Abstract
BACKGROUND: Where people die depends on many factors and is important to the quality of end-of-life care. Many people prefer to avoid end-of-life hospital admissions and yet hospital remains the most common place of death across high-income countries and is more likely for people who live in more deprived areas. This study examines moderators and mediators of socioeconomic inequality in place of death. METHODS: We used census data linked to mortality data for people who died in England and Wales between 2011 and 2017 to investigate the association between area-based income deprivation and death in hospital versus home, hospice, and care home. We tested moderators including age, sex, ethnicity, underlying cause of death and region, and mediating pathways through housing deprivation, living alone, and worse health. RESULTS: Among 34,230 decedents, after adjusting for age and sex, the proportion of deaths in hospital was higher in more deprived areas; 52.4 % (95 % CI: 51.2 %-53.6 %) and 46.7 % (45.5 %-48.0 %) for people living in the most and least deprived areas, respectively. This association was moderated by underlying cause of death; a social gradient was observed for deaths from cancer, dementia and 'other' causes but not for people who died from respiratory, cardiovascular, and sudden causes (F = 43.81; df (20), p = 0.0016). In a subsample of people who died from cancer, people living in the most deprived areas were more likely to live alone (36 % (95 % CI 30 %-41 %)) than those in the least deprived areas (19 % (15 %-23 %)), and this partly explained why they were more likely to die in hospital, accounting for 12.2 % of the total effect of income deprivation on death in hospital. CONCLUSION: This study contributes novel findings that deepen our understanding of socioeconomic inequality in place of death. Improving support for people living alone in more deprived areas is identified as a potential way to reduce inequalities in place of death.