Care Home Deaths Research Articles

News analysis

Nursing and Residential CareVol. 22, No. 12 News AnalysisNews analysisMelissa McAleesMelissa McAleesFreelance journalist, UKSearch for more papers by this authorMelissa McAleesPublished Online:4 Dec 2020https://doi.org/10.12968/nrec.2020.22.12.2aAboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Care Industry News. Clarity needed as care home deaths inch higher again. 2020. https://tinyurl.com/y6z9dl5x (accessed 3 November 2020) Google ScholarDepartment of Health and Social Care. More than £500 million for social care to reduce coronavirus transmission over winter. 2020. https://tinyurl.com/y466fd6m (accessed 3 November 2020) Google ScholarThe Independent Care Group. The ICG′s Urgent Appeal for Matt Hancock′s support for family visits to Care and Nursing Homes during second wave of COVID-19. 2020. https://tinyurl.com/yyc7mq4x (accessed 3 November 2020) Google Scholar FiguresReferencesRelatedDetails 2 December 2020Volume 22Issue 12ISSN (print): 1465-9301ISSN (online): 2052-2932 Metrics History Published online 4 December 2020 Published in print 2 December 2020 Information© MA Healthcare LimitedPDF download

Evolution and effects of COVID-19 outbreaks in care homes: a population analysis in 189 care homes in one geographical region of the UK

BackgroundCOVID-19 has affected care home residents internationally, but detailed information on outbreaks is scarce. We aimed to describe the evolution of outbreaks of COVID-19 in all care homes in one large health region in Scotland.MethodsWe did a population analysis of testing, cases, and deaths in care homes in the National Health Service (NHS) Lothian health region of the UK. We obtained data for COVID-19 testing (PCR testing of nasopharyngeal swabs for severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2]) and deaths (COVID-19-related and non-COVID-19-related), and we analysed data by several variables including type of care home, number of beds, and locality. Outcome measures were timing of outbreaks, number of confirmed cases of COVID-19 in care home residents, care home characteristics associated with the presence of an outbreak, and deaths of residents in both care homes and hospitals. We calculated excess deaths (both COVID-19-related and non-COVID-19-related), which we defined as the sum of deaths over and above the historical average in the same period over the past 5 years.FindingsBetween March 10 and Aug 2, 2020, residents at 189 care homes (5843 beds) were tested for COVID-19 when symptomatic. A COVID-19 outbreak was confirmed at 69 (37%) care homes, of which 66 (96%) were care homes for older people. The size of care homes for older people was strongly associated with a COVID-19 outbreak (odds ratio per 20-bed increase 3·35, 95% CI 1·99–5·63). 907 confirmed cases of SARS-CoV-2 infection were recorded during the study period, and 432 COVID-19-related deaths. 229 (25%) COVID-19-related cases and 99 (24%) COVID-related deaths occurred in five (3%) of 189 care homes, and 441 (49%) cases and 207 (50%) deaths were in 13 (7%) care homes. 411 (95%) COVID-19-related deaths occurred in the 69 care homes with a confirmed COVID-19 outbreak, 19 (4%) deaths were in hospital, and two (<1%) were in one of the 120 care homes without a confirmed COVID-19 outbreak. At the 69 care homes with a confirmed COVID-19 outbreak, 74 excess non-COVID-19-related deaths were reported, whereas ten non-COVID-19-related excess deaths were observed in the 120 care homes without a confirmed COVID-19 outbreak. 32 fewer non-COVID-19-related deaths than expected were reported among care home residents in hospital.InterpretationThe effect of COVID-19 on care homes has been substantial but concentrated in care homes with known outbreaks. A key implication from our findings is that, if community incidence of COVID-19 increases again, many care home residents will be susceptible. Shielding care home residents from potential sources of SARS-CoV-2 infection, and ensuring rapid action to minimise outbreak size if infection is introduced, will be important for any second wave.FundingNone.

Coronavirus fears leave families less likely to seek residential care

Nursing and Residential CareVol. 22, No. 8 News AnalysisCoronavirus fears leave families less likely to seek residential careMelissa McAleesMelissa McAleesFreelance journalistSearch for more papers by this authorMelissa McAleesPublished Online:21 Jul 2020https://doi.org/10.12968/nrec.2020.22.8.2aAboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Independent Age. Comment on research about affect of COVID-19 on care. 2020. https://tinyurl.com/ycf4uhrn (accessed 13 June 2020) Google ScholarOffice for National Statistics. Number of deaths in care homes notified to the Care Quality Commission, England. 2020. https://tinyurl.com/y6uzorkw (accessed 13 June 2020) Google ScholarSocial Care Institute for Excellence. ‘A sorry indictment’. SCIE response to survey. 2020. https://tinyurl.com/y9pjhlu7 (accessed 13 June 2020) Google ScholarThe Department for Health and Social Care. Whole home testing rolled out to all care homes in England. 2020. https://tinyurl.com/y9pk43zh (accessed 13 June 2020) Google ScholarThe Institute for Public Policy Research. A third of people less likely to seek residential social care for relatives in wake of Covid-19 crisis, poll finds. 2020. https://tinyurl.com/y9chg2hn (accessed 13 June 2020) Google Scholar FiguresReferencesRelatedDetails 2 August 2020Volume 22Issue 8ISSN (print): 1465-9301ISSN (online): 2052-2932 Metrics History Published online 21 July 2020 Published in print 2 August 2020 Information© MA Healthcare LimitedPDF download

Changing patterns of mortality during the COVID-19 pandemic: Population-based modelling to understand palliative care implications

Background: COVID-19 has directly and indirectly caused high mortality worldwide. Aim: To explore patterns of mortality during the COVID-19 pandemic and implications for palliative care, service planning and research. Design: Descriptive analysis and population-based modelling of routine data. Participants and setting: All deaths registered in England and Wales between 7 March and 15 May 2020. We described the following mortality categories by age, gender and place of death: (1) baseline deaths (deaths that would typically occur in a given period); (2) COVID-19 deaths and (3) additional deaths not directly attributed to COVID-19. We estimated the proportion of people who died from COVID-19 who might have been in their last year of life in the absence of the pandemic using simple modelling with explicit assumptions. Results: During the first 10 weeks of the pandemic, there were 101,614 baseline deaths, 41,105 COVID-19 deaths and 14,520 additional deaths. Deaths in care homes increased by 220%, while home and hospital deaths increased by 77% and 90%, respectively. Hospice deaths fell by 20%. Additional deaths were among older people (86% aged ⩾ 75 years), and most occurred in care homes (56%) and at home (43%). We estimate that 22% (13%–31%) of COVID-19 deaths occurred among people who might have been in their last year of life in the absence of the pandemic. Conclusion: The COVID-19 pandemic has led to a surge in palliative care needs. Health and social care systems must ensure availability of palliative care to support people with severe COVID-19, particularly in care homes.

From special powers to legislating the lockdown: the Health Protection (Coronavirus, Restrictions) Regulations (Northern Ireland) 2020

The Health Protection (Coronavirus, Restrictions) Regulations (Northern Ireland) 2020 were made through temporarily inserted provisions by Westminster’s vast and rushed Coronavirus Act 2020. This itself limits duties to notify deaths to the coroner, despite Article 2 European Convention on Human Rights duties being particularly relevant to deaths in care homes and of frontline workers. The regularly amended March 2020 Northern Ireland regulations have themselves raised ‘legal certainty’ issues. Until June, official websites carried no accessible information as to their scope. Initial concerns on lack of clarity over matters such as driving for exercise gave way to greater controversy regarding the application of the regulations to the Black Lives Matter protests on 6 June 2020 through Police Service of Northern Ireland powers that had only been extended through an eleventh hour amendment the night before. The enforcement powers themselves are so widely drafted that they are reminiscent of the Special Powers Acts of the past. These issues are explored in this article.

COVID-19 in care homes: ‘a scandal behind closed doors’

Nursing and Residential CareVol. 22, No. 7 News AnalysisCOVID-19 in care homes: ‘a scandal behind closed doors’Melissa McAleesMelissa McAleesFreelance journalistSearch for more papers by this authorMelissa McAleesPublished Online:18 Jun 2020https://doi.org/10.12968/nrec.2020.22.7.2aAboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Age UK. Age UK response to more care home deaths. 2020. https://tinyurl.com/y8tpkgxu (accessed 15 May 2020) Google ScholarGilroy R. New support pledged for care homes as PM confronted over ‘slow’ response. Nursing Times. 13 May 2020. https://tinyurl.com/yblj8sqf (accessed 15 May 2020) Google ScholarGov.uk. COVID-19: number of outbreaks in care homes—management information. 2020. https://tinyurl.com/ybweukot (accessed 15 May 2020) Google ScholarThe Care Home Environment. Government pledges extra £600m for care home infection control. 2020. https://tinyurl.com/yc6rkgjs (accessed 15 May 2020) Google ScholarThe National Care Association. COVID-19 testing for care services. 2020. https://tinyurl.com/yb46ajgu (accessed 15 May 2020) Google Scholar FiguresReferencesRelatedDetails 2 July 2020Volume 22Issue 7ISSN (print): 1465-9301ISSN (online): 2052-2932 Metrics History Published online 18 June 2020 Published in print 2 July 2020 Information© MA Healthcare LimitedPDF download

COVID-19 and a sector under strain

Nursing and Residential CareVol. 22, No. 6 EditorialCOVID-19 and a sector under strainFrancesca RamadanFrancesca RamadanEditor, NRCSearch for more papers by this authorFrancesca RamadanPublished Online:17 May 2020https://doi.org/10.12968/nrec.2020.22.6.1AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Brawn S. COVID-19 care home deaths account for 75 percent of Renfrewshire's total. 4 May 2020. Daily Record. www.dailyrecord.co.uk/authors/paisley-daily-express/covid-19-care-home-deaths-21969361 (accessed 5 May 2020) Google ScholarCare England. Coronavirus (COVID-19). 2020. www.careengland.org.uk/coronavirus-covid-19 (accessed 5 May 2020) Google ScholarCowburn A. Tory MP says people considered ‘low-skilled’ in post-Brexit immigration system ‘actually pretty crucial to running of our country’. 23 March 2020. Independent. www.independent.co.uk/news/uk/politics/coronavirus-brexit-immigration-system-key-workers-low-skilled-steve-double-a9419116.html (accessed 5 May 2020) Google ScholarGibbons K. Acting quickly can reduce coronavirus death toll in care homes. 4 May 2020. Times. www.thetimes.co.uk/article/acting-quickly-can-reduce-coronavirus-death-toll-in-care-homes-dxk7sdldn (accessed 5 May 2020) Google ScholarLintern S. Coronavirus: NHS Nightingale hospital to stop admitting patients this week, leaked email reveals. 4 May 2020a. Independent. www.independent.co.uk/news/health/coronavirus-nhs-nightingale-hospital-london-excel-centre-nhs-patients-a9497596.html (accessed 5 May 2020) Google ScholarLintern S. Coronavirus set to re-emerge in society through care homes, warns NHS chief. 1 May 2020b. Independent. www.independent.co.uk/news/health/coronavirus-nhs-england-lockdown-keith-willett-uk-a9493036.html (accessed 5 May 2020) Google ScholarMarsh S. Lack of PPE killed care home nurse who died of coronavirus, says her son. 2 May 2020. Guardian. www.theguardian.com/uk-news/2020/may/02/lack-of-ppe-care-home-nurse-coronavirus-suzanne-loverseed-ian-oneal (accessed 5 May 2020) Google ScholarOffice for National Statistics. Dataset: number of deaths in care homes notified to the Care Quality Commission, England. 2020. www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/datasets/numberofdeathsincarehomesnotifiedtothecarequalitycommissionengland (accessed 5 May 2020) Google ScholarPadgham M. Care providers react to rising Covid-19 death figures. Independent Care Group [media release]. 5 May 2020 (accessed 5 May 2020) Google ScholarParveen N, Proctor K. Boris Johnson: it was 50-50 whether to put me on ventilator. 3 May 2020. Guardian. www.theguardian.com/world/2020/may/03/boris-johnson-it-was-50-50-whether-to-put-me-on-ventilator-coronavirus (accessed 5 May 2020) Google ScholarSkentelbery G. Rotary clubs help provide PPE provision in hospices and care homes. 2 May 2020. Warrington Worldwide. www.warrington-worldwide.co.uk/2020/05/02/rotary-clubs-help-provide-ppe-provision/ (accessed 5 May 2020) Google ScholarSwerling G. 7500 feared to have died of coronavirus in UK care homes. 17 April 2020. Telegraph. www.telegraph.co.uk/news/2020/04/17/number-coronavirus-deaths-care-homes-could-high-7500-according/ (accessed 5 May 2020) Google Scholar FiguresReferencesRelatedDetails 2 June 2020Volume 22Issue 6ISSN (print): 1465-9301ISSN (online): 2052-2932 Metrics History Published online 17 May 2020 Published in print 2 June 2020 Information© MA Healthcare LimitedPDF download

Covid-19: Experts urge strategies to prevent further outbreaks in care homes.

With data showing that covid-19 outbreaks are occurring in 38% of care homes, a concerted effort is needed to prevent outbreaks in the rest, say experts. Office for National Statistics data for the week ending 8 May 2020 showed that deaths from all causes in care homes fell by around a third, from 6409 the previous week to 4248.12 Deaths involving covid-19 as a proportion of all deaths in care homes continued to rise, however, to 39.2%, from 37.8% in the previous week. Speaking at a press briefing hosted by the Science Media Centre, David Spiegelhalter, chair of the Winton Centre for Risk and Evidence Communication at the University of Cambridge, said that the …

The cost of prevalent and incident cardiovascular disease in people with type 2 diabetes in Scotland: data from the Scottish Care Information-Diabetes Collaboration.

To compare costs for three groups of people with type 2 diabetes, those at high risk of future cardiovascular disease, those without cardiovascular disease and those with established cardiovascular disease, and to also compare costs incurred by people with type 2 diabetes with an incident cardiovascular disease event with those who remain incident event-free over a 3-year period. Data about people with type 2 diabetes in Scotland were obtained from the Scottish Care Information Diabetes registry. Data linkage was used to retrieve information on healthcare utilization, care home use and deaths. Productivity effects were estimated for those of non-pensionable age. We estimated costs over 12months (prevalent cardiovascular disease) and 3years from incident cardiovascular disease event. Mean annual cost per person with established cardiovascular disease was £6900, £3300 for a person at high risk of future cardiovascular disease, and £2500 for a person without cardiovascular disease and not at high risk. In year 1, the cost of an incident cardiovascular disease event was £16 700 compared with £2100 for people without an incident event. Over 2years, the cumulative costs were £21 500 and £4200, and by year 3, £25 000 and £5900, respectively. Cardiovascular disease in people with type 2 diabetes places a significant financial burden on healthcare and the wider economy. Our results emphasize the financial consequences of cardiovascular disease prevention strategies.

The impact of population ageing on end-of-life care in Scotland: projections of place of death and recommendations for future service provision

BackgroundGlobal annual deaths are rising. It is essential to examine where future deaths may occur to facilitate decisions regarding future service provision and resource allocation.AimsTo project where people will die from 2017 to 2040 in an ageing country with advanced integrated palliative care, and to prioritise recommendations based on these trends.MethodsPopulation-based trend analysis of place of death for people that died in Scotland (2004–2016) and projections using simple linear modelling (2017–2040); Transparent Expert Consultation to prioritise recommendations in response to projections.ResultsDeaths are projected to increase by 15.9% from 56,728 in 2016 (32.8% aged 85+ years) to 65,757 deaths in 2040 (45% aged 85+ years). Between 2004 and 2016, proportions of home and care home deaths increased (19.8–23.4% and 14.5–18.8%), while the proportion of hospital deaths declined (58.0–50.1%). If current trends continue, the numbers of deaths at home and in care homes will increase, and two-thirds will die outside hospital by 2040. To sustain current trends, priorities include: 1) to increase and upskill a community health and social care workforce through education, training and valuing of care work; 2) to build community care capacity through informal carer support and community engagement; 3) to stimulate a realistic public debate on death, dying and sustainable funding.ConclusionTo sustain current trends, health and social care provision in the community needs to grow to support nearly 60% more people at the end-of-life by 2040; otherwise hospital deaths will increase.

Implications of socio-demographic change in place of death in Scotland 2001-2011: an analysis of linked census and death registration data

Background with rationaleCare in the final stages of life care constitutes a marked component of all health and social care expenditure. Whether people die at home or in an institutional setting is influenced by a range of social and demographic factors. Understanding the implications of socio-demographic trends for people die can contribute to planning services.&#x0D; Main AimTo describe changes in place of death 2001-2011 and to ascertain the extent to which these might be explained by social or demographic trends.&#x0D; Methods/ApproachData from the Care in the Last Days of Life Study was drawn on. This dataset linked census to death registration and hospital admissions data for all deaths occurring in the 12 months following the 2001 and 2011 censuses. Deaths in these two time periods were compared and contrasted using logistic regression.&#x0D; Results and DiscussionExcluding deaths for which no census record could be linked, a total of 56,766 people died in the year following the 2001 census and 53,517 following in the same period after the 2011 census. A slight decline was apparent in the period proportion of deaths in hospital (52.3% of all deaths in 2011-12 against 56.9% in 2001-02) with a concomitant increase in deaths in care homes and hospices. Deaths at home were virtually unchanged. Age at death increased markedly with 31.4% occurring to people aged 85+ years in the latter compared to 26.6% in the earlier period. Further analysis to be presented will explore the extent to which these changes can be explained by an ageing population, shifting causes of death, changes in hospital discharge policies, or social composition of the Scottish population between these two timepoints. Implications of findings for policy will be considered.

An inquiry into what organised difficult advance care planning conversations in a Scottish residential care home using institutional ethnography.

This paper provides an institutional ethnographic analysis of how advance care planning discussions, which included advance decisions about serious illness, hospital admission and Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) forms, were systematically placed into the hands of senior social care workers (SSCWs) in a residential care home (RCH). RCHs are care settings where there are no on-site nurses, and access to hospital and/or community doctors and nurses is limited. The paper traces the organising features of day-to-day work gathered from interviews with SSCWs (n = 4) and others (n = 6) whose (well-intentioned) work shaped what happened in the RCH. It shows how the experience of SSCWs was socially organised to happen as it did as they (and others) complied with powerful organising texts such as national and local policy documents, care plans and audit forms. The paper concludes that although SSCWs decision-making conversations were out of alignment with the national DNACPR policy, they cannot simply be described as poor practice. This is because they were socially organised by a complex web of institutional practices related to the occupancy rate in the RCH, the inspection process of the care home scrutiny body, the quality assurance process of the RCH company, the funding of palliative care education, and powerful political and fiscal drives to reduce spending on over-75s. These practices had little to do with the actual care needs of RCH residents or the actual support needs of RCH staff. The paper points towards necessary policy changes. It also highlights how 'competent' work driven by ideological institutional practices can result in ethically troubling situations in day-to-day working life. This emphasises the importance of carefully examining the social organisation of situations typically described as poor practice if we are to understand how they are (re)produced. It also offers a different account of care home deaths than is typically presented in the professional literature.

Effects of health and social care spending constraints on mortality in England: a time trend analysis

ObjectiveSince 2010, England has experienced relative constraints in public expenditure on healthcare (PEH) and social care (PES). We sought to determine whether these constraints have affected mortality rates.MethodsWe collected data...

What is the impact of population ageing on the future provision of end-of-life care? Population-based projections of place of death

Background: Population ageing represents a global challenge for future end-of-life care. Given new trends in place of death, it is vital to examine where the rising number of deaths will occur in future years and implications for health and social care. Aim: To project where people will die from 2015 to 2040 across all care settings in England and Wales. Design: Population-based trend analysis and projections using simple linear modelling. Age- and gender-specific proportions of deaths in hospital, care home, home, hospice and ‘other’ were applied to numbers of expected future deaths. Setting/population: All deaths (2004–2014) from death registration data and predicted deaths (2015–2040) from official population forecasts in England and Wales. Results: Annual deaths are projected to increase from 501,424 in 2014 (38.8% aged 85 years and over) to 635,814 in 2040 (53.6% aged 85 years and over). Between 2004 and 2014, proportions of home and care home deaths increased (18.3%–22.9% and 16.7%– 21.2%) while hospital deaths declined (57.9%–48.1%). If current trends continue, numbers of deaths in care homes and homes will increase by 108.1% and 88.6%, with care home the most common place of death by 2040. If care home capacity does not expand and additional deaths occur in hospital, hospital deaths will start rising by 2023. Conclusion: To sustain current trends, end-of-life care provision in care homes and the community needs to double by 2040. An infrastructure across care settings that supports rising annual deaths is urgently needed; otherwise, hospital deaths will increase.

End of life care for urological cancer patients

Background: Each year around 15,000 men and 2900 women die from a urological cancer. The trajectory at end of life can be long and progressive or punctuated by acute events. Nonetheless those who die from urological cancer share some certain common disease manifestations that necessitate input from secondary care. Methods: All records of people dying from a urological cancer in 2004–2013 were extracted from Office for National Statistics and National Cancer Registration and Analysis Service databases. Records were linked to hospital episode statistics to analyse patterns of admitted patient care, outpatient attendances and emergency department attendances. Results: There has been a progressive decline in the proportion of deaths in hospital, from 47% to 35% of deaths. There has been a notable increase in care home deaths, which have risen from 13% to 19% of deaths and overtaken deaths in a hospice. Despite an only modest rise in total deaths from urological cancers (15,573 per year 2004–2006; 16,921 per year 2011–2013) there has been a much larger increase in secondary care activity in the last year of life. The largest change was for outpatient attendances, where the mean number increased from 3.0 to 13.6 per person. Conclusion: Differences in age at death may account for some of the differences in place of death. Those dying at an older age will be more likely to require care for comorbidities or frailty, and hence be in a care home already. The large increase in outpatient activity could reflect attempts to manage more end of life care without hospital admissions. Yet inpatient activity has increased more quickly than the number of deaths. The increase in outpatient activity may instead be due to developments in treatment for advanced cancer, and prostate cancer in particular, being offered to patients close to the end of life.

Geographical and temporal Understanding In place of Death in England (1984–2010): analysis of trends and associated factors to improve end-of-life Care (GUIDE_Care) – primary research

BackgroundPlace of death (PoD) has been used as an outcome measure for end-of-life care. Analysis of variations in PoD can improve understanding about service users’ needs and thus better target health-care services.Objectives(1) To describe PoD in England by demographic, socioeconomic and temporal variables; (2) to determine how much of the variation in PoD can be explained by potential explanatory variables at the area level, and building on this to develop individual-level multivariable regression models; and (3) to evaluate factors associated with PoD and to construct risk assessment models to inform practice.MethodsA population-based study of all registered deaths between 1984 and 2010 in England (n = 13,154,705). The outcome was the PoD. Explanatory variables included age, gender, cause of death (CoD), marital status, year of death, whether or not the death was in a holiday period (Christmas, Easter, New Year), season of death, the location of usual residence and area-level deprivation. The proportion of explained variation in PoD was estimated using the weighted aggregate-level linear regression. Factors associated with PoD were investigated using generalised linear models. The risk assessment models were constructed using the 2006–9 data; the performance was evaluated using the 2010 data.ResultsHospital was the most common PoD in 2001–10 [overall 57.3%; range – cancer 46.1% to chronic obstructive pulmonary disease (COPD) 68.3%], followed by home [overall 19.0%; range – cerebrovascular disease (CBD) 6.7% to cardiovascular disease 27.4%] or care home (overall 17.2%; range – cancer 10.1% to neurological conditions 35.2%), depending on CoD. Over the period, the proportion of hospital deaths for people who died from non-cancer increased (57.1–61.2%) and care home deaths reduced (21.2% down to 20.0%); a reverse pattern was seen for those who died of cancer (hospital: reduced, 48.6–47.3%; care home: increased, 9.3–10.1%). Hospice deaths varied considerably by CoD (range – CBD 0.2% to cancer 17.1%), and increased slightly overall from 4.1% in 1993–2000 to 5.1% in 2001–10. Multivariable analysis found that hospital deaths for all causes combined were more likely for people aged 75+ years [proportion ratios (PRs) 0.863–0.962 vs. aged 25–54 years], those who lived in London (PRs 0.872–0.988 vs. North West), those who were divorced, single and widowed (PRs 0.992–1.001 vs. married), those who lived in more deprived areas (PRs 0.929–1.000 more deprived vs. less deprived) and those who died in autumn, winter or at New Year. We were able to develop risk assessment models but the areas under the receiver operating characteristic curve indicating poor predictive performance, ranging from 0.552 (COPD) to 0.637 (CBD).ConclusionsHospital remains the most common PoD, followed by home and care home. Hospices play an important role for people who died from cancer but little for other diseases. Place of death is strongly associated with the underlying CoD. The variation in PoD by region, age, marital status and area deprivation suggests that inequities exist, which services and clinical commissioning groups could seek to address.FundingThe National Institute for Health Services and Delivery Research programme.

Reversal of English trend towards hospital death in dementia: a population-based study of place of death and associated individual and regional factors, 2001–2010

BackgroundEngland has one of the highest rates of hospital death in dementia in Europe. How this has changed over time is unknown. This study aimed to analyse temporal trends in place of death in dementia over a recent ten year period.MethodsPopulation-based study linking Office for National Statistics mortality data with regional variables, in England 2001–2010. Participants were adults aged over 60 with a death certificate mention of dementia. Multivariable Poisson regression was used to determine the proportion ratio (PR) for death in care home (1) and home/hospice (1) compared to hospital (0). Explanatory variables included individual factors (age, gender, marital status, underlying cause of death), and regional variables derived at area level (deprivation, care home bed provision, urbanisation).Results388,899 deaths were included. Most people died in care homes (55.3%) or hospitals (39.6%). A pattern of increasing hospital deaths reversed in 2006, with a subsequent decrease in hospital deaths (−0.93% per year, 95% CI −1.08 to −0.79 p < 0.001), and an increase in care home deaths (0.60% per year, 95% CI 0.45 to 0.75 p < 0.001). Care home death was more likely with older age (PR 1.11, 1.10 to 1.13), and in areas with greater care home bed provision (PR 1.82, 1.79 to 1.85) and affluence (PR 1.29, 1.26 to 1.31). Few patients died at home (4.8%) or hospice (0.3%). Home/hospice death was more likely in affluent areas (PR 1.23, 1.18 to 1.29), for women (PR 1.61, 1.56 to 1.65), and for those with cancer as underlying cause of death (PR 1.84, 1.77 to 1.91), and less likely in the unmarried (PRs 0.51 to 0.66).ConclusionsTwo in five people with dementia die in hospital. However, the trend towards increasing hospital deaths has reversed, and care home bed provision is key to sustain this. Home and hospice deaths are rare. Initiatives which aim to support the end of life preferences for people with dementia should be investigated.

Sociodemographic determinants of place of death in dementia: whole population cross-sectional analysis in England, 2001–10

BackgroundThe in-hospital death rate from dementia in England is among the highest in Europe. The personal, regional, and temporal factors influencing place of death in dementia are unknown. MethodsOffice for National Statistics mortality data were used for whole population cross-sectional analysis of deaths from dementia in England, 2001–10. Place of death (home, hospice, care home, hospital) was the outcome variable. Explanatory variables included demographic, social, and regional factors. Multivariable Poisson regression analysis was used to provide an independent relative risk of place of death for each of the variables studied. The change in place of death over time was studied using linear regression. Findings387 004 deaths were included. Most patients died in care homes (55·3%) or hospital (39·6%). Home deaths (4·8%) and hospice deaths (0·3%) were rare. Hospital deaths were less likely with increasing affluence (relative risk [RR] 0·83, 95% CI 0·81–0·85), and increasing provision of a care-home bed (0·61, 95% CI 0·58–0·63). Lack of social support (marital status) reduced home deaths (RRs 0·45–0·60). Hospice deaths were increased in areas with greater hospice bed provision (RR 4·23, 95% CI 2·14–8·35) and in patients whose underlying cause of death was cancer (19·0, 95% CI 16·2–22·3). Deaths in care homes were more common with increasing affluence (RR 1·28, 95% CI 1·24–1·32) and increased provision of a care-home bed (2·02, 95% CI 1·97–2·08). Time-trend analysis showed a recent decrease in hospital deaths and reciprocal increase in care-home deaths. InterpretationGovernments and policy makers recognise the urgent need for public health planning in dementia. Reducing the number of deaths in hospital, and increasing those at home, in dementia has both societal and economic benefits. Social support, deprivation, and service provision are key targets for policy. FundingNational Institute for Health Research.

Study of recent and future trends in place of death in Belgium using death certificate data: a shift from hospitals to care homes

BackgroundSince most patients prefer out-of-hospital death, place of death can be considered an indicator of end-of-life care quality. The study of trends in place of death is necessary to examine causes of shifts, to evaluate efforts to alter place of death and develop future policies. This study aims to examine past trends and future projections of place of death.MethodsAnalysis of death certificates (decedents aged ≥ 1 year) in Belgium (Flanders and Brussels Capital region) 1998-2007. Trends in place of death were adjusted for cause of death, sociodemographic characteristics, environmental factors, numbers of hospital beds, and residential and skilled nursing beds in care homes. Future trends were based on age- and sex-specific mortality prognoses.ResultsHospital deaths decreased from 55.1% to 51.7% and care home deaths rose from 18.3% to 22.6%. The percentage of home deaths remained stable. The odds of dying in a care home versus hospital increased steadily and was 1.65 (95%CI:1.53-1.78) in 2007 compared to 1998. This increase could be attributed to the replacement of residential beds by skilled nursing beds. Continuation of these trends would result in the more than doubling of deaths in care homes and a decrease in deaths at home and in hospital by 2040.ConclusionsAdditional end-of-life care resources in care homes largely explain the decrease in hospital deaths. Care homes will become the main locus of end-of-life care in the future. Governments should provide sufficient skilled nursing resources in care homes to fulfil the end-of-life care preferences and needs of patients.

Supporting care home residents at the end of life

The English Department of Health's 2008 End of Life Care Strategy reported that 17% of deaths in England occur in care homes, with the majority of these in the 85 years and over age group. Given this, the ageing population, and the projected increase in the number of people dying, it is evident that the number of deaths in care homes is likely to increase. The research presented here seeks to consider the factors that support residents to remain in care homes towards the end of life. This study is based on four case studies of care homes in England and on interviews with external health and social care professionals who interact with these care homes. The findings indicate that three core features are fundamental to the delivery of high-quality end-of-life care in care homes: advance care planning, multidisciplinary communication and working, and provision of dignified and compassionate care. Previous research has uncovered some of these issues; this study suggests that it is the combination of these factors that makes them fundamental to meeting residents' care preferences and ensuring high-quality care.