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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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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

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

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