Association of patient sex with use of palliative care in Ontario, Canada: a population-based study

BACKGROUND: It is unclear whether there are sex-based differences in use of palliative care near the end of life. The objective of this study was to measure the association between sex and palliative care use. METHODS: We performed a population-based retrospective cohort study of all patients aged 18 years or older in the last year of life who died in Ontario, Canada, between 2010 and 2018. The primary exposure was patient biologic sex (male or female). The primary outcome was receipt of physician-delivered palliative care; secondary outcomes were approach to in-hospital palliative care and sex concordance of the patient and referring physician. We used multivariable modified Poisson regression to measure the association between patient sex and palliative care receipt, as well as patient–physician sex concordance. RESULTS: There were 706 722 patients (354 657 females [50.2%], median age 80 yr [interquartile range 69–87 yr]) in the study cohort, 377 498 (53.4%) of whom received physician-delivered palliative care. After adjustment for age and selected comorbidities, female sex was associated with a 9% relative increase (adjusted relative risk [RR] 1.09, 95% CI 1.08–1.10) in receipt of physician-delivered palliative care. Female patients were 16% more likely than male patients (adjusted RR 1.14, 95% CI 1.14–1.18) to have had their first hospital admission in their final year of life categorized as having a likely palliative intent. Female patients were 18% more likely than male patients (RR 1.18, 95% CI 1.17–1.19) to have had a female referring physician, and male patients were 20% more likely than female patients (adjusted RR 1.20, CI 1.19–1.21) to have had a male referring physician. INTERPRETATION: After adjustment for age and comorbidities, male patients were slightly less likely than female patients to have received physician-delivered palliative care, and female patients were more likely than male patients to have had their first hospital admission in their final year of life categorized as having a likely palliative care intent. These results may reflect a between-sex difference in overall end-of-life care preferences or sex differences in decision-making influenced by patient-specific factors; further studies exploring how these factors affect end-of-life decision-making are required.