Date Published: April 23, 2019
Publisher: Public Library of Science
Author(s): Joanna M. Davies, Katherine E. Sleeman, Javiera Leniz, Rebecca Wilson, Irene J. Higginson, Julia Verne, Matthew Maddocks, Fliss E. M. Murtagh, Holly Gwen Prigerson
Abstract: BackgroundLow socioeconomic position (SEP) is recognized as a risk factor for worse health outcomes. How socioeconomic factors influence end-of-life care, and the magnitude of their effect, is not understood. This review aimed to synthesise and quantify the associations between measures of SEP and use of healthcare in the last year of life.Methods and findingsMEDLINE, EMBASE, PsycINFO, CINAHL, and ASSIA databases were searched without language restrictions from inception to 1 February 2019. We included empirical observational studies from high-income countries reporting an association between SEP (e.g., income, education, occupation, private medical insurance status, housing tenure, housing quality, or area-based deprivation) and place of death, plus use of acute care, specialist and nonspecialist end-of-life care, advance care planning, and quality of care in the last year of life. Methodological quality was evaluated using the Newcastle-Ottawa Quality Assessment Scale (NOS). The overall strength and direction of associations was summarised, and where sufficient comparable data were available, adjusted odds ratios (ORs) were pooled and dose-response meta-regression performed.A total of 209 studies were included (mean NOS quality score of 4.8); 112 high- to medium-quality observational studies were used in the meta-synthesis and meta-analysis (53.5% from North America, 31.0% from Europe, 8.5% from Australia, and 7.0% from Asia). Compared to people living in the least deprived neighbourhoods, people living in the most deprived neighbourhoods were more likely to die in hospital versus home (OR 1.30, 95% CI 1.23–1.38, p < 0.001), to receive acute hospital-based care in the last 3 months of life (OR 1.16, 95% CI 1.08–1.25, p < 0.001), and to not receive specialist palliative care (OR 1.13, 95% CI 1.07–1.19, p < 0.001). For every quintile increase in area deprivation, hospital versus home death was more likely (OR 1.07, 95% CI 1.05–1.08, p < 0.001), and not receiving specialist palliative care was more likely (OR 1.03, 95% CI 1.02–1.05, p < 0.001). Compared to the most educated (qualifications or years of education completed), the least educated people were more likely to not receive specialist palliative care (OR 1.26, 95% CI 1.07–1.49, p = 0.005).The observational nature of the studies included and the focus on high-income countries limit the conclusions of this review.ConclusionsIn high-income countries, low SEP is a risk factor for hospital death as well as other indicators of potentially poor-quality end-of-life care, with evidence of a dose response indicating that inequality persists across the social stratum. These findings should stimulate widespread efforts to reduce socioeconomic inequality towards the end of life.
Partial Text: Social inequality in health status, access to, and quality of healthcare is a global phenomenon . For example, in the United Kingdom, people living in the most deprived neighbourhoods (measured using the Index of Multiple Deprivation at Lower Layer Super Output Area Level) have a life expectancy up to 7 years shorter, and experience the onset of disease and disability as much as 17 years earlier, than people living in the least deprived neighbourhoods . Explanations for the social determinants of health emphasise the cumulative effect of events throughout the life course on health outcomes later in life . Structural (policy and culture), individual (material, behavioural, and psychosocial), and health-system factors all contribute to health inequality .
The protocol was registered (CRD42017055686) with PROSPERO, the international prospective register of systematic reviews , and the study was conducted and reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement (S1 PRISMA Checklist)  and MOOSE  guidelines for meta-analysis and systematic reviews of observational studies. Ethical approval was not required for this review.
A total of 682 full-text articles were screened for eligibility, of which 209 were included in the review (Fig 2).
This review finds consistent evidence that, in high-income countries, low SEP is associated with adverse healthcare outcomes towards the end of life, including increased odds of hospital versus home death, increased odds of using acute care services in the last 3 months of life, and reduced odds of receiving specialist palliative care in the last year of life. A dose-response association is evident between area deprivation and both place of death and receipt of specialist palliative care, which confirms that inequality persists across the social stratum. Evidence of social inequality in the use of nonspecialist end-of-life care and advance care planning is based on a smaller number of studies and is less conclusive but similarly suggests pro–high-SEP associations. Although awareness of the association between SEP and place of death is longstanding [7,29], this review is the first to synthesise international evidence on social inequality across several components of service use at the end of life.
We have found consistent evidence from high-income countries that low SEP is a risk factor across several components of service use at the end of life, including dying in hospital rather than at home, receiving acute hospital-based care in the last 3 months of life, and not receiving specialist palliative care in the last year of life. We also found evidence of a pervasive social gradient in place of death and use of specialist palliative care. These findings should stimulate widespread efforts to reduce socioeconomic inequality towards the end of life. We recommend that all research on care received towards the end of life should attempt to account for SEP, end-of-life care interventions should be analysed for their different effects across the social strata, and the planning and provision of end-of-life care services should consider SEP in local populations.