Background

Many patients prefer to avoid hospital-based care towards the end of life, yet hospitalisation is common and more likely for people with low socioeconomic position. The reasons underlying this socioeconomic inequality are not well understood. This study investigated health, service access, and social support as potential mediating pathways between socioeconomic position and receipt of hospital-based care towards the end of life.

Methods

For this observational cohort study, we included deceased participants from the nationally representative English Longitudinal Study of Ageing of people aged 50 years or older in England. We used a multiple mediation model with age-adjusted and gender-adjusted probit regression to estimate the direct effect of socioeconomic position (measured by wealth and education) on death in hospital and three or more hospital admissions in the last 2 years of life, and the indirect effects of socioeconomic position via three mediators: health and function, access to health-care services, and social support.

Findings

737 participants were included (314 [42·6%] female, 423 [57·4%] male), with a median age at death of 78 years (IQR 71–85). For death in hospital, higher wealth had a direct negative effect (probit coefficient −0·16, 95% CI −0·25 to −0·06), which was not mediated by any of the pathways tested. For frequent hospital admissions, health and function mediated the effect of wealth (−0·04, −0·08 to −0·01), accounting for 34·6% of the total negative effect of higher wealth (−0·13, −0·23 to −0·02). Higher wealth was associated with better health and function (0·25, 0·18 to 0·33). Education was associated with the outcomes only indirectly via wealth.

Interpretation

Our findings suggest that worse health and function could partly explain why people with lower wealth have more hospital admissions, highlighting the importance of socioeconomically driven health differences in explaining patterns of hospital use towards the end of life. The findings should raise awareness about the related risk factors of low wealth and worse health for patients approaching the end of life, and strengthen calls for resource allocation to be made on the basis of health need and socioeconomic profile.

Funding

Dunhill Medical Trust Fellowship Grant (RTF74/0116).

中文翻译：

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临终时的社会经济地位和医院护理的使用：使用英国老龄化纵向研究进行的中介分析

 背景

许多患者在临终时宁愿避免住院治疗，但住院治疗很常见，而且对于社会经济地位较低的人来说住院治疗的可能性更大。这种社会经济不平等背后的原因尚不清楚。这项研究调查了健康、服务获取和社会支持作为社会经济地位和临终时接受医院护理之间的潜在中介途径。

 方法

在这项观察性队列研究中，我们纳入了具有全国代表性的英格兰老龄化纵向研究的已故参与者，研究对象为英格兰 50 岁或以上人群。我们使用了具有年龄调整和性别调整概率回归的多重中介模型来估计社会经济地位（通过财富和教育程度来衡量）对医院死亡和生命最后两年内三次或以上住院的直接影响，以及社会经济地位通过三个中介因素产生的间接影响：健康和功能、获得医疗保健服务的机会以及社会支持。

 发现

共有 737 名参与者（314 名 [42·6%] 女性，423 名 [57·4%] 男性），死亡中位年龄为 78 岁（IQR 71-85）。对于医院死亡，较高的财富具有直接的负面影响（概率系数 -0·16，95% CI -0·25 至 -0·06），这种影响不是由任何测试的途径介导的。对于频繁入院，健康和功能介导了财富的影响（−0·04、-0·08 至 -0·01），占较高财富的总负面影响（−0·13、-0·13、-0·08）的 34·6%。 -0·23至-0·02)。更高的财富与更好的健康和功能相关（0·25、0·18 至 0·33）。教育仅通过财富间接与结果相关。

 解释

我们的研究结果表明，健康状况和功能较差可以部分解释为什么财富较低的人住院次数较多，这凸显了社会经济驱动的健康差异在解释临终医院使用模式方面的重要性。研究结果应提高人们对临终患者低财富和健康状况恶化的相关风险因素的认识，并加强呼吁根据健康需求和社会经济状况进行资源分配。

 资金

登喜路医疗信托奖学金补助金 (RTF74/0116)。