• Nathalie Bossuyt, Lieve Van den Block, Joachim Cohen, Koen Meeussen, Johan Bilsen, Michael Echteld, Luc Deliens, and Viviane Van Casteren.
• Scientific Institute of Public Health, Operational Directorate Public Health & Surveillance, Brussels, Belgium. nathalie.bossuyt@wiv-isp.be
• J Palliat Med. 2011 Oct 1;14(10):1135-41.

BackgroundEducational level has repeatedly been identified as an important determinant of access to health care, but little is known about its influence on end-of-life care use.ObjectivesTo examine the relationship between individual educational attainment and end-of-life care use and to assess the importance of individual educational attainment in explaining differential end-of-life care use.Research DesignA retrospective cohort study via a nationwide sentinel network of general practitioners (GPs; SENTI-MELC Study) provided data on end-of-life care utilization. Multilevel analysis was used to model the association between educational level and health care use, adjusting for individual and contextual confounders based upon Andersen's behavioral model of health services use.SubjectsA Belgian nationwide representative sample of people who died not suddenly in 2005-2007.ResultsIn comparison to their less educated counterparts, higher educated people equally often had a palliative treatment goal but more often used multidisciplinary palliative care services (odds ratios [OR] for lower secondary education 1.28 [1.04-1.59] and for higher [secondary] education: 1.31 [1.02-1.68]), moved between care settings more frequently (OR: 1.68 [1.13-2.48] for lower secondary education and 1.51 [0.93-2.48] for higher [secondary] education) and had more contacts with the GP in the final 3 months of life.ConclusionsLess well-educated people appear to be disadvantaged in terms of access to specialist palliative care services, and GP contacts at the end of life, suggesting a need for empowerment of less well-educated terminally ill people regarding specialist palliative and general end-of-life care use.

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