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Sveréus S, Petzold M, Rehnberg C. Change in avoidable hospitalizations for low-income elders following quasi-market reform in primary care - Evidence from a natural experiment in Sweden. Soc Sci Med 2024; 346:116711. [PMID: 38430872 DOI: 10.1016/j.socscimed.2024.116711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 02/13/2024] [Accepted: 02/20/2024] [Indexed: 03/05/2024]
Abstract
Quasi-market reforms have been increasingly implemented in tax-funded health care, but their effects in terms of equity, quality and socioeconomic differentials in quality remain sparsely studied. We create a natural experiment setup exploiting the differential timing of a set of quasi-market reforms - including patient choice, free establishment of providers and changes in provider remuneration -, implemented in primary care in the two largest Swedish regions (Stockholm and Västra Götaland) in 2008-2009. Using a database with individual level data from 2005 to 2009, we construct a difference-in-difference-in-differences model that compares pre to post reform changes in avoidable hospitalizations (AHs) for low-income elders and a matched comparison group, in the region exposed to, versus unexposed to, reform (total N ∼ 200 000). The results show that for low-income elders - a group dominated by older women - reform led to higher AH rates, i.e., worse primary health care quality, than what would have been the case in absence of reform. Specifically, low-income elders exposed to reform missed out on improvements in AHs seen simultaneously in the unexposed region. At the same time, the reform had on average no effect for comparable, non-low-income, peers. The fact that this pattern was specific for avoidable hospitalizations - judged as amenable to interventions in primary care -, but not present for total hospitalizations, supports that it was driven by reform implementation rather than other factors. The study contributes with high-quality empirical evidence to a policy relevant but sparsely researched area and highlights the necessity to consider differential effects of organizational changes across socioeconomic groups.
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Affiliation(s)
- Sofia Sveréus
- Department of Learning, Informatics, Management & Ethics (LIME), Karolinska Institutet, SE, 17177, Stockholm, Sweden; Stockholm Centre for Health Economics, Region Stockholm, Karolinska Institutet, Tomtebodavägen 18A, SE, 17177, Stockholm, Sweden.
| | - Max Petzold
- School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Box 428, SE-40530, Gothenburg, Sweden
| | - Clas Rehnberg
- Department of Learning, Informatics, Management & Ethics (LIME), Karolinska Institutet, SE, 17177, Stockholm, Sweden; Stockholm Centre for Health Economics, Region Stockholm, Karolinska Institutet, Tomtebodavägen 18A, SE, 17177, Stockholm, Sweden
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Satokangas M, Arffman M, Agerholm J, Thielen K, Hougaard CØ, Andersen I, Burström B, Keskimäki I. 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. BMC Health Serv Res 2023; 23:835. [PMID: 37550672 PMCID: PMC10405465 DOI: 10.1186/s12913-023-09855-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 07/27/2023] [Indexed: 08/09/2023] Open
Abstract
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.
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Affiliation(s)
- Markku Satokangas
- Health Economics and Equity in Health Care, Finnish Institute for Health and Welfare, P.O. Box 30, 00271, Helsinki, Finland.
- Network of Academic Health Centres and Department of General Practice and Primary Health Care, University of Helsinki, P.O. Box 20, 00014, Helsinki, Finland.
| | - Martti Arffman
- Health Economics and Equity in Health Care, Finnish Institute for Health and Welfare, P.O. Box 30, 00271, Helsinki, Finland
| | - Janne Agerholm
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Karsten Thielen
- Section of Social Medicine, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Charlotte Ørsted Hougaard
- Section of Social Medicine, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Ingelise Andersen
- Section of Social Medicine, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Bo Burström
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Ilmo Keskimäki
- Health Economics and Equity in Health Care, Finnish Institute for Health and Welfare, P.O. Box 30, 00271, Helsinki, Finland
- Faculty of Social Sciences, Tampere University, 33014, Tampere, Finland
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Chen S, Fu H, Jian W. Trends in avoidable hospitalizations in a developed City in eastern China: 2015 to 2018. BMC Health Serv Res 2022; 22:856. [PMID: 35788227 PMCID: PMC9252061 DOI: 10.1186/s12913-022-08275-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 06/30/2022] [Indexed: 11/18/2022] Open
Abstract
Objective This study aimed to measure the avoidable hospitalization rate and the treatment cost per hospitalization in large cities of eastern China. Methods In this study, the hospital discharge data of all inpatients in the city from 2015 to 2018 were collected. In accordance with the organization for Economic Cooperation and Development (OECD) definition of avoidable hospitalizations, five diseases were selected as the measurement objects, including hypertension, diabetes, asthma, chronic obstructive pulmonary disease (COPD), as well as congestive heart failure (CHF). We described the avoidable hospitalization rate, average cost and length of stay for avoidable hospitalization cases. Linear probability model and log-linear model were used to control the basic characteristics and disease severity of patients, and to measure the trend of the avoidable hospitalization rate and expenditure of avoidable hospitalizations. Results From 2015 to 2018, the absolute number of avoidable hospitalizations in the city increased while fluctuating, which reached 125,372 in 2018. Among the five avoidable hospitalizations, the number of hospitalizations for diabetes increased continuously in the 4-year period. Congestive heart failure showed the most significant increase over the four years. Avoidable hospitalizations in the city have remained at a high level, while avoidable hospitalizations of hypertension and asthma fell to levels lower than those in 2015 in 2017 and 2018 after rising in 2016. The cost per hospitalization and length of stay per hospitalization decreased. Conclusions Avoidable hospitalizations in the city remain at a high level, and more effective policies should be formulated to guide patients with avoidable hospitalizations, so as to more effectively exploit outpatient services and continuously improve the quality of primary health care services. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08275-w.
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Affiliation(s)
- Siyuan Chen
- Department of Health Policy and Management, School of Public Health, Peking University, No. 38, Xueyuan Road, Haidian District, Beijing, 100191, China
| | - Hongqiao Fu
- Department of Health Policy and Management, School of Public Health, Peking University, No. 38, Xueyuan Road, Haidian District, Beijing, 100191, China.
| | - Weiyan Jian
- Department of Health Policy and Management, School of Public Health, Peking University, No. 38, Xueyuan Road, Haidian District, Beijing, 100191, China.
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Impact of Integrated Care on the Rate of Hospitalization for Ambulatory Care Sensitive Conditions among Older Adults in Stockholm County: An Interrupted Time Series Analysis. Int J Integr Care 2021; 21:22. [PMID: 34163311 PMCID: PMC8195125 DOI: 10.5334/ijic.5505] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Introduction: Reducing avoidable hospital admissions is often viewed as a possible positive consequence of introducing integrated care (IC). The aim of this study was to investigate the impact of implementing IC in Norrtälje on the rate of admissions for ambulatory care sensitive conditions (ACSC). Method: Using interrupted time series analyses we investigated the effect of implementing IC in Norrtälje municipality in the northern part of Stockholm county, Sweden. The time period included 48 time points, from year 2000 to year 2011 with measurements before and after introducing IC in Norrtälje in 2006. In order to control for other extraneous events that could affect the outcome measure, but not related to the introduction of IC, we included a control population from Stockholm municipality. Results: After introducing IC in Norrtälje the rate of admissions for ACSC decreased. This decrease was greater in Norrtälje than in the matched control population, however the difference between the two areas was not statistically significant (p = 0.08). Conclusion: Introducing IC in Norrtälje may have had positive impact on admissions for ACSC for older people living in Norrtälje; however, the interpretation of the impact of IC on admissions for ACSC is complicated by intervening policy changes in health and social care during the study period.
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Satokangas M, Arffman M, Antikainen H, Leyland AH, Keskimäki I. Individual and Area-level Factors Contributing to the Geographic Variation in Ambulatory Care Sensitive Conditions in Finland: A Register-based Study. Med Care 2021; 59:123-130. [PMID: 33201086 PMCID: PMC7899221 DOI: 10.1097/mlr.0000000000001454] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Markku Satokangas
- Department of General Practice and Primary Health Care, Network of Academic Health Centres, University of Helsinki
- Service System Research Unit, Finnish Institute for Health and Welfare, Helsinki
| | - Martti Arffman
- Service System Research Unit, Finnish Institute for Health and Welfare, Helsinki
| | | | - Alastair H. Leyland
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, Scotland
| | - Ilmo Keskimäki
- Service System Research Unit, Finnish Institute for Health and Welfare, Helsinki
- Faculty of Social Sciences, Tampere University, Tampere, Finland
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Pinto A, Santos JV, Souza J, Viana J, Costa Santos C, Lobo M, Freitas A. Comparison and Impact of Four Different Methodologies for Identification of Ambulatory Care Sensitive Conditions. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E8121. [PMID: 33153171 PMCID: PMC7662634 DOI: 10.3390/ijerph17218121] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 10/29/2020] [Accepted: 10/30/2020] [Indexed: 11/30/2022]
Abstract
Ambulatory care sensitive conditions (ACSCs) are conditions for which hospitalizations are thought to be avoidable if effective and accessible primary health care is available. However, to define which conditions are considered ACSCs, there is a considerable number of different lists. Our aim was to compare the impact of using different ACSC lists considering mainland Portugal hospitalizations. A retrospective study with inpatient data from Portuguese public hospital discharges between 2011 and 2015 was conducted. Four ACSC list sources were considered: Agency for Healthcare Research and Quality (AHRQ), Canadian Institute for Health Information (CIHI), the Victorian Ambulatory Care Sensitive Conditions study, and Sarmento et al. Age-sex-adjusted rates of ACSCs were calculated by district (hospitalizations per 100,000 inhabitants). Spearman's rho, the intraclass correlation coefficient (ICC), the information-based measure of disagreement (IBMD), and Bland and Altman plots were computed. Results showed that by applying the four lists, different age-sex-adjusted rates are obtained. However, the lists that seemed to demonstrate greater agreement and consistency were the list proposed by Sarmento et al. compared to AHRQ and the AHRQ method compared to the Victorian list. It is important to state that we should compare comparable indicators and ACSC lists cannot be used interchangeably.
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Affiliation(s)
- Andreia Pinto
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of Porto, 4200-450 Porto, Portugal; (J.V.S.); (J.S.); (J.V.); (C.C.S.); (M.L.); (A.F.)
- CINTESIS–Center for Health Technology and Services Research, 4200-450 Porto, Portugal
| | - João Vasco Santos
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of Porto, 4200-450 Porto, Portugal; (J.V.S.); (J.S.); (J.V.); (C.C.S.); (M.L.); (A.F.)
- CINTESIS–Center for Health Technology and Services Research, 4200-450 Porto, Portugal
- Public Health Unit, ACES Grande Porto VIII–Espinho/Gaia, 4500-330 Porto, Portugal
| | - Júlio Souza
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of Porto, 4200-450 Porto, Portugal; (J.V.S.); (J.S.); (J.V.); (C.C.S.); (M.L.); (A.F.)
- CINTESIS–Center for Health Technology and Services Research, 4200-450 Porto, Portugal
| | - João Viana
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of Porto, 4200-450 Porto, Portugal; (J.V.S.); (J.S.); (J.V.); (C.C.S.); (M.L.); (A.F.)
- CINTESIS–Center for Health Technology and Services Research, 4200-450 Porto, Portugal
| | - Cristina Costa Santos
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of Porto, 4200-450 Porto, Portugal; (J.V.S.); (J.S.); (J.V.); (C.C.S.); (M.L.); (A.F.)
- CINTESIS–Center for Health Technology and Services Research, 4200-450 Porto, Portugal
| | - Mariana Lobo
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of Porto, 4200-450 Porto, Portugal; (J.V.S.); (J.S.); (J.V.); (C.C.S.); (M.L.); (A.F.)
- CINTESIS–Center for Health Technology and Services Research, 4200-450 Porto, Portugal
| | - Alberto Freitas
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of Porto, 4200-450 Porto, Portugal; (J.V.S.); (J.S.); (J.V.); (C.C.S.); (M.L.); (A.F.)
- CINTESIS–Center for Health Technology and Services Research, 4200-450 Porto, Portugal
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Lumme S, Manderbacka K, Arffman M, Karvonen S, Keskimaki I. Cumulative social disadvantage and hospitalisations due to ambulatory care-sensitive conditions in Finland in 2011─2013: a register study. BMJ Open 2020; 10:e038338. [PMID: 32847920 PMCID: PMC7451287 DOI: 10.1136/bmjopen-2020-038338] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES To study the interplay between several indicators of social disadvantage and hospitalisations due to ambulatory care-sensitive conditions (ACSC) in 2011─2013. To evaluate whether the accumulation of preceding social disadvantage in one point of time or prolongation of social disadvantage had an effect on hospitalisations due to ACSCs. Four common indicators of disadvantage are examined: living alone, low level of education, poverty and unemployment. DESIGN A population-based register study. SETTING Nationwide individual-level register data on hospitalisations due to ACSCs for the years 2011-2013 and preceding data on social and socioeconomic factors for the years 2006─2010. PARTICIPANTS Finnish residents aged 45 or older on 1 January 2011. OUTCOME MEASURE Hospitalisations due to ACSCs in 2011-2013. The effect of accumulation of preceding disadvantage in one point of time and its prolongation on ACSCs was studied using modified Poisson regression. RESULTS People with preceding cumulative social disadvantage were more likely to be hospitalised due to ACSCs. The most hazardous combination was simultaneously living alone, low level of education and poverty among the middle-aged individuals (aged 45-64 years) and the elderly (over 64 years). Risk ratio (RR) of being hospitalised due to ACSC was 3.16 (95% CI 3.03-3.29) among middle-aged men and 3.54 (3.36-3.73) among middle-aged women compared with individuals without any of these risk factors when controlling for age and residential area. For the elderly, the RR was 1.61 (1.57-1.66) among men and 1.69 (1.64-1.74) among women. CONCLUSIONS To improve social equity in healthcare, it is important to recognise not only patients with cumulative disadvantage but also-as this study shows-patients with particular combinations of disadvantage who may be more susceptible. The identification of these vulnerable patient groups is also necessary to reduce the use of more expensive treatment in specialised healthcare.
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Affiliation(s)
- Sonja Lumme
- Department of Health and Social Care Systems, Finnish Institute for Health and Welfare, Helsinki, Uusimaa, Finland
- Department of Psychology and Logopedics, University of Helsinki, Helsinki, Finland
| | - Kristiina Manderbacka
- Department of Health and Social Care Systems, Finnish Institute for Health and Welfare, Helsinki, Uusimaa, Finland
| | - Martti Arffman
- Department of Health and Social Care Systems, Finnish Institute for Health and Welfare, Helsinki, Uusimaa, Finland
| | - Sakari Karvonen
- Department of Health and Social Care Systems, Finnish Institute for Health and Welfare, Helsinki, Uusimaa, Finland
| | - Ilmo Keskimaki
- Department of Health and Social Care Systems, Finnish Institute for Health and Welfare, Helsinki, Uusimaa, Finland
- Faculty of Social Sciences, Tampere University, Tampere, Pirkanmaa, Finland
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