Performing up to Nordic principles? Geographic and socioeconomic equity in ambulatory care sensitive conditions among older adults in capital areas of Denmark, Finland and Sweden in 2000-2015.

BACKGROUND: Denmark, Finland and Sweden pursue equity in health for their citizens through universal health care. However, it is unclear if these services reach the older adult population equally across different socioeconomic positions or living areas. Thus, we assessed geographic and socioeconomic equity in primary health care (PHC) performance among the older adults in the capital areas of Denmark (Copenhagen), Finland (Helsinki) and Sweden (Stockholm) in 2000-2015. Hospitalisations for ambulatory care sensitive conditions (ACSC) were applied as a proxy for PHC performance. METHODS: We acquired individual level ACSCs for those aged ≥ 45 in 2000-2015 from national hospitalisation registers. To identify whether the disparities varied by age, we applied three age groups (those aged 45-64, 65-75 and ≥ 75). Socioeconomic disparities in ACSCs were described with incidence rate ratios (IRR) and annual rates by education, income and living-alone; and then analysed with biennial concentration indices by income. Geographic disparities were described with biennial ACSC rates by small areas and analysed with two-level Poisson multilevel models. These models provided small area estimates of IRRs of ACSCs in 2000 and their slopes for development over time, between which Pearson correlations were calculated within each capital area. Finally, these models were adjusted for income to distinguish between geographic and socioeconomic disparities. RESULTS: Copenhagen had the highest IRR of ACSCs among those aged 45-64, and Helsinki among those aged ≥ 75. Over time IRRs decreased among those aged ≥ 45, but only in Helsinki among those aged ≥ 75. All concentration indices slightly favoured the affluent population but in Stockholm were mainly non-significant. Among those aged ≥ 75, Pearson correlations were low in Copenhagen (-0.14; p = 0.424) but high in both Helsinki (-0.74; < 0.001) and Stockholm (-0.62; < 0.001) - with only little change when adjusted for income. Among those aged ≥ 45 the respective correlations were rather similar, except for a strong correlation in Copenhagen (-0.51, 0.001) after income adjustment. CONCLUSIONS: While socioeconomic disparities in PHC performance persisted among older adults in the three Nordic capital areas, geographic disparities narrowed in both Helsinki and Stockholm but persisted in Copenhagen. Our findings suggest that the Danish PHC incorporated the negative effects of socio-economic segregation to a lesser degree.

Pandemic preparedness and response regulations in Finland: Experiences and implications for post-COVID-19 reforms.

The COVID-19 pandemic has plagued health systems in an unprecedented way and challenged the traditional ways to respond to epidemics. It has also revealed several vulnerabilities in countries' health systems and preparedness. In this paper we take the Finnish health system as an example to analyse how pre-COVID-19 preparedness plans, regulations, and health system governance were challenged by the pandemic and what lessons can be learned for the future. Our analysis draws on policy documents, grey literature, published research, and the COVID-19 Health System Response Monitor. The analysis shows how major public health crises often reveal weaknesses in health systems, also in countries which have been ranked highly in terms of crisis preparedness. In Finland, there were apparent regulative and structural problems which challenged the health system response, but in terms of epidemic control, the results appear to be relatively good. The pandemic may have long-term effects on the health system functioning and governance. In January 2023, an extensive health and social services reform has taken place in Finland. The new health system structure needs to be adjusted to take on board the legacy of the pandemic and a new regulatory frame for health security should be considered.

Can we optimize locations of hospitals by minimizing the number of patients at risk?

BACKGROUND: To reduce risk of death in acute ST-segment elevation myocardial infraction (STEMI), patients must reach a percutaneous coronary intervention (PCI) within 120 min from the start of symptoms. Current hospital locations represent choices made long since and may not provide the best possibilities for optimal care of STEMI patients. Open questions are: (1) how the hospital locations could be better optimized to reduce the number of patients residing over 90 min from PCI capable hospitals, and (2) how this would affect other factors like average travel time. METHODS: We formulated the research question as a facility optimization problem, which was solved by clustering method using road network and efficient travel time estimation based on overhead graph. The method was implemented as an interactive web tool and tested using nationwide health care register data collected during 2015-2018 in Finland. RESULTS: The results show that the number of patients at risk for not receiving optimal care could theoretically be reduced significantly from 5 to 1%. However, this would be achieved at the cost of increasing average travel time from 35 to 49 min. By minimizing average travel time, the clustering would result in better locations leading to a slight decrease in travel time (34 min) with only 3% patients at risk. CONCLUSIONS: The results showed that minimizing the number of patients at risk alone can significantly improve this single factor but, at the same time, increase the average burden of others. A more appropriate optimization should consider more factors. We also note that the hospitals serve also for other operators than STEMI patients. Although optimization of the entire health care system is a very complex optimization problems goal, it should be the aim of future research.

Explaining regional variation in elective hip and knee arthroplasties in Finland 2010 - 2017-a register-based cohort study.

BACKGROUND: A persistent research finding in industrialised countries has been regional variation in medical practices including elective primary hip and knee arthroplasty. The aim of the study was to examine regional variations in elective total hip and knee arthroplasties over time, and the proportions of these variations which can be explained by individual level or area-level differences in need. METHODS: We obtained secondary data from the Care Register for Health Care to study elective primary hip and knee arthroplasties in total Finnish population aged 25 + years between 2010 and 2017. Two-level Poisson regression models - individuals and hospital regions - were used to study regional differences in the incidence of elective hip and knee arthroplasties in two time periods: 2010 - 2013 and 2014 - 2017. The impact of several individual level explanatory factors (age, socioeconomic position, comorbidities) and area-level factors (need and supply of operations) was measured with the proportional change in variance. Predictions of incidence were measured with incidence rate ratios. The relative differences in risk of the procedures in regions were described with median rate ratios. RESULTS: We found small and over time relatively stable regional variation in hip arthroplasties in Finland, while the variation was larger in knee arthroplasties and decreased during the study period. In 2010 - 2013 individual socioeconomic variables explained 10% of variation in hip and 4% in knee arthroplasties, an effect that did not emerge in 2014 - 2017. The area-level musculoskeletal disorder index reflecting the need for care explained a further 44% of the variation in hip arthroplasties in 2010 - 2013, but only 5% in 2014 - 2017 and respectively 22% and 25% in knee arthroplasties. However, our final models explained the regional differences only partially. CONCLUSIONS: Our results suggest that eligibility criteria in total hip and knee arthroplasty are increasingly consistent between Finnish hospital districts. Factors related to individual level and regional level need both had an important role in explaining regional variations. Further study is needed on the effect of health policy on equity in access to care in these operations.

Individual and Area-level Factors Contributing to the Geographic Variation in Ambulatory Care Sensitive Conditions in Finland: A Register-based Study.

BACKGROUND: Measuring primary health care (PHC) performance through hospitalizations for ambulatory care sensitive conditions (ACSCs) remains controversial-recent cross-sectional research claims that its geographic variation associates more with individual socioeconomic position (SEP) and health status than PHC supply. OBJECTIVES: To clarify the usage of ACSCs as a PHC performance indicator by quantifying how disease burden, both PHC and hospital supply and spatial access contribute over time to geographic variation in Finland when individual SEP and comorbidities were adjusted for. METHODS: The Finnish Care Register for Health Care provided hospitalizations for ACSCs (divided further into subgroups of acute, chronic, and vaccine-preventable causes) in 2011-2017. With 3-level nested multilevel Poisson models-individuals, PHC authorities, and hospital authorities-we estimated the proportion of the variance in ACSCs explained by selected factors at 3 time periods. RESULTS: In age-adjusted and sex-adjusted analysis of total ACSCs the variances between hospital authorities was nearly twice that between PHC authorities. Individual SEP and comorbidities explained 19%-30% of the variance between PHC authorities and 25%-36% between hospital authorities; and area-level disease burden and arrangement and usage of hospital care a further 14%-16% and 32%-33%-evening out the unexplained variances between PHC and hospital authorities. CONCLUSIONS: Alongside individual factors, areas' disease burden and factors related to hospital care explained the excess variances in ACSCs captured by hospital authorities. Our consistent findings over time suggest that the local strain on health care and the regional arrangement of hospital services affect ACSCs-necessitating caution when comparing areas' PHC performance through ACSCs.

Trajectory modelling of ambulatory care sensitive conditions in Finland in 1996-2013: assessing the development of equity in primary health care through clustering of geographic areas - an observational retrospective study.

BACKGROUND: Due to stagnating resources and an increase in staff workload, the quality of Finnish primary health care (PHC) is claimed to have deteriorated slowly. With a decentralised PHC organisation and lack of national stewardship, it is likely that municipalities have adopted different coping strategies, predisposing them to geographic disparities. To assess whether these disparities emerge, we analysed health centre area trajectories in hospitalisations due to ambulatory care sensitive conditions (ACSCs). METHODS: ACSCs, a proxy for PHC quality, comprises conditions in which hospitalisation could be avoided by timely care. We obtained ACSCs of the total Finnish population aged ≥20 for the years 1996-2013 from the Finnish Hospital Discharge Register, and divided them into subgroups of acute, chronic and vaccine-preventable causes, and calculated annual age-standardised ACSC rates by gender in health centre areas. Using these rates, we conducted trajectory analyses for identifying health centre area clusters using group-based trajectory modelling. Further, we applied area-level factors to describe the distribution of health centre areas on these trajectories. RESULTS: Three trajectories - and thus separate clusters of health centre areas - emerged with different levels and trends of ACSC rates. During the study period, chronic ACSC rates decreased (40-63%) within each of the clusters, acute ACSC rates remained stable and vaccine-preventable ACSC rates increased (1-41%). While disparities in rate differences in chronic ACSC rates between trajectories narrowed, in the two other ACSC subgroups they increased. Disparities in standardised rate ratios increased in vaccine-preventable and acute ACSC rates between northern cluster and the two other clusters. Compared to the south-western cluster, 13-16% of health centre areas, in rural northern cluster, had 47-92% higher ACSC rates - but also the highest level of morbidity, most limitations on activities of daily living and highest PHC inpatient ward usage as well as the lowest education levels and private health and dental care usage. CONCLUSIONS: We identified three differing trajectories of time trends for ACSC rates, suggesting that the quality of care, particularly in northern Finland health centre areas, may have lagged behind the general improvements. This calls for further investments to strengthen rural area PHC.

Regional variation of avoidable hospitalisations in a universal health care system: a register-based cohort study from Finland 1996-2013.

OBJECTIVES: A persistent finding in research concerning healthcare and hospital use in Western countries has been regional variation in the medical practices. The aim of the current study was to examine trends in the regional variation of avoidable hospitalisations, that is, hospitalisations due to conditions treatable in ambulatory care in Finland in 1996-2013 and the influence of different healthcare levels on them. SETTING: Use of hospital inpatient care in 1996-2013 among the total population in Finland. PARTICIPANTS: Altogether 1 931 012 hospital inpatient care episodes among all persons residing in Finland identified from administrative registers in Finland in 1996-2013 and alive in 1 January 1996. OUTCOME MEASURES: We examined hospitalisations due to avoidable causes including vaccine-preventable hospitalisations, hospitalisations due to complications of chronic conditions and acute conditions treatable in ambulatory care. We calculated annual age-adjusted rates per 10 000 person-years. Multilevel models were used for studying time trends in regional variation. RESULTS: There was a steep decline in avoidable hospitalisation rates during the study period. The decline occurred almost exclusively in hospitalisations due to chronic conditions, which diminished by about 60%. The overall correlation between hospital district intercepts and slopes in time was -0.46 (p<0.05) among men and -0.20 (ns) among women. Statistically highly significant diminishing variation was found in hospitalisations due to chronic conditions among both men (-0.90) and women (-0.91). The variation was mainly distributed to the hospital district level. CONCLUSIONS: The results suggest that chronic conditions are managed better in primary care in the whole country than before. Further research is needed on whether this is the case or whether this has more to do with supply of hospital care.