Comparing ischaemic stroke in six European countries. The EuroHOPE register study.

BACKGROUND AND PURPOSE: The incidence of hospitalizations, treatment and case fatality of ischaemic stroke were assessed utilizing a comprehensive multinational database to attempt to compare the healthcare systems in six European countries, aiming also to identify the limitations and make suggestions for future improvements in the between-country comparisons. METHODS: National registers of hospital discharges for ischaemic stroke identified by International Classification of Diseases codes 433-434 (ICD-9) and code I63 (ICD-10), medication purchases and mortality were linked at the patient level in each of the participating countries and regions: Finland, Hungary, Italy, the Netherlands, Scotland and Sweden. Patients with an index admission in 2007 were followed for 1 year. RESULTS: In all, 64,170 patients with a disease code for ischaemic stroke were identified. The number of patients registered per 100,000 European standard population ranged from 77 in Scotland to 407 in Hungary. Large differences were observed in medication use. The age- and sex-adjusted all-cause case fatality amongst hospitalized patients at 1 year from stroke was highest in Hungary at 31.0% (95% confidence interval 30.5-31.5). Regional differences in age- and sex-adjusted 1-year case fatality within countries were largest in Hungary (range 23.6%-37.6%) and smallest in the Netherlands (20.5%-27.3%). CONCLUSIONS: It is feasible to link population-wide register data amongst European countries to describe incidence of hospitalizations, treatment patterns and case fatality of ischaemic stroke on a national level. However, the coverage and validity of administrative register data for ischaemic stroke should be developed further, and population-based and clinical stroke registers should be created to allow better control of case mix.

The characteristics and outcomes of hospitalised and outpatient-treated first-onset schizophrenia patients: a 5-year register linkage study.

AIM: We compared the course and outcome of schizophrenia in two groups: (i) hospitalised patients (HP) (n = 5980) who were identified based on their first hospital admission for schizophrenia and (ii) outpatient-treated patients (OTP) who received disability pension because of schizophrenia but who had no hospital admissions for schizophrenia or other psychotic disorder before having been granted a disability pension for schizophrenia (n = 1220). Outcomes were compared using data on mortality, psychiatric hospital utilisation, relapse rate and occupational functioning. METHODS: A nationwide register-based 5-year follow-up study of all first-onset schizophrenia cases between 1998 and 2003 in Finland. The data were linked with the register information of hospital admissions, disability pensions and National Causes of Death Registers. RESULTS: When outcome of treatment was evaluated using mortality rate, relapses, hospital treatment and involuntary admissions as outcome measures, results indicated that OTP group had got along better with their illnesses than HP group. The mortality rates, number of psychiatric treatment days and relapse rate during the 5-year follow up were significantly lower in OTP group. Within the OTP group, there was a notable subgroup of never HP (n = 737, 60.4%), who did not require any psychiatric hospitalisation during the 5-year follow up. CONCLUSIONS: Patients first identified as outpatients had better outcomes than patients first identified following a hospitalisation. Future studies are required to establish whether outpatient treatment is associated with more favourable prognosis, even after fully adjusting for severity of initial symptoms. The higher suicide mortality of hospital-treated patients suggests that hospital treatment of first-onset patients does not protect from suicide.

The effect of hospital volume on the outcome of breast cancer surgery.

BACKGROUND: This study was conducted to investigate whether annual surgical unit caseload affects extent of breast cancer surgery, breast cancer recurrence or breast cancer-specific survival. METHODS: In a population-based cohort study, 12,604 women diagnosed with breast cancer in Finland during the years 1998-2001 were followed up until the end of year 2008. Surgical units were divided into subgroups: >200, 100-200, 50-99 or <50 breast cancer operations per year. Information on patients, treatment, and follow-up was obtained from two national registries. The analyses were adjusted for age and disease stage. The reliability of the registry information was validated by comparison with information from one hospital area. Cox proportional hazard and logistic regression models were employed in the analyses. RESULTS: Validation of the registry data showed that date of diagnosis, age, stage, extent of surgery, and date and cause of death were reliably recorded in the registers. Information on radiotherapy was obtained by combining different registry data. Data on local and distant recurrences were not reliable enough to allow analyses. Patients in hospitals with smaller caseloads underwent mastectomy more often than those operated in hospitals with higher caseloads (P < 0.001). Higher caseloads were also related to improved survival (P = 0.031). CONCLUSIONS: National registries should include information on both local and distant recurrences in order to provide reliable population-based data for evaluation of treatment results. Centralization of surgery to high-volume centers is supported by a higher incidence of conservative surgery and better survival.

Health and the use of health care services in 5-year-old very-low-birth-weight infants.

AIM: We aimed to study the effect of prematurity, time of birth and level of birth hospital on morbidity and the use of health care services at age 5. METHODS: This national study included all very-low-birth-weight infants (VLBWI, <32 gestational weeks or birth weight < or =1500 g) born in Finnish level II or III hospitals in 2001-2002 (n = 918), and full-term controls (n = 381). Parental questionnaires and register data were used to compare morbidity, and the use of health care services between VLBWI and full-term controls, and within VLBWI according to the time of birth and birth hospital level. RESULTS: Cerebral palsy, retinopathy of prematurity, other ophthalmic problems, respiratory infections, asthma or chronic lung disease, and inguinal hernia were overrepresented in VLBWI compared with the controls. VLBWI had more outpatient and inpatient days than the controls. The time of birth and birth hospital level were not associated with the use of services or with prematurity-related morbidity. CONCLUSION: Although morbidity and the use of health care services were increased in the surviving VLBWI, the average use of services was relatively small at age 5. In surviving VLBWI, the time of birth and the birth hospital level did not affect morbidity or the use of services.

Modeling the length of the care episode after hip fracture: does the type of fracture matter?

BACKGROUND AND AIMS: Hip fractures are common events that require intensive operative hospital care and a lengthy rehabilitation. The effect of hip fracture type on successful rehabilitation is not well known. The aim of this study is to model and compare the length of the care episodes between intra- and extracapsular hip fractures in Finland. MATERIAL AND METHODS: 15544 hip fracture patients living at home in Finland 1998-2001 were followed using register-based data. Patient characteristics, outcomes, and length of stay (LOS) distributions were analyzed using a Bayesian nonparametric multilayer perceptron (MLP) network model. RESULTS: Mortality was similar in intra- and extracapsular hip fractures. Patients were more likely to need long-term care after extracapsular hip fracture. The average LOS at the surgical ward was similar for intra- and extracapsular fractures (1.7 weeks), but there was a considerable difference for the total inpatient LOS between the groups (5.2 weeks vs. 6.9 weeks). Intracapsular fractures had a simple unimodal LOS distribution, whereas the LOS distribution for the extracapsular fractures was multimodal with two clear peaks. Patients with more comorbidities required a longer LOS. CONCLUSIONS: The causes for differences in LOS between fracture types were most likely due to the different surgical methods and rehabilitation practices for the fracture types. As national guidelines suggest similar rehabilitation for all hip fracture patients, there is a need for early and aggressive rehabilitation of patients with extracapsular fractures, including full-weight bearing for all but selected patients.

Evaluation of the relationship between preoperative risk scores, postoperative and total length of stays and hospital costs in coronary bypass surgery.

OBJECTIVES: Several risk indices have been developed for the prediction of postoperative mortality and morbidity in coronary artery bypass operations, in which the risk scores are currently recorded as routine praxis. The aim of the present study was to determine whether the risk scores can be used to predict the hospital (LOS) and postoperative (POS) lengths of stay and total costs among coronary artery bypass graft (CABG) patients. METHODS: All first-time CABG patients (n=2104) treated at Helsinki University Central Hospital during 1997-1998 were preoperatively scored using the Cleveland Clinic preoperative model. A multivariate analysis was used to evaluate the effects of the risk scores on the LOS and POS and total costs. RESULTS: The mean preoperative risk score for the patients was 1.69. The increase in preoperative risk score was associated with an increase in the LOS (0.8 days by point), and POS (with 0.55 days by point). An age over 74 years increased the LOS by an extra day. The mean total cost for the CABG procedure was 8750 euros (SD 4430 euros). The costs increased as the risk score increased. Compared with the zero risk score, a score value of 2 was associated with a 1300 euros increase in total cost and a score value of over 6 was associated with an over 7000 euros cost increase. On average, the costs increased by 6980 euros (80%) for one major complication and by 935 euros (10%) in the elderly (>74 years of age). CONCLUSIONS: The results show that increasing risk scores were associated with longer postoperative hospital lengths of stay (POS and LOS) and with increased total costs. An age over 74 years appears to be an independent risk factor in increased POS, LOS and total cost. These results may help to estimate the impact of the preoperative risk profile on the resource requirement in CABG surgery.

Measuring efficiency of long-term care units in Finland.

Data Envelopment Analysis (DEA) was used to measure the nursing care efficiency of 64 long-term care units in Finland. New approaches introduced for evaluating efficiency were unit/ward level analysis, and the case-mix classification Resource Utilization Groups (RUG-III). Efficiency determinations were based on four DEA measures: cost, technical, allocative, and scale efficiency. The results indicated considerable variation in efficiency between units, suggesting that efficiency could be improved through better management and allocation of resources. Larger units seemingly operated more efficiently than smaller units. Allocative inefficiency resulted from using too many registered nurses and aides, and too few licensed practical nurses.

Equity in the delivery of health care in Europe and the US.

This paper presents a comparison of horizontal equity in health care utilization in 10 European countries and the US. It does not only extend previous work by using more recent data from a larger set of countries, but also uses new methods and presents disaggregated results by various types of care. In all countries, the lower-income groups are more intensive users of the health care system. But after indirect standardization for need differences, there is little or no evidence of significant inequity in the delivery of health care overall, though in half of the countries, significant pro-rich inequity emerges for physician contacts. This seems to be due mainly to a higher use of medical specialist services by higher-income groups and a higher use of GP care among lower-income groups. These findings appear to be fairly general and emerge in countries with very diverse characteristics regarding access and provider incentives.

Validity and reliability of Resource Utilization Groups (RUG-III) in Finnish long-term care facilities.

Resource Utilization Groups, Version III (RUG-III) is a case-mix system developed in the USA for classification of long-term care residents. This paper examines the validity and reliability of an adapted 22-group version of RUG-III (RUG-III/22) for use in long-term care facilities in Finland. Finnish cost weights for RUG-III/22 groups are calculated and different methods for their computation are evaluated. The study sample (1,964 residents) was collected in 1995-96 from ten long-term care facilities in Finland. RUG-III/22 alone explained 38.2% of the variance of total patient-specific (nursing + auxiliary staff) per diem cost. Resource use within RUG groups was relatively homogeneous. Other predictors of resource use included age, gender and length of stay. RUG-III/22 also met the standard for good reliability (i.e. a kappa value of 0.6 or higher) for crucial classification items, such as activities of daily living and high correlation between assessments based on relative cost.

Critical incident stress debriefing (CISD) in a shipping company.

Critical incident stress debriefing (CISD) is a method used successfully to reduce suffering from stress-related ailments such as insomnia, depression, anger, headaches etc. The resources of the shipping company are very limited and, thus, networking with existing organizations and specialists is necessary to carry out CISD effectively. The present company model has been adopted to take into account various situations and levels of disaster. The model has been adopted at three levels of events:Level 1. Serious accidents on shore, sudden deaths, severe events and threats. Events involving one or only few persons. Level 2. Life-threatening occupational accidents on board ship, suicide of a workmate, sudden death and fire on board ship. Events involving one person or limited group of persons. Level 3. Disasters at sea. Severe events involving all or nearly all persons on board ship. Actions at different levels: Level 1: A leaflet describing CISD, situations where it would be appropriate and where it is available, is given to each sailor. The victim is encouraged to seek CISD from public health care centres, most of which have their own services in Finland. Level 2. Training of about 8 hours is carried out by an experienced crisis psychologist for supervisors and officers on board ship. After the training they are able to identify stressful situations. At each harbour, the shipping company has made agreements with experienced crisis psychologists to act as specialists and contact persons on shore. These nominated psychologists will initiate CISD actions when necessary. If they need extra manpower they will turn to other psychologists. Level 3. In such serious accidents, the company's own resources alone are insufficient to provide effective CISD. All available public and private resources will he needed (health care organizations, Red Cross, Church etc.).

Priority-setting in Finnish healthcare.

The characteristics which affect priority setting in the Finnish healthcare system include strong municipal (local) administration, no clear separation between producers and purchasers, a duality in funding, and the potential for physicians in public hospitals to practice in the private sector. This system has its strengths, such as the possibility to effectively co-ordinate social and healthcare services, and a strong incentive to take care of local needs, because of municipal responsibility to finance these services largely through local taxes. However, the municipalities are typically too small to take advantage of these potentials, their knowledge is scarce especially of secondary care and their negotiating power with respect to hospitals is low. Local politicians also have a dual role: they represent the needs of the local population but simultaneously they are decision-makers in hospitals. Full-time physicians are allowed to act in a dual role as well; they can run a private practice, which is paid for on a fee-for-service basis, while the hospital pays (mostly) a fixed monthly salary. The share of financing which flows from the National Sickness Insurance system to healthcare users may have adverse effects on the local use of resources. The broad national consensus statement on patient-level priorities did not reach any general rules on priorities. Strong support was given to citizens' equal right to access all healthcare services. In healthcare practice, this general rule has some exemptions. First, the reimbursement schemes for prescribed drugs vary depending on the severity and chronic nature of the disease. Secondly, the tax-financed dental services for the young are clearly prioritised over those of older citizens. In the consensus statement, emphasis was put on improving the efficiency of producing health services in order to avoid having to impose patient-level priorities.

An econometric study of costs of teaching and research in Finnish hospitals.

In this study we used stochastic frontier cost functions to estimate the teaching and research costs of Finnish hospitals. Average and marginal cost estimates were used to evaluate the current reimbursement system as well as to calculate the total expenditure on teaching and research in hospitals. The efficiency adjustment had significant impact on the marginal and average cost estimates of the teaching and research output. The main policy implication of this study is that university teaching hospitals are able to produce both teaching and research output at significantly lower marginal and average incremental costs than other hospitals. According to our results 55% of the total state reimbursement budget for teaching and research (FIM 665 million) should be allocated to teaching and 45% to research.

Micro-level analysis of distributional changes in health care financing in Finland.

OBJECTIVES: In the early 1990s the Finnish economy suffered a severe recession at the same time as health care reforms were taking place. This study examines the effects of these changes on the distribution of contributions to health care financing in relation to household income. Explanations for changes in various indicators of health care expenditure and use during that time are offered. METHOD: The analysis is based partly on actual income data and partly on simulated data from the base year (1990). It employs methods that allow the estimation of confidence intervals for inequality indices (the Gini coefficient and Kakwani's progressivity index). RESULTS: In spite of the substantial decrease in real incomes during the recession, the distribution of income remained almost unaltered. The share of total health care funding derived from poorer households increased somewhat, due purely to structural changes. The financial plight of the public sector led to the share of total funding from progressive income taxes to decrease, while regressive indirect taxes and direct payments by households contributed more. CONCLUSIONS: It seems that, aside from an increased financing burden on poorer households, Finland's health care system has withstood the tremendous changes of the early 1990s fairly well. This is largely attributable to the features of the tax-financed health care system, which apportions the effects of financial and functional disturbances equitably.

Decreased nitrogen rates and irrigation effect on celery yield and internal quality.

The effect of decreased nitrogen rates (90, 60 and 30 kg N/ha) with and without irrigation on celery yield quantity and internal quality were studied in field experiments in 1993 and 1994. The decreased nitrogen rates reduced yields in both years. In the dry and warm conditions of 1994 nitrogen x irrigation interaction was clearly observed; irrigation increased yield more at higher nitrogen rates than at lower nitrogen rates. In the rainy conditions of 1993 irrigation did not effect the yield level. On the other hand, in both years, decreased nitrogen rates increased dry matter, vitamin C and dietary fiber contents, and nitrogen had a minor effect on total sugar content. In 1994 alpha- and beta carotene and thiamin were also analyzed but nitrogen had no effect on them. Irrigation increased dry matter and total sugar contents at the two lowest nitrogen rates in 1994, but decreased vitamin C contents in both years. There was also slight evidence that irrigation might decrease alpha- and beta-carotene and thiamin contents.

Soil forming and plant density effects on carrot yield and internal quality.

The effects of soil forming (SF) and plant density (PD) on the carrot yield, mean root weight and internal quality was studied in field experiments in 1993 and 1994. 'Fontana BZ' carrots were grown in flat land, a narrow ridge, a broad ridge, and a compacted broad ridge soil configurations with low (LD) and high (HD) target plant densities, four and seven hundred thousand carrots per hectar. The total and marketable yields were larger in flat land and narrow ridge than in the broad- and compacted broad ridges in 1993 and in 1994 at HD. The number of marketable carrots were highest with the flat land soil configurations in both years. A dry spring in 1993 favored flat land growing conditions; in ridges the fine sand dried quickly. SF did not influence the mean weight of a marketable carrot in 1993, but in 1994 the narrow ridge configuration resulted in heavier carrots than the flat land or broad ridge growing conditions. In the climatically more unfavorable year of 1993, SF and PD affected quality; dry matter was lower in flat land than in the ridges. At HD, the flat land soil configuration produced higher glucose and fructose than carrots grown in the narrow and broad ridges. Dietary fiber and vitamin C were higher in narrow ridge than in compacted broad ridge grown carrots. At LD the flat land and broad ridge produced highest and compacted broad ridge the lowest beta-carotene contents; alpha-carotene was higher at LD than at HD.

Income-related inequalities in health: some international comparisons.

This paper presents evidence on income-related inequalities in self-assessed health in nine industrialized countries. Health interview survey data were used to construct concentration curves of self-assessed health, measured as a latent variable. Inequalities in health favoured the higher income groups and were statistically significant in all countries. Inequalities were particularly high in the United States and the United Kingdom. Amongst other European countries, Sweden, Finland and the former East Germany had the lowest inequality. Across countries, a strong association was found between inequalities in health and inequalities in income.

Economic depression and the use of physician services in Finland.

At the start of the 1990s, the economic situation in Finland deteriorated radically. During the depression (1991-93), health care expenditure decreased by about 10%, and was associated with considerable changes in Finnish health care. This paper reports studies of the determinants of use of physician services in Finland in the 1990s. The particular aim was to evaluate how utilization altered during the economic depression and during the changes in the health care system. Using econometric methods, an attempt was made to describe the changes in structure and level of utilization. The study was based on annual computer-assisted telephone interviews made during 1991-94. Visits to a doctor were analysed using a two-part model (logit and truncated negative binomial regression). Structural changes were tested by Chow-type tests and changes in the level of utilization by chronologically defined dummy variables for each year. The most significant changes (both in structure and level) occurred in the model explaining the number of visits (negative binomial regression) of chronically ill persons. Variables describing the continuity of care seem to be more important determinants of visits to a doctor than certain other availability and socioeconomic variables.