Background In Sweden, the number of older people using emergency department (ED) care is rising. Among older persons an ED visit is a stressful event, which potentially could have been prevented or treated at other levels of care. Frequent ED use (> 4 visits a year) by older persons might reflect issues in the organisation of health care system to address their needs. We aimed to explore socio-demographic differences among older people seeking ED care in terms age and gender, and to investigate the association between income and frequent ED use. Methods A population-based study analysing the utilisation of ED care by ( N = 356,375) individuals aged 65+ years. We linked register data on socio-demographic characteristics from 2013 to health care utilisation data in 2014. Multivariable logistic regression was used to estimate the income differences in the frequent use of ED care, adjusting for living situation, country of birth, residential area, age in years, multi-morbidity and the use of other health care services. Results Those 65+ years accounted for (27%) of all ED visits in Stockholm County in 2014. In the study population (2.5%) were identified as frequent ED users, who were predominantly in the lower income groups, living alone or in an institution, had more multi-morbidity, and utilised more of other health care services. The lowest income groups had a three-fold greater odds of being a frequent ED user than those in the highest income group. In the adjusted models, the odds were reduced by 12–44% for those in the lowest income groups. However, age and gender differences were observed with men 65–79 years (OR 1.75 CI: 1.51–2.03) and women 80+ years (OR 1.50, CI 1.19–1.87) in the lowest income groups having a higher odds of frequent ED use. Conclusion This study observed that ED visits by older persons are driven by a need of care, and those that frequently visit hospital-based EDs are a socially disadvantaged group, which suggests that the organisation of care for older people should be reviewed in order to better meet their needs in other levels of care. Electronic supplementary material The online version of this article (10.1186/s12913-019-4029-x) contains supplementary material, which is available to authorized users.
ObjectiveTo investigate the association between the implementation of an integrated care (IC) system in Norrtälje municipality and changes in trends of the rate of emergency department (ED) visits.DesignInterrupted time series analysis from 2000 to 2015.SettingStockholm County.ParticipantsAll inhabitants 65+ years in Stockholm County on 31 December of each study year.InterventionIC was established by combining the funding, administration and delivery of health and social care for older persons in Norrtälje municipality, within Stockholm County.OutcomeRates of hospital-based ED visits.ResultsIC was associated with a decrease in the rate of ED visits (incidence rate ratio: 0.997, 95% CI 0.995 to 0.998) among inhabitants 65+ years in Norrtälje. However, the rate of ED visits remained higher in Norrtälje than the rest of Stockholm in the preintervention and postintervention periods. Stratified analyses showed that IC was associated with a decline in the trend of the rate of ED visits among those 65–79 years, the lowest income group and born outside of Sweden. However, there was no significant decrease in the trend among those 80+ years.ConclusionThe implementation of IC was associated with a modest change in the trend of ED visits in Norrtälje, though the rate of ED visits remained higher than in the rest of Stockholm. Changes in the composition of the population and contextual changes may have impacted our findings. Further research, using other outcome measures is needed to assess the impact of IC on healthcare utilisation.
Aims: Polypharmacy and potentially inappropriate medications (PIM) are risk factors for negative health outcomes among older people. This study aimed to investigate socio-demographic differences in polypharmacy and PIM use among older people with different care needs in a standard versus an integrated care setting. Methods: Population-based register data on residents aged ⩾65 years in Stockholm County based on socio-demographic background and social care use in 2014 was linked to prescription drug use in 2015. A logistic regression analysis was used to estimate socio-demographic differences in polypharmacy and PIM, adjusting for education, age group, sex, country of birth, living alone, morbidity and dementia by care setting based on area and by care need (i.e. independent, home help or institutionalised). Results: The prevalence of polypharmacy and PIM was greater among home-help users (60.4% and 11.5% respectively) and institutional residents (74.4% and 11.9%, respectively). However, there were greater socio-demographic differences among the independent, with those with lower education, older age and females having higher odds of polypharmacy and PIM. Morbidity was a driver of polypharmacy (odds ratio (OR)=1.19, confidence interval (CI) 1.16–1.22) among home-help users. Dementia diagnosis was associated with reduced odds of polypharmacy and PIM among those in institutions (OR=0.78, CI 0.71–0.87 and OR 0.52, CI 0.45–0.59, respectively) and of PIM among home-help users (OR=0.53, 95% CI 0.42–0.67). Conclusions: Polypharmacy and PIM were associated with care needs, most prevalent among home-help users and institutional residents, but socio-demographic differences were most prominent among those living independently, suggesting that municipal care might reduce differences between socio-demographic groups. Care setting had little effect on inappropriate drug use, indicating that national guidelines are followed.
Background In Sweden, health care is a regional responsibility and social care of older people is a municipal responsibility. The system is fragmented and the use of emergency care by older persons is rising. Better integration, coordination, and collaboration between health and social care providers is necessary to address the complex needs of an ageing population. Since 2006, Norrtälje municipality in Stockholm Region has integrated health and social care. This study aims to assess the impact of the integrated care system in Norrtälje on rates of emergency care visits, compared to the rest of Stockholm county. Methods A repeated cross-sectional study with an interrupted time series analysis compared the integrated care system in Norrtälje to a matched control from Stockholm county, using. population-based register data between 2000-2015 obtained from Stockholm Region’s administrative database of healthcare utilization and from the Longitudinal Integration database for Health Insurance and labour market studies from Statistics Sweden. Results There was no statistically significant difference in the post-intervention rates of emergency care visits in Norrtälje compared to the matched control. However, there was a decreasing trend in the rate of visits among females 65-79 years, those in lower income groups, those living alone and those born outside of Sweden. Conclusions The implementation of the integrated care system in Norrtälje had no statistically significant impact on the rate of emergency care visits among older persons compared to standard care. However, there was a reduced rate of visits among potentially vulnerable sub-groups. Further research is needed as the full implementation of the Norrtälje Model was completed as recently as 2016 and the full impact may not yet be realised. Key messages Bringing about change in the delivery of health and social care is complex and challenging. Thus, to observe differences in the utilisation of emergency care requires more time and resources. Innovation in the delivery of health and social care is needed to effectively manage and coordinate the ever changing needs of older persons with complex needs given the current fragmented services.
ObjectivesTo investigate the association between inpatient care expenditure (ICE) and income group and the effect of demographic factors, health status, healthcare and social care utilisation on ICE in the last year of life.DesignRetrospective population-based study.SettingStockholm County.ParticipantsDecedents ≥65 years in 2015 (N=13 538).OutcomeICE was calculated individually for the month of, and 12 months preceding death using healthcare register data from 2014 and 2015. ICE included the costs of admission and treatment in inpatient care adjusted for the price level in 2018.ResultsThere were difference between income groups and ICE incurred at the 75th percentile, while a social gradient was found at the 95th percentile where the highest income group incurred higher ICE (SEK45 307, 95% CI SEK12 055 to SEK79 559) compared with the lowest income groups. Incurring higher ICE at the 95th percentile was driven by greater morbidity (SEK20 333, 95% CI SEK12 673 to SEK29 993) and emergency department care visits (SEK77 995, 95% CI SEK64 442 to SEK79 549), while lower ICE across the distribution was associated with older age and residing in institutional care.ConclusionGaining insight into patterns of healthcare expenditure in the last year of life has important implications for policy, particularly as socioeconomic differences were visible in ICE at a time of greater care need for all. Future policies should focus on engaging in advanced care planning and strengthening the coordination of care for older people.
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