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
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

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

by British Sociological Association on Dec 04, 2009

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