Abstract
SummaryBackgroundMany 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.MethodsFor 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.Findings737 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.InterpretationOur 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.FundingDunhill Medical Trust Fellowship Grant (RTF74/0116).
Highlights
Many patients prefer to remain at home towards the end of life,[1] yet 90% have a hospital admission in the last year of life, and the number of admissions increases sharply during the last months of life.[2]
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
In high-income countries, low socioeconomic position is consistently associated with dying in hospital and with a higher number of hospital admissions in the last months of life.[8]
Summary
Many patients prefer to remain at home towards the end of life,[1] yet 90% have a hospital admission in the last year of life, and the number of admissions increases sharply during the last months of life.[2]. Characteristics that contribute to increased hospital use include individual factors (such as sex, ethnicity, and preferences), illness-related factors (such as functional status and diagnosis), and environmental factors (such as access to care at home).[6,7] In high-income countries, low socioeconomic position is consistently associated with dying in hospital (vs dying at home or in hospice) and with a higher number of hospital admissions in the last months of life.[8]
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