Trajectory modelling of ambulatory care sensitive conditions in Finland in 1996–2013: assessing the development of equity in primary health care through clustering of geographic areas – an observational retrospective study

Abstract

Background Due to stagnating resources and an increase in staff workload, the quality of Finnish primary health care (PHC) is claimed to have deteriorated slowly. With a decentralised PHC organisation and lack of national stewardship, it is likely that municipalities have adopted different coping strategies, predisposing them to geographic disparities. To assess whether these disparities emerge, we analysed health centre area trajectories in hospitalisations due to ambulatory care sensitive conditions (ACSCs). Methods ACSCs, a proxy for PHC quality, comprises conditions in which hospitalisation could be avoided by timely care. We obtained ACSCs of the total Finnish population aged ≥20 for the years 1996–2013 from the Finnish Hospital Discharge Register, and divided them into subgroups of acute, chronic and vaccine-preventable causes, and calculated annual age-standardised ACSC rates by gender in health centre areas. Using these rates, we conducted trajectory analyses for identifying health centre area clusters using group-based trajectory modelling. Further, we applied area-level factors to describe the distribution of health centre areas on these trajectories. Results Three trajectories – and thus separate clusters of health centre areas – emerged with different levels and trends of ACSC rates. During the study period, chronic ACSC rates decreased (40–63%) within each of the clusters, acute ACSC rates remained stable and vaccine-preventable ACSC rates increased (1–41%). While disparities in rate differences in chronic ACSC rates between trajectories narrowed, in the two other ACSC subgroups they increased. Disparities in standardised rate ratios increased in vaccine-preventable and acute ACSC rates between northern cluster and the two other clusters. Compared to the south-western cluster, 13–16% of health centre areas, in rural northern cluster, had 47–92% higher ACSC rates – but also the highest level of morbidity, most limitations on activities of daily living and highest PHC inpatient ward usage as well as the lowest education levels and private health and dental care usage. Conclusions We identified three differing trajectories of time trends for ACSC rates, suggesting that the quality of care, particularly in northern Finland health centre areas, may have lagged behind the general improvements. This calls for further investments to strengthen rural area PHC. Electronic supplementary material The online version of this article (10.1186/s12913-019-4449-7) contains supplementary material, which is available to authorized users.

Cumulative social disadvantage and hospitalisations due to ambulatory care-sensitive conditions in Finland in 2011─2013: a register study

“…In addition, there are structural differences in access to ambulatory care services between the working-age population and others due to occupational healthcare. 3 Men and women were studied mainly separately due to differing levels of hospitalisations due to ACSCs 7 and the effects of risk factors. Hospital districts were used as an indicator of the region of residence.…”

“…[2][3][4][5] Challenges in providing timely access to primary care are encountered in some areas 6 and there are indications of differences in primary healthcare quality between regions. 7 However, Strengths and limitations of this study ► The individual-level register-based data allowed us to study simultaneously several indicators of social and socioeconomic disadvantage. ► The nationwide register data covered all hospitalisations due to ambulatory care-sensitive conditions (ACSCs) in Finland.…”

“… 2–5 Challenges in providing timely access to primary care are encountered in some areas 6 and there are indications of differences in primary healthcare quality between regions. 7 However, Finland has—compared with most other European countries—a strong publicly funded primary healthcare. 8 …”

Individual and Area-level Factors Contributing to the Geographic Variation in Ambulatory Care Sensitive Conditions in Finland

“…Of these we identified ACSCs using the UK definition 29 —with an addition of unspecified pneumonia (ICD-10 diagnosis code J18.9) as used previously in Finland. 23 Further, we divided ACSCs into subgroups of acute, chronic, and vaccine-preventable (Supplemental Digital Content 1, http://links.lww.com/MLR/C130 ). Competent authorities linked hospitalization data into individual sociodemographic data.…”

“…Few studies have assessed over time the development of geographic distribution 23 , 24 or variation in ACSC rates, 25 , 26 but describe these only with area-level factors. 23 , 24 It is still unclear how a comprehensive array of area-level factors over time contributes to geographic variation in ACSCs, when individual SEP and health status are adjusted for.…”