Effects of prepartum concentrate feeding on reticular pH, plasma energy metabolites, acute phase proteins, and milk performance in grass silage-fed dairy cows

We investigated how concentrate feeding during the last 21 d of pregnancy affects reticular pH, inflammatory response, dry matter (DM) intake, and production performance of dairy cows. We hypothesized that adding concentrates to dairy cows' diet before calving reduces the decrease in reticular pH postpartum and thus alleviates inflammatory response. We also hypothesized that prepartum concentrate feeding increases DM intake postpartum and consequently improves milk performance. Two feeding experiments were conducted using a randomized complete block design. In each experiment, 16 multiparous Finnish Ayrshire cows were paired based on parity, expected calving date, body weight, and milk yield of the previous lactation. Within the pairs, cows were randomly allocated on one of the 2 dietary treatments 21 d before expected calving. In experiment 1 (Exp1), diets were ad libitum feeding of grass silage as a sole feed or supplemented with increasing amounts of concentrate offered separately (increased to 4 kg/d by d -7). In experiment 2 (Exp2), diets were ad libitum feeding of a total mixed ration containing either grass silage, barley straw, and rapeseed meal (64%, 28%, and 8% on DM basis, respectively) or grass silage, barley straw, and cereal-based concentrate mixture (49%, 29%, and 30% on DM basis, respectively). Following calving, all the cows were fed similarly and observed until d 56 postpartum. Feed intake and milk yield were recorded daily, and reticular pH was monitored continuously by reticular pH bolus. Blood samples were collected at the beginning of the experiments, 7 d before the expected calving date, 1 d (in Exp1) or 5 d (in Exp2), 10 d, and 21 d postpartum. In Exp1, concentrate feeding increased metabolizable energy intake and tended to increase DM and crude protein intake prepartum. Moreover, prepartum concentrate feeding increased the concentrations of plasma β-hydroxybutyrate and insulin, but differences in nonesterified fatty acids, glucose, or acute phase proteins were not observed. After calving, prepartum diet did not affect DM or nutrient intake, plasma energy metabolites, or milk production in Exp1. Although prepartum concentrate feeding increased reticular pH on the first day of lactation, it elevated plasma concentrations of serum amyloid-A and haptoglobin postpartum in the grass silage-based diet. In Exp2, adding concentrates to the diet based on a mixture of grass silage and straw did not affect prepartum DM intake or plasma concentrations of nonesterified fatty acids, glucose, or insulin. Adding concentrates to prepartum diet increased plasma concentration of β-hydroxybutyrate before calving as in Exp1. After calving, prepartum concentrate feeding increased DM and nutrient intake during the second week of lactation in Exp2, but no effects were observed thereafter. In contrast to our hypothesis, prepartum concentrate feeding decreased reticular pH after calving in Exp2, but no differences in inflammatory markers were observed. Based on this study, close-up concentrate feeding in diets based on grass silage with or without straw does not alleviate the decrease in reticular pH or mitigate inflammatory response postpartum.

Health-Related Costs of Intimate Partner Violence: Using Linked Police and Health Registers

This study aims to estimate direct health-related costs for victims of intimate partner violence (IPV) using nationwide linked data based on police reports and two healthcare registers in Finland from 2015 to 2020 (N = 21,073). We used a unique register dataset to identify IPV victims from the data based on police reports and estimated the attributable costs by applying econometric models to individual-level data. We used exact matching to create a reference group who had not been exposed to IPV. The mean, unadjusted, attributable healthcare cost for victims of IPV was €6,910 per individual over the 5-year period after being first identified as a victim. When adjusting for gender, age, education, occupation, and mental-health- and pregnancy-related diagnoses, the mean attributable health-related cost for the 5 years was €3,280. The annual attributable costs of the victims were consistently higher than those for nonvictims during the entire study period. Thus, our results suggest that the adverse health consequences of IPV persist and are associated with excess health service use for 5 years after exposure to IPV. Most victims of IPV were women, but men were also exposed to IPV, although the estimates were statistically significant only for female victims. Victims of IPV were over-represented among individuals outside the labor force and lower among those who were educated. The total healthcare costs of victims of IPV varied according to the socioeconomic factors. This study highlights the need for using linked register data to understand the characteristics of IPV and to assess its healthcare costs. The study results suggest that there is a significant socioeconomic gradient in victimization, which could also be useful to address future IPV prevention and resource allocation.

Educational attainment of adolescents treated in psychiatric inpatient care: a register study over 3 decades

Mental disorders may for various reasons impair educational attainment, and with far-reaching consequences given the impact of education on subsequent employment, social life, life choices and even health and mortality. This register-based study addresses trends in educational attainment among Finnish adolescents aged 13-17 with mental disorders severe enough to necessitate inpatient treatment between 1980 and 2010. Our subjects (N = 14,435), followed up until the end of 2014, were at greater risk of discontinuing education beyond compulsory comprehensive school or of lower educational attainment than their age-peers in general population. Only 50.0% had completed any post-comprehensive education compared to 84.9% in same-aged general population. Those at highest risk were males and those with organic, intellectual disabilities and developmental, externalizing disorders or schizophrenia group diagnoses. Despite improvements in adolescent psychiatric care, school welfare services and pedagogical support, risks have remained high. Greater effort in psychiatric treatment, school welfare and pedagogy are needed to combat this severe inequality.

Effects of forage and grain legume-based silages supplemented with faba bean meal or rapeseed expeller on lactational performance, nitrogen utilization, and plasma amino acids in dairy cows

The objective of this experiment was to investigate the effect of forage type [red clover (51%)-grass silage, i.e., RCG; vs. faba bean (66%)-grass silage, i.e., FBG] and concentrate type (faba bean, FB; vs. rapeseed expeller, RE) on lactational performance, milk composition and nitrogen (N) utilization in lactating dairy cows. Eight lactating multiparous Nordic Red cows were used in a replicated 4 × 4 Latin Square experiment, with 21-d periods, in a 2 × 2 factorial arrangement of treatments. The experimental treatments were as follows: (1) RCG with RE, (2) RCG with FB, (3) FBG with RE, and (4) FBG with FB. Inclusion rates of RE and FB were isonitrogenous. Crude protein contents of the experimental diets were 16.3, 15.9, 18.1, and 17.9% of dry matter, respectively. All diets included oats and barley and were fed ad libitum as total mixed rations with forage-to-concentrate ratio of 55:45. Dry matter intake and milk yield were recorded daily, and spot samples of urine, feces, and blood were collected at the end of each experimental period. Dry matter intake did not differ across diets, averaging 26.7 kg/d. Milk yield averaged 35.6 kg/d and was 1.1 kg/d greater for RCG versus FBG, and milk urea N concentration was lower for RCG compared with FBG. Milk yield was 2.2 kg/d and milk protein yield 66 g/d lower for FB versus RE. Nitrogen intake, urinary N, and urinary urea N excretions were lower, and milk N excretion tended to be lower for RCG compared with FBG. The proportion of the dietary N excreted as fecal N was larger in cows fed RCG than for those fed FBG, and the opposite was true for urinary N. We detected an interaction for milk N as percentage of N intake: it increased with RE compared with FB for RCG-based diet, but only a marginal increase was observed for FBG-based diet. Plasma concentration of His and Lys were lower for RCG than for FBG, whereas His tended to be greater and Lys lower for FB compared with RE. Further, plasma Met concentration was around 26% lower for FB than for RE. Of milk fatty acids, saturated fatty acids were decreased by RCG and increased by FB compared with FBG and RE, respectively, whereas monounsaturated fatty acids were increased by RCG versus FBG, and were lower for FB than for RE. In particular, 18:1n-9 concentration was lower for FB compared with RE. Polyunsaturated fatty acids, such as 18:2n-6 and 18:3n-3, were greater for RCG than for FBG, and 18:2n-6 was greater and 18:3n-3 was lower for FB versus RE. In addition, cis-9,trans-11 conjugated linoleic acid was lower for FB compared with RE. Faba bean whole-crop silage and faba bean meal have potential to be used as a part of dairy cow rations, but further research is needed to improve their N efficiency. Red clover-grass silage from a mixed sward, without inorganic N fertilizer input, combined with RE, resulted in the greatest N efficiency in the conditions of this experiment.

Socioeconomic factors and regional differences in mental disorder-based disability pensioning in Finland

Introduction

Prior literature has indicated low socioeconomic status (SES) and regional differences as epidemiological risk factors for disability pension (DP) due to mental disorders.

Objectives

Our studies aimed to examine these associations and differences in greater detail, with separate consideration of the risk factors for mood disorders (F30–39) and non-affective psychotic disorder (F20–29) DP.

Methods

Subjects (N = 36 879) were all those granted DP due to a mental disorder for the first time between 2010 and 2015 in Finland. All the subjects were matched with three controls. Education, income and occupational status were used as measures of SES. Conditional logistic regression models were used to study SES differences. Negative binomial regression analysis was used to study the levels of DP risk in the Finnish hospital districts.

Results

DP recipients had low educational and income levels and often lived alone. The risk of DP was greater in white-collar occupational groups compared with blue-collar workers. Students had the greatest risk of DP for all mental and mood disorders. Significant differences in the regional mental disorder DP risks did not appear to follow the traditional Finnish health differences.

Conclusions

We found evidence of SES factors and regional variation associating with mental disorder-related severe loss of working and studying ability in a disorder-specific way. The increased risk of white-collar worker DP could be related to the psychosocially demanding contemporary working life. Regional variation in DP may at least partly relate to differences in regional mental health service systems.

Disclosure

No significant relationships.

Association of diabetes type and chronic diabetes complications with early exit from the labour force: register-based study of people with diabetes in Finland

AIMS/HYPOTHESIS

Diabetes and diabetes complications are a cause of substantial morbidity, resulting in early exits from the labour force and lost productivity. The aim of this study was to examine differences in early exits between people with type 1 and 2 diabetes and to assess the role of chronic diabetes complications on early exit. We also estimated the economic burden of lost productivity due to early exits.

METHODS

People of working age (age 17-64) with diabetes in 1998-2011 in Finland were detected using national registers (N_{type 1} = 45,756, N_{type 2} = 299,931). For the open cohort, data on pensions and deaths, healthcare usage, medications and basic demographics were collected from the registers. The outcome of the study was early exit from the labour force defined as pension other than old age pension beginning before age 65, or death before age 65. We analysed the early exit outcome and its risk factors using the Kaplan-Meier method and extended Cox regression models. We fitted linear regression models to investigate the risk factors of lost working years and productivity costs among people with early exit.

RESULTS

The difference in median age at early exit from the labour force between type 1 (54.0) and type 2 (58.3) diabetes groups was 4.3 years. The risk of early exit among people with type 1 diabetes increased faster after age 40 compared with people with type 2 diabetes. Each of the diabetes complications was associated with an increase in the hazard of early exit regardless of diabetes type compared with people without the complication, with eye-related complications as an exception. Diabetes complications partly but not completely explained the difference between diabetes types. The mean lost working years was 6.0 years greater in the type 1 diabetes group than in the type 2 diabetes group among people with early exit. Mean productivity costs of people with type 1 diabetes and early exit were found to be 1.4-fold greater compared with people with type 2 diabetes. The total productivity costs of incidences of early exits in the type 2 diabetes group were notably higher compared with the type 1 group during the time period (€14,400 million, €2800 million).

CONCLUSIONS/INTERPRETATION

We found a marked difference in the patterns of risk of early exit between people with type 1 and type 2 diabetes. The difference was largest close to statutory retirement age. On average, exits in the type 1 diabetes group occurred at an earlier age and resulted in higher mean lost working years and mean productivity costs. The potential of prevention, timely diagnosis and management of diabetes is substantial in terms of avoiding reductions in individual well-being and productivity.

Quality of life, psychological distress and violence among women in close relationships: a population-based study in Finland

BACKGROUND

The aim of this study was to examine associations between exposure to violence, quality of life, and psychological distress. Women aged 19-54 years who had been exposed to violence by someone in a close relationship were compared with women unexposed to violence in Finland. We also aimed to investigate associations between different forms of violence (physical, sexual, emotional, or any combination of these) with quality of life and psychological distress.

METHODS

We selected a sample of 22,398 women who had returned self-completed questionnaires from a Finnish population-based health survey between 2013 and 2016. Exposure to violence during the past year was assessed through specific questions from the survey. The EUROHIS-QOL 8-item index was used to measure quality of life, and ordinary least square regressions were fitted. The mental health inventory (MHI-5) was used to measure psychological distress. We investigated associations with multivariate logistic regression analysis.

RESULTS

Among women in Finland, the prevalence of exposure to violence in any type of close relationship during the past year was 7.6%. Women who had been exposed to violence had significantly worse scores of the EUROHIS-QOL 8-item index, and psychological distress was significantly worse (p < 0.001), compared with unexposed women. Strong associations were found between combinations of violence and both quality of life (coefficient - 0.51, p < 0.001) and mental health (odds ratio 4.16, 95% confidence interval 3.44-5.03). Compared with women who had been exposed to violence by a stranger, women who had been exposed to violence by someone in a close relationship had significantly lower quality-of-life scores (p < 0.001).

CONCLUSIONS

This study found that experience of close relationship violence had a negative influence on both quality of life and psychological distress among women in the general Finnish population. Comparison with victims of violence by strangers shows that some of the lower quality-of-life scores among victims are driven by the perpetrator and victim being in a close relationship. Preventive policies in primary care settings aimed at screening and educating young people should be considered as an early form of intervention to reduce the negative mental health consequences of violence.

Cost-effectiveness analysis of PSA-based mass screening: Evidence from a randomised controlled trial combined with register data

In contrast to earlier studies which have used modelling to perform cost-effectiveness analysis, this study links data from a randomised controlled trial with register data from nationwide registries to reveal new evidence on costs, effectiveness, and cost-effectiveness of organised mass prostate-cancer screening based on prostate-specific antigen (PSA) testing. Cost-effectiveness analyses were conducted with individual-level data on health-care costs from comprehensive registers and register data on real-world effectiveness from the two arms of the Finnish Randomised Study of Screening for Prostate Cancer (FinRSPC), following 80,149 men from 1996 through 2015. The study examines cost-effectiveness in terms of overall mortality and, in addition, in terms of diagnosed men’s mortality from prostate cancer and mortality with but not from prostate cancer. Neither arm of the FinRSPC was clearly more cost-effective in analysis in terms of overall mortality. Organised screening in the FinRSPC could be considered cost-effective in terms of deaths from prostate cancer: averting just over one death per 1000 men screened. However, even with an estimated incremental cost-effectiveness ratio of below 20,000€ per death avoided, this result should not be considered in isolation. This is because mass screening in this trial also resulted in increases in death with, but not from, prostate cancer: with over five additional deaths per 1000 men screened. Analysis of real-world data from the FinRSPC reveals new evidence of the comparative effectiveness of PSA-based screening after 20 years of follow-up, suggesting the possibility of higher mortality, as well as higher healthcare costs, for screening-arm men who have been diagnosed with prostate cancer but who do not die from it. These findings should be corroborated or contradicted by similar analyses using data from other trials, in order to reveal if more diagnosed men have also died in the screening arms of other trials of mass screening for prostate cancer.

Early part-time sick leave results in considerable savings in social security costs at national level: an analysis based on a quasi-experiment in Finland

Objectives We analyzed social security costs based on an earlier quasi-experiment that compared work participation between partial sickness beneficiaries and a matched group of full sickness beneficiaries. Methods Utilizing a population-based 70% representative sample, 1878 persons with part-time sick leave (intervention group) due to musculoskeletal diseases or mental disorders at an early stage of work disability and their propensity-score-matched controls with full-time sick leave were followed for two years. The outcome was the difference (absolute and relative) in social security costs between the intervention and control groups during follow-up. Costs of sickness absence, vocational rehabilitation, unemployment, and retirement days were calculated from national administrative registers. Results A cost reduction of €2395 per person per year [95% confidence interval (CI) -2890- -1899) was observed in the intervention compared with the control group. The cost ratio was 0.512 (95% CI 0.511-0.513). The largest savings were attributable to differences in the costs of retirement and vocational rehabilitation. The savings were higher for the second compared with the first follow-up year. Costs were saved across both genders and diagnostic groups, however, savings for women with musculoskeletal diseases were lowest. Conclusions Part-time instead of full-time sick leave, at the early stage of work disability due to musculoskeletal diseases or mental disorders, leads to considerable social security cost savings during two years, in correspondence with increased work participation and in addition to earlier reported health benefits. Part-time sick leave can be recommended from an economic perspective; however more consideration should be given to women with musculoskeletal diseases.

The Joint Impact of Age at Death and Dementia on Long-Term Care Use in the Last Years of Life: Changes From 1996 to 2013 in Finland

Welfare states increasingly rely on aging in place policies and have cut back on institutional long-term care (LTC) provision. Simultaneously, the major determinants of LTC use, that is, dementia and living to very old age, are increasing. We investigated how increasing longevity and concomitant dementia were associated with changes in round-the-clock LTC use in the last 5 years of life between 1996 and 2013. Retrospective data drawn from national registers included all those who died aged 70+ in 2007 and 2013, plus a 40% random sample from 2001 (N = 86,554). A generalized estimating equations (GEE) were used to estimate the association of dementia and age with LTC use during three study periods 1996-2001, 2002-2007, and 2008-2013. Between the study periods, the total number of days spent in LTC increased by around 2 months. Higher ages at death and the increased number of persons with dementia contributed to this increase. The group of the most frequent LTC users, that is, people aged 90+ with or without dementia, grew the most in size, yet their LTC use decreased. The implications of very old age and concomitant dementia for care needs must be acknowledged to guarantee an adequate quantity and quality of care.

Long-term care is increasingly concentrated in the last years of life: a change from 2000 to 2011

Background

The use of long-term care (LTC) is common in very old age and in the last years of life. It is not known how the use pattern is changing as death is being postponed to increasingly old age. The aim is to analyze the association between the use of LTC and approaching death among old people and the change in this association from 2000 to 2011.

Methods

The data were derived from national registers. The study population consists of 315 458 case-control pairs. Cases (decedents) were those who died between 2000 and 2011 at the age of 70 years or over in Finland. The matched controls (survivors) lived at least 2 years longer. Use of LTC was studied for the last 730 days for decedents and for the same calendar days for survivors. Conditional logistic regression analyses were performed to test the association of LTC use with decedent status and year.

Results

The difference in LTC use between decedents and survivors was smallest among the oldest (OR 9.91 among youngest, 4.96 among oldest). The difference widened from 2000 to 2011 (OR of interaction of LTC use and year increased): use increased or held steady among decedents, but decreased among survivors.

Conclusions

The use of LTC became increasingly concentrated in the last years of life during the study period. The use of LTC is also common among the oldest survivors. As more people live to very old age, the demand for LTC will increase.

Changes in older people's care profiles during the last 2 years of life, 1996-1998 and 2011-2013: a retrospective nationwide study in Finland

OBJECTIVES

The time of death is increasingly postponed to a very high age. How this change affects the use of care services at the population level is unknown. This study analyses the care profiles of older people during their last 2 years of life, and investigates how these profiles differ for the study years 1996-1998 and 2011-2013.

DESIGN

Retrospective cross-sectional nationwide data drawn from the Care Register for Health Care, the Care Register for Social Care and the Causes of Death Register. The data included the use of hospital and long-term care services during the last 2 years of life for all those who died in 1998 and in 2013 at the age of ≥70 years in Finland.

METHODS

We constructed four care profiles using two criteria: (1) number of days in round-the-clock care (vs at home) in the last 2 years of life and (2) care transitions during the last 6 months of life (ie, end-of-life care transitions).

RESULTS

Between the study periods, the average age at death and the number of diagnoses increased. Most older people (1998: 64.3%, 2013: 59.3%) lived at home until their last months of life (profile 2) after which they moved into hospital or long-term care facilities. This profile became less common and the profiles with a high use of care services became more common (profiles 3 and 4 together in 1998: 25.0%, in 2013: 30.9%). People with dementia, women and the oldest old were over-represented in the latter profiles. In both study periods, fewer than one in ten stayed at home for the whole last 6 months (profile 1).

CONCLUSIONS

Postponement of death to a very old age may translate into more severe disability in the last months or years of life. Care systems must be prepared for longer periods of long-term care services needed at the end of life.

Trends in the use and costs of round-the-clock long-term care in the last two years of life among old people between 2002 and 2013 in Finland

BACKGROUND

The structure of long-term care (LTC) for old people has changed: care has been shifted from institutions to the community, and death is being postponed to increasingly old age. The aim of the study was to analyze how the use and costs of LTC in the last two years of life among old people changed between 2002 and 2013.

METHODS

Data were derived from national registers. The study population contains all those who died at the age of 70 years or older in 2002-2013 in Finland (N = 427,078). The costs were calculated using national unit cost information. Binary logistic regression and Cox proportional hazard models were used to study the association of year of death with use and costs of LTC.

RESULTS

The proportion of those who used LTC and the sum of days in LTC in the last two years of life increased between 2002 and 2013. The mean number of days in institutional LTC decreased, while that for sheltered housing increased. The costs of LTC per user decreased.

CONCLUSIONS

Use of LTC in the last two years of life increased, which was explained by the postponement of death to increasingly old age. Costs of LTC decreased as sheltered housing replaced institutional LTC. However, an accurate comparison of costs of different types of LTC is difficult, and the societal costs of sheltered housing are not well known.

Care service use in 2 years preceding suicide among older adults: comparison with those who died a natural death and those who lived longer

The aim of the study is (1) to describe and analyse health and social service use and medicine purchases in the last 2 years of life among older adults who died by suicide and (2) to compare use and purchases between three groups: those who died by suicide, died a natural death or who lived longer. Nation-wide Finnish register data were used. The data consist of 316,639 decedents who died at the age of 70 years or older in 1998-2008 and 222,967 people who lived longer. Use of hospital, long-term care and home care, and the purchase of prescribed psychotropic medications were studied for the 2-year period. Binary logistic regression analyses were applied. 1118 older adults died by suicide (0.4 % of all deaths). A majority of older adults who died by suicide had multiple somatic diseases and mental disorders, especially depression, and had contact with health and social services in the last 2 years of life. At the same level of morbidity, use of hospital and long-term care was less common among those who died by suicide than among those who died of natural causes, but more common than among those who lived longer. Those who died by suicide received less home care than those who lived longer. A high proportion of suicides occurred in the first month following hospital discharge. Health and social services should improve support for older adults with chronic diseases and depression.

Long-term care use among old people in their last 2 years of life: variations across Finland

Variations across Finland in the use of six different long-term care (LTC) services among old people in their last 2 years of life, and the effects of characteristics of municipalities on the variations were studied. We studied variations in the use of residential home, sheltered housing, regular home care and inpatient care in health centre wards by using national registers. We studied how the use of LTC was associated with characteristics of the individuals and in particular characteristics of the municipalities in which they lived. Analyses were conducted with multilevel binary logistic regression. Data included all individuals (34,753) who died in the year 2008 at the age of 70 or over. Of those, 58.3% used some kind of LTC during their last 2 years of life. We found considerable variations between municipalities in the use of different kinds of LTC. A portion of the variation was explained by municipality characteristics. The size and location of the municipality had the strongest association with the use of different kinds of LTC. The economic status of the municipality and morbidity at the population level were poorly associated with LTC use, whereas old-age dependency showed no association. When individual-level characteristics were added to the models, these associations did not alter. Results indicated that the delivery system characteristics had an important effect on the use of LTC services. The considerable variation in LTC services also poses questions with respect to equity in access and to quality of LTC across the country.

Costs after hip fracture in independently living patients: a randomised comparison of three rehabilitation modalities

OBJECTIVE

To evaluate costs and cost-effectiveness of physical and geriatric rehabilitation after hip fracture.

DESIGN

Prospective randomised study (mean age 78 years, 105 male, 433 female) in different rehabilitation settings: physically oriented (187 patients), geriatrically oriented (171 patients), and healthcare centre hospital (control, 180 patients).

MAIN MEASURES

At 12 months post-fracture, we collected data regarding days in rehabilitation, post-rehabilitation hospital treatment, other healthcare service use, number of re-operations, taxi use by patient or relative, and help from relatives.

RESULTS

Control rehabilitation (4945,2€) was significantly less expensive than physical (6609.0€, p=0.002) and geriatric rehabilitation (7034.7€ p<0.001). Total institutional care costs (primary treatment, rehabilitation, and post-rehabilitation hospital care) were lower for control (13,438.4€) than geriatric rehabilitation (17,201.7€, p<0.001), but did not differ between control and physical rehabilitation (15659.1€, p=0.055) or between physical and geriatric rehabilitation ( p=0.252). Costs of help from relatives (estimated as 30%, 50% and 100% of a home aid's salary) with physical rehabilitation were lower than control ( p=0.016) but higher than geriatric rehabilitation ( p=0.041). Total hip fracture treatment costs were lower with physical (36,356€, 51,018€) than control rehabilitation (38,018€, 57,031€) at 50% and 100% of salary ( p=0.032, p=0.014, respectively). At one year post-fracture, 15D-score was significantly higher in physical rehabilitation group (0.697) than geriatric rehabilitation group (0.586, p=0.008) and control group (0.594, p=0.009).

CONCLUSIONS

Considering total costs one year after hip fracture the treatment including physical rehabilitation is significantly more cost-effective than routine treatment. This effect could not be seen between routine treatment and treatment including geriatric rehabilitation.

Is longer waiting time associated with health and social services utilization before treatment? A randomized study

Objective: To determine whether longer waiting time for major joint replacement is associated with health and social services utilization before treatment.

Methods: When placed on the waiting list, patients were randomized to short (≤3 months) or a non-fixed waiting time. Utilization measures were the use of home health care, rehabilitation and social services before treatment.

Results: A total of 833 patients with osteoarthritis of the hip or knee joint were recruited into the study. Six hundred and twenty-two patients were included in the analysis. The majority of patients were not using any services before hospital admission for joint replacement surgery. The most commonly used service was unpaid home help provided by relatives, neighbours, friends and volunteers (informal care). In both groups, private support services were utilized more often than public ones. Patients with a short waiting time were more likely than those with a non-fixed waiting time to use rehabilitation (13.5% versus 8.2%, P = 0.032) and visiting care services (7.5% versus 3.9%, P = 0.054).

Conclusions: Only a few patients used professional care. They were more likely to require informal care during the waiting time. A longer waiting time did not result in a higher utilization rate before admission for treatment.

Photodynamic Therapy for Actinic Keratoses: A Randomized Prospective Non-sponsored Cost-effectiveness Study of Daylight-mediated Treatment Compared with Light-emitting Diode Treatment

Daylight-mediated photodynamic therapy (DL-PDT) is considered as effective as conventional PDT using artificial light (light-emitting diode (LED)-PDT) for treatment of actinic keratoses (AK). This randomized prospective non-sponsored study assessed the cost-effectiveness of DL-PDT compared with LED-PDT. Seventy patients with 210 AKs were randomized to DL-PDT or LED-PDT groups. Effectiveness was assessed at 6 months. The costs included societal costs and private costs, including the time patients spent in treatment. Results are presented as incremental cost-effectiveness ratio (ICER). The total costs per patient were significantly lower for DL-PDT (€132) compared with LED-PDT (€170), giving a cost saving of €38 (p = 0.022). The estimated probabilities for patients' complete response were 0.429 for DL-PDT and 0.686 for LED-PDT; a difference in probability of being healed of 0.257. ICER showed a monetary gain of €147 per unit of effectiveness lost. DL-PDT is less costly and less effective than LED-PDT. In terms of cost-effectiveness analysis, DL-PDT provides lower value for money compared with LED-PDT.

Use of hospital resources in the Finnish colorectal cancer screening programme: a randomised health services study

Objective

To estimate the difference in use of hospital resources in the Finnish Colorectal Cancer (CRC) screening programme between those invited and controls, within the year of randomisation and the next year.

Design

CRC screening was implemented in Finland in 2004 as a population-based randomised design using biennial faecal occult blood test (FOBT) for men and women aged 60–69 years. Those randomised to screening and control groups during years 2004–2009 were included in this analysis and use of hospital resources was estimated. Data were collected from the national register on hospital discharges. Outpatient visits, inpatient episodes and colonoscopies were compared between the two groups.

Results

The screening group comprised of 123 149 and control group of 122 930 people. Most people in both groups had not used hospital resources at all. More people in the screening group than in the control group had at least one hospital-based outpatient visit (7.8% vs 7.4%), inpatient episode (3.9% vs 3.8%) and colonoscopy (1.5% vs 1.3%). In total, the screening group had 31 975 and control group 27 061 cumulative outpatient visits, 9260 and 7903 inpatient episodes, and 2686 and 1756 hospital colonoscopies, respectively. The proportion of those with a positive FOBT result with at least one outpatient visit, one inpatient episode or one colonoscopy, was 3.7 times, 2.5 times or 9 times that of those with a negative FOBT result, respectively.

Conclusions

CRC screening using the FOBT slightly increased the volume of hospital outpatient visits, inpatient episodes and hospital colonoscopies in Finland.

Geriatric and physically oriented rehabilitation improves the ability of independent living and physical rehabilitation reduces mortality: a randomised comparison of 538 patients

OBJECTIVE

To examine effects of physical and geriatric rehabilitation on institutionalisation and mortality after hip fracture.

DESIGN

Prospective randomised study.

SETTING

Physically oriented (187 patients), geriatrically oriented (171 patients), and health centre hospital rehabilitation (180 patients, control group).

SUBJECTS

A total of 538 consecutively, independently living patients with non-pathological hip fracture.

MAIN MEASURES

Patients were evaluated on admission, at 4 and 12 months for social status, residential status, walking ability, use of walking aids, pain in the hip, activities of daily living (ADL) and mortality.

RESULTS

Mortality was significantly lower at 4 and 12 months in physical rehabilitation (3.2%, 8.6%) than in geriatric rehabilitation group (9.6%, 18.7%, P=0.026, P=0.005, respectively) or control group (10.6%, 19.4%, P=0.006, P=0.004, respectively). At 4 months more patients in physical (84.4%) and geriatric rehabilitation group (78.0%) were able to live at home or sheltered housing than in control group (71.9%, P=0.0012 and P<0.001, respectively). No significant difference was found between physical rehabilitation and geriatric rehabilitation (P=0.278). Analysis of femoral neck and trochanteric fractures showed that significant difference was true only for femoral neck fractures (physical rehabilitation vs geriatric rehabilitation P=0.308, physical rehabilitation vs control group P<0,001 and geriatric rehabilitation vs control group P<0.001). Effects of intensified rehabilitations disappeared at 12 months. No impact on walking ability or ADL functions was observed.

CONCLUSIONS

Physical rehabilitation reduced mortality. Physical and geriatric rehabilitation significantly improved the ability of independent living after 4 months especially among the femoral neck fracture patients but this effect could not be seen after 12 months.

Burdensome transitions at the end of life among long-term care residents with dementia

OBJECTIVES

The purpose of the study was to examine the frequency of burdensome care transitions at the end of life, the difference between different types of residential care facilities, and the changes occurring between 2002 and 2008.

DESIGN

A nationwide, register-based retrospective study.

SETTING

Residential care facilities offering long-term care, including traditional nursing homes, sheltered housing with 24-hour assistance, and long-term care facilities specialized in care for people with dementia.

STUDY GROUP

All people in Finland who died at the age of 70 or older, had dementia, and were in residential care during their last months of life.

MAIN OUTCOME MEASURES

Three types of potentially burdensome care transition: (1) any transition to another care facility in the last 3 days of life; (2) a lack of continuity with respect to a residential care facility before and after hospitalization in the last 90 days of life; (3) multiple hospitalizations (more than 2) in the last 90 days of life. The 3 types were studied separately and as a whole.

RESULTS

One-tenth (9.5%) had burdensome care transitions. Multiple hospitalizations in the last 90 days were the most frequent, followed by any transitions in the last 3 days of life. The frequency varied between residents who lived in different baseline care facilities being higher in sheltered housing and long-term specialist care for people with dementia than in traditional nursing homes. During the study years, the number of transitions fluctuated but showed a slight decrease since 2005.

CONCLUSIONS

The ongoing change in long-term care from institutional care to housing services causes major challenges to the continuity of end-of-life care. To guarantee good quality during the last days of life for people with dementia, the underlying reasons behind transitions at the end of life should be investigated more thoroughly.

Patient-specific computer-based decision support in primary healthcare--a randomized trial

BACKGROUND

Computer-based decision support systems are a promising method for incorporating research evidence into clinical practice. However, evidence is still scant on how such information technology solutions work in primary healthcare when support is provided across many health problems. In Finland, we designed a trial where a set of evidence-based, patient-specific reminders was introduced into the local Electronic Patient Record (EPR) system. The aim was to measure the effects of such reminders on patient care. The hypothesis was that the total number of triggered reminders would decrease in the intervention group compared with the control group, indicating an improvement in patient care.

METHODS

From July 2009 to October 2010 all the patients of one health center were randomized to an intervention or a control group. The intervention consisted of patient-specific reminders concerning 59 different health conditions triggered when the healthcare professional (HCP) opened and used the EPR. In the intervention group, the triggered reminders were shown to the HCP; in the control group, the triggered reminders were not shown. The primary outcome measure was the change in the number of reminders triggered over 12 months. We developed a unique data gathering method, the Repeated Study Virtual Health Check (RSVHC), and used Generalized Estimation Equations (GEE) for analysing the incidence rate ratio, which is a measure of the relative difference in percentage change in the numbers of reminders triggered in the intervention group and the control group.

RESULTS

In total, 13,588 participants were randomized and included. Contrary to our expectation, the total number of reminders triggered increased in both the intervention and the control groups. The primary outcome measure did not show a significant difference between the groups. However, with the inclusion of patients followed up over only six months, the total number of reminders increased significantly less in the intervention group than in the control group when the confounding factors (age, gender, number of diagnoses and medications) were controlled for.

CONCLUSIONS

Computerized, tailored reminders in primary care did not decrease during the 12 months of follow-up time after the introduction of a patient-specific decision support system.

TRIAL REGISTRATION

ClinicalTrial.gov NCT00915304.

[Cost effects of laparoscopic and hysteroscopic female sterilization]

INTRODUCTION

The aim was to elucidate the costs and clinical results of sterilization.

MATERIAL AND METHODS

A retrospective analysis was carried out on sterilizations conducted at the Hyvinkää hospital in 2006 to 2007 by tubal ligation with clips and by microimplants.

RESULTS

Total costs obtained for microimplant sterilization per patient were 1,146 Euros and for clip sterilization 1,712 Euros. Postoperative pain was significantly less in the microimplant group, and adverse effects associated with the procedure were more common in the clip sterilization group.

CONCLUSIONS

Microimplant sterilization performed on an outpatient basis is more cost-effective than laparoscopic clip sterilization.

Does informal care reduce public care expenditure on elderly care? Estimates based on Finland's Age Study

BACKGROUND

To formulate sustainable long-term care policies, it is critical first to understand the relationship between informal care and formal care expenditure. The aim of this paper is to examine to what extent informal care reduces public expenditure on elderly care.

METHODS

Data from a geriatric rehabilitation program conducted in Finland (Age Study, n = 732) were used to estimate the annual public care expenditure on elderly care. We first constructed hierarchical multilevel regression models to determine the factors associated with elderly care expenditure. Second, we calculated the adjusted mean costs of care in four care patterns: 1) informal care only for elderly living alone; 2) informal care only from a co-resident family member; 3) a combination of formal and informal care; and 4) formal care only. We included functional independence and health-related quality of life (15D score) measures into our models. This method standardizes the care needs of a heterogeneous subject group and enabled us to compare expenditure among various care categories even when differences were observed in the subjects' physical health.

RESULTS

Elder care that consisted of formal care only had the highest expenditure at 25,300 Euros annually. The combination of formal and informal care had an annual expenditure of 22,300 Euros. If a person received mainly informal care from a co-resident family member, then the annual expenditure was only 4,900 Euros and just 6,000 Euros for a person living alone and receiving informal care.

CONCLUSIONS

Our analysis of a frail elderly Finnish population shows that the availability of informal care considerably reduces public care expenditure. Therefore, informal care should be taken into account when formulating policies for long-term care. The process whereby families choose to provide care for their elderly relatives has a significant impact on long-term care expenditure.

Impact of HPV16/18 vaccination on quality of life: a pilot study

OBJECTIVES

Genital human papillomavirus (HPV) infections and associated precancerous lesions adversely affect health-related quality of life (HRQoL). HPV vaccines provide effective protection against these conditions. We therefore investigated the impact of HPV vaccination on HRQoL in young women five years after participation in a phase III HPV vaccination trial.

METHODS

A total of 4808 originally 16- to 17-year-old Finnish girls had participated in the PATRICIA trial and received either bivalent HPV 16/18 vaccine or hepatitis A-virus (HAV) vaccine in 2004 to 2005. Unvaccinated girls (n = 9602), from adjacent birth cohorts, had participated in the control cohort in 2005. From 2009 to 2011, at 22 to 23 years of age, all participants received a questionnaire consisting of two generic HRQoL instruments (RAND36 and EQ VAS) and a disease-specific questionnaire (CECA10).

RESULTS

We analysed responses of 1143 HPV 16/18-vaccinated, 980 HAV-vaccinated, and 3753 unvaccinated young women. The unadjusted mean outcome measures of the different HRQoL estimates were similar in the three different responder cohorts.

CONCLUSIONS

Five years after vaccination the health-related quality of life of HPV 16/ 18- vaccinated young women did not differ from those of HAV-vaccinated or unvaccinated controls representing the general population.

Effects of municipality factors on care transitions

Aims: To analyse whether transitions between care settings differ between municipalities in the last 2 years of life among older people in Finland. Methods: Data were derived from Finnish national registers, and include all those who died in 2002 and 2003 at the age of 70 or older except those living in very small municipalities ( n=67,027). Data include admissions and discharges from health and social care facilities (university hospitals, general hospitals, health centres, residential care facilities) and time spent outside care facilities for 730 days prior to death. Three-level negative binomial regression analyses were performed to study the effect of municipal factors on (1) the total number of all care transitions, (2) the number of transitions between home and different care facilities, and (3) transitions between different care facilities. Results: The municipality of residence had only a minor effect on the total number of care transitions, but greater variation between municipalities was found when different types of care transition were examined separately. Largest differences were found in care transitions involving specialised care. Age structure, urbanity, and economic situation of the municipality had an impact on several different care transitions. Conclusion: The total number of care transitions in 2 final years of life was approximately similar irrespective of the municipality of residence, but the findings imply differences in transitioning specialised care. Potentially, this may suggest inequality between the municipalities, but more detailed studies are needed to confirm the factors underlying these differences.

Health-related quality of life in the Finnish trial of screening for prostate cancer

BACKGROUND

Evidence of the potential impact of systematic screening for prostate cancer (PCa) on health-related quality of life (HRQoL) at a population-based level is currently scarce.

OBJECTIVE

This study aims to quantify the long-term HRQoL impact associated with screening for PCa.

DESIGN, SETTING, AND PARTICIPANTS

Postal questionnaire surveys were conducted in 1998, 2000, 2004, and 2011 among men in the Finnish PCa screening trial diagnosed with PCa (total n=7011) and among a random subsample of the trial population (n=2200). In 2011, for example, 1587 responses were received from men with PCa in the screening arm and 1706 from men in the control arm. In addition, from the trial subsample, 549 men in the screening arm and 539 in the control arm provided responses.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Health-state-value scores were compared between the intervention and control arms using three distinct HRQoL measures (15D, EQ-5D, and SF-6D), and statistical significance was assessed using t tests. In addition, differences over repeated assessments of HRQoL between groups were evaluated using generalised estimating equations.

RESULTS AND LIMITATIONS

In the 2011 survey, a small but statistically significant difference emerged between the trial arms among men diagnosed with PCa (mean scores, screening vs control arm: 15D: 0.872 vs 0.866, p=0.14; EQ-5D: 0.852 vs 0.831, p=0.03; and SF-6D: 0.763 vs 0.756, p=0.06). Such differences in favour of the screening arm were not found among the sample of men from the trial (15D: 0.889 vs 0.892, p=0.62; EQ-5D: 0.831 vs 0.852, p=0.08; and SF-6D: 0.775 vs 0.777, p=0.88). The slight advantage with screening among men with PCa was reasonably consistent across time in the longitudinal analysis and was strongest among men with early-stage disease.

CONCLUSIONS

These results show some long-term HRQoL benefit from screening for men with PCa but suggest little impact overall in the trial population.

Conservative treatment, plate fixation, or prosthesis for proximal humeral fracture. A prospective randomized study

Background

Proximal humerus fracture is the third most common fracture type after hip and distal radius fracture in elderly patients. A comprehensive study by Palvanen et al. demonstrated an increase in the annual fracture rate of 13.7% per year over the past 33 years. Should this trend continue, the fracture rate would triple over the next three decades. The increasing incidence of low-energy fractures raises questions about the optimal treatment in terms of functional outcome, pain, and rehabilitation time, as well as the economical impact. Despite the high incidence and costs of proximal humerus fractures, there is currently no valid scientific evidence for the best treatment method. Several publications, including a Cochrane review outline the need for high-quality, well-designed randomized controlled trials.

Methods/Design

The study is a prospective, randomized, national multi-center trial. The hypothesis of the trial is that surgical treatment of displaced proximal humerus fractures achieves better functional outcome, pain relief, and patient satisfaction compared to conservative treatment. The trial is designed to compare conservative and surgical treatment of proximal humerus fractures in patients 60 years and older. The trial includes two strata. Stratum I compares surgical treatment with locking plates to conservative treatment for two-part fractures. Stratum II compares multi-fragmented fractures, including three- and four-part fractures. The aim of Stratum II is to compare conservative treatment, surgical treatment with the Philos locking plate, and hemiarthroplasty with an Epoca prosthesis. The primary outcome measure will be the Disabilities of the Arm, Shoulder and Hand (DASH) score and the secondary outcome measures will be the EuroQol-5D (EQ-5D) value, OSS, Constant-Murley Score, VAS, and 15D.

Recruiting time will be 3 years. The results will be analyzed after the 2-year follow-up period.

Discussion

This publication presents a prospective, randomized, national multi-center trial. It gives details of patient flow, randomization, aftercare and also ways of analysis of the material and ways to present and publish the results.

Trial registration

ClinicalTrials.gov identifier: NCT01246167

Health care costs associated with gestational diabetes mellitus among high-risk women--results from a randomised trial

Background

The costs of gestational diabetes mellitus (GDM) screening have been frequently reported, but total GDM-related health care costs compared to the health care costs of women without GDM have not been reported. The aim of this study was to analyse GDM-related health care costs among women with an elevated risk of GDM.

Methods

The study was based on a cluster-randomised GDM prevention trial (N = 848) carried out at maternity clinics, combined with data from the Finnish Medical Birth Register and Care Registers for Social Welfare and Health Care. Costs of outpatient visits to primary and secondary care, cost of inpatient hospital care before and after delivery, the use of insulin, delivery costs and babies’ stay in the neonatal intensive care unit were analysed. Women who developed GDM were compared to those who were not diagnosed with GDM.

Results

Total mean health care costs adjusted for age, body mass index and education were 25.1% higher among women diagnosed with GDM (€6,432 vs. €5,143, p < 0.001) than among women without GDM. The cost of inpatient visits was 44% higher and neonatal intensive care unit use was 49% higher in the GDM group than among women without GDM. The delivery costs were the largest single component in both groups.

Conclusions

A confirmed GDM diagnosis was associated with a significant increase in total health care costs. Effective lifestyle counselling by primary health care providers may offer a means of reducing the high costs of secondary care.

Factors associated with the utilization and costs of health and social services in frail elderly patients

Background

Universal access is one of the major aims in public health and social care. Services should be provided on the basis of individual needs. However, municipal autonomy and the fragmentation of services may jeopardize universal access and lead to variation between municipalities in the delivery of services. This paper aims to identify patient-level characteristics and municipality-level service patterns that may have an influence on the use and costs of health and social services of frail elderly patients.

Methods

Hierarchical analysis was applied to estimate the effects of patient and municipality-level variables on services utilization.

Results

The variation in the use of health care services was entirely due to patient-related variables, whereas in the social services, 9% of the variation was explained by the municipality-level and 91% by the patient-level characteristics. Health-related quality of life explained a major part of variation in the costs of health care services. Those who had reported improvement in their health status during the preceding year were more frequent users of social care services. Low informal support, poor functional status and poor instrumental activities of daily living, living at a residential home, and living alone were associated with higher social services expenditure.

Conclusions

The results of this study showed municipality-level variation in the utilization of social services, whereas health care services provided for frail elderly people seem to be highly equitable across municipalities.

Another important finding was that the utilization of social and health services were connected. Those who reported improvement in their health status during the preceding year were more frequently also using social services. This result suggests that if municipalities continue to limit the provision of support services only for those who are in the highest need, this saving in the social sector may, in the long run, result in increased costs of health care.

The impact of dementia on care transitions during the last two years of life

BACKGROUND

Dementia is one of the main challenges to our health and social care. This study compares the number and timing of transitions between care settings in the last 2 years of life among older people with and without dementia.

METHODS

Data were derived from Finnish national registers, and include all those who died in 2002 and 2003 at the age of 70 or older (n = 70,366). Negative binomial regression analyses were used to analyse the impact of dementia on number of transitions among people with and without dementia and to adjust the number for age, gender and other diagnoses.

RESULTS

In the group that lived at home 2 years before death people with a dementia diagnosis had 32% more care transitions than people without dementia, while the group that was in residential care facility 2 years before death people with dementia had 12% fewer moves than those without dementia The average number of transition was highest in last 3 months of life. People with dementia had their last move more often between care facilities and hospitals offering basic health care than people without dementia.

CONCLUSION

Dementia has a significant impact on the number and type of transitions. As the number of people with dementia increases, the quality and equity of care of these patients in their last years constitute a special challenge.

Dementia as a determinant of social and health service use in the last two years of life 1996-2003

BACKGROUND

Dementia is one of the most common causes of death among old people in Finland and other countries with high life expectancies. Dementing illnesses are the most important disease group behind the need for long-term care and therefore place a considerable burden on the health and social care system. The aim of this study was to assess the effects of dementia and year of death (1998-2003) on health and social service use in the last two years of life among old people.

METHODS

The data were derived from multiple national registers in Finland and comprise all those who died in 1998, 2002 or 2003 and 40% of those who died in 1999-2001 at the age of 70 or over (n = 145 944). We studied the use of hospitals, long-term care and home care in the last two years of life. Statistics were performed using binary logistic regression analyses and negative binomial regression analyses, adjusting for age, gender and comorbidity.

RESULTS

The proportion of study participants with a dementia diagnosis was 23.5%. People with dementia diagnosis used long-term care more often (OR 9.30, 95% CI 8.60, 10.06) but hospital (OR 0.33, 95% CI 0.31, 0.35) and home care (OR 0.50, 95% CI 0.46, 0.54) less often than people without dementia. The likelihood of using university hospital and long-term care increased during the eight-year study period, while the number of days spent in university and general hospital among the users decreased. Differences in service use between people with and without dementia decreased during the study period.

CONCLUSIONS

Old people with dementia used long-term care to a much greater extent and hospital and home care to a lesser extent than those without dementia. This difference persisted even when controlling for age, gender and comorbidity. It is important that greater attention is paid to ensuring that old people with dementia have equitable access to care.

Municipal variation in health and social service use in the last 2 years of life among old people

Aims: To describe and analyse municipal differences in health and social service use among old people in the last 2 years of life. Methods: The data were derived from national registers. All those who died in 2002 or 2003 at the age of ≥70 years were included except those who lived in very small municipalities. The services included were different types of hospitals, long-term care, and home care. The variation in service use was described by coefficients of variation (CV). To analyse local differences, three-level (individual, municipal, and regional) binary logistic and Poisson regression analyses were performed. Results: A total of 67,027 decedents from 315 municipalities in 20 hospital districts were included. There was considerable variation in service use between residents of different municipalities, especially in the types of hospital used. Of the individual-level variables age and use of other services were associated (p < 0.05) with use of all services. Of the municipal-level variables, indicators describing the service pattern in the municipality were associated with use of all services and average age of decedents with most of the services. The presence of a university hospital in the hospital district increased the probability of using university and general hospitals, but among the users increased days in university hospital and decreased days in general hospital. Conclusions: Considerable differences between municipalities exist, but these cannot be exhaustively explained. Behind the differences are probably factors which are difficult to describe and quantify, such as historical developments and political realities.

Impact of HPV vaccination on young women's quality of life - a five year follow-up study

OBJECTIVES

Human papillomavirus (HPV) vaccines protect against infections/conditions which potentially adversely affect quality of life (QoL). We investigated the impact of HPV infection on QoL five years post vaccination in 22-23 year-old women and a group of controls.

METHODS

Participants were 22-23 year-old women who had either previously been enrolled in the FUTURE II trial of the quadrivalent HPV vaccine in Finland at age 16-17 (n = 1749), or were unvaccinated females in the birth cohort above those eligible for participation in FUTURE II in Finland (n = 6534). Participants were sent a questionnaire consisting of two generic QoL instruments (RAND36 and EQ VAS).

RESULTS

We received and analysed 4438 valid responses. Unadjusted mean outcomes of the different QoL measures (RAND36 domains and EQ VAS) were similar. Multiple regression analysis showed that reporting current or previous genital warts, or cytological abnormalities, was significantly associated with reduced QoL. There were no significant differences between the HPV-vaccinated group and the placebo or unvaccinated groups.

CONCLUSIONS

Diagnoses of genital warts or of cervical anomalies have a significant impact on QoL. The QoL of women who received the placebo or no vaccine was no lower, five years later, than that of those who received the active HPV vaccine.

Economic evaluation of a geriatric rehabilitation programme: a randomized controlled trial

OBJECTIVE

Cost-effectiveness of a geriatric rehabilitation programme.

DESIGN

Economic evaluation alongside a randomized controlled trial.

METHODS

A total of 741 subjects with progressively decreasing functional ability and unspecific morbidity were randomly assigned to either an inpatient rehabilitation programme (intervention group) or standard care (control group). The difference between the mean cost per person for 12 months' care in the rehabilitation and control groups (incremental cost) and the ratio between incremental cost and effectiveness were calculated. Clinical outcomes were functional ability (Functional Independence Measure (FIM(TM))) and health-related quality of life (15D score).

RESULTS

The FIM(TM) score decreased by 3.41 (standard deviation 6.7) points in intervention group and 4.35 (standard deviation 8.0) in control group (p = 0.0987). The decrease in the 15D was equal in both groups. The mean incremental cost of adding rehabilitation to standard care was 3111 euros per person. The incremental cost-effectiveness ratio for FIMTM did not show any clinically significant change, and the rehabilitation was more costly than standard care. A cost-effectiveness acceptability curve suggests that if decision-makers were willing to pay 4000 euros for a 1-point improvement in FIMTM, the rehabilitation would be cost-effective with 70% certainty.

CONCLUSION

The rehabilitation programme was not cost-effective compared with standard care, and further development of outpatient protocols may be advisable.

Transitions in health and social service system at the end of life

This study focuses on the amount and types of transitions in health and social service system during the last 2 years of life and the places of death and among Finnish people aged 70-79, 80-89 and 90 or older. The data set, derived from multiple national registers, consists of 75,578 people who died between 1998 and 2001. The services included university hospitals, general hospitals, health centres and residential care facilities. The most common place of death was the municipal health centre: half of the whole research population died in a health centre. The place of death varied by age and gender: men and people in younger age groups died more often in general or in university hospital or at home, while dying in health centres or in residential care homes was more common among women or the very old. Number of transitions varied from zero to over a hundred transitions during the last 2 years. Number of transitions increased as death approached. Men and younger age groups had more transitions than women and older age groups. Among men and younger age groups transitions between home and general or university hospital were common while transitions between home and health centre or residential care were more common to women and older people. The results indicate that municipal health centres have a major role as care providers as death approaches. Differences between gender and age in numbers and types of transitions were clear. Future research is needed to clarify the causes to these differences.

Healthcare professionals' intentions to use clinical guidelines: a survey using the theory of planned behaviour

Background

Finnish clinical guidelines are evolving toward integration of knowledge modules into the electronic health record in the Evidence-Based Medicine electronic Decision Support project. It therefore became important to study which factors affect professionals' intention to use clinical guidelines generally in their decision-making on patient care. A theory-based approach is a possible solution to explore determinants of professionals' behaviour. The study's aim was to produce baseline information for developers and implementers by using the theory of planned behaviour.

Methods

A cross-sectional internet-based survey was carried out in Finnish healthcare organisations within three hospital districts. The target population (n = 2,252) included physicians, nurses, and other professionals, of whom 806 participated. Indicators of the intention to use clinical guidelines were observed by using a theory-based questionnaire. The main data analysis was done by means of multiple linear regressions.

Results

The results indicated that all theory-based variables--the attitude toward the behaviour, the subjective norm, and the perceived behaviour control--were important factors associated with the professionals' intention to use clinical practice guidelines for their area of specialisation in the decisions they would make on the care of patients in the next three months. In addition, both the nurse and the physician factors had positive (p < 0.01) effects on this intention in comparison to other professionals. In the similar models for all professions, the strongest factor for the physicians was the perceived behaviour control, while the key factor for the nurses and the other professionals was the subjective norm. This means that context- and guideline-based factors either facilitate or hinder the intention to use clinical guidelines among physicians and, correspondingly, normative beliefs related to social pressures do so for nurses and other healthcare professionals.

Conclusions

The results confirm suggestions that the theory of planned behaviour is a suitable theoretical basis for implementing clinical guidelines in healthcare practices. Our new finding was that, in general, profession had an effect on intention to use clinical guidelines in patient care. Therefore, the study reaffirms the general contention that different strategies need to be in place when clinical guidelines are targeted at different professional groups.

The effect of waiting time on health-related quality of life, pain, and physical function in patients awaiting primary total hip replacement: a randomized controlled trial

OBJECTIVE

This prospective randomized study assessed the effect of waiting time (WT) on health outcomes in Finnish patients admitted to hospital for primary total hip replacement (THR).

METHODS

A total of 395 consecutive patients with a need for a primary THR because of osteoarthritis and who were placed on the waiting list between August 2002 and November 2003. After placement on the waiting list, the patients were randomly assigned to a short WT (<or=3 months) group (n = 174) or a nonfixed WT group (n = 221). The patients completed self-administered questionnaires at the time of placing on the waiting list and at hospital admission. Health-related quality of life was measured by the generic 15D instrument. Hip pain and function were measured by the patient self-report Harris hip score (HHS).

RESULTS

Of the 395 patients, 312 (79%) completed the follow-up (140 patients with short and 172 with nonfixed WT). At admission, the mean 15D scores for patients with short and nonfixed WT were 0.784 and 0.783, respectively. In the intention-to-treatment analysis, the difference between the groups (Delta 0.001, 95% confidence interval [CI]: -0.019 to 0.021) was not statistically significant or clinically important. The mean self-report HHS in patients with short WT was 43.5, and among those with nonfixed WT was 41.9. The difference (Delta 1.6, 95% CI: -1.77 to 4.87) was not statistically significant.

CONCLUSIONS

Both generic and disease-specific measures revealed that longer WTs did not result in poorer health status at admission.

Variation in use and costs of primary health and social services in mental health or drinking problems

BACKGROUND

Psychiatric inpatient hospital care was cut dramatically in Finland in recent last decades, and patients were assigned to care in the community. Consequently, the burden of care shifted from hospital districts to municipalities, which have considerable autonomy in organizing health and social services. These changes probably created locally differing service patterns in mental health care.

AIMS OF THE STUDY

We assessed the use of primary social and health care due to mental health and drinking problems and the resulting costs. We also examined differences between municipalities, and analysed factors which may be associated with the variation in use and costs of these services.

METHODS

Data were collected in five municipalities in Pirkanmaa Hospital District, Finland, using a short questionnaire containing questions on e.g. the reason for the visit, time spent during the visit, and of the client's psychosocial functioning (Global Assessment of Function Scale, GAF). The questionnaire was completed at all individual clients' visits to these services during a two-week period in December 2003, by professionals (MD's, nurses, social workers etc.) who worked in either local health or social services. Descriptive statistics and several regression techniques were used to describe and analyse factors associated with the use and costs of services.

RESULTS

During the study period, altogether 25,738 visits took place, the total number of visitors being 10,265. Of these visitors, 1,360 had mental health or drinking problems totalling to 4,471 visits. Most of these visits took place to mental health clinics or were visits made as home care. The average cost of mental health work in primary care per client was 29.8 in two weeks, ranging between municipalities from 29 to 52 . Client's poor GAF and being a recipient of home care were associated with higher costs of services. Even after controlling for visitor-related factors, use and costs of services were associated with the local service patterns.

DISCUSSION

The response rate could not be calculated for each service producer; however, we estimated that this varied between 50% and 100%. Therefore our results represent this visitor population. However, our limited data did not allow any analysis of municipality-related factors which might explain the role of service patterns in costs and use of services.

IMPLICATIONS FOR HEALTH CARE PROVISION AND USE

A considerable proportion of total use and costs of local welfare services are due to mental health problems. The differences between municipal service patterns cause variation in total costs of care of mental disorders.

IMPLICATIONS FOR HEALTH POLICIES

Some capacity in local primary services is allocated to mental health problems, thus enabling a shift from institutional care toward community care. However, varying local patterns may cause a risk to unequal access to mental health services.

IMPLICATIONS FOR FURTHER RESEARCH

In future studies it is important to analyse the properties of local service patterns which influence appropriate use and optimal costs of care.

The labor supply of registered nurses in Finland: the effect of wages and working conditions

Many countries report, to varying degrees, of suffering from a shortage of nurses. We examined both pecuniary and non-pecuniary factors that may be associated with nurses' labor supply. We approximated a classical labor supply model and calculated the wage elasticities of hours of work and participation. Even though the wage elasticity was quite small, the effect on the hours supplied was significant. However, wages alone may not sufficiently increase the labor supply from the current stock of nurses; other elements, such as contractual conditions, seem to play an important role as well.

Age and closeness of death as determinants of health and social care utilization: a case-control study

BACKGROUND

We used case-control design to compare utilization of health and social services between older decedents and survivors, and to identify the respective impact of age and closeness of death on the utilization of services.

METHODS

Data were derived from multiple national registers. The sample consisted of 56,001 persons, who died during years 1998-2000 at the age of > or = 70, and their pairs matched on age, gender and municipality of residence, who were alive at least 2 years after their counterpart's death. Data include use of hospitals, long-term care and home care. Decedents' utilization within 2 years before death and survivors' utilization in the same period of time was assessed in three age groups (70-79, 80-89 and > or = 90 years) and by gender.

RESULTS

Decedents used hospital and long-term care more than their surviving counterparts, but the time patterns were different. In hospital care the differences between decedents and survivors rose in the last months of the study period, whereas in long-term care there were clear differences during the whole 2-year period. The differences were smaller in the oldest age group than in younger age groups.

CONCLUSION

Closeness of death is an important predictor of health and social service use in old age, but its influence varies between age groups. Not only the changing age structure, but also the higher average age at death affects the future need for services.