Subjective and objective cervical spine mobility after two-level anterior cervical discectomy and fusion - A prospective observational trial.

Individuals with higher levels of educational attainment can expect to live longer and spend more years free of disability than their lower-educated counterparts (; ). Although the educational gradient in disability is well established (; ), less is known about how this pattern manifests at the end of life. It is not self-evident that educational inequalities persist in the final stage of life, because proximity to death may come with substantial health deterioration across educational groups. Understanding educational inequalities in end-of-life disability is important, as disability not only impacts health related quality of life () but also increases the likelihood of initial and recurrent hospitalizations (), which is of particular policy concern considering that healthcare expenditures peak in the last year of life (; ). Moreover, as explained in further detail later, welfare state arrangements may shape the extent to which educational inequalities translate into differences in later-life health outcomes (e.g., ). Yet, empirical evidence on how institutional contexts shape and potentially mitigate educational inequalities in disability at the end of life remains limited. Prior studies covering educational differences in end-of-life disability have relied exclusively on single country designs and produced mixed results for different contexts. Some studies report a persistent gradient, with lower-educated individuals experiencing worse disability outcomes at the end of life (; ; ; ; ), while others find minimal differences (), no significant difference (), or even an opposite pattern (). Substantial methodological heterogeneity precludes comparisons across these studies, leaving it unclear whether divergent results reflect genuine contextual differences or methodological artifacts. A comparative, cross-national design is therefore necessary; only by examining multiple countries within a harmonized framework can it be evaluated whether educational inequalities manifest consistently or vary across institutional contexts. The current study provides the first cross-national comparison and develops an analytical framework that integrates individual life-course processes with cross-national institutional variation. At the individual level, we draw on competing theoretical perspectives to derive contrasting expectations about whether educational inequalities in disability widen or diminish as death approaches. At the contextual level, we examine whether these processes are conditioned by institutional arrangements, specifically by welfare regimes. Using harmonized end-of-life interviews from 6957 deceased participants in the Survey of Health, Ageing and Retirement in Europe (SHARE) – the only large-scale cross-national survey with harmonized end-of-life interviews – we examine how the educational gradient in disability manifests at the end of life and whether welfare regimes moderate these inequalities.