title: End-of-life care for people with chronic kidney disease: cause of death, place of death and hospital costs.
abstract: BACKGROUND
  End-of-life care for people with chronic kidney disease (CKD) has been identified as an area of great clinical need internationally. We estimate causes and place of death and cost of hospital care for people with CKD in England in the final 3 years of life.
  
  
  METHODS
  Hospital Episode Statistics data were linked to Office for National Statistics mortality data to identify all patients in England aged ≥18 years who died 1 April 2006-31 March 2010, and had a record of hospital care after 1 April 2003 (the study group). The underlying cause and place of death were examined in Office for National Statistics data, for patients without and with CKD (identified by International Classification of Diseases version 10 codes N18, I12 and I13). Costs of hospital admissions and outpatient attendances were estimated using National Health Service Reference Cost data. Associations between CKD and hospital costs, and between place of death and hospital costs in those with CKD, were examined using multivariate regressions.
  
  
  RESULTS
  There were 1 602 105 people in the study group. Of these, 13.2% were recorded as having CKD. The proportion of deaths at home was 10.7% in people with CKD and 17.2% in the age- and gender-matched non-CKD group. Regression analysis suggests that CKD was associated with an increase in hospital costs of £3380 in the last 12 months of life, holding constant place of death, comorbidities and other variables. For the CKD group, home death was associated with a reduction in hospital costs of £2811 in the 12 months before death. The most commonly recorded cause of death in people with CKD was heart disease. CKD was not mentioned on the death certificate in two-thirds of deaths in people with the condition.
  
  
  CONCLUSIONS
  People with CKD are less likely to die at home than those without CKD. The condition is associated with increased hospital costs at the end of life regardless of place of death. Home death in CKD is associated with a substantial reduction in hospital costs at the end of life.
authors.affiliation: Insight Health Economics Ltd, Richmond, Surrey, UK.
authors.forename: Marion
authors.initials: M
authors.lastname: Kerr
authors.affiliation: NHS England, London, UK.
authors.forename: Beverley
authors.initials: B
authors.lastname: Matthews
authors.affiliation: University Hospitals of Leicester NHS Trust, Leicester, UK.
authors.forename: James F
authors.initials: JF
authors.lastname: Medcalf
authors.affiliation: Salford Royal NHS Foundation Trust, Salford, UK.
authors.forename: Donal
authors.initials: D
authors.lastname: O'Donoghue
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002423:Cause of Death; D004739:England / Q000453:epidemiology; D005260:Female; D017721:Hospital Costs / Q000706:statistics & numerical data*; D006760:Hospitalization / Q000191:economics* / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008875:Middle Aged; D051436:Renal Insufficiency, Chronic / Q000191:economics* / Q000453:epidemiology / Q000401:mortality*; D013727:Terminal Care / Q000191:economics*; D055815:Young Adult
keywords: chronic kidney disease; costs; end of life; health economics