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

Background: Providing equitable care to patients in need across the life course is a priority for many healthcare systems.

Aim: 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).

Design: 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).

Setting/participants: A total of 729,290 decedents aged ⩾18 years in Ontario, Canada from 2009 to 2016.

Results: 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).

Conclusion: 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.