Hospitalisations at the end of life in four European countries: a cross-national population-based mortality followback study.

Background: Most people would prefer to be cared for and to die at home. On the other hand, hospital admissions towards the end of life have been related to aggressive care, higher cost than community care, and they may indicate a low quality of dying. Population-based cross-national data on hospital use at the end of life are scarce, although they are needed to develop effective public health policies on end-of-life care. We described and compared the frequency, length and timing of hospital admissions in the last three months of life in Belgium, the Netherlands, Italy and Spain. Methods: Cross-national population-based mortality followback study with data collection through nationwide representative epidemiological surveillance networks of general practitioners (GPs). Using a standardised form, GPs recorded the care in the last three months of life of every deceased adult (>18 years) patient of their practice (01/01/2009-31/12/2011). Nursing home deaths from the Netherlands (6%) were excluded as they are not attended by GPs. Results: We studied 7209 deaths of which the GPs described 66% as non-sudden. In Belgium, the Netherlands, Italy and Spain, 53%, 47%, 51% and 52% of patients, respectively (p < .001, adjusted for differences in age, sex, cause of death), were hospitalised at least once in the last three months of life, for median 14 days (inter-quartile range (IQR) 6 to 25) in Belgium and median 10 days in the other countries (IQR 3 to 20 in the Netherlands; IQR 5 to 20 in Italy and Spain). At thirty days before death Belgium revealed nearly twice the proportion of patients in hospital (13%) than did the Netherlands (7%), Italy and Spain (both 6%), but this difference decreased towards the day of death. All countries revealed an increase in the percentage of hospitalised patients over the last 10 days of life (21% to 37% in Belgium, 15% to 29% in the Netherlands, 16% to 37% in Italy, 14% to 31% in Spain). Conclusions: Across countries, and particularly in Belgium, hospital care in the last three months of life is highly prevalent and increases considerably over the final days of life, potentially counteracting patients’ preferences. Differences between countries may reflect differences in healthcare policy and end- of-life care practice. Key messages In Belgium, the Netherlands, Italy and Spain 53%, 47%, 51% and 52% of patients, respectively, are hospitalised at least once in the final three months of life. Thirty days before death Belgium had the highest percentage of patients in hospital, but in all four countries this percentage increased considerably over the final 10 days of life