<ul><li>End of life care: socio-economic status as a predictor of access to palliative care services </li></ul><ul><li>Cha...
Project Team <ul><li>Dr. Dai Roberts  Head of Research & Development, St. Ann’s Hospice, Cheadle, Cheshire </li></ul><ul><...
Palliative Care <ul><li>‘ An approach that improves the quality of life of patients and their families facing problems ass...
Aims <ul><ul><li>to prevent and relieve suffering by means of early identification  </li></ul></ul><ul><ul><li>to assess a...
Underpinning ethos <ul><li>affirms life and regards dying as a normal process </li></ul><ul><li>intends neither to hasten ...
Palliative Services <ul><li>Hospital  </li></ul><ul><li>Hospice    </li></ul><ul><li>Day Care  </li></ul><ul><li>Hospice a...
Unequal access <ul><li>Patients of low socio-economic status (SES) less likely to access; </li></ul><ul><ul><li>inpatient ...
Study site <ul><li>Study site (St.Ann’s Hospice) serves two Local Authorities of Greater Manchester </li></ul><ul><li>Inde...
Research aims <ul><li>Why? </li></ul><ul><li>To explore the relationship between socio-economic status and other demograph...
Research Design <ul><li>Population level study  </li></ul><ul><li>1.  To compare Salford and Trafford on; </li></ul><ul><l...
Data sources <ul><li>Secondary data analysis </li></ul><ul><li>UK National Census data 2001: socio-economic indicators of ...
SES Indicators <ul><li>Demographics:  age, ethnicity </li></ul><ul><li>Education:  none, secondary, tertiary </li></ul><ul...
Data analysis <ul><li>Salford & Trafford comparisons: T-tests & Mann-Whitney U for skewed distributions </li></ul><ul><li>...
Results: Part 1 <ul><li>Statistically significant differences (p<0.05) </li></ul><ul><li>Compared to Trafford, Salford war...
Results: Part 1 <ul><li>Compared to Salford, Trafford wards:  lower </li></ul><ul><li>cancer mortality (2004, 526 rate 25)...
Referrals to Hospice at Home Table 1. Referrals to Hospice at Home; number (rate per 10,000 of LA) 2004 2005 2006 Total Sa...
Referrals: Part 1 <ul><li>Referral rates not significantly associated with cancer mortality  </li></ul><ul><li>( B  =0.03,...
Results: Part 2 <ul><li>13/18 indicator variables strongly associated with referral rate p<0.001 or showed a significant m...
Results: Part 2 <ul><li>General pattern of results indicates an inverse relationship between referrals and deprivation at ...
Conclusion <ul><li>Poorer access to specialist palliative care is associated with deprivation at the population level </li...
Conclusion <ul><li>Implications for allocation and distribution of resources </li></ul><ul><li>‘ up to twice the resources...
Conclusion <ul><li>Persistence of disadvantage as an issue in end-of-life care </li></ul><ul><li>‘ Class’ in health scienc...
Further interest <ul><li>Forthcoming publication; </li></ul><ul><li>Campbell, M. Grande, G. Wilson, C. Caress, A-L. Robert...
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End of life care: socio-economic status as a predictor of access to palliative care services by Charlotte Wilson

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Charlotte Wilson's presentation from British Sociological Association Death, Dying and Bereavement Symposium - November 2009

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End of life care: socio-economic status as a predictor of access to palliative care services by Charlotte Wilson

  1. 1. <ul><li>End of life care: socio-economic status as a predictor of access to palliative care services </li></ul><ul><li>Charlotte Wilson </li></ul><ul><li>Research Associate </li></ul>
  2. 2. Project Team <ul><li>Dr. Dai Roberts Head of Research & Development, St. Ann’s Hospice, Cheadle, Cheshire </li></ul><ul><li>Dr. Gunn Grande Reader, School of Nursing Midwifery & Social Work </li></ul><ul><li>Dr. Malcolm Campbell Senior Lecturer, School of Nursing Midwifery & Social Work </li></ul><ul><li>Professor Ann-Louise Caress Senior Lecturer , School of Nursing Midwifery & Social Work </li></ul><ul><li>Funded by The British Academy </li></ul>
  3. 3. Palliative Care <ul><li>‘ An approach that improves the quality of life of patients and their families facing problems associated with life-threatening illness’ </li></ul><ul><li> World Health Organisation </li></ul>
  4. 4. Aims <ul><ul><li>to prevent and relieve suffering by means of early identification </li></ul></ul><ul><ul><li>to assess and treat physical, psychosocial and spiritual problems </li></ul></ul>
  5. 5. Underpinning ethos <ul><li>affirms life and regards dying as a normal process </li></ul><ul><li>intends neither to hasten or postpone death </li></ul><ul><li>holistic approach </li></ul>
  6. 6. Palliative Services <ul><li>Hospital </li></ul><ul><li>Hospice </li></ul><ul><li>Day Care </li></ul><ul><li>Hospice at home </li></ul>
  7. 7. Unequal access <ul><li>Patients of low socio-economic status (SES) less likely to access; </li></ul><ul><ul><li>inpatient hospice care </li></ul></ul><ul><ul><li>specialist palliative care </li></ul></ul><ul><ul><li>palliative home care </li></ul></ul><ul><li>(Sources: Addington-Hall & Altmann, 2000; Lammi 2001, Costantini et.al. 1993 Grande et.al. 1998, 2002, Walshe et.al. 2009) </li></ul>
  8. 8. Study site <ul><li>Study site (St.Ann’s Hospice) serves two Local Authorities of Greater Manchester </li></ul><ul><li>Index Multiple Deprivation </li></ul><ul><li>(National Census, 2001) </li></ul><ul><li>Salford : 20 wards 43.7 </li></ul><ul><li>b) Trafford : 21 wards 21.0 </li></ul><ul><li>Similar pattern across Greater Manchester & UK </li></ul><ul><li>Manchester State of the City Report 2007; Joseph Rowntree Foundation 2007 </li></ul>
  9. 9. Research aims <ul><li>Why? </li></ul><ul><li>To explore the relationship between socio-economic status and other demographic indicators on access to hospice at home services </li></ul><ul><li>To test the ‘inverse care law’: Is differential access attributable to poorer service availability in deprived areas or due to an actual referral or uptake bias affecting disadvantaged groups? </li></ul>
  10. 10. Research Design <ul><li>Population level study </li></ul><ul><li>1. To compare Salford and Trafford on; </li></ul><ul><li>socio-economic indicators </li></ul><ul><li>cancer mortality </li></ul><ul><li>referral rates </li></ul><ul><li>2. To investigate the relationships between socio-economic indicators and referrals at ward level, controlling for cancer mortality </li></ul>
  11. 11. Data sources <ul><li>Secondary data analysis </li></ul><ul><li>UK National Census data 2001: socio-economic indicators of ward characteristics </li></ul><ul><li>Hospice service referral data 2004-6; patients’ postcodes matched to ward level </li></ul><ul><li>Cancer Registry data 2004; cancer mortality data as an indicator of palliative care need </li></ul>
  12. 12. SES Indicators <ul><li>Demographics: age, ethnicity </li></ul><ul><li>Education: none, secondary, tertiary </li></ul><ul><li>Adults in household: number, with / without children </li></ul><ul><li>Household Tenure: owner-occupied / rented / private </li></ul><ul><li>Approximated Social Grade: managerial-professional / skilled-unskilled / lowest grade –unemployed </li></ul><ul><li>Deprivation / economic activity: IMD, Income Domain; economically active persons </li></ul>
  13. 13. Data analysis <ul><li>Salford & Trafford comparisons: T-tests & Mann-Whitney U for skewed distributions </li></ul><ul><li>Relationships at ward level: Multiple linear regression controlling for; </li></ul><ul><li>interactions </li></ul><ul><li>local authority effect </li></ul><ul><li>multi-collinearity </li></ul><ul><li>Negative binomial regression & Poisson regression </li></ul>
  14. 14. Results: Part 1 <ul><li>Statistically significant differences (p<0.05) </li></ul><ul><li>Compared to Trafford, Salford wards: higher </li></ul><ul><li>cancer mortality (2004; 643, rate 30) </li></ul><ul><li>(IMD) global deprivation </li></ul><ul><li>(IDS) income deprivation </li></ul><ul><li>social / council rented households </li></ul><ul><li>lower </li></ul><ul><li>economically active persons </li></ul><ul><li>owner occupier households </li></ul>
  15. 15. Results: Part 1 <ul><li>Compared to Salford, Trafford wards: lower </li></ul><ul><li>cancer mortality (2004, 526 rate 25) </li></ul><ul><li>global and income deprivation </li></ul><ul><li>qualifications: none </li></ul><ul><li>manual and lower grade occupations </li></ul><ul><li>higher </li></ul><ul><li>economically active </li></ul><ul><li>highest level of qualifications </li></ul><ul><li>household reference: non-manual </li></ul>
  16. 16. Referrals to Hospice at Home Table 1. Referrals to Hospice at Home; number (rate per 10,000 of LA) 2004 2005 2006 Total Salford Trafford 85 (3.9) 98 (4.6) 106 (4.9) 151 (7.1) 106 (4.9) 151 (7.1) 297 400 Source: St. Ann’s Hospice 2007
  17. 17. Referrals: Part 1 <ul><li>Referral rates not significantly associated with cancer mortality </li></ul><ul><li>( B =0.03, 95% CI=-.002 to -0.07, p=0.239) </li></ul><ul><li>Referral rate was significantly associated with local authority </li></ul><ul><li>( B =2.06, 95% CI=0.91 to 3.20, p=0.001) </li></ul>
  18. 18. Results: Part 2 <ul><li>13/18 indicator variables strongly associated with referral rate p<0.001 or showed a significant main effect p <0.05 </li></ul><ul><li>For example </li></ul>Indicator Coeff. 95% CI P IMD -0.06 -0.08 to -0.04 <0.001 IDS (Income) -0.08 -0.12 to -0.05 <0.001 Econ. active 0.14 0.07 to 0.20 <0.001 ASG lowest -0.21 -0.31 to -0.11 <0.001 ASG highest 0.08 0.04 to 0.12 <0.001 House: owner 0.06 0.03 to 0.08 <0.001 House: social -0.07 -0.10 to 0.03 <0.001 Education: none -0.12 -0.18 to -0.06 <0.001
  19. 19. Results: Part 2 <ul><li>General pattern of results indicates an inverse relationship between referrals and deprivation at ward level </li></ul><ul><li>Inequalities of referral strongly related to both global deprivation and discrete deprivation indicators </li></ul>
  20. 20. Conclusion <ul><li>Poorer access to specialist palliative care is associated with deprivation at the population level </li></ul><ul><li>SES rather than cancer mortality predicts referrals to hospice at home </li></ul><ul><li>SES rather than service provision predicts referrals to hospice at home </li></ul>
  21. 21. Conclusion <ul><li>Implications for allocation and distribution of resources </li></ul><ul><li>‘ up to twice the resources are needed to support patients at home in areas of acute deprivation compared with the most affluent areas’ </li></ul><ul><li>(Palliative Care Survey, 1999;5) </li></ul>
  22. 22. Conclusion <ul><li>Persistence of disadvantage as an issue in end-of-life care </li></ul><ul><li>‘ Class’ in health science research </li></ul><ul><li>Principle of equitable access </li></ul>
  23. 23. Further interest <ul><li>Forthcoming publication; </li></ul><ul><li>Campbell, M. Grande, G. Wilson, C. Caress, A-L. Roberts, D. 2009 Exploring differences in referrals to a Hospice at Home Service in two socio-economically distinct areas of Manchester, UK. Palliative Medicine . </li></ul><ul><li>Contact details; </li></ul><ul><li>Charlotte Wilson: [email_address] </li></ul><ul><li>Tel. 0161 3067887 </li></ul><ul><li>Gunn Grande: [email_address] </li></ul><ul><li>Tel. 0161 3067695 </li></ul>

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