Groenewoud A Stef, Atsma Femke, Arvin Mina, Westert Gert P, Boer Theo A
Radboud Institute for Health Sciences/Scientific Center for Quality of Healthcare (IQ healthcare), Radboud University Medical Center, Nijmegen, The Netherlands
Radboud Institute for Health Sciences/Scientific Center for Quality of Healthcare (IQ healthcare), Radboud University Medical Center, Nijmegen, The Netherlands.
BMJ Support Palliat Care. 2021 Jan 14. doi: 10.1136/bmjspcare-2020-002573.
The annual incidence of euthanasia in the Netherlands as a percentage of all deaths rose from 1.9% in 1990 to 4.4% in 2017. Scarce literature on regional patterns calls for more detailed insight into the geographical variation in euthanasia and its possible explanations.
This paper (1) shows the geographical variation in the incidence of euthanasia over time (2013-2017); (2) identifies the associations with demographic, socioeconomic, preferential and health-related factors; and (3) shows the remaining variation after adjustment and discusses its meaning.
DESIGN, SETTING AND METHODS: This cross-sectional study used national claims data, covering all healthcare claims during 12 months preceding the death of Dutch insured inhabitants who died between 2013 and 2017. From these claims all euthanasia procedures by general practitioners were selected (85% of all euthanasia cases). Rates were calculated and compared at three levels: 90 regions, 388 municipalities and 196 districts in the three largest Dutch cities. Data on possibly associated variables were retrieved from national data sets. Negative binomial regression analysis was performed to identify factors associated with geographical variation in euthanasia.
There is considerable variation in euthanasia ratio. Throughout the years (2013-2017) the ratio in the three municipalities with the highest incidence was 25 times higher than in the three municipalities with the lowest incidence. Associated factors are age, church attendance, political orientation, income, self-experienced health and availability of voluntary workers. After adjustment for these characteristics a considerable amount of geographical variation remains (factor score of 7), which calls for further exploration.
The Netherlands, with 28 years of legal euthanasia, experiences large-scale unexplained geographical variation in the incidence of euthanasia. Other countries that have legalised physician-assisted dying or are in the process of doing so may encounter similar patterns. The unexplained part of the variation may include the possibility that part of the euthanasia practice may have to be understood in terms of underuse, overuse or misuse.
在荷兰，安乐死的年发生率占所有死亡人数的比例从1990年的1.9%上升至2017年的4.4%。关于地区模式的文献稀缺，这就需要更深入地了解安乐死的地理差异及其可能的解释。
本文（1）展示了安乐死发生率随时间（2013 - 2017年）的地理差异；（2）确定与人口、社会经济、偏好和健康相关因素的关联；（3）展示调整后的剩余差异并讨论其意义。
设计、设置与方法：这项横断面研究使用了全国索赔数据，涵盖2013年至2017年间死亡的荷兰参保居民死亡前12个月内的所有医疗索赔。从这些索赔中，选取了全科医生实施的所有安乐死程序（占所有安乐死病例的85%）。在三个层面计算并比较发生率：90个地区、388个市镇以及荷兰三大城市的196个区。从国家数据集检索可能相关变量的数据。进行负二项回归分析以确定与安乐死地理差异相关的因素。
安乐死比率存在相当大的差异。在整个研究期间（2013 - 2017年），发生率最高的三个市镇的比率比发生率最低的三个市镇高25倍。相关因素包括年龄、去教堂做礼拜的频率、政治倾向、收入、自我感知的健康状况以及志愿者的可获得性。在对这些特征进行调整后，仍存在相当大的地理差异（因素得分7），这需要进一步探索。
荷兰有28年的合法安乐死历史，在安乐死发生率方面存在大规模无法解释的地理差异。其他已将医生协助死亡合法化或正在进行此项工作的国家可能会遇到类似模式。差异中无法解释的部分可能包括这样一种可能性，即部分安乐死行为可能需要从使用不足、过度使用或滥用的角度来理解。
