socio-demographic determinants of entry into and exit from long-term institutional care – a linked...
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Socio-demographic determinants of entry into and exit from long-term institutional care – a linked register based follow-up study of
older Finns
Pekka Martikainen
&
Elina Nihtilä
&
Heta Moustgaard
&
Others
Background on long-term institutional care
Long-term care costs are almost 50% of all health care cost
of the elderly, and institutional care is not the preferred living
arrangement of the elderly
With population ageing the demand and costs of long-term
care are expected to grow rapidly
At the proximate level entry is determined by health and
cognitive and physical functional status, but also more distal
socio-demographic factors have been shown to be important
Focus and aims
How institutional care is determined by living
arrangements (or marital status) and socioeconomic
position
We have three main focuses of interest: First entry into institutional care Duration of care Care over the life course
Types of data sources
Individual level data on the total Finnish population Based on
Censuses from 1970-2005 (every 5-years)Population registration 1987-2007 (annual)
Linked with data on e.g.Mortality (1971-2007)Hospital discharge and medicationTaxation
Linkage is based on social security numbers Allows for:
Longitudinal analysesMultilevel analyses: areas, couples/families
An example of data content for a study of An example of data content for a study of entry into institutional care (40% sample entry into institutional care (40% sample of 65+)of 65+)
Sociodemographic Sociodemographic factors:factors:SexSexAgeAgeMarital statusMarital statusLiving Living arrangements arrangements EducationEducationSocial classSocial classIncomeIncomeHousingHousingPartnerPartnerRegionRegion
Use of homecare Use of homecare servicesservices
Institutional care:Institutional care:
Care episodesCare episodes
Date of entryDate of entry
Date of exitDate of exit
Type of institutionType of institution
(in health & social (in health & social care sectors)care sectors)
Supply of care:Supply of care:
Regional coverage of Regional coverage of institutional careinstitutional care
STAKESStatisticsFinland
STAKES
STAKES
STAKES
Pension instituteHealth:Health:
MedicationMedication
Hospital dischargeHospital discharge
Definition of long-term institutional care
24-hour care in nursing homes, service homes, hospitals
and health centers lasting for over 90 days or confirmed
by a long-term care decision.
The over-90-days criterion was met if a patient had
stayed in the same institution or successively in different
institutions for the time required.
Approximately 75 per cent of first stays begun in hospitals
or health centres
Living arrangements(with spouse, alone, others)
Informal care
Adequate availability of informal care is an important
determinant of independent living in the community and
postpones entry into institutional care
The importance of informal care is amplified because of
deteriorating dependency ratio and potential shortage of
care staff in the formal care system
Distribution by gender and living arrangements. Finnish older adults aged 65 and over living in the community
72
36
22
50
614
0%
20%
40%
60%
80%
100%
Men (N=108 474) Women (N=172 248)
with others
alone
with spouse
Probability of survival without long-term institutionalisation by living arrangements among Finnish older adults living in the community at baseline
Nihtilä & Martikainen, Scandinavian Journal of Public Health 2008
Probability of survival without long-term institutionalisation by living arrangements among Finnish older adults living in the community at baseline
Nihtilä & Martikainen, Scandinavian Journal of Public Health 2008
Institutionalisation among Finnish men and women aged 65+; adjusted hazard ratios
Men WomenFisrt entry
Living arrangement (LA) with spouse 1.00 * 1.00 alone 1.72 * 1.34 * other 1.55 * 1.24 *Home ownership (HO) yes 1.00 1.00 no 1.70 * 1.35 *Household income (HHI) 1. Quartile (high) 1.00 1.00 2. Quartile 1.19 * 1.09 * 3. Quartile 1.38 * 1.22 * 4. Quartile (low) 1.39 * 1.28 *
First entry
Nihtilä & Martikainen, Scandinavian Journal of Public Health 2008
Life-events: widowhood
A major life-event among the elderly
(with spouse -> alone) May lead to:
decline in health (effects of grief) loss of emotional/social support loss of task support
These in turn may influence entry into care May interact strongly e.g. with poor health or low SES
Figure 1. Relative age-adjusted institutionalization rates in
relation to duration of bereavement, Finnish elderly 65+
(Reference = married)
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
0-1 1-2 2-3 3-6 6-12 12-24 24-36 36-42 42+
Time since spouse's or partner's death (months)
Haz
ard
ratio
(ins
titut
iona
lizat
ion)
MEN
WOMEN
Nihtilä & Martikainen, American Journal of Public Health 2008
Duration of care & gender difference
Human experience; rather than first entry total
duration of care is what people are interested in Costs determined by duration of stay
Inequalities/differences may be compounded E.g. gender differences in long-term care use
Women have higher chances of entry (and may
enter in better health)Women stay for longer (lower chances of exit)
Hazard ratios (women vs. men) of institutionalisation
and mode of exit from institution
Total (N=280722) Those institionalised (N=35926)First entry Died in institution Returned home Total exit
Model Hazard ratio Hazard ratio Hazard ratio Hazard ratio
unadjusted 1.42 0.70 0.81 0.74age-adjusted 1.12 0.66 0.89 0.75age+living arrangement 0.97 0.68 0.92 0.77age+household income 1.10 0.67 0.90 0.75age+home ownership 1.09 0.66 0.90 0.75age+health status 1.08 0.67 0.88 0.75full model 0.94 0.68 0.91 0.77
Martikainen, Moustgaard, Murphy, Nihtilä, Koskinen, Martelin, Noro, The Gerontologist 2008
= >
Adjusted for age:
Women stay in care on average 1064 days
- if living with spouse at baseline 994 days
- if living alone at baseline 1105 days
Men stay in care on average 686 days
- if living with spouse at baseline 645 days
- if living alone at baseline 746 days
Income
Are the effects of income independent of other socio-demographic
factors?
The independent effects may relate to e.g. the ability to pay for private
home care
Household income / consumption unit Source: Tax Administration and the Social Insurance Institution Incomes of all household members, including wages, capital
income and taxable income transfers and accounts for taxes and
non-taxable income transfers. Adjusted for household composition
(OECD, 1982).
Table 3. Relative insitutitionalisation rates by income quintiles obtained from the different Cox regression models, Finnish women and men aged 65 years and over
BASIC EXPLANATORY MEDIATING ALLMODEL FACTORS FACTORS
Model (1) (2) (3) (4) (5) (6) (7)Control 1+living 1+education 1+car 1+house type 1+chronic All
variables (a) arrangements + social class + level of medical factors
+ home equipment in conditions
ownership dwelling
HR HR HR HR HR HR HRWomenHousehold income5. Quintile (highest) 1.00 1.00 1.00 1.00 1.00 1.00 1.004. Quintile 1.07 * 1.07 * 1.05 1.06 * 1.06 * 1.06 * 1.033. Quintile 1.23 * 1.22 * 1.17 * 1.21 * 1.21 * 1.21 * 1.14 *2. Quintile 1.30 * 1.26 * 1.20 * 1.27 * 1.27 * 1.26 * 1.15 *1. Quintile (lowest) 1.35 * 1.31 * 1.23 * 1.32 * 1.30 * 1.28 * 1.15 *
MenHousehold income5. Quintile (highest) 1.00 1.00 1.00 1.00 1.00 1.00 1.004. Quintile 1.16 * 1.17 * 1.05 1.10 * 1.16 * 1.15 * 1.07 *3. Quintile 1.40 * 1.37 * 1.19 * 1.26 * 1.38 * 1.41 * 1.20 *2. Quintile 1.52 * 1.42 * 1.26 * 1.31 * 1.49 * 1.51 * 1.18 *1. Quintile (lowest) 1.59 * 1.47 * 1.29 * 1.31 * 1.52 * 1.51 * 1.13 *
* Different from the reference group (1.00) at 5% significance level
(a) Control variables: age, first language, area characteristics (level of urbanisation, region of residence)
Nihtilä & Martikainen, Population Studies 2007
Use of care towards the end of life
Older age and people’s proximity to death are
the most significant determinants of health
status and health needs Part of older age groups’ higher cost will thus reflect
the greater number of people close to death Acute health care costs are strongly associated with
proximity to death, with more than a quarter of all
acute health care costs incurred in the last year of
life May imply that projections of costs for acute care
that do not account for proximity to death
overestimate future increases by up to 20-25%
Less is known about long-term care
Less is know about how social factors affect these
associations
Care use patterns before death have repercussion for
future care demand and costs, as well as individual
quality of life
Murphy and Martikainen
Murphy and Martikainen
Proximity to death is important for acute care, but age is
more important for long-term care
Marital status differentials are quite substantial and future
changes in marital status distributions may be important
for future projections of elderly use of health and social
services.
Summary
Overall, the results demonstrates the strength of register based data in the
analyses of long-term institutional care
The consequences of population ageing on long-term care are not simply
determined by number and age of people, and their individual functional
status
The examples presented here show that also social factors - living
arrangements, change in living arrangements and socioeconomic
characteristics - have important consequences for entry into long-term care
Summary continued …
Similar factors define duration of care with strong
evidence of compounding of differences
To the extent that LTC is determined by age rather than
proximity to death implies that cost saving similar to those
expected for acute care can not be obtained for LTC in
the coming decades