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Socioeconomic position and use of health care in the last year of life: a systematic review and meta-analysis

Davies, Joanna M.; Sleeman, Katherine E.; Leniz, Javiera; Wilson, Rebecca; Higginson, Irene J.; Verne, Julia; Maddocks, Matthew; Murtagh, Fliss E.M.


Joanna M. Davies

Katherine E. Sleeman

Javiera Leniz

Rebecca Wilson

Irene J. Higginson

Julia Verne

Matthew Maddocks


BACKGROUND: Low socioeconomic position (SEP) is recognized as a risk factor for worse health outcomes. How socioeconomic factors influence end-of-life care, and the magnitude of their effect, is not understood. This review aimed to synthesise and quantify the associations between measures of SEP and use of healthcare in the last year of life. METHODS AND FINDINGS: MEDLINE, EMBASE, PsycINFO, CINAHL, and ASSIA databases were searched without language restrictions from inception to 1 February 2019. We included empirical observational studies from high-income countries reporting an association between SEP (e.g., income, education, occupation, private medical insurance status, housing tenure, housing quality, or area-based deprivation) and place of death, plus use of acute care, specialist and nonspecialist end-of-life care, advance care planning, and quality of care in the last year of life. Methodological quality was evaluated using the Newcastle-Ottawa Quality Assessment Scale (NOS). The overall strength and direction of associations was summarised, and where sufficient comparable data were available, adjusted odds ratios (ORs) were pooled and dose-response meta-regression performed. A total of 209 studies were included (mean NOS quality score of 4.8); 112 high- to medium-quality observational studies were used in the meta-synthesis and meta-analysis (53.5% from North America, 31.0% from Europe, 8.5% from Australia, and 7.0% from Asia). Compared to people living in the least deprived neighbourhoods, people living in the most deprived neighbourhoods were more likely to die in hospital versus home (OR 1.30, 95% CI 1.23-1.38, p < 0.001), to receive acute hospital-based care in the last 3 months of life (OR 1.16, 95% CI 1.08-1.25, p < 0.001), and to not receive specialist palliative care (OR 1.13, 95% CI 1.07-1.19, p < 0.001). For every quintile increase in area deprivation, hospital versus home death was more likely (OR 1.07, 95% CI 1.05-1.08, p < 0.001), and not receiving specialist palliative care was more likely (OR 1.03, 95% CI 1.02-1.05, p < 0.001). Compared to the most educated (qualifications or years of education completed), the least educated people were more likely to not receive specialist palliative care (OR 1.26, 95% CI 1.07-1.49, p = 0.005). The observational nature of the studies included and the focus on high-income countries limit the conclusions of this review. CONCLUSIONS: In high-income countries, low SEP is a risk factor for hospital death as well as other indicators of potentially poor-quality end-of-life care, with evidence of a dose response indicating that inequality persists across the social stratum. These findings should stimulate widespread efforts to reduce socioeconomic inequality towards the end of life.

Journal Article Type Article
Publication Date Apr 23, 2019
Journal PLoS medicine
Print ISSN 1549-1277
Electronic ISSN 1549-1676
Publisher Public Library of Science
Peer Reviewed Peer Reviewed
Volume 16
Issue 4
Article Number e1002782
APA6 Citation Davies, J. M., Sleeman, K. E., Leniz, J., Wilson, R., Higginson, I. J., Verne, J., …Murtagh, F. E. (2019). Socioeconomic position and use of health care in the last year of life: a systematic review and meta-analysis. PLoS Medicine, 16(4),
Keywords Socioeconomic position
Publisher URL


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Copyright Statement
© 2019 Davies et al. This is an open
access article distributed under the terms of the
Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.

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