Is the level of education associated with transitions between care settings in older adults near the end of life? A nationwide,retrospective cohort study

Abstract

Background:

End-of-life transitions between care settings can be burdensome for older adults and their relatives.

Aim:

To analyze the association between the level of education of older adults and their likelihood to experience care transitions during the final months before death.

Design:

Nationwide, retrospective cohort study using register data.

Setting/participants:

Older adults (⩾65 years) who died in Sweden in 2013 (n = 75,722). Place of death was the primary outcome. Institutionalization and multiple hospital admissions during the final months of life were defined as secondary outcomes. The decedents’ level of education (primary, secondary, or tertiary education) was considered as the main exposure. Multivariable analyses were stratified by living arrangement and adjusted for sex, age at time of death, illness trajectory, and number of chronic diseases.

Results:

Among community-dwellers, older adults with tertiary education were more likely to die in hospitals than those with primary education (55.6% vs 49.9%; odds ratio (OR) = 1.21, 95% confidence interval (CI) = 1.14–1.28), but less likely to be institutionalized during the final month before death (OR = 0.83, 95% CI = 0.76–0.91). Decedents with higher education had greater odds of remaining hospitalized continuously during their final 2 weeks of life (OR = 1.12, 95% CI = 1.02–1.22). Among older adults living in nursing homes, we found no association between the decedents’ level of education and their likelihood to be hospitalized or to die in hospitals.

Conclusion:

Compared with those who completed only primary education, individuals with higher educational attainment were more likely to live at home until the end of life, but also more likely to be hospitalized and die in hospitals.

Keywords

Education social inequalities elderly end of life place of death

Get full access to this article

View all access options for this article.

References

Gomes

Calanzani

Gysels

et al

Heterogeneity and changes in preferences for dying at home: a systematic review. BMC Palliat Care 2013; 12(1): 7.

Wang

Aldridge

Gross

et al

End-of-life care transition patterns of Medicare beneficiaries. J Am Geriatr Soc 2017; 65: 1406–1413.

Van den Block

Pivodic

Pardon

et al

Transitions between health care settings in the final three months of life in four EU countries. Eur J Public Health 2015; 25(4): 569–575.

Pennec

Gaymu

Morand

et al

Trajectories of care home residents during the last month of life: the case of France. Ageing Soc 2017; 37(2): 325–351.

Penders

Van den Block

Donker

et al

Comparison of end-of-life care for older people living at home and in residential homes: a mortality follow-back study among GPs in the Netherlands. Br J Gen Pract 2015; 65(640): e724–e730.

Aaltonen

Raitanen

Forma

et al

Burdensome transitions at the end of life among long-term care residents with dementia. J Am Med Dir Assoc 2014; 15(9): 643–648.

Abarshi

Echteld

Van den Block

et al

Transitions between care settings at the end of life in the Netherlands: results from a nationwide study. Palliat Med 2010; 24(2): 166–174.

Gozalo

Teno

Mitchell

et al

End-of-life transitions among nursing home residents with cognitive issues. N Engl J Med 2011; 365(13): 1212–1221.

Wang

Aldridge

Gross

et al

Transitions between healthcare settings of hospice enrollees at the end of life. J Am Geriatr Soc 2016; 64(2): 314–322.

10.

Hanratty

Lowson

Grande

et al

Transitions at the end of life for older adults—patient, carer and professional perspectives: a mixed-methods study. Heal Serv Deliv Res 2014; 2(17): 1–102.

11.

Hedinger

Braun

Zellweger

et al

Moving to and dying in a nursing home depends not only on health: an analysis of socio-demographic determinants of place of death in Switzerland. PLoS One 2014; 9(11): e113236.

12.

Sleeman

Verne

et al

Reversal of English trend towards hospital death in dementia: a population-based study of place of death and associated individual and regional factors, 2001–2010. BMC Neurol 2014; 14(1): 59.

13.

Cohen

Pivodic

Miccinesi

et al

International study of the place of death of people with cancer: a population-level comparison of 14 countries across 4 continents using death certificate data. Br J Cancer 2015; 113(9): 1397–1404.

14.

Black

Waugh

Munoz-Arroyo

et al

Predictors of place of death in South West Scotland 2000-2010: retrospective cohort study. Palliat Med 2016; 30(8): 764–771.

15.

Pivodic

Pardon

Morin

et al

Place of death in the population dying from diseases indicative of palliative care need: a cross-national population-level study in 14 countries. J Epidemiol Community Health 2016; 70(1): 17–24.

16.

Houttekier

Cohen

Bilsen

et al

Place of death in metropolitan regions: metropolitan versus non-metropolitan variation in place of death in Belgium, The Netherlands and England. Health Place 2010; 16(1): 132–139.

17.

Pocock

Ives

Pring

et al

Factors associated with hospital deaths in the oldest old: a cross-sectional study. Age Ageing 2016; 45(3): 372–376.

18.

Håkanson

Öhlén

Morin

et al

A population-level study of place of death and associated factors in Sweden. Scand J Public Health 2015; 43(7): 744–751.

19.

Morin

Aubry

Where do older people die? A nationwide study in France (1990–2010). Médecine Palliat 2015; 14(3): 179–190.

20.

Gruneir

Mor

Weitzen

et al

Where people die: a multilevel approach to understanding influences on site of death in America. Med Care Res Rev 2007; 64(4): 351–378.

21.

Houttekier

Cohen

Pepersack

et al

Dying in hospital: a study of incidence and factors related to hospital death using death certificate data. Eur J Public Health 2014; 24(5): 751–756.

22.

Cohen

Bilsen

Hooft

et al

Dying at home or in an institution using death certificates to explore the factors associated with place of death. Health Policy 2006; 78(2–3): 319–329.

23.

Grande

Addington-Hall

Todd

CJ.

Place of death and access to home care services: are certain patient groups at a disadvantage?

Soc Sci Med 1998; 47(5): 565–579.

24.

Gisquet

Julliard

Geoffroy-Perez

Do social factors affect the place of death? Analysis of home versus institutional death over 20 years. J Public Health 2016; 38(4): e472–e479.

25.

Cárdenas-Turanzas

Torres-Vigil

Tovalín-Ahumada

et al

Hospital versus home death: results from the Mexican health and aging study. J Pain Symptom Manage 2011; 41(5): 880–892.

26.

Kwak

Haley

Chiriboga

DA.

Racial differences in hospice use and in-hospital death among Medicare and Medicaid dual-eligible nursing home residents. Gerontologist 2008; 48(1): 32–41.

27.

Hanratty

Burström

Walander

et al

Hospital deaths in Sweden: are individual socioeconomic factors relevant?

J Pain Symptom Manage 2007; 33(3): 317–323.

28.

Bossuyt

Van den Block

Cohen

et al

Is individual educational level related to end-of-life care use? Results from a nationwide retrospective cohort study in Belgium. J Palliat Med 2011; 14(10): 1135–1141.

29.

Cohen

Bilsen

Miccinesi

et al

Using death certificate data to study place of death in 9 European countries: opportunities and weaknesses. BMC Public Health 2007; 7: 283.

30.

Mirowsky

Ross

CE.

Education, social status, and health. New York: Aldine Transaction, 2003.

31.

Organisation for Economic Co-operation and Development (OECD). Health at a glance 2015: OECD indicators. Paris: OECD Publishing, 2015.

32.

Ludvigsson

Almqvist

Bonamy

et al

Registers of the Swedish total population and their use in medical research. Eur J Epidemiol 2016; 31(2): 125–136.

33.

Ludvigsson

Andersson

Ekbom

et al

External review and validation of the Swedish national inpatient register. BMC Public Health 2011; 11(1): 450.

34.

Johnell

Fastbom

Comparison of prescription drug use between community-dwelling and institutionalized elderly in Sweden. Drugs Aging 2012; 29: 751–758.

35.

Statistics Sweden. Education of the population, 2014, http://www.scb.se/Statistik/UF/UF0506/_dokument/UF0506_DO_2014.pdf

36.

Halldén

. The Swedish educational system and classifying education using the ISCED-97. In: Schneider

(ed.) The international standard classification of education (ISCED-97). An evaluation of content and criterion validity for 15 European countries. Mannheim: University of Mannheim, 2008, pp. 253–267.

37.

Pivodic

Pardon

Miccinesi

et al

Hospitalisations at the end of life in four European countries: a population-based study via epidemiological surveillance networks. J Epidemiol Community Health 2016; 70(5): 430–436.

38.

Teno

Gozalo

Bynum

et al

Change in end-of-life care for Medicare beneficiaries: site of death, place of care, and health care transitions in 2000, 2005, and 2009. JAMA 2013; 309(5): 470–477.

39.

Luta

Maessen

Egger

et al

Measuring intensity of end of life care: a systematic review. PLoS One 2015; 10(4): e0123764.

40.

Murray

Kendall

Boyd

et al

Illness trajectories and palliative care. BMJ 2005; 330(7498): 1007–1011.

41.

Morin

Aubry

Frova

et al

Estimating the need for palliative care at the population level: a cross-national study in 12 countries. Palliat Med 2017; 31(6): 526–536.

42.

Gill

Gahbauer

Han

et al

Trajectories of disability in the last year of life. N Engl J Med 2010; 362(13): 1173–1180.

43.

Calderón-Larrañaga

Vetrano

Onder

et al

Assessing and measuring chronic multimorbidity in the older population: a proposal for its operationalization. J Gerontol A Biol Sci Med Sci. Epub ahead of print 21 December 2016. DOI: 10.1093/gerona/glw233.

44.

Benchimol

Smeeth

Guttmann

et al

The REporting of studies Conducted using Observational Routinely-collected health Data (RECORD) statement. PLoS Med 2015; 12(10): e1001885.

45.

Broad

Gott

Kim

et al

Where do people die? An international comparison of the percentage of deaths occurring in hospital and residential aged care settings in 45 populations, using published and available statistics. Int J Public Health 2013; 58(2): 257–267.

46.

Ulmanen

Szebehely

From the state to the family or to the market? Consequences of reduced residential eldercare in Sweden. Int J Soc Welf 2015; 24(1): 81–92.

47.

Hedinger

Hämmig

Bopp

Social determinants of duration of last nursing home stay at the end of life in Switzerland: a retrospective cohort study. BMC Geriatr 2015; 15(1): 114.

48.

Wastesson

Fors

Parker

et al

Inequalities in health care use among older adults in Sweden 1992–2011: a repeated cross-sectional study of Swedes aged 77 years and older. Scand J Public Healt 2014; 42(8): 795–803.

49.

Howard

Sentell

Gazmararian

JA.

Impact of health literacy on socioeconomic and racial differences in health in an elderly population. J Gen Intern Med 2006; 21(8): 857–861.

50.

Hayward

Hummer

Sasson

Trends and group differences in the association between educational attainment and US adult mortality: implications for understanding education’s causal influence. Soc Sci Med 2015; 127: 8–18.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.43 MB