Admitted patient palliative care and other end-of-life care and hospital-based facilities

This section presents information on episodes of admitted patient palliative care and other end-of-life care occurring in Australian hospitals, using data on palliative care-related hospitalisations from the National Hospital Morbidity Database (NHMD). The NHMD is a collation of data about admitted patient care in Australian hospitals, based on the Admitted Patient Care National Minimum Data Set.

Information is presented on hospitalisations for which palliation was provided. A palliative care-related hospitalisation is defined as an episode of admitted patient care for which the principal clinical intent was palliation during all or part of that episode.

In this section, palliative care-related hospitalisations are separated into two groups: palliative care hospitalisations and other end-of-life care hospitalisations. The term palliative care as used in this section refers to specialist palliative care. The term other end-of-life care as used in this section refers to hospitalisations where a diagnosis of palliative care was recorded, but that care was not necessarily delivered by a palliative care specialist. Further information can be found in the data sources section and Identifying palliative care hospitalisations section.

Time series data for the period from 2014–15 to 2018–19 are presented to show the changes in hospitalisations for palliative care and other end-of-life care over this 5-year period. Wherever possible, corresponding data on all hospitalisations have been provided for comparative purposes. It should be noted that this section reports on the time period before the COVID-19 pandemic.

This section also presents information on public acute and private hospital-based hospice care units.

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The information in this section was last updated in May 2021.

Key points

  • 83,430 palliative care-related hospitalisations were reported from public acute and private hospitals in Australia in 2018–19; 57.3% were for palliative care, and 42.7% were for other end-of-life care.
  • 53.6% of palliative care hospitalisations and 54.2% of other end-of-life care hospitalisations were for people aged 75 and over.
  • 17.7% increase in palliative care hospitalisations and 47.5% increase in other end-of-life care hospitalisations between 2014–15 and 2018–19, compared to a 13.7% increase in hospitalisations for all reasons over the same period.
  • 38.4% of all hospitalisations in which the patient died, the patient had received palliative care in 2018–19; 18.6% had received other end-of-life care.
  • 53.6% of palliative care and 33.9% of other end-of-life care hospitalisations involved cancer as the principal diagnosis in 2018–19.
  • 110 public acute hospitals reported that they had a hospice care unit in 2018–19, with just over a quarter located in both New South Wales (27.3%) and Western Australia (27.3%).
  • 1 in 6 (16.4%) public acute hospitals (excluding public psychiatric hospitals) in Australia had a hospice care unit in 2018–19.

Admitted patient palliative care and other end-of-life care

In 2018–19, there were 47,845 palliative care and 35,585 other end-of-life care hospitalisations reported from public acute and private hospitals in Australia, totalling 83,430 palliative care-related hospitalisations (see Table APC.1). This accounted for about 1 in 140 (0.7%) of all hospitalisations (11.5 million). A higher proportion of hospitalisations for palliative care were for males (53.2%) than females (46.8%), and the rate was also higher for males than females (20.4 and 17.6 per 10,000 population, respectively). This pattern was very similar for other end-of-life care (see Table APC.2).

People aged 75 and over accounted for just over half of palliative care (53.6%) and of other end-of-life care (54.2%) hospitalisations in 2018–19. The average age of the patient at admission was 73.9 for palliative care hospitalisations and 74.1 for other end-of-life care hospitalisations, with little difference between the sexes. This was considerably older than the average age of 56.0 years for hospitalisations for all reasons. Only about 1 in 10 of the total number of palliative care hospitalisations (9.6%) and other end-of life care hospitalisations (10.4%) were for patients aged under 55 (see Table APC.3).

Between 2014–15 and 2018–19 the number of palliative care hospitalisations increased by 17.7%, from 40,634 to 47,845, whilst the number of other end-of-life care hospitalisations increased by 47.5%, from 24,128 to 35,585. The number of all hospitalisations increased by 13.7% over the same period.

The population rate for hospitalisations also trended upward between 2014–15 and 2018–19, from 17.2 to 19.0 per 10,000 population for palliative care and from 10.2 to 14.1 for other end-of-life care. The 5-year rate of change by age group for palliative care hospitalisations showed a variable pattern – larger increases in the average annual rate of change for those aged less than 20 and those aged 85 years and over, but smaller variations in the rate of change for all other age groups. For other end-of-life care hospitalisations, the rate of change per year increased across all age groups.

Profile of palliative care and other end-of-life care hospitalisations

Where was palliative care and other end-of-life care provided?

In 2018–19, similar to previous years’ findings, a high proportion of palliative care and other end-of-life care hospitalisations were recorded from public hospitals (85.9% and 82.3%, respectively or 41,102 and 29,299 hospitalisations, respectively). In contrast, 59.7% of all hospitalisations were recorded from public hospitals (see Tables APC.8–APC.10 for further detail).

Private sector data were not able to be published for all states and territories. Where it was published, the proportion of palliative care hospitalisations in public hospitals varied, from 48.9% in Western Australia to 97.8% in New South Wales. A similar range of variation by state was also present for other end-of-life care hospitalisations in public hospitals, from 61.6% in Queensland to 85.9% in South Australia.

There was considerable variation by state in the rates of palliative care and other end-of-life care hospitalisations in both public and private hospitals. The Australian Capital Territory reported the highest population rate at 22.5 palliative care hospitalisations per 10,000 population for public hospitals, and Western Australia had the lowest (7.4) (Figure APC.1). In those states where private sector data were able to be published, Western Australia reported the highest rate (7.8 per 10,000 population) for palliative care hospitalisations in private hospitals, and New South Wales reported the lowest (0.5). For those states and territories where all hospitalisations were able to be published, Queensland had the highest rate of palliative care hospitalisations in all hospitals (24.7 per 10,000 population), and Victoria had the lowest overall rate for all hospitals (13.4). See Table APC.9 for further detail.

Figure APC.1 -  Palliative care hospitalisations by state and territory, rate per 10,000 population, public and private hospitals 2018-19.

Vertical bar chart showing the rate per 10,000 population of palliative care hospitalisations by jurisdiction. Public hospitals, NSW 21.2, Vic 12.2, Qld 19.2, WA 7.4, SA 13.1, Tas 15.9, ACT 22.5, NT 16.5, Total 16.3. Private hospitals, NSW 0.5, Vic 1.2, Qld 5.5, WA 7.8, SA 2.7, Tas not published, ACT not published, NT not published, Total 2.7. Refer to Table APC.9.

Source data: Admitted patient palliative care and hospital-based facilities Table APC.9

Change over time by sector

The number of admitted patient palliative care-related hospitalisations between 2014–15 and 2018–19 increased in both public and private hospitals. The number of public palliative care and other end-of-life care hospitalisations increased by 19.4% (average annual change of 4.5%) and 42.7% (average annual change of 9.3%), respectively, with public hospitalisations for all reasons increasing by 15.8% (average annual change of 3.7%) over the same period.

Numbers of palliative care and other end-of-life care hospitalisations in private hospitals also increased, resulting in a net increase of 8.5% and 74.7%, respectively over the same period. This equated to an average annual change of 2.1% and 15.0% per year, respectively. The increase in all private hospital hospitalisations, was 10.7% over the same period.

For public hospitals, the rate of palliative care hospitalisations increased from 14.6 in 2014–15 to 16.3 per 10,000 in 2018–19. The rate of palliative care hospitalisations in private hospitals was steady over the same period from 2.6 to 2.7 per 10,000 population. For all hospitals, the rate of palliative hospitalisations increased slightly from 17.2 to 19.0 per 10,000 over the period.

Figure APC.2 Palliative care hospitalisations, rate per 10,000 population, public and private hospitals, 2014-15 to 2018-19

Line graph with two lines showing the rate per 10,000 population of public and private palliative care hospitalisations from 2014–15 to 2018–19. The rate for public hospitals increased over time from 14.6 in 2014–15 to 16.3 in 2018–19. The rate for private hospitals remained steady from 2.6 in 2014–15 to 2.7 in 2018–19. Refer to table APC.9.

Source data: Admitted patient palliative care and hospital-based facilities Table APC.9

Change over time by jurisdiction

For public hospitals, the largest average annual increases in palliative care hospitalisations between 2014–15 and 2018–19 were for the Australian Capital Territory (10.5%) and New South Wales (6.1%), and the largest increases for other end-of-life care were for New South Wales (14.2%) and South Australia (9.7%) (see Table APC.8). The population rate of palliative hospitalisations (see Table APC.9) increased across most states and territories between 2014–15 and 2018–19. The rate for other end-of-life care hospitalisations over the same period varied across states and territories.

Among the states and territories where data could be reported for private hospitals, the number of palliative and other end-of-life care hospitalisations varied over time and across jurisdictions over the period.

For those states and territories where data could be reported for all hospital sectors, there was an increase in the number of palliative care and other end-of-life care hospitalisations between 2014–15 and 2018–19. For palliative care, the range in the average annual increase was from 2.1% in Victoria, to 5.8% in New South Wales. For other end-of-life care, the range was more pronounced, from 1.2% in Victoria to 15.3% in New South Wales.

How long did patients stay?

Palliative care and other end-of-life care hospitalisations accounted for about 447,997 and 387,659 patient days, respectively with an average length of stay (ALOS) of 9.4 and 10.9 days, respectively. This is 3.5 to 4 times as long as the ALOS of 2.7 days for all hospitalisations. When only those hospitalisations that involved an overnight stay (ALOS excluding same-day separations) are considered, the difference narrows to close to twice the length for palliative care (9.8 days) and other end-of-life care (11.3 days) hospitalisations compared to all hospitalisations (5.4 days).

For jurisdictions where private hospitals data can be reported, the average length of stay for palliative care hospitalisations in 2018–19 was longer in private than public hospitals for all jurisdictions with the exception of Victoria. The greatest difference was in Queensland, with a 7.3 day longer ALOS in private compared to public hospitals (Figure APC.3) in 2018–19.

Nationally, ALOS, when excluding same-day separations, was higher in private (12.6 days) than in public hospitals (9.3 days) for overnight palliative care hospitalisations. The ALOS in public hospitals for overnight hospitalisations was highest in Victoria (11.1 days), and lowest in Queensland (7.2 days). For private hospitals, Queensland recorded the highest overnight ALOS, at 14.5 days.

Figure APC.3: Palliative care hospitalisations, average length of stay, public and private hospitals, by states and territory, 2018-19

Vertical bar chart showing the average length of stay for palliative care hospitalisations by jurisdiction for public and private hospitals. Average length of stay in public hospitals ranged from 6.8 days in Qld to 10.8 days in Vic. In private hospitals, average length of stay ranged from 9.7 days in Vic to 14.0 days in Qld. Refer to Table APC.11.

Source data: Admitted patient palliative care and hospital-based facilities Table APC.11

Change over time in length of stay

The number of patient days for palliative care hospitalisations in admitted patient settings increased by 5.0% between 2014–15 and 2018–19, from 426,835 to 447,997 patient days. The ALOS for palliative care hospitalisations trended downwards over the same period, from 10.5 to 9.4 days over this period (Figure APC.4). Patient days for other end-of-life care increased by 49.6% over the same period, from 259,071 to 387,659 days, and ALOS for other end-of-life care was fairly stable.

Figure APC.4: Palliative care hospitalisations, patient days and ALOS, public and private hospitals 2014-15 to 2018-19

A combined bar and line graph showing patient days (bars) and average length of stay (line) for palliative care hospitalisations from 2014–15 to 2018–19. Patient days showed an increase over time from 426,835 days in 2014–15 to 447,997 days in 2018–19. Average length of stay showed a decrease from 10.5 days in 2014–15 to 9.4 in 2018–19. Refer to table APC.1.

Source data: Admitted patient palliative care and hospital-based facilities Table APC.1

Who paid for the care?

In 2018–19, public patient funding accounted for 76.2% of palliative care hospitalisations in public hospitals; private health insurance was the next most common funding source (20.2%). Results for other end-of-life care hospitalisations were similar. By comparison, public patient funding for all hospitalisations in public hospitals was 84.2% and private health insurance 12.9%.

In private hospitals, private health insurance was the funding source for 60.6% of palliative care hospitalisations, compared with 83.1% of all hospitalisations. Public patient funding was more likely for palliative care hospitalisations in private hospitals (25.4%) than all hospitalisations (4.4%).

The funding pattern for palliative care in public and private hospitals combined was mostly consistent across states and territories (see Table APC.14). There was also a mostly consistent distribution of funding source across all hospitals by state for other end-of-life care.

How was the care completed?

The ‘mode of completing a hospitalisation’ indicates the status of a patient at the end of the hospitalisation; for example, whether the person died, or their destination on discharge from hospital.

Table APC.13 provides information on modes of completing hospitalisation. Six in 10 palliative care hospitalisations ended with the patient’s death (62.6%), compared with 4 in 10 (40.7%) for other end-of-life care and less than 1 in a hundred (0.7%) for all hospitalisations. The next most common reason for completing hospitalisation for palliative care and other end-of-life care was discharge to usual residence (24.3% and 31.0% respectively). Differences between palliative care and other end-of-life care were observable for the remaining modes of completing hospitalisation, with only 13.0% of palliative care patients having another separation mode, compared to 28.3% of patients with other end of life care.

Patterns of completing palliative care hospitalisations were mostly similar across both public and private hospitals, although patients from private hospitals were more likely to be discharged to their usual residence (37.7%) than patients from public hospitals (22.1%) and less likely for their hospitalisation to end with death (private hospitals: 55.6%; public hospitals: 63.8%). In public hospitals, other end-of-life care hospitalisations were less likely to end with death than palliative care hospitalisations (38.8% compared with 63.8% respectively), and patients were more likely to be discharged to their usual residence (29.6% compared with 22.1% respectively). Patterns for completing other end-of-life care hospitalisations was mostly similar to that of palliative care hospitalisations for private hospitals.

Jurisdictional differences were evident within and across sectors. The proportion of palliative care hospitalisations in public hospitals ending with the patient’s death was lowest in New South Wales (60.5%) and highest in Tasmania (77.8%). For private hospitals, the proportion of hospitalisations in which the patient died were generally lower for states and territories with reported data, ranging from 46.6% in Queensland to 66.2% in Western Australia. Palliative care patients from private hospitals were much more likely to be transferred to another hospital in Victoria compared with other jurisdictions reported. Jurisdictional variation was also seen for other end-of-life care (see Table APC.13 for further detail).

Characteristics of admitted palliative care and other end-of-life care patients 

This section presents information on the number and proportion of palliative care and other end-of-life care hospitalisations for various demographic groups. Further detail can be seen in Tables APC.5-APC.7.

Socioeconomic status

Socioeconomic status generally refers to the level of economic and social resources of an individual (such as income, education and employment) and it is well established that it is associated with health outcomes (AIHW 2020). The Index of Relative Socio Economic Disadvantage (IRSD) is used here to indicate socioeconomic status of the area in which the individual lives.

In 2018–19, people living in areas classified as having the lowest socioeconomic status (Quintiles 1 and 2) accounted for a higher proportion of palliative care hospitalisations (24.4% and 25.1% respectively) in public hospitals than those living in other areas. The rate of palliative care public hospitalisations was also highest for those living in these areas (19.8 and 20.5 per 10,000 population respectively). Conversely, the rate of public palliative care hospitalisations was lowest for those living in the highest socioeconomic status areas (11.1 per 10,000). These patterns are similar to those for other end-of-life-care and for all hospitalisations.

A contrasting pattern is apparent for palliative care hospitalisations in private hospitals, where the rate was highest for those living in the highest socioeconomic status areas (4.1 per 10,000 population) compared to lowest socioeconomic status areas (1.4 per 10,000 population). This pattern was also seen for other end-of-life care for these socioeconomic groups and for all private hospitalisations.

Indigenous status

Aboriginal and Torres Strait Islander people are disadvantaged relative to other Australians across a range of health-related and socioeconomic indicators (AIHW 2015a). This may affect their use of, and access to, admitted patient palliative care and other end-of-life care.

A total of 1,142 palliative care and 728 other end-of-life care hospitalisations for Indigenous Australians were reported in 2018–19, with the majority occurring in public hospitals (94.2% and 97.3%, respectively). This compares to 88.5% of all hospitalisations among Indigenous Australians that occurred in public hospitals.

Remoteness of patient’s usual residence

Most palliative care hospitalisations in 2018–19 across all hospital sectors were for patients whose usual residence was in Major cities (63.5%), with the proportion of palliative care hospitalisations decreasing as remoteness increased. After taking into account the size of the population in these regions, the rate of public hospital hospitalisations for palliative care per 10,000 population was lowest in Major cities and Remote and Very remote areas (14.1 and 13.3 per 10,000 population, respectively). The rate was highest for Inner regional (23.0 per 10,000) and Outer regional areas (23.5 per 10,000). In contrast, the rate of public hospital hospitalisations for other end-of-life care was similar across all remoteness areas.

Diagnosis

The principal diagnosis recorded for a hospitalisation is ‘the diagnosis established after study to be chiefly responsible for occasioning an episode of admitted patient care’ (AIHW 2015b; ACCD 2015). Additional diagnoses are those ‘conditions or complaints either coexisting with the principal diagnosis or arising during the episode of admitted patient care’. One or more additional diagnoses can be assigned to the care episode (AIHW 2015b; ACCD 2015).

About half of all palliative care (53.6%) and one third of other end-of-life care (33.9%) hospitalisations recorded a principal diagnosis of cancer in 2018–19. The most frequently reported principal cancer diagnosis with a palliative care-related hospitalisation was secondary site cancer (cancer of an unknown or ill-defined primary site), of which 11.2% had a palliative care hospitalisation, and 10.6% had other end-of-life care. The next most common principal diagnosis of cancer was lung cancer, for both palliative care and other end-of-life care (8.5% and 4.5%, respectively).

The most frequently reported principal diagnoses other than cancer for palliative care hospitalisations were cerebrovascular disease and heart failure and complications (4.3% and 3.1%, respectively). For other end-of-life care, the most frequently reported principal diagnoses other than cancer were septicaemia and other ill-defined causes (4.9% and 4.8%, respectively).

Palliative care and other end-of-life care deaths in hospital

This section presents data on a subset of palliative care and other end-of-life care hospitalisations—those that ended with the patient’s death. Some admitted patients who died in hospital but were not identified as being ‘palliative care patients’ or ‘other end-of-life care patients’ may also have received some palliation during the hospitalisation that ended with their death. However, as elsewhere in this section, the focus is on those hospitalisations for which palliation was a substantial component of the care provided.

Place of death

In 2018–19, it is estimated that about 162,600 people died in Australia (ABS 2020). According to data from the NHMD (Table APC.1), there were 77,999 hospitalisations that ended in death in 2018-19, indicating that close to half (48.0%) of total deaths occurred in hospital.

Most states and territories operate hospital-in-the-home (HITH) programs, under which patients are provided with hospital-type care, are categorised as an admitted patient, but receive this care in their home as a substitute for hospital accommodation (AIHW 2012). Admitted patients receiving HITH may have their final hospitalisation in their home; although it is also possible for HITH patients to return to hospital during their final hospitalisation.

Palliative care and other end-of-life care patients and death

In 2014–15, 33.3% of admitted patients had been a palliative care patient during the hospitalisation that ended with their death, and 12.6% had received other end-of-life care. This proportion has steadily increased such that by 2018–19, 38.4% of people who died as an admitted patient had been a palliative care patient during their final hospitalisation, and 18.6% had received other end-of-life care. Although it is difficult to be definitive about the reasons for this increase over time, the growth and ageing of Australia’s population, and the corresponding increase in the prevalence of chronic, progressive and generally incurable illnesses has broadened the type of patient groups requiring palliative care (AIHW 2020; Murtagh et al. 2013).