Persistent socioeconomic inequalities in location of death and receipt of palliative care: A population-based cohort study.

Abstract

Providing equitable care to patients in need across the life course is a priority for many healthcare systems. To estimate socioeconomic inequality trends in the proportions of decedents that died in the community and that received palliative care within 30 days of death (including home visits and specialist/generalist physician encounters). Cohort study based on health administrative data. Socioeconomic position was measured by area-level material deprivation. Inequality gaps were quantified annually and longitudinally using the slope index of inequality (absolute gap) and relative index of inequality (relative gap). A total of 729,290 decedents aged ⩾18 years in Ontario, Canada from 2009 to 2016. In 2016, the modelled absolute gap (corresponding 95% confidence interval) between the most- and least-deprived neighbourhoods in community deaths was 4.0% (2.9-5.1%), which was 8.6% (6.2-10.9%) of the overall mean (46.6%). Relative to 2009, these inequalities declined modestly. Inequalities in 2016 were evident for palliative home visits (6.8% (5.8-7.8%) absolute gap, 26.3% (22.5-30.0%) relative gap) and for physician encounters (6.8% (5.7-7.9%) absolute gap, 13.2% (11.0-15.3%) relative gap), and widened from 2009 for physician encounters only on the absolute scale. Inequalities varied considerably across disease trajectories (organ failure, terminal illness, frailty, and sudden death). Key measures of end-of-life care are not achieved equally across socioeconomic groups. These data can be used to inform policy strategies to improve delivery of palliative and end-of-life services.