Socio-economic differences in the healthcare utilisation of older persons in Sweden

The global population is ageing and this demographic change has important implications for the provision of healthcare and social care. Older people often have multiple and complex health problems and a range of different care needs. Equity in healthcare is a cornerstone of the Swedish system, making it crucial to examine whether socio-economic differences are visible in different aspects of healthcare utilisation, especially given the changes in organisation of healthcare and social care for older people. The overall aim of this thesis is to assess socio-economic differences in the utilisation of healthcare and prescription drugs among older persons in Sweden in light of recent changes to the healthcare and social care system. In study I, socio-demographic differences among older people seeking emergency department (ED) care were explored in terms of age and sex, the association between income groups and frequent ED use was also investigated. This study included persons 65 years and older (N=356,375), and followed their utilisation of ED care in 2014. Frequent ED users were mostly in low income groups living alone or in institutional care. Men 65-79 years and women 80 years and older in low income groups were found to be more frequent ED users. In study II, the impact of the introduction of an integrated care system in Norrtälje Municipality on subsequent changes in the trend of the rate of ED visits were investigated. An interrupted time series analysis was performed, using data from 2000-2015, in order to assess whether the introduction of integrated care in 2006 in Norrtälje Municipality changed the pattern of ED care utilisation among inhabitants 65 years and older, and were further stratified by socio-demographic group. Overall, there was a modest decrease in the rate of ED visits after the introduction of integrated care. In study III, the socio-demographic differences in polypharmacy and potentially inappropriate medication (PIM) use among older people with different care needs in a standard vs integrated care setting was examined. Care needs were defined based on exposure to social care services in 2014 and subsequent prescription drug utilisation was measured in 2015. Polypharmacy and PIM were more prevalent among home-help users and institutional care residents. However, socio-demographic differences, including education level and age, were more noticeable among those living independently. There were slight differences in inappropriate drug use between care settings. In study IV, the association between income groups and inpatient care expenditure, as well as the impact of demographic factors, health status, and healthcare and social care utilisation in the last year of life was investigated. We included 13,538 individuals who died during 2015 and retrospectively measured the inpatient care costs accrued over their last year of life. Higher income groups incurred higher inpatient care costs at the 75th and 95th percentile compared to lower income groups. Older age and more months in institutional care were associated with lower inapatient care expenditure. In conclusion, socio-economic differences were observed among older people in the utilisation of ED care, drug prescription and inpatient care expenditure in the last year of life. This thesis indicates that there are differences in the healthcare utilisation among older people who have a greater need of care. The introduction of integrated care model in Norrtälje in 2006 did not produce the expected change though the full impact of integrated care remains difficult to evaluate. However, the approach could, when fully implemented, potentially provide higher quality care for older people with complex needs

Socio-demographic differences in the frequent use of emergency department care by older persons: a population-based study in Stockholm County

Abstract 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

Differences in Covid-19 mortality among persons 70 years and older in an integrated care setting in region Stockholm: a multi-level analysis between March 2020-February 2021

Abstract Background In Norrtälje municipality, within Region Stockholm, there is a joint integrated care organisation providing health and social care, which may have facilitated a more coordinated response to the covid-19 pandemic compared to the otherwise decentralised Swedish system. This study compares the risk of covid-19 mortality among persons 70 years and older, in the municipalities of Stockholm, Södertälje, and Norrtälje, while considering area and individual risk factors. Methods A population-based study using linked register data to examine covid-19 mortality among those 70 + years (N = 127,575) within the municipalities of interest between the periods March-August 2020 and September 2020-February 2021. The effect of individual and area level variables on covid-19 mortality among inhabitants in 68 catchment areas were examined using multi-level logistic models. Results Individual factors associated with covid-19 mortality were sex, older age, primary education, country of birth and poorer health as indicated by the Charlson Co-morbidity Index. The area-level variables associated were high deprivation (OR: 1.56, CI: 1.18–2.08), population density (OR: 1.14, CI: 1.08–1.21), and usual care. Together, this explained 85.7% of the variation between catchment areas in period 1 and most variation was due to individual risk factors in period 2. Little of the residual variation was attributed to differences between catchment areas. Conclusion Integrated care in Norrtälje may have facilitated a more coordinated response during period 1, compared to municipalities with usual care. In the future, integrated care should be considered as an approach to better protect and meet the care needs of older people during emergency situations

Additional file 1 of Differences in Covid-19 mortality among persons 70 years and older in an integrated care setting in region Stockholm: a multi-level analysis between March 2020-February 2021

Supplementary Material

Effectiveness of integrated person-centered interventions for older people's care : Review of Swedish experiences and experts' perspective

Older adults have multiple medical and social care needs, requiring a shift toward an integrated person-centered model of care. Our objective was to describe and summarize Swedish experiences of integrated person-centered care by reviewing studies published between 2000 and 2023, and to identify the main challenges and scientific gaps through expert discussions. Seventy-three publications were identified by searching MEDLINE and contacting experts. Interventions were categorized using two World Health Organization frameworks: (1) Integrated Care for Older People (ICOPE), and (2) Integrated People-Centered Health Services (IPCHS). The included 73 publications were derived from 31 unique and heterogeneous interventions pertaining mainly to the micro- and meso-levels. Among publications measuring mortality, 15% were effective. Subjective health outcomes showed improvement in 24% of publications, morbidity outcomes in 42%, disability outcomes in 48%, and service utilization outcomes in 58%. Workshop discussions in Stockholm (Sweden), March 2023, were recorded, transcribed, and summarized. Experts emphasized: (1) lack of rigorous evaluation methods, (2) need for participatory designs, (3) scarcity of macro-level interventions, and (4) importance of transitioning from person- to people-centered integrated care. These challenges could explain the unexpected weak beneficial effects of the interventions on health outcomes, whereas service utilization outcomes were more positively impacted. Finally, we derived a list of recommendations, including the need to engage care organizations in interventions from their inception and to leverage researchers' scientific expertise. Although this review provides a comprehensive snapshot of interventions in the context of Sweden, the findings offer transferable perspectives on the real-world challenges encountered in this field

Exome Array Analysis of 9721 Ischemic Stroke Cases from the SiGN Consortium

Recent genome wide association studies have identified 89 common genetic variants robustly associated with ischemic stroke and primarily located in non-coding regions. To evaluate the contribution of coding variants, which are mostly rare, we performed an exome array analysis on 106,101 SNPs for 9721 ischemic stroke cases from the SiGN Consortium, and 12,345 subjects with no history of stroke from the Health Retirement Study and SiGN consortium. We identified 15 coding variants significantly associated with all ischemic stroke at array-wide threshold (i.e., p −7), including two common SNPs in ABO that have previously been associated with stroke. Twelve of the remaining 13 variants were extremely rare in European Caucasians (MAF n = 5613 cases) or UK Biobank (n = 5874 stroke cases), although power to replicate was very low given the low allele frequencies of the associated variants and a shortage of samples from diverse ancestries. Our study highlights the need for acquiring large, well-powered diverse cohorts to study rare variants, and the technical challenges using array-based genotyping technologies for rare variant genotyping