Background Studies of individual-level data report that palliative care (PC) availability is associated with lower risk of death in hospital.

Methods We compiled a cross-national longitudinal dataset to identify factors associated with hospital mortality rate in Europe across the years 2005–2017. We sought place of death data from the national statistics offices of the 32 EU-EEA countries. Data on palliative care availability by country were collected from the European Association of Palliative Care (EAPC) Atlases. Our primary predictor of interest was binary: in a given nation in a given year, did the palliative care provision meet EAPC recommendations, controlling for population size and age distribution? We collected additional predictors hypothesised to be associated with outcome from Eurostat, OECD and WHO: indicators of national wealth, societal factors, population health, and other health system variables. Our final dataset included 30 countries, excluding Greece (no outcome data) and Liechtenstein (which does not have its own palliative care services). We used linear regression with panel-corrected standard errors to assess association between hospital mortality rate, palliative care availability and other factors. Sensitivity analyses were performed to check robustness to imputed data. We took p<0.05 to represent statistical significance.

Results Average hospital mortality rate ranged from 27% to 67% over the observation period, with notable differences between Eastern, Southern and North(wester)ern nations both cross-sectionally and over time. The regression analysis found palliative care provision was significantly associated with lower hospital mortality rate: services in line with EAPC recommendations was associated with a 4.3% lower hospital mortality rate (95% CI: -2.8% to -0.3%; p=0.01). With respect to the national economic indicators, low HDI countries groups were significantly associated with high hospital mortality, with south countries showing the highest hospital mortality rate. In the healthcare policy domain, government funding of long term care, and lack of assistance in functional issues were significantly associated with decreased hospital mortality. Avoidable death rate, total healthcare spending on ambulatory care, and home care provision were significantly negatively associated with hospital mortality. With respect to healthcare system, the number of total hospital beds and the percent of population with unmet need due to financial reasons were significantly associated with lower hospital mortality, while the mean hospital length of stay showed significant positive association with hospital mortality.

Conclusion Hospital mortality rates varied markedly between countries and were changing in different directions over time. Palliative care access increased in the observation period and was associated with lower hospital mortality rate. Additionally, significant associations between outcome and economic, societal, and health system factors were identified in our analysis.