Socioeconomic inequalities in the place of death in urban small areas of three Mediterranean cities

Interest in the study of decision-making regarding the place of death has increased in recent decades [1, 2]. Dying at home is the most frequent preference of patients with advanced chronic diseases [3‐6], their caregivers [4], and the general population [4], and so it has become an indicator of the quality of palliative care [7]. However, up until today, most deaths continue to occur in hospitals [6, 8].

Place of death predictors are traditionally grouped into three categories: disease-related factors, individual factors, and environmental factors [2]. Research on these predictors through death certificates has usually examined a country’s global information, or that of a region, a municipality, or a specific population subgroup in relation to individual factors such as age [6, 7, 9, 10], sex [6, 7, 9, 10], educational level [7, 11], marital status [6, 10], place of residence in the rural or urban context [6, 7] or the patient’s own preferences [2]. Similarly, the relationship with disease factors, like the diagnosis of the patient’s pathology [6‐8, 12‐14] and environmental factors such as the availability of family support and home care resources [15‐17], as well as other more generally related to or derived from local laws or health policies, has also been examined [6, 18].

In addition, recent studies have also explored the relationship between place of death and aggregate indicators of socioeconomic deprivation [11, 19] with the areas of greatest deprivation being those with the highest hospital mortality rates. Furthermore, various studies seem to indicate that social differences have a lesser effect on the place of death when measured at the individual level (for example, educational level) than when measured at the aggregate level (commonly by means of deprivation at the area level) [19]. In this regard, an adequate instrument to measure inequalities is a deprivation index (DI), like those used in the MEDEA and INEQ-CITIES studies on social inequalities and risk of death [20‐22], that combine a set of indicators such as the percentages of unemployed, temporary workers, low educational level of different population groups, or manual workers and allow classifying small geographic areas according to their level of socioeconomic deprivation [23].

In Spain, although some retrospective studies have included indicators of deprivation with respect to the place of death, they have only done so for some specific pathologies [24‐26]. No studies of the relationship between these indices of deprivation and place of death for general mortality and according to different causes of death have been carried out as far as this team is aware. Knowledge of these aspects, especially in urban settings, where the majority of the population in Europe and Spain concentrates, would allow the adoption of organizational and guidance measures for health services, particularly those related to palliative care and end-of-life care.

Therefore, the objective of this study was to analyse the socioeconomic inequalities in the place of death among the deaths in the large cities of the Valencian Community (Alicante, Castellón, and Valencia) during the period 2010–2015, using levels of deprivation by small areas of the cities, and also to assess if such inequalities are different depending on palliative (oncological, non-oncological) or non-palliative causes of death.

From 2010 to 2015, there were 67,521 deaths among the resident population in the cities under study, of which 67,200 (99.5% of the total) occurred in the population aged 15 or over. Of these, 876 (1.3%) could not be assigned to their census tract of residence due to the unavailability of a valid residence address or that it did not belong to the city. Of the 66,324 deaths, 60,748 occurred at home, hospital, or residential care facilities, and therefore they were used in the data analysis. Of these, 49,021 were related to CNPC.

The objective of this study was to analyse the socioeconomic inequalities in the place of death in the large cities of the Valencian Community (Alicante, Castellón, and Valencia) during the period 2010–2015, using levels of socioeconomic deprivation by small areas of the cities. A part of our aims was to assess if such inequalities were different depending on whether the deaths were due to conditions needing palliative care (oncological, non-oncological) or conditions not needing palliative care. The results have highlighted the existence of socioeconomic inequalities in the sense that greater deprivation would clearly increase the probability of death in hospital vs. home. This effect is not so evident in the case of death in a nursing home. There was no evidence to affirm that the estimated inequalities are different according to the different cause of death groupings. As in previous research [13], other sociodemographic variables such as country of birth, sex, age, marital status, or cause of death have also been associated with place of death.

Importantly, the Survey of Care for Patients with Terminal Illness shows that in 2009 the Spanish population (18+ years) preferred to be cared for at home (45.0%), followed by care in a specialized center (31.9%) and only 17.8% would choose a hospital in the case of irreversible disease in terminal phase [30]. This shows the high percentage of the population that prefers to end their days of life at home.

Regarding the excesses of deaths in hospital vs. home, significantly higher values ​​were observed in the most deprived CT, especially in respiratory disease, Alzheimer’s disease, malignant neoplasm, heart disease, and other non-palliative causes. In all cases, an association was observed between living in areas with greater deprivation and probability of dying in hospital, as indicated by previous studies [11, 19, 31, 32]. This is an important result since death at home is usually considered an indicator of the quality of palliative care services [3, 10]. The higher number of deaths in hospital may be related to the difficulty that people living in CT with higher deprivation have to access health resources, which might not reach these patients adequately [11]. Likewise, it is possible that, in line with what other authors suggest, people who live in a place with greater deprivation prefer to die in hospital as compared to home or residential care home [33, 34], as well as other contextual factors that might be at work, such as the difficult economic or labour situation associated with the places of greatest deprivation [19].

Another possible explanation for these results has to do with the care burden and social support to the caregivers. A lower socioeconomic level is associated with a greater burden of care, and a greater difficulty in receiving formal support. The burden of care has been associated, in many cases, with the need for help in daily life tasks, rather than with the specific symptoms presented by the patient [35]. This burden of care can make caregivers prefer to have their family members dying in hospital, where there are more resources and will receive more support to cope with the end of life.

In this regard, a recent qualitative study explored the relationships between social disparities and the burden of care in cancer patients and showed how the social determinants of health such as low income, low education, precarious housing conditions, rurality (associated with difficulty in the access to palliative care) or lack of social support could exacerbate the caregiver’s overload [36]. Likewise, social support is an important variable that can mediate and positively regulate the perceived care burden [37, 38]. Neergaard et al. identified in their review a series of variables related to social support such as living with other family members, having family support, being married, availability of space at home, the region of residence, as well as the caregiver’s sociodemographic variables (age, sex, and relationship with the patient) [19].

Regarding the diagnoses most associated with the different levels of deprivation, a very heterogeneous profile was found. This includes the three trajectories associated with the end-of-life process: advanced cancer (malignant neoplasm), advanced organ disease (heart and respiratory disease), and advanced dementia (Alzheimer’s dementia and senility) [39]. In addition to these CNPC, diagnoses for CnotPC were also significant, and deprivation seems to have an important role. This great variability in the diagnoses found is consistent with studies that indicate that the burden of care is similar among those diagnosed with an oncological process or in cases of diseases not related to cancer [35, 40].

Results regarding the risk of death in residential care home vs. home showed a more complex association pattern, with both high and low deprivation CTs showing an excess probability of death in residential care vs. home. An increase in the number of deaths in residential care facilities can be observed, related to the ongoing aging of the population, as well as an increase in pathologies such as dementia, which can mean that, regardless of the level of deprivation, many people end up dying in residential care homes. Also, the situation of nursing homes in Spain includes both public and private institutions, and so, regardless of the level of deprivation of a person’s CT, it is possible to move to them. In this regard, various studies in countries such as the United States have associated low socioeconomic status with access to poorer quality nursing homes [41, 42].

It is important to highlight that the progressive breakdown of the Spanish health system, in particular primary care and public health, due to the long period of austerity and privatizations (particularly in some regions) [43, 44], plus the overload of care resulting from budget cuts has had a serious impact on the quality of primary care [45]. The consequences of this deterioration have differentially affected the most deprived populations. This may explain why the hospital is the main place of death for many people living in more deprived places.

This work presents a series of limitations among which are those related to the use of data from the CMD-BED, since there may have been undetected errors in the diagnosis or during encoding and transcription. The CMD-BED was not modified during the study period. On the other hand, the CMD-BED in Spain includes a limited number of variables, so it was not possible to consider some of them individually, i.e. the employment situation or the type of work. Instead, the deprivation level variable included information on such variables, considered at the contextual level of the area of ​​residence, and thus, the excess probability of death in one or other locations according to the level of deprivation could reflect both the effect of the individual socioeconomic level as much as the contextual effect of the area of residence.

Another limitation comes from not having geo-referenced all deaths. Nevertheless, only a very small percentage (1.3%), lower than usual in this type of study, was not included. These losses should have had little effect on the results obtained.

It should be borne in mind that the classification in DL would not be the only possible one either. Nevertheless, it responds to the objective of preferentially evaluating the inequality existing between the population groups of greater and lesser deprivation, with consistent results across the different categories used.

Finally, this work did not include preferences about the place of death. Further research is needed to investigate the effect that deprivation may have on the congruence or incongruence between the place where a person wants to die and where death finally occurs.

The results of this study indicate that the probability of dying in hospital as compared to dying at home, increases as the socioeconomic deprivation of the urban area of ​​residence rises, and this generally happens either for any type of palliative death (oncological and non-oncological) or non-palliative. However, when comparing death in residential care vs. home it can be seen that the effect of the level of socioeconomic deprivation is very limited since only the areas of least socio-economic deprivation (the first level) are slightly associated with a lower probability of death in residential care. While socioeconomic differences in access to formal and informal care may explain the greater probability of death in hospital for people living in areas of greater deprivation, the way these factors influence death in residential care vs. home is largely unknown. Further qualitative research is required to explore the needs and preferences of low-income families who have a terminally-ill family member and, in particular, their attitudes towards home-based and hospital-based death.