1. Variation in place of death from cancer: studies in South East England Elizabeth Davies, Peter Madden, Victoria Coupland, Karen Linklater, Henrik Møller Thames Cancer Registry, King’s College London

2. Outline of topics to be covered Variation over time By cancer network of residence By PCT of residence And by individual ethnicity

3. Percentage of home cancer deaths in English regions 1985-1994 (all ages) Higginson et al, Palliative Medicine 1998;12:353-363

4. 1.Trends in place of death South East England 1985-2002 Objectives:  To describe trends for place of death for four most common cancers  To explore relationship with growth of palliative care and nursing home services

5. Methods for trend study 1985-2002 Sample  216,404 residents diagnosed and dying 1985 to 2002  Not notified by death certificate only  Recorded as dying from breast, lung, colorectal or prostate cancer Information on services  Hospice Information Directories 1985-2002  Department of Health Outcome  Death in acute hospitals, at home, in hospices or nursing homes

6. Note: Figure excludes the proportion dying in private hospitals and patients where place of death was not known Trends for place of death for patients with breast, colorectal, lung and prostate cancer in South East England 1985-2002

7. Trends for nursing home deaths for breast, lung, colorectal and prostate and nursing home beds, South East England 1985-2002

8. Trends for hospice deaths for breast, lung, colorectal and prostate cancer and hospice beds, South East England 1985-2002

9. Trends for hospital death for breast, lung, colorectal, and prostate cancer and hospital palliative care services, South East England 1985-2002

10. Trends for home deaths for breast, lung, colorectal and prostate cancer and home palliative care services, South East England 1985-2002

11. 2. Cancer network study 1998-2002 Objective: To analyse variation across cancer networks Adjusting for case mix variables (age, sex, cancer site, clinical or microscopic diagnosis, treatment and deprivation at ward level)

12. Proportion of hospital cancer deaths by cancer network, South East England 1998-2002

13. Proportion of home cancer deaths by cancer network, South East England 1998-2002

14. Proportion of hospice cancer deaths by cancer network, South East England 1998-2002

15. Proportion of nursing home deaths by cancer network, South East England 1998-2002

16.  Cancer patients remain more likely to die in hospital  Influence of hospice and nursing home beds  Decline in home death needs investigation  Network variation in place of death not explained by case mix Davies et al. British Journal of Cancer (2006) 95,593-600 Conclusions

17. 3. Variation by PCT of residence in London 2002-2005 Objectives To use maps and funnel plots to examine variation in the proportion of home and hospice deaths from cancer in PCTs

18. Variation by PCT in London 2002-2005 Methods Sample  Office of National Statistics (ONS) mortality data for 2002-2005  The number of residents in London with cancer recorded as the underlying cause of deathOutcome  Proportion of cancer deaths occurring at home, hospital, hospice and nursing home, calculated for residents of each of the 31 London PCTs

19. Place of death from cancer, London 2002-2005 2002200320042005 Hospital 56%54%55%54% Home 18% 19% Hospice 18%20% 19% Long stay/ nursing home 6%7% Other/not known 2%1% 14,68114,43214,04213,632

20. Proportion of all patients dying from cancer at home by PCT of residence, London 2005

22. Proportion of all patients dying from cancer in hospice by PCT of residence, London 2005

24. Conclusion Less than 1 in 5 cancer deaths in London were at home Funnel plots and maps are useful for examining variation in place of death and trends in performance Next steps PCT variation by case mix, for example, ethnicity, age, sex, deprivation Data on provision of palliative care services in hospital

25. 4. Variation by ethnic group in South East England 1998-2006 Sample Breast and prostate cancer Diagnosed between 1960 and 2006 Died of disease between 1998 and 2006 Resident in South East England DCO registrations excluded HES and TCR ethnicity codes

26. Method - analysis Proportions dying at home in each ethnic group Logistic regression – Death at home vs death elsewhere – The White group was used as the baseline group – Unadjusted – Adjusted for age, deprivation, cancer network, stage and time between diagnosis and death

27. Proportions dying from breast cancer at home

28. Logistic regression results: Death from breast cancer at home * age, deprivation, cancer network of residence, stage, and time between diagnosis and death

29. Proportions dying from prostate cancer at home

30. Logistic regression results: Death from prostate cancer at home * age, deprivation, cancer network of residence, stage, and time between diagnosis and death

31. Conclusions Black Caribbean and Black African women less likely to die at home from breast cancer Black African men less likely to die at home from prostate cancer Next steps Understand preferences and barriers for end of life care in different communities