Understanding the Social Determinants of Outcomes Important to Older People Towards the End of Life
As our population ages, we face the challenge of how to care equitably for the increasing number of older people requiring end-of-life care. Socioeconomic inequality in health is a global phenomenon; people with lower socioeconomic position (lower wealth, less education or living in a more deprived area) tend to experience earlier onset of disease and have reduced life expectancy. In end-of-life care, there is growing recognition that low socioeconomic position is a risk factor for worse care, yet our understanding of how socioeconomic position influences the care received by older people towards the end of life is limited. This study investigates the social determinants of outcomes important to older people towards the end of life.
To investigate the association between socioeconomic position and the care received by older people towards the end of life, and explore potential mediating factors.
This study has three components (1 and 2 are complete, 3 is ongoing):
- Systematic review of studies from high income countries reporting an association between a measure of socioeconomic position (income, education, area-deprivation etc) and healthcare received by adults in their last year of life, including: place of death, acute care, specialist palliative care, non-specialist end-of-life care, advance care planning and quality of care. We pooled adjusted odds ratios (OR) and performed a dose-response meta-regression.
- Observational cohort study using secondary analysis of data from the English Longitudinal Study of Ageing (ELSA). We used a multiple mediation model to estimate the direct effect of socioeconomic position (measured by wealth and education) on death in hospital and three or more hospital admissions in the last 2 years of life, and the indirect effects of socioeconomic position via three mediators: health and function, access to health-care services, and social support.
- Retrospective cohort study using routinely collected clinical data on patients seen by Specialist Palliative Care (SPC) teams at King’s College Hospital (KCH) and Princess Royal University Hospital (PRUH), investigating the association between socioeconomic position (measured using area-based deprivation) and symptom profile on referral to palliative care, using the Integrated Palliative Care Outcome Scale (IPOS).
Summary of Findings
Our systematic review found that in high-income countries, low socioeconomic position 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.
Compared with people with the highest socioeconomic position, people with the lowest socioeconomic position were more likely to die in hospital than at home or in a hospice, to receive acute hospital-based care in the last 3 months of life, and to not receive specialist palliative care.
We found no studies that investigated mediating pathways to explain why people with lower socioeconomic position experience more hospital-based care towards the end of life.
Using data on a cohort of 737 deceased participants from the English Longitudinal Study of Ageing (ELSA), we investigated potential mediating pathways between socioeconomic position and receipt of hospital-based care towards the end of life.
For death in hospital, higher wealth had a direct negative effect, which was not mediated by any of the pathways tested. For frequent hospital admissions, health and function mediated the effect of wealth, accounting for 34·6% of the total negative effect of higher wealth.
Our findings suggest that worse health and function could partly explain why people with lower wealth have more hospital admissions, highlighting the importance of socioeconomically driven health differences in explaining patterns of hospital use towards the end of life.
Funding Body: Dunhill Medical Trust
Period: January 2017 - May 2021