Home medical care is a form of healthcare aimed at managing and continuing medical treatment in the patient’s residence. It is expected to improve the quality of life (QOL) of patients and reduce medical expenses, therefore, it is being promoted as a national policy [1].

However, in end-of-life situations, although many patients express a desire to die at home, the reality often does not align with the wishes of patients or their families. According to the Ministry of Health, Labour and Welfare’s report titled “Results of the FY2022 Survey on Attitudes Toward Medical Care and Support at the End of Life”, 53.8% of the general public wished to spend their final moments at home or in a care facility [2]. Yet, the actual data from FY2022 showed that only 28.4% of deaths occurred in such locations [3]. Moreover, patient transfers to a hospital during the terminal phase impose significant economic and social burdens, making the avoidance of such transfers an urgent issue [4].

Various factors have been identified as contributing to this discrepancy, and if the factors influencing the place of death can be identified, they could serve as predictive indicators. This would allow for care that aligns with patient preferences and the implementation of Advance Care Planning (ACP), potentially improving both the quality and efficiency of home medical care.

Several previous studies in Japan have analyzed the actual place of death and related factors in home medical care. (Hereafter, “home” refers to the original place of residence, while “residence” includes both private homes and care facilities.)

Ishikawa attempted an analysis based on indicators of medical and nursing care supply, finding that regional characteristics such as population density, the extent to which clinics provide end-of-life care, and the availability of home-visit nursing services were positively correlated with residential deaths. In contrast, the number of hospitalizations, the capacity of group homes, and the proportion of end-of-life care provided in nursing homes were negatively correlated [5].

Abe and colleagues conducted interviews with eight care managers, analyzing 16 cases related to end-of-life care. They reported that family cooperation was a facilitating factor for home death, while lack of information about home care at discharge, caregiver exhaustion in cases with uncertain prognoses, and financial burdens were inhibiting factors [6].

Hasegawa and colleagues conducted a three-year prospective cohort study involving 1,875 elderly individuals requiring nursing care who were receiving home care. They investigated the place and cause of death and found that only the age of the care recipient was significantly associated with home death. Malignant tumors (cancer) and diabetes were negatively associated [7]. However, this study did not examine the use of home-visit medical services, and given the variety of reports on factors determining death at home, we decided to re-examine which factors are involved in the place of death under home-visit medical care, based on a chart review of our own cases.

The purpose of this study was to identify the factors influencing the place of death (home death vs. in-hospital death) among patients treated at our medical corporation, Ohisama Clinic. These factors included gender, age, number of hospitalizations, length of hospital stay, level of nursing care required, type of residence (private home or facility), and comorbidities. The aim was to generate data that could serve as a reference for improving the quality and efficiency of home medical care.

Subjects
The study targeted 1,101 patients who received home medical care by Medical Corporation Ohisama-kai Yamaguchi Clinic (currently Ohisama Clinic) and died during the 12 years and 8 months between October 2005 and May 2018.

Items

The survey items included:

1. Gender
2. Date of birth
3. Final level of nursing care required
4. Comorbidities
5. Starting date of medical care
6. Type of residence
7. Date of death
8. Date of hospitalization
9. Date of discharge
10. Place of death

The place of death was categorized as follows: deaths occurring at home or in care facilities were defined as “residential deaths” (deaths at the place of residence; non-hospital deaths), while deaths occurring after hospitalization were defined as “in-hospital deaths.” Thus, deaths were classified based on whether they occurred at the location where home medical care was being provided (residence: home or facility) or elsewhere (hospital).

Data Aggregation

1. Number of hospitalizations and total days hospitalized

The total number of hospitalizations and total days hospitalized from the start of home medical care to death were aggregated for each patient.

2. Age at the start of care and age at death

For the analysis, the age one year prior to death (age at death minus one year) was used.

3. Type of residence

Residences were categorized as either private homes or facilities (non-home).

*Facilities included: nursing homes, special nursing homes, group homes, senior housing with services, small-scale multifunctional home care facilities, care houses, low-cost elderly homes, and others.

4. Level of nursing care required

The final level of nursing care required at the time of death was used. Among the 1,101 cases, 1,042 had known care levels and were included in the analysis. The remaining 59 cases were excluded due to unknown care levels (e.g., under application, not applicable, not using services, or unclear).

5. Comorbidities

Patients with the following comorbidities were identified: cancer, dementia, diabetes, heart disease, and respiratory disease (excluding lung cancer).

Statistical Analysis

1. Relationship between place of death and variables such as duration of home medical care, age one year before death, number of hospitalizations, days hospitalized (from one year before death to death), level of nursing care, and comorbidities (univariate analysis) Comparisons were made using the Wilcoxon rank-sum test and chi-square test. As this univariate analysis was exploratory, factors with a p-value less than 0.1 were selected for inclusion as explanatory variables in the multivariate logistic regression model.
2. Examination of multicollinearity among factors related to in-hospital death
   To eliminate confounding factors directly related to the number of hospitalizations (hospitalization events), Kendall’s rank correlation coefficient was used to check for multicollinearity among the selected factors.
   (Factors with a correlation coefficient of 0.4 or higher were excluded from the multivariate logistic regression model.)
3. Exploration of factors related to place of death (in-hospital death vs. residential death) using a multivariate logistic regression model Using in-hospital death as the dependent variable and the selected factors (number of hospitalizations, age one year before death, level of nursing care, type of residence, and comorbidities) as explanatory variables, parameter estimates and odds ratios were calculated using a multivariate logistic regression model.

The statistical analyses were conducted using JMP® 17 ver.1.0 (SAS, North Carolina, USA), and a p-value of less than 0.05 was considered statistically significant.

Ethical Considerations

This study was conducted with the approval of the Research Ethics Committee of Japan University of Economics (Approval No.: 2023-1110-02). It was carried out in accordance with the ethical principles for medical research involving human subjects as stated in the Declaration of Helsinki by the World Medical Association (WMA). Personal information such as the names of participants and other identifying data were anonymized within the facility using ID codes and were strictly managed with password protection. All data analyses were conducted within the facility.

1. Patient Backgrounds in Residential Deaths vs. In-hospital Deaths

Table 1 presents the patient backgrounds for residential and in-hospital deaths. In cases of in-hospital death, the number of hospitalizations from one year before death to the time of death was significantly higher compared to residential death cases. While there were no notable differences in gender, age at the start of care, or duration of care, the age one year prior to death and the level of nursing care required were both higher in residential death cases. Regarding type of residence (home vs. facility), residential deaths were more common among those living in facilities. The proportion of residential deaths was higher among patients with dementia, whereas in-hospital deaths were more frequent among those with heart disease or respiratory disease.

Table 1: Exploration of Factors Influencing Place of Death (Univariate Analysis).

In decision-making support for home-based care—including emergency hospital transfers-decisions are not based solely on medical judgment. They also take into account the wishes of the patient and family, anticipated quality of life, and economic and social circumstances. However, since this study was based on medical chart reviews, the analysis did not include these contextual factors and instead focused solely on identifying causal relationships.

Given that hospitalization events (i.e., number of hospitalizations) were strongly associated with in-hospital deaths, the study period was set to the final year of life. As shown in Table 1, the number of hospitalizations emerged as a strong determinant of hospital death. At this stage, other factors such as younger age at death, presence of heart or respiratory disease were also associated with hospital death, while dementia, higher levels of nursing care, and residence in a facility were associated with residential death. One possible explanation is that heart and respiratory diseases often follow a rapid course, leading to hospitalization in hopes of life-saving treatment or better prognosis—unlike cancer or dementia. Additionally, higher care needs and facility residence may have facilitated end-of-life care at the place of residence.

Table 2 confirmed that factors other than hospitalization count could be treated as independent variables. Ultimately, as shown in Tables 3 and 4, number of hospitalizations, non-cancer diagnosis, and living at home were strongly associated with in-hospital death, while higher levels of nursing care were strongly associated with residential death.

From these findings, the following can be inferred:

- Hospitalization during the terminal phase is highly likely to result in in-hospital death.

- Cancer and facility residence are closely associated with residential death, and avoiding hospitalization as much as possible can make dying at home a realistic outcome.

- Since the level of nursing care was found to be an independent factor from hospitalization, it may represent a different kind of barrier to in-hospital death.

In other words, while these findings align with what has already been practiced in clinical settings, they reinforce the importance of avoiding hospitalization—especially for cancer patients—when residential death is desired. Moreover, patients with high care needs are also likely to achieve their wish to die at home.

According to Hamano [8], among terminal cancer patients receiving palliative care either at home or in hospital, those in the home care group had an average survival of 65 days when life expectancy was measured in months, compared to 32 days in the hospital group—about twice as long. Even among those with a life expectancy of weeks, the home group survived 32 days versus 22 days in the hospital group. This suggests that palliative care at home may be more beneficial than hospital-based care.

This report supports the feasibility of end-of-life care for cancer patients at home, and the present analysis further suggests that minimizing hospitalization is key to making this possible.

As for why higher care needs and facility residence were associated with residential rather than in-hospital death, the following factors may be relevant:

• When care needs are high, both patients/families and healthcare providers may intentionally avoid

hospitalization due to the increased risk of in-hospital death.

• In the case of facility residents, if there was a mutual understanding between the facility and the patient/family that the facility would serve as the “final residence,” hospital transfers at the end of life may have been intentionally avoided.

While these possibilities suggest that the intentions of patients, families, and healthcare providers played a role, this study did not directly investigate those aspects. However, previous research by Sasaki et al [9]. has pointed out that the wishes of patients and families strongly influence the actual place of death, and it is likely that such preferences were reflected in the present findings as well.

On the other hand, it is important to consider these findings in relation to Advance Care Planning (ACP).

In 2018, Japan revised its “Guidelines on the Decision-Making Process for Medical Care and Care in the Final Stage of Life,” which broadened the scope of discussions related to ACP, including preferences regarding the place of death [10]. However, due to varying levels of awareness and acceptance among patients and families, ACP must be adapted to each situation—regarding when, under what circumstances, for whom, and by whom it should be conducted—making it difficult to draw clear boundaries [11].

Although predicting the prognosis of terminal patients is inherently challenging, it has been shown that cancer patients often experience a rapid decline in Activities of Daily Living (ADL) during the final month of life [12]. Various indicators are being developed to help predict the timing of death [13].These tools are expected to contribute to the advancement of ACP. However, for diseases such as heart failure and COPD, where symptoms can change rapidly, identifying the terminal phase remains extremely difficult [14].

Nonetheless, even in these areas, the need for palliative care has prompted the development of various approaches to prognosis prediction [15,16]. As a result, opportunities to share prognostic expectations with patients and families—taking into account factors such as age and level of nursing care—are likely to increase.

Currently, in situations where it is difficult to estimate the patient’s wishes, there is a risk that hospital transfers may occur against the patient’s intent. This underscores the growing importance of ACP. Freund and colleagues categorized the reasons for hospital transfers into five levels: (1) system-level, (2) physician-level, (3) medical-level, (4) patient-level, and (5) social-level factors. They concluded that 41% of transfers were potentially avoidable, with more than half of the avoidable cases falling under system- and patient-level factors [17].

Inoue and colleagues also reported on emergency transfers of patients receiving home medical care [18]. They analyzed two years of data, classifying the reasons into four categories: medical, provider-related, patient-related, and social factors. They found that approximately 80% of transfers were due to social factors on the patient side, and about 48% of emergency hospitalizations could have been avoided.

The “social factors” referred to in this context include lack of social support, financial difficulties, caregiving for patients with dementia or psychiatric disorders, and cases where care facilities were unable to manage the situation. Their multivariate analysis showed that patients who had undergone ACP and had their wishes confirmed in advance were less likely to be transferred in emergencies. This supports the conclusion that ACP is an important factor in avoiding unnecessary hospitalizations.

In the present study, the concept of ACP had not yet become widespread in Japan during the study period, and the wishes of patients and families could not be confirmed from the medical records. Moving forward, it will be essential to conduct research and analysis that incorporates social factors such as the patient’s and family’s preferences regarding the place of death, cohabitation status, level of awareness and independence, and use of services like home-visit nursing.

Nevertheless, this study is meaningful in that it identified factors related to the place of death based on real-world data, aligning with previous research. It offers valuable insights for both patients receiving home medical care and healthcare providers in supporting care aligned with patient and family wishes and in implementing effective ACP.

As this was a retrospective observational study conducted at a single clinic, future research should include long-term, prospective, multi-institutional studies to clarify the clinical course of home medical care in greater detail. Additionally, since this study reflects the clinical landscape prior to the COVID-19 pandemic, and given the significant changes in the healthcare system since then, future research should also consider comparisons before and after the pandemic and incorporate a broader range of influencing factors.

Among patients receiving home medical care, those who died in hospital had a higher number of hospitalizations in the final year of life compared to those who died at home. It was confirmed that the number of hospitalizations was not associated with age one year before death, level of nursing care, type of residence, or comorbidities. 

The number of hospitalizations was the most influential factor associated with in-hospital death. 

In contrast, factors such as living in a facility, having cancer, and higher levels of nursing care were not triggers for in-hospital death but were instead associated with dying at home.

Considering the factors that influence the place of death may serve as a valuable reference for realizing care that aligns with patient preferences and for implementing Advance Care Planning (ACP).

Acknowledgments
We would like to express our special thanks to Journal of Japanese Association for Home Care Medicine for the permission to secondary publication in English, and to Mr. Roderick Lange for checking the translation of our English abstract.

This is an article originally published in Japanese in Journal of Japanese Association for Home Care Medicine.

(Title: “Factors which affect place of death in home medical care including medical resource consumption, nursing care level, and disease.” published in 2024)

Funding Informatiom

No authors are associated with specific fundings to this article.

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