title: Which patients with advanced respiratory disease die in hospital? A 14-year population-based study of trends and associated factors.
abstract: Strategies in many countries have sought to improve palliative care and reduce hospital deaths for non-cancer patients, but their effects are not evaluated. We aimed to determine the trends and factors associated with dying in hospital in two common progressive respiratory diseases, and the impact of a national end of life care (EoLC) strategy to reduce deaths in hospital.
  
  
  
  This population-based observational study linked death registration data for people in England dying from chronic obstructive pulmonary disease (COPD) or interstitial pulmonary diseases (IPD). We plotted age- and sex-standardised trends, assessed during the pre-strategy (2001-2004), first strategy phase (2004-2008), and strategy intensification (2009-2014) periods, and identified factors associated with hospital death using multiple adjusted proportion ratios (PRs).
  
  
  
  Over 14 years, 380,232 people died from COPD (334,520) or IPD (45,712). Deaths from COPD and IPD increased by 0.9% and 9.2% annually, respectively. Death in hospital was most common (67% COPD, 70% IPD). Dying in hospice was rare (0.9% COPD, 2.9% IPD). After a plateau in 2004-2005, hospital deaths fell (PRs 0.92-0.94). Co-morbidities and deprivation independently increased the chances of dying in hospital, with larger effects in IPD (PRs 1.01-1.55) than COPD (PRs 1.01-1.39) and dose-response gradients. The impact of multimorbidity increased over time; hospital deaths did not fall for people with two or more co-morbidities in COPD, nor one or more in IPD. Living in rural areas (PRs 0.94-0.94) or outside London (PRs, 0.89-0.98) reduced the chances of hospital death. In IPD, increased age reduced the likelihood of hospital death (PR 0.81, ≥ 85 versus ≤ 54 years); divergently, in COPD, being aged 65-74 years was associated with increased hospital deaths (PR 1.13, versus ≤ 54 years). The independent effects of sex and marital status differed for COPD versus IPD (PRs 0.89-1.04); in COPD, hospital death was associated with being married.
  
  
  
  The EoLC strategy appeared to have contributed to tangible reductions in hospital deaths, but did not reach people with multimorbidity and this gap widened over time. Integrating palliative care earlier in the disease trajectory especially﻿ in deprived areas and cities, and where multimorbidity is present, should be boosted, taking into account the different demographic factors in COPD and IPD.
authors.affiliation: Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, Bessemer Road, London, SE5 9PJ, UK. irene.higginson@kcl.ac.uk.
authors.forename: Irene J
authors.initials: IJ
authors.lastname: Higginson
authors.affiliation: Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, Bessemer Road, London, SE5 9PJ, UK.
authors.forename: Charles C
authors.initials: CC
authors.lastname: Reilly
authors.affiliation: Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, Bessemer Road, London, SE5 9PJ, UK.
authors.forename: Sabrina
authors.initials: S
authors.lastname: Bajwah
authors.affiliation: Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, Bessemer Road, London, SE5 9PJ, UK.
authors.forename: Matthew
authors.initials: M
authors.lastname: Maddocks
authors.affiliation: Arcispedale Santa Maria Nuova-IRCCS, Viale Umberto I, 50 - 42123, Reggio Emilia, Italy.
authors.forename: Massimo
authors.initials: M
authors.lastname: Costantini
authors.affiliation: Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, Bessemer Road, London, SE5 9PJ, UK.
authors.forename: Wei
authors.initials: W
authors.lastname: Gao
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D004739:England / Q000453:epidemiology; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D012140:Respiratory Tract Diseases / Q000401:mortality*; D013727:Terminal Care
keywords: Chronic obstructive pulmonary disease; End of life care; Hospital; Interstitial lung disease; Interstitial pulmonary diseases; Palliative care; Place of death; Policy; Respiratory