PT - JOURNAL ARTICLE AU - Groenewoud, A Stef AU - Atsma, Femke AU - Arvin, Mina AU - Westert, Gert P AU - Boer, Theo A TI - Euthanasia in the Netherlands: a claims data cross-sectional study of geographical variation AID - 10.1136/bmjspcare-2020-002573 DP - 2024 May 01 TA - BMJ Supportive & Palliative Care PG - e867--e877 VI - 14 IP - e1 4099 - http://spcare.bmj.com/content/14/e1/e867.short 4100 - http://spcare.bmj.com/content/14/e1/e867.full SO - BMJ Support Palliat Care2024 May 01; 14 AB - Background The annual incidence of euthanasia in the Netherlands as a percentage of all deaths rose from 1.9% in 1990 to 4.4% in 2017. Scarce literature on regional patterns calls for more detailed insight into the geographical variation in euthanasia and its possible explanations.Objectives This paper (1) shows the geographical variation in the incidence of euthanasia over time (2013–2017); (2) identifies the associations with demographic, socioeconomic, preferential and health-related factors; and (3) shows the remaining variation after adjustment and discusses its meaning.Design, setting and methods This cross-sectional study used national claims data, covering all healthcare claims during 12 months preceding the death of Dutch insured inhabitants who died between 2013 and 2017. From these claims all euthanasia procedures by general practitioners were selected (85% of all euthanasia cases). Rates were calculated and compared at three levels: 90 regions, 388 municipalities and 196 districts in the three largest Dutch cities. Data on possibly associated variables were retrieved from national data sets. Negative binomial regression analysis was performed to identify factors associated with geographical variation in euthanasia.Results There is considerable variation in euthanasia ratio. Throughout the years (2013–2017) the ratio in the three municipalities with the highest incidence was 25 times higher than in the three municipalities with the lowest incidence. Associated factors are age, church attendance, political orientation, income, self-experienced health and availability of voluntary workers. After adjustment for these characteristics a considerable amount of geographical variation remains (factor score of 10), which calls for further exploration.Conclusion The Netherlands, with 28 years of legal euthanasia, experiences large-scale unexplained geographical variation in the incidence of euthanasia. Other countries that have legalised physician-assisted dying or are in the process of doing so may encounter similar patterns. The unexplained part of the variation may include the possibility that part of the euthanasia practice may have to be understood in terms of underuse, overuse or misuse.Data are available upon reasonable request with the first author of the article. The results will be disseminated to both patient organisations (NVVE, NPV, Dutch Patient Federation), and physicians organisations (NHG, LHV, KNMG).