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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Differences in place of death between lung cancer and COPD patients: a 14-country study using death certificate data</title><author><name sortKey="Cohen, Joachim" sort="Cohen, Joachim" uniqKey="Cohen J" first="Joachim" last="Cohen">Joachim Cohen</name><affiliation><nlm:aff id="Aff1"><institution-wrap><institution-id institution-id-type="ISNI">0000 0001 2290 8069</institution-id><institution-id institution-id-type="GRID">grid.8767.e</institution-id><institution></institution><institution>Vrije Universiteit Brussel (VUB) and Ghent University, End-of-Life Care Research Group,</institution></institution-wrap>Brussels, Belgium</nlm:aff></affiliation></author><author><name sortKey="Beernaert, Kim" sort="Beernaert, Kim" uniqKey="Beernaert K" first="Kim" last="Beernaert">Kim Beernaert</name><affiliation><nlm:aff id="Aff1"><institution-wrap><institution-id institution-id-type="ISNI">0000 0001 2290 8069</institution-id><institution-id institution-id-type="GRID">grid.8767.e</institution-id><institution></institution><institution>Vrije Universiteit Brussel (VUB) and Ghent University, End-of-Life Care Research Group,</institution></institution-wrap>Brussels, Belgium</nlm:aff></affiliation></author><author><name sortKey="Van Den Block, Lieve" sort="Van Den Block, Lieve" uniqKey="Van Den Block L" first="Lieve" last="Van Den Block">Lieve Van Den Block</name><affiliation><nlm:aff id="Aff1"><institution-wrap><institution-id institution-id-type="ISNI">0000 0001 2290 8069</institution-id><institution-id institution-id-type="GRID">grid.8767.e</institution-id><institution></institution><institution>Vrije Universiteit Brussel (VUB) and Ghent University, End-of-Life Care Research Group,</institution></institution-wrap>Brussels, Belgium</nlm:aff></affiliation><affiliation><nlm:aff id="Aff2"><institution-wrap><institution-id institution-id-type="ISNI">0000 0001 2290 8069</institution-id><institution-id institution-id-type="GRID">grid.8767.e</institution-id><institution>Department of Family Medicine and Chronic Care,</institution><institution>Vrije Universiteit Brussel (VUB),</institution></institution-wrap>Brussels, Belgium</nlm:aff></affiliation></author><author><name sortKey="Morin, Lucas" sort="Morin, Lucas" uniqKey="Morin L" first="Lucas" last="Morin">Lucas Morin</name><affiliation><nlm:aff id="Aff3">National Observatory of End of Life Care, Paris, France</nlm:aff></affiliation><affiliation><nlm:aff id="Aff4"><institution-wrap><institution-id institution-id-type="ISNI">0000 0004 1936 9377</institution-id><institution-id institution-id-type="GRID">grid.10548.38</institution-id><institution></institution><institution>Aging Research Center, Karolinska Institutet and Stockholm University,</institution></institution-wrap>Stockholm, Sweden</nlm:aff></affiliation></author><author><name sortKey="Hunt, Katherine" sort="Hunt, Katherine" uniqKey="Hunt K" first="Katherine" last="Hunt">Katherine Hunt</name><affiliation><nlm:aff id="Aff5"><institution-wrap><institution-id institution-id-type="ISNI">0000 0004 1936 9297</institution-id><institution-id institution-id-type="GRID">grid.5491.9</institution-id><institution></institution><institution>University of Southampton, Health Sciences,</institution></institution-wrap>Southampton, UK</nlm:aff></affiliation></author><author><name sortKey="Miccinesi, Guido" sort="Miccinesi, Guido" uniqKey="Miccinesi G" first="Guido" last="Miccinesi">Guido Miccinesi</name><affiliation><nlm:aff id="Aff6"><institution-wrap><institution-id institution-id-type="ISNI">0000 0004 1758 0566</institution-id><institution-id institution-id-type="GRID">grid.417623.5</institution-id><institution></institution><institution>Cancer Prevention and Research Institute, ISPO, Clinical and Descriptive Epidemiology Unit,</institution></institution-wrap>Florence, Italy</nlm:aff></affiliation></author><author><name sortKey="Cardenas Turanzas, Marylou" sort="Cardenas Turanzas, Marylou" uniqKey="Cardenas Turanzas M" first="Marylou" last="Cardenas-Turanzas">Marylou Cardenas-Turanzas</name><affiliation><nlm:aff id="Aff7"><institution-wrap><institution-id institution-id-type="ISNI">0000 0001 2291 4776</institution-id><institution-id institution-id-type="GRID">grid.240145.6</institution-id><institution></institution><institution>The University of Texas MD Anderson Cancer Center,</institution></institution-wrap>Houston, TX USA</nlm:aff></affiliation></author><author><name sortKey="Onwuteaka Philipsen, Bregje" sort="Onwuteaka Philipsen, Bregje" uniqKey="Onwuteaka Philipsen B" first="Bregje" last="Onwuteaka-Philipsen">Bregje Onwuteaka-Philipsen</name><affiliation><nlm:aff id="Aff8"><institution-wrap><institution-id institution-id-type="ISNI">0000 0001 0686 3219</institution-id><institution-id institution-id-type="GRID">grid.466632.3</institution-id><institution></institution><institution>EMGO Institute for Health and Care Research, Public and Occupational Health, and Palliative Care Expertise Centre, VU Medical Centre,</institution></institution-wrap>Amsterdam, The Netherlands</nlm:aff></affiliation></author><author><name sortKey="Macleod, Rod" sort="Macleod, Rod" uniqKey="Macleod R" first="Rod" last="Macleod">Rod Macleod</name><affiliation><nlm:aff id="Aff9"><institution-wrap><institution-id institution-id-type="ISNI">0000 0004 1936 834X</institution-id><institution-id institution-id-type="GRID">grid.1013.3</institution-id><institution></institution><institution>Hammond Care and University of Sydney,</institution></institution-wrap>Sydney, Australia</nlm:aff></affiliation></author><author><name sortKey="Ruiz Ramos, Miguel" sort="Ruiz Ramos, Miguel" uniqKey="Ruiz Ramos M" first="Miguel" last="Ruiz-Ramos">Miguel Ruiz-Ramos</name><affiliation><nlm:aff id="Aff10"><institution-wrap><institution-id institution-id-type="ISNI">0000 0004 1768 2343</institution-id><institution-id institution-id-type="GRID">grid.436087.e</institution-id><institution></institution><institution>Ministry of Health, Government of Andalusia,</institution></institution-wrap>Seville, Spain</nlm:aff></affiliation></author><author><name sortKey="Wilson, Donna M" sort="Wilson, Donna M" uniqKey="Wilson D" first="Donna M" last="Wilson">Donna M. Wilson</name><affiliation><nlm:aff id="Aff11"><institution-wrap><institution-id institution-id-type="GRID">grid.17089.37</institution-id><institution></institution><institution>Faculty of Nursing, University of Alberta,</institution></institution-wrap>Edmonton, AB Canada</nlm:aff></affiliation></author><author><name sortKey="Loucka, Martin" sort="Loucka, Martin" uniqKey="Loucka M" first="Martin" last="Loucka">Martin Loucka</name><affiliation><nlm:aff id="Aff12"><institution-wrap><institution-id institution-id-type="ISNI">0000 0004 1937 116X</institution-id><institution-id institution-id-type="GRID">grid.4491.8</institution-id><institution></institution><institution>Center for Palliative Care, Third Faculty of Medicine, Charles University in Prague,</institution></institution-wrap>Prague, Czech Republic</nlm:aff></affiliation></author><author><name sortKey="Csikos, Agnes" sort="Csikos, Agnes" uniqKey="Csikos A" first="Agnes" last="Csikos">Agnes Csikos</name><affiliation><nlm:aff id="Aff13"><institution-wrap><institution-id institution-id-type="ISNI">0000 0001 0663 9479</institution-id><institution-id institution-id-type="GRID">grid.9679.1</institution-id><institution></institution><institution>University of Pécs Medical School,</institution></institution-wrap>Pécs, Hungary</nlm:aff></affiliation></author><author><name sortKey="Rhee, Yong Joo" sort="Rhee, Yong Joo" uniqKey="Rhee Y" first="Yong-Joo" last="Rhee">Yong-Joo Rhee</name><affiliation><nlm:aff id="Aff14"><institution-wrap><institution-id institution-id-type="ISNI">0000 0004 0532 5816</institution-id><institution-id institution-id-type="GRID">grid.412059.b</institution-id><institution></institution><institution>Dongduk Women’s University, Health Sciences,</institution></institution-wrap>Seoul, Republic of Korea</nlm:aff></affiliation></author><author><name sortKey="Teno, Joan" sort="Teno, Joan" uniqKey="Teno J" first="Joan" last="Teno">Joan Teno</name><affiliation><nlm:aff id="Aff15"><institution-wrap><institution-id institution-id-type="ISNI">0000000122986657</institution-id><institution-id institution-id-type="GRID">grid.34477.33</institution-id><institution></institution><institution>University of Washington, Cambia Palliative Care Center of Excellence, Division of Gerontology and Geriatrics,</institution></institution-wrap>Seatle, WA USA</nlm:aff></affiliation></author><author><name sortKey="Ko, Winne" sort="Ko, Winne" uniqKey="Ko W" first="Winne" last="Ko">Winne Ko</name><affiliation><nlm:aff id="Aff1"><institution-wrap><institution-id institution-id-type="ISNI">0000 0001 2290 8069</institution-id><institution-id institution-id-type="GRID">grid.8767.e</institution-id><institution></institution><institution>Vrije Universiteit Brussel (VUB) and Ghent University, End-of-Life Care Research Group,</institution></institution-wrap>Brussels, Belgium</nlm:aff></affiliation></author><author><name sortKey="Deliens, Luc" sort="Deliens, Luc" uniqKey="Deliens L" first="Luc" last="Deliens">Luc Deliens</name><affiliation><nlm:aff id="Aff1"><institution-wrap><institution-id institution-id-type="ISNI">0000 0001 2290 8069</institution-id><institution-id institution-id-type="GRID">grid.8767.e</institution-id><institution></institution><institution>Vrije Universiteit Brussel (VUB) and Ghent University, End-of-Life Care Research Group,</institution></institution-wrap>Brussels, Belgium</nlm:aff></affiliation><affiliation><nlm:aff id="Aff16"><institution-wrap><institution-id institution-id-type="ISNI">0000 0001 2069 7798</institution-id><institution-id institution-id-type="GRID">grid.5342.0</institution-id><institution>Department of Medical Oncology,</institution><institution>Ghent University,</institution></institution-wrap>Ghent, Belgium</nlm:aff></affiliation></author><author><name sortKey="Houttekier, Dirk" sort="Houttekier, Dirk" uniqKey="Houttekier D" first="Dirk" last="Houttekier">Dirk Houttekier</name><affiliation><nlm:aff id="Aff1"><institution-wrap><institution-id institution-id-type="ISNI">0000 0001 2290 8069</institution-id><institution-id institution-id-type="GRID">grid.8767.e</institution-id><institution></institution><institution>Vrije Universiteit Brussel (VUB) and Ghent University, End-of-Life Care Research Group,</institution></institution-wrap>Brussels, Belgium</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">28258277</idno><idno type="pmc">5434782</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5434782</idno><idno type="RBID">PMC:5434782</idno><idno type="doi">10.1038/s41533-017-0017-y</idno><date when="2017">2017</date><idno type="wicri:Area/Pmc/Corpus">000D83</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000D83</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Differences in place of death between lung cancer and COPD patients: a 14-country study using death certificate data</title><author><name sortKey="Cohen, Joachim" sort="Cohen, Joachim" uniqKey="Cohen J" first="Joachim" last="Cohen">Joachim Cohen</name><affiliation><nlm:aff id="Aff1"><institution-wrap><institution-id institution-id-type="ISNI">0000 0001 2290 8069</institution-id><institution-id institution-id-type="GRID">grid.8767.e</institution-id><institution></institution><institution>Vrije Universiteit Brussel (VUB) and Ghent University, End-of-Life Care Research Group,</institution></institution-wrap>Brussels, Belgium</nlm:aff></affiliation></author><author><name sortKey="Beernaert, Kim" sort="Beernaert, Kim" uniqKey="Beernaert K" first="Kim" last="Beernaert">Kim Beernaert</name><affiliation><nlm:aff id="Aff1"><institution-wrap><institution-id institution-id-type="ISNI">0000 0001 2290 8069</institution-id><institution-id institution-id-type="GRID">grid.8767.e</institution-id><institution></institution><institution>Vrije Universiteit Brussel (VUB) and Ghent University, End-of-Life Care Research Group,</institution></institution-wrap>Brussels, Belgium</nlm:aff></affiliation></author><author><name sortKey="Van Den Block, Lieve" sort="Van Den Block, Lieve" uniqKey="Van Den Block L" first="Lieve" last="Van Den Block">Lieve Van Den Block</name><affiliation><nlm:aff id="Aff1"><institution-wrap><institution-id institution-id-type="ISNI">0000 0001 2290 8069</institution-id><institution-id institution-id-type="GRID">grid.8767.e</institution-id><institution></institution><institution>Vrije Universiteit Brussel (VUB) and Ghent University, End-of-Life Care Research Group,</institution></institution-wrap>Brussels, Belgium</nlm:aff></affiliation><affiliation><nlm:aff id="Aff2"><institution-wrap><institution-id institution-id-type="ISNI">0000 0001 2290 8069</institution-id><institution-id institution-id-type="GRID">grid.8767.e</institution-id><institution>Department of Family Medicine and Chronic Care,</institution><institution>Vrije Universiteit Brussel (VUB),</institution></institution-wrap>Brussels, Belgium</nlm:aff></affiliation></author><author><name sortKey="Morin, Lucas" sort="Morin, Lucas" uniqKey="Morin L" first="Lucas" last="Morin">Lucas Morin</name><affiliation><nlm:aff id="Aff3">National Observatory of End of Life Care, Paris, France</nlm:aff></affiliation><affiliation><nlm:aff id="Aff4"><institution-wrap><institution-id institution-id-type="ISNI">0000 0004 1936 9377</institution-id><institution-id institution-id-type="GRID">grid.10548.38</institution-id><institution></institution><institution>Aging Research Center, Karolinska Institutet and Stockholm University,</institution></institution-wrap>Stockholm, Sweden</nlm:aff></affiliation></author><author><name sortKey="Hunt, Katherine" sort="Hunt, Katherine" uniqKey="Hunt K" first="Katherine" last="Hunt">Katherine Hunt</name><affiliation><nlm:aff id="Aff5"><institution-wrap><institution-id institution-id-type="ISNI">0000 0004 1936 9297</institution-id><institution-id institution-id-type="GRID">grid.5491.9</institution-id><institution></institution><institution>University of Southampton, Health Sciences,</institution></institution-wrap>Southampton, UK</nlm:aff></affiliation></author><author><name sortKey="Miccinesi, Guido" sort="Miccinesi, Guido" uniqKey="Miccinesi G" first="Guido" last="Miccinesi">Guido Miccinesi</name><affiliation><nlm:aff id="Aff6"><institution-wrap><institution-id institution-id-type="ISNI">0000 0004 1758 0566</institution-id><institution-id institution-id-type="GRID">grid.417623.5</institution-id><institution></institution><institution>Cancer Prevention and Research Institute, ISPO, Clinical and Descriptive Epidemiology Unit,</institution></institution-wrap>Florence, Italy</nlm:aff></affiliation></author><author><name sortKey="Cardenas Turanzas, Marylou" sort="Cardenas Turanzas, Marylou" uniqKey="Cardenas Turanzas M" first="Marylou" last="Cardenas-Turanzas">Marylou Cardenas-Turanzas</name><affiliation><nlm:aff id="Aff7"><institution-wrap><institution-id institution-id-type="ISNI">0000 0001 2291 4776</institution-id><institution-id institution-id-type="GRID">grid.240145.6</institution-id><institution></institution><institution>The University of Texas MD Anderson Cancer Center,</institution></institution-wrap>Houston, TX USA</nlm:aff></affiliation></author><author><name sortKey="Onwuteaka Philipsen, Bregje" sort="Onwuteaka Philipsen, Bregje" uniqKey="Onwuteaka Philipsen B" first="Bregje" last="Onwuteaka-Philipsen">Bregje Onwuteaka-Philipsen</name><affiliation><nlm:aff id="Aff8"><institution-wrap><institution-id institution-id-type="ISNI">0000 0001 0686 3219</institution-id><institution-id institution-id-type="GRID">grid.466632.3</institution-id><institution></institution><institution>EMGO Institute for Health and Care Research, Public and Occupational Health, and Palliative Care Expertise Centre, VU Medical Centre,</institution></institution-wrap>Amsterdam, The Netherlands</nlm:aff></affiliation></author><author><name sortKey="Macleod, Rod" sort="Macleod, Rod" uniqKey="Macleod R" first="Rod" last="Macleod">Rod Macleod</name><affiliation><nlm:aff id="Aff9"><institution-wrap><institution-id institution-id-type="ISNI">0000 0004 1936 834X</institution-id><institution-id institution-id-type="GRID">grid.1013.3</institution-id><institution></institution><institution>Hammond Care and University of Sydney,</institution></institution-wrap>Sydney, Australia</nlm:aff></affiliation></author><author><name sortKey="Ruiz Ramos, Miguel" sort="Ruiz Ramos, Miguel" uniqKey="Ruiz Ramos M" first="Miguel" last="Ruiz-Ramos">Miguel Ruiz-Ramos</name><affiliation><nlm:aff id="Aff10"><institution-wrap><institution-id institution-id-type="ISNI">0000 0004 1768 2343</institution-id><institution-id institution-id-type="GRID">grid.436087.e</institution-id><institution></institution><institution>Ministry of Health, Government of Andalusia,</institution></institution-wrap>Seville, Spain</nlm:aff></affiliation></author><author><name sortKey="Wilson, Donna M" sort="Wilson, Donna M" uniqKey="Wilson D" first="Donna M" last="Wilson">Donna M. Wilson</name><affiliation><nlm:aff id="Aff11"><institution-wrap><institution-id institution-id-type="GRID">grid.17089.37</institution-id><institution></institution><institution>Faculty of Nursing, University of Alberta,</institution></institution-wrap>Edmonton, AB Canada</nlm:aff></affiliation></author><author><name sortKey="Loucka, Martin" sort="Loucka, Martin" uniqKey="Loucka M" first="Martin" last="Loucka">Martin Loucka</name><affiliation><nlm:aff id="Aff12"><institution-wrap><institution-id institution-id-type="ISNI">0000 0004 1937 116X</institution-id><institution-id institution-id-type="GRID">grid.4491.8</institution-id><institution></institution><institution>Center for Palliative Care, Third Faculty of Medicine, Charles University in Prague,</institution></institution-wrap>Prague, Czech Republic</nlm:aff></affiliation></author><author><name sortKey="Csikos, Agnes" sort="Csikos, Agnes" uniqKey="Csikos A" first="Agnes" last="Csikos">Agnes Csikos</name><affiliation><nlm:aff id="Aff13"><institution-wrap><institution-id institution-id-type="ISNI">0000 0001 0663 9479</institution-id><institution-id institution-id-type="GRID">grid.9679.1</institution-id><institution></institution><institution>University of Pécs Medical School,</institution></institution-wrap>Pécs, Hungary</nlm:aff></affiliation></author><author><name sortKey="Rhee, Yong Joo" sort="Rhee, Yong Joo" uniqKey="Rhee Y" first="Yong-Joo" last="Rhee">Yong-Joo Rhee</name><affiliation><nlm:aff id="Aff14"><institution-wrap><institution-id institution-id-type="ISNI">0000 0004 0532 5816</institution-id><institution-id institution-id-type="GRID">grid.412059.b</institution-id><institution></institution><institution>Dongduk Women’s University, Health Sciences,</institution></institution-wrap>Seoul, Republic of Korea</nlm:aff></affiliation></author><author><name sortKey="Teno, Joan" sort="Teno, Joan" uniqKey="Teno J" first="Joan" last="Teno">Joan Teno</name><affiliation><nlm:aff id="Aff15"><institution-wrap><institution-id institution-id-type="ISNI">0000000122986657</institution-id><institution-id institution-id-type="GRID">grid.34477.33</institution-id><institution></institution><institution>University of Washington, Cambia Palliative Care Center of Excellence, Division of Gerontology and Geriatrics,</institution></institution-wrap>Seatle, WA USA</nlm:aff></affiliation></author><author><name sortKey="Ko, Winne" sort="Ko, Winne" uniqKey="Ko W" first="Winne" last="Ko">Winne Ko</name><affiliation><nlm:aff id="Aff1"><institution-wrap><institution-id institution-id-type="ISNI">0000 0001 2290 8069</institution-id><institution-id institution-id-type="GRID">grid.8767.e</institution-id><institution></institution><institution>Vrije Universiteit Brussel (VUB) and Ghent University, End-of-Life Care Research Group,</institution></institution-wrap>Brussels, Belgium</nlm:aff></affiliation></author><author><name sortKey="Deliens, Luc" sort="Deliens, Luc" uniqKey="Deliens L" first="Luc" last="Deliens">Luc Deliens</name><affiliation><nlm:aff id="Aff1"><institution-wrap><institution-id institution-id-type="ISNI">0000 0001 2290 8069</institution-id><institution-id institution-id-type="GRID">grid.8767.e</institution-id><institution></institution><institution>Vrije Universiteit Brussel (VUB) and Ghent University, End-of-Life Care Research Group,</institution></institution-wrap>Brussels, Belgium</nlm:aff></affiliation><affiliation><nlm:aff id="Aff16"><institution-wrap><institution-id institution-id-type="ISNI">0000 0001 2069 7798</institution-id><institution-id institution-id-type="GRID">grid.5342.0</institution-id><institution>Department of Medical Oncology,</institution><institution>Ghent University,</institution></institution-wrap>Ghent, Belgium</nlm:aff></affiliation></author><author><name sortKey="Houttekier, Dirk" sort="Houttekier, Dirk" uniqKey="Houttekier D" first="Dirk" last="Houttekier">Dirk Houttekier</name><affiliation><nlm:aff id="Aff1"><institution-wrap><institution-id institution-id-type="ISNI">0000 0001 2290 8069</institution-id><institution-id institution-id-type="GRID">grid.8767.e</institution-id><institution></institution><institution>Vrije Universiteit Brussel (VUB) and Ghent University, End-of-Life Care Research Group,</institution></institution-wrap>Brussels, Belgium</nlm:aff></affiliation></author></analytic><series><title level="j">NPJ Primary Care Respiratory Medicine</title><idno type="eISSN">2055-1010</idno><imprint><date when="2017">2017</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><p>Chronic obstructive pulmonary disease and lung cancer are leading causes of death with comparable symptoms at the end of life. Cross-national comparisons of place of death, as an important outcome of terminal care, between people dying from chronic obstructive pulmonary disease and lung cancer have not been studied before. We collected population death certificate data from 14 countries (year: 2008), covering place of death, underlying cause of death, and demographic information. We included patients dying from lung cancer or chronic obstructive pulmonary disease and used descriptive statistics and multivariable logistic regressions to describe patterns in place of death. Of 5,568,827 deaths, 5.8% were from lung cancer and 4.4% from chronic obstructive pulmonary disease. Among lung cancer decedents, home deaths ranged from 12.5% in South Korea to 57.1% in Mexico, while hospital deaths ranged from 27.5% in New Zealand to 77.4% in France. In chronic obstructive pulmonary disease patients, the proportion dying at home ranged from 10.4% in Canada to 55.4% in Mexico, while hospital deaths ranged from 41.8% in Mexico to 78.9% in South Korea. Controlling for age, sex, and marital status, patients with chronic obstructive pulmonary disease were significantly less likely die at home rather than in hospital in nine countries. Our study found in almost all countries that those dying from chronic obstructive pulmonary disease as compared with those from lung cancer are less likely to die at home and at a palliative care institution and more likely to die in a hospital or a nursing home. This might be due to less predictable disease trajectories and prognosis of death in chronic obstructive pulmonary disease.</p></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Lozano, R" uniqKey="Lozano R">R Lozano</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="White, P" uniqKey="White P">P White</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Gore, Jm" uniqKey="Gore J">JM Gore</name></author><author><name sortKey="Brophy, Cj" uniqKey="Brophy C">CJ Brophy</name></author><author><name sortKey="Greenstone, Ma" uniqKey="Greenstone M">MA Greenstone</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Beernaert, K" uniqKey="Beernaert K">K Beernaert</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Edmonds, P" uniqKey="Edmonds P">P Edmonds</name></author><author><name sortKey="Karlsen, S" uniqKey="Karlsen S">S Karlsen</name></author><author><name sortKey="Khan, S" uniqKey="Khan S">S Khan</name></author><author><name sortKey="Addington Hall, J" uniqKey="Addington Hall J">J Addington-Hall</name></author></analytic></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Pinnock, H" uniqKey="Pinnock H">H Pinnock</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Levy, Mh" uniqKey="Levy M">MH Levy</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Au, Dh" uniqKey="Au D">DH Au</name></author><author><name sortKey="Udris, Em" uniqKey="Udris E">EM Udris</name></author><author><name sortKey="Fihn, Sd" uniqKey="Fihn S">SD Fihn</name></author><author><name sortKey="Mcdonell, Mb" uniqKey="Mcdonell M">MB McDonell</name></author><author><name sortKey="Curtis, Jr" uniqKey="Curtis J">JR Curtis</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Carlucci, 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<front><journal-meta><journal-id journal-id-type="nlm-ta">NPJ Prim Care Respir Med</journal-id><journal-id journal-id-type="iso-abbrev">NPJ Prim Care Respir Med</journal-id><journal-title-group><journal-title>NPJ Primary Care Respiratory Medicine</journal-title></journal-title-group><issn pub-type="epub">2055-1010</issn><publisher><publisher-name>Nature Publishing Group UK</publisher-name><publisher-loc>London</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">28258277</article-id><article-id pub-id-type="pmc">5434782</article-id><article-id pub-id-type="publisher-id">17</article-id><article-id pub-id-type="doi">10.1038/s41533-017-0017-y</article-id><article-categories><subj-group subj-group-type="heading"><subject>Article</subject></subj-group></article-categories><title-group><article-title>Differences in place of death between lung cancer and COPD patients: a 14-country study using death certificate data</article-title></title-group><contrib-group><contrib contrib-type="author" corresp="yes"><contrib-id contrib-id-type="orcid">http://orcid.org/0000-0002-7224-9476</contrib-id><name><surname>Cohen</surname><given-names>Joachim</given-names></name><address><phone>+32(0)24774714</phone><email>jcohen@vub.ac.be</email></address><xref ref-type="aff" rid="Aff1">1</xref></contrib><contrib contrib-type="author"><name><surname>Beernaert</surname><given-names>Kim</given-names></name><xref ref-type="aff" rid="Aff1">1</xref></contrib><contrib contrib-type="author"><name><surname>Van den Block</surname><given-names>Lieve</given-names></name><xref ref-type="aff" rid="Aff1">1</xref><xref ref-type="aff" rid="Aff2">2</xref></contrib><contrib contrib-type="author"><name><surname>Morin</surname><given-names>Lucas</given-names></name><xref ref-type="aff" rid="Aff3">3</xref><xref ref-type="aff" rid="Aff4">4</xref></contrib><contrib contrib-type="author"><name><surname>Hunt</surname><given-names>Katherine</given-names></name><xref ref-type="aff" rid="Aff5">5</xref></contrib><contrib contrib-type="author"><name><surname>Miccinesi</surname><given-names>Guido</given-names></name><xref ref-type="aff" rid="Aff6">6</xref></contrib><contrib contrib-type="author"><name><surname>Cardenas-Turanzas</surname><given-names>Marylou</given-names></name><xref ref-type="aff" rid="Aff7">7</xref></contrib><contrib contrib-type="author"><name><surname>Onwuteaka-Philipsen</surname><given-names>Bregje</given-names></name><xref ref-type="aff" rid="Aff8">8</xref></contrib><contrib contrib-type="author"><name><surname>MacLeod</surname><given-names>Rod</given-names></name><xref ref-type="aff" rid="Aff9">9</xref></contrib><contrib contrib-type="author"><name><surname>Ruiz-Ramos</surname><given-names>Miguel</given-names></name><xref ref-type="aff" rid="Aff10">10</xref></contrib><contrib contrib-type="author"><name><surname>Wilson</surname><given-names>Donna M</given-names></name><xref ref-type="aff" rid="Aff11">11</xref></contrib><contrib contrib-type="author"><name><surname>Loucka</surname><given-names>Martin</given-names></name><xref ref-type="aff" rid="Aff12">12</xref></contrib><contrib contrib-type="author"><name><surname>Csikos</surname><given-names>Agnes</given-names></name><xref ref-type="aff" rid="Aff13">13</xref></contrib><contrib contrib-type="author"><name><surname>Rhee</surname><given-names>Yong-Joo</given-names></name><xref ref-type="aff" rid="Aff14">14</xref></contrib><contrib contrib-type="author"><name><surname>Teno</surname><given-names>Joan</given-names></name><xref ref-type="aff" rid="Aff15">15</xref></contrib><contrib contrib-type="author"><name><surname>Ko</surname><given-names>Winne</given-names></name><xref ref-type="aff" rid="Aff1">1</xref></contrib><contrib contrib-type="author"><name><surname>Deliens</surname><given-names>Luc</given-names></name><xref ref-type="aff" rid="Aff1">1</xref><xref ref-type="aff" rid="Aff16">16</xref></contrib><contrib contrib-type="author"><name><surname>Houttekier</surname><given-names>Dirk</given-names></name><xref ref-type="aff" rid="Aff1">1</xref></contrib><aff id="Aff1"><label>1</label><institution-wrap><institution-id institution-id-type="ISNI">0000 0001 2290 8069</institution-id><institution-id institution-id-type="GRID">grid.8767.e</institution-id><institution></institution><institution>Vrije Universiteit Brussel (VUB) and Ghent University, End-of-Life Care Research Group,</institution></institution-wrap>Brussels, Belgium</aff><aff id="Aff2"><label>2</label><institution-wrap><institution-id institution-id-type="ISNI">0000 0001 2290 8069</institution-id><institution-id institution-id-type="GRID">grid.8767.e</institution-id><institution>Department of Family Medicine and Chronic Care,</institution><institution>Vrije Universiteit Brussel (VUB),</institution></institution-wrap>Brussels, Belgium</aff><aff id="Aff3"><label>3</label>National Observatory of End of Life Care, Paris, France</aff><aff id="Aff4"><label>4</label><institution-wrap><institution-id institution-id-type="ISNI">0000 0004 1936 9377</institution-id><institution-id institution-id-type="GRID">grid.10548.38</institution-id><institution></institution><institution>Aging Research Center, Karolinska Institutet and Stockholm University,</institution></institution-wrap>Stockholm, Sweden</aff><aff id="Aff5"><label>5</label><institution-wrap><institution-id institution-id-type="ISNI">0000 0004 1936 9297</institution-id><institution-id institution-id-type="GRID">grid.5491.9</institution-id><institution></institution><institution>University of Southampton, Health Sciences,</institution></institution-wrap>Southampton, UK</aff><aff id="Aff6"><label>6</label><institution-wrap><institution-id institution-id-type="ISNI">0000 0004 1758 0566</institution-id><institution-id institution-id-type="GRID">grid.417623.5</institution-id><institution></institution><institution>Cancer Prevention and Research Institute, ISPO, Clinical and Descriptive Epidemiology Unit,</institution></institution-wrap>Florence, Italy</aff><aff id="Aff7"><label>7</label><institution-wrap><institution-id institution-id-type="ISNI">0000 0001 2291 4776</institution-id><institution-id institution-id-type="GRID">grid.240145.6</institution-id><institution></institution><institution>The University of Texas MD Anderson Cancer Center,</institution></institution-wrap>Houston, TX USA</aff><aff id="Aff8"><label>8</label><institution-wrap><institution-id institution-id-type="ISNI">0000 0001 0686 3219</institution-id><institution-id institution-id-type="GRID">grid.466632.3</institution-id><institution></institution><institution>EMGO Institute for Health and Care Research, Public and Occupational Health, and Palliative Care Expertise Centre, VU Medical Centre,</institution></institution-wrap>Amsterdam, The Netherlands</aff><aff id="Aff9"><label>9</label><institution-wrap><institution-id institution-id-type="ISNI">0000 0004 1936 834X</institution-id><institution-id institution-id-type="GRID">grid.1013.3</institution-id><institution></institution><institution>Hammond Care and University of Sydney,</institution></institution-wrap>Sydney, Australia</aff><aff id="Aff10"><label>10</label><institution-wrap><institution-id institution-id-type="ISNI">0000 0004 1768 2343</institution-id><institution-id institution-id-type="GRID">grid.436087.e</institution-id><institution></institution><institution>Ministry of Health, Government of Andalusia,</institution></institution-wrap>Seville, Spain</aff><aff id="Aff11"><label>11</label><institution-wrap><institution-id institution-id-type="GRID">grid.17089.37</institution-id><institution></institution><institution>Faculty of Nursing, University of Alberta,</institution></institution-wrap>Edmonton, AB Canada</aff><aff id="Aff12"><label>12</label><institution-wrap><institution-id institution-id-type="ISNI">0000 0004 1937 116X</institution-id><institution-id institution-id-type="GRID">grid.4491.8</institution-id><institution></institution><institution>Center for Palliative Care, Third Faculty of Medicine, Charles University in Prague,</institution></institution-wrap>Prague, Czech Republic</aff><aff id="Aff13"><label>13</label><institution-wrap><institution-id institution-id-type="ISNI">0000 0001 0663 9479</institution-id><institution-id institution-id-type="GRID">grid.9679.1</institution-id><institution></institution><institution>University of Pécs Medical School,</institution></institution-wrap>Pécs, Hungary</aff><aff id="Aff14"><label>14</label><institution-wrap><institution-id institution-id-type="ISNI">0000 0004 0532 5816</institution-id><institution-id institution-id-type="GRID">grid.412059.b</institution-id><institution></institution><institution>Dongduk Women’s University, Health Sciences,</institution></institution-wrap>Seoul, Republic of Korea</aff><aff id="Aff15"><label>15</label><institution-wrap><institution-id institution-id-type="ISNI">0000000122986657</institution-id><institution-id institution-id-type="GRID">grid.34477.33</institution-id><institution></institution><institution>University of Washington, Cambia Palliative Care Center of Excellence, Division of Gerontology and Geriatrics,</institution></institution-wrap>Seatle, WA USA</aff><aff id="Aff16"><label>16</label><institution-wrap><institution-id institution-id-type="ISNI">0000 0001 2069 7798</institution-id><institution-id institution-id-type="GRID">grid.5342.0</institution-id><institution>Department of Medical Oncology,</institution><institution>Ghent University,</institution></institution-wrap>Ghent, Belgium</aff></contrib-group><pub-date pub-type="epub"><day>3</day><month>3</month><year>2017</year></pub-date><pub-date pub-type="pmc-release"><day>3</day><month>3</month><year>2017</year></pub-date><pub-date pub-type="collection"><year>2017</year></pub-date><volume>27</volume><elocation-id>14</elocation-id><history><date date-type="received"><day>31</day><month>7</month><year>2016</year></date><date date-type="rev-recd"><day>13</day><month>1</month><year>2017</year></date><date date-type="accepted"><day>1</day><month>2</month><year>2017</year></date></history><permissions><copyright-statement>© The Author(s) 2017</copyright-statement><license license-type="OpenAccess"><license-p>This work is licensed under a Creative Commons Attribution 4.0 International License. The images or other third party material in this article are included in the article’s Creative Commons license, unless indicated otherwise in the credit line; if the material is not included under the Creative Commons license, users will need to obtain permission from the license holder to reproduce the material. To view a copy of this license, visit <ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/licenses/by/4.0/">http://creativecommons.org/licenses/by/4.0/</ext-link></license-p></license></permissions><abstract id="Abs1"><p>Chronic obstructive pulmonary disease and lung cancer are leading causes of death with comparable symptoms at the end of life. Cross-national comparisons of place of death, as an important outcome of terminal care, between people dying from chronic obstructive pulmonary disease and lung cancer have not been studied before. We collected population death certificate data from 14 countries (year: 2008), covering place of death, underlying cause of death, and demographic information. We included patients dying from lung cancer or chronic obstructive pulmonary disease and used descriptive statistics and multivariable logistic regressions to describe patterns in place of death. Of 5,568,827 deaths, 5.8% were from lung cancer and 4.4% from chronic obstructive pulmonary disease. Among lung cancer decedents, home deaths ranged from 12.5% in South Korea to 57.1% in Mexico, while hospital deaths ranged from 27.5% in New Zealand to 77.4% in France. In chronic obstructive pulmonary disease patients, the proportion dying at home ranged from 10.4% in Canada to 55.4% in Mexico, while hospital deaths ranged from 41.8% in Mexico to 78.9% in South Korea. Controlling for age, sex, and marital status, patients with chronic obstructive pulmonary disease were significantly less likely die at home rather than in hospital in nine countries. Our study found in almost all countries that those dying from chronic obstructive pulmonary disease as compared with those from lung cancer are less likely to die at home and at a palliative care institution and more likely to die in a hospital or a nursing home. This might be due to less predictable disease trajectories and prognosis of death in chronic obstructive pulmonary disease.</p></abstract><abstract id="Abs2" abstract-type="LongSummary"><title>Lung disease: improving end-of-life care</title><p>Structured palliative care similar to that offered to cancer sufferers should be in place for patients with chronic lung disease. Joachim Cohen at Vrije University in Brussels and co-workers examined international death certificate data collected from 14 countries to determine place of death for patients with lung cancer and chronic obstructive pulmonary disease (COPD). While patients with COPD suffer similar symptoms to lung cancer in their final days, few COPD patients receive palliative care or achieve the common wish of dying at home. This may be partly due to the inherent unpredictability of final-stage COPD compared with lung cancer. Cohen’s team found that, with the exception of Italy, Spain, and Mexico, patients with COPD were significantly more likely to die in hospital than at home. They highlight the need for improved COPD palliative care provision.</p></abstract><custom-meta-group><custom-meta><meta-name>issue-copyright-statement</meta-name><meta-value>© The Author(s) 2017</meta-value></custom-meta></custom-meta-group></article-meta></front><body><sec id="Sec1" sec-type="introduction"><title>Introduction</title><p>Lung cancer and chronic obstructive pulmonary disease (COPD) are two major causes of death in many countries, appearing as the fifth and third most common cause of death globally.<sup><xref ref-type="bibr" rid="CR1">1</xref></sup> Both illnesses affect patients’ quality of life with various stages of functional decline before death. Studies suggested that patients from both disease groups suffer from considerable dyspnea and pain.<sup><xref ref-type="bibr" rid="CR2">2</xref>–<xref ref-type="bibr" rid="CR4">4</xref></sup> Other studies have indicated that people with COPD have severe symptoms causing major disruptions to normal life but these are often perceived and accepted as a “way of life” rather than an illness.<sup><xref ref-type="bibr" rid="CR5">5</xref>, <xref ref-type="bibr" rid="CR6">6</xref></sup> Despite similar problems, existing literature has reported a disadvantage for people with COPD compared with those with lung cancer in receiving end-of-life care.<sup><xref ref-type="bibr" rid="CR3">3</xref>, <xref ref-type="bibr" rid="CR4">4</xref>, <xref ref-type="bibr" rid="CR7">7</xref>, <xref ref-type="bibr" rid="CR8">8</xref></sup> Lung cancer patients seem to receive a more holistic palliative approach to care.<sup><xref ref-type="bibr" rid="CR3">3</xref></sup> Fewer palliative care resources were used by people with COPD<sup><xref ref-type="bibr" rid="CR3">3</xref>, <xref ref-type="bibr" rid="CR4">4</xref>, <xref ref-type="bibr" rid="CR9">9</xref>, <xref ref-type="bibr" rid="CR10">10</xref></sup> and end-of-life care discussions occurred later in their disease trajectories.<sup><xref ref-type="bibr" rid="CR11">11</xref></sup> Those with COPD also seem to face unmet care needs to a larger extent<sup><xref ref-type="bibr" rid="CR12">12</xref>, <xref ref-type="bibr" rid="CR13">13</xref></sup> and appear to have less access to palliative care services.<sup><xref ref-type="bibr" rid="CR9">9</xref>, <xref ref-type="bibr" rid="CR14">14</xref></sup> The historical focus of palliative care on cancer patients may be one reason for this.<sup><xref ref-type="bibr" rid="CR7">7</xref></sup> Another reason might be the difference in disease trajectories.<sup><xref ref-type="bibr" rid="CR15">15</xref></sup> Predicting outcomes or prognosis is often easier for patients with lung cancer with a rapid decline and a distinct terminal phase than for those with COPD who have more acute exacerbations and have less recognizable terminal phase.<sup><xref ref-type="bibr" rid="CR16">16</xref></sup></p><p>Previous research comparing end-of-life care for COPD and lung cancer patients has focused on symptom management<sup><xref ref-type="bibr" rid="CR17">17</xref>–<xref ref-type="bibr" rid="CR19">19</xref></sup> and communication,<sup><xref ref-type="bibr" rid="CR14">14</xref>, <xref ref-type="bibr" rid="CR20">20</xref>, <xref ref-type="bibr" rid="CR21">21</xref></sup> little is known about how place of death differs between them. Place of death is often seen as a contributing factor in quality of dying, particularly because most people prefer to be cared for and to die at home.<sup><xref ref-type="bibr" rid="CR22">22</xref>, <xref ref-type="bibr" rid="CR23">23</xref></sup> The setting of dying has been shown to influence the characteristics of care and the dying experience. From research using Medicare data from the United States (USA), we know that COPD patients were more likely to die in hospital than were lung cancer patients.<sup><xref ref-type="bibr" rid="CR24">24</xref></sup> Nonetheless, cross-national comparisons for both populations remain scarce and such studies encourage mutual learning across borders by shedding a light on how patients with the same or different diseases die in different countries. Even neighboring countries with relatively similar cultures may organize end-of-life care differently and this evidence is valuable for evidence-based health policy-making.</p><p>The research aims of this study were first to compare and describe place of death of those persons diagnosed with lung cancer compared with those diagnosed with COPD in 14 countries and second to examine to what extent place of death differences between the two disease groups are due to confounding socio-economic and residential factors.</p></sec><sec id="Sec2" sec-type="results"><title>Results</title><sec id="Sec3"><title>Country and death characteristics</title><p>A total of 5,568,827 deaths were documented in the 14 countries. In all countries, except New Zealand and Mexico, more people died from lung cancer than COPD (Table <xref rid="Tab1" ref-type="table">1</xref>, country abbreviations explained). Lung cancer deaths ranged from 1.2% of all in Mexico to 7.6% in the Netherlands. Deaths from COPD ranged from 1.7% in France to 5.3% in the USA.<table-wrap id="Tab1"><label>Table 1</label><caption><p>Deaths from COPD and lung cancer in 14 countries during the year 2008 (<italic>N</italic> = 5,568,827)</p></caption><table frame="hsides" rules="groups"><thead><tr><th>Country</th><th>Abbreviations</th><th>Total number of deaths</th><th>COPD deaths (<italic>N</italic>)</th><th>COPD deaths (% of all deaths)</th><th>Lung cancer deaths (<italic>N</italic>)</th><th>Lung cancer deaths (% of all deaths)</th></tr></thead><tbody><tr><td>France</td><td>FR</td><td>541,135</td><td>9274</td><td>1.7</td><td>29,221</td><td>5.4</td></tr><tr><td>Italy</td><td>IT</td><td>578,192</td><td>21,356</td><td>3.7</td><td>33,004</td><td>5.7</td></tr><tr><td>Spain (Andalusia)</td><td>ES</td><td>57,380</td><td>2564</td><td>4.5</td><td>3198</td><td>5.6</td></tr><tr><td>Belgium</td><td>BE</td><td>102,924</td><td>4751</td><td>4.6</td><td>6491</td><td>6.3</td></tr><tr><td>The Netherlands</td><td>NL</td><td>135,136</td><td>6303</td><td>4.9</td><td>9918</td><td>7.6</td></tr><tr><td>The Czech Republic</td><td>CZ</td><td>101,804</td><td>2161</td><td>2.1</td><td>5310</td><td>5.2</td></tr><tr><td>Hungary</td><td>HU</td><td>130,027</td><td>4875</td><td>3.7</td><td>8330</td><td>6.4</td></tr><tr><td>England</td><td>ENG</td><td>475,763</td><td>25,143</td><td>5.3</td><td>28,222</td><td>5.9</td></tr><tr><td>Wales</td><td>WAL</td><td>32,066</td><td>1730</td><td>5.4</td><td>2032</td><td>6.3</td></tr><tr><td>New Zealand</td><td>NZ</td><td>29,312</td><td>1837</td><td>6.3</td><td>1634</td><td>6.0</td></tr><tr><td>Canada</td><td>CA</td><td>182,134</td><td>8185</td><td>4.5</td><td>12,902</td><td>7.1</td></tr><tr><td>United States of America</td><td>USA</td><td>2,428,343</td><td>12,8021</td><td>5.3</td><td>15,8889</td><td>6.5</td></tr><tr><td>Mexico</td><td>MX</td><td>528,093</td><td>21,804</td><td>4.6</td><td>6563</td><td>1.2</td></tr><tr><td>Korea</td><td>KR</td><td>247,757</td><td>7349</td><td>3.0</td><td>14,883</td><td>6.0</td></tr><tr><td>Total</td><td></td><td>5,568,827</td><td>245,345</td><td>4.4</td><td>320,591</td><td>5.8</td></tr></tbody></table><table-wrap-foot><p><italic>COPD</italic> chronic obstructive pulmonary disease</p></table-wrap-foot></table-wrap></p><p>As compared with people dying from lung cancer, those dying from COPD were more often older, female, and widowed or divorced (Table <xref rid="Tab2" ref-type="table">2</xref>). Most lung cancer patients were married (England: 51.3% to Italy: 69.3%), whereas those with majority COPD were more often widowed or divorced (Spain: 37.6% to USA: 57.5%).<table-wrap id="Tab2"><label>Table 2</label><caption><p>Demographic characteristics of people with COPD or lung cancer who died during 2008 in 14 countries (<italic>N</italic> = 562,151)</p></caption><table frame="hsides" rules="groups"><thead><tr><th></th><th></th><th>Number of deaths</th><th colspan="3">Age (%)</th><th>Sex (%)</th><th colspan="3">Marital status (%)</th></tr><tr><th></th><th></th><th></th><th>18–64</th><th>65–84</th><th>85 or older</th><th>Female</th><th>Unmarried</th><th>Married</th><th>Widowed/divorced</th></tr></thead><tbody><tr><td>France</td><td>COPD</td><td>9274</td><td>10.2</td><td>30.0</td><td>59.6</td><td>37.5</td><td>12.4</td><td>40.4</td><td>47.3</td></tr><tr><td></td><td>Lung cancer</td><td>29,221</td><td>40.4</td><td>40.3</td><td>19.3</td><td>23.6</td><td>11.4</td><td>60.8</td><td>27.8</td></tr><tr><td>Italy</td><td>COPD</td><td>21,356</td><td>3.5</td><td>26.2</td><td>70.3</td><td>39.3</td><td>10.8</td><td>42.5</td><td>46.7</td></tr><tr><td></td><td>Lung cancer</td><td>33,004</td><td>22.3</td><td>50.7</td><td>27.0</td><td>23.4</td><td>8.1</td><td>69.3</td><td>22.6</td></tr><tr><td>Spain (Andalusia)</td><td>COPD</td><td>2564</td><td>6.0</td><td>38.7</td><td>55.2</td><td>20.6</td><td>9.1</td><td>53.3</td><td>37.6</td></tr><tr><td></td><td>Lung cancer</td><td>3198</td><td>33.1</td><td>47.1</td><td>19.8</td><td>13.7</td><td>8.5</td><td>71.6</td><td>19.9</td></tr><tr><td>Belgium</td><td>COPD</td><td>4751</td><td>11.5</td><td>37.2</td><td>51.2</td><td>36.5</td><td>8.2</td><td>43.0</td><td>48.8</td></tr><tr><td></td><td>Lung cancer</td><td>6491</td><td>30.9</td><td>47.3</td><td>21.8</td><td>23.8</td><td>7.1</td><td>61.3</td><td>31.7</td></tr><tr><td>The Netherlands</td><td>COPD</td><td>6303</td><td>9.4</td><td>36.8</td><td>53.7</td><td>44.2</td><td>59.7</td><td>40.3</td><td>N/A</td></tr><tr><td></td><td>Lung cancer</td><td>9918</td><td>31.5</td><td>48.5</td><td>20.0</td><td>35.6</td><td>38.9</td><td>61.1</td><td>N/A</td></tr><tr><td>The Czech Republic</td><td>COPD</td><td>2161</td><td>21.4</td><td>42.4</td><td>36.2</td><td>39.7</td><td>8.0</td><td>39.9</td><td>52.1</td></tr><tr><td></td><td>Lung cancer</td><td>531</td><td>39.6</td><td>46.7</td><td>13.6</td><td>27.4</td><td>5.7</td><td>57.2</td><td>37.1</td></tr><tr><td>Hungary</td><td>COPD</td><td>4875</td><td>15.8<sup>a</sup></td><td>48.4<sup>a</sup></td><td>35.7<sup>a</sup></td><td>40.9</td><td>9.5</td><td>36.3</td><td>54.1</td></tr><tr><td></td><td>Lung cancer</td><td>833</td><td>33.5<sup>a</sup></td><td>55.5<sup>a</sup></td><td>10.9<sup>a</sup></td><td>32.8</td><td>7.5</td><td>53.6</td><td>38.9</td></tr><tr><td>England</td><td>COPD</td><td>25,143</td><td>10.5</td><td>39.2</td><td>50.1</td><td>48.7</td><td>7.8</td><td>36.9</td><td>55.3</td></tr><tr><td></td><td>Lung cancer</td><td>28,222</td><td>22.3</td><td>48.2</td><td>29.5</td><td>43.2</td><td>6.8</td><td>51.3</td><td>41.9</td></tr><tr><td>Wales</td><td>COPD</td><td>173</td><td>9.1</td><td>40.8</td><td>50.1</td><td>50.8</td><td>6.0</td><td>39.0</td><td>54.9</td></tr><tr><td></td><td>Lung cancer</td><td>2032</td><td>22.5</td><td>49.2</td><td>28.3</td><td>42.4</td><td>6.1</td><td>51.8</td><td>42.1</td></tr><tr><td>New Zealand</td><td>COPD</td><td>1837</td><td>12.2</td><td>37.8</td><td>49.9</td><td>50.2</td><td><sup>b</sup></td><td><sup>b</sup></td><td><sup>b</sup></td></tr><tr><td></td><td>Lung cancer</td><td>1634</td><td>28.8</td><td>47.1</td><td>24.1</td><td>45.6</td><td><sup>b</sup></td><td><sup>b</sup></td><td><sup>b</sup></td></tr><tr><td>Canada</td><td>COPD</td><td>8185</td><td>8.5</td><td>34.3</td><td>57.1</td><td>46.9</td><td>7.7</td><td>36.8</td><td>55.6</td></tr><tr><td></td><td>Lung cancer</td><td>12,902</td><td>26.7</td><td>47.7</td><td>25.7</td><td>46.0</td><td>6.8</td><td>55.5</td><td>37.7</td></tr><tr><td>USA</td><td>COPD</td><td>128,021</td><td>14.2</td><td>40.2</td><td>45.4</td><td>52.1</td><td>6.3</td><td>36.2</td><td>57.5</td></tr><tr><td></td><td>Lung cancer</td><td>158,889</td><td>28.8</td><td>47.1</td><td>24.1</td><td>44.3</td><td>6.0</td><td>51.0</td><td>43.0</td></tr><tr><td>Mexico</td><td>COPD</td><td>21,804</td><td>11.8</td><td>35.9</td><td>51.4</td><td>44.5</td><td>11.2</td><td>44.6</td><td>44.2</td></tr><tr><td></td><td>Lung cancer</td><td>6563</td><td>31.3</td><td>47.3</td><td>21.3</td><td>33.7</td><td>10.8</td><td>61.8</td><td>27.4</td></tr><tr><td>Korea</td><td>COPD</td><td>7349</td><td>7.9</td><td>42.8</td><td>49.3</td><td>38.7</td><td>2.8</td><td>47.7</td><td>49.7</td></tr><tr><td></td><td>Lung cancer</td><td>14,883</td><td>25.3</td><td>56.3</td><td>18.4</td><td>26.4</td><td>2.3</td><td>69.2</td><td>28.5</td></tr></tbody></table><table-wrap-foot><p><italic>Note</italic>: Percentages are row percentages. Percentages may not add up to 100 due to rounding</p><p><sup>a</sup>For age, the Hungarian file was delivered using a different aggregation: 0–17, 18–59, 60–79 (65–84), 80 or above (85 or above)</p><p><sup>b</sup>Variable not available for the country; N/A: category within variable not presented on the data file of the Netherlands; variable was dichotomized into married or not</p></table-wrap-foot></table-wrap></p></sec><sec id="Sec4"><title>Place of death</title><p>From 12.5% (Korea) to 57.1% (Mexico) of persons diagnosed with lung cancer died at home (Table <xref rid="Tab3" ref-type="table">3</xref>). Hospital deaths accounted for 27.5% (New Zealand) to 86.5% (Korea) of lung cancer deaths. Another 0.9% (Korea) to 22.5% (New Zealand) of lung cancer deaths occurred in nursing homes. For countries where the category hospice (i.e., palliative care institution) was available (England, Wales, New Zealand, and the USA), from 5.2% (USA) to 17.6% (New Zealand) of lung cancer deaths took place there. Of the COPD deaths, 10.4% (Canada) to 55.4% (Mexico) took place at home, 41.8% (The Netherlands) to 78.9% (Korea) in hospital, 1.5% (Korea) to 35.4% (The Netherlands) in nursing homes, and 0.2% (Wales) to 2.9% (USA) in palliative care institutions. A comparison with the place of death distribution for all-cause mortality can be found in the supplementary online appendix (Table <xref rid="MOESM1" ref-type="media">S1</xref>).<table-wrap id="Tab3"><label>Table 3</label><caption><p>The place of death of deceased patients with COPD and lung cancer by country (<italic>N</italic> = 562,151)</p></caption><table frame="hsides" rules="groups"><thead><tr><th></th><th></th><th>Number of deaths</th><th>Home (%)</th><th>Hospital (%)</th><th>Nursing home (%)</th><th>Hospice setting (%)</th><th>Others (%)</th></tr></thead><tbody><tr><td>France</td><td>COPD</td><td>9274</td><td>25.6</td><td>60.2</td><td>11.2</td><td>/<sup>a</sup></td><td>3.0</td></tr><tr><td></td><td>Lung cancer</td><td>29,221</td><td>17.0</td><td>77.4</td><td>3.0</td><td>/<sup>a</sup></td><td>2.7</td></tr><tr><td>Italy</td><td>COPD</td><td>21,356</td><td>41.6</td><td>47.4</td><td>7.5</td><td>/<sup>a</sup></td><td>3.5</td></tr><tr><td></td><td>Lung cancer</td><td>33,004</td><td>44.2</td><td>49.5</td><td>2.9</td><td>/<sup>a</sup></td><td>3.5</td></tr><tr><td>Spain (Andalusia)</td><td>COPD</td><td>2564</td><td>36.3</td><td>56.7</td><td>6.2</td><td>/<sup>a</sup></td><td>.8</td></tr><tr><td></td><td>Lung cancer</td><td>3198</td><td>33.1</td><td>64.5</td><td>2.1</td><td>/<sup>a</sup></td><td>.2</td></tr><tr><td>Belgium</td><td>COPD</td><td>4751</td><td>22.0</td><td>52.8</td><td>24.4</td><td>/<sup>a</sup></td><td>.8</td></tr><tr><td></td><td>Lung cancer</td><td>6491</td><td>28.8</td><td>63.9</td><td>6.8</td><td>/<sup>a</sup></td><td>.6</td></tr><tr><td>The Netherlands</td><td>COPD</td><td>6303</td><td>20.5</td><td>41.8</td><td>35.4</td><td>1.5<sup>b</sup></td><td>0.8</td></tr><tr><td></td><td>Lung cancer</td><td>9918</td><td>48.0</td><td>28.0</td><td>15.3</td><td>7.2<sup>b</sup></td><td>1.5</td></tr><tr><td>The Czech Republic</td><td>COPD</td><td>2161</td><td>17.2</td><td>66.8</td><td>14.7</td><td>/<sup>a</sup></td><td>1.3</td></tr><tr><td></td><td>Lung cancer</td><td>531</td><td>17.3</td><td>66.4</td><td>15.5</td><td>/<sup>a</sup></td><td>.8</td></tr><tr><td>Hungary</td><td>COPD</td><td>4875</td><td>/<sup>a</sup></td><td>69.8</td><td>/<sup>a</sup></td><td>/<sup>a</sup></td><td>30.2</td></tr><tr><td></td><td>Lung cancer</td><td>833</td><td>/<sup>a</sup></td><td>72.1</td><td>/<sup>a</sup></td><td>/<sup>a</sup></td><td>27.9</td></tr><tr><td>England</td><td>COPD</td><td>25,143</td><td>19.8</td><td>67.5</td><td>10.8</td><td>.9</td><td>1.0</td></tr><tr><td></td><td>Lung cancer</td><td>28,222</td><td>28.2</td><td>45.8</td><td>9.0</td><td>15.3</td><td>1.7</td></tr><tr><td>Wales</td><td>COPD</td><td>173</td><td>16.9</td><td>73.9</td><td>8.2</td><td>.2</td><td>.8</td></tr><tr><td></td><td>Lung cancer</td><td>2032</td><td>28.1</td><td>57.5</td><td>4.2</td><td>8.5</td><td>1.6</td></tr><tr><td>New Zealand</td><td>COPD</td><td>1837</td><td>15.5</td><td>44.7</td><td>34.0</td><td>1.9</td><td>4.0</td></tr><tr><td></td><td>Lung cancer</td><td>1634</td><td>29.9</td><td>27.5</td><td>22.5</td><td>17.6</td><td>2.6</td></tr><tr><td>Canada</td><td>COPD</td><td>8185</td><td>10.4</td><td>65.4</td><td>20.7</td><td>/<sup>a</sup></td><td>3.6</td></tr><tr><td></td><td>Lung cancer</td><td>12,902</td><td>16.3</td><td>69.0</td><td>9.9</td><td>/<sup>a</sup></td><td>4.9</td></tr><tr><td>USA</td><td>COPD</td><td>128,021</td><td>26.2</td><td>44.5</td><td>22.7</td><td>2.9</td><td>3.7</td></tr><tr><td></td><td>Lung cancer</td><td>158,889</td><td>40.3</td><td>33.9</td><td>15.0</td><td>5.2</td><td>5.7</td></tr><tr><td>Mexico</td><td>COPD</td><td>21,804</td><td>55.4</td><td>41.8</td><td>/<sup>a</sup></td><td>/<sup>a</sup></td><td>2.8</td></tr><tr><td></td><td>Lung cancer</td><td>6563</td><td>57.1</td><td>40.1</td><td>/<sup>a</sup></td><td>/<sup>a</sup></td><td>2.8</td></tr><tr><td>Korea</td><td>COPD</td><td>7349</td><td>19.4</td><td>78.9</td><td>1.5</td><td>/<sup>a</sup></td><td>.3</td></tr><tr><td></td><td>Lung cancer</td><td>14,883</td><td>12.5</td><td>86.5</td><td>.9</td><td>/<sup>a</sup></td><td>.1</td></tr></tbody></table><table-wrap-foot><p><italic>Note</italic>: Percentages are row percentages. Percentages may not add up to 100 due to rounding</p><p><sup>a</sup>Category not presented on death certificate. In Hungary, the death certificate registry only coded hospital or others as the place of death and nursing home does not exist as a separate health service in Mexico</p><p><sup>b</sup>In the Netherlands, the category “other institutions” on the death certificate mostly concerns hospices in these disease groups</p></table-wrap-foot></table-wrap></p></sec><sec id="Sec5"><title>Comparison of the place of death for COPD and lung cancer sufferers</title><p>As compared with COPD sufferers, those with lung cancer had higher crude chances of dying at home in nine countries, with the difference particularly large in the Netherlands (2.34) and New Zealand (1.93) (Fig. <xref rid="Fig1" ref-type="fig">1</xref>). In six of these nine countries, lung cancer patients were less likely to die in hospitals. In three countries—Belgium, Italy, and Canada—persons with lung cancer had both a higher ratio of dying at home and in hospital compared with people with COPD. Those with lung cancer in all countries (except in the Czech Republic) were less likely to die in a nursing home. In countries where palliative care institutions were available as a category of place of death, lung cancer sufferers were more likely than COPD ones to die there [risk ratios: 17.93 (England), 36.82 (Wales), 9.52 (New Zealand), and 1.78 (USA)] (not presented in figure).<fig id="Fig1"><label>Fig. 1</label><caption><p>Crude risk ratios for dying at home, in hospital, in a nursing home, in a palliative care institution of those dying from lung cancer vs. those from COPD. Risk ratios calculated as proportion lung cancer/proportion COPD dying in each place. A risk ratio >1 indicates that those with lung cancer were relatively more likely to die in that place compared to those with COPD deaths; a risk ratio <1 means that they were less likely</p></caption><graphic xlink:href="41533_2017_17_Fig1_HTML" id="d29e2791"></graphic></fig></p></sec><sec id="Sec6"><title>Multivariable analyses</title><sec id="Sec7"><title>Home vs. any other place of death</title><p>Controlling for confounders (age, sex, marital status), using binary logistic regression analyses (Table <xref rid="Tab4" ref-type="table">4</xref>), persons dying of COPD were significantly less likely than lung cancer patients to die at home in 10 countries [OR from 0.4 (The Netherlands) to 0.8 (Belgium, Spain, and Mexico)]. An opposite pattern was found in France (OR 1.7) and Korea (OR 1.5), with COPD sufferers there more likely to die at home.<table-wrap id="Tab4"><label>Table 4</label><caption><p>Odds ratios of COPD vs. lung cancer patients (reference) stratified by place of death: binary multivariable logistic regression models of death certificates data from 14 countries during 2008 (<italic>N</italic> = 562,151)</p></caption><table frame="hsides" rules="groups"><thead><tr><th>Country</th><th>Home (vs. all others) (<italic>N</italic> = 562,151)</th><th>Home (vs. hospital) (<italic>N</italic> = 447,537)</th><th>Hospital (vs. all others) (<italic>N</italic> = 562,151)</th><th>Nursing home (vs. hospital) (<italic>N</italic> = 345,463)</th><th>Hospice setting (vs. others) (<italic>N</italic> = 41,092)</th></tr><tr><th></th><th>OR (95% CI)</th><th>OR (95% CI)</th><th>OR (95% CI)</th><th>OR (95% CI)</th><th>OR (95% CI)</th></tr></thead><tbody><tr><td>France</td><td><bold>1.7 (1.58</bold>–<bold>1.80)</bold></td><td><bold>1.8 (1.71</bold>–<bold>1.94)</bold></td><td><bold>0.5 (0.52</bold>–<bold>0.58)</bold></td><td><bold>2.1 (1.89</bold>–<bold>2.33)</bold></td><td>/<sup>a</sup></td></tr><tr><td>Italy</td><td><bold>0.9 (0.87</bold>–<bold>0.94)</bold></td><td><bold>0.9 (0.88</bold>–<bold>0.96)</bold></td><td><bold>1.0 (1.00</bold>–<bold>1.08)</bold></td><td><bold>1.6 (1.42</bold>–<bold>1.72)</bold></td><td>/<sup>a</sup></td></tr><tr><td>Spain</td><td><bold>0.8 (0.75</bold>–<bold>0.96)</bold></td><td>0.9 (0.79–1.01)</td><td>1.0 (0.91–1.17)</td><td><bold>1.9 (1.34</bold>–<bold>2.67)</bold></td><td>/<sup>a</sup></td></tr><tr><td>Belgium</td><td><bold>0.8 (0.77</bold>–<bold>0.93)</bold></td><td>0.97 (0.9–1.07)</td><td><bold>0.8 (0.71</bold>–<bold>0.84)</bold></td><td><bold>2.4 (2.09</bold>–<bold>2.73)</bold></td><td>/<sup>a</sup></td></tr><tr><td>The Netherlands</td><td><bold>0.4 (0.33</bold>–<bold>0.39)</bold></td><td><bold>0.3 (0.27</bold>–<bold>0.33)</bold></td><td><bold>2.4 (2.23</bold>–<bold>2.59)</bold></td><td><bold>0.9 (0.81</bold>–<bold>0.98)</bold></td><td>/<sup>a</sup></td></tr><tr><td>The Czech Republic</td><td>1.1 (0.96–1.26)</td><td>1.1 (0.92–1.22)</td><td>1.1 (0.95–1.19)</td><td><bold>0.8 (0.68</bold>–<bold>0.92)</bold></td><td>/<sup>a</sup></td></tr><tr><td>Hungary</td><td>/<sup>a</sup></td><td>/<sup>a</sup></td><td>0.9 (0.85–1.01)</td><td>/<sup>a</sup></td><td>/<sup>a</sup></td></tr><tr><td>England</td><td><bold>0.7 (0.68</bold>–<bold>0.74)</bold></td><td><bold>0.5 (0.50</bold>–<bold>0.54)</bold></td><td><bold>2.5 (2.42</bold>–<bold>2.60)</bold></td><td><bold>0.6 (0.55</bold>–<bold>0.62)</bold></td><td><bold>0.1 (0.07</bold>–<bold>0.11)</bold></td></tr><tr><td>Wales</td><td><bold>0.6 (0.49</bold>–<bold>0.68)</bold></td><td><bold>0.5 (0.43</bold>–<bold>0.61)</bold></td><td><bold>2.1 (1.80</bold>–<bold>2.40)</bold></td><td>1.1 (0.82–1.48)</td><td><bold>0.1 (0.01</bold>–<bold>0.20)</bold></td></tr><tr><td>New Zealand</td><td><bold>0.5 (0.43</bold>–<bold>0.60)</bold></td><td><bold>0.3 (0.27</bold>–<bold>0.40)</bold></td><td><bold>2.7 (2.28</bold>–<bold>3.10)</bold></td><td><bold>0.6 (0.51</bold>–<bold>0.75)</bold></td><td><bold>0.1 (0.05</bold>–<bold>0.14)</bold></td></tr><tr><td>USA</td><td><bold>0.6 (0.56</bold>–<bold>0.58)</bold></td><td><bold>0.5 (0.47</bold>–<bold>0.49)</bold></td><td><bold>1.8 (1.81</bold>–<bold>1.87)</bold></td><td><bold>0.8 (0.77</bold>–<bold>0.81)</bold></td><td><bold>0.9 (0.87</bold>–<bold>0.98)</bold></td></tr><tr><td>Canada</td><td><bold>0.7 (0.63</bold>–<bold>0.76)</bold></td><td><bold>0.7 (0.67</bold>–<bold>0.80)</bold></td><td>0.98 (0.92–1.05)</td><td><bold>1.5 (1.40</bold>–<bold>1.66)</bold></td><td>/<sup>a</sup></td></tr><tr><td>Mexico</td><td><bold>0.8 (0.72</bold>–<bold>0.82)</bold></td><td><bold>0.8 (0.72</bold>–<bold>0.81)</bold></td><td><bold>1.3 (1.21</bold>–<bold>1.37)</bold></td><td>/<sup>a</sup></td><td>/<sup>a</sup></td></tr><tr><td>Korea</td><td><bold>1.5 (1.43</bold>–<bold>1.68)</bold></td><td><bold>1.6 (1.43</bold>–<bold>1.69)</bold></td><td><bold>0.7 (0.60</bold>–<bold>0.71)</bold></td><td>1.2 (0.90–1.57)</td><td>/<sup>a</sup></td></tr></tbody></table><table-wrap-foot><p><italic>Note</italic>: Bold denotes a significant difference between lung cancer and COPD patients. Variables included in model: age, sex, marital status (except NZ, where marital status was not available)</p><p><sup>a</sup>Category did not exist on death certificate</p></table-wrap-foot></table-wrap></p></sec><sec id="Sec8"><title>Home vs. hospital as place of death</title><p>Lower odds ratios for home death (less than one) were observed in COPD decedents in nine countries [OR from 0.3 (The Netherlands and New Zealand) to 0.9 (Spain)] with France (OR 1.8) and Korea (OR 1.6) showing patients with COPD more likely to die in hospitals.</p></sec><sec id="Sec9"><title>Hospital vs. any other place of death</title><p>Compared with those with lung cancer, COPD patients were significantly more likely to die in hospital instead of outside a hospital in seven countries [OR from 1.0 (Italy) to 2.7 (New Zealand)], but the opposite was observed in France (OR 0.5), Korea (OR 0.7), and Belgium (OR 0.8). The Czech Republic was the only country showing no differences between the two disease groups with regard to place of death.</p></sec><sec id="Sec10"><title>Nursing home vs. hospital as place of death</title><p>COPD patients were more likely than lung cancer patients to die in a nursing home in five countries [OR from 1.5 (Canada) to 2.4 (Belgium)], while in five other countries (The Netherlands, The Czech Republic, England, New Zealand, USA) COPD decedents died more often in hospitals than did lung cancer decedents.</p></sec><sec id="Sec11"><title>Palliative care institutions vs. any other place of death</title><p>Lastly, a comparison between palliative care institutions and other places of death for England, Wales, New Zealand, and the USA showed that in all these countries COPD decedents had a significantly lower chance of dying in a palliative care institution compared with lung cancer decedents (ORs ranging from 0.1 to 0.9).</p></sec></sec></sec><sec id="Sec12" sec-type="discussion"><title>Discussion</title><sec id="Sec13"><title>Main findings</title><p>This study captures variations in place of death of people dying from lung cancer and COPD, two major causes of death, across different health-care systems. We found that patients dying from COPD were more likely to die in hospital than at home (or in a palliative care institution) than those dying from lung cancer, even when considering characteristics in terms of age, gender, and marital status. France and Korea were the exceptions.</p></sec><sec id="Sec14"><title>Strengths and limitations of this study</title><p>Using population death certificate data to study cross-national variation in place of death may induce some limitations that need to be taken into account.<sup><xref ref-type="bibr" rid="CR25">25</xref></sup> Due to coding and processing delays in some countries and our stipulation to select the same year across the different countries the data used are relatively old (2008) and it may be that some changes in the place of death have occurred in some countries since then.<sup><xref ref-type="bibr" rid="CR26">26</xref></sup> However, no other previous study has examined cross-national variation in place of death of people who died from lung cancer or COPD in both European and non-European countries. Death certificates have been shown to sometimes be inaccurate in recording the correct cause of death.<sup><xref ref-type="bibr" rid="CR27">27</xref>, <xref ref-type="bibr" rid="CR28">28</xref></sup> COPD is known to be under-reported on death certificates.<sup><xref ref-type="bibr" rid="CR29">29</xref></sup> However, for the purpose of comparison with those who died from lung cancer (which may be less prone to underreporting as a cause of death) and selection of only those people whose recorded underlying cause of death was COPD (i.e., those who died from COPD and thus were probably in an advanced stage and with a clear diagnosis of COPD at the time of death), this problem of under-reporting may be less problematic. An additional limitation, inherent to using robust population-level data, is that a loss of information at the individual level is inevitable. For instance, the death certificate does not provide information on important aspects of the end-of-life process such as preferences of place of death, choices of place of care, and course of decision-making levels, i.e., patients, family, health-care professionals, and/or health-care policy makers. Nevertheless, the statistical patterns about place of death do reflect important differences in the health-care organizational choices countries have made regarding end-of-life care in lung cancer vs. COPD and inspire further studies to provide us with a deeper understanding of observed patterns and the cross-national differences underlying those patterns.</p></sec><sec id="Sec15"><title>Interpretation of findings in relation to previously published work</title><p>Previous studies have found on average 75% of respondents prefer to die at home, among the terminally ill and the general public.<sup><xref ref-type="bibr" rid="CR22">22</xref></sup> However, for the majority of countries in our study, COPD decedents were substantially more likely than lung cancer decedents to die in hospital even after controlling for confounders; this may suggest a lack of options for COPD patients to die at home in most countries. This is likely to be due to a combination of factors, including a long-standing cancer focus on palliative care. COPD is an illness characterized by unpredictable exacerbations and prognosis of death. There is no clear-cut indicator with enough evidence to be effective to estimate the end-of-life phase for COPD.<sup><xref ref-type="bibr" rid="CR30">30</xref></sup> In addition, these patients and their family caregivers often do not realize that they have a limited life expectancy.<sup><xref ref-type="bibr" rid="CR8">8</xref>, <xref ref-type="bibr" rid="CR31">31</xref></sup> However, recently a cluster randomized controlled trial has shown that advance care planning in COPD sufferers might decrease hospitalizations and increases home deaths.<sup><xref ref-type="bibr" rid="CR32">32</xref></sup> Previous experiences have indicated that working with a coordinator for care planning may also be a way to improve end-of-life care for persons diagnosed with COPD.<sup><xref ref-type="bibr" rid="CR33">33</xref></sup> Making of advance care plans and establishing contact with end-stage care services could possibly result in a reduction of hospitalizations of advanced COPD patients at the end of life and increase the opportunity to honor their preferences for place of death.</p><p>We found that the percentages of COPD patients dying in nursing homes are substantially higher compared with lung cancer. This finding may reflect their older age and their disability or loss of functional performance in home management.<sup><xref ref-type="bibr" rid="CR34">34</xref></sup> This functional performance was found to be higher in older females,<sup><xref ref-type="bibr" rid="CR34">34</xref></sup> often leading to admission to a nursing home, and might explain why female COPD patients are more likely to die in a nursing home. However, the role of the nursing home as a place of end-of-life care and death is not well understood. Previous studies highlighted barriers to performing end-of-life care in long-term care settings because of a lack of communication and failure to initiate a palliative trajectory in good time.<sup><xref ref-type="bibr" rid="CR35">35</xref>, <xref ref-type="bibr" rid="CR36">36</xref></sup> This is an important consideration as hospital deaths can potentially be avoided if location preferences are known through optimal advance care planning. Improving the quality of end-of-life care in nursing homes, including policies to reduce hospitalizations at the end of life, thus seems to be an important policy priority for COPD sufferers as opposed to simply focusing all efforts on enabling them to die at home.</p><p>While the differences in terms of place of death between COPD and lung cancer decedents were large in most countries, they were very small in Italy, Spain, and Mexico. In these three countries, a relatively large proportion of both COPD and lung cancer patients died at home. This is probably due to a culture of family (or community) caregiving rather than the result of specific public health policies to facilitate home deaths. In spite of the observed general patterns of differences in place of death across the two groups of patients in each country, there were some additional cross-border differences. Home deaths were generally high for all decedents in Mexico (55.4–57.1%) and Italy (41.6–44.2%), whereas hospital deaths were high in France (60.2–77.4%) and South Korea (78.9–86.5%). The trend in France might be a result of the continued dominance of hospital-centered care and the insufficient training of oncologists and pulmonologists in palliative care. This might be understood in the light of different cultures of caregiving as well as of the surrounding medical culture. In those countries where hospice was recorded as a category, lung cancer patients were found to die there in far greater proportions than COPD patients. However, this was not the case in the USA and it might reflect how countries differ in placing the long-term focus of their palliative care services on cancer as opposed to other illnesses eligible for palliative care.<sup><xref ref-type="bibr" rid="CR7">7</xref></sup> More wider structural country-specific factors, such as insurance and reimbursement systems and regulations might, however, also play a role.</p></sec><sec id="Sec16"><title>Implications for future research, policy, and practice</title><p>In order to create equal opportunities for dying at home and for access to palliative care for COPD sufferers, a “palliative care” culture for COPD is needed as well as the awareness (both in caregivers and in patients) that early discussions about end-of-life care preferences might result in better care according to the patients’ wishes and less hospitalizations and more home deaths,<sup><xref ref-type="bibr" rid="CR10">10</xref></sup> although the trajectory and the death of COPD sufferers may be more difficult to accurately predict.</p></sec></sec><sec id="Sec17"><title>Conclusions</title><p>Our study found in almost all countries that COPD sufferers as compared with lung cancer sufferers are less likely to die at home and more likely to die in a hospital or a nursing home. In the four countries that record palliative care institutions as a place of death, we found lung cancer sufferers to be much more likely to die there than COPD patients.</p></sec><sec id="Sec18" sec-type="materials|methods"><title>Materials and methods</title><sec id="Sec19"><title>Study design and data</title><p>This study is part of the International Place of Death (IPoD) study, which is a study of population-level death certificate data. An open call was launched by the principal investigators and candidate partners negotiated a full year’s death certificate data for inclusion. An exploration by all candidate partners revealed the most recent available year in all targeted countries was or would be 2008, which was chosen as the reference year. Exceptions were the USA (2007) and Spain (no data were recorded prior to 2010). Fourteen out of the 27 candidate countries obtained permission for data use and their data were integrated into an international database. The principal investigators pooled all data guaranteeing uniform coding throughout the database.</p><p>Death certification was executed in similar ways in the 14 countries: a physician or a qualified person such as a nurse completes the part of the death certificate indicating cause of death, time, and place of death<sup><xref ref-type="bibr" rid="CR37">37</xref></sup> along with a limited range of demographic information (e.g., sex) for the deceased. In some countries another part of the death certificate, containing more socio-demographic information about the deceased, is completed by a civil servant. All information is then processed by trained coders, following strict coding protocols, with the necessary quality checks. The death certificate data were linked across a number of countries with similar population databases such as the Census Data to include more socio-demographic information about the decedents in the database. For this study we used the death certificate data of all 14 countries included in the IPoD study: Belgium, France, Italy, Spain (Andalusia), the Netherlands, The Czech Republic, Hungary, England, Wales, New Zealand, the USA, Canada, Mexico, and Korea. More details on the database and methods can also be found in other publications based on the IPoD database.<sup><xref ref-type="bibr" rid="CR38">38</xref>–<xref ref-type="bibr" rid="CR40">40</xref></sup></p></sec><sec id="Sec20"><title>Data</title><p>We selected cases where lung cancer (ICD-10 codes C33-C34) or COPD (ICD-10 codes J40-44, J47) was an underlying cause of death. The outcome for our study was the place of death as recorded in the death certificate. The available categories of place of death were: hospital, home, nursing home/residential long-term care, hospice, or others. In Hungary, the death certificate only contains two categories of place of death, hospital and others, whereas hospice (e.g., palliative care institution) was only available as a category in England, Wales, New Zealand, Canada, and the USA.</p></sec><sec id="Sec21"><title>Statistical analysis</title><p>Descriptive statistics were used to examine differences in the place of death between patients dying from lung cancer and those from COPD. Crude ratios (the percentages of lung cancer deaths divided by the percentages of COPD deaths) were calculated to compare the differences in place of death between the two disease groups.</p><p>Multivariable binary logistic regression models were constructed to determine the odds ratios of dying at home (comparing home vs. all other places and comparing home vs. hospital), in hospital (vs. all other places), in nursing home (vs. hospital), and in PC institutions (vs. all other places). All analyses used lung cancer as the reference group. Independent variables used in the multivariable analyses included demographics and health-care resources. Demographic factors included age (categories 0–17, 18–64, 65–85, 85 or above), sex, and marital status (unmarried, married, widowed, or divorced). Relevant confounders and covariates in the models were entered using a forward stepwise selection method with <italic>P</italic> < 0.05 set as an entry criterion.</p><p>All statistical analyses were conducted using IBM-SPSS Statistics version 20 (SPSS Inc., Chicago, IL, 2010). For all analyses, significance was set at <italic>P</italic> < .05 (two-tailed).</p></sec></sec><sec sec-type="supplementary-material"><title>Electronic supplementary material</title><sec id="Sec22"><p><supplementary-material content-type="local-data" id="MOESM1"><media xlink:href="41533_2017_17_MOESM1_ESM.docx"><caption><p>Supplementary Information</p></caption></media></supplementary-material></p></sec></sec></body><back><fn-group><fn><p><bold>Electronic supplementary material</bold></p><p>Supplementary Information accompanies the paper on the <italic>npj Primary Care Respiratory Medicine</italic> website (doi:10.1038/s41533-017-0017-y).</p></fn></fn-group><ack><title>Acknowledgements</title><p>The authors thank the IPoD and EURO IMPACT consortium members in giving anonymous suggestions to earlier versions of the manuscript. The International Place of Death (IPoD) study is supported by a fund from the Research Foundation Flanders. This work was supported by EURO IMPACT (FP7/2007–2013, under grant agreement no [264697]). Joachim Cohen and Lieve Van den Block are supported by a postdoctoral grant from the Research Foundation—Flanders, Belgium.</p><sec id="FPar3"><title>Competing interests</title><p> The authors declare that they have no competing interests.</p></sec></ack><notes notes-type="author-contribution"><title>Author Contributions</title><p>J.C., W.K., and K.B. did the data analyses. J.C. and W.K. started the manuscript drafting, and K.B. drafted a revised manuscript and tables after review. D.H., L.V.D.B., L.M., K.H., G.M., M.C.T., B.O.P., R.M., M.R.R., D.M.W., M.L., A.C., Y.J.R., J.T., L.D., J.C. contributed to the conceptualization of the study and data collection. D.H. and J.C. created the database and performed data cleaning. All authors read and approved the manuscript. 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