How is place of death for cancer patients changing and what affects it?

UKACR Conference

September 28th 2004

Elizabeth DaviesKaren Linklater

Ruth JackLaura Clark

Henrik Møller

Why study place of death?

• Symptom control and place of death matter to patients and their relatives

• Research reviews find 50-70% of seriously ill patients would prefer to be cared for at home

• 30-year growth of the hospice and palliative care movement with public support

Is this important for policy and planning?

United Kingdom • 2003 NICE Supportive and Palliative Care for Adults with Cancer • 2004 House of Commons Health Committee Palliative CareEurope• 2004 WHO – Palliative Care – The Solid Facts• 2004 WHO Better Palliative Care for Older PeopleUSA• 2004 Forthcoming National Institutes of Health State of the Science on

improving end of life care

Percentage of home cancer deaths in English regions1985-1994 (all ages)

Higginson et al, Palliative Medicine 1998;12:353-363

Objectives

• To describe trends for place of death for four most common cancers between 1985 and 2002 in our area

• To test associations with case mix variables:

age

sex

cancer site (lung, breast, colorectal and prostate)

basis of diagnosis (clinical or microscopic)

• To explore association with income deprivation

Methods

Analysis of 216,404 cases• Residents diagnosed and dying between 1985 and 2002• In our area• Not notified by death certificate only• Recorded as dying from their cancerOutcome• Death in acute hospitals, at home, in hospices or nursing

homes• Modelled logistic regression, adjusted for case mix

variables

0%

10%

20%

30%

40%

50%

60%

70%

80%

1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

Year of death

Acute

Home

Hospice

Nursing home

Adjusted for case mix (age group, sex, basis of diagnosis, site)

Trends for place of death in south east England 1985-2002

0%

10%

20%

30%

40%

50%

60%

<65 65-74 75-84 85+

Age group

Acute

Home

Hospice

Nursing home

Adjusted for case mix (sex, basis of diagnosis, site)

Age of patient and place of death from cancer in SE England 1985-2002

Income deprivation and place of death in SE England 1985-2002

0%

10%

20%

30%

40%

50%

60%

1 2 3 4 5

IMD income quintile

Acute

Home

Hospice

Nursing home

Adjusted for case mix (age group, sex, basis of diagnosis, site)

Implications

• Cancer patients remain more likely to die in hospital• Recent decline in home death needs investigation• Does death in a nursing home count as “home death”? • By what mechanism does deprivation affect hospital and

home death?Next steps• Develop models exploring disease stage at diagnosis and

length of survival • Relate to palliative care service availability over time in

network areas