The inverse palliative care law in advanced lung disease: a mixed-methods systematic review and meta-analysis

Our plain-English summary of The inverse palliative care law in advanced lung disease: a mixed-methods systematic review and meta-analysis, by D. Wakefield, T. Dehpour, C. Bambra, et al (EClinicalMedicine, 2026).

The study

• Authors: D. Wakefield, T. Dehpour, C. Bambra, J. Davies, F.E.M. Murtagh, J. Koffman
• Journal: EClinicalMedicine
• Published: 2026;91:103697
• Cited by: 1 article, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Background: People from socioeconomically deprived backgrounds are at greater risk of developing lung disease and having a higher symptom burden. It remains unclear whether they have equitable access to and experience of palliative care. Therefore, we aimed to synthesise evidence on socioeconomic inequalities in access, receipt of, preference for, and experience of palliative care among people with advanced lung disease.

Methods: Mixed-methods systematic review, searching four databases (MEDLINE, Embase, PsychINFO, CINAHL) from inception to March 28, 2025. We included studies that reported on socioeconomic position and palliative care in advanced lung disease (lung cancer, mesothelioma, chronic obstructive pulmonary disease, interstitial lung disease). Study quality was assessed using the Mixed Methods Appraisal Tool. Both meta-analysis (using a random effects model with I2 to assess heterogeneity, sensitivity analysis and GRADE of evidence) and narrative synthesis were performed. PROSPERO CRD42024546502.

Findings: Of 10,572 records, 54 studies met inclusion criteria (4.2 million participants). Meta-analysis of six studies showed people with lung cancer in the lowest SEP group were 18% less likely to receive palliative care than those in the highest (OR 0.82, 95% CI 0.75-0.90, I2 = 93.9%). GRADE of evidence was assessed as moderate. Qualitative findings identified financial hardship and insurance barriers limited access to pain relief and oxygen. Few studies considered multiple demographic characteristics, but those that did reported worse access among ethnic minorities and rural populations.

Interpretation: This review provides novel evidence of how the inverse care law operates in advanced lung disease. People from lower socioeconomic groups are significantly less likely to access palliative care, despite greater need. There is an urgent need for equity-focused research and policy interventions, co-produced with underserved communities that account for intersecting social disadvantages.

Funding: National Institute for Health and Care Research.

© 2025 The Authors.

In plain English

This was a mixed-methods systematic review and meta-analysis of published studies on socioeconomic position and palliative care in advanced lung disease. The diseases covered were lung cancer, pleural mesothelioma, COPD and interstitial lung disease. The authors searched four databases up to 28 March 2025 and included 54 studies (45 quantitative, five qualitative, four mixed-methods), all from high-income countries. These studies covered 4,224,659 people with lung disease, of whom 169 had pleural mesothelioma. Six lung cancer studies could be pooled. People in the lowest area-level socioeconomic group had lower odds of receiving palliative care than those in the highest (odds ratio 0.82, 95% CI 0.75 to 0.90). Results varied widely between studies, and the authors rated the certainty of this evidence as moderate. COPD and interstitial lung disease studies were too varied to pool, but indicated less palliative care for lower socioeconomic groups. The authors concluded that those most in need, especially people from disadvantaged backgrounds, were consistently least likely to receive palliative care. They noted that mesothelioma data were particularly scarce.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Mixed-methods systematic review and meta-analysis (random-effects pooling of odds ratios plus narrative synthesis)
• Who was studied: 54 published studies (2003 to 2025, 11 high-income countries, mostly USA). The databases were searched from inception to 28 March 2025. The studies included 4,224,659 people with lung disease (lung cancer, COPD, both, interstitial lung disease, pleural mesothelioma), plus 297 carers and 187 healthcare professionals.
• Exposure: Socioeconomic position, measured at individual level (income, education) or area level (deprivation, poverty, income, education). The review did not concern asbestos or fiber exposure.
• Main results:
  • 54 studies were included: 45 quantitative, five qualitative and four mixed-methods.
  • Of the people with lung disease in the included studies, 169 had pleural mesothelioma.
  • Pooled analysis of six lung cancer studies (area-level socioeconomic position, adjusted odds ratios): people in the lowest group had odds of receiving palliative care of 0.82 (95% CI 0.75 to 0.90) compared with the highest group.
  • Heterogeneity between studies was high. A leave-one-out sensitivity analysis showed the result was robust.
  • The certainty of evidence for the pooled result was rated moderate (GRADE).
  • Studies of COPD and interstitial lung disease were not pooled. They included evidence that people from lower socioeconomic groups were less likely to receive palliative care.
  • In one included study of COPD, 53% of people had encountered barriers to receiving oxygen because of insurance issues.
  • In studies of COPD, people with lower educational attainment were less likely to accept palliative care.
  • Two studies of COPD or interstitial lung disease found that people of lower socioeconomic position were more likely to die in hospital.
  • No included study directly examined quality or patient experience of palliative care by socioeconomic position.
  • Eight intervention studies were identified, but none focused specifically on socioeconomic inequalities.
  • Only two studies analysed multiple overlapping characteristics together (an intersectional approach).
• The authors' conclusion: The authors concluded that those most in need of palliative care for advanced lung disease, especially people from socioeconomically disadvantaged backgrounds, were consistently least likely to receive it. They called for equity-focused research and services.
• Limitations the authors state:
  • Screening and quality assessment were done by a single reviewer, with only a proportion checked by a second reviewer.
  • Few comparable studies were available for meta-analysis, and heterogeneity was high.
  • In-depth qualitative data were lacking, and data on interstitial lung disease and mesothelioma were particularly scarce.
  • All included studies came from high-income countries.
  • The funnel plot suggested a small effect size or possible publication bias, to be interpreted with caution given the small number of studies.

Topics

Medical terms in this study, explained in our Lexicon: Palliative Care, Systematic Review, Meta-Analysis, Lung Cancer, Mesothelioma, Interstitial Lung Disease.

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