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

Sammanfattning: 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.