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 (every 5-years) Population registration (annual) Linked with data on e.g. Mortality ( ) Hospital discharge and medication Taxation Linkage is based on social security numbers Allows for: Longitudinal analyses Multilevel analyses: areas, couples/families

An example of data content for a study of entry into institutional care (40% sample of 65+) Sociodemographic factors: SexAge Marital status Living arrangements Education Social class IncomeHousingPartnerRegion Use of homecare services Institutional care: Care episodes Care episodes Date of entry Date of entry Date of exit Date of exit Type of institution Type of institution (in health & social care sectors) (in health & social care sectors) Supply of care: Regional coverage of institutional care STAKES Statistics Finland STAKES Pension institute Health:Medication Hospital 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

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 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) 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 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).

Nihtilä & Martikainen, Population Studies 2007

Use of care towards the end of life Older age and peoples 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

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