# The inverse palliative care law in advanced lung disease: a mixed-methods systematic review and meta-analysis

## TL;DR

People with advanced lung disease from deprived backgrounds are less likely to receive palliative care despite needing it more, highlighting a need for equitable healthcare policies.

## Contribution

This study is the first to systematically synthesize evidence on socioeconomic inequalities in palliative care access for advanced lung disease.

## Key findings

- People with lung cancer in the lowest socioeconomic group were 18% less likely to receive palliative care than those in the highest group.
- Financial hardship and insurance barriers were identified as limiting access to pain relief and oxygen for lower socioeconomic groups.
- Ethnic minorities and rural populations had worse access to palliative care when multiple demographic factors were considered.

## Abstract

People from socioeconomically deprived backgrounds are at greater risk of developing lung disease and having a higher symptom burden. It remains unclear whether they have equitable access to and experience of palliative care. Therefore, we aimed to synthesise evidence on socioeconomic inequalities in access, receipt of, preference for, and experience of palliative care among people with advanced lung disease.

Mixed-methods systematic review, searching four databases (MEDLINE, Embase, PsychINFO, CINAHL) from inception to March 28, 2025. We included studies that reported on socioeconomic position and palliative care in advanced lung disease (lung cancer, mesothelioma, chronic obstructive pulmonary disease, interstitial lung disease). Study quality was assessed using the Mixed Methods Appraisal Tool. Both meta-analysis (using a random effects model with I2 to assess heterogeneity, sensitivity analysis and GRADE of evidence) and narrative synthesis were performed. PROSPERO CRD42024546502.

Of 10,572 records, 54 studies met inclusion criteria (4.2 million participants). Meta-analysis of six studies showed people with lung cancer in the lowest SEP group were 18% less likely to receive palliative care than those in the highest (OR 0.82, 95% CI 0.75–0.90, I2 = 93.9%). GRADE of evidence was assessed as moderate. Qualitative findings identified financial hardship and insurance barriers limited access to pain relief and oxygen. Few studies considered multiple demographic characteristics, but those that did reported worse access among ethnic minorities and rural populations.

This review provides novel evidence of how the inverse care law operates in advanced lung disease. People from lower socioeconomic groups are significantly less likely to access palliative care, despite greater need. There is an urgent need for equity-focused research and policy interventions, co-produced with underserved communities that account for intersecting social disadvantages.

10.13039/501100000272National Institute for Health and Care Research.