Department of Palliative Care, Policy and Rehabilitation, King's College London, Cicely Saunders Institute, London, United Kingdom.
Knowledge & Intelligence (South West), National End of Life Care Intelligence Network, Public Health England, Bristol, United Kingdom.
PLoS One. 2020 Apr 17;15(4):e0231666. doi: 10.1371/journal.pone.0231666. eCollection 2020.
There is much variation in hospice use with respect to geographic factors such as area-based deprivation, location of patient's residence and proximity to services location. However, little is known about how the association between geographic access to inpatient hospice and hospice deaths varies by patients' region of settlement.
To examine regional differences in the association between geographic access to inpatient hospice and hospice deaths.
A regional population-based observational study in England, UK. Records of patients aged ≥ 25 years (n = 123088) who died from non-accidental causes in 2014, were extracted from the Office for National Statistics (ONS) death registry. Our cohort comprised of patients who died at home and in inpatient hospice. Decedents were allocated to each of the nine government office regions of England (London, East Midlands, West Midlands, East, Yorkshire and The Humber, South West, South East, North West and North East) through record linkage with their postcode of usual residence. We defined geographic access as a measure of drive times from patients' residential location to the nearest inpatient hospice. A modified Poisson regression estimated the association between geographic access to hospice, comparing hospice deaths (1) versus home deaths (0). We developed nine regional specific models and adjusted for regional differences in patient's clinical & socio-demographic characteristics. The strength of the association was estimated with adjusted Proportional Ratios (aPRs).
The percentage of deaths varied across regions (home: 86.7% in the North East to 73.0% in the South East; hospice: 13.3% in the North East to 27.0% in the South East). We found wide differences in geographic access to inpatient hospices across regions. Median drive times to hospice varied from 4.6 minutes in London to 25.9 minutes in the North East. We found a dose-response association in the East: (aPRs: 0.22-0.78); East Midlands: (aPRs: 0.33-0.63); North East (aPRs: 0.19-0.87); North West (aPRs: 0.69-0.88); South West (aPRs: 0.56-0.89) and West Midlands (aPRs: 0.28-0.92) indicating that decedents who lived further away from hospices locations (≥ 10 minutes) were less likely to die in a hospice.
The clear dose-response associations in six regions underscore the importance of regional specific initiatives to improve and optimise access to hospices. Commissioners and policymakers need to do more to ensure that home death is not due to limited geographic access to inpatient hospice care.
在临终关怀的使用方面存在着许多差异，例如基于地域的贫困、患者居住地的位置以及与服务地点的接近程度等。然而，人们对地理上接近住院临终关怀与临终关怀死亡之间的关联如何因患者的定居区域而有所不同知之甚少。
检验地理上获得住院临终关怀与临终关怀死亡之间关联的区域性差异。
这是在英国的一项基于区域的人群观察性研究。从国家统计局（ONS）死亡登记处提取了 2014 年死于非意外原因的年龄≥25 岁（n=123088）患者的记录。我们的队列包括在家中以及在住院临终关怀中死亡的患者。通过与他们的常住地邮政编码进行记录链接，将死者分配到英格兰的九个政府办公区域（伦敦、东米德兰兹、西米德兰兹、东安格利亚、约克郡和亨伯、西南、东南、西北和东北）。我们将地理可达性定义为从患者居住地点到最近的住院临终关怀机构的驾车时间的衡量标准。通过修正泊松回归，我们比较了临终关怀死亡（1）与在家中死亡（0）之间的地理上接近临终关怀的关联。我们制定了九个区域特定模型，并根据患者的临床和社会人口统计学特征的区域差异进行了调整。使用调整后的比例比（aPR）来估计关联的强度。
各区域的死亡百分比存在差异（在家中死亡：东北 86.7%，东南 73.0%；在临终关怀机构中死亡：东北 13.3%，东南 27.0%）。我们发现各区域住院临终关怀的地理可达性存在很大差异。到临终关怀机构的驾车时间中位数从伦敦的 4.6 分钟到东北的 25.9 分钟不等。我们在东安格利亚地区发现了一种剂量反应关联：（aPR：0.22-0.78）；在东米德兰兹地区（aPR：0.33-0.63）；在东北地区（aPR：0.19-0.87）；在西北地区（aPR：0.69-0.88）；在西南地区（aPR：0.56-0.89）和西米德兰兹地区（aPR：0.28-0.92），表明距离临终关怀机构位置较远（≥10 分钟）的死者不太可能在临终关怀机构中死亡。
在六个区域中明确的剂量反应关联强调了制定针对特定区域的举措以改善和优化临终关怀服务的重要性。决策者需要做更多的工作，以确保在家中死亡不是由于地理上无法获得住院临终关怀服务所致。
