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We examined the prevalence of depressive disorders and associated factors in the general population in Finland using the Computer-Assisted Telephone Interview (CATI) method. A total of 2293 (71%) of 3250 individuals randomly drawn from the population registry and representing the adult population of Finland in the age group 25-79 years were interviewed by telephone in autumn 1994. The interview included a short form of the University of Michigan version of the Composite International Diagnostic Interview (UM-CIDI) generating probability diagnoses of DSM-III-R major depressive episode and dysthymia. The age-adjusted 6-month prevalence was 4.1% for major depressive episode and 1.7% for current dysthymia; depressive mood during the preceding month was reported in 17% of cases. Major depressive episodes and depressive mood were significantly more prevalent among females than males. In the logistic regression analyses, factors associated with the depressive disorders were found to vary somewhat depending on sex and type of disorder. Only about 50% of those with major depressive episode or dysthymia reported a self-perceived need for mental health services.

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Implementation of a 'population responsibility' principle in Finnish health centres began in the late 1980s. The aim of this study was to describe public health nurses' (PHNs') experiences of primary health care based on this principle and to identify contextual and personal factors related to their experiences. The sample consisted of PHNs in 10 health centres. A questionnaire was developed based on a qualitative study. The survey was conducted in 1990 and repeated in 1992. The response rate was 84% for the 1990 sample (n = 102) and 91% for the 1992 sample (n = 131). In the multivariate analysis of variance type of community (urban/rural), size of the target population, task division model and existence of regular teamwork between social and health care personnel were chosen as contextual factors studied. Age, length of professional experience and having specialist education in midwifery were chosen as personal factors. Dependent variables were subscales on: experiences of planning and implementation, perceived influence of population responsibility on nurse-client relationships, comparison with previous experiences, views and experiences on comprehensiveness of care and job satisfaction. The majority of the PHNs experienced only minor changes in their work after the implementation of population responsibility. They were most critical about the way these changes were planned and implemented. Changes were mainly perceived as positive. There were some differences in the two samples, reflecting a shift from both positive and negative responses towards more neutral or more positive responses. Several contextual factors were multi-dimensionally related to the PHNs' experiences.

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Finland's active deinstitutionalization policy aims to reduce the number of elderly people in long-term residential care and to keep noninstitutionalized elderly people living at home as long as possible. As a contribution to the issue of the appropriateness of long-term institutional care, we compared the health and functional ability of elderly people living at home or in residential care to assess the theoretical possibility of discharging the least dependent elderly from residential homes. Findings from two separate data sets collected in 1992 were compared; one (n = 475) was obtained by computer-assisted telephone interview (elderly at home) and the other (n = 459) by postal survey (elderly in residential care). The direct method was used in age and gender standardization, and logistic regression analysis was applied. Elderly people living at home were found to be in better health and with better functional ability than those in residential care. However, a proportion of home-dwellers needing some help with Activities of Daily Living (ADLs) assessed their health as being even worse than those in care, and approximated that of institutionalized elderly judged by the personnel to be able to manage with home-based care. Compared with home-dwellers, those assessed as able to manage in-home care were mostly single and had less education and more restrictions in their Instrumental ADLs and medication. Our results indicate that one third of those assessed as able to manage in-home care could possibly be discharged if adequate servicers and housing were available.

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The success of Finnish deinstitutionalization policy among the elderly in 1981-1991 was evaluated in terms of institutionalization rates and case-mix. Censuses of institutionalized people in all public and private residential homes and health centre hospitals (or nursing homes) were performed in 1981, 1986 and 1991. Data on demographic factors, diagnoses and dependency level were gathered. Censuses from the closest years of psychiatric patients were also used to obtain a comprehensive view of institutionalization. The eligibility criteria for the study were (1) age 65 years or more (2) currently in long-term care. In both men and women the overall relative reduction was 33%, and largest in psychiatric care, at over 67%. In residential home care the relative reduction was about 40%. In health centre hospitals a slight increase was seen, about 10%. Length of stay shortened in residential homes but increased in health centre wards. Dependency level increased among the elderly people in long-term institutional care during ten years. In conclusion, the deinstitutionalization rate was substantial among the elderly in Finland. However, because of rapid demographic change the absolute number of elderly in long-term care remained almost constant. The case-mix has become more demanding and the proportion of elderly in constant need of extensive help has risen.

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The extensive benefits of the total hip (THA) and knee (TKA) replacements are well documented, but surprisingly little is known about their economics. We assessed costs, cost-effectiveness (C/E), and patient-related C/E variances in THA and TKA from data on 276 THA and 176 TKA patients. Patients with primary arthrosis, primary operation, and total joint replacement were recruited from seven hospitals between March 1991 and June 1992. Their use of health and other welfare services together with health-related quality of life (HRQoL) were measured before the surgery and at 6, 12, and 24 months postoperatively. HRQoL was assessed by the 15D, a 15-dimensional HRQoL instrument, and the Nottingham Health Profile. Costs were assessed from questionnaire responses, the Finnish Hospital Discharge Register, and Finnish Arthroplasty Register. Total hospital costs per patient were 45,000 FIM (US $10,500) for THA and 49,600 FIM (US $11,500) for TKA. Prosthesis costs comprised 21% of these costs in THA and 24% in TKA. On average, hip patients gained more in terms of HRQoL, and the operations were more cost-effective. The C/E ratio for younger (< or = 60 years) knee patients did not differ from those in all age groups of hip patients, whereas TKAs in those over 60 years had a worse C/E ratio compared with all other patient subgroups. It was concluded that allocation efficiency can be improved by considering not only the intervention but also patient characteristics such as age. Indeed, the C/E ratio varied more across age groups of knee patients than between average THA and TKA patients.

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The aim of this study was to evaluate potential access to personal community nursing services and the desirability of these services from the point of view of different population groups. Potential access to personal community nursing services was defined as having one or more particular nurses to contact when needing help and advice in health matters. The desirability of these services was defined as the respondents' estimation of how useful they considered it to be for them to have access to personal community nursing services. A computer-assisted telephone interview for the population living in the catchment areas of 10 health centres in Finland was conducted. A random sample of the total population aged 16-79 years was drawn from the population register. Logistic regression revealed that gender, type of community and employment status had best explanatory power in having potential access to personal nursing services and in considering these services desirable. However, many of those who considered personal nursing services very desirable, indicated that they did not have potential access to such services. Most of these persons were elderly and had a chronic disease or disability. Developing access to personal community nursing services particularly for these population. groups appears to be needed.

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At the start of the 1990s, the economic situation in Finland deteriorated radically. During the depression (1991-93), health care expenditure decreased by about 10%, and was associated with considerable changes in Finnish health care. This paper reports studies of the determinants of use of physician services in Finland in the 1990s. The particular aim was to evaluate how utilization altered during the economic depression and during the changes in the health care system. Using econometric methods, an attempt was made to describe the changes in structure and level of utilization. The study was based on annual computer-assisted telephone interviews made during 1991-94. Visits to a doctor were analysed using a two-part model (logit and truncated negative binomial regression). Structural changes were tested by Chow-type tests and changes in the level of utilization by chronologically defined dummy variables for each year. The most significant changes (both in structure and level) occurred in the model explaining the number of visits (negative binomial regression) of chronically ill persons. Variables describing the continuity of care seem to be more important determinants of visits to a doctor than certain other availability and socioeconomic variables.

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The purpose of this study was to investigate health-related quality of life (HRQOL) and functional ability among the least dependent elderly in residential care, and to compare them with information on the general population. A stratified systematic sample (n = 1,587) was drawn from a one-day census of patients in all public residential homes in Finland on December 2, 1991. Sixty-nine per cent of residents in 1992 were able to participate (n = 1,097) and 86% of them returned the questionnaire (n = 948), of which n = 795 were acceptable, the response rate being 72%. A postal survey was used for data collection. The personnel of residential homes were allowed to help residents complete the questionnaire, and 90% of respondents received such help. HRQOL was measured by the Nottingham Health Profile (NHP) and functional ability by a 14-item questionnaire. Finnish studies among the general population were used for comparisons. According to the NHP, the HRQOL appeared lower in institutional care and this was associated with the dependency level. Similarly, for most ADL items the general population had less restrictions than the least dependent residential care patients. In general, women expressed more difficulties in physical mobility and lack of energy than men. The longest stay elderly expressed better HRQOL. In multivariate models adjusted for age and gender those with poor vision had worse HRQOL in almost every dimension of NHP. Difficulties in speech were connected with emotional reactions and social isolation. Chronic illness limiting normal daily life predicted more problems in energy, pain, physical mobility, and emotional reactions. The married or widowed experienced less social isolation than single elderly. Higher education was related to better HRQOL in all NHP dimensions. Poorer perceived health was associated with lack of energy, pain, and emotional reactions. We conclude from these results that there are only a few clients in residential care whose HRQOL or functional ability compare with the non-institutionalized population.

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The aim of the study was to evaluate socioeconomic equity in access to surgical services in Finland and to explore the contribution of private sector procedures to any inequities. Data on nine common surgical procedures performed on patients aged 25 and over were obtained from the 1987-88 Finnish Hospital Discharge Register. Socioeconomic indicators were linked to the procedure data by personal identity numbers from the 1987 population census, which was also used to derive the data on population at risk. The study revealed marked differences in rates across socioeconomic categories for several procedures. Some of these disparities are probably explained by variations in need for surgery across socioeconomic groups. However, for cataract operations and hip replacements due to arthrosis or deformity, the surgery rates favoured the better-off, despite low social status being considered a risk factor for these disorders. The correlation or disposable family income with hysterectomy and prostatectomy rates, and the low surgery rates for many procedures in the lowest income quintile also suggested socioeconomic disparities in access to services. The specific effect of private sector seems to have contributed to the socioeconomic differences in rates for, at least, hysterectomy, prostatectomy, and cataract operations. Although the Finnish health care system operates universal coverage without formal barriers to equal access, systematic socioeconomic inequity in the use of individual surgical treatments prevail. Part of these inequities is evidently due to private sector services.

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OBJECTIVE: The aim of the present study was to examine both the structure, including modes of drug treatment, ambulatory care, and hospital inpatient care, and the costs of health care for drug-treated diabetic patients in Finland. RESEARCH DESIGN AND METHODS: The modes of drug treatment and ambulatory care were studied with the help of a questionnaire given to all diabetic patients obtaining their medication through pharmacies in Finland during a 7-week period in 1989. The questionnaire sought information on drug treatment, site of health care, and frequency of visits to physicians. Hospital inpatient care was evaluated by linking the patient data from the Hospital Discharge Register and the Central Drug Register. The direct costs of health care were calculated by using relevant average costs. RESULTS: A total of 30,266 questionnaires were returned, representing > 70% of all drug-treated diabetic patients receiving medication in the period studied. Of the diabetic patients, 63% were treated by oral medication only, 31% by insulin only, and 6% by a combination of insulin and oral agents. Of the patients in whom diabetes was diagnosed at > or = 30 years of age, 75% were treated at health centers, whereas > 60% of those in whom diabetes was diagnosed at < 30 years of age were treated at outpatient clinics. The mean annual frequency of visits was 4.0 for patients receiving insulin treatment and 3.3 for patients receiving treatment with oral medications. The diabetic patients used 1.5 million hospital inpatient days per year, which was 13% of the total inpatient days in Finland. Of the inpatient days, 20% were for diabetes as the principal cause, 52% for diabetes-related diseases, and 28% for causes unrelated to diabetes. The direct costs of the health care of drug-treated diabetic patients in 1989 were 5.8% of the total costs of health care in Finland and were three times higher than the average costs of care for nondiabetic individuals. The direct costs were divided into inpatient care (81%), medication (9%), ambulatory care (8%), and self-care equipment (2%). CONCLUSIONS: Hospital inpatient care is the major contributor to the excess of health care expenditures for diabetic patients.

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The aim of the study was to investigate the influence of outpatient care, overall hospital bed provision and the prevalence of diabetes on the hospital use by adult diabetic patients. Population based data were collected in Finland from a 3-year period. Hospital admissions, inpatient days, and mean length of stay due to diabetes were derived from the Hospital Discharge Register. Estimates of diabetes prevalence were derived from the Central Drug Register. Primary outpatient site, annual number of physician visits, and age at onset among diabetic patients were assessed by questionnaire. The unit of analysis was hospital district (n = 21) and all analyses refer to the 15-64 years age group. Linear regression models were used to explain discharge rates and inpatient days in the district. Large variations between hospital districts were observed in diabetes prevalence, discharge rates due to diabetes, and mean length of stay among diabetic patients. Prevalence of diabetes and overall supply of hospital beds in the district were not related to hospital use. Univariate analyses showed that the larger the proportion of diabetic patients primarily using a private practitioner, the lower the hospital use. In districts where early onset of diabetes was more common, the average number of inpatient days was significantly lower than in other districts. In stepwise regression analyses, early onset of diabetes was the only variable that entered the models. In the full model, 24.6% of the variance in inpatient days and 16.1% of the variance in discharge rates were explained. In conclusion, factors related to health care structure, provision of hospital beds or morbidity explain little of the regional variation in hospital use. The observed variations in hospital use probably depend mainly on local treatment policies and differences in clinical decision-making.

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The impact of hip (THA) and knee arthroplasty (TKA) on patients' health-related quality of life (HRQOL), physical ability and functioning was assessed in a two year follow-up study of 276 hip and 176 knee patients. The eligibility criteria were a diagnosis of primary arthrosis, a primary operation, and total joint arthroplasty. Patients were interviewed by questionnaire prior to the operation and 6, 12 and 24 months after the surgery. Subjective health outcomes were assessed with the Nottingham Health Profile and the 15D, a fifteen dimensional HRQOL measure. Patients' physical ability was assessed using measures of activities of daily living, and of physical mobility. Patient related outcome variations were analyzed by regression models. Major improvements were observed for pain, sleep and physical mobility. On average, in most of the quality of life dimensions the patients attained a similar quality of life as the comparable general population and only 4.7% of hip and 9.7% of knee patients had a worse HRQOL score at all three post-operative measurements than at baseline. Naturally, those with the poorest HRQOL pre-operatively gained most from the operation. High age did not lessen HRQOL gains from THA, but in TKA the oldest patients gained least in terms of 15D scores. Hip, but not knee patients with a long education tended to have greater improvements in quality of life and functional ability.

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Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are among the most prestigious health care technologies. Their popularity has grown rapidly, and an increasing proportion of health care resources is allocated to them. We studied patient- and hospital-related factors that cause variation in a major determinant of hospital costs, the length of hospital stay (LOS) for THA and TKA. We gathered data on 10,288 hip and 5,173 knee patients with primary or secondary arthrosis from the Finnish Arthroplasty Register, which we linked with the Finnish Hospital Discharge Register. Patient- and hospital-related variations in LOS were explained using regression models. Of the patient-related factors, complications caused the greatest prolongation of hospital stay, but patient's age, gender, and charge category also influenced LOS. Hospital-related factors were major causes of LOS variation. In the hospitals the average case-mix-adjusted LOS ranged from less than a week to 3 weeks. The number of arthroplasties performed in hospital was inversely related to LOS. The within-hospital LOS figures for THA and TKA were strikingly similar and persistent.

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The aim of the study was to evaluate the success of Finnish health care policy in establishing socioeconomic equity in the use of hospital inpatient care. We studied the use of short-term (< 30 days) care at Finnish general hospitals among those aged 25 or over, psychiatric and obstetric patients excluded. The data on service utilization were obtained from the 1988 Finnish Hospital Discharge Register. Patient data were linked with socioeconomic indicators from the 1970-1987 population censuses by personal identification number. The data on population at risk were obtained from the 1987 census. Hospital utilization was measured by annual risk of hospitalization, discharge rate, and inpatient days. The socioeconomic distribution of hospital utilization according to need was assessed by mortality and morbidity data. The same data were used to calculate inequity indices. Low socioeconomic groups used more hospital services than high in all age-groups and both genders. The socioeconomic differences in hospital utilization were similar to the gradients in death rate or to the prevalences of poor self-perceived health and limiting long-standing illness. In relation to need, the lower socioeconomic groups used at least as much inpatient care as the higher. The inequity index showed a neutral distribution of hospital services with respect to need. Finnish health care policy in the late 1980s seems to have been successful in providing hospital care equitably. This study compared overall hospital use with overall mortality and morbidity. It did not address possible socioeconomic differences in hospital use by causes of hospitalization or the quality of hospital services provided.

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BACKGROUND: Social mobility among patients with schizophrenia or major affective disorder was compared with that among the general population. METHOD: Mobility was studied retrospectively from 1970 to 1987. Socio-economic status (SES) was defined by occupation as in the population census (upper white-collar, lower white-collar, blue-collar, entrepreneur, farmer, unemployed). All patients aged 30-60 years at discharge (2901 men and 3620 women) in 1987-88 in Finland were included in the study. The SES structure of the general population was used for comparisons. RESULTS: Among patients with schizophrenia there was a constant downward drift, commonly to unemployment. This risk was higher among men than women. In the youngest age group a marked decline from the parents' social status was observed. Among patients with major affective disorder the distribution of SES in 1970 was similar to that of the general population. By 1987, a downward drift was again observed, mainly to unemployment regardless of the initial SES group. The number of patients in occupational categories were usually 30-50% lower than expected. CONCLUSIONS: Schizophrenic patients had a high risk of social drop-out. Among patients with major affective disorder the downward drift was much less.

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This population-based study presents socioeconomic differences in psychiatric inpatient care by diagnosis. Inpatient care among the Finnish population aged 25-64 years was studied using data from the Finnish National Hospital Discharge Register. All major mental disorders in the ICD-9 were included in the study. The socioeconomic status of individual patients was defined by years of education in the population census. Discharge rates, first-time admission rates and hospitalization risk were usually 2- to 4-fold higher in the low educational group compared with the highly educated population. The socioeconomic gradient was steepest for schizophrenia. No gradient was observed for major affective disorders. However, bipolar disorder was most common in the highest educational category. For most conditions, the socioeconomic gradient among women was lower than among men. In Finland hospitalization was more common among low than high socioeconomic groups for most mental disorders and most indicators of inpatient care. Most of these differences are fairly consistent with previous data on socioeconomic gradients in the prevalence of mental disorders.

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The impact of hip and knee arthroplasty based on the patients' own evaluations of their health, quality of life, and physical ability was assessed using a cross-sectional study design. The eligibility criteria were a diagnosis of primary arthrosis, primary operation, and total joint arthroplasty. Preoperative hip and knee patient groups were compared with similar groups who underwent arthroplasty 2 or 5 years previously. Subjective health outcome was assessed with the Nottingham health profile and a 15-dimensional, health-related quality of life measure. Patients' physical ability was assessed using a measure of activities of daily living. Major improvements were observed for pain, sleep, range of motion, and physical ability. However, after surgery, patients were less healthy than the general population of the same age. The health status of patients operated on 2 or 5 years ago was similar, suggesting that health gains persist for several years.

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OBJECTIVE: This register-based linkage study compared hospital use among diabetic and nondiabetic populations. The study focused on overall use, use by disease categories, and inpatient care caused by complications. RESEARCH DESIGN AND METHODS: The patient data were derived from the Hospital Discharge Register and the Central Drug Register in Finland. All drug-treated diabetic patients and discharges of patients in a 3-year period were included in the study. Hospital use was measured by inpatient days, mean length of stay, and discharge rate. RESULTS: Among diabetic patients were eligible for drug reimbursement, 14.2% had at least one hospital stay because of diabetes in a year, while 50.7% had at least one hospital stay for any cause. Only 12.4% of the nondiabetic population was hospitalized annually. Patients with diabetes as the principal diagnosis consumed about 3% of all inpatient days; patients who had diabetes either as the principal or as a subsidiary diagnosis used 8.3%; and people who were eligible for antidiabetic drug reimbursement used 13.3% of total inpatient days. Among diabetic children, the risk for hospitalization was 6.5 times higher than among nondiabetic children. With advancing age, causes other than diabetes increasingly dominated hospitalization among diabetic patients. Inpatient days because of cardiovascular diseases were 1.6-18 times more common among diabetic patients than among nondiabetic patients, depending on gender and age-group. Diabetic patients used many more hospital inpatient days than did the nondiabetic population for a number of other disease categories that are usually not related to diabetes. CONCLUSIONS: Hospital use among diabetic patients is substantially greater than that among the nondiabetic population, mainly because of cardiovascular and microvascular complications, but also because of diseases unrelated to diabetes.

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