Dying at home for terminal cancer patients: differences by level of education and municipality of residence in Spain

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Original

article

Dying

at

home

for

terminal

cancer

patients:

differences

by

level

of

education

and

municipality

of

residence

in

Spain

Beatriz

G. López-Valcárcel,

Jaime

Pinilla

∗

,

Patricia

Barber

DepartmentofQuantitativeMethodsinEconomicsandManagement,UniversityofLasPalmasdeGranCanaria,LasPalmas,Spain

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received30January2018 Accepted10June2018

Availableonline1November2018

Keywords:

Palliativecare Death Neoplasms

Socioeconomicfactors Spain

a

b

s

t

r

a

c

t

Objective:Tomeasureandassessdifferencesbyeducationallevelintheplaceofdeathforcancerpatients, andtodeterminewhetherpatternsofgeographicaldisparitiesareassociatedwithaccesstopalliative careservicesinthemunicipalityofresidence.

Method: Weanalysed thedeath certificatesofadults(olderthan24) whodiedofcancer(ICD-10 C00toC97)inSpainduring2015,eitherathome,inhospitalorinalong-termcarecentre.Ofthe 105,758individualsincludedinthestudypopulation,75.2%livedinoneofthe746identifiable munic-ipalities(morethan10,000inhabitants).Thisindividualdatabasewascombinedwiththreeeconomic databasesatmunicipallevelandwithadirectoryofpalliativecareresourcespublishedbytheSociedad Espa˜noladeCuidadosPaliativos.Multilevelmodelswereestimatedtopredicttheplaceofdeath accord-ingtoindividualcharacteristics.Generalisedleastsquaresregressionmodelswerethenappliedtothe municipaleffectsestimatedinthefirststage.

Results:Theprobabilityofdyinginlong-termcarecentredecreasesaslevelsofeducationincrease;the probabilityofdyingathome,ratherthaninhospital,ishigherforpatientswithhighereducation.Dying inhospitalisanurbanphenomenon.TherearelargedifferencesbetweenSpanishregions.Accessto palliativeservicesisonlyofmarginalsignificanceinaccountingforthesystematicdifferencesobserved betweenmunicipalities.

Conclusions:Developingspecificplansforpalliativecare,withanactiverolebeingplayedbyprimary careteams,mayhelpimproveend-of-lifecareinSpain.

Morir

en

casa

pacientes

terminales

con

cáncer:

diferencias

por

nivel

de

educación

y

municipio

de

residencia

en

Espa ˜

na

Palabrasclave:

Cuidadospaliativos Muerte

Cáncer

Factoressocioeconómicos Espa˜na

r

e

s

u

m

e

n

Objetivo:Mediryevaluarlasdiferenciasporniveleducativorespectoallugardemuertedepacientescon cáncerenEspa˜na,ydeterminarsilospatronesdedesigualdadgeográficaestánasociadosconelaccesoa serviciosdecuidadospaliativosenelmunicipioderesidencia.

Método:Analizamosloscertificadosdedefuncióndemayoresde24añosquemurierondecáncer(CIE-10 C00-C97)enEspañadurante2015,enelhogar,enelhospitaloenunaresidenciasociosanitaria.Sobre unapoblacióntotalde105.758personas,el75,2%vivíaenunodelos746municipiosidentificables (másde10.000habitantes).Labasededatosindividualsecombinacondatoseconómicosdeámbito municipalyconeldirectorioderecursosdecuidadospaliativospublicadoporlaSociedadEspañolade CuidadosPaliativos.Seestimanmodelosmultinivelparapredecirellugardelamuertedeacuerdocon lascaracterísticasindividuales.Acontinuación,seestimanmodelosderegresiónpormínimoscuadrados generalizadossobrelosefectosmunicipalesestimadosenelmodeloanterior.

Resultados:Laprobabilidaddemorirencasa,frentealhospital,esmayorenlospacientesconeducación superior.Morirenelhospitalresultaunfenómenourbano.Haygrandesdiferenciasentreregiones.El accesoalosserviciospaliativossolotieneunaimportanciamarginalenlaexplicacióndelasdiferencias entremunicipios.

Conclusión:Eldesarrollodeplanesespecíficosparacuidadospaliativos,conunpapelmásactivodelos equiposdeatenciónprimaria,puedeayudaramejorarlaatenciónsanitariaalfinaldelavidaenEspa˜na. ©2018SESPAS.PublicadoporElsevierEspa˜na,S.L.U.Esteesunart´ıculoOpenAccessbajolalicencia CCBY-NC-ND(http://creativecommons.org/licenses/by-nc-nd/4.0/).

∗ _{Corresponding}_author.

E-mailaddress:[email protected](J.Pinilla). https://doi.org/10.1016/j.gaceta.2018.06.011

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B.G.López-Valcárceletal./GacSanit.2019;33(6):568–574

Introduction

Veryfewstudieshaveaddressedthequestionofthequalityof death,despitethefactthatthisis,andhasalwaysbeen,amajor concerntohumanity.1–3_When_an_incurable_disease_is_diagnosed,_as

wellastreatingthesymptomspresented,plansshouldbemadefor providinghealthcareintheterminalphase.Thereisevidencethat factorssuchasearlypalliativecareandthecontrolofsymptoms arestronglyassociatedwithabetterqualityofdeath.4

Itisknownthatmostpatientswithadvancedcancerpreferto dieathome.5–17_In_Europe,_according_to_a_random_sampling_study

ofthegeneralpopulationofsevencountries,8_more_than_half_would

prefertodieathome(inSpain,66%).Thereisnoevidencethatthe educationallevelofpatientswithterminalcancerisassociatedwith theirpreferencefortheplaceofdeath.Inthisrespect,preferences areassociatedwithotherfactors,suchasreligiousbeliefs,personal valuesorthedurationoftheillness.8

Nevertheless,themajorityofdeathsbycancerpatientsoccur inhospitals,9,10_where_the_quality_of_death_may_be_worse.11_Many

patientswhosedeathwasforeseeableonadmissiondieafter inva-sivediagnosticandtherapeuticactions,whilepsychological,social andfamilyneeds,whichcanbeasimportantasphysicalones,or evenmoreso,areignored.12

Therearethreemainplacesofdeath:athome,inhospitaland inalong-termcarecentre(LTCC).Amongthem,thedistributionof cancerdeathspresentslargevariationsbetweenandwithin coun-tries.AstudyconductedinsixEuropeancountriesreportedthat betterchancesofdying athomeare associatedwithsolid can-cers,beingmarried,highereducationalattainmentandlivingin lessurbanisedareas.10_Many_studies_have_identified_predictors_of

deathathome,ofwhichthemostinfluentialisthepresenceofan informalcaregiver.Inaddition,theaccessibilityofpalliativecare servicesinthecommunityataffordablecostisasignificant prog-nosticfactor,whichmightaccountforthelargedifferencesfound betweencountries.14_Access_to_community_palliative_services_is_not

homogeneousbysocioeconomicgroups:thus,ithasbeenreported

that “patientsin higher socioeconomicgroups wereboth more

likelytodieathomeandtoaccesshomecare”.15_Since_the_1980s,

thehighestfrequenciesofdeathsathomehavecorrespondedto patientswithhigherlevelsofeducation;16 _similar_findings_have

beenreportedinSpain.17_One_explanation_for_this_could_be_that

areaswithhighersocioeconomicstatushavemorepalliativecare servicesavailable.18–20_In_Italy,_the_territorial_differences_between

13provincesintheproportionsofdeathsathomepersistevenafter adjustingforindividualcharacteristicsandcontext,whichsuggests therearesystematicdifferencesinaccesstopalliativeservices.21,22

Spainprovidesaninterestingcasestudy.Ithasauniversal,

free-of-chargenational health system and an expanding specialised

networkofpalliativecare,followinganationalpalliativecare strat-egythathasbeenupdatedfortheperiod2010-2014.Accordingly, itmightbeexpectedthattherewouldbenomajorpersonalor ter-ritorialdifferencesinthequalityofdeathorsystematicdifferences intheplaceofdeathduetocancer,amongpatientsor municipal-ities.Butasamatteroffact,thedevelopmentofpalliativecare differssubstantiallybetweenregions.23,24_._The_Spanish_Society_for

PalliativeCare(SECPAL)producesastandardised,detailedrecord ofavailable infrastructure,humanandorganisationalresources, providing a basic sourceof information.24 _There_are _important

differencesbetweenautonomouscommunitiesinSpaininthe allo-cation,organisationandmanagementofpalliativecareresources.25

Someregionshavespecialplansforsocio-healthcareand/or pal-liativecare,followingtheguidelinesoftheNationalStrategyfor PalliativeCarethatwaslaunchednationallyin2006.Thatisthe caseofCatalonia,wherepalliativecareisintegratedinthe strat-egyofsocialandlongtermcare26_and_Basque_Country,_which_have

definedaplancoordinatingprimaryandspecializedresources.27

Palliativemedicineisnotamedicalspecialtyandthevariability amonghealthareasandregionsintheorganizationofend-of-life careisnoticeable,particularlyregardingtheroleofprimarycare versushospitalcare.

Themainstudyaimistoexamineindividualandterritorial vari-ationsinrelationtotheplaceofdeathduetocancerinSpain.To ourknowledge,nopreviousstudieshavebeenconductedtoanalyse territorialvariationsintheplaceofdeath(home,hospitalorLTCC) duetocancerusingpopulationdata,includingeducationamong individualdeterminants.

Methods

Studydesign,sourcesofinformationandvariables

This is a retrospective, cross-sectional, observational study. We usedthe nationwideregister ofdeathcertificatesissued in SpainduringtheperiodJanuarytoDecember2015.Thedataare structuredintwolevels:individual(level1)andthe municipal-ityofresidence(level2).Attheindividuallevel,weanalysedthe anonymiseddatafromthepopulationcauseofdeathregisterin Spainduring2015(NationalInstituteofStatistics).We included allpatientsolderthan25yearswhodiedofcancer(ICD-10codes C00toC97)ina statedplace(hospital,homeorLTCC)inSpain,

and lived in a municipality withmore than 10,000 population

(n=79,506).Theindividualdatabasecontainsthedetailedcause ofdeath(ICD-10),placeofdeath,educationallevel,sex,age, mari-talstatusandmunicipalityofresidence.Municipalitieswithfewer than10,000inhabitantswerecensoredtoguaranteeanonymity(it isonlyknownthatthedecedentlivedinasmallmunicipality,not inwhichone).Patientswhoseplaceofdeathwerenotstatedor wereotherthanthehome,ahospitaloraLTCCwerealsoexcluded (n=4964).Oftheremaining105,758individuals,79,506(75.2%) livedinanidentifiablemunicipality(ofover10,000inhabitants) amongthe746municipalitiescomprisingthoseincludedinlevel 2(seeFig.IintheAppendixonline).Themodelsareestimatedfor these79,506individuals.Theanalysisofrobustnessincludedall individualswhodiedofcancer,whetherornotthemunicipalityof

residencewasknown.

Theabove-mentionedregister ofdeaths wascombinedwith

threeeconomicdatabasesformunicipalitiesandafourthdatabase createdfromthedirectoryofpalliativecareresources.The

eco-nomic databaseswere obtainedfrom thefollowing sources: 1)

socialsecurityarchives:monthlydataofthenumberofaffiliates, averagedfortheyear,bytypeofaffiliation(agriculture,seeworkers, socialsecuritygeneralscheme);2)Taxagencyfiles:highlydetailed taxdata,includingincometax;3)MinistryofPublicAdministration files:detailedmunicipalbudgets.Thelattertwodatabasesexclude themunicipalitiesoftheBasqueCountry,whichhasaspecialfiscal regime.

Based on the2015 Directoryof Palliative CareResources in Spain,publishedbySECPAL,24_we_constructed_a_municipal_database

describingthephysical,humanandorganisationalresources avail-ablein themunicipality, includingpublicand privatefacilities: numberofunitsandpersonnel,bytype,ofpalliativecare, provid-ingservicesathome,inhospitaland/orinaLTCC.Thelocationand characteristicsofeachresourceorcareunitwererecorded.

Tomeasurethedifficultiesofaccesstopalliativecareathome, datafortraveltimewereobtainedfromtheGoogleMapsDistance MatrixApplicationProgramInterface(GoogleMapsAPI)usingthe R package googleway,28 _calculating _the _distance _in _travel _time

bycarfromtheheadquartersofthepalliativehome-carefacility closesttothecentreofthemunicipalityofresidenceofthedying patient.Alackofaccesstopalliativehome-careservicesisdefined asresidenceinamunicipalitywithoutpalliativehome-carewhen

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Table1

Univariatestatisticaldescriptionandfrequenciesofthevariablesinidentifiedandnon-identifiedmunicipalities.

Identifiedmunicipality (morethan10,000inhabitants)

Non-identifiedmunicipality (fewerthan10,000inhabitants)

Level1:individual N=79,506 N=26,252

Placeofdeath (dependentvariable)

LTCC 8.0% LTCC 8.7%

Hospital 66.4% Hospital 58.6%

Home 25.6% Home 32.7%

Ageinyearsatthemomentofdeath 73.7(13.0)a _75.7_(12.7)a

Nostudies(reference) 19.5% 27.6%

Primaryeduc./impompletesecondary 53.9% 59.6%

Secondaryeduc./vocationltrainig 11.8% 6.4%

Highervocationalanduniversitydegree 14.8% 6.3%

Maritalstatus:single(reference) 10.3% 12.4%

Married 57.1% 59.2%

Widowed 26.8% 28.7%

Divorced 5.8% 3.7%

Male(reference) 59.9% 63.3%

Female 40.1% 33.7%

Haematologicalcancer:dummy=1ifICD10isC81toC97 7.4% 7.5%

Level2:municipality N=746

PersonsaffiliatedtotheagriculturalSocialsecuritysystemasa percentageoftotalaffiliates

6.5%

Capital:dummy=1forprovincialorislandcapital 7.1%

Dummiesfortheautonomouscommunitieswithover40municipalities

Andalusia 20.6%

CanaryIslands 5.6%

Catalonia 16.0%

Valencia 13.1%

Galicia 7.5%

Madrid 6.6%

BasqueCountry 5.4%

Dummy=1ifthemunicipalityprovidespalliativeservicesin LTCCsb

10.7%

Dummy=1ifthemunicipalityprovidespalliativeservicesin hospitalsb

11.3%

Dummy=1ifthemunicipalityprovidespalliativeservicesin patients’homesb

13.5%

Dummy=1ifthemunicipalityprovidespalliativeservicesonlyin LTCCsb

0.3%

Dummy=1ifthemunicipalityprovidespalliativeservicesonlyin hospitalsb

2.3%

Dummy=1ifthereisnoaccesstohome-basedpalliativeservices lessthanonehour’sdriveawayb

6.8%

LTCC:long-termcarecentre.

a_Mean_and_(standard_deviation) b _Source:_SECPAL.24

thenearestresource,accordingtotheSECPALdirectory,ismore

than an hour’s drive away. The study variables are defined in

Table1.

Statisticalanalysis

Theeconometricanalysisconsistedoftwoseparate,sequential regressionmodels.Inthefirststageoftheanalysis,wecreated mul-tilevellinearprobabilitymodelstoestimatetheprobabilityofa persondyinginaLTCCvs.athomeorinhospital(model1,M1), dyinginhospitalvs.athomeorinaLTCC(model2,M2)anddying athomevs.inhospital(model3,M3):

Yij = X

′

ijˇ+j+εij (1)

Inequation[1]thedependentvariableYisadummy0/1variable identifyingtheplaceofdeath(=1forLTCCinM1,=1forhospital inM2and=1forhomeinM3)ofindividualilivinginmunicipality

j.M3excludesfromsamplethosepersonsdyingina LTCC.The individualexplanatoryvariables (X)arethepersonal character-isticsidentifiedintheliterature,age,sex,haematologicalcancer, educationallevel(infourordinalcategories, fromnostudiesto

highereducation)andmaritalstatus.Theerrorhastwo compo-nents,themunicipalityeffectj,whichrepresentsthedifferencein theprobabilityofdyingintheplacetaggedwithY=1betweenthe municipalityjandtheglobalsample,andtheindividualerror␧_ij,

whichisassumedtobeindependentofj.

An advantage of the probability model is its metric, since

it directly supplies the estimated average probability of a

patient dying at home for each municipality, which will be

used as the endogenous variable of the second regression.

TableIinAppendixonlinecontainstheresultofthemultinomial logisticregressionmodelfordyingathomeandinaLTCCwiththe mostfrequentcategory(hospital)asreference.

Frommodelsinequation[1]weestimatetheintra-group cor-relation,whichapproximatestheproportionoftheerrorvariance thatisattributabletothemunicipality.

The next step in the process is to calculate the posteriori Bayesianpredictorforeachmunicipality,ˆj(municipalityeffect) anditsestimatedstandarddeviation(sdmunicipalityeffect).

In the second stage of the analysis, the municipality effect is regressed against relevant socioeconomic characteristics of themunicipalityandvariablesforaccessibilitytopalliativecare

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services(equation[2]).Inaddition,fixedeffectsareincludedfor

theautonomouscommunitiesthatcontainmorethan40

munic-ipalitiesinthesample.Weuseweightedleastsquaresregression, defining the weights with the sdmunicipality effect estimated in stage 1. In the robustness analysis, the weights are defined alternatelywiththenumberofcancerdeathsinthemunicipality.

ˆ

j = Z

′

jı+uj (2)

Thestrategyintwostepsallowsustoseparatetheindividual factorsfromtheterritorialfactorsinfluencingtheplaceofdeath.

Asanadditionalproofofrobustness,we evaluatedthesame modelsfor2014andcomparedtheresults.

Results

Table1presentsthedescriptivestatisticsforthetotalnumber ofdeathsduetocancer,differentiatingaccordingtowhetherthe municipalityofresidenceisidentifiedornot.Italsodescribesthe municipalvariablesfinallyincludedinthemodels.

In large and medium-sized municipalities, 25.6% of deaths

causedbycancerdieathome,comparedto32.7%insmall munici-palities.Dyinginhospitalismorefrequentinmunicipalitiesofmore than10,000inhabitants(66.4%vs.58.6%),whiledyinginaLTCCis veryuncommoninSpain,theincidencebeingslightlyhigheramong residentsofsmallmunicipalities.Thereareotherdifferencesbysize ofplaceofresidence:decedentsinsmallmunicipalitiestendtobe older,thereisahigherproportionofmenandwidowersinthe pop-ulationandalowerproportionofresidentshavehighereducation qualifications.

Therearealsolargevariationsamongidentifiable municipali-tiesinthepercentageofcancerdeathsathome.Countingonlythe municipalitiesthatrecordedmorethan100deathsfromcancerin 2015,therawdatashowanenormousrangeofvariation,from6.7% to57.0%intheproportionofhomedeaths.DeathsinLTCCsrange from0%to33.1%ofthetotal,andthoseinhospital,from39.3%to 90.5%.

Themultilevelmodelswithindividualdataandmunicipality effectsclearlyshowthateducationisaverysignificant prognos-ticfactoroftheplaceofcancerdeath(Table2).Thus,whenthe patienthashighereducationqualifications,theprobabilityofdying athomevs.inhospitalisincreasedby0.047comparedwith individ-ualswithoutstudies.TheprobabilityofdyinginaLTCCdecreases monotonicallybyeducationlevel.Theotherexplanatoryvariables

areverysignificant,inparticularhaematologicalcancer,butalso sex andmaritalstatus, withtheexpected signs: femalehave a

higherprobabilitytodieathomethanmale asthemainstream

oftheliteraturefinds;thesamestandsformarriedpatients.Itis moreprobableforafemaletodieathomethanforamale(0.033).

Figure1representstheestimatedmunicipaleffectsbysizeof popu-lation(10,000-20,000,20,000-50,000,50,000-100,000,largerthan 100,000and capitalsofprovince irrespectivelytheirpopulation size).Themunicipaleffectsareverysignificantandrepresent8.6% oftheresidualvariancefordeathinLTCCs,6.23%fordeathathome and5.97%fordeathinhospital.Thatmeansthatsome characteris-ticsofthemunicipalityareinfluencingsystematicallytheplaceof deatheventhoughitmaybenotpossibletoidentifythose charac-teristicstoincludethemexplicitlyinthemodel.Themunicipality effectsaccountforthe“unobservedheterogeneity”among munic-ipalities.

Thesecond-stagemodels(Table3)findthatdyinginhospitalis morelikelyinprovincialorislandcapitalcities.Significanteffects, whichprovidethehigheststandardisedcoefficients,wererecorded forsomeofthe17autonomouscommunities;especially notewor-thywerethefactsthatdeathinaLTCCisassociatedwithCatalonia, deathinahospital,withMadridandtheCanaryIslands,anddeath athome,withAndalusiaandValencia.

Accordingtotheresultsofthemodels,theavailabilityof pallia-tivecareservicesisonlymarginallysignificant,butalwayswiththe expectedsigns:themoreavailabilityofhomeservices,thehigher theprobabilitytodieathome.DeathinaLTCCismorelikelyif pal-liativecareservicesareprovidedatLTCCsinthemunicipality,while deathathomeislesslikelyiftheonlypalliativeservicesavailable arehospital-based.Thelackofaccesstopalliativeservicesathome isnotsignificantinthemodel.

Therobustnesstestswithdatafor2014andidenticalmodels showsimilarresults.Themunicipaleffects obtainedin thefirst stageinbothyearsindependentlyshowalinearcorrelationofover 0.7inallcases(0.81,0.73and0.72formodels1,2and3 respec-tively).

Discussion

Accordingtoourresultstheplaceofdeathforpatientssuffering cancerisrelatedtothemunicipalityofresidence,educationand gender.Dyingofcancerinhospitalisanurbanphenomenonwhile homedeathsaremorefrequentinruralmunicipalities.

Table2

Estimationresults.Step1.Multilevellinearprobabilitymodelforplaceofdeathin2015.

Step1 Variables LTCC(M1)Coef.(SE) Hospital(M2)Coef.(SE) Home(M3)Coef.(SE)

Level1Individual variables

Age −0.0079(0.0006)a 0.0163(0.0011)a −0.0139(0.0011)a

Age2 0.0001(4.52e−06₎a −0.0002(7.95e−06₎a _0.0001_(7.99e−06₎a Primaryeduc. −0.0080(0.0026)a −0.0029(0.0045) 0.0075(0.0046) Second.educ. −0.0159(0.0036)a −0.0043(0.0063) 0.0174(0.0064)a Univ.degree −0.0261(0.0034)a −0.0255(0.0060)a 0.0474(0.0061)a Married −0.0987(0.0032)a 0.0448(0.0056)a 0.0258(0.0058)a Widowed −0.0673(0.0036)a 0.0379(0.0063)a 0.0097(0.0066) Divorced −0.0440(0.0048)a 0.0526(0.0085)a −0.0231(0.0086)a Female 0.0090(0.0020)a −0.0353(0.0035)a 0.0330(0.0035)a CancerHaemat. −0.0171(0.0035)a 0.1034(0.0061)a −0.0989(0.0061)a Constant 0.3011(0.0223)a _0.3620_(0.0391)a _0.5158_(0.0388)a

Randomeffectsparameters Estimate(SE)

Municipaleffectsvariance 0.0061(0.0004) 0.0127(0.0009) 0.0123(0.0009) Individualerrorvariance 0.0649(0.0003) 0.2007(0.0010) 0.1847(0.0010)

Intraclasscorrelation(%) 8.60% 5.97% 6.23%

N◦_._of_obs. _Level₁ _79,506 _79,506 _73,126

N◦_._of_groups _Level₂ ₇₄₆ ₇₄₆ ₇₄₆

LTCC:long-termcarecentre;SE:standarderror.

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0,25

0,20

0,15

0,10

0,05

0,00

-0.05

-0.10

-0.15

-0.20

-0.25

10,000-20,000 inhabitants 20,000-50,000 inhabitants 50,000-100,000 inhabitants More than-100,000 inhabitants

Elche

Gijón Algeciras

Barakaldo

Cartagena Alcalá de Henares

Vigo _{Dos Hermanas}

Parla Móstoles

Terrassa Badalona Telde

Getafe L'Hospitalet de Llobregat Torrejón de ardoz Leganés

Mataró Fuenlabrada Santa Coloma de Gramenet Reus

Alcorcón Alcobendas

Jerez de la Frontera

Sabadell San Cristóbal de la Laguna

Santa Cruz de Tenerife Soria

Palencia Palma Vitoria-Gasteiz Las Palmas de Gran Canaria

Salamanca Ciudad Real Bilbao

Zaragoza Sevilla Teruel Almería Jaén

Barcelona Guadalajara

Madrid

Avila

GironaBadajoz Huelva

León Pontevedra

Pamplona

Logroño Cádiz

Zomora

Sogovia Huesca Valladolid

Albacete

Rurgos Cáceres Alicante

Granada Ourense Castellón de la Plana Málaga

Lugo Oviedo Donostia-San Sebastián

Córdoba Coruña A Santander

Valencia Murcia

Tarragona LIeida Cuenca

Province capital N=68 municipalities

N=253 municipalities

N=27 municipalities N=50 municipalities

N=348 municipalities

Badia del Vallés Manlleu

Ponferrada Cangas del Narcea

Jávea

Motril

Marbella

Toledo

Figure1.MunicipalityeffectsestimatedwithmultilevelmodelM3dyingathomevs.inhospitalbysizeofmunicipality.Theaverageofallmunicipalitiesinsampleis0.In municipalitieswithpositivesigndyingathomeismorefrequentthanforaverage,inmunicipalitieswithnegativesigndyinginhospitalismorefrequentthanforaverage. Provincecapitalincludesallcapitalsirrespectiveoftheirpopulationsize.

Table3

Estimationresults.Step2.Modellingmunicipaleffectsin2015,weightedleastsquaresestimation.

Step2Variables LTCC(M1)Coef.(SE) Hospital(M2)Coef.(SE) Home(M3)Coef.(SE)

DummyforpalliativeserviceinLTCC 0.0196(0.0086)a −0.0165(0.0134) DummyforpalliativeserviceonlyinLTCC 0.0243(0.0421) 0.0057(0.0657)

Dummyforpalliativeserviceonlyinhospital 0.0737(0.0286)a −0.0620(0.0264)a Dummyfornoaccesstopalliativecareathome 0.0146(0.0144) −0.0114(0.0133) Socialsecurityaffiliatesinagriculture(%) −0.0005(0.0002)b 1.45e−06_(0.0003) _0.0003_(0.0003)

Andalusia −0.0125(0.0068)c −0.0178(0.0107) 0.0279(0.0099)b

Galicia −0.0248(0.0085)b −0.0058(0.0133) 0.0211(0.0123)c

Catalonia 0.0995(0.0065)b −0.0169(0.0119) −0.0475(0.0092)b

BasqueCountry −0.0078(0.0100) −0.0132(0.0157) 0.0186(0.0145)

Madrid 0.0053(0.0089) 0.0701(0.0140)b ₋_0.0781_(0.0129)b

Valencia −0.0156(0.0069)a −0.0625(0.0108)b 0.0759(0.0100)b

CanaryIslands −0.0346(0.0091)b 0.0852(0.0161)b −0.0689(0.0150)b

Dummyforcapitalofprovinceorisland −0.0025(0.0124) 0.0578(0.0194)b −0.582(0.0170)b

Constant −0.0046(0.0043) −0.0010(0.0068) 0.0049(0.0062)

R2 _0.4029 _0.1935 _0.2819

N 746 746 746

LTCC:long-termcarecentre;SE:standarderror.

Note:weightsdefinedbystandarddeviationofthemunicipaleffectsobtainedinstep1.

a_p_<0.05. b _p_<0.01. c _p_<0.1.

Malediemorefrequentlyinhospitals,womendoitathome.This resultisinaccordancewiththemainstreamoftheliterature,which systematicallyfindsahigherdiagnosticandtherapeuticintensity formale.29_Our_results_coincide_with_those_obtained_for_other

coun-tries,suchasFrance,30_on_the_influence_of_education_and_marital

statusontheplaceofdeath.Somestudiesconductedincountries wherethereisuniversalfree-of-chargeaccesstothepublichealth servicesuggestthatmorehighlyeducatedpatientsmayobtaina betterqualityofdeath,perhapsduetotheirgreatercompetencein navigatingthesystem.31,32_If_this_were_so,_there_could_be_a_need_for

measurestofacilitateaccesstothesystemandtoeliminate non-monetarybarriers.Thesebarriersmightbeduetothefactthatthe

homesofpeoplewithloweducationalleveldonotmeetthe mini-mumconditionstoreceivepalliativecareinthem.Ifthatisthecase, thebarriersmightbecounteractedbytheinterventionof social-healthliaisonofficers.Morehighlyeducatedpeoplemightobtain greateraccesstohome-basedpalliativecareattheendoflifeeither becausetheyresideinareaswithbetterprovision,orbecausethey arebetterequippedtonavigatethroughtheadministrativesystem orbecausetheconditionsoftheirhomesfacilitateit.Such inequali-tieswouldoccurevenwithinpublic,universal,freeofchargehealth systems.Thus,thebarriersarenotinstitutional.

The finding that dying of cancer in hospital is an urban

(6)

municipalitiesis robust. Boththeprovincial capital (and island capital)dummyvariableandthedummyforlargemunicipalities

(over 100,000 inhabitants), which are included in some tests,

arehighlysignificant.Ourmodelfindsthatthelackofaccessto palliativeservicesathomeisnotsignificantinthemodel.

Thisunexpectedresultmaybeduetothehighnumberof munic-ipalitieswithoutsuchaccessinaspecificregion(CanaryIslands), whichisalsoincludedasadummyinthemodel.Whenthisdummy isexcludedfromthemodel,thelackofaccessisverysignificantat 1%,withacoefficientof−0.045(resultnotshown).

Someautonomouscommunities,particularlyMadridandthe

CanaryIslands,haveextremelylowpercentagesofhomedeaths

comparedwithdeathsinhospitals.Thisfindingshouldbe inter-pretedwithcaution.WhileintheCanaryIslandsitcouldbedue tolackofaccesstopalliativeservicesathome,inMadriditcould beaconsequenceofhospital-centerednessderivedfroma hospi-talsupplythatissubstantiallygreaterthaninothersautonomous communities.Attheotherextreme,Valenciahasahigher preva-lenceofhomedeath,whichmaybeassociatedwithculturaland supplyfactors:itisthesecondregionintherankingofpalliative carestaffendowment(2.9doctorsper100,000inhabitantsvs.1.7 forSpainasawhole).

IneconomicallydepressedareasoftheUnitedKingdom, termi-nalcancerpatientshavealowerprobabilityofdyingathomethan inotherlocations.20_However,_our_study_found_no_evidence_that

theeconomiclevelofthemunicipalityinfluencestheprobability ofdyinginoneplaceoranother.Althoughweanalyseda compre-hensiveeconomicdatabaseofmunicipalinformation,includingtax bases,socialsecurityaffiliationdataanddetailedmunicipal bud-gets,theonlyclearconclusiontobedrawnisthatwecannotaffirm theexistenceofsuchanassociation.Asweuseddatafromexternal sourcesandtheyshowednosignificantresults,theyarenotshown inpaper.

Thisstudy,whichusescross-informationfromvarioussources, suchastheinvaluableDirectoryofPalliativeCareResources,isthe firsttoconductanin-depthexaminationwithpopulationdataon differencesintheplaceofdeathinSpain,anditprovidesvaluable informationforcancertreatmentplansandforpalliativecare.

However,ithaslimitations.Thefirstisthatsmallmunicipalities (fewerthan10,000inhabitants)hadtobeexcluded,forreasonsof anonymity.Secondly,thefactofdyingathomedoesnotnecessarily implyagooddeath,ifthedecedentfailedtorequestpalliativecare servicesfromtheprimarycarephysicianorfromspecialised pallia-tivecareservices.Thelackofrealmeasuresofthequalityofdeath isalimitationofthestudy.Anotherlimitationisthefactthatweare notabletoknowwhichresourceshavepublicorprivateownership orwhichresourcesareaccessibletopubliclyinsuredpatientswith nocharge.

Takingintoaccountthegreaterfrequencyofdeathsin hospi-talsthaninpatients’homes,andtheeaseofaccesstohospitals, atleastinurbanareas,itis tobeassumed thatalarge propor-tionofhomedeathsareaccompaniedbytheprovisionofpalliative

services.Ontheotherhand,somepatientsandfamilymembers

preferdeathtotakeplaceinthehospital,becausethisenvironment offersthereassurancethatunnecessarypainandsufferingwillbe avoided.33_In_the_autonomous_communities_in_Spain_there_are

dif-ferentlevelsofimplementationoftheadvancedirectives,which reportthepreferredplaceofdeath.Unfortunately,individualdata arenotavailableintheregistryofdeathcertificates.Anacutecare hospital,inmanycases,isnotthemostappropriateplaceinwhich todie.Inaddition,asignificantnumberofpatientsdieinthe emer-gencydepartment,wherestafffocusmoreontryingtoprolonglife thaninthepalliativeapproach(approximately20%ofin-hospital deathsoccurinthissituation).34,35

Developing specific plans for palliative care, with an active

rolebeingplayedbyprimarycareteams,mayhelpimprovethe

situation.Therefore, healthcarepoliciesshouldtakeaccountof theneedtoensureaccesstopalliativeservicesinthehome.Onthe otherhand,thereisanactivedebateonthecomplementaryversus substitutiveroleofprimarycareandhospitalcareintheoptimum palliativecare provision.Professional specializationinpalliative carelacksregulation.Specifictraining intheskillsforpalliative caremustbeapartofthecorecurriculumofallaccreditedtraining programsindifferentprofessions(physicians,nursesandothers).

Whatisknownaboutthetopic?

Abouttwo thirdof the Spanish populationprefer dying athome,butthemajorityofdeaths(52%)occurinhospital (aroundtwothirdsforcancerpatients).

Whatdoesthisstudyaddtotheliterature?

InSpain,therearelargeterritorialvariationsintheplaceof death(home,hospitalorlong-termcarecentreduetocancer, buttheexistanceofhomepalliativecareisnotaclearfactor. Dyinginhospitalisanurbanphenomenum,andhavinghigher educationincreasestheprobabilityofhomedeathwhiledeath atalong-termcarecentreismorefrequentasonedoesdown intheeducationallevel.Dyingofcancerinhospitalisanurban phenomenonwhilehomedeathsaremorefrequentinrural municipalities.

Editorincharge

DavidEpstein.

Transparencydeclaration

Thecorrespondingauthoronbehalfoftheotherauthors

guar-antee the accuracy, transparency and honesty of the data and

informationcontainedinthestudy,thatnorelevantinformation hasbeenomittedandthatalldiscrepanciesbetweenauthorshave beenadequatelyresolvedanddescribed.

Authorshipcontributions

B.G.López-Valcárcel,J.PinillaandP.Barberconceptualisedand designedthestudy.B.G.López-Valcárcel,J.Pinillaand P.Barber oversawdatacollectionandperformedthestatisticalanalysis.B.G. López-Valcárceldraftedthemanuscriptandallco-authors partici-patedequallyintherevisionandfinalapprovalofthemanuscript. B.G.López-Valcárcelistheguarantorforthestudy.Allauthorshad fullaccesstoallthedatainthestudy(includingstatisticalanalysis, tablesandfigures)andcantakeresponsibilityfortheintegrityof thedataandtheaccuracyofthedataitsanalysis.

Funding

Authorsgratefullyacknowledgethefinancialsupportreceived

fromtheECO2013-48217-C2-1-RprojectfundedbytheSpanish

StateProgrammeofR+D+I(http://invesfeps.ulpgc.es/en).

Conflictsofinterest

(7)

AppendixA. Supplementarydata

Supplementarydataassociatedwiththisarticlecanbefound,in theonlineversion,atdoi:10.1016/j.gaceta.2018.06.011.

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