Analysis of the Number of Days Required for Full-Time Care Before Death and the Cost of Care in the Last Month of Life Among the Chinese Elderly

Abstract

A growing number of studies in western nations have found that an important component in improving the quality of end of life is to meet the care needs of individuals approaching death. Information on the cost of these care needs would be useful in determining how to reduce the burden on family and society, but such studies are near-absent in developing countries. This chapter provides an analysis of care needs and expenses before death in China, where the proportion of the elderly population will rapidly increase in the next few decades. Based on the fourth wave of the Chinese Longitudinal Healthy Longevity Survey (CLHLS) in 2005, we estimate the number of days needed for full-time care before death and the care costs in the last month of life among the deceased elderly aged 65 and over by using sequential models in a multi-level context. The CLHLS, a unique specially designed nationwide survey, included data on care needs before death and expenditure in 2005 for those respondents who died between the 2002 and 2005 waves in randomly selected half of counties and cities in 22 of 31 provinces in mainland China. Data on the number of days required for full-time care and care costs in the last month of life were obtained from 5,729 deceased persons in 774 counties by asking their next-of-kin. Both the number of days requiring full-time care and care expenses are re-classified into eight categories to best describe the data according to their distributions. A two-step estimation approach is applied to estimate the days and costs. Multi-level multi-nominal logit regressions are first applied to estimate the membership probability of each group for each study variable. These probabilities are multiplied by the mean of each corresponding group of days or costs to estimate the weighted average needs or costs. Three sequential models are employed to investigate how individual characteristics and community level factors are associated with these estimates. Model I controls for age, gender, ethnicity, urban/rural residence, education, family economic condition, personal economic independence, accessibility to healthcare plus community socioeconomic development factors measured by education, per capita GDP, and number of hospital beds per thousand population. Model II further controls for proximity to children, marital status, religious participation, health practices (smoking, alcohol use, and exercise), life satisfaction, and psychological disposition. Model III additionally adjusts for overall health condition measured by the frailty index. Our results show that the average number of days required for full-time care before death for a Chinese elder is approximately 80, and this number differs significantly by sex, education, access to healthcare, proximity to children, involvement in religious activities, and baseline overall health condition. However, it is not associated with community factors. Elders who are male, educated, have easy access to healthcare, live farther from children, are religious, and are healthier tend to require fewer days of full-time care before death.

Our analyses further reveal that the average payment for care in the last month of life is 3,106 RMB (approximately $383). Those who are older, female, non-Han minorities, living in rural areas, non-educated, have a poor family economic condition, economically dependent, unable to access healthcare, not currently married, and from underdeveloped communities tend to spend a smaller amount on care in the last month of life. Observed differences by sex, urban/rural residence, and proximity to children are mediated by other confounders. We also find nonlinear relationships between costs and overall health conditions, and between costs and the community educational level. These findings are useful for the improvement of quality of end of life care and successful aging among the Chinese elderly in the context of largely reduced family size and greatly changing household structure due to population aging and migration.

Keywords: Care needs, care costs, care expenditure, China, Chinese elderly, disability, eldercare, end-of-life care, hospice care, last month of life, long-term care, multilevel analysis, multinomial logit, oldest-old