The organisation and responsibility for care for older people in Denmark, Finland and Sweden: outline and comparison of care systems

AIM

To outline the organisation and responsibility for health and social care provided to older people in Denmark, Finland and Sweden.

METHODS

Non-quantifiable data on the care systems were collated from the literature and expert consultations. The responsibilities for primary healthcare, specialised healthcare, prevention and health promotion, rehabilitation, and social care were presented in relation to policy guidance, funding and organisation.

RESULTS

In all three countries, the state issues policy and to some extent co-funds the largely decentralised systems; in Denmark and Sweden the regions and municipalities organise the provision of care services - a system that is also about to be implemented in Finland to improve care coordination and make access more equal. Care for older citizens focuses to a large extent on enabling them to live independently in their own homes.

CONCLUSIONS

Decentralised care systems are challenged by considerable local variations, possibly jeopardising care equity. State-level decision and policy makers need to be aware of these challenges and monitor developments to prevent further health and social care disparities in the ageing population.

Opportunities for transitional care and care continuity following hospital discharge of older people in three Nordic cities: A comparative study

AIM

To outline and discuss care transitions and care continuity following hospital discharge of older people with complex care needs in three Nordic cities: Copenhagen, Tampere and Stockholm.

METHODS

Data on potential pathways following hospital discharge of older people were obtained from existing literature and expert consultations. The pathways for each system were outlined and presented in three figures. The hospital discharge process of the systems was then compared.

RESULTS

In all three care systems, the main care path from hospital is to home. Short-term intermediate healthcare can be provided in all three systems, possibly creating additional care transitions; however, once home, extensive home healthcare may prevent further care transitions. Opportunities for continuity of care include needs assessments (all cities) and meetings with the patient about care upon return home (Copenhagen, Stockholm). Yet this is challenged by lack of transfer of information (Tampere) and patients' having to apply for some services themselves (Tampere, Stockholm).

CONCLUSIONS

Comparisons of the discharge processes studied suggest that despite individual care planning and short- and long-term care options, transitional care and care continuity are challenged by limited access as some services need to be applied for by the older person themselves.

Nurses' Roles, Responsibilities and Actions in the Hospital Discharge Process of Older Adults with Health and Social Care Needs in Three Nordic Cities: A Vignette Study

The hospital discharge process of older adults in need of both medical and social care post hospitalisation requires the involvement of nurses at multiple levels across the different phases. This study aims to examine and compare what roles, responsibilities and actions nurses take in the hospital discharge process of older adults with complex care needs in three Nordic cities: Copenhagen (Denmark), Stockholm (Sweden) and Tampere (Finland). A vignette-based interview study consisting of three cases was conducted face-to-face with nurses in Copenhagen (n = 11), Stockholm (n = 16) and Tampere (n = 8). The vignettes represented older patients with medical conditions, cognitive loss and various home situations. The interviews were conducted in the local language, recorded, transcribed and analysed thematically. The findings show that nurses exchanged information with both healthcare (all cities) and social care services (Copenhagen, Tampere). Nurses in all cities, particularly Stockholm, reported to inform, and also convince patients to make use of home care. Nurses in Stockholm and Tampere reported that some patients refuse care due to co-payment. Nurses in these two cities were more likely to involve close relatives, possibly due to such costs. Not accepting care, due to costs, poses inequity in later life. Additionally, organisational changes towards a shift in location of care, i.e., from hospital to home, and from professional to informal caregivers, might be reflected in the work of the nurses through their initiatives to convince older patients to accept home care and to involve close relatives.

Professionals’ roles in the hospital discharge of older adults in 3 Nordic cities: a vignette study

Background

The hospital discharge process of older adults in need of both medical and social care post hospitalisation requires extensive care coordination. Cooperation and continuity between involved care providers are essential, however, existing care systems including the Nordic care systems, are poorly designed to provide health and social care to patients with complex health and social care needs which increases the risk of certain groups not receiving optimal care.

Aim and methods

This study aims to examine and compare what roles, responsibility and actions nurses take in the hospital discharge process of older adults with complex care needs in three Nordic cities: Copenhagen (Denmark), Stockholm (Sweden) and Tampere (Finland). A vignette study consisting of three fictive cases was conducted face-to-face with nurses in Copenhagen (n = 11), Stockholm (n = 16) and Tampere (n = 8). Participants were identified through the researchers’ networks and snowball sampling. The vignettes represent older patients with age-related medical conditions of which one also has cognitive loss and one looks after their partner with dementia. The cases further include differences in the home help received by their children, physical obstacles in their homes and unwillingness of becoming a burden to the system. A thematic approach is used for the data analysis.

Results and conclusions

Preliminary results suggest that the informants’ roles and engagement in the coordination and collaboration may differ both within and between the systems studied, and that they take responsibility beyond their job roles particularly if the patient has no close relatives. The study is of public health importance as it identifies gaps in how the care is organised in the three welfare states targeted. It also sheds light on the complexities of providing universal care in ageing societies where a growing proportion of older adults have both medical and social care needs.

Key messages

Convergence in disability policies in the welfare states Denmark, Sweden, the UK and Australia?

Background

A state’s relation to citizens who are not able to support themselves due to illness is one of the cornerstones of welfare states. However, rising numbers of people on disability benefits is a challenge in many welfare states. The first aim is to investigate how policies around eligibility to disability benefits articulate a concept of ’incapacity to work’ across social democratic (Denmark and Sweden) and liberal welfare states (Australia and the UK). Secondly, we wish to explore how the conceptualisation of capacity and incapacity to work shapes prevailing constructions of disability.

Methods

In this study, we analyse official policy documents from governments, legislation, scientific and grey literature on disability benefit reforms in the selected countries. The analytical framework introduces the notion of decommodification of labour for people with disability and the ’social model of disability’ in relation to the constructions of disability in current disability benefit reforms.

Results (preliminary)

Restricting access to disability benefits has been a key feature of the recent reforms across all different types of welfare states. Liberal welfare states are more pervasive in reassessment of previously granted benefits compared to social democratic welfare states. The construction of disability in recent reforms is at odds with the social model of disability.

Conclusions (preliminary)

Across both liberal and social democratic welfare states eligibility for disability benefits is articulated around notions of incapacity to work. Retrenchment of benefits is, overall, most pervasive in liberal welfare states.

Key messages

The convergence in social policies across both social democratic and liberal welfare states speaks to the pervasiveness of neo-liberal notions in current social policy. The tightening of eligibility criteria for disability benefits poses great financial and health risks to people with illness struggling to support themselves.

The use of dialogue tools to promote dialogue-based and person-centred patient education for people with type 2 diabetes

OBJECTIVES

To explore educator experiences of implementing dialogue tools in practice to engender participatory patient education.

METHODS

Data were collected through qualitative interviews with 31 educators and 20 ethnographic observations of group-based education sessions at eight education sites. Data were analysed using systematic text condensation and the theoretical concepts of script and de-script. Three dialogue tools including 'My Illness and Me', 'Goals and Plan's and 'Wheel of Change' were selected for analysis because they were used most frequently. The tools are intended to support educators in facilitating participatory patient education.

RESULTS

Consistent with the intended purpose of the dialogue tools, educators reported that the dialogue tools helped engender participatory education in the form of reflection and dialogue among participants regarding living with diabetes. However, educators also reported instances of discrepancies between the tools' intended purpose and their actual use because some participants found it difficult to relate to the tools.

DISCUSSION

The application of dialogue tools to engender participatory patient education is highly dependent on educators' and participants' understanding and use of dialogue tools in practice. This implies that substantial educator skills are needed to facilitate dialogue and participation in patient education.

A dialogue-based approach to patient education

In recent years, the need for person-centered patient education has become evident. To translate this approach into practice, new theoretically and empirically sound methods and models are required. This brief communication introduces a newly developed toolkit that has shown promise in facilitating person-centered education and active involvement of patients. Two health education models constituting the underlying basis for the toolkit are also presented.

Experiences with treating immigrants: a qualitative study in mental health services across 16 European countries

PURPOSE

While there has been systematic research on the experiences of immigrant patients in mental health services within certain European countries, little research has explored the experiences of mental health professionals in the delivery of services to immigrants across Europe. This study sought to explore professionals' experiences of delivering care to immigrants in districts densely populated with immigrants across Europe.

METHODS

Forty-eight semi-structured interviews were conducted with mental health care professionals working in 16 European countries. Professionals in each country were recruited from three areas with the highest proportion of immigrants. For the purpose of this study, immigrants were defined as first-generation immigrants born outside the country of current residence, including regular immigrants, irregular immigrants, asylum seekers, refugees and victims of human trafficking. Interviews were transcribed and analysed using thematic analysis.

RESULTS

The interviews highlighted specific challenges to treating immigrants in mental health services across all 16 countries including complications with diagnosis, difficulty in developing trust and increased risk of marginalisation.

CONCLUSIONS

Although mental health service delivery varies between and within European countries, consistent challenges exist in the experiences of mental health professionals delivering services in communities with high proportions of immigrants. Improvements to practice should include training in reaching appropriate diagnoses, a focus on building trusting relationships and measures to counter marginalisation.

Health care for irregular migrants: pragmatism across Europe: a qualitative study

BACKGROUND

Health services in Europe face the challenge of delivering care to a heterogeneous group of irregular migrants (IM). There is little empirical evidence on how health professionals cope with this challenge. This study explores the experiences of health professionals providing care to IM in three types of health care service across 16 European countries.

RESULTS

Semi-structured interviews were conducted with health professionals in 144 primary care services, 48 mental health services, and 48 Accident & Emergency departments (total n = 240). Although legal health care entitlement for IM varies across countries, health professionals reported facing similar issues when caring for IM. These issues include access problems, limited communication, and associated legal complications. Differences in the experiences with IM across the three types of services were also explored. Respondents from Accident & Emergency departments reported less of a difference between the care for IM patients and patients in a regular situation than did respondents from primary care and mental health services. Primary care services and mental health services were more concerned with language barriers than Accident & Emergency departments. Notifying the authorities was an uncommon practice, even in countries where health professionals are required to do this.

CONCLUSIONS

The needs of IM patients and the values of the staff appear to be as important as the national legal framework, with staff in different European countries adopting a similar pragmatic approach to delivering health care to IM. While legislation might help to improve health care for IM, more appropriate organisation and local flexibility are equally important, especially for improving access and care pathways.

Providing medical care for undocumented migrants in Denmark: what are the challenges for health professionals?

Background

The rights of undocumented migrants are frequently overlooked. Denmark has ratified several international conventions recognizing the right to health care for all human beings, but has very scanty legislation and no existing policies for providing health care to undocumented migrants. This study focuses on how health professionals navigate and how they experience providing treatment for undocumented migrants in the Danish health care system.

Methods

The study was carried out as part of an EU-project on European Best Practices in Access, Quality and Appropriateness of Health Services for Immigrants in Europe (EUGATE). This presentation is based on 12 semi-structured interviews with general practitioners (9) and emergency room physicians (3) in Denmark.

Results

The emergency room physicians express that treatment of undocumented migrants is no different from the treatment of any other person. However, care may become more complicated due to lack of previous medical records and contact persons. Contrary to this, general practitioners explain that undocumented migrants will encounter formal barriers when trying to obtain treatment. Additional problems in the treatment of undocumented migrants include language issues, financial aspects for general practitioners, concerns about how to handle the situation including possibilities of further referrals, and an uncertainty as to whether to involve the police.

Conclusions

The health professionals in our study describe that undocumented migrants experience an unequal access to primary care facilities and that great uncertainties exist amongst health professionals as how to respond in such situations. The lack of official policies concerning the right to health care for undocumented migrants continue to pass on the responsibility to health professionals and, thereby, leaves it up to the individual to decide whether treatment can be obtained or not.

Efficacy and safety of prolonged thromboprophylaxis with a low molecular weight heparin (dalteparin) after total hip arthroplasty--the Danish Prolonged Prophylaxis (DaPP) Study

The aim of this study was to compare the efficacy and safety of prolonged (35 days) thromboprophylaxis with a standard length (7 days) regimen of a low molecular weight heparin in patients undergoing total hip arthroplasty. The study was multicentre, randomised, double-blind, and prospective with two groups. Following seven days on a standard length regimen of dalteparin (5000 antifactor Xa units subcutaneously once daily starting 12 h before surgery), patients were randomized to continue the prophylaxis with either subcutaneous injections of dalteparin or placebo injections for a further 28 days. Efficacy was evaluated at the end of the study (day 35) in all patients with bilateral ascending phlebography to detect deep vein thrombosis. Bleeding complications and other adverse events were registered throughout the study period. Three hundred consecutive patients agreed to participate before the operation: 281 were finally randomised and 215 completed the study; two patients died before randomisation; 17 developed deep vein thrombosis; none developed pulmonary embolism; and five of 113 patients (4.4%, 95% CI 1-10%) developed deep vein thrombosis in the dalteparin group, compared with 12 of 102 (11.8%; 95% CI 6-20%) in the placebo group (p=0.039). Deep vein thrombosis in the proximal veins was diagnosed in one patient (0.9%; 95% CI 0-5%) in the dalteparin group, and in five (5.0%; 95% CI 2-11%) in the placebo group (p=0.076). Major bleeding was observed in one patient in the placebo group; minor bleeding complications and adverse events were equally distributed between the groups. We concluded that prolonged (35 days) thrombo prophylaxis with dalteparin is more effective than a standard length (7 days) regimen without increased risk of bleeding complications or other adverse events.

External tissue stretching for closing skin defects in 22 patients

In this prospective study, we treated 12 women and 10 men with a newly developed skin-stretching system. The stretching device was used for the closure of 9 fasciotomies and for preoperative skin extension before excision of 6 tattooes, 7 splitskin transplants, 4 giant naevi, and 3 scars. The stretching device was placed under the skin, using local anesthesia. The patient stretched the skin. The mean stretching time was 4 (2-11) days. 20 patients completed the expansion successfully, with no pain or only slight discomfort. In 2 cases, we observed minor complications during the expansion. The external skin-stretching system can be used to obtain primary closure of defects where splitskin transplants otherwise would be necessary. The method can be applied in out-patients, using local anesthesia.

Pressure-controlled palpation: a new technique which increases the reliability of manual palpation

The objective of the present study was to investigate whether the reliability of tenderness evaluation can be increased by using a new technique called "pressure-controlled palpation" (pcp). The technique has been made possible by a newly invented piece of equipment called a palpometer, with which a pressure-sensitive plastic film attached to the index finger records the pressure exerted. In 15 patients with chronic tension-type headache and in 15 healthy volunteers, 2 investigators studied myofascial tenderness using conventional palpation and pressure-controlled palpation. Tenderness was scored on a 4-point scale in each of the examined pericranial regions. The sum of tenderness scores recorded by two observers using conventional palpation differed significantly (p = 0.0003), while results did not differ between observers using pressure-controlled palpation (p = 0.89). During palpation with seven different pressure intensities a positive and linear relation between pressure and pain intensity was found (p = 0.00006). Pain intensity reported by the subjects correlated highly with tenderness scored by the observer (rs = 0.95, p < 0.0001). These results demonstrate for the first time that tenderness scores can be compared between observers if palpation pressure is controlled. Pressure-controlled palpation represents a major improvement on current palpation techniques and should be standard in future research on myofascial pain disorders.

Observer variation in histological classification of cutaneous malignant melanoma

To evaluate the variations within and between observers in the interpretation of important histological prognostic factors, a series of 96 melanoma patients was randomly selected from a database of 1691 patients with cutaneous malignant melanoma. The stained sections were examined on two occasions by four experienced pathologists. Analysis by observed agreement and kappa statistics showed maximal tumour thickness to be the best reproducible variable, with ulceration the second best. Regression was the least reproducible, with level of invasion and type of melanoma in the mid range. Intra-observer variation was uniformly less than inter-observer variation for each variable. For tumour thickness a variance component analysis was done to quantify the variability further. The clinician should not base his choice of treatment entirely on the microscopic classification but take into consideration the clinical course and appearance of the tumour.

Synovial haemangiopericytoma of the knee joint

We report a case of haemangiopericytoma occurring intra-articularly in the synovium of the knee joint. This is a rare tumour which, as far as is known to the authors, has not previously been described in a subsynovial site.

Adult, acquired reactive perforating collagenosis. Report of a case including ultrastructural findings

A case of reactive perforating collagenosis in an adult male patient with chronic renal failure. Pruritic, umbilicate papules, showing extrusion of collagen fibers through the epidermis were detected histopathologically. Electron microscopy showed absence of basal membrane beneath the perforation and collagen fibers with preserved periodicity passing through widened intercellular spaces with islands of cytoplasmic material.

ARDS after accidental inhalation of zinc chloride smoke

Five soldiers were injured by inhalation of hexite smoke (ZnCl2) during military training. Two soldiers, not wearing gas masks breathed hexite for 1 or 2 min, they slowly developed severe adult respiratory distress syndrome (ARDS) over the ensuing 2 weeks. This slow, progressive clinical course has not been previously described. In both patients, an increased plasma zinc concentration was measured 3 weeks after the incident. Intravenous and nebulized acetylcysteine increased the urinary excretion of zinc, and briefly decreased the plasma levels. In an attempt to arrest collagen deposition in the lungs, L-3,4 dehydroproline was administered. Both patients died of severe respiratory failure (25 and 32 days after inhalation). At autopsy diffuse microvascular obliteration, widespread occlusion of the pulmonary arteries and extensive interstitial and intra-alveolar fibrosis was observed. Three soldiers wearing ill fitting gas masks, immediately developed severe coughing and dyspnea. They improved, and 12 months after exposure their lung function tests were nearly normal, but they still had slight dyspnea on exercise.

Prenatal diagnosis of trisomy 20 mosaicism indicating esophageal and rectal origin

Trisomy 20 mosaicism in cultured amniotic fluid cells has in only a few cases been confirmed in fetal tissue. This may lead to the assumption that the trisomic cells are of extra-fetal origin and interruption of the pregnancy is not advisable. Chromosome analysis of numerous fetal tissues indicated in two cases the presence of one or more trisomy 20 cell clones in rectum and esophagus, respectively. The clinical significance of trisomy 20 mosaicism in single organs remains to be elucidated. Besides the karyotype, genetic counselling should take into account all accessible information of the pregnancy, e.g. ultra-sound, serum alpha-fetoprotein values and obstetrical history.

Acrokeratosis paraneoplastica (Bazex' syndrome)

A 63-year-old man had acrokeratosis paraneoplastica (Bazex' syndrome) characterized by violaceous erythema and scaling of the fingers, toes, nose, and aural helices. Severe nail dystrophy was present. Extensive examination of the patient for malignant neoplasms a few months after the initial appearance of the skin changes disclosed no abnormalities, but one year after onset, an epidermoid carcinoma of the lung was found.

Malignant histiocytosis. The diagnosis based on chromosomal, immunologic and histiopathologic analysis

A 38-year-old female suffered for several months from persistent fever without signs of infectious or immunologic disease. 57Co-bleomycin scintigraphy revealed abnormal concentration in the liver. Following a diagnostic laparotomy, the patient died from abdominal haemorrhage. Malignant cell infiltration was demonstrated in a biopsy from the liver. Histiocytic cells were demonstrated in a bone marrow smear obtained shortly before death. Investigation of cultured lymphocytes obtained from the patient the day before she died showed deficiency of T-lymphocytes. Investigations of chromosomes delineated several clones with polyploidi. The diagnosis of malignant histiocytosis was based on erythrophagocytosis, and immunologic and chromosomal aberrations. If malignant histiocytosis is the primary disease, a terminal stage of different diseases or a sign of complication secondary to immuno incompetence (e.g. virus infection) is an open question.

Permanent cardiac pacemakers implanted in the pleural space

Intrapleural implantation is recommended for children, active adolescents and adults, psychiatric patients, and infection-prone patients because of the protection afforded by the pleural space. The implantation technique is briefly described. Complications include diaphragmatic muscle stimulation (with a unipolar unit) and continuous migration of the pulse generator. The advantages of this implantation site include the following (1) reduced risk of lead fracture, (2) protection from physical trauma, (3) reduced risk of infection and erosion. (4) improved cosmetic appearance, and (5) minimized child/generator size disproportion. In one groups of patients undergoing both standard and intrapleural implantation, the number of pacing months per surgical procedure was increased from 5.1 months (standard implant) to 26.2 months (intrapleural implant). Intrapleural implantation may be considered the generator position of choice for the small percentage of patients who require special pacing system protection.

The extent of carcinoma in situ in urinary bladders with primary carcinomas

The occurrence of carcinoma in situ was examined in a consequtive series of cystectomy specimens from 43 patients. All patients were suffering from or had been suffering from primary bladder cancer. Carcinoma in situ was defined as a definitive polymorphia of enlarged nuclei with abnormal chromatin structure in non-tumour bearing areas. It was found in 26 bladders. By means of a systematic technique of cutting the specimens, the extent of the alterations was quantitied, relating the number of blocks containing the alteration to the total number of blocks in which the changes possibly might be present. The extent of carcinoma in situ ranged from 2 to 81% with an average of 20%. The distribution of the alterations was unpredictable, often strongly focal, most often in continuation of the tumour. In one specimen, the margins of resection were involved. The extent was largest in bladders with poorly differentiated tumours. A temporal relationship between in situ carcinoma and invasive carcinoma could not be shown, as regards tumour size and duration of clinical symptoms. The morphology of the changes is discussed seen in the light of variations in the normal epithelium lining the lower urinary tract. Minor degrees of atypia of the epithelium showed rather bad reproduction. The dominating occurrence of carcinoma in situ in bladders with poorly differentiated tumours may either be a manifestation of a biological difference between tumours of different grades of differentiation or that the morphological criteria used correspond to the in situ type of poorly differentiated tumours.

Types of metaplasia in forty urothelial bladder carcinomas. A systematic histological investigation

In a systematic study of bladders from consecutively cystectomized patients, 40 primary urinary bladder carcinomas were examined with regard to the type of differentiation. Metaplastic areas were found in 24 of the tumours. A positive reaction of keratin to Kreybergs stain was required for the definition squamous metaplasia. Squamous areas were found in 16 of the tumours. In 4 tumours there was, in addition to squamos metaplasia, glandular metaplasia which was defined as definite glandular tissue with dysplasia of the epithelium. In 4 tumours, glandular metaplasia was also present in addition to the urothelial carcinoma. In 18 cases, metaplastic changes were present in the luminal portion of the tumour from which the biopsy material and desquaminated material originated. The occurrence of metaplasia was related to the degree of differentiation of the urothelial part of the tumour. Metaplastic changes were most frequent in the poorly differentiated tumours. The biopsies obtained pre-operatively permitted of the diagnosis metaplasia being made in 15 cases, while the cytological material suggested metaplastic changes in 4 cases only. The biological function of metaplasia is unknow. The possibility that these areas will react differently to radiation and chemotherapy is present and the frequency of such changes would suggest that their importance should be studied by their registration as mixed forms as stated by WHO.