title: Transitions between health care settings in the final three months of life in four EU countries.
abstract: BACKGROUND
  Transitions between care settings may be related to poor quality in end-of-life care. Yet there is a lack of cross-national population-based data on transitions at the end of life.
  
  
  METHODS
  International mortality follow-back study with data collection in Belgium, Netherlands, Italy and Spain (2009-11) via existing representative epidemiological surveillance networks of general practitioners (GPs). All general practitioners reported weekly, on a standardized registration form, every deceased patient (≥18 years) in their practice and identified those who died 'non-suddenly'.
  
  
  RESULTS
  Among 4791 non-sudden deaths in Belgium, Netherlands, Italy and Spain, 59%, 55%, 60% and 58%, respectively, were transferred between care settings at least once in the final 3 months of life (10%, 8%, 10% and 13% in final 3 days of life); 10%, 5%, 8% and 12% were transferred three times or more (P < 0.001 in multivariate analyses adjusting for country differences in age, sex, cause of death, presence of dementia). In all countries, transitions were more frequent among patients residing at home (61-73%) than among patients residing in a care home (33-40%). Three months before death 5-7% of patients were in hospital, and this rose to 27-39% on the day of death. Patient wishes were cited as the reason for the last transition before death in 27%, 39%, 9% and 6% of cases in Belgium, Netherlands, Italy and Spain, respectively (P < 0.001).
  
  
  CONCLUSIONS
  End-of-life transitions between health care settings are common across EU countries, in particular late hospitalizations for people residing at home. Frequency, type and reasons for terminal hospitalizations vary between countries.
authors.affiliation: 1 End-of-Life Care Research Group, Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium lvdblock@vub.ac.be lvdblock@vub.ac.be.
authors.forename: Lieve
authors.initials: L
authors.lastname: Van den Block
authors.affiliation: 1 End-of-Life Care Research Group, Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium.
authors.forename: Lara
authors.initials: L
authors.lastname: Pivodic
authors.affiliation: 1 End-of-Life Care Research Group, Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium.
authors.forename: Koen
authors.initials: K
authors.lastname: Pardon
authors.affiliation: 2 NIVEL, Netherlands Institute for Health Services Research, Utrecht, The Netherlands.
authors.forename: Gé
authors.initials: G
authors.lastname: Donker
authors.affiliation: 3 ISPO Cancer Prevention and Research Institute, Florence, Italy.
authors.forename: Guido
authors.initials: G
authors.lastname: Miccinesi
authors.affiliation: 4 Scientific Institute of Public Health, Brussels, Belgium.
authors.forename: Sarah
authors.initials: S
authors.lastname: Moreels
authors.affiliation: 5 Public Health Directorate, Ministry of Health, Autonomous Community of Castile and Leon, Valladolid, Spain.
authors.forename: Tomas
authors.initials: T
authors.lastname: Vega Alonso
authors.affiliation: 1 End-of-Life Care Research Group, Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium.
authors.forename: Luc
authors.initials: L
authors.lastname: Deliens
authors.affiliation: 6 Department of Public and Occupational Health, EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands.
authors.forename: Bregje
authors.initials: B
authors.lastname: Onwuteaka-Philipsen
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002423:Cause of Death; D003704:Dementia / Q000453:epidemiology; D005060:Europe; D005260:Female; D006738:Hospices / Q000706:statistics & numerical data*; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D013727:Terminal Care / Q000458:organization & administration* / Q000706:statistics & numerical data*; D000069341:Transitional Care / Q000706:statistics & numerical data*; D055815:Young Adult