Place of death in the Czech Republic and Slovakia: a population based comparative study using death certificates data

Death certificates represent a useful monitoring tool for public health policy [ 1, 2]. Choosing the best quality measures for end-of-life care is a very complex issue [ 3, 4] and information about place of death has been suggested to be one of the key indicators [ 5– 7]. Together with research on place of death preferences [ 8, 9], the analysis of actual place of death is essential in planning appropriate end-of-life care policy [ 10]. Although the relationship between preference for place of death and actual choice is rather complex and influenced by various factors [ 11, 12], dying at home is often cited as the indicator of quality of end-of-life care because home is usually the preferred place for most people [ 13]. Previous studies have also highlighted the association between place of death with health care expenditure [ 14], the quality of life of dying patients and the bereavement outcomes of their relatives [ 15].

The modern form of death certificates (List o prohlídce mrtvého) has been collected in the Czech Republic and Slovakia since 1964 [ 16]. Similar to other European Union countries, it is completed by the attending physician usually at the place of death. It consists of both an administrative and clinical section and is subsequently sent to national statistics offices for further processing. The national statistics offices use parts of death certificates to analyse and publish official mortality statistics. Data about place of death have been included in this official database since 2007 in the Czech Republic and since 2011 in Slovakia.

To our knowledge, this is the first study using the whole population death certificates data from the Czech Republic and Slovakia and also from the region of Eastern Europe. The study sought to answer the following research questions:

Only 20% and 30% of all deaths in the Czech Republic and Slovakia in 2011 occurred at home. This highlights a major discrepancy between actual and preferred place of death as the majority of people in these countries expressed a preference to die at home (78% in CZ, [ 17]). This result is similar to other European countries [ 6, 18] and confirms a common trend with more than half of the populations dying in a hospital setting (58.4% in CZ, 54.8% in SK).

Further analysis showed that almost two thirds of patients with chronic conditions died in hospitals in the Czech Republic and Slovakia. This number is considerably higher than in other countries with similar sized populations, such as the Netherlands [ 2], where only around 30% of deaths in people with chronic conditions occur in a hospital setting. Regression analysis confirmed that place of death is strongly associated with underlying cause of death with cancer patients being more likely to die at home than patients dying from other chronic conditions.

The results of this study support several trends identified in other countries, such as the discovery that more than half of the population die in hospitals and that men are more likely to die at home than women, probably because they die at a younger age when their wives or partners can help facilitate care at home [ 6, 10, 18, 19]. However, we also found some differences between the Czech Republic and Slovakia and other countries. In the Czech Republic and Slovakia most people who died from chronic conditions in 2011 died in hospitals (around 63% in both countries). There are several possible explanations for this finding. In the Netherlands, where only a third of such patients die in hospitals, nursing home care is developed to a very high level and provides care for similar proportion of dying people as hospitals [ 2]. In neither the Czech Republic nor Slovakia are such nursing homes available. Care homes for older people or local variations of nursing homes usually do not have a physician on the staff and many GPs do not have enough experience with symptom management at the end of life [ 20]. When complications occur the patient is most likely to be transported to hospital. Institutes for long term patients, which do have physicians on the staff, are often under such budgetary pressures that they can’t afford for example appropriate analgesics (Slama O, unpublished presentation ^a).

Odds of dying at home are increased when home palliative care services are available [ 13]. There are only few palliative home care services available in the Czech Republic and none in Slovakia [ 21]. The reason for this might be the fact that palliative home care is still not recognized in the health care insurance law and hence the palliative home care services can’t access the governmental health care budget. Legislative issues are main barriers in the further development in both countries, with long term care (including hospice care) being especially challenging area where two sectors, health and social care, are involved and coordination of their policies is difficult [ 22– 24]. The housing situation in the Czech Republic and Slovakia is also an important factor which influences the potential care for a dying relative at home. Typical home environments currently available are either two bedroom flat in cities or larger family houses in the countryside which means that when children want to provide care for their elderly parents they have to struggle either with space limitations or availability of support services which are rarely provided in rural areas [ 24].

There was a contradictory effect of education found in the selected countries. In the Czech Republic, people with higher education were more likely to die from chronic conditions at home (OR 1.223) while in Slovakia this was less likely (OR 0.793). In other countries the effect between greater education and chance of dying at home is usually positive [ 6, 10, 25]. Possible explanation for the difference in Slovakia might be the trend of massive urbanization in 1970’s and 1980’s with higher educated people typically moving into small flats and consequently being less likely to access and provide informal care at their homes. However, recent trends show that older people with university education tend to move out of cities [ 26], so this association has to be further explored.

This study also has its limitations. Firstly, not all variables, relevant to predicting place of death were available [ 1, 25], for example socio-economic status or level of urbanization. Problems with cause of death coding in death certificates is another well-known issue [ 27, 28] and has been reported also from both selected countries [ 29, 30]. A specific complication is the coding of place of death. Apart from lacking an universally accepted coding system [ 1] the practice of completing this question in forms is not unified. One example of confused practice is when death in social care home is coded as death at home. This situation sometimes happens when the patient has the address of the care home registered as his or her home address. It is not known how often it is, but bias of up to several percentages is possible in the Czech Republic [ 31]. In Slovakia, this category is not available at all. Similar confusion can occur in coding deaths in institutes for long term patients, which are sometimes mixed with acute hospitals, especially when it was only a long term care ward within a larger hospital. Palliative care units or hospices are not included in either of Czech and Slovak certificates and the coding of hospice deaths is also not clear as hospices can be recognized either as social care homes or “other”.

Analysis of Czech and Slovak death certificates data pointed out several trends previously identified in other countries. More than half of the population dies in hospitals, although the preferred place of death is home for most people. Patients with cancer or heart failure have better chances to die at home than patients dying from other chronic conditions. Apart from cause of death, other sociodemographic variables like gender, age or education influence the place of death. Czech and Slovak patients who died from chronic conditions were more likely to die in hospital setting than patients in other countries. This finding should be taken into account by policy makers and potential changes in health care services delivery suggested, for example with regards of end-of-life care education for general practitioners or the role of nursing homes. Support for palliative care home teams could also improve the likelihood to balance the preferred and actual place of death. However, more research is needed to understand what are the motives for place of death preferences, what conditions at home would really meet people’s expectations, as well as to explore the complex system of influencing factors in more detail.

^aSlama O: Improving Access to Pain Medicines: the example of the Czech Republic. Presentation during 13th World Congress of the European Association for Palliative Care; Prague; 1st June, 2013.