Foot-related diabetes complications : care pathways, patient profiles and costs

Publisher Copyright: © 2022, The Author(s).Background: Foot-related diabetes complications reduce individual well-being, increase mortality and results in increased healthcare costs. Despite their notable stress on health services, studies examining the foot complication care pathways, especially from the viewpoint of health services, are limited. We aimed to identify the most typical care pathways following an initial foot-related diabetes complication, to characterize the patients on each pathway and calculate the related healthcare costs. Methods: The identification of pathways was based on population-wide register-based data including all persons diagnosed with diabetes in Finland from 1964 to 2017. For each patient, initial foot-related complication from 2011–2016 was identified using the ICD-10 codes and related healthcare episodes were followed for two years until the end of 2017 or death. A sequence analysis was conducted on care episodes resulting in groups of typical care pathways, as well as their patient profiles. The costs of pathways resulting from the care episodes were calculated based on the data and the reported national unit costs and analyzed using linear models. Results: We identified six groups of typical pathways each comprising mainly single type of care episodes. Three of the groups comprised over 10 000 patients while the remaining groups ranged from a few hundred to a few thousand. Majority of pathways consisted only single care episode. However, among the rest of the care pathways variability in length of care pathways was observed between and within group of pathways. On average, the patients were over 65 years of age and were diagnosed with diabetes for over a decade. The pathways resulted in an annual cost of EUR 13 million. The mean costs were nearly 20-fold higher in the group with the highest costs (EUR 11 917) compared to the group with the lowest costs (EUR 609). Conclusions: We identified groups of typical care pathways for diabetic foot and discovered notable heterogeneity in the resource use within the groups. This information is valuable in guiding the development of diabetes care to meet the growing need. Nevertheless, reasons underlying the observed heterogeneity requires further examination. Since foot complications are largely preventable, substantial savings could be achieved using cost-effective technologies and more efficient organization of care.Peer reviewe

Toimeentulotuen asiakkaiden terveyspalvelujen käyttö Helsingissä vuonna 2014

Huonossa sosioekonomisessa asemassa olevat sairastavat muita enemmän ja heillä on tyydyttymätöntä terveyspalvelujen tarvetta, vaikka he käyttävät runsaasti perusterveydenhuollonpalveluja (1). Hyvin toimeentulevat käyttävät tutkimusten mukaan erikoislääkäripalveluja yleisemmin kuin alemmat tuloryhmät (20, 21). Helsinkiläisten toimeentulotukiasiakkaidenperusterveydenhuollon ja erikoissairaanhoidon käyttöä ei ole tutkittu. Tässä tutkimuksessa helsinkiläisten toimeentulotuen asiakkaiden (N=38 434) sosiaali- ja terveysviraston taiHelsingin ja Uudenmaan sairaanhoitopiirin (HUS) erikoissairaanhoidon vuoden 2014 käynti- ja hoitojaksotietoja verrattiin muiden helsinkiläisten (N=401 231) käynti- ja hoitojaksotietoihin ja toimeentulotuen asiakkuuden yhteyttä terveyspalvelujen käynteihin ja hoitojaksoihin analysoitiin käyttäen menetelmänä logistista regressioanalyysia ja Poisson-regressioanalyysia. Tulosten mukaan terveyspalveluja käyttäneillä toimeentulotuen asiakkailla oli ikävakioituna selvästi todennäköisemmin diagnosoitu sairaus sekä hampaiden reikiintymistä ja kiinnityskudosten sairauksia kuin niillä, jotka eivät olleet toimeentulotuen asiakkaita. Toimeentulotuen asiakkuus oli voimakkaasti yhteydessä lisääntyneisiin päihde- ja mielenterveyskäynteihin ja -hoitojaksoihin, perusterveydenhuollon käynteihin ja päivystysvastaanottokäynteihin sekä perusterveydenhuollon ja päivystyksen akuuttihoitojaksoihin. Sen sijaan toimeentulotuen asiakkuuden yhteys erikoislääkäritutkimuksiin ja suun terveydenhuollon käynteihin oli heikompi ja osassa erikoislääkäritutkimuksia toimeentulotuen asiakkaan käynti oli suhteellisesti epätodennäköisempi kuin niiden, jotka eivät olleet toimeentulotuen asiakkaita. Toimeentulotuen asiakkuus oli heikommin yhteydessä HUS:n käynteihin kuin sosiaali- ja terveysviraston perusterveydenhuollon käynteihin. Toimeentulotuen asiakkuus selitti miehillä käyntejä HUS:ssa vammojen ja myrkytysten, hermoston sairauksien ja infektioiden vuoksi ja naisilla sisäerityselinten ja ruoansulatuselinten sairauksien sekä infektioiden vuoksi. Toimeentulotuen asiakkuus selitti HUS:n hoitojaksoja sisäerityselinten, ihon ja ihonalaiskudoksen, hermoston ja hengityselinten sairauksien vuoksi

Regional trends in avoidable hospitalisations due to complications among population with diabetes in Finland in 1996-2011 : a register-based cohort study

Objectives: Diabetes requires continuous medical care including prevention of acute complications and risk reduction for long-term complications. Diabetic complications impose a substantial burden on public health and care delivery. We examined trends in regional differences in hospitalisations due to diabetes-related complications among the total diabetes population in Finland. Research design: A longitudinal register-based cohort study 1996-2011 among a total population with diabetes in Finland. Participants: All persons with diabetes identified from several administrative registers in Finland in 1964-2011 and alive on 1 January 1996. Outcome measures: We examined hospitalisations due to diabetes-related short-term and long-term complications, uncomplicated diabetes, myocardial infarction, stroke, lower extremity amputation and end-stage renal disease (ESRD). We calculated annual age-adjusted rates per 10 000 person years and the systematic component of variation. Multilevel models were used for studying time trends in regional variation. Results: There was a steep decline in complication-related hospitalisation rates during the study period. The decline was relatively small in ESRD (30%), whereas rates of hospitalisations for short-term and long-term complications as well as uncomplicated diabetes diminished by about 80%. The overall correlation between hospital district intercepts and slopes in time was -0.72 (p Conclusions: Our study suggests that the prevention of complications among persons with diabetes has improved in Finland between 1996 and 2011. The results further suggest that the prevention of complications has become more uniform throughout the country.Peer reviewe

Explaining regional variation in elective hip and knee arthroplasties in Finland 2010-2017-a register-based cohort study

Background A persistent research finding in industrialised countries has been regional variation in medical practices including elective primary hip and knee arthroplasty. The aim of the study was to examine regional variations in elective total hip and knee arthroplasties over time, and the proportions of these variations which can be explained by individual level or area-level differences in need. Methods We obtained secondary data from the Care Register for Health Care to study elective primary hip and knee arthroplasties in total Finnish population aged 25 + years between 2010 and 2017. Two-level Poisson regression models - individuals and hospital regions - were used to study regional differences in the incidence of elective hip and knee arthroplasties in two time periods: 2010 - 2013 and 2014 - 2017. The impact of several individual level explanatory factors (age, socioeconomic position, comorbidities) and area-level factors (need and supply of operations) was measured with the proportional change in variance. Predictions of incidence were measured with incidence rate ratios. The relative differences in risk of the procedures in regions were described with median rate ratios. Results We found small and over time relatively stable regional variation in hip arthroplasties in Finland, while the variation was larger in knee arthroplasties and decreased during the study period. In 2010 - 2013 individual socioeconomic variables explained 10% of variation in hip and 4% in knee arthroplasties, an effect that did not emerge in 2014 - 2017. The area-level musculoskeletal disorder index reflecting the need for care explained a further 44% of the variation in hip arthroplasties in 2010 - 2013, but only 5% in 2014 - 2017 and respectively 22% and 25% in knee arthroplasties. However, our final models explained the regional differences only partially. Conclusions Our results suggest that eligibility criteria in total hip and knee arthroplasty are increasingly consistent between Finnish hospital districts. Factors related to individual level and regional level need both had an important role in explaining regional variations. Further study is needed on the effect of health policy on equity in access to care in these operations.Peer reviewe

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

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.Peer reviewe

Regional variation of avoidable hospitalisations in a universal health care system: a register-based cohort study from Finland 1996−2013

Objectives A persistent finding in research concerning healthcare and hospital use in Western countries has been regional variation in the medical practices. The aim of the current study was to examine trends in the regional variation of avoidable hospitalisations, that is, hospitalisations due to conditions treatable in ambulatory care in Finland in 1996–2013 and the influence of different healthcare levels on them.Setting Use of hospital inpatient care in 1996–2013 among the total population in Finland.Participants Altogether 1 931 012 hospital inpatient care episodes among all persons residing in Finland identified from administrative registers in Finland in 1996−2013 and alive in 1 January 1996.Outcome measures We examined hospitalisations due to avoidable causes including vaccine-preventable hospitalisations, hospitalisations due to complications of chronic conditions and acute conditions treatable in ambulatory care. We calculated annual age-adjusted rates per 10 000 person-years. Multilevel models were used for studying time trends in regional variation.Results There was a steep decline in avoidable hospitalisation rates during the study period. The decline occurred almost exclusively in hospitalisations due to chronic conditions, which diminished by about 60%. The overall correlation between hospital district intercepts and slopes in time was −0.46 (p<0.05) among men and −0.20 (ns) among women. Statistically highly significant diminishing variation was found in hospitalisations due to chronic conditions among both men (−0.90) and women (−0.91). The variation was mainly distributed to the hospital district level.Conclusions The results suggest that chronic conditions are managed better in primary care in the whole country than before. Further research is needed on whether this is the case or whether this has more to do with supply of hospital care.Peer reviewe

FinDM database on diabetes in Finland

This paper describes the collection of database of the Diabetes in Finland (FinDM) project which aims to identify all potential persons with diabetes from national registers in Finland between 1964 and 2017. Further, it lists the definitions used in the research of diabetes and its complications in the project