Association of socioeconomic status with medical assistance in dying: a case-control analysis

Abstract

Objectives: Economic constraints are a common explanation of why patients with low socioeconomic status tend to experience less access to medical care. We tested whether the decreased care extends to medical assistance in dying in a healthcare system with no direct economic constraints.

Design: Population-based case-control study of adults who died.

Setting: Ontario, Canada, between 1 June 2016 and 1 June 2019.

Patients: Patients receiving palliative care under universal insurance with no user fees.

Exposure: Patient's socioeconomic status identified using standardised quintiles.

Main outcome measure: Whether the patient received medical assistance in dying.

Results: A total of 50 096 palliative care patients died, of whom 920 received medical assistance in dying (cases) and 49 176 did not receive medical assistance in dying (controls). Medical assistance in dying was less frequent for patients with low socioeconomic status (166 of 11 008=1.5%) than for patients with high socioeconomic status (227 of 9277=2.4%). This equalled a 39% decreased odds of receiving medical assistance in dying associated with low socioeconomic status (OR=0.61, 95% CI 0.50 to 0.75, p<0.001). The relative decrease was evident across diverse patient groups and after adjusting for age, sex, home location, malignancy diagnosis, healthcare utilisation and overall frailty. The findings also replicated in a subgroup analysis that matched patients on responsible physician, a sensitivity analysis based on a different socioeconomic measure of low-income status and a confirmation study using a randomised survey design.

Conclusions: Patients with low socioeconomic status are less likely to receive medical assistance in dying under universal health insurance. An awareness of this imbalance may help in understanding patient decisions in less extreme clinical settings.

Keywords: adult palliative care; cancer pain; health policy; primary care; rationing.

Figure 1

Frequency of medical assistance in dying plot shows frequency of receiving medical assistance in dying among patients receiving palliative care who have different socioeconomic status. X-axis denotes quintiles of socioeconomic status spanning from lowest to highest. Y-axis denotes frequency of receiving medical assistance in dying. Solid circles indicate estimate and vertical bars indicate 95% CI. Square brackets denote total patients in each analysis. P value indicates trend. Results suggest gradient where patients with lowest socioeconomic status are less likely to receive medical assistance in dying than patients with highest socioeconomic status.

Figure 2

Consistent reductions across subgroups forest plot of relative frequency of receiving medical assistance in dying in different subgroups. Each analysis compares patients in lowest socioeconomic quintile to patients in highest socioeconomic quintile. Circles denote estimate and horizontal lines denote 95% CI. Vertical line shows perfect equity. Square brackets show count of patients in each subgroup. Summary analysis for total cohort positioned at top. Findings show generally reduced frequency of medical assistance in dying for patients with low socioeconomic status (exception subgroup of rural home location attributable to chance).

Figure 3

Perceptions of patient suffering plot shows mean ratings of patient suffering from survey of clinicians (n=494). X-axis denotes average of all adverse events and the four specific components (dripping faucet making noise, forgetting patient name despite being in hospital for days, failures of hand washing when entering room and worsening dyspnoea). Y-axis denotes mean ratings of patient suffering. red bars for survey describing a poor patient. Blue bars for survey describing a rich patient. Vertical beams denote standard errors. P values compare mean ratings of same adverse event. Results show significantly lower mean ratings of suffering in the poor version than rich version (exception of dyspnoea).