Death monitoring is a key basis for formulating social and economic development plans, evaluating the health level of residents, and optimizing the allocation of health resources (China Disease Control and Health Publish, 2005; Guowei Planning Publish, 2013). Almost all socio-demographic variables, including gender, education degree, urbanization level, marital status, age, and the country of birth, are correlated with where a person with a terminal disease dies (i.e., at home or in a medical institution) (Cabaero-Martínez et al., 2019). There are many factors influencing where people choose to die, including age, marital status, education degree, occupation, and the type of terminal disease (Han et al., 2015). For example, in China, the people without spouses are more likely to die outside the hospital ward (Han et al., 2015), while people with lower education degree, influenced by Chinese traditional culture, are more likely to die at home (Liao et al., 2019; Li et al., 2012). In China, the proportion of hospital deaths is less than 20%, about 1/3 of those in the western countries (Jiang et al., 2020). Data from two hospitals in Wuhan showed that patients with advanced cancer were more likely to die at home, accounting for 79.61%, and 20.39% in other death sites (Liao et al., 2019). The distribution of death sites has its imbalance. For example, in Min Hang District of Shanghai, more residents died in the medical wards than at home (40% and 20% of deaths, respectively) (Chen et al., 2021). A study in the United Kingdom showed that from 2004 to 2014, the proportion of deaths in homes and nursing homes increased (18.3% to 22.9% and 16.7% to 21.2% respectively), while the proportion of deaths in hospital decreased (57.9% to 48.1%) (Bone et al., 2018). A similar trend has occurred in Spain, where death tallies from 2012 to 2015 reveal that two-fold more people are dying in hospitals than at home.

According to the World Health Organization, bone malignant tumors account for 0.2% of all tumors (Chen et al., 2012a). From 2003 to 2007, Chinese bone cancer mortality rate ranked 19th in the malignant cancer death rates in the country (Chen et al., 2012b). Our previous work has revealed that mortality of bone cancer was 1.12/10⁵ in Inner Mongolia during the 2008-2012 (Guo et al., 2015). In the same period, the mortality of colon cancer was five-fold than in bone cancer (Xin et al., 2014), and the mortality of breast cancer was nine-fold than in bone cancer (Hu et al., 2014). However, there are few epidemiological studies on bone cancer. Despite the low mortality rate of bone-related diseases, they still have an impact on human life. Therefore, it is necessary to analyze the characteristics of bone-related disease death.

The average mortality rate of bone-related disease was 1.59/10⁵ over the eight-year study period. The mortality of primary bone cancer (64.07%) was twice that of secondary bone cancer (30.95%), while bone disease only accounted for 4.98% of bone-related disease mortality. Overall, the mortality rate of male was 1.63-fold higher than that of female. The mortality rate of primary bone cancer was higher in the eastern regions than in the Midwest by a factor of 1.25:1. Secondary bone cancer and bone disease mortality rates were substantially lower in the east than in the mid-west (0.66:1 and 0.27:1, respectively). Average bone-related disease mortality rate increased with advancing age: while growth rates ranged from 108.19% to 270.49% across all results, with the highest growth rate in the 55-year age group (Table 1).

For the proportion of education degree, the male and female deaths were 63.48% and 74.85%, respectively in the low education group (Table 2). Male deaths in the low education group were 1.73-fold that in the high education group, while female deaths in the low education group were 2.98-fold that of females in the high education group. Elderly (age ≥ 55) patients with low education degree were 3.3-fold more likely to die than those in the high education group. The death proportion of low education is higher than that of high education, whether in the eastern or the mid-western regions. In the east, patients with lower education degree were 1.87-folds more likely to die than those with higher education, while in the mid- west, patients with lower education were 2.26-fold more likely to die than those with higher degree of education.

The highest proportion of the death site in the bone-related death is at home (68.61%). Of these home-based deaths, primary bone cancer death accounted for 66.89%, while secondary bone cancer death accounted for 73.42%, and bone disease death accounted for 60.87% by proportion of various death site. The second most common death site was in the hospital ward. In hospital wards, bone-related disease death accounted for 18.40%; of these, primary bone cancer, secondary bone cancer, and bone disease death accounted for 20.27%, 13.99%, and 21.74% respectively in proportion of various death site. As such, we classified all death sites as two categories: one is at home, and the other is in medical institutions (Table 3).

Table 4 shows the proportions of the two death sites. In the lower education group, 78.03% of deaths occurred at home, which was a rate 1.5-fold higher than in the high education group (P < 0.001, X² = 33.988) (Table 4). In the east, 80.73% of deaths occurred at home compared to 61.13% in the mid-west (P < 0.001, X² = 20.121). Nearly 3/4 of those older than 55 died at home (P < 0.05, X² = 7.135). The proportion of death at home by death sites showed that the widower was 77.78%, the married was 69.70%, and the unmarried was 51.52%. Male and females accounted for 68.15% and 71.52% of deaths at home, respectively. However, the death site from bone-related disease did not differ between males and females (P > 0.05).

The proportion of low education death at home was 76.04%, which was 1.58-fold higher than that in medical related institutions. The proportion of high education death in medical related institutions was 51.80%, which was 2.13-fold higher than those that occurred at home. The proportion of low education with secondary bone cancer death at home was 80.58%, which was more than twice as many deaths in medical related institutions. The proportion of high education with secondary bone cancer death in medical related institutions was 61.11%, which was 3.15-fold higher than those that occurred at home (Table 5).

There was no difference between low education and high education in the proportion of death sites across the year. The only seasonal differences in death sites occurred in the summer and spring (P = 0.035) (Table 6).

Here, we reveal that the bone-related disease mortality rate in Inner Mongolia (1.59/100,000) was slightly higher than that in China (1.36/100,000) (Chen et al., 2012b). The mortality rate of primary bone cancer was higher than that of secondary bone cancer. The primary and secondary bone cancers accounted for the majority of all bone-related deaths, exceeding 95%. More than half of bone-re- lated disease deaths occurred at home, with secondary bone cancer deaths occurring at home being higher compared to those from primary bone cancer. The lower the education degree, the higher the proportion of death at home (Li et al., 2012). Our research showed that the proportion of low education degree died at home is high. It is consistent with a study on the death site of Chinese citizens in 2016 (Jing & Yuan, 2016). Much previous research has investigated the factors influencing the death site, including social economic status, education degree, availability of medical services, and traditional beliefs (Han et al., 2015; Li et al., 2012; Jing & Yuan, 2016). However, a comprehensive study showed that the relationship between the death site and education degree is inconclusive (Neergaard et al., 2019). It is worth noting that the proportion of low education degree of bone-related disease death in elderly exceeded 3/4 and the mortality increased linearly with age, which is consistent with our previous results (Guo et al., 2015). We also found that age had a correlation with death site, and nearly 3/4 of people over 55 years old died at home. Due to the low education degree, as well as the familiar relatives in the environment of home, which can reduce the fear of death (Liao et al., 2019), the elderly prefer to die at home. Marriage status did not influence death site.

We revealed that people with lower degrees of education were more likely to die at home, which is in accord with previously published findings (Li et al., 2012; Jing & Yuan, 2016). Whether in the mid-western regions or the eastern regions, the death proportion of low education degree is higher than that of high education degree, although there are differences in the death proportion between the eastern and mid-western regions. We also discovered that the proportion of deaths at home was lower in the mid-western region than in the eastern regions. In Inner Mongolia, the western economy is better than that in the East (Tian & Bao, 2018), which may help explain this pattern (Wang et al., 2020). In both regions, however, more home deaths occurred among those with lower degrees of education. Those who with lower incomes tend to die at home due to high medical expenses and other reasons (Liao et al., 2019; Li et al., 2012). Due to the long and cold winter in Inner Mongolia, the land is sparsely populated, and transportation is inconvenient. As such, we compared the proportion of deaths by both season and education degree. The results showed that the season did not influence the death site.

Our findings showed that deaths from bone-related diseases are mostly at home, which mainly come from bone cancer. Moreover, the lower the education degree, the higher the proportion of deaths at home. This study will be helpful to understand the influence of various demographic characteristics on the distribution of death sites.

The authors declare no conflicts of interest regarding the publication of this paper.

Chen, L. F., Su, R. N., Li, F. Q., Lu, Z. Y., Yan, M. J., Chi, G. H., Zhang, C. Y., Yang, H. B., Wen, K. P., Li, Z. M., Sun, D. J., & Sun, J. (2021). Relationship between Death Site and Education Degree of Deaths from Bone-Related Diseases in Inner Mongolia. Advances in Applied Sociology, 11, 585-594. https://doi.org/10.4236/aasoci.2021.1111050