Socioeconomic inequalities in the place of death in urban small areas of three Mediterranean cities.

BACKGROUND: Dying at home is the most frequent preference of patients with advanced chronic conditions, their caregivers, and the general population. However, most deaths continue to occur in hospitals. The objective of this study was to analyse the socioeconomic inequalities in the place of death in urban areas of Mediterranean cities during the period 2010-2015, and to assess if such inequalities are related to palliative or non-palliative conditions. METHODS: This is a cross-sectional study of the population aged 15 years or over. The response variable was the place of death (home, hospital, residential care). The explanatory variables were: sex, age, marital status, country of birth, basic cause of death coded according to the International Classification of Diseases, 10th revision, and the deprivation level for each census tract based on a deprivation index calculated using 5 socioeconomic indicators. Multinomial logistic regression models were adjusted in order to analyse the association between the place of death and the explanatory variables. RESULTS: We analysed a total of 60,748 deaths, 58.5% occurred in hospitals, 32.4% at home, and 9.1% in residential care. Death in hospital was 80% more frequent than at home while death in a nursing home was more than 70% lower than at home. All the variables considered were significantly associated with the place of death, except country of birth, which was not significantly associated with death in residential care. In hospital, the deprivation level of the census tract presented a significant association (p < 0.05) so that the probability of death in hospital vs. home increased as the deprivation level increased. The deprivation level was also significantly associated with death in residential care, but there was no clear trend, showing a more complex association pattern. No significant interaction for deprivation level with cause of death (palliative, not palliative) was detected. CONCLUSIONS: The probability of dying in hospital, as compared to dying at home, increases as the socioeconomic deprivation of the urban area of residence rises, both for palliative and non-palliative causes. Further qualitative research is required to explore the needs and preferences of low-income families who have a terminally-ill family member and, in particular, their attitudes towards home-based and hospital-based death.

Changes in Socioeconomic Inequalities in Amenable Mortality after the Economic Crisis in Cities of the Spanish Mediterranean Coast.

Several studies have described a decreasing trend in amenable mortality, as well as the existence of socioeconomic inequalities that affect it. However, their evolution, particularly in small urban areas, has largely been overlooked. The aim of this study is to analyse the socioeconomic inequalities in amenable mortality in three cities of the Valencian Community, namely, Alicante, Castellon, and Valencia, as well as their evolution before and after the start of the economic crisis (2000-2007 and 2008-2015). The units of analysis have been the census tracts and a deprivation index has been calculated to classify them according to their level of socioeconomic deprivation. Deaths and population were also grouped by sex, age group, period, and five levels of deprivation. The specific rates by sex, age group, deprivation level, and period were calculated for the total number of deaths due to all causes and amenable mortality and Poisson regression models were adjusted in order to estimate the relative risk. This study confirms that the inequalities between areas of greater and lesser deprivation in both all-cause mortality and amenable mortality persisted along the two study periods in the three cities. It also shows that these inequalities appear with greater risk of death in the areas of greatest deprivation, although not uniformly. In general, the risks of death from all causes and amenable mortality have decreased significantly from one period to the other, although not in all the groups studied. The evolution of death risks from before the onset of the crisis to the period after presented, overall, a general pro-cyclical trend. However, there are population subgroups for which the trend was counter-cyclical. The use of the deprivation index has made it possible to identify specific geographical areas with vulnerable populations in all three cities and, at the same time, to identify the change in the level of deprivation (ascending or descending) of the geographical areas throughout the two periods. It is precisely these areas where more attention is needed in order to reduce inequalities.

Socioeconomic Inequalities in Mortality among Foreign-Born and Spanish-Born in Small Areas in Cities of the Mediterranean Coast in Spain, 2009-2015.

Many studies have analysed socioeconomic inequalities and its association with mortality in urban areas. However, few of them have differentiated between native and immigrant populations. This study is an ecological study of mortality by overall mortality and analyses the inequalities in mortality in these populations according to the level of deprivation in small areas of large cities in the Valencian Community, from 2009 to 2015. The census tract was classified into five deprivation levels using an index based on socioeconomic indicators from the 2011 census. Rates and relative risks of death were calculated by sex, age, level of deprivation and country of birth. Poisson regression models have been used. In general, there was a higher risk of death in natives at the levels of greatest deprivation, which did not happen in immigrants. During the 2009-2015 period, there were socioeconomic inequalities in mortality, particularly in natives, who presented a higher risk of death than immigrants. Future interventions and social policies should be implemented in order to reduce inequalities in mortality amongst socioeconomic levels and to maintain the advantage that the immigrant population enjoys.