Socioeconomic position and use of healthcare in the last year of life: A systematic review and meta-analysis

Background Low socioeconomic position (SEP) is recognized as a risk factor for worse health outcomes. How socioeconomic factors influence end-of-life care, and the magnitude of their effect, is not understood. This review aimed to synthesise and quantify the associations between measures of SEP and use of healthcare in the last year of life. Methods and findings MEDLINE, EMBASE, PsycINFO, CINAHL, and ASSIA databases were searched without language restrictions from inception to 1 February 2019. We included empirical observational studies from high-income countries reporting an association between SEP (e.g., income, education, occupation, private medical insurance status, housing tenure, housing quality, or area-based deprivation) and place of death, plus use of acute care, specialist and nonspecialist end-of-life care, advance care planning, and quality of care in the last year of life. Methodological quality was evaluated using the Newcastle-Ottawa Quality Assessment Scale (NOS). The overall strength and direction of associations was summarised, and where sufficient comparable data were available, adjusted odds ratios (ORs) were pooled and dose-response meta-regression performed. A total of 209 studies were included (mean NOS quality score of 4.8); 112 high- to medium-quality observational studies were used in the meta-synthesis and meta-analysis (53.5% from North America, 31.0% from Europe, 8.5% from Australia, and 7.0% from Asia). Compared to people living in the least deprived neighbourhoods, people living in the most deprived neighbourhoods were more likely to die in hospital versus home (OR 1.30, 95% CI 1.23–1.38, p < 0.001), to receive acute hospital-based care in the last 3 months of life (OR 1.16, 95% CI 1.08–1.25, p < 0.001), and to not receive specialist palliative care (OR 1.13, 95% CI 1.07–1.19, p < 0.001). For every quintile increase in area deprivation, hospital versus home death was more likely (OR 1.07, 95% CI 1.05–1.08, p < 0.001), and not receiving specialist palliative care was more likely (OR 1.03, 95% CI 1.02–1.05, p < 0.001). Compared to the most educated (qualifications or years of education completed), the least educated people were more likely to not receive specialist palliative care (OR 1.26, 95% CI 1.07–1.49, p = 0.005). The observational nature of the studies included and the focus on high-income countries limit the conclusions of this review. Conclusions In high-income countries, low SEP 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. These findings should stimulate widespread efforts to reduce socioeconomic inequality towards the end of life. Author summary Why was this study done? Social inequality in health is a global phenomenon; people with lower socioeconomic position (SEP) experience earlier onset of disease and have reduced life expectancy. Studies have identified low SEP as a risk factor for worse care at the end of life, and several socioeconomic factors have been identified as determinants of care towards the end of life. Despite growing recognition, no empirical synthesis of evidence exists to support efforts to reduce socioeconomic inequality at the end of life. What did the researchers do and find? We carried out a systematic review of studies that reported an association between a measure of SEP (including income, education, occupation, private medical insurance status, housing tenure, housing quality, or area-based deprivation) and healthcare received by adults in their last year of life (including place of death, use of acute care, use of specialist palliative care, use of nonspecialist end-of-life care, use of advance care planning, or quality of care) in high-income countries. A total of 209 studies were included in the review; we found consistent evidence that low SEP increases the odds of hospital versus home death and of using acute care services in the last 3 months of life and reduces the odds of using specialist palliative care in the last year of life. We also found that measurement of SEP in this field is dominated by measures of area deprivation and education, and justification for choice of SEP measure(s) is often inadequately described. What do these findings mean? We have found consistent evidence of socioeconomic inequality in the care received by people towards the end of life, in that people with lower SEP are more likely to experience worse care. We must now make further efforts to reduce this inequality. We recommend the following: that all research on care received towards the end of life should attempt to account for SEP, end-of-life care interventions should be analysed for their different effects across the social strata, and the planning and provision of end-of-life care services should consider SEP in local populations.