Place of death for people who may benefit from palliative care: How does New Zealand compare in a multi-national population-level study?

Wayne Naylor, Hospice Waikato(on behalf of the End of Life Care Research Group)Hospice NZ Conference, November 2014

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International Place of Death Study (IPoD) Authors

Lara Pivodic, Koen Pardon, Lucas Morin, Julia Addington-Hall, Guido Miccinesi, Marylou Cardenas-Turanzas, Bregje Onwuteaka-Philipsen, Wayne Naylor, Miguel Ruiz Ramos, Lieve Van den Block, Donna Wilson, Martin Loucka, Agnes Csikos, Yong Joo Rhee, Joan Teno, Luc Deliens, Dirk Houttekier, Joachim Cohen

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Why does place of death matter?

Increasing number of people dying of chronic conditions

Patient preference to die at homeDeaths in hospital still high and increasing

◦ Avoidable admissions◦ Burdensome/aggressive treatments◦ High cost

Changing policies worldwide to focus on enabling death in community settings

Few cross-national comparisons of PoD3

Why does place of death matter?

Essential for planning, implementation and evaluation of policy decisions

Optimal allocation of health and social care resources

International benchmarkingReveal inequitiesProvide hypotheses about alternative

ways to provide EOLC

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Aim of the studyTo describe and compare place of death

for people who died of diseases indicative of palliative care need in 14 countries across four continents◦ to what extent place of death is associated

with socio-demographic characteristics, cause of death, and healthcare supply

◦ to what extent differences in these characteristics explain country-differences in place of death

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MethodPart of the IPoD Study27 countries approached14 countries provided anonymized individual death

certificate data for the full population of deaths during one year (2008)◦ Belgium ◦ New Zealand◦ England ◦ Spain (Andalusia, 2010)◦ Wales ◦ Canada◦ France ◦ Czech Republic◦ Italy ◦ Hungary◦ Mexico ◦ South Korea◦ Netherlands ◦ USA (2007)

Data collected during 2011-20136

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Variable Categories NZ data fields equivalent

PLACE OF DEATH      

Hospital Care home / long term care

institute/ residential care Home/private residence Hospice Other institute

(drug/alcohol/IHC facility) Other Unknown

Place of death category(as per Needs Assessment data set)     

AGE (continuous) exact age Age at death

SEX  

male female

Sex 

SOCIO-ECONOMIC-STATUS ??? NZ deprivation index decile

Underlying CAUSE OF DEATH In ICD-10 codes Underlying cause of death (Diagnosis type ‘D’)

MUNICIPALITY OF RESIDENCE Code TLA of domicile

MUNICIPALITY OF DEATH ZIP code TLA of domicileDHB of domicile

CITIZENSHIP/RACE/ETHNICITY New Zealand vs. other Ethnic group (prioritised at level 2)

INTERMEDIARY CAUSES OF DEATH

In ICD-10 codes Other contributing causes (Diagnosis type ‘G’)

IMMEDIATE CAUSE OF DEATH In ICD-10 codes (as above for underlying cause of death)

COMORBIDITIES In ICD-10 codes Other relevant diseases present (Diagnosis type ‘F’)

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Study PopulationAll deaths of persons aged 1 year and overThose who would benefit from palliative care

◦ Underlying cause of death corresponding to Minimal Estimate of the potential palliative care population (by ICD-10 code) (Rosenwax et al., 2005)

◦ Cancer ◦ Motor neurone disease

◦ Heart failure ◦ Parkinson’s disease◦ Renal failure ◦ Huntington’s disease◦ Liver failure ◦ Alzheimer’s disease◦ COPD ◦ HIV/AIDS

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Study data: dependent variable Place of death

◦ Home◦ Hospital◦ Long-term care facility◦ Other

Similar certification of deaths in all countries Death certificate data were linked with statistics on

density of hospital and long-term care beds, and GPs per health region

Hungary: hospital vs other Mexico: home vs hospital vs other

England, Wales, New Zealand, USA: additional category palliativecare institution

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Study data: independent variables

Socio-demographic◦age, sex, marital status

Clinical◦underlying cause of death

Residential◦degree of urbanization of region of residence

Healthcare supply◦density of hospital and long-term care beds

and GPs per region of residence

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ResultsTotal deaths N = 5,570,066Study population N = 2,330,843% of deaths in different settingsMultivariable binary logistic regressionHierarchical binary logistic regression analysis

with the dependent variable death at home vs in hospital◦ Model 1 - country◦ Model 2 - cause of death, age, gender, marital status◦ Model 3 - health care supply◦ Belgium as reference country

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Cause of death in total population (N = 5,568,827)

IT ES FR BE NL ENG WAL CZ HU NZ US CA KR MX0

10

20

30

40

50

60

31 29.4

13.2

0.7

5.9

8.9 17.21

Cancer Organ failureDiseases of the nervous system HIV/AIDS

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Population potentially benefitting from PC

Italy 41.9% Spain (Andalusia) 46.9% France 43.5% Belgium 43.5% Netherlands 48.8% England 41.5% Wales 41.2% Czech Republic 32.6% Hungary 38.8% New Zealand 44.3% USA 45.3% Canada 46.3% South Korea 37.6% Mexico 24.9%

Place of death (N = 2,220,997)

FR IT ES BE NL ENG WAL CZ HU NZ CA US MX KR0

10

20

30

40

50

60

70

80

90

100

25

28

85

35

33

1

2313

53

134

Home Hospital LTC setting PC institution

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Death at home in relation to cause of death (N = 2,220,997)

FR IT ES BE NL CZ ENG WAL NZ CA US MX KR0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Cancer Non-cancer Home death more likely if death from cancer (multivariable analysis controlling for sex, age, marital status, degree of urbanization, healthcare supply)

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Death at home in relation to age(N = 2,220,997)

FR IT ES BE NL CZ ENG WAL NZ CA US MX KR0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

≤69 70-79 ≥80 Home death more likely if <80 years (multivariable analysis controlling for sex, cause of death, marital status, degree of urbanization, healthcare supply)

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Factors associated with home death(N = 1,544,759) - Reference category: Belgium

0 0.5 1 1.5 2 2.5 3 3.5

KR

MX

US

CA

WAL

ENG

CZ

NL

ES

Series1 Series1

FR

IT Series1

OR model 1

OR model 2

OR model 3

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ConclusionsConsiderable differences in place of death

and factors associated with it between countries

Variations only partly explained by differences in independent variables

Indicate current settings for EOLCHighlight settings in need of evaluation of

availability and quality of PC and EOLCHigh number of hospital deaths in many

countries19

http://endoflifecare.be

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