Abstract
BackgroundStrategies in many countries have sought to improve palliative care and reduce hospital deaths for non-cancer patients, but their effects are not evaluated. We aimed to determine the trends and factors associated with dying in hospital in two common progressive respiratory diseases, and the impact of a national end of life care (EoLC) strategy to reduce deaths in hospital.MethodsThis population-based observational study linked death registration data for people in England dying from chronic obstructive pulmonary disease (COPD) or interstitial pulmonary diseases (IPD). We plotted age- and sex-standardised trends, assessed during the pre-strategy (2001–2004), first strategy phase (2004–2008), and strategy intensification (2009–2014) periods, and identified factors associated with hospital death using multiple adjusted proportion ratios (PRs).ResultsOver 14 years, 380,232 people died from COPD (334,520) or IPD (45,712). Deaths from COPD and IPD increased by 0.9% and 9.2% annually, respectively. Death in hospital was most common (67% COPD, 70% IPD). Dying in hospice was rare (0.9% COPD, 2.9% IPD). After a plateau in 2004–2005, hospital deaths fell (PRs 0.92–0.94). Co-morbidities and deprivation independently increased the chances of dying in hospital, with larger effects in IPD (PRs 1.01–1.55) than COPD (PRs 1.01–1.39) and dose-response gradients. The impact of multimorbidity increased over time; hospital deaths did not fall for people with two or more co-morbidities in COPD, nor one or more in IPD. Living in rural areas (PRs 0.94–0.94) or outside London (PRs, 0.89–0.98) reduced the chances of hospital death. In IPD, increased age reduced the likelihood of hospital death (PR 0.81, ≥ 85 versus ≤ 54 years); divergently, in COPD, being aged 65–74 years was associated with increased hospital deaths (PR 1.13, versus ≤ 54 years). The independent effects of sex and marital status differed for COPD versus IPD (PRs 0.89–1.04); in COPD, hospital death was associated with being married.ConclusionsThe EoLC strategy appeared to have contributed to tangible reductions in hospital deaths, but did not reach people with multimorbidity and this gap widened over time. Integrating palliative care earlier in the disease trajectory especially in deprived areas and cities, and where multimorbidity is present, should be boosted, taking into account the different demographic factors in COPD and IPD.
Highlights
Strategies in many countries have sought to improve palliative care and reduce hospital deaths for non-cancer patients, but their effects are not evaluated
Over the 14 years, 334,520 people died from chronic obstructive pulmonary disease (COPD) and 45,712 from interstitial pulmonary disease (IPD) (Table 1), representing 5.3% and 0.7% of the total 6,368,760 non-accidental deaths during the period
Our findings suggest the end of life care (EoLC) Strategy contributed to tangible impact in reducing hospital deaths for people with respiratory diseases
Summary
Strategies in many countries have sought to improve palliative care and reduce hospital deaths for non-cancer patients, but their effects are not evaluated. Mortality from IPDs is climbing, with current age-standardized mortality ranging from 4 to 10 per 100,000 population (highest in UK and lowest in Sweden) [2] Both conditions result in a high use of hospital services across all medical areas, especially among people in advanced stages, when the systemic effects of disease lead to dependency [3]; this leads to high healthcare costs. UK population-based data on admissions suggests that, in IPD, the estimated financial burden of hospitalisation in 2010 was £16.2 million per year [4] Despite this expenditure, there are concerns that care in advanced disease is suboptimal, inadequately co-ordinated, and with patients suffering an average of 14 symptoms, plus psychological and information concerns [5,6,7,8]. For most patients with a progressive illness, the hospital is among the least preferred places of death [9]
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