Ilmo Keskimäki

An international study of hospital readmissions and related utilization in Europe and the USA.

This study concerns a comparative analysis of hospital readmission rates and related utilization in six areas, including three European countries (Finland, Scotland and the Netherlands) and three states in the USA (New York, California, Washington State). It includes a data analysis on six major causes of hospitalization across these areas. Its main focus is on two questions. (1) Do hospital readmission rates vary among the causes of hospitalization and the study populations? (2) Are hospital inpatient lengths of stay inversely related to readmissions rates? The study demonstrated that diagnoses such as chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF) were the major causes of hospital readmission rates. The data showed that (initial) hospital stays were generally longer for patients who were readmitted than for those who were not. As a result, short stays were not associated with a higher risk of readmission, meaning that hospital readmissions were not produced by premature hospital discharges in the study population. Furthermore, the spatial variation in readmission rates within 7 versus 8-30 days showed to be identical. Finally, it was found that countries or states with relatively shorter stays showed higher readmission rates and vice versa. Since patients with readmissions in all of the areas had on average longer initial stays, this finding at country level does illustrate that there seems to be a country specific trade off between length of stay and rate of readmission. An explanation should be sought in differences in health care arrangements per area, including factors that determine length of stay levels and readmission rates in individual countries (e.g. managed care penetration, after care by GPs or home care).

Risk of multiple reoperations after lumbar discectomy: a population-based study.

Study Design. Retrospective follow-up study of patients undergoing multiple (two or more) reoperations after initial lumbar discectomy using an administrative database. Objectives. To identify the population-based risk of multiple reoperations after lumbar discectomy and to analyze factors associated with the risk. Summary of Background Data. Although multiple reoperations after initial lumbar discectomy are likely uncommon, research to better understand reasons for and outcomes of reoperations is needed because of the large number of discectomies performed. Methods. Data on all lumbar spine operations during 1987–1998 were obtained from the Finnish Hospital Discharge Register. The patient’s initial disc operation during the study period was linked to subsequent operations, and patients with two or more reoperations were analyzed further. The risk of multiple reoperations was determined using the methods of event history analysis. Results. Among 35,309 patients undergoing an initial discectomy, 4943 (14.0%) had at least one reoperation and 803 (2.3%) had two or more reoperations. A total of 63% of the second reoperations were discectomies, 14% were fusions, and the remaining 23% were decompressions. Patients with one reoperation after lumbar discectomy had a 25.1% cumulative risk of further spinal surgery in a 10-year follow-up. Reduced risk was seen when the first reoperation took place more than 1 year after the initial discectomy (relative risk 0.83, 95% confidence interval 0.72–0.96), in patients for whom the first reoperation had been a fusion (relative risk 0.27, 95% confidence interval 0.12–0.61), and in patients 50–64 years of age (relative risk 0.62, 95% confidence interval 0.48–0.79). Conclusion. Patients with one reoperation after lumbar discectomy are at considerable risk of further spinal surgery.

Causes of death among Finnish women with cosmetic breast implants, 1971-2001.

Mortality patterns among women with cosmetic breast implants have not been well characterized. We examined cause-specific mortality among women who underwent cosmetic breast implantation at major public hospitals and private clinics in Finland from 1970 through 2000. Causes of death through 2001 were identified through the national mortality register. Expected numbers of deaths were calculated on the basis of mortality rates in the general female population, and standardized mortality ratios (SMR), i.e. ratios of observed to expected deaths, and 95% confidence intervals (CI) were calculated. Among the 2166 women with cosmetic breast implants, we observed 31 deaths versus 32.1 expected. Overall disease mortality was below expectation, mainly due to low mortality from diseases of the circulatory system (SMR, 0.28; 95% CI, 0.03–1.02). Mortality from cancer was close to expectation. There was a statistically significant excess of suicide, based on 10 deaths, which was most pronounced during the first 5 years of follow-up (SMR, 4.26; 95% CI, 1.56–9.26). In conclusion, although based on small numbers, women with cosmetic breast implants did not experience higher mortality overall than women in the general population. The high suicide risk supports other studies and warrants further detailed investigation.

Trends in Fatal and Nonfatal Strokes Among Persons Aged 35 to ≥85 Years During 1991–2002 in Finland

Background and Purpose— Declining trends in the incidence and mortality of stroke have been observed in Finland since the beginning of the 1980s until 1997. In this study we analyzed the trends in fatal and nonfatal strokes in Finland during 1991–2002. Methods— The Finnish Hospital Discharge Register was linked to the National Causes of Death Register to produce a Cardiovascular Disease Register, which includes data on 410 760 cerebrovascular events (International Statistical Classification of Diseases, 10th Revision [ICD-10] codes I60–I69) in patients aged ≥35 years in 1991–2002. Results— Age-standardized incidence of first-ever stroke (ICD-10 codes I60–I64, excluding I63.6) per 100 000 persons declined during 1991–2002 annually by 2.2% (95% CI, −2.4% to −1.9%) among men and 2.5% (−2.8% to −2.2%) among women aged 35 to 74 years. In patients aged 75 to 84 years, the change in the incidence of first-ever stroke was −2.6% per year (−3.0% to −2.2%) among men and −3.2% per year (−3.5% to −2.9%) among women. A similar trend was observed also in the oldest age group, in patients aged ≥85 years. Among patients aged 35 to 74 years, the 28-day case fatality of first-ever stroke declined annually by 3.2% (−3.9% to −2.5%) among men and by 3.0% (−3.8% to −2.2%) among women. A significant decrease was found in the 28-day case fatalities of all subtypes of stroke in this age group. Conclusions— The favorable development in stroke incidence, mortality, and case-fatality has continued in Finland during 1991–2002.

Hysterectomy trends in Finland in 1987-1995--a register based analysis.

BACKGROUND The study objective was to identify trends in the use of hysterectomy by nationwide register based analysis in Finland. METHODS All women (n=89,069) undergoing hysterectomy in 1987-1995 according to the Finnish Hospital Discharge Register were the numerator. The annual denominator data were obtained from the population database of Statistics Finland. RESULTS From 1987 to 1992 the hysterectomy rate increased by 22%, from 340 to 414 per 100,000 females, almost half of this being attributable to the changing age structure. From 1993 on, ambiguity in coding laparoscopically assisted vaginal hysterectomies prohibited detailed analyses. However, the overall trend continued at least among women 50 years and over until 1995. The age-adjusted 12% increase from 1987 to 1992 coincided with a rapid increase in operation rates in postmenopausal groups (60% or more among women aged 55 59 and 70-79 years). Among women aged 55-64 years, operations for fibroids and uterine bleeding more than doubled, suggesting an influence of increased use of estrogen replacement therapy. Among all women, operations due to bleeding disorders and genital prolapse showed the largest increase (41% and 42% respectively). Bilateral oophorectomy became more common in all age groups over 46 years. CONCLUSIONS There was a modest increase in the overall hysterectomy rate. However, the operation became far more common in postmenopausal women, possibly due to the growing use of estrogen replacement therapy. Register data can be used for describing changes in clinical practice, but other methods are needed to confirm the causal relationships underlying the changes.

Socioeconomic equity in finnish hospital care in relation to need

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.

Comparing Properties of Audit Data and Routinely Collected Register Data in Case of Performance Assessment of Hip Fracture Treatment in Finland

OBJECTIVES To compare prospective audit data and secondary administrative register data in the production of performance assessment information in the case of hip fracture treatment, and to cross-validate the quality of information. METHODS First, a conceptual model for the performance assessment of hip fracture treatment was defined. This model was then utilized in comparisons between the prospective audit data concerning 106 consecutive hip fracture patients from the Kuusankoski Regional Hospital and corresponding register data from the Finnish Health Care Register and the Causes of Death Register. We examined the completeness of registration of patients and also the accuracy and degree of completeness of the registered data. Observed differences were checked against the medical records. RESULTS Register data lack clinical detail, but outperform prospective data in the recording of inpatient care history. Completeness of the register data is very good. The accuracy of easily measurable variables in the register is at least 95%. The agreement between register and audit data was 86.3% for detailed hip fracture diagnosis. Polyserial correlation between the functional dependency variables was 0.68. CONCLUSIONS Register and audit data have certain limitations and problems, but both seem to be suitable for the performance assessment of hip fracture treatment. To improve the feasibility of the administrative register data, the voluntary input of additional hip fracture event data to the register should be made possible. Standardized instructions that guide the use of available register classifications in a sensible way would improve the quality of data.

Hospitalizations and deaths associated with Clostridium difficile infection, Finland, 1996-2004.

The age-standardized mortality rate associated with CDAD increased from 9 per million in 1996 to 17 per million in 2004 among persons >64 years of age.

How did Finland's economic recession in the early 1990s affect socio-economic equity in the use of hospital care?

The study evaluates the changes in socio-economic equity in the use of general hospital care in Finland from the late 1980s to the mid 1990s. In the early 1990s the Finnish economy plunged into a deep recession which slashed over 10% of GDP and resulted in a 12% decrease in national health expenditure. At the same time, the administration and financing of specialised health services were reformed. The impact on general hospital care was controversial: budgets were reduced but better productivity increased the supply of many services. According to the study, data, based on individual linkage of nationwide hospital registers to disposable family income data in population censuses, overall acute general hospital admission rates among Finns aged 25-74 increased by over 10% from 1988 to 1996. For some surgical procedures, such as cataract, coronary revascularisation and some orthopaedic operations, rates more than doubled. In both years, lower-income groups generally used hospital care more than the better-off. However, there was a slight shift towards a pro-rich distribution, mainly due to a larger increase in surgical care among the high-income groups. In 1988 the lowest income quintile used 8% and in 1996 15% fewer operations than the highest. For individual procedures and surgical diagnostic categories, the general trends of increasing disparities were similar. Despite cuts in expenditures in the early 1990s, the Finnish general hospital system based on public funding and provision managed to increase the supply of services. However, this increase coincided with widening socio-economic discrepancies in the use of surgical services. The paper proposes that these increasing inequities were due to certain features of the Finnish health care system which create social discrepancies in access to hospital care. These include the high profile of the private sector in specialised ambulatory care and in the supply of some elective procedures, and semi-private public hospital services requiring supplementary payments from patients.

The feasibility of combining data from routine Hospital Discharge and Causes-of-Death Registers for epidemiological studies on stroke

We assessed the validity of hospital discharge data on stroke in Finland and the feasibility of linked hospital discharge and causes-of-death data for epidemiological studies using the FINMONICA Stroke Register as the reference. The results showed that such data can, with some caution, be used for incidence studies and for identifying first stroke events. They cannot, however, be used for assessing secular trends in all stroke events.