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Health and Care Pathways in the Last Year of Life from Non-Sudden Causes between 2014 and 2023 in Wales: A Population-Scale Retrospective Cohort Study
32 Pages Posted: 1 May 2025
More...Abstract
Background: End-of-life health and care service provision are complex processes. In response to the National Programme for Palliative and End of Life Care in Wales, we aimed to quantify the uptake of health and care services at the end of life from non-sudden causes.
Methods: Population-scale linked administrative and health data in the last year of life for Welsh residents who died of non-sudden causes were modelled using multi-state models between 2014 to 2023. Cox regression were used to estimate hazards for transitions between care settings including non-care homes, care homes with and without nursing, emergency, elective and other hospital admissions, and death. Hazard ratios (HR) and expected length of stay (ELOS), with 95% confidence intervals (95%CI) are presented, adjusted for age, sex, rurality, area-level deprivation, and palliative care registration.
Findings: Our analyses included 267,199 individuals, with 1,845,572 transitions. There were 74,045 (27·7%) individuals registered for palliative care, under-represented groups included men, most-deprived and living alone. Most time was spent in non-care homes, with 90·3% of emergency admissions from non-care homes. There was a 23% increased transition rate of emergency admissions from non-care homes for palliative care registered individuals compared to unregistered (HR 1.23 [95%CI 1.22-1.25]), with a decreased expected length of stay (ELOS 25.34 [95%CI 25.34–25.34] vs 26.87 [26.87–26.87]). Emergency admissions from care homes with and without nursing were 17% (HR 0·83 [95%CI 0·80-0·86]) and 18% (HR 0·82 [95%CI 0·79-0·85]) lower for palliative care registered individuals compared to unregistered, with an increased rate of discharge from hospital (HR 2·00 [95%CI 1·92-2·09], and 1·62 [1·54-1·69]).
Interpretation: Palliative care status had an important impact on health and care utilisation at the end-of-life. Efficient identification of individuals needing palliative care and additional support in non-care homes should be prioritised for system optimisation.
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