated by measures of area deprivation and education.

They acknowledged some limitations of their review, such as the observational nature of the included studies and the focus on high-income countries – but a ‘major strength’ was the inclusion of multiple exposure and outcome variables, and a large number of observational studies.

They concluded: “We have found consistent evidence from high-income countries that low SEP is a risk factor across several components of service use at the end of life, including dying in hospital rather than at home, receiving acute hospital-based care in the last three months of life, and not receiving specialist palliative care in the last year of life. We also found evidence of a pervasive social gradient in place of death and use of specialist palliative care.

“These findings should stimulate widespread efforts to reduce socioeconomic inequality towards the end of life. We recommend that all research on care received towards the end of life should attempt to account for SEP, end-of-life care interventions should be analysed for their different effects across the social strata, and the planning and provision of end-of-life care services should consider SEP in local populations.”


*Davies JM, Sleeman KE, Leniz J, et al. Socioeconomic position and use of healthcare in the last year of life: A systematic review and meta-analysis. PLoS Med 2019; 16(4): e1002782.

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