In the UK cancer registries record the occurrence of cancer in their residential populations as well as treatments given in the first 6 months after diagnosis. Information about death is provided by the National Health Service Central Register through the Office for National Statistics. Death certificates routinely record place of death and assign cancer as a main or contributing cause of death in part I of the certificate.
We extracted data on 216
404 residents in South East England who had been diagnosed with breast, lung, colorectal and prostate cancer between 1985 and 2002, and who died from their disease between 1985 and 2002. Cases where the only registration information was from the death certificate were not included. From death certificates, we classified death as occurring in NHS acute hospitals, hospices, long stay hospitals or nursing homes, private hospitals, at home or as unknown. We could identify nursing homes by their address, but death certificates do not distinguish deaths in hospital palliative care units from those in other wards.
We extracted data on hospice and palliative care services from Hospice Information directories for 1985–2002 (Hospice Information, 2006
) and calculated the number of hospice beds, home care teams, day care services, hospital palliative care or support teams and hospital support nurses in our area. We summed home care services regardless of their funding (independent, NHS and Macmillan Cancer Relief) or base (hospices, NHS hospital or community), although there was insufficient detail about Marie Curie home services to include these. We could not deduce team size or caseload. We also obtained aggregate data on numbers of beds in registered nursing homes from the Department of Health where this was available for 1991–2001. We first plotted the proportion of deaths occurring in each of home, hospital, hospice and nursing home against the growth of different services over time. Data on acute and general hospital beds in our area were available only between 1996 and 2002 and were not plotted.
We then took death in hospice, nursing home, NHS acute hospital and at home as our four dependent variables and fitted logistic regression models to identify individual demographic, disease-related and area of residence factors predicting in turn each of these outcomes versus the others. Our first analysis for the entire period 1985–2002 included sex, age at diagnosis, whether the diagnosis was based on clinical or microscopic evidence, primary site of cancer and treatment with surgery, radiotherapy, chemotherapy or hormone therapy. We also adjusted for year of death and years since diagnosis to examine trends over time. We grouped age into four bands: <65 years, 65–74 years, 75–84 years and 85 years plus. Our second analysis explored the additional influence of area of residence for the years 1998–2002. For this, we assigned each individual to an electoral ward and a cancer network using their postcode of residence. We calculated the deprivation score for each ward using the income domain of the Indices of Multiple Deprivation (IMD) 2000 for England (Department of Environment, 2000
) and assigned individuals to a quintile of deprivation ranging from most (1) to least affluent (5) wards.
We present the results of logistic regression analyses as proportions of deaths occurring in each place for each factor. Proportions are easier to interpret than odds ratios, and were derived from a back calculation from the odds ratios obtained from the logistic regression analyses. We present unadjusted and adjusted proportions to show the effect of controlling for all other factors. Our large sample size means that many small differences reach statistical significance. We draw attention only to those factors producing at least five percentage points difference – a difference which we believe a clinical service might be interested to explore further.