# Geographic variations in place of death and palliative care utilisation in the last three months of life in high-income countries: a systematic review

## TL;DR

This study reviews how geography affects where people die and their use of palliative care in high-income countries.

## Contribution

The paper is the first systematic review to synthesize evidence on geographic influences on end-of-life care utilization.

## Key findings

- Rural areas are associated with higher rates of home deaths and lower palliative care use.
- Proximity to healthcare facilities increases likelihood of death in those facilities.
- Hospital deaths are more common in densely populated regions and capital cities.

## Abstract

Geographic variations in end-of-life healthcare utilisation may highlight disparities in access to care, including palliative care. Studies demonstrate that place of death and palliative care utilisation are influenced by geographic exposures such as sociodemographic and socioeconomic characteristics, rurality, and health service availability. No systematic review has synthesised the evidence across multiple geographic exposures. This is important to provide conclusions from a broader evidence base and inform equitable commissioning of palliative care services.

To investigate the influence of geographic exposures on individual-level place of death and palliative care utilisation in the last three months of life, to identify potential disparities in end-of-life healthcare provision.

In this systematic literature review of quantitative data with narrative synthesis, nine databases were searched for peer-reviewed observational studies published between 1st January 2004 and 1st October 2024. Eligible studies recruited adults in high-income countries and compared two or more geographic exposures. Methodological quality was assessed using the Newcastle-Ottawa Scale.

Of 9,296 studies identified, 51 retrospective studies across 24 countries were included. Rurality was positively associated with home death and decreased palliative care utilisation. Regarding healthcare availability, greater bed availability in hospital or long-term care facilities increased likelihood of death in that facility. Similarly, closer proximity to a hospice or hospital location increased likelihood of death in that facility. Hospital death may be positively associated with residence in certain countries, regions of high population density, and those containing capital cities.

Findings highlight geographic variations as areas of focus for commissioners and policymakers to reduce local end-of-life healthcare inequities. We make recommendations regarding structural care gaps, service efficiency, and innovation in palliative care provision.

Prospero registration number CRD42019154912.

The online version contains supplementary material available at 10.1186/s12904-025-01869-1.