This thesis is grounded on four articles. Article I generally examines the factors affecting dental service utilization. Article II studies the factors associated with sector-specific utilization among young adults entitled to age-based subsidized dental care. Article III explores the determinants of dental ill-health as measured by the occurrence of caries and the relationship between dental ill-health and dental care use. Article IV measures and explains income-related inequality in utilization. Data employed were from the 1996 Finnish Health Care Survey (I, II, IV) and the 1997 follow-up study included in the longitudinal study of the Northern Finland 1966 Birth Cohort (III). Utilization is considered as a multi-stage decision-making process and measured as the number of visits to the dentist. Modified count data models and concentration and horizontal equity indices were applied. Dentist s recall appeared very efficient at stimulating individuals to seek care. Dental pain, recall, and the low number of missing teeth positively affected utilization. Public subvention for dental care did not seem to statistically increase utilization. Among young adults, a perception of insufficient public service availability and recall were positively associated with the choice of a private dentist, whereas income and dentist density were positively associated with the number of visits to private dentists. Among cohort females, factors increasing caries were body mass index and intake of alcohol, sugar, and soft drinks and those reducing caries were birth weight and adolescent school achievement. Among cohort males, caries was positively related to the metropolitan residence and negatively related to healthy diet and education. Smoking increased caries, whereas regular teeth brushing, regular dental attendance and dental care use decreased caries. We found equity in young adults utilization but pro-rich inequity in the total number of visits to all dentists and in the probability of visiting a dentist for the whole sample. We observed inequity in the total number of visits to the dentist and in the probability of visiting a dentist, being pro-poor for public care but pro-rich for private care. The findings suggest that to enhance equal access to and use of dental care across population and income groups, attention should focus on supply factors and incentives to encourage people to contact dentists more often. Lowering co-payments and service fees and improving public availability would likely increase service use in both sectors. To attain favorable oral health, appropriate policies aimed at improving dental health education and reducing the detrimental effects of common risk factors on dental health should be strengthened. Providing equal access with respect to need for all people ought to take account of the segmentation of the service system, with its two parallel delivery systems and different supplier incentives to patients and dentists.

Although the principle of equal access to medically justified treatment has been promoted by official health policies in many Western health care systems, practices do not completely meet policy targets. Waiting times for elective surgery vary between patient groups and regions, and growing problems in the availability of services threaten equal access to treatment. Waiting times have come to the attention of decision-makers, and several policy initiatives have been introduced to ensure the availability of care within a reasonable time. In Finland, for example, the treatment guarantee came into force in 2005. However, no consensus exists on optimal waiting time for different patient groups. The purpose of this multi-centre randomized controlled trial was to analyse health-related quality of life, pain and physical function in total hip or knee replacement patients during the waiting time and to evaluate whether the waiting time is associated with patients health outcomes at admission. This study also assessed whether the length of waiting time is associated with social and health services utilization in patients awaiting total hip or knee replacement. In addition, patients health-related quality of life was compared with that of the general population. Consecutive patients with a need for a primary total hip or knee replacement due to osteoarthritis were placed on the waiting list between August 2002 and November 2003. Patients were randomly assigned to a short waiting time (maximum 3 months) or a non-fixed waiting time (waiting time not fixed in advance, instead the patient followed the hospitals routine practice). Patients health-related quality of life was measured upon being placed on the waiting list and again at hospital admission using the generic 15D instrument. Pain and physical function were evaluated using the self-report Harris Hip Score for hip patients and a scale modified from the Knee Society Clinical Rating System for knee patients. Utilization measures were the use of home health care, rehabilitation and social services, physician visits and inpatient care. Health and social services use was low in both waiting time groups. The most common services used while waiting were rehabilitation services and informal care, including unpaid care provided by relatives, neighbours and volunteers. Although patients suffered from clear restrictions in usual activities and physical functioning, they seemed primarily to lean on informal care and personal networks instead of professional care. While longer waiting time did not result in poorer health-related quality of life at admission and use of services during the waiting time was similar to that at the time of placement on the list, there is likely to be higher costs of waiting by people who wait longer simply because they are using services for a longer period. In economic terms, this would represent a negative impact of waiting. Only a few reports have been published of the health-related quality of life of patients awaiting total hip or knee replacement. These findings demonstrate that, in addition to physical dimensions of health, patients suffered from restrictions in psychological well-being such as depression, distress and reduced vitality. This raises the question of how to support patients who suffer from psychological distress during the waiting time and how to develop strategies to improve patients initiatives to reduce symptoms and the burden of waiting. Key words: waiting time, total hip replacement, total knee replacement, health-related quality of life, randomized controlled trial, outcome assessment, social service, utilization of health services

Background and aims Cancer is a huge burden to patients, families and to societies in both human and monetary terms. Breast (BC), prostate (PC) and colorectal (CRC) cancer are the three most common cancer types in Finland. Due to improved survival, health-related quality of life (HRQoL) aspects are gaining increasing attention in cancer care. Understanding the cost and HRQoL consequences of different treatment choices is critical to be able to use scarce health-care resources optimally. The aims of this thesis were to evaluate costs and patient-reported HRQoL using three standard instruments (15D, EQ-5D-3L+VAS and EORTC QLQ-C30) in all phases of CRC, to assess HRQoL among end-stage BC, PC and CRC patients, and to assess the direct economic burden of BC, PC and CRC for patients and analyse what are its implications for HRQoL. Patients and methods A total of 1978 cancer patients from the Helsinki and Uusimaa region having either BC (840), PC (630) or CRC (508) participated in this observational cross-sectional study. Patients were recruited between 2009 and 2011 from different phases of the disease and divided into five mutually exclusive groups according to the stage of their disease: primary treatments; rehabilitation; remission; metastatic disease; and palliative care. Patients completed a questionnaire, which in addition to the HRQoL questionnaires, enquired about demographic factors, health care and informal care resource utilization and work capacity. Furthermore, data on direct medical resource use in both primary and secondary care and productivity costs were obtained from several different registries. Multivariate regression modelling was used to find determinants of deteriorated HRQoL and cost drivers. Results The HRQoL of CRC patients is fairly good compared to age-, gender- and education-standardized general population except for those under palliative care. The 15D gave highest scores across all states compared to EQ-5D and VAS. Fatigue, pain, age and financial difficulties were strongly associated with impaired HRQoL. The total six-month costs of CRC varied between disease states from €2106 in rehabilitation to €22,200 in the primary treatment state. The costs were highest at the beginning and in the advanced phases of the disease. Most of the CRC-related costs were direct medical costs. Productivity costs were highest in the primary treatment state (40%) and informal care costs highest in the palliative phase (33%). Outpatient medication was responsible for the major part of patients’ out-of-pocket (OOP) payments. High OOP payments were associated with financial difficulties and deteriorated HRQoL. Conclusions All instruments were applicable for the evaluation of HRQoL of cancer patients in all states of the disease, however the results the different instruments provided varied significantly. Cost of CRC is driven by direct health-care costs in the intense primary care and metastatic phase. Financial difficulties are a substantial burden to some and they have a clear negative impact on patients’ HRQoL. Outcomes and costs of the care should be measured routinely in health care to ensure scare resources are used to maximize patients’ health.

Background. In Finland, the incidence of type 1 diabetes mellitus (T1DM) is the highest in the world, and it continues to increase steadily. No effective preventative interventions exist either for individuals at high risk or for the population as a whole. In addition to problems with daily lifelong insulin replacement therapy, T1DM patients with long-lasting disease suffer from various diabetes related complications. The complications can lead to severe impairments and reductions in functional capacity and quality of life and in the worst case they can be fatal. Longitudinal studies on the costs of T1DM are extremely rare, especially in Finland. Typically, in these studies, distinctions between the various types of diabetes have not been made, and costs have not been calculated separately for the sexes. Aims. The aim of this study was to describe inpatient hospital care and costs of inpatient care in a cohort of 5,166 T1DM patients by sex during 1973-1998 in Finland. Inpatient care and costs of care due to T1DM without complications, due to T1DM with complications and due to other causes were calculated separately. Material and Methods. The study population consisted of all Finnish T1DM patients diagnosed before the age of 18 years between January 1st in 1965 and December 31st in 1979 and derived from the Finnish population based T1DM register (N=5,120 in 1979 and N=4,701 in 1997). Data on hospitalisations were obtained from the Finnish Hospital Discharge Register. Results. In the early stages of T1DM, the majority of the use of inpatient care was due to the treatment of T1DM without complications. There were enormous increases in the use of inpatient care for certain complications when T1DM lasted longer (from 9.5 years to 16.5 years). For women, the yearly number of bed-days for renal complications increased 4.8-fold, for peripheral vascular disease 4.3-fold and for ophthalmic complications 2.5-fold. For men, the corresponding increases were as follows: 5-fold, 6.9-fold and 2.5-fold. The yearly bed-days for glaucoma increased 8-fold, nephropathy 7-fold and microangiopathy 6-fold in the total population. During these 7 years, the yearly numbers of bed-days for T1DM without complications dropped dramatically. The length of stay in inpatient care decreased notably, but hospital visits became more frequent when the length of duration of T1DM increased from 9.5 years to 16.5 years. The costs of treatments due to complications increased when T1DM lasted longer. Costs due to inpatient care of complications in the cohort 2.5-folded as duration of T1DM increased from 9.5 years to 16.5 years, while the total costs of inpatient care in the cohort dropped by 22% due to an 80% decrease in the costs of care of T1DM without complications. Treating complications of female patients was more expensive than treating complications of men when T1DM had lasted 9.5 years; the mean annual costs for inpatient care of a female diabetic (any cause) were 1,642 , and the yearly costs of care of complications were 237 . The corresponding yearly mean costs for a male patient were 1,198 and 167 . Treating complications of female patients was more expensive than that of male patients also when the duration of diabetes was 16.5 years, although the difference in average annual costs between sexes was somewhat smaller. Conclusions. In the early phases of T1DM, the treatment of T1DM without complications causes a considerable amount of hospital bed-days. The use of inpatient care due to complications of T1DM strongly increases with ageing of patients. The economic burden of inpatient care of T1DM is substantial.

Cost-utility analysis provides a means to determine the health benefit and economic burden of different health-care interventions. In cost-utility analyses, the benefit of care is measured in quality-adjusted life years (QALYs) gained. The calculation of QALYs requires knowledge of the change in health-related quality of life (HRQoL) and assumptions concerning when the benefit of care materialises and how long the benefit lasts. The gold standard for QALY calculations has not yet been defined and, as a consequence, the HRQoL instruments and calculation methods used vary from study to study. The aim of the current study was to clarify how much the differences in the components used for the calculation of QALYs are reflected in the end result, i.e., the number of QALYs gained in the critical care setting. The detailed aims were to study 1) the effect of the instrument used (the EQ-5D or the 15D) on the HRQoL score and the measured changes in it; 2) the effects of the baseline HRQoL and the assumptions concerning the progress of recovery on the number of QALYs; 3) how to estimate life expectancy in the critical care setting, and 4) which factors have an effect on the follow-up HRQoL. The results are based on two study populations. The first population comprises patients having been treated in an intensive care or high-dependency unit (n = 3600), and whose HRQoL was assessed using the EQ-5D and 15D HRQoL instruments 6 and 12 months after treatment. The second population consists of patients having underone treatment in a cardiac surgery intensive care unit (n = 980), and whose HRQoL was assessed using the 15D HRQoL instrument at baseline, when placed on a waiting list for surgery and 6 months after treatment. The results of the studies show that the HRQoL index score is dependent on the instrument used. The distribution of the patients HRQoL scores differed between instruments. The differences are explained, inter alia, by the ceiling effect of the EQ-5D i.e., for a significant proportion of the respondents, the instrument produced the best possible HRQoL score of 1 and by the negative scores of the EQ-5D i.e., for health states worse than death. The 15D produced higher mean HRQoL scores than the EQ-5D. The 15D was able to distinguish between a greater number of health states than the EQ-5D, thus showing a better discriminatory power. The choice of instrument was also reflected in the change observed in HRQoL. The two instruments classified patients according to the change in HRQoL (improved, remained stable, deteriorated) in a similar manner only in approximately half of the cases. The 15D was more sensitive to detecting a change than the EQ-5D. Consequently, both its discriminatory power and responsiveness to change were better than those for the EQ-5D. The assumptions concerning the progression of recovery and the baseline HRQoL score had an effect on the number of QALYs gained both within and between instruments and, consequently, on the cost per QALY ratio. The EQ-5D and the 15D performed differently under different calculation assumptions. The greatest difference in the number of QALYs gained was caused by the negative HRQoL scores observed with the EQ-5D enabling the accrual of more than 1 QALY per year. Patients having been treated in an intensive care unit showed long-lasting excess mortality and, as a consequence, a reduced life expectancy. By contrast, in cardiac surgery patients, the life expectancy was similar to or even better than that of the general population. In patient groups with excess mortality, neither the follow-up time nor the life expectancy of the general population can be regarded as optimal indicators for the duration of the benefit of care. In those patient groups, life expectancy should be extrapolated in relation to the observed excess mortality. In cardiac surgery patients, factors predicting mortality and morbidity are not able to accurately predict the follow-up HRQoL. Instead, patient experiences, such as restlessness and pain during intensive care, predicted poor post-treatment HRQoL. Given that these results are novel, future studies should be directed to patient experiences during treatment. They may be confounding factors in analyses concerning treatment effectiveness, and also diminish the effectiveness of treatment. QALY is not a universal measure, but is dependent on the HRQoL instrument used and on how the factors to be taken into account in the calculation of QALYs are chosen and defined. Furthermore, factors external to the interventions under evaluation, such as the patient s psychological experiences during treatment, may have an effect on the follow-up HRQoL. The ranking of different interventions in terms of their effectiveness calls for standardisation in the calculation of QALYs and more information on the effect of patient experiences during treatment on the follow-up HRQoL  

Aims: The aims of this study were 1) to identify and describe health economic studies that have used quality-adjusted life years (QALYs) based on actual measurements of patients' health-related quality of life (HRQoL); 2) to test the feasibility of routine collection of health-related quality of life (HRQoL) data as an indicator of effectiveness of secondary health care; and 3) to establish and compare the cost-utility of three large-volume surgical procedures in a real-world setting in the Helsinki University Central Hospital, a large referral hospital providing secondary and tertiary health-care services for a population of approximately 1.4 million. Patients and methods: So as to identify studies that have used QALYs as an outcome measure, a systematic search of the literature was performed using the Medline, Embase, CINAHL, SCI and Cochrane Library electronic databases. Initial screening of the identified articles involved two reviewers independently reading the abstracts; the full-text articles were also evaluated independently by two reviewers, with a third reviewer used in cases where the two reviewers could not agree a consensus on which articles should be included. The feasibility of routinely evaluating the cost-effectiveness of secondary health care was tested by setting up a system for collecting HRQoL data on approximately 4 900 patients' HRQoL before and after operative treatments performed in the hospital. The HRQoL data used as an indicator of treatment effectiveness was combined with diagnostic and financial indicators routinely collected in the hospital. To compare the cost-effectiveness of three surgical interventions, 712 patients admitted for routine operative treatment completed the 15D HRQoL questionnaire before and also 3-12 months after the operation. QALYs were calculated using the obtained utility data and expected remaining life years of the patients. Direct hospital costs were obtained from the clinical patient administration database of the hospital and a cost-utility analysis was performed from the perspective of the provider of secondary health care services. Main results: The systematic review (Study I) showed that although QALYs gained are considered an important measure of the effectiveness of health care, the number of studies in which QALYs are based on actual measurements of patients' HRQoL is still fairly limited. Of the reviewed full-text articles, only 70 reported QALYs based on actual before after measurements using a valid HRQoL instrument. Collection of simple cost-effectiveness data in secondary health care is feasible and could easily be expanded and performed on a routine basis (Study II). It allows meaningful comparisons between various treatments and provides a means for allocating limited health care resources. The cost per QALY gained was 2 770 for cervical operations and 1 740 for lumbar operations. In cases where surgery was delayed the cost per QALY was doubled (Study III). The cost per QALY ranges between subgroups in cataract surgery (Study IV). The cost per QALY gained was 5 130 for patients having both eyes operated on and 8 210 for patients with only one eye operated on during the 6-month follow-up. In patients whose first eye had been operated on previous to the study period, the mean HRQoL deteriorated after surgery, thus precluding the establishment of the cost per QALY. In arthroplasty patients (Study V) the mean cost per QALY gained in a one-year period was 6 710 for primary hip replacement, 52 270 for revision hip replacement, and 14 000 for primary knee replacement. Conclusions: Although the importance of cost-utility analyses has during recent years been stressed, there are only a limited number of studies in which the evaluation is based on patients own assessment of the treatment effectiveness. Most of the cost-effectiveness and cost-utility analyses are based on modeling that employs expert opinion regarding the outcome of treatment, not on patient-derived assessments. Routine collection of effectiveness information from patients entering treatment in secondary health care turned out to be easy enough and did not, for instance, require additional personnel on the wards in which the study was executed. The mean patient response rate was more than 70 %, suggesting that patients were happy to participate and appreciated the fact that the hospital showed an interest in their well-being even after the actual treatment episode had ended. Spinal surgery leads to a statistically significant and clinically important improvement in HRQoL. The cost per QALY gained was reasonable, at less than half of that observed for instance for hip replacement surgery. However, prolonged waiting for an operation approximately doubled the cost per QALY gained from the surgical intervention. The mean utility gain following routine cataract surgery in a real world setting was relatively small and confined mostly to patients who had had both eyes operated on. The cost of cataract surgery per QALY gained was higher than previously reported and was associated with considerable degree of uncertainty. Hip and knee replacement both improve HRQoL. The cost per QALY gained from knee replacement is two-fold compared to hip replacement. Cost-utility results from the three studied specialties showed that there is great variation in the cost-utility of surgical interventions performed in a real-world setting even when only common, widely accepted interventions are considered. However, the cost per QALY of all the studied interventions, except for revision hip arthroplasty, was well below 50 000, this figure being sometimes cited in the literature as a threshold level for the cost-effectiveness of an intervention. Based on the present study it may be concluded that routine evaluation of the cost-utility of secondary health care is feasible and produces information essential for a rational and balanced allocation of scarce health care resources.

Osteoarthritis is the most common cause of musculoskeletal disability and pain. Long waiting times for elective surgery have been a concern and in many countries health care reforms have tried to improve patients' position and increase effectiveness in spite of limited resources. The aim of this study was to evaluate the effect of waiting time on health outcomes and costs of total joint replacement in hip and knee patients. When placed on the waiting list, patients were randomly allocated to a short waiting time (waiting time ≤ 3 months) or a non-fixed waiting time (waiting time not fixed in advance, patients followed the hospitals routine practice) groups. The outcomes were measured by the15D- questionnaire, modified Harris Hip and Knee Scores and Visual Analogue Scale. The use and costs of medication, health care and social services were measured. The measurement points were, when placed on the waiting list upon admission, three and twelve months postoperatively. Quality-adjusted life years were calculated to evaluate the effect of waiting time on the cost-utility of total joint replacement. The evaluation is based on randomization and analyses are carried out based on intention-to-treat principle. The waiting time difference did not result in a significant difference in health outcomes. After surgery, the mean scores of outcomes improved in both randomized groups by a statistically significant margin. The point estimates from cost-utility analyses showed that hip patients in the short waiting time group compared to the non-fixed group gained more QALYs at lower costs, thus suggesting a strong dominance for the shorter waiting time. In knee patients, the situation was the opposite. There were refusals and dropouts during the follow-up, which might introduce bias and uncertainly into the results. There does not seem to be a significant difference between the cost-utility of short and longer waiting times for total joint replacement, at least given the waiting time difference between our study groups. However, due to quite a lot of uncertainty in the results, one has to be cautious about generalizing the findings. Keywords: waiting time, health-related quality of life, total hip and knee replacement, cost-utility, randomization

Tutkimuksen tavoite on kartoittaa Kelan sairaanhoitokorvausten alueellista vaihtelua selittäviä tekijöitä kuntatasolla tilastotieteellisin menetelmin. Erityistarkastelussa on kuntien terveydenhuoltomenojen ja Kelan sairaanhoitokorvausten yhteys. Sairaanhoitokorvauksilla tarkoitetaan tässä yhteydessä yksityisen terveydenhuollon korvauksia, joita ovat lääkärin ja hammaslääkärin palkkiosta sekä tutkimuksesta ja hoidosta maksettavat korvaukset. Lääke- ja matkakorvaukset jätetään sairaanhoitokorvauksista tutkimuksen ulkopuolelle. Tutkimuksen aineisto koostuu Kelan ja Tilastokeskuksen kuntakohtaisista tilastotiedoista vuodelta 2007. Muuttujia on pyritty keräämään niin, että kaikki olennaiset kunnan yhteiskuntarakennetta kuvaavat indikaattorit olisivat edustettuina. Tilastollinen regressiomallinnus on keskeinen osa tämän opinnäytetyön menetelmiä. Regressiomallinnuksessa käytetään sekä PNS-menetelmää että robustia MM-menetelmää. Lisäksi aineistossa olevaa puuttuvuutta käsitellään imputoimalla ja aineiston informaatiota tiivistetään pääkomponenttianalyysilla. Rekisterimuuttujien yhdistelyssä ja aineiston muodostamisessa käytetään hyväksi rekisteriaineistojen käsittelyn tilastotiedettä. Yksittäisistä muuttujista asukkaiden tulotaso ja korkeakoulutettujen osuus, jotka korreloivat vahvasti keskenään, selittävät eniten yksityisen terveydenhuollon sairaanhoitokorvausten kunnittaisesta vaihtelusta. Kun tulotaso tai korkeakoulutettujen osuus on mallissa, työttömyysaste selittää eniten jäljelle jäänyttä vaihtelua. Suurimman selitysasteen saa tulotason ja työttömyysasteen malli, joka selittää yli 50 % yksityisen terveydenhuollon sairaanhoitokorvausten vaihtelusta. Jäännösten perusteella mallin sopivuudessa on kuitenkin alueellista vaihtelua. Kun malliin lisätään alueulottuvuuden sisältäviä yhdysvaikutustermejä, sen selitysaste kasvaa lähes 70 %:iin. Kun mallit muodostetaan Kelan vakuutusalueiden tasolla, selittävimpiin malleihin valikoituu eri vakuutusalueissa eri muuttujia. Etelä-Suomen selittävillä malleilla on huomattavasti suurempi selitysaste kuin muissa vakuutusalueissa. Yksi syy tähän voi olla, että Etelä-Suomessa yksityisten terveyspalvelujen tarjonta on vahvemmin kiinnittynyt kunnan ominaisuuksiin, mikä taas on tulosta alueen palvelujen käyttökulttuurin ominaispiirteistä ja markkinoiden muodostumisesta. Yksityisen terveydenhuollon sairaanhoitokorvauksilla on melko vahva negatiivinen korrelaatio sekä kuntien terveydenhuoltomenojen että ikä- ja sukupuolivakioidun sairastavuusindeksin kanssa. Nämä yhteydet kuitenkin häviävät, kun esimerkiksi kunnan asukkaiden tulotaso vakioidaan. Koska vakuutusalueittaisessa tarkastelussa selittävimpiin malleihin valikoituneet muuttujat vaihtelivat paljon, voidaan päätellä, että tämän tutkimuksen perusteella ei ole olemassa valtakunnallista pelkkien päävaikutusten mallia, joka selittäisi yksityisen terveydenhuollon sairaanhoitokorvausten vaihtelua tyydyttävästi. Alueulottuvuus on syytä ottaa huomioon joko yhdysvaikutustermein tai muodostamalla mallit kokonaan pienemmässä aluekehyksessä. Mitä suuremmat kunnallisen terveydenhuollon kustannukset olivat vuonna 2007, sitä vähemmän kunnassa käytettiin yksityisen terveydenhuollon palveluja (ts. myönnettiin sairaanhoitokorvauksia). Samoin mitä suurempi kunnan ikä- ja sukupuolivakioitu sairastavuusindeksi oli, sitä vähemmän siellä käytettiin yksityisen terveydenhuollon palveluja. Yhteydet kuitenkin selittyvät välillisesti esimerkiksi kunnan asukkaiden tulotasolla: sairastavimmissa kunnissa on keskimäärin pienempi tulotaso. Tutkimuksen tuloksia voidaan käyttää sairausvakuutusjärjestelmän arvioinnin ja kehittämisen tukena. Tutkimus voi myös luoda pohjaa yleisemmän terveystaloustieteellisen teorian kehittämiselle.