The organisation and responsibility for care for older people in Denmark, Finland and Sweden: outline and comparison of care systems.

AIM: To outline the organisation and responsibility for health and social care provided to older people in Denmark, Finland and Sweden. METHODS: Non-quantifiable data on the care systems were collated from the literature and expert consultations. The responsibilities for primary healthcare, specialised healthcare, prevention and health promotion, rehabilitation, and social care were presented in relation to policy guidance, funding and organisation. RESULTS: In all three countries, the state issues policy and to some extent co-funds the largely decentralised systems; in Denmark and Sweden the regions and municipalities organise the provision of care services - a system that is also about to be implemented in Finland to improve care coordination and make access more equal. Care for older citizens focuses to a large extent on enabling them to live independently in their own homes. CONCLUSIONS: Decentralised care systems are challenged by considerable local variations, possibly jeopardising care equity. State-level decision and policy makers need to be aware of these challenges and monitor developments to prevent further health and social care disparities in the ageing population.

Socioeconomic differences in inpatient care expenditure in the last year of life among older people: a retrospective population-based study in Stockholm County.

OBJECTIVES: To investigate the association between inpatient care expenditure (ICE) and income group and the effect of demographic factors, health status, healthcare and social care utilisation on ICE in the last year of life. DESIGN: Retrospective population-based study. SETTING: Stockholm County. PARTICIPANTS: Decedents ≥65 years in 2015 (N=13 538). OUTCOME: ICE was calculated individually for the month of, and 12 months preceding death using healthcare register data from 2014 and 2015. ICE included the costs of admission and treatment in inpatient care adjusted for the price level in 2018. RESULTS: There were difference between income groups and ICE incurred at the 75th percentile, while a social gradient was found at the 95th percentile where the highest income group incurred higher ICE (SEK45 307, 95% CI SEK12 055 to SEK79 559) compared with the lowest income groups. Incurring higher ICE at the 95th percentile was driven by greater morbidity (SEK20 333, 95% CI SEK12 673 to SEK29 993) and emergency department care visits (SEK77 995, 95% CI SEK64 442 to SEK79 549), while lower ICE across the distribution was associated with older age and residing in institutional care. CONCLUSION: Gaining insight into patterns of healthcare expenditure in the last year of life has important implications for policy, particularly as socioeconomic differences were visible in ICE at a time of greater care need for all. Future policies should focus on engaging in advanced care planning and strengthening the coordination of care for older people.

Health system reforms and the needs of the ageing population-an analysis of recent policy paths and reform trends in Finland and Sweden.

Population ageing with an increasing number of people experiencing complex health and social care needs challenges health systems. We explore whether and how health system reforms and policy measures adopted during the past two decades in Finland and Sweden reflect and address the needs of the older people. We discuss health system characteristics that are important to meet the care needs of older people and analyse how health policy agendas have highlighted these aspects in Finland and Sweden. The analysis is based on "most similar cases". The two countries have rather similar health systems and are facing similar challenges. However, the policy paths to address these challenges are different. The Swedish health system is better resourced, and the affordability of care better ensured, but choice and market-oriented competition reforms do not address the needs of the people with complex health and social care needs, rather it has led to increased fragmentation. In Finland, the level of public funding is lower which may have negative impacts on people who need multiple services. However, in terms of integration and care coordination, Finland seems to follow a path which may pave the way for improved coordination of care for people with multiple care needs. Intensified monitoring and analysis of patterns of health care utilization among older people are warranted in both countries to ensure that care is provided equitably.

Socio-demographic differences in the frequent use of emergency department care by older persons: a population-based study in Stockholm County.

BACKGROUND: In Sweden, the number of older people using emergency department (ED) care is rising. Among older persons an ED visit is a stressful event, which potentially could have been prevented or treated at other levels of care. Frequent ED use (> 4 visits a year) by older persons might reflect issues in the organisation of health care system to address their needs. We aimed to explore socio-demographic differences among older people seeking ED care in terms age and gender, and to investigate the association between income and frequent ED use. METHODS: A population-based study analysing the utilisation of ED care by (N = 356,375) individuals aged 65+ years. We linked register data on socio-demographic characteristics from 2013 to health care utilisation data in 2014. Multivariable logistic regression was used to estimate the income differences in the frequent use of ED care, adjusting for living situation, country of birth, residential area, age in years, multi-morbidity and the use of other health care services. RESULTS: Those 65+ years accounted for (27%) of all ED visits in Stockholm County in 2014. In the study population (2.5%) were identified as frequent ED users, who were predominantly in the lower income groups, living alone or in an institution, had more multi-morbidity, and utilised more of other health care services. The lowest income groups had a three-fold greater odds of being a frequent ED user than those in the highest income group. In the adjusted models, the odds were reduced by 12-44% for those in the lowest income groups. However, age and gender differences were observed with men 65-79 years (OR 1.75 CI: 1.51-2.03) and women 80+ years (OR 1.50, CI 1.19-1.87) in the lowest income groups having a higher odds of frequent ED use. CONCLUSION: This study observed that ED visits by older persons are driven by a need of care, and those that frequently visit hospital-based EDs are a socially disadvantaged group, which suggests that the organisation of care for older people should be reviewed in order to better meet their needs in other levels of care.

Planned and Unplanned Hospital Admissions and Their Relationship with Social Factors: Findings from a National, Prospective Study of People Aged 76 Years or Older.

OBJECTIVE: To examine the relationship between social factors and planned and unplanned hospital admissions among older people. DATA SOURCES/STUDY SETTING: 2011 data from the Swedish Panel Study of Living Conditions of the Oldest Old (SWEOLD) and data from the Swedish National Patient Register until December 31, 2012. STUDY DESIGN: The study had a prospective design. Data were analyzed via Cox proportional hazard regressions with variables entered as blocks (social factors, sociodemographic and ability factors, health factors). DATA COLLECTION: Data were collected via interviews with people aged 76+ (n = 931). PRINCIPAL FINDINGS: Living in institutions was negatively associated with planned admissions (hazard ratio (HR): 0.29; confidence interval (CI): 0.09-0.88), while being in receipt of home help was positively associated with unplanned admissions (HR: 1.57; CI: 1.15-2.14). Low levels of social contacts and social activity predicted unplanned admissions in bivariate analyses only. Higher ability to deal with public authorities was positively associated with planned admissions (HR: 1.77; CI: 1.13-2.78) and negatively associated with unplanned admissions, although the latter association was only significant in the bivariate analysis. CONCLUSIONS: Hospital admissions are not only due to health problems but are also influenced by the social care situation and by the ability to deal with public authorities.

Towards a postponement of activities of daily living dependence and mobility limitations: Trends in healthy life years in old age in Sweden.

AIMS: To investigate the development of healthy life expectancy from 65 years (HLE65) in Sweden in the period 1980-2011 using the health indicators activities of daily living (ADL) and mobility limitations within the framework of the postponement, compression and expansion theories. METHODS: Sources of data for the HLE computations were Swedish national mortality statistics and the nationwide Swedish Surveys of Living Conditions, conducted biennially by Statistics Sweden since 1974. We used the Sullivan method for calculations of HLE and a decomposition into mortality and disability effects was made. RESULTS: Life expectancy at age 65 (LE65) increased by 3.1 years for women and 4.0 years for men from 1980-1985 to 2006-2011. HLE65 calculated according to ADL and mobility limitations increased more rapidly than LE65 for both men and women ( p<0.05). CONCLUSIONS: Our results for trends in the Swedish LE65 and HLE65, computed on the basis of ADL and mobility limitations and using the Swedish Surveys of Living Conditions study, are in line with the postponement hypothesis and there is also a tendency for compression. Thus the years with ADL dependence and mobility limitations are postponed to a higher age and the numbers of these years have decreased.

Healthy life years in old age: Swedish development 1980-2010 according to different health indicators.

AIMS: To investigate the development of healthy life expectancy from 65 years (HLE65) in Sweden in the period 1980 and 2010 by using two different health indicators: self-rated health and the global activity limitation indicator (GALI). METHODS: Sources of data for the HLE computations were Swedish national mortality statistics and the nationwide Swedish Survey of Living Conditions (SSLC), which have been conducted biennially by Statistics Sweden since 1974. We used the Sullivan method for calculations of HLE. A decomposition into mortality and disability effect has been made in accordance with the method devised by Nusselder. RESULTS: Life expectancy at age 65 (LE65) increased by 3.1 years for women and 4.0 years for men from 1980/85 to 2006/11. Regardless of which health measure investigated - self-rated health or GALI - HLE65 increased between the periods 1980/85 to 2006/2011 more rapidly than LE65 and as a consequence the years with bad self-rated health and years with activity limitations decreased. These increases as well as the decreases were significant (p<0.05). CONCLUSIONS: The Swedish LE65 and HLE65 development, as judged by the SSLC study, are compatible with the postponement hypothesis and there is even a clear tendency for compression. Thus, the years with bad self-rated health and years with activity limitations are postponed to a higher age and the number of those years have decreased. From this respect, the Swedish development looks positive. The need of old age care in 2010 would have been much higher if it had been expansion - not postponement - of bad self-rated health and years with activity limitations during the time period.

Gender differences in associations between ADL and other health indicators in 1992 and 2002.

BACKGROUND AND AIMS: Research has shown increased prevalence rates over time in several health indicators in the older population. These increases have not been accompanied by corresponding increases in ADL and IADL disability. As disability and other health indicators follow different trends, the associations between them may change. And, as both health and disability also appear to follow different trends for men and women, we can expect gender differences in the associations. We examined gender differences in how objective tests of function, as well as self-reported health and function indicators, were associated with ADL/IADL in 1992 and 2002. METHODS: Data came from the Swedish Panel Study of Living Conditions among the Oldest Old (SWEOLD), a nationally representative interview survey of persons aged 77+. RESULTS: Compared with men, women had significantly higher prevalence rates for most health indicators in both survey years, but there were no significant gender differences in ADL/IADL limitations. Prevalence rates increased significantly between 1992 and 2002 for all health indicators, but not for ADL/IADL. Most of the associations between ADL/IADL and other health indicators were stronger for men than for women. The overall pattern found was that associations have become weaker for women over time; for men, the picture was mixed. CONCLUSIONS: The changing associations between ADL/IADL and other health indicators may reflect complex interplay between changes in several social and environmental factors, some of which may be modifiable. ADL/IADL appear to reflect different dimensions of health and different kinds of needs for men and women.