Geographic equity in primary health care performance in Finland : from individual socioeconomic position into the blind spot of the service system

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dc.contributor.author Satokangas, Markku
dc.date.accessioned 2021-09-21T10:31:08Z
dc.date.available 2021-10-25
dc.date.available 2021-09-21T10:31:08Z
dc.date.issued 2021-11-04
dc.identifier.uri URN:ISBN:978-951-51-7508-3
dc.identifier.uri http://hdl.handle.net/10138/334486
dc.description.abstract Primary health care (PHC) has been shown to promote socioeconomic equity in health. However, geographic equity in health outcomes related to PHC performance remains little studied in Finland. This gap mirrors both the limited number of suitable indicators for comprehensive PHC performance evaluation and the complexity of measuring PHC performance at the population level. This thesis applied hospitalisations for ambulatory care sensitive conditions (ACSCs) and mortality potentially preventable by health policy and care (amenable mortality) to measure PHC as well as overall health care performance in Finland. These internationally utilized, population-level proxy health outcomes are suggested to be preventable by timely care. The aims of this thesis were to analyse what individual and area-level variables over time explained geographic variation in ACSCs in Finland – and what kind of over time developmental paths would emerge among areas providing public PHC in Finland when these areas were clustered by their age-standardised ACSC subgroup rates. Moreover, this thesis also aimed to analyse how geographic disparities in amenable mortality developed over time between three geographic areas in Finland – and whether this development disfavoured the capital City of Helsinki due to its increasing residential differentiation. ACSCs were obtained and identified from the Finnish Care Register for Health Care for the total Finnish adult population – and amenable mortality respectively from the Causes of Death statistics for all Finns aged 25-74. These outcomes were then linked to individual sociodemographic data and allocated into areas providing public PHC by individual area of residence. The associations between several selected variables and geographic variation in ACSCs were analysed with three-level nested Poisson regression models (individuals nested in areas providing PHC, nested in areas providing hospital care). The proportion of variance explained by each variable was quantified at three time points in 2011-2017 and in two separate datasets (all ACSCs and ACSC emergency admissions). In the null model, variances between areas providing hospital care were up to twice that between providers of PHC. While individual incomes and comorbidities explained up to third of the variances at both area-levels, area-level disease burden and arrangement and usage of hospital care explained an additional 14-16% and 32-33% of these variances in all ACSCs – and 7-15% and 28-33% in ACSC emergency admissions. After these adjustments the remaining variances in the two area-levels emerged to be nearly alike. To identify geographic disparities over time in the level and development of ACSCs in Finland, a group-based multi-trajectory model was applied. This model clustered areas providing PHC by their annual age-standardised acute, chronic and vaccine-preventable ACSC rates in 1996-2013. Moreover, it was tested which within-cluster values of area-level variables differed between the clusters over time. Three clusters emerged – each of them having a distinct level and development of ACSC rates. In these clusters, chronic ACSC rates over time halved, acute ACSC rates stagnated and vaccine-preventable ACSC rates increased slightly. The northern cluster had constantly the highest ACSC rates. While between-cluster absolute disparities in chronic ACSCs diminished over time, the respective relative disparities stagnated. Moreover, both of these disparities increased in acute and vaccine-preventable ACSC rates disfavouring the northern cluster. However, areas within the rural northern cluster shared the highest disease burden and usage of GP led inpatient wards – as well as the lowest education level and use of private health and dental care. Over time the development of amenable mortality was assessed both within and between three geographic areas in Finland: the city of Helsinki, the nine next most populated municipalities and the rest of Finland. Within these areas, development of geographic disparities in amenable mortality were quantified with Gini coefficients – and development of socioeconomic disparities with concentration indices. Finally, both the levels and over time changes of these disparities were compared between the three geographic areas. Over time geographic disparities in amenable mortality within the three geographic areas remained stable, but the socioeconomic ones slightly increased in the favour of the affluent population. The increase in socioeconomic disparities seemed to mirror both stagnating mortality rates in the lowest income quintile and otherwise consistent gradient in decreasing mortality rates among those with higher incomes. However, over time development in both of these within-area disparities were similar between the three geographic areas – and no hypothesised effect for increasing residential differentiation on mortality was found. To conclude, if age- and gender-adjusted ACSCs are applied to compare PHC performance between local providers in Finland, these values are not only confounded by individual socioeconomic position and health status but also by areas’ disease burden and variables related to hospital care. Indeed, when assessing over time geographic disparities in ACSCs, rural northern Finland seemed to be lagging behind the other parts of the country – possibly due to both high usage of GP led inpatient wards (low-threshold basic level hospital care) and excess disease burden in northern Finland. Either way, this finding emphasizes the need to strengthen health care in rural northern Finland. Finally, despite increasing residential differentiation in Helsinki, disparities in its health care performance did not diverge from those observed elsewhere in Finland – which might mirror the effects of policies of positive discrimination and social mixing applied in Helsinki. en
dc.description.abstract Perusterveydenhuollon (PTH) on kansainvälisesti havaittu kaventavan sosioekonomiseen asemaan liittyviä terveyseroja. Alueellista eriarvoisuutta PTH:n laaja-alaisissa laatumittareissa on kuitenkin tutkittu vähänlaisesti Suomessa. Tämä juontuu sekä kyseisten mittareiden vähäisestä tarjonnasta että useista väestötason tarkastelua sekoittavista tekijöistä. Tutkimuksessa tarkasteltiin alueellista eriarvoisuutta avohoidon keinoin vältettävissä olevissa sairaalahoitojaksoissa (VOS) ja terveydenhuollon keinoin vältettävissä olevassa kuolleisuudessa. Näiden mittareiden ajatuksena on, että niiden päätetapahtumia voidaan ehkäistä terveydenhuollon oikea-aikaisin toimin. Koko Suomen aikuisväestön kattavat tutkimusaineistot kerättiin terveydenhuollon hoitoilmoitusrekisteristä sekä kuolinsyyrekisteristä ja yhdistettiin yksilötason sosiodemografisiin taustamuuttujiin (mm. ikä, sukupuoli, asuinkunta ja tulotaso). Tutkimuksessa tarkasteltiin: 1) yksilö- ja aluetason tekijöiden yhteyttä VOS-jaksojen alueelliseen vaihteluun vuosina 2011–2017, 2) VOS-jaksojen alueellisia kehityskulkuja vuosina 1996–2013 ja 3) vältettävissä olevan kuolleisuuden alueellisten ja sosioekonomisten erojen kehitystä Helsingissä sekä muualla maassa vuosina 1992–2008. Tutkimuksessa havaittiin, että yksilötason tekijöiden ohella myös aluetason sairastavuus sekä sairaalahoidon järjestämiseen liittyvät tekijät selittivät VOS-jaksojen alueellista vaihtelua. Lisäksi VOS-jaksojen havaittiin painottuvan Pohjois-Suomen maaseutumaisille alueille. Vaikka absoluuttiset alue-erot pitkäaikaissairauksiin liittyvissä VOS-jaksoissa selvästi vähenivät, äkilliseen sairastumiseen ja rokotuksiin liittyvissä VOS-jaksoissa erot kasvoivat. Lisäksi VOS-jaksojen suhteelliset alue-erot pysyivät joko ennallaan tai kasvoivat. Vältettävissä olevan kuolleisuuden alue-erot puolestaan lisääntyivät maltillisesti, kun taas sosioekonomiset erot kasvoivat selvästi. Helsingin sisäiset alue-erot olivat tasoltaan ja kehitykseltään yhteneväisiä muun maan vastaaviin eroihin verrattuna. Tutkimuksen tulokset osoittavat, että käytettäessä VOS-jaksoja PTH:n laatumittarina tulee ottaa huomioon, että mittarin alueelliset arvot heijastelevat myös väestörakenteen eroja, alueen sairastavuutta ja sairaalahoidon järjestämistä. VOS-jaksojen ajalliset kehityskulut viittaavat siihen, että Pohjois-Suomen maaseutumaisten alueiden terveydenhuollon laatu saattaa olla jäämässä jälkeen muun maan kehityksestä. Helsingin pienalueiden lisääntyvä eriytyminen ei puolestaan näyttäisi korostaneen terveydenhuollon laadun alueellisia eroja. fi
dc.format.mimetype application/pdf
dc.language.iso eng
dc.publisher Helsingin yliopisto fi
dc.publisher Helsingfors universitet sv
dc.publisher University of Helsinki en
dc.relation.isformatof URN:ISBN:978-951-51-7507-6
dc.relation.isformatof Unigrafia: 2021, Dissertationes Scholae Doctoralis Ad Sanitatem Investigandam Universitatis Helsinkiensis. 2342-3161
dc.relation.ispartof Dissertationes Scholae Doctoralis Ad Sanitatem Investigandam Universitatis Helsinkiensis
dc.relation.ispartof URN:ISSN:2342-317X
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dc.rights This publication is copyrighted. You may download, display and print it for Your own personal use. Commercial use is prohibited. en
dc.rights Publikationen är skyddad av upphovsrätten. Den får läsas och skrivas ut för personligt bruk. Användning i kommersiellt syfte är förbjuden. sv
dc.subject yleislääketiede
dc.title Geographic equity in primary health care performance in Finland : from individual socioeconomic position into the blind spot of the service system en
dc.type.ontasot Doctoral dissertation (article-based) en
dc.type.ontasot Artikkeliväitöskirja fi
dc.type.ontasot Artikelavhandling sv
dc.ths Keskimäki, Ilmo
dc.ths Elonheimo, Outi
dc.opn Jorm, Louisa
dc.type.dcmitype Text
dc.contributor.organization University of Helsinki, Faculty of Medicine, The Department of General Practice and Primary Health Care en
dc.contributor.organization Doctoral Program in Population Health en
dc.contributor.organization Finnish Institute for Health and Welfare, Health Economics and Equity in Health Care en
dc.contributor.organization Helsingin yliopisto, lääketieteellinen tiedekunta fi
dc.contributor.organization Väestön terveyden tohtoriohjelma fi
dc.contributor.organization Helsingfors universitet, medicinska fakulteten sv
dc.contributor.organization Doktorandprogrammet i befolkningshälsan sv
dc.type.okm 3121 Yleislääketiede, sisätaudit ja muut kliiniset lääketieteet fi
dc.type.okm 3121 Allmänmedicin, inre medicin och annan klinisk medicin sv
dc.type.okm 3121 General medicine, internal medicine and other clinical medicine en
dc.type.okm 3142 Kansanterveystiede, ympäristö ja työterveys fi
dc.type.okm 3142 Folkhälsovetenskap, miljö och arbetshälsa sv
dc.type.okm 3142 Public health care science, environmental and occupational health en
dc.type.publication doctoralThesis

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