International study of the place of death of people with cancer: a population-level comparison of 14 countries across 4 continents using death certificate data

Abstract

Background: Where people die can influence a number of indicators of the quality of dying. We aimed to describe the place of death of people with cancer and its associations with clinical, socio-demographic and healthcare supply characteristics in 14 countries.

Methods: Cross-sectional study using death certificate data for all deaths from cancer (ICD-10 codes C00-C97) in 2008 in Belgium, Canada, Czech Republic, England, France, Hungary, Italy, Mexico, the Netherlands, New Zealand, South Korea, Spain (2010), USA (2007) and Wales (N=1,355,910). Multivariable logistic regression analyses evaluated factors associated with home death within countries and differences across countries.

Results: Between 12% (South Korea) and 57% (Mexico) of cancer deaths occurred at home; between 26% (Netherlands, New Zealand) and 87% (South Korea) occurred in hospital. The large between-country differences in home or hospital deaths were partly explained by differences in availability of hospital- and long-term care beds and general practitioners. Haematologic rather than solid cancer (odds ratios (ORs) 1.29-3.17) and being married rather than divorced (ORs 1.17-2.54) were most consistently associated with home death across countries.

Conclusions: A large country variation in the place of death can partly be explained by countries' healthcare resources. Country-specific choices regarding the organisation of end-of-life cancer care likely explain an additional part. These findings indicate the further challenge to evaluate how different specific policies can influence place of death patterns.

Figure 1

Country differences (ORs) in home death (vs other), accounting for socio-demographic factors, cause of death and healthcare supply. Hierarchical binary logistic regression analyses with home vs all other places of death as dependent variable. France is the reference category in the independent variable country. Independent variables: Model 1: country (reference category: France); Model 2: additionally sex, age, cancer site (17 categories: head and neck; stomach; colon, rectum and anus; pancreas; other gastrointestinal; trachea, bronchus and lung; other respiratory; breast; cervix uteri, corpus uteri and ovary; prostate; urinary tract; other genitourinary; central nervous system; Non-Hodgkin's lymphoma; leukaemia; and other haematologic malignancies); Model 3: additionally number of hospital beds per 1000 inhabitants, long-term care beds per 1000 inhabitants, and general practitioners per 10 000 inhabitants in the region of residence. Comparing the three models allows evaluating whether certain variables explain part of the variation between countries. ORs getting closer to each other and closer to 1 when independent variables are added to the model means that part of the variation in place of death between countries is explained by these independent variables. For many countries this is particularly the case in Model 3, which indicates that the variables entered in Model 3 explain part of the variation (more than the ones entered in Model 2). Model 3 provides the ORs for home death of the different countries as compared with France in case the density of available health resources was the same as in France. In some countries (Spain, England and Wales) the larger ORs compared with France became smaller than 1, which suggests that if these countries had the same healthcare supply as in France the home death rate could be expected to be lower than in France. However, a large part of the variation between countries remained unexplained and thus needs to be attributed to other factors.