Does informal care impact utilization of healthcare services? Evidence from a longitudinal study of stroke patients

The Impact of Informal Care on Healthcare Utilization of Older Adults with Functional Limitations in China

Our study examines the impact of informal care on healthcare utilization, focusing on caregiver types, urban-rural, and gender differences. Analyzing data from the China Health and Retirement Longitudinal Study and using fixed effects models, we discovered complementary effects between informal care and healthcare. Specifically, spousal care increased inpatient care use, adult child care boosted both inpatient and outpatient use, and dual care from children and spouses showed the most significant impact on healthcare use. The association between informal care and healthcare use varied across gender or urban-rural residence. Our findings highlight the importance of caregivers in accessing healthcare services.

Rapid systematic review of readmissions costs after stroke

BACKGROUND

Stroke readmissions are considered a marker of health quality and may pose a burden to healthcare systems. However, information on the costs of post-stroke readmissions has not been systematically reviewed.

OBJECTIVES

To systematically review information about the costs of hospital readmissions of patients whose primary diagnosis in the index admission was a stroke.

METHODS

A rapid systematic review was performed on studies reporting post-stroke readmission costs in EMBASE, MEDLINE, and Web of Science up to June 2021. Relevant data were extracted and presented by readmission and stroke type. The original study's currency values were converted to 2021 US dollars based on the purchasing power parity for gross domestic product. The reporting quality of each of the included studies was assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist.

RESULTS

Forty-four studies were identified. Considerable variability in readmission costs was observed among countries, readmissions, stroke types, and durations of the follow-up period. The UK and the USA were the countries reporting the highest readmission costs. In the first year of follow-up, stroke readmission costs accounted for 2.1-23.4%, of direct costs and 3.3-21% of total costs. Among the included studies, only one identified predictors of readmission costs.

CONCLUSION

Our review showed great variability in readmission costs, mainly due to differences in study design, countries and health services, follow-up duration, and reported readmission data. The results of this study can be used to inform policymakers and healthcare providers about the burden of stroke readmissions. Future studies should not solely focus on improving data standardization but should also prioritize the identification of stroke readmission cost predictors.

The impact of informal caregiving on U.S. Veterans Health Administration utilization and expenditures

Few studies have examined the effect of informal care receipt on health care utilization and expenditures while accounting for the potentially endogenous relationship between informal and formal care, and none have examined these relationships for U.S. Veterans. With rapidly increasing investments in caregiver supports over the past decade, including stipends for caregivers, the U.S. Department of Veterans Affairs (VA) needs to better understand the costs and benefits of informal care provision. Using a unique data linkage between the 1998-2010 Health and Retirement Study and VA administrative data (n = 2083 Veterans with 9511 person-wave observations), we applied instrumental variable techniques to understand the effect of care from an adult child on Veterans' two-year VA utilization and expenditures. We found that informal care decreased overall utilization by 53 percentage points (p < 0.001) and expenditures by $19,977 (p < 0.01). These reductions can be explained by informal care decreasing the probability of inpatient utilization by 17 percentage points (p < 0.001), outpatient utilization by 57 percentage points (p < 0.001), and institutional long-term care by 3 percentage points (p < 0.05). There were no changes in the probability of non-institutional long-term care use, though these expenditures decreased by $882 (p < 0.05). Expenditure decreases were greatest amongst medically complex patients. Our results indicate relative alignment between VA's stipend payments, which are based on replacement cost methods, and the monetary benefits derived through VA cost avoidances due to informal care. For health systems considering similar caregiver stipend payments, our findings suggest that the cost of these programs may be offset by informal care substituting for formal care, particularly for higher need patients.

Effects of the bio-psycho-social frailty dimensions on healthcare utilisation among elderly in Europe: A cross-country longitudinal analysis

Frailty represents an emerging challenge and has major implications for clinical practice, public health, and the sustainability of health systems. It is a geriatric condition, related to but distinct from disability and multimorbidity and characterized by a diminished physiological reserve of multiple organs. Despite limited consensus and evidence, it has been argued that cognitive and social aspects influence the condition. Therefore, we aim to provide evidence on the importance of taking a broader approach in defining frailty, by investigating the role of its physical, social, and psychological subdomains to predict healthcare utilisation in elderly Europeans. The study is based on the Survey of Health, Ageing and Retirement in Europe (SHARE), and uses 185,169 total observations from 12 European countries included in wave 4, 5, 6, and 8. The analysis investigates the influence of the physical frailty index (a proxy of the Frailty Phenotype definition), psychological and social frailty indexes (built to proxy the Tilburg Frailty Index) on the likelihood of hospitalisation and the number of doctor visits. We addressed missing values due to item non-response with fully conditional specification multivariate imputation and exploited the longitudinal structure of the data to control for time-fixed unobserved characteristics. In addition, our two multivariate models included regressors to correct for demand side factors (health status, socio-economic status, and behavioral risk) as well as for country-specific characteristics. Physical and psychological frailty positively influence the likelihood of hospitalisation (OR = 1.90 and OR = 1.31, respectively) and the number of doctor visits (IRR = 1.30 and IRR = 1.07), while social frailty reduces the two types of health services utilisation (OR = 0.53 and IRR = 0.90). The three frailty dimensions are relevant risk stratification factors in elderly Europeans, and health policies should focus more on the psycho-social aspects of this condition, as a strategy to both contain expenditures and avoid potential healthcare inequalities.

Trajectories of Disability and Long-Term Care Utilization After Acute Health Events

Hip fractures, strokes, and heart attacks are common acute health events that can lead to long-term disability, care utilization, and unmet needs. However, such impacts, especially in the long term, are not fully understood. Using data from the Health and Retirement Study, 1992-2018, this study examines the long-term trajectories of individuals suffering such health shocks, comparing with individuals not experiencing health shocks. Hip fracture, stroke, and heart attack are confirmed to have severe implications for disability. In most cases of stroke and heart attack, informal caregivers provide the daily support needed by survivors, whereas following hip fracture, nursing home care is more relevant. These health shocks put individuals on worse trajectories of disability, care utilization, and unmet needs. There is no long-term recovery or convergence with individuals who do not suffer shocks. Unmet need is prevalent, even pre-shock and among individuals who do not experience health shocks, emphasizing the importance of preventative care measures. These findings support policy action to ensure hospitalized individuals, especially those aged 50 and above, receive rehabilitative services and other post-acute care. Furthermore, hospitalization is an event that requires the detection and addressing of unmet care needs beyond the short run.

Experiences of individuals with acquired brain injury and their families interacting with community services: a systematic scoping review

PURPOSE

This scoping review aims to (1) synthesise the research findings on the experiences of individuals with acquired brain injuries, and their families, when interacting with, or accessing, community-based services and (2) identify where gaps in service provision may exist and their cause.

METHODS

A systematic search strategy was employed across multiple databases to identify all studies relating to the experiences of individuals with acquired brain injuries and their families when interacting with, or accessing, community-based services. Inclusion was assessed by at least two reviewers at each stage and data extraction was completed by one researcher and validity checked by another. A narrative synthesis was employed.

RESULTS

A total of 101 papers met the inclusion criteria with the narrative synthesis identifying three main themes of (1) unmet needs, (2) types of access, and (3) barriers to access.

CONCLUSIONS

The results identify that those with acquired brain injuries, and their families, experience significant difficulties interacting with community-based services and often do not receive appropriate access. Many barriers to access were identified including a lack of knowledge of the long-term effects of acquired brain injury amongst professionals working in health and social care services.Implications for rehabilitationBrain injury is a leading cause of disability worldwide with a range of physical, cognitive, emotional, and behavioural difficulties.It is important that service users and families are given appropriate information about the long-term difficulties associated with ABI so they are better informed about the types of support they may need upon discharge from hospital.Rehabilitation professionals need to ensure they have good level of knowledge of the difficulties associated with ABI to ensure appropriate access to services for individuals and their families.Understanding more about unmet needs allows community rehabilitation services to be tailored and person-centred.

Out-of-Pocket Health Care Spending at Older Ages: Do Caregiving Arrangements Matter?

Identifying the correlates of out-of-pocket (OOP) health care spending is an important step for ensuring the financial security of older adults. Whether or not someone has a family member providing assistance is one such factor that could be associated with OOP spending. If family caregivers facilitate better health, health care spending could be reduced. On the other hand, costs would be higher if family members facilitate more (or more costly) care for loved ones. This paper explores the relationship between caregiving arrangements and OOP spending using data from 5045 individuals in the 2000-2016 Health and Retirement Study with Medicare coverage and caregiving needs. We do not find a relationship between family caregiving and OOP health care costs, overall. However, among those with Medicare HMO insurance, having a family caregiver is associated with more spending than having no helper. This is mainly due to differences in spending on prescription medications.

Does informal care reduce health care utilisation in older age? Evidence from China

Studies in Western countries suggest that receiving informal care from family members may reduce utilisation of health care services. This hypothesis has not been examined in China, where the population is ageing rapidly. We assess the impact of informal care from offspring (children and grandchildren) on health care utilisation and expenditures among older people in China. Data are drawn from the 2011, 2014, and 2018 waves of the Chinese Longitudinal Healthy Longevity Survey. Using lagged model with the instrumental variable approach, we find that the impact of informal care is different by type of health care: More hours of informal care from offspring reduces overall health care utilisation, and in particular, outpatient care utilisation, but it increases inpatient care utilisation and expenditures. Our results suggest that informal care reduces the demand for outpatient care but increases the demand for inpatient care, possible reflecting the fact that the latter involves more advanced procedures for which informal care is not a substitute but a complement. Results highlight the need for incorporating health care impacts in the analysis and evaluation of policies that affect informal care provision.

Effect of informal care on health care utilisation for the elderly in urban and rural China: evidence from China health and retirement longitudinal study (CHARLS)

Background

Receiving informal care from family members is the mainstream way of care for the elderly in China because of the influence of the culture of filial piety. However, the relationship between informal care and health care use in urban and rural areas needs to be further explored. This study aimed to understand the association between informal care and health care utilisation for the elderly and explore how this effect may differ between urban and rural China.

Method

A total of 5704 residents aged 65 years and above were selected from wave 3 (2015) and wave 4 (2018) of the China Health and Retirement Longitudinal Study, which is a nationally representative survey. A negative binomial regression model for the panel data was used to explore the relationship between informal care and health care utilisation. A fixed-effect binary choice model for panel data was used for the sensitivity test.

Result

The elderly who received informal care had increased in outpatient and inpatient visits compared with those who did not receive informal care. The inpatient visits of the elderly who received 15–29 days of informal care was higher than the elderly who did not receive informal care (incidence rate ratio [IRR] = 2.082, P < 0.05). Moreover, the elderly who received informal care for more than 30 days had 39.6% more inpatient visits (IRR = 1.396, P < 0.01) and 37.4% more outpatient visits than the elderly who did not receive informal care (IRR = 1.374, P < 0.05). For urban respondents, receiving informal care can facilitate outpatient use of the elderly, but for rural respondents, receiving informal care can predict an increase in outpatient and inpatient visits.

Conclusion

Informal care was associated with higher use of health services. The association between informal care and health care utilisation varies between rural and urban residents. These findings indicate the role of informal care and remind that relevant departments should pay attention to the differences in medical service utilisation levels amongst different elderly groups.

Formal Health and Social Services That Directly and Indirectly Benefit Stroke Caregivers: A Scoping Review of Access and Use

Stroke can be a life altering event that necessitates considerable amounts of formal and informal care. The impacts of stroke often persist over time requiring ongoing support for stroke survivors. Family members provide the majority of care and experience many life changes as a result of their caregiving role including social, financial, employment and health impacts. Formal supports such as counselling, respite, and health promotion initiatives that directly benefit caregivers or benefit them indirectly through supporting the stroke survivor, are well-placed to help caregivers manage their caregiving role. However, to date little is known about formal service use by stroke caregivers and the factors that influence their service use. This scoping review provides a critique and synthesis of what is known about stroke caregivers’ access and use of formal services intended to support them. Findings suggest that while services are available, caregivers’ ability to use them are impacted by both facilitators and barriers. Facilitators included: sex, age, and having a higher household income (depending on services used). Barriers included: high cost, poor service quality and deficient knowledge/communication regarding service availability. This review highlights a significant gap in our knowledge of caregivers’ experience in accessing and using formal services.

Trends in Receipt of Help at Home After Hospital Discharge Among Older Adults in the US

Importance

With declining use of institutional postacute care, more patients are going directly home after hospital discharge. The consequences on the amount of help needed at home after discharge are unknown.

Objective

To estimate trends in the frequency and duration of receipt of help with activities of daily living (ADLs) among older adults discharged home.

Design, Setting, and Participants

Repeated cross-sectional study of a national sample of community-dwelling older adults who returned home after hospital discharge from 2011 to 2017. Participants included respondents to National Health and Aging Trends Study (NHATS), an annual population-based, nationally representative survey of Medicare beneficiaries, who were 69 years or older and were discharged from an acute care hospital to home during the years of the study. A nationally representative sample was estimated using NHATS' analytic weights. Unweighted frequencies and weighted and unweighted percentages are reported. The analysis was conducted from September 2020 to October 2021.

Exposures

Discharge from an acute care hospitalization.

Main Outcomes and Measures

Receipt of help with ADLs during the 3 months after hospital discharge.

Results

Of the 3591 survey participants who were discharged home from an acute care hospital during the study period, 53.3% were female, 54.8% were married or living with a partner, and the mean (SD) age was 78.5 (7.0) years. Of these, 1710 (44.1%) reported receiving help within 3 months of discharge. Compared with people not receiving help, those receiving help were older (mean [SD] years, 79.7 [7.5] years vs 77.6 [6.3] years), had worse self-rated health at baseline (47.1% with fair or poor health vs 26.5%) and were more likely to have dementia (21.8% vs 5.5%). The percentage of respondents who reported receiving help increased during the study period from 38.1% of hospital discharges in 2011 to 51.5% in 2017. For those who were independent in their ADLs before hospitalization, the percentage receiving help after discharge more than doubled over the study period increasing from 9.3% receiving help in 2011 to 31.8% in 2017. Among patients who did not receive Medicare-reimbursed home health, the percentage receiving help also increased from 22.1% to 28.1%. Among those who received help after discharge, the need for help slowly declined to prehospitalization levels over the ensuing 9 months.

Conclusions and Relevance

In this cross-sectional study, older adults' receipt of help at home after hospital discharge increased from 2011 to 2017, including patients relying on non-Medicare funded sources of care. As payers steer patients away from inpatient postacute care facilities, policymakers will need to pay attention to this shifting burden of care.

The determinants of the intensity of home-based informal care among cancer patients in receipt of home-based palliative care

BACKGROUND

Understanding the determinants of the intensity of informal care may assist policy makers in the identification of supports for informal caregivers. Little is known about the utilization of informal care throughout the palliative care trajectory.

AIM

The purpose of this study was to analyze the intensity and determinants of the use of informal care among cancer patients over the palliative care trajectory.

DESIGN

This was a longitudinal, prospective cohort design conducted in Canada. Regression analysis using instrumental variables was applied.

SETTING/PARTICIPANTS

From November 2013 to August 2017, a total of 273 caregivers of cancer patients were interviewed biweekly over the course of the care recipient's palliative care trajectory. The outcome was the number of hours of informal care provided by unpaid caregivers, that is, hours of informal care.

RESULTS

The number of hours of informal care increased as patients approached death. Home-based nursing care complemented, and hence, increased the provision of informal care. Patients living alone and caregivers who were employed were associated with the provision of fewer hours of informal care. Spousal caregivers provided more hours of informal care. Patient's age, sex, and marital status, and caregiver's age, sex, marital status, and education were associated with the number of hours of informal care.

CONCLUSIONS

The intensity of informal care was determined by predisposing, enabling, and needs-based factors. This study provides a reference for the planning and targeting of supports for the provision of informal care.

Do Family Caregivers Offset Healthcare Costs for Older Adults? A Mapping Review on the Costs of Care for Older Adults With Versus Without Caregivers

BACKGROUND AND OBJECTIVES

Older adults face significant long-term care and health care costs. But some of these costs can potentially be offset through family caregivers who may serve as substitutes for formal care or directly improve the care recipient's health and reduce health care utilization and expenditures. This article reviews the current literature to determine whether it is possible through existing work to compare the costs of care for individuals with versus without family caregivers and, if not, where the data, measurement, and other methodological challenges lie.

RESEARCH DESIGN AND METHODS

A mapping review of published works containing information on health care utilization and expenditures and caregiving was conducted. A narrative approach was used to review and identify methodological challenges in the literature.

RESULTS

Our review identified 47 articles that met our criteria and had information on caregiving and health care costs or utilization. Although findings were mixed, for the most part, having a family caregiver was associated with reduced health care utilization and a decreased risk of institutionalization however, the precise difference in health care expenditures for individuals with caregivers compared to those without was rarely examined, and findings were inconsistent across articles reviewed.

DISCUSSION AND IMPLICATIONS

The number of family caregivers providing care to loved ones is expected to grow with the aging of the Baby Boomers. Various programs and policies have been proposed to support these caregivers, but they could be costly. These costs can potentially be offset if family caregivers reduce health care spending. More research is needed, however, to quantify the savings stemming from family caregiving.

Association between caregiver engagement and patient-reported healthcare utilization after stroke: a mixed-methods study

Background: Caregivers (CGs) are critical in helping stroke survivors (SSs) retain function and receive adequate healthcare. Objectives: We aimed to identify the activities that CGs are engaged in over the course of stroke care from open-ended SS interviews and explore the association between CG engagement and SS healthcare utilization post-stroke.Methods: We qualitatively analyzed 9-month post-stroke interviews with 118 SSs about their experiences before, during and following acute care from the Caring for Adults Recovering from the Effects of Stroke (CARES) study. We classified each SS as having either an engaged or non-engaged CG based on whether the SS indicated CG involvement in any part of their stroke care. We compared differences between groups in self-reported use of outpatient therapy, home health care, ambulatory care, mental health services, and acute care.Results: SSs who were interviewed most often described CG involvement as driving the SS to the hospital or calling 911 (n = 48; 23.4%), coordinating medical appointments (n = 43; 21.0%) and monitoring recovery (n = 23; 11.2%). SSs with engaged CGs were more likely to see a speech-language pathologist and had more emergency room visits compared to those with non-engaged CGs. No differences were observed after adjusting for stroke severity.Conclusions: Higher rates of healthcare utilization by SSs with engaged CGs may be driven by greater stroke severity and greater need for services. Interestingly, the presence of an engaged CG did not facilitate more care for the SS after adjusting for stroke severity.

Economic burden of stroke: a systematic review on post-stroke care

OBJECTIVES

Stroke is a leading cause for disability and morbidity associated with increased economic burden due to treatment and post-stroke care (PSC). The aim of our study is to provide information on resource consumption for PSC, to identify relevant cost drivers, and to discuss potential information gaps.

METHODS

A systematic literature review on economic studies reporting PSC-associated data was performed in PubMed/MEDLINE, Scopus/Elsevier and Cochrane databases, Google Scholar and gray literature ranging from January 2000 to August 2016. Results for post-stroke interventions (treatment and care) were systematically extracted and summarized in evidence tables reporting study characteristics and economic outcomes. Economic results were converted to 2015 US Dollars, and the total cost of PSC per patient month (PM) was calculated.

RESULTS

We included 42 studies. Overall PSC costs (inpatient/outpatient) were highest in the USA ($4850/PM) and lowest in Australia ($752/PM). Studies assessing only outpatient care reported the highest cost in the United Kingdom ($883/PM), and the lowest in Malaysia ($192/PM). Fifteen different segments of specific services utilization were described, in which rehabilitation and nursing care were identified as the major contributors.

CONCLUSION

The highest PSC costs were observed in the USA, with rehabilitation services being the main cost driver. Due to diversity in reporting, it was not possible to conduct a detailed cost analysis addressing different segments of services. Further approaches should benefit from the advantages of administrative and claims data, focusing on inpatient/outpatient PSC cost and its predictors, assuring appropriate resource allocation.

Causal effects of informal care and health on falls and other accidents among the elderly population in China

PURPOSE

This article analyzes the causal effects of informal care, mental health, and physical health on falls and other accidents (e.g., traffic accidents) among elderly people. We also examine if there are heterogeneous impacts on elderly of different gender, urban status, and past accident history.

METHODS

To purge potential reversal causal effects, e.g., past accidents induce more future informal care, we use two-stage least squares to identify the impacts. We use longitudinal data from a representative national China Health and Retirement Longitudinal Study of people aged 45 and older in China. A total of 3935 respondents with two-wave data are included in our study. Each respondent is interviewed to measure health status and report their accident history. Mental health is assessed using CES-D questions.

RESULTS

Our findings indicate that while informal care decreased the occurrence of accidents, poor health conditions increase the occurrence of accidents. We also find heterogeneous impacts on the occurrence of accidents, varying by gender, urban status, and past accident history.

CONCLUSIONS

Our findings suggest the following three policy implications. First, policy makers who aim to decrease accidents should take informal care of elders into account. Second, ease of birth policy and postponed retirement policy are urgently needed to meet the demands of informal care. Third, medical policies should attach great importance not only to physical health but also mental health of elderly parents especially for older people with accident history.

Self-reported physical and mental health of Australian carers: a cross-sectional study

OBJECTIVE

To report on self-reported physical and mental health of informal carers in rural regions of New South Wales, Australia.

METHODS

A cross-sectional community-based sample (n=222) of carers completed a questionnaire incorporating self-reported measures of health from validated international instruments including Medical Outcomes Study Scale (SF-36), the Centre for Epidemiology-Depression (CES-D) and Kessler-10 (K-10) Psychological Distress Scales, along with information on participant demographics and other key caregiving characteristics such as health condition of care recipient.

RESULTS

Rural carers' self-reported health was poor as evident on the SF-36 Physical and Mental Health component scores as well as each individual domain of the SF-36. Results from the CES-D and K-10 scores indicated very high rates of depressive symptoms and psychological distress. Over 70% of carers within the current study had CES-D scores indicative of depressive symptoms. Scores on the K-10 indicate almost half the carers were experiencing high levels of psychological distress, which is over 4 times the rate reported in the general Australian population.

CONCLUSIONS AND IMPLICATIONS

Results from this study were compared to Australian population normative data and were found to be significantly below Australian age-matched population norms for SF-36, CES-D and K-10. These findings illustrate the poor health profile of informal carers relative to the general Australian population, especially in terms of depressive symptoms and psychological distress. This highlights the need for additional support for rural carers in order to ease the accumulated mental and physical health burdens of this group.

Protocol for a systematic review of preference-based instruments for measuring care-related outcomes and their suitability for the palliative care setting

INTRODUCTION

Despite informal caregivers' integral role in supporting people affected by disease or disability, economic evaluations often ignore the costs and benefits experienced by this group, especially in the palliative setting. The purpose of this systematic review is to identify preference-based instruments for measuring care-related outcomes and provide guidance on the selection of instrument in palliative care economic evaluations.

METHODS AND ANALYSIS

A comprehensive search of the literature will be conducted from database inception (ASSIA; CINAHL; Cochrane library including DARE, NHS EED, HTA; Econlit; Embase; PsychINFO; PubMed). Published peer-reviewed, English-language articles reporting preference-based instruments for measuring care-related outcomes in any clinical area will be included. One researcher will complete the searches and screen the results for potentially eligible studies. A randomly selected subset of 10% citations will be independently screened by two researchers. Any disagreement will be resolved by consensus among the research team. Subsequently, a supplementary search will identify studies detailing the development, valuation, validation and application of the identified instruments. The degree of suitability of the instruments for palliative economic evaluations will be assessed using criteria in the International Society for Quality of Life Research minimum standards for patient-reported outcome measures, the checklist for reporting valuation studies of multiattribute utility-based instruments and information on the development of the instrument in the palliative setting. A narrative summary of the included studies and instruments will be provided; similarities and differences will be described and possible reasons for variations explored. Recommendations for practice on selection of instruments in palliative care economic analyses will be provided.

ETHICS AND DISSEMINATION

This is a planned systematic review of published literature. Therefore, ethics approval to conduct this research is not required. Findings will be presented at leading palliative care and health economic conferences and published in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

CRD42016034188.

Exploring access to care among older people in the last phase of life using the behavioural model of health services use: a qualitative study from the perspective of the next of kin of older persons who had died in a nursing home

BACKGROUND

There is little investigation into what care older people access during the last phase of their life and what factors enable access to care in this group. Illuminating this from the perspective of the next of kin may provide valuable insights into how the health and social care system operates with reference to providing care for this vulnerable group. The behavioural model of health services use has a wide field of application but has not been tested conceptually regarding access to care from the perspective of the next of kin. The aim of this study was to explore the care accessed by older people during the last phase of their life from the perspective of the next of kin and to conceptually test the behavioural model of health services use.

METHODS

The data collection took place in 2011 by means of qualitative interviews with 14 next of kin of older people who had died in a nursing home. The interviews were analysed using directed content analysis. The behavioural model of health services use was used in deriving the initial coding scheme, including the categories: utilization of health services, consumer satisfaction and characteristics of the population at risk.

RESULTS

Utilization of health services in the last phase of life was described in five subcategories named after the type of care accessed i.e. admission to a nursing home, primary healthcare, hospital care, dental care and informal care. The needs were illuminated in the subcategories: general deterioration, medical conditions and acute illness and deterioration when death approaches. Factors that enabled access to care were described in three subcategories: the organisation of care, next of kin and the older person. These factors could also constitute barriers to accessing care. Next of kin's satisfaction with care was illuminated in the subcategories: satisfaction, dissatisfaction and factors influencing satisfaction. One new category was constructed inductively: the situation of the next of kin.

CONCLUSIONS

A bed in a nursing home was often accessed during what the next of kin regarded as the last phase of life. The needs among older people in the last phase of life can be regarded as complex and worsening over time. Most enabling factors lied within the organisation of care but the next of kin enabled access to care and contributed significantly to care quality. More research is needed regarding ageism and stigmatic attitudes among professionals and informal caregivers acting as a barrier to accessing care for older people in the last phase of their life. The behavioural model of health services use was extended with a new category showing that the situation of the next of kin must be taken into consideration when investigating access to care from their perspective. It may also be appropriate to include informal care as part of the concept of access when investigating access to care among older people in the last phase of their life. The results may not be transferable to older people who have not gained access to a bed in a nursing home or to countries where the healthcare system differs largely from the Swedish.