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Bindley K, Lewis J, Travaglia J, DiGiacomo M. Bureaucracy and burden: An Intersectionality-Based Policy Analysis of social welfare policy with consequences for carers of people with life-limiting illness. Palliat Med 2022; 37:543-557. [PMID: 36114642 DOI: 10.1177/02692163221122289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND For informal carers of people with life-limiting illness, social welfare policy related to income support and housing has been associated with varied psychosocial issues, yet remains relatively under-explored. An intersectional approach offers potential to illuminate diverse experiences and implications. AIM To explore the way in which caring in the context of life-limiting illness is framed within welfare policy, to articulate inequities encountered by carers, and to identify policy and practice recommendations. DESIGN The Intersectionality-Based Policy Analysis (IBPA) Framework was used to situate findings of a broader qualitative study. SETTING/PARTICIPANTS Data were collected via semi-structured interviews with participants who were bereaved carers (n = 12), welfare workers (n = 14) and palliative care workers (n = 7), between November 2018 and April 2020, in an Australian region associated with socioeconomic disadvantage. Five elements of IBPA were applied to the products of analysis of this data. RESULTS Use of the IBPA Framework revealed that representations of carers and causes of their welfare needs in policy were underpinned by several assumptions; including that caring and grieving periods are temporary or brief, and that carers have adequate capacity to navigate complex systems. Policy and processes had differentiated consequences for carers, with those occupying certain social locations prone to accumulating disadvantage. CONCLUSIONS This intersectional analysis establishes critical exploration of the framing and consequences of welfare policy for carers of people with life-limiting illness, presented in a novel conceptual model. Implications relate to intersectoral development of structural competency, responsiveness to structurally vulnerable carers in clinical practice, and needed policy changes.
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Affiliation(s)
- Kristin Bindley
- Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT), Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia.,Supportive and Palliative Care, Western Sydney Local Health District, Mount Druitt, NSW, Australia
| | - Joanne Lewis
- School of Nursing and Health, Avondale University, Wahroonga, NSW, Australia.,School of Nursing and Midwifery, University of Technology Sydney, Ultimo, NSW, Australia
| | - Joanne Travaglia
- Health Services Management, School of Public Health, The University of Technology Sydney, Ultimo, NSW, Australia
| | - Michelle DiGiacomo
- Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT), Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia
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Bindley K, Lewis J, Travaglia J, DiGiacomo M. Caring and Grieving in the Context of Social and Structural Inequity: Experiences of Australian Carers With Social Welfare Needs. QUALITATIVE HEALTH RESEARCH 2022; 32:64-79. [PMID: 34836471 DOI: 10.1177/10497323211046875] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Caring for and bereavement following the death of someone with a life-limiting illness may precipitate social welfare needs related to income support and housing. Nevertheless, carer experiences of welfare policy and institutions have not received significant attention. This qualitative study explored experiences of carers who navigated social welfare policy while caring for someone with a life-limiting illness, and in bereavement. In-depth interviews were conducted with 12 bereaved carers in an area associated with socioeconomic disadvantage. Carers differentially encountered precariousness, with some experiencing structural vulnerability. These positionalities appeared to be shaped by policy and process-related burdens, perceptions of the welfare state, and degrees of legitimisation or disenfranchisement of forms of capital and coping orientations. Recommendations that may improve carer experience were identified. Implications relate to the need for an expanded conceptualisation of vulnerability in health and welfare practice, policy that authentically validates caring and grieving, and upstream strategies that address inequity.
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Affiliation(s)
- Kristin Bindley
- Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT), Faculty of Health, 110561The University of Technology, Ultimo, NSW, Australia
- Supportive and Palliative Care, 1760Western Sydney Local Health District, Mount Druitt NSW, Australia
| | - Joanne Lewis
- Faculty of Health, 110561The University of Technology Sydney, Ultimo, NSW, Australia
- Faculty of Health,110446University of Canberra, Bruce, ACT, Australia
| | - Joanne Travaglia
- Faculty of Health, 110561The University of Technology Sydney, Ultimo, NSW, Australia
| | - Michelle DiGiacomo
- Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT), Faculty of Health, 110561The University of Technology, Ultimo, NSW, Australia
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French M, Keegan T, Anestis E, Preston N. Exploring socioeconomic inequities in access to palliative and end-of-life care in the UK: a narrative synthesis. BMC Palliat Care 2021; 20:179. [PMID: 34802450 PMCID: PMC8606060 DOI: 10.1186/s12904-021-00878-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 11/05/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Efforts inequities in access to palliative and end-of-life care require comprehensive understanding about the extent of and reasons for inequities. Most research on this topic examines differences in receipt of care. There is a need, particularly in the UK, for theoretically driven research that considers both receipt of care and the wider factors influencing the relationship between socioeconomic position and access to palliative and end-of-life care. METHODS This is a mixed studies narrative synthesis on socioeconomic position and access to palliative and end-of-life care in the UK. Study searches were conducted in databases AMED, Medline, Embase, CINAHL, SocIndex, and Academic Literature Search, as well as grey literature sources, in July 2020. The candidacy model of access, which describes access as a seven-stage negotiation between patients and providers, guided study searches and provided a theoretical lens through which data were synthesised. RESULTS Searches retrieved 5303 studies (after de-duplication), 29 of which were included. The synthesis generated four overarching themes, within which concepts of candidacy were evident: identifying needs; taking action; local conditions; and receiving care. CONCLUSION There is not a consistent or clear narrative regarding the relationship between socioeconomic position and receipt of palliative and end-of-life care in the UK. Attempts to address any inequities in access will require knowledge and action across many different areas. Key evidence gaps in the UK literature concern the relationship between socioeconomic position, organisational context, and assessing need for care.
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Affiliation(s)
- Maddy French
- Division of Health Research, Lancaster University, Lancaster, UK.
| | - Thomas Keegan
- Lancaster Medical School, Lancaster University, Lancaster, UK
| | | | - Nancy Preston
- Division of Health Research, Lancaster University, Lancaster, UK
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Moody E, Ganann R, Martin-Misener R, Ploeg J, Macdonald M, Weeks LE, Orr E, McKibbon S, Jefferies K. Out-of-pocket expenses related to aging in place for frail older people: a scoping review. JBI Evid Synth 2021; 20:537-605. [PMID: 34738979 PMCID: PMC8860225 DOI: 10.11124/jbies-20-00413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Objective: The objective of this scoping review was to map and describe the available evidence reporting out-of-pocket expenses related to aging in place for older people with frailty and their caregivers. Introduction: As the global population ages, there has been increasing attention on supporting older people to live at home in the community as they experience health and functional changes. Older people with frailty often require a variety of supports and services to live in the community, yet the out-of-pockets costs associated with these resources are often not accounted for in health and social care literature. Inclusion criteria: Sources that reported on the financial expenses incurred by older people (60 years or older) with frailty living in the community, or on the expenses incurred by their family and friend caregivers, were eligible for inclusion in the review. Methods: We searched for published and unpublished (ie, policy papers, theses, and dissertations) studies written in English or French between 2001 and 2019. The following databases were searched: CINAHL, MEDLINE, Scopus, Embase, PsycINFO, Sociological Abstracts, and Public Affairs Index. We also searched for gray literature in a selection of websites and digital repositories. JBI scoping review methodology was used, and we consulted with a patient and family advisory group to support the relevance of the review. Results: A total of 42 sources were included in the review, including two policy papers and 40 research papers. The majority of the papers were from the United States (n = 18), with others from Canada (n = 6), the United Kingdom (n = 3), Japan (n = 2), and one each from Australia, Brazil, China, Denmark, Israel, Italy, The Netherlands, Poland, Portugal, Singapore, South Korea, Taiwan, and Turkey. The included research studies used various research designs, including cross-sectional (n = 18), qualitative (n = 15), randomized controlled trials (n = 2), longitudinal (n = 2), cost effectiveness (n = 1), quasi-experimental (n = 1), and mixed methods (n = 1). The included sources used the term “frailty” inconsistently and used various methods to demonstrate frailty. Categories of out-of-pocket expenses found in the literature included home care, medication, cleaning and laundry, food, transportation, medical equipment, respite, assistive devices, home modifications, and insurance. Five sources reported on out-of-pocket expenses associated with people who were frail and had dementia, and seven reported on the out-of-pocket expenses for caregivers of people with frailty. While seven articles reported on specific programs, there was very little consistency in how out-of-pocket expenses were used as outcome measures. Several studies used measures of combined out-of-pocket expenses, but there was no standard approach to reporting aggregate out-of-pocket expenses. Conclusions: Contextual factors are important to the experiences of out-of-pocket spending for older people with frailty. There is a need to develop a standardized approach to measuring out-of-pocket expenses in order to support further synthesis of the literature. We suggest a measure of out-of-pocket spending as a percentage of family income. The review supports education for health care providers to assess the out-of-pocket spending of community-dwelling older people with frailty and their caregivers. Health care providers should also be aware of the local policies and resources that are available to help older people with frailty address their out-of-pocket spending.
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Affiliation(s)
- Elaine Moody
- School of Nursing, Dalhousie University, Halifax, Canada Aligning Health Needs with Evidence for Transformative Change (AH-NET-C): A JBI Centre of Excellence, Dalhousie University, Halifax, Canada School of Nursing, McMaster University, Hamilton, Canada WK Kellogg Health Sciences Library, Dalhousie University, Halifax, Canada Faculty of Applied Health Sciences, Brock University, St. Catharines, Canada
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Webb EJD, Meads D, Gardiner C. Changing the eligibility criteria for welfare payments at the end of life - a budget impact analysis for England and Wales. BMC Health Serv Res 2021; 21:421. [PMID: 33947386 PMCID: PMC8094542 DOI: 10.1186/s12913-021-06390-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 04/14/2021] [Indexed: 11/29/2022] Open
Abstract
Background Terminal illness can cause a financial burden for many households. In England and Wales, fast-track access to welfare payments is available through special rules for the terminally ill (SRTI). Individuals are eligible for SRTI if they are judged to have 6 months or less to live. This criterion has been criticised as lacking a clinical basis, and being unfair for people with conditions where life-expectancy is difficult to accurately assess. Aim To conduct a budget impact analysis on the possible increase in expenditure of personal independence payments (PIP) following a change in England and Wales to SRTI so that everyone with a terminal illness is eligible. Methods The fraction of individuals with a given long-term condition was estimated by combining data from the Health Survey for England, the Office for National Statistics (ONS) and the Department for Work and Pensions. Logistic growth modelling and ONS population projections were used to project PIP expenditure from 2020 to 2025. The increased expenditure was calculated for hypothetical scenarios which may occur following an SRTI regime change, specifically an increase of 1, 2 and 3 percentage points in the fraction of individuals claiming PIP under SRTI. Data from the literature on the projected prevalence of mild, moderate and severe dementia was used to calculate the cost if everyone with a given severity of dementia claimed PIP under SRTI. Results Under the current SRTI regime, PIP expenditure under SRTI was projected to increase from £0.231bn in 2020 to £0.260bn in 2025, compared to equivalent figures of £11.1bn and £12.7bn under non-SRTI. Expenditure in 2025 following an increase in the fraction claiming of 1, 2 and 3 percentage points was projected to be £1.1bn, £1.9bn and £2.7bn respectively. In 2025, PIP expenditure was estimated to be £7.4bn if everyone with dementia claimed under SRTI, compared to £6.4bn if only individuals with moderate and severe dementia claimed, and £4.7bn if only individuals with severe dementia claimed. Conclusion Changes in SRTI are projected to lead to increases in PIP expenditure. However, the increased cost is small compared to expenditure under non-SRTI, especially as the highest costs were associated with extreme scenarios. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06390-8.
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Affiliation(s)
- Edward J D Webb
- Leeds Institute of Health Sciences, University of Leeds, Clarendon Way, Leeds, LS2 9NL, UK.
| | - David Meads
- Leeds Institute of Health Sciences, University of Leeds, Clarendon Way, Leeds, LS2 9NL, UK
| | - Clare Gardiner
- Health Sciences School, The University of Sheffield, Barber House Annexe, 387 Glossop Road, Sheffield, S10 2HQ, UK
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Bindley K, Lewis J, Travaglia J, DiGiacomo M. Social welfare needs of bereaved Australian carers: Implications of insights from palliative care and welfare workers. HEALTH & SOCIAL CARE IN THE COMMUNITY 2021; 29:631-642. [PMID: 33704840 DOI: 10.1111/hsc.13339] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 11/09/2020] [Accepted: 02/11/2021] [Indexed: 06/12/2023]
Abstract
An individual and psychological emphasis has influenced practice and research on bereavement following informal care provision in the context of life-limiting illness. Consideration of the potential for bereavement to be shaped by intersecting social and structural inequities is needed; and should include an understanding of interactions with government institutions and social policy. This qualitative study employed interpretive description to explore the way in which palliative care workers and welfare sector workers perceive and approach experiences and needs of bereaved carers receiving government income support or housing assistance in Western Sydney, an area associated with recognised socioeconomic disadvantage. A total of 21 palliative care workers within a public health service and welfare workers from two government social welfare services participated in in-depth interviews. Data were analysed using framework analysis. Participants highlighted social welfare policy and related interactions that may impact bereavement, potentially related to financial, housing and employment precariousness. Personal, interpersonal and structural factors perceived to shape the navigation of welfare needs were explored, alongside needed professional and structural changes envisioned by workers. With limited forms of capital, vulnerably positioned carers may encounter difficulties that heighten their precariousness in bereavement. Transactional organisational cultures alongside health and welfare agencies that function in a siloed manner appear to contribute to structural burden for carers, following death due to life-limiting illness. Palliative care and welfare workers also associated elements of their work with bereaved carers with their own experiences of helplessness, frustration and distress. Findings point to a need for the development of interagency strategies in addition to policy underpinned by more nuanced understandings of vulnerability in bereavement, post-caring.
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Affiliation(s)
- Kristin Bindley
- Faculty of Health, The University of Technology Sydney, Ultimo, NSW, Australia
- Supportive and Palliative Care, Western Sydney Local Health District, Mt Druitt, NSW, Australia
| | - Joanne Lewis
- Faculty of Health, The University of Technology Sydney, Ultimo, NSW, Australia
| | - Joanne Travaglia
- Faculty of Health, The University of Technology Sydney, Ultimo, NSW, Australia
| | - Michelle DiGiacomo
- Faculty of Health, The University of Technology Sydney, Ultimo, NSW, Australia
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Bindley K, Lewis J, Travaglia J, DiGiacomo M. Caring precariously: An interpretive description of palliative care and welfare worker perspectives on end of life carers navigating social welfare. Palliat Med 2021; 35:169-178. [PMID: 33112209 DOI: 10.1177/0269216320966492] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Caring at end-of-life is associated with financial burden, economic disadvantage, and psychosocial sequelae. Health and social welfare systems play a significant role in coordinating practical resources and support in this context. However, little is known about social policy and interactions with public institutions that shape experiences of informal carers with social welfare needs at end-of-life. AIM To explore ways in which palliative care and welfare sector workers perceive and approach experiences and needs of the carers of people with life-limiting illnesses who receive government income support or housing assistance, in an area of recognised socioeconomic disadvantage. DESIGN An interpretive descriptive study employed in-depth, qualitative interviews to explore participants' reflections on working with carers of someone with a life-limiting illness. Data were analysed using the framework approach. SETTING/PARTICIPANTS Twenty-one workers employed within three public services in Western Sydney were recruited. RESULTS Workers articulated understandings of welfare policy and its consequences for carers at end-of-life, including precariousness in relation to financial and housing circumstances. Identified resources and barriers to the navigation of social welfare needs by carers were categorised as personal, interpersonal and structural. CONCLUSIONS Caring at end-of-life while navigating welfare needs was seen to be associated with precariousness by participants, particularly for carers positioned in vulnerable social locations. Findings highlighted experiences of burdensome system navigation, inconsistent processes and inequity. Further exploration of structural determinants of experience is needed, including aspects of palliative care and welfare practice and investment in inter-agency infrastructure for supporting carers at end-of-life.
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Affiliation(s)
- Kristin Bindley
- Faculty of Health, The University of Technology Sydney, Ultimo, NSW, Australia.,Supportive and Palliative Care, Western Sydney Local Health District, Mt Druitt, NSW, Australia
| | - Joanne Lewis
- Faculty of Health, The University of Technology Sydney, Ultimo, NSW, Australia
| | - Joanne Travaglia
- Faculty of Health, The University of Technology Sydney, Ultimo, NSW, Australia
| | - Michelle DiGiacomo
- Faculty of Health, The University of Technology Sydney, Ultimo, NSW, Australia
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Davies JM, Sleeman KE, Leniz J, Wilson R, Higginson IJ, Verne J, Maddocks M, Murtagh FEM. Socioeconomic position and use of healthcare in the last year of life: A systematic review and meta-analysis. PLoS Med 2019; 16:e1002782. [PMID: 31013279 PMCID: PMC6478269 DOI: 10.1371/journal.pmed.1002782] [Citation(s) in RCA: 84] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 03/14/2019] [Indexed: 12/21/2022] Open
Abstract
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.
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Affiliation(s)
- Joanna M. Davies
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, United Kingdom
| | - Katherine E. Sleeman
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, United Kingdom
| | - Javiera Leniz
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, United Kingdom
| | - Rebecca Wilson
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, United Kingdom
| | - Irene J. Higginson
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, United Kingdom
| | - Julia Verne
- Health Intelligence, Public Health England, Bristol, United Kingdom
| | - Matthew Maddocks
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, United Kingdom
| | - Fliss E. M. Murtagh
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, United Kingdom
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, United Kingdom
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Maetens A, Beernaert K, Deliens L, Gielen B, Cohen J. Who finds the road to palliative home care support? A nationwide analysis on the use of supportive measures for palliative home care using linked administrative databases. PLoS One 2019; 14:e0213731. [PMID: 30861057 PMCID: PMC6414004 DOI: 10.1371/journal.pone.0213731] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 02/27/2019] [Indexed: 11/19/2022] Open
Abstract
Background Many countries developed supportive measures for palliative home care, such as financial incentives or multidisciplinary palliative home care teams. For policy makers, it is important to evaluate the use of these national palliative home care supportive measures on a population level. Methods and findings Using routinely-collected data on all deaths in Belgium in 2012 (n = 107,847) we measured the use of four statutory supportive measures, specifically intended for patients who have obtained the legal palliative status, and three non-statutory supportive measures. Factors associated with uptake were analysed using multivariable logistic regression. Of all deaths of adult home-dwelling persons in Belgium (n = 87,007), 17.9 percent used at least one statutory supportive measure and 51.5 percent used at least one non-statutory supportive measure. In those who died of an illness indicative of palliative care needs 33.1 percent used at least one statutory supportive measure and 62.2 percent used at least one non-statutory supportive measure. Younger people and persons dying from cancer were more likely to use a statutory policy measure. Older people and persons dying from COPD were most likely to use a non-statutory policy measure. Women, non-single people, and those living in less urbanised areas were most likely to use any supportive measure. Conclusions Statutory supportive measures for palliative home care are underused, even in a subpopulation of persons with potential palliative care needs. Policy makers should stimulate an equitable uptake, and reducing the observed inequalities is an important focus for health care policy.
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Affiliation(s)
- Arno Maetens
- Department of Family Medicine & Chronic Care, End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
- * E-mail:
| | - Kim Beernaert
- Department of Family Medicine & Chronic Care, End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Luc Deliens
- Department of Family Medicine & Chronic Care, End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
- Department of Public Health and Primary Care, Ghent University Hospital, Ghent, Belgium
| | - Birgit Gielen
- Intermutualistic Agency (IMA-AIM), Brussels, Belgium
| | - Joachim Cohen
- Department of Family Medicine & Chronic Care, End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
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Wales J, Kurahashi AM, Husain A. The interaction of socioeconomic status with place of death: a qualitative analysis of physician experiences. BMC Palliat Care 2018; 17:87. [PMID: 29925364 PMCID: PMC6011451 DOI: 10.1186/s12904-018-0341-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 06/12/2018] [Indexed: 11/25/2022] Open
Abstract
Background Home is a preferred place of death for many people; however, access to a home death may not be equitable. The impact of socioeconomic status on one’s ability to die at home has been documented, yet there remains little literature exploring mechanisms that contribute to this disparity. By exploring the experiences and insights of physicians who provide end-of-life care in the home, this study aims to identify the factors perceived to influence patients’ likelihood of home death and describe the mechanisms by which they interact with socioeconomic status. Methods In this exploratory qualitative study, we conducted interviews with 9 physicians who provide home-based care at a specialized palliative care centre. Participants were asked about their experiences caring for patients at the end of life, focusing on factors believed to impact likelihood of home death with an emphasis on socioeconomic status, and opportunities for intervention. We relied on participants’ perceptions of SES, rather than objective measures. We used an inductive content analysis to identify and describe factors that physicians perceive to influence a patient’s likelihood of dying at home. Results Factors identified by physicians were organized into three categories: patient characteristics, physical environment and support network. Patient preference for home death was seen as a necessary factor. If this was established, participants suggested that having a strong support network to supplement professional care was critical to achieving home death. Finally, safe and sustainable housing were also felt to improve likelihood of home death. Higher SES was perceived to increase the likelihood of a desired home death by affording access to more resources within each of the categories. This included better health and health care understanding, a higher capacity for advocacy, a more stable home environment, and more caregiver support. Conclusions SES was not perceived to be an isolated factor impacting likelihood of home death, but rather a means to address shortfalls in the three identified categories. Identifying the factors that influence ability is the first step in ensuring home death is accessible to all patients who desire it, regardless of socioeconomic status.
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Affiliation(s)
- Joshua Wales
- The Temmy Latner Centre for Palliative Care, Sinai Health System, 60 Murray Street, 4th Floor, Box 13, Toronto, ON, M5T 3L9, Canada.
| | - Allison M Kurahashi
- The Temmy Latner Centre for Palliative Care, Sinai Health System, 60 Murray Street, 4th Floor, Box 13, Toronto, ON, M5T 3L9, Canada
| | - Amna Husain
- The Temmy Latner Centre for Palliative Care, Sinai Health System, 60 Murray Street, 4th Floor, Box 13, Toronto, ON, M5T 3L9, Canada
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Gardiner C, Ingleton C, Ryan T, Ward S, Gott M. What cost components are relevant for economic evaluations of palliative care, and what approaches are used to measure these costs? A systematic review. Palliat Med 2017; 31:323-337. [PMID: 27670418 PMCID: PMC5405843 DOI: 10.1177/0269216316670287] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND It is important to understand the costs of palliative and end-of-life care in order to inform decisions regarding cost allocation. However, economic research in palliative care is very limited and little is known about the range and extent of the costs that are involved in palliative care provision. AIM To undertake a systematic review of the health and social care literature to determine the range of financial costs related to a palliative care approach and explore approaches used to measure these costs. DESIGN A systematic review of empirical literature with thematic synthesis. Study quality was evaluated using the Weight of Evidence Framework. DATA SOURCES The databases CINAHL, Cochrane, PsycINFO and Medline were searched from 1995 to November 2015 for empirical studies which presented data on the financial costs associated with palliative care. RESULTS A total of 38 papers met our inclusion criteria. Components of palliative care costs were incurred within four broad domains: hospital care, community or home-based care, hospice care and informal care. These costs could be considered from the economic viewpoint of three providers: state or government, insurers/third-party/not-for-profit organisations and patient and family and/or society. A wide variety of costing approaches were used to derive costs. CONCLUSION The evidence base regarding the economics of palliative care is sparse, particularly relating to the full economic costs of palliative care. Our review provides a framework for considering these costs from a variety of economic viewpoints; however, further research is required to develop and refine methodologies.
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Affiliation(s)
- Clare Gardiner
- 1 School of Nursing and Midwifery, The University of Sheffield, Sheffield, UK
| | - Christine Ingleton
- 1 School of Nursing and Midwifery, The University of Sheffield, Sheffield, UK
| | - Tony Ryan
- 1 School of Nursing and Midwifery, The University of Sheffield, Sheffield, UK
| | - Sue Ward
- 2 ScHARR, The University of Sheffield, Sheffield, UK
| | - Merryn Gott
- 3 The University of Auckland, Auckland, New Zealand
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Neergaard MA, Olesen F, Sondergaard J, Vedsted P, Jensen AB. Are Cancer Patients' Socioeconomic and Cultural Factors Associated with Contact to General Practitioners in the Last Phase of Life? INTERNATIONAL JOURNAL OF FAMILY MEDICINE 2015; 2015:952314. [PMID: 26413319 PMCID: PMC4564657 DOI: 10.1155/2015/952314] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/14/2015] [Accepted: 08/16/2015] [Indexed: 06/05/2023]
Abstract
Introduction. General practitioners (GPs) play an important role in end of life care, which should be offered regardless of socioeconomic position and cultural factors. The aim was to analyse associations between GP contacts at the end of life and socioeconomic and cultural characteristics of Danish cancer patients. Method. Population-based study identifying 599 adults who died of cancer from March to November 2006, in Aarhus County, Denmark. Associations between health register-based data on "total GP face-to-face contacts" and "GP home visits" during the last 90 days of life and patients' socioeconomic and cultural characteristics were calculated. Results. Having low income (RR: 1.18 (95% CI: 1.03; 1.35)) and being immigrants or descendants of immigrants (RR: 1.17 (95% CI: 1.02; 1.35)) were associated with GP face-to-face contacts. However, patients living in large municipalities had lower likelihood of having both GP face-to-face contacts in general (RR: 0.85 (95% CI: 0.77;0.95)) and GP home visits (RR: 0.89 (95% CI: 0.80; 0.99)). Conclusion. This study indicates higher proportion of GP contacts to economically deprived patients and immigrants/descendants of immigrants. These subgroups were, however, small and results should be looked upon with caution. Furthermore, palliative needs were not included and together with urban/rural the underlying causes need further investigation.
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Affiliation(s)
- M. A. Neergaard
- The Palliative Team, Aarhus University Hospital, Noerrebrogade 44, 8000 Aarhus C, Denmark
| | - F. Olesen
- The Research Unit for General Practice, Aarhus University, 8000 Aarhus C, Denmark
| | - J. Sondergaard
- The Research Unit for General Practice, University of Southern Denmark, 7000 Odense, Denmark
| | - P. Vedsted
- Research Centre for Cancer Diagnosis in Primary Care, The Research Unit for General Practice, Aarhus University, 8000 Aarhus C, Denmark
| | - A. B. Jensen
- Department of Oncology, Aarhus University Hospital, 8000 Aarhus C, Denmark
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13
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Socioeconomic variation in the financial consequences of ill health for older people with chronic diseases: A systematic review. Maturitas 2013; 74:313-33. [DOI: 10.1016/j.maturitas.2013.01.015] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2013] [Accepted: 01/21/2013] [Indexed: 11/21/2022]
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14
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Allmark P, Baxter S, Goyder E, Guillaume L, Crofton-Martin G. Assessing the health benefits of advice services: using research evidence and logic model methods to explore complex pathways. HEALTH & SOCIAL CARE IN THE COMMUNITY 2013; 21:59-68. [PMID: 23039788 PMCID: PMC3557712 DOI: 10.1111/j.1365-2524.2012.01087.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 06/27/2012] [Indexed: 06/01/2023]
Abstract
Poverty is positively associated with poor health; thus, some healthcare commissioners in the UK have pioneered the introduction of advice services in health service locations. Previous systematic reviews have found little direct evidence for a causal relationship between the provision of advice and physical health and limited evidence for mental health improvement. This paper reports a study using a broader range of types of research evidence to construct a conceptual (logic) model of the wider evidence underpinning potential (rather than only proven) causal pathways between the provision of advice services and improvements in health. Data and discussion from 87 documents were used to construct a model describing interventions, primary outcomes, secondary and tertiary outcomes following advice interventions. The model portrays complex causal pathways between the intervention and various health outcomes; it also indicates the level of evidence for each pathway. It can be used to inform the development of research designed to evaluate the pathways between interventions and health outcomes, which will determine the impact on health outcomes and may explain inconsistencies in previous research findings. It may also be useful to commissioners and practitioners in making decisions regarding development and commissioning of advice services.
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Affiliation(s)
- Peter Allmark
- Health and Social Care Research Centre, Sheffield Hallam University, UK.
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15
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Currow DC, Allingham S, Bird S, Yates P, Lewis J, Dawber J, Eagar K. Referral patterns and proximity to palliative care inpatient services by level of socio-economic disadvantage. A national study using spatial analysis. BMC Health Serv Res 2012; 12:424. [PMID: 23176397 PMCID: PMC3529682 DOI: 10.1186/1472-6963-12-424] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2011] [Accepted: 10/22/2012] [Indexed: 12/25/2022] Open
Abstract
Background A range of health outcomes at a population level are related to differences in levels of social disadvantage. Understanding the impact of any such differences in palliative care is important. The aim of this study was to assess, by level of socio-economic disadvantage, referral patterns to specialist palliative care and proximity to inpatient services. Methods All inpatient and community palliative care services nationally were geocoded (using postcode) to one nationally standardised measure of socio-economic deprivation – Socio-Economic Index for Areas (SEIFA; 2006 census data). Referral to palliative care services and characteristics of referrals were described through data collected routinely at clinical encounters. Inpatient location was measured from each person’s home postcode, and stratified by socio-economic disadvantage. Results This study covered July – December 2009 with data from 10,064 patients. People from the highest SEIFA group (least disadvantaged) were significantly less likely to be referred to a specialist palliative care service, likely to be referred closer to death and to have more episodes of inpatient care for longer time. Physical proximity of a person’s home to inpatient care showed a gradient with increasing distance by decreasing levels of socio-economic advantage. Conclusion These data suggest that a simple relationship of low socioeconomic status and poor access to a referral-based specialty such as palliative care does not exist. Different patterns of referral and hence different patterns of care emerge.
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Affiliation(s)
- David C Currow
- Discipline, Palliative and Supportive Services, Flinders University, 700 Goodwood Rd, Daw Park, South Australia, 5041, Australia.
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Bossuyt N, Van den Block L, Cohen J, Meeussen K, Bilsen J, Echteld M, Deliens L, Van Casteren V. Is individual educational level related to end-of-life care use? Results from a nationwide retrospective cohort study in Belgium. J Palliat Med 2011; 14:1135-41. [PMID: 21815816 DOI: 10.1089/jpm.2011.0045] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Educational level has repeatedly been identified as an important determinant of access to health care, but little is known about its influence on end-of-life care use. OBJECTIVES To examine the relationship between individual educational attainment and end-of-life care use and to assess the importance of individual educational attainment in explaining differential end-of-life care use. RESEARCH DESIGN A retrospective cohort study via a nationwide sentinel network of general practitioners (GPs; SENTI-MELC Study) provided data on end-of-life care utilization. Multilevel analysis was used to model the association between educational level and health care use, adjusting for individual and contextual confounders based upon Andersen's behavioral model of health services use. SUBJECTS A Belgian nationwide representative sample of people who died not suddenly in 2005-2007. RESULTS In comparison to their less educated counterparts, higher educated people equally often had a palliative treatment goal but more often used multidisciplinary palliative care services (odds ratios [OR] for lower secondary education 1.28 [1.04-1.59] and for higher [secondary] education: 1.31 [1.02-1.68]), moved between care settings more frequently (OR: 1.68 [1.13-2.48] for lower secondary education and 1.51 [0.93-2.48] for higher [secondary] education) and had more contacts with the GP in the final 3 months of life. CONCLUSIONS Less well-educated people appear to be disadvantaged in terms of access to specialist palliative care services, and GP contacts at the end of life, suggesting a need for empowerment of less well-educated terminally ill people regarding specialist palliative and general end-of-life care use.
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Affiliation(s)
- Nathalie Bossuyt
- Scientific Institute of Public Health, Operational Directorate Public Health & Surveillance, Brussels, Belgium.
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Lewis JM, DiGiacomo M, Currow DC, Davidson PM. Dying in the margins: understanding palliative care and socioeconomic deprivation in the developed world. J Pain Symptom Manage 2011; 42:105-18. [PMID: 21402460 DOI: 10.1016/j.jpainsymman.2010.10.265] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2010] [Revised: 10/04/2010] [Accepted: 10/17/2010] [Indexed: 11/23/2022]
Abstract
CONTEXT Individuals from low socioeconomic (SE) groups have less resources and poorer health outcomes. Understanding the nature of access to appropriate end-of-life care services for this group is important. OBJECTIVES To evaluate the literature in the developed world for barriers to access for low SE groups. METHODS Electronic databases searched in the review included MEDLINE (1996-2010), CINAHL (1996-2010), PsychINFO (2000-2010), Cochrane Library (2010), and EMBASE (1996-2010). Publications were searched for key terms "socioeconomic disadvantage," "socioeconomic," "poverty," "poor" paired with "end-of-life care," "palliative care," "dying," and "terminal Illness." Articles were analyzed using existing descriptions for dimensions of access to health services, which include availability, affordability, acceptability, and geographical access. RESULTS A total of 67 articles were identified for the literature review. Literature describing end-of-life care and low SE status was limited. Findings from the review were summarized under the headings for dimensions of access. CONCLUSION Low SE groups experience barriers to access in palliative care services. Identification and evaluation of interventions aimed at reducing this disparity is required.
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Affiliation(s)
- Joanne M Lewis
- School of Nursing and Midwifery and Centre for Cardiovascular and Chronic Care, Curtin University, Sydney, Australia.
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