[show abstract][hide abstract] ABSTRACT: To formulate sustainable long-term care policies, it is critical first to understand the relationship between informal care and formal care expenditure. The aim of this paper is to examine to what extent informal care reduces public expenditure on elderly care.
Data from a geriatric rehabilitation program conducted in Finland (Age Study, n = 732) were used to estimate the annual public care expenditure on elderly care. We first constructed hierarchical multilevel regression models to determine the factors associated with elderly care expenditure. Second, we calculated the adjusted mean costs of care in four care patterns: 1) informal care only for elderly living alone; 2) informal care only from a co-resident family member; 3) a combination of formal and informal care; and 4) formal care only. We included functional independence and health-related quality of life (15D score) measures into our models. This method standardizes the care needs of a heterogeneous subject group and enabled us to compare expenditure among various care categories even when differences were observed in the subjects' physical health.
Elder care that consisted of formal care only had the highest expenditure at 25,300 Euros annually. The combination of formal and informal care had an annual expenditure of 22,300 Euros. If a person received mainly informal care from a co-resident family member, then the annual expenditure was only 4,900 Euros and just 6,000 Euros for a person living alone and receiving informal care.
Our analysis of a frail elderly Finnish population shows that the availability of informal care considerably reduces public care expenditure. Therefore, informal care should be taken into account when formulating policies for long-term care. The process whereby families choose to provide care for their elderly relatives has a significant impact on long-term care expenditure.
BMC Health Services Research 08/2013; 13(1):317. · 1.77 Impact Factor
[show abstract][hide abstract] ABSTRACT: Abstract Purpose: The primary aim of the study was to investigate the interrelation between needs and functional difficulties and the therapeutic goals in children with cerebral palsy (CP) as documented in individual written rehabilitation plans. Method: The study was a retrospective cross-sectional register study. The data consisted of randomly chosen register documents for 77 children and adolescents with CP in different predetermined age ranges. The International Classification of Functioning, Disability and Health - Child and Youth version (ICF-CY) was used as a reference for analyzing the content of the written statements. Results: The rehabilitation plans for 70 children, 1-16 years of age, representing all GMFCS levels were analyzed. Goals were not well reflected in the children's needs and functional difficulties. The needs, functional difficulties and goals mainly encompassed the components of body functions and activity/participation. In half of the plans the presence of the parents was mentioned, and the plans were made in multidisciplinary collaboration. Conclusions: The results of this study indicate deficiencies in the content and goals of the written rehabilitation plans. The ICF-CY could serve as a framework to help professionals and parents identify the child's needs and those areas where the goals should be targeted. Implications for Rehabilitation Documenting the child's and family's needs in relation to activity and participation preferences is critical to rehabilitation and intervention planning. Goals, based on the child's needs, should be identified in collaboration with all parties involved, and focus on the child's functioning in meaningful everyday activities. The ICF-CY could serve as a framework for the family and professionals to identify needs and to communicate rehabilitation goals.
Disability and Rehabilitation 05/2013; · 1.54 Impact Factor
[show abstract][hide abstract] ABSTRACT: Universal access is one of the major aims in public health and social care. Services should be provided on the basis of individual needs. However, municipal autonomy and the fragmentation of services may jeopardize universal access and lead to variation between municipalities in the delivery of services. This paper aims to identify patient-level characteristics and municipality-level service patterns that may have an influence on the use and costs of health and social services of frail elderly patients.
Hierarchical analysis was applied to estimate the effects of patient and municipality-level variables on services utilization.
The variation in the use of health care services was entirely due to patient-related variables, whereas in the social services, 9% of the variation was explained by the municipality-level and 91% by the patient-level characteristics. Health-related quality of life explained a major part of variation in the costs of health care services. Those who had reported improvement in their health status during the preceding year were more frequent users of social care services. Low informal support, poor functional status and poor instrumental activities of daily living, living at a residential home, and living alone were associated with higher social services expenditure.
The results of this study showed municipality-level variation in the utilization of social services, whereas health care services provided for frail elderly people seem to be highly equitable across municipalities. Another important finding was that the utilization of social and health services were connected. Those who reported improvement in their health status during the preceding year were more frequently also using social services. This result suggests that if municipalities continue to limit the provision of support services only for those who are in the highest need, this saving in the social sector may, in the long run, result in increased costs of health care.
BMC Health Services Research 07/2012; 12:204. · 1.77 Impact Factor
[show abstract][hide abstract] ABSTRACT: The aim of this study was to identify and characterize studies that have used quality-adjusted life-years (QALYs) based on measurements of patients' health-related quality of life (HRQoL) as an indicator of effectiveness of screening programs.
Systematic search of the literature until March 2010, using several electronic databases. Initial screening of articles based on abstracts, and evaluation of full-text articles were done by at least two of the authors.
The search identified 1,610 articles. Based on review of abstracts, 431 full-text articles were obtained for closer inspection and, of these, 81 reported QALYs based on patient-derived data using a valid HRQoL assessment. The most frequently used method to assess HRQoL was Time Trade-Off (55 percent) followed by EQ-5D (26 percent). The most frequently studied medical conditions were malignant diseases (23 percent) followed by cardiovascular diseases (19 percent). All studies employed some kind of modeling with the Markov model being the most prevalent type (65 percent). Majority of the articles (59 percent) concluded that the screening program studied was cost-effective.
The use of QALYs in the evaluation of screening programs has expanded during the last few years. However, only a minority of studies have used HRQoL data derived from patients, using direct or indirect valuation. Further investigation and harmonization of the methodology in evaluation of screening programs is needed to ensure better comparability across different screening programs.
International Journal of Technology Assessment in Health Care 04/2012; 28(2):145-51. · 1.55 Impact Factor
[show abstract][hide abstract] ABSTRACT: To study the relations between postnatal maternal morbidity, child morbidity and welfare interventions in families with prenatal alcohol or substance abuse.
A register-based longitudinal retrospective cohort study. The exposed cohort included 638 children born to 524 women followed-up during pregnancy for alcohol or substance abuse 1992-2001. Non-exposed children (n = 1914) born to control women were matched for maternal age, parity, number of foetuses, month of birth and delivery hospital of the index child. Perinatal and follow-up data of both cohorts were collected from national registers until 2007.
Postnatal maternal abuse-related healthcare utilization and use of medication were associated with child out-of-home care. Significant differences were in particular observed in the categories of maternal mental and behavioural disorders caused by psychoactive substance use as well as injury and poisoning. Maternal inpatient care for mental and behavioural disorders peaked at the time of child out-of-home care. Maternal abuse-related healthcare utilization was associated with early child healthcare utilization and use of medication for mental and behavioural disorders. These associations were largely explained by the association with child out-of-home care.
Postnatal maternal abuse-related morbidity is associated with significant early child morbidity, use of medication and timing of out-of-home care.
[show abstract][hide abstract] ABSTRACT: BACKGROUND: Previous studies indicate an association between tobacco smoking and infectious diseases. However, large population-based follow-up studies including both accurate measurements of smoking behaviour and confounders and a reliable register-based follow-up of infections are lacking. OBJECTIVE: To examine the effect of smoking on use of antibacterials as an indicator of infections among working-aged population. METHODS: The participants of the population-based Health and Social Support Study (24 283 working-aged Finns) were followed up for 9 years. Information on smoking behaviour and confounders was obtained from a questionnaire in 1998. Number of antibacterial purchases was obtained from the National-Drug-Prescription-Register. The association between smoking and use of antibacterials was analysed using multinomial regression models. RESULTS: A graded association between lifetime smoking as measured by pack-years and use of antibacterials was found. Compared with never-smokers, the age-adjusted OR for multiple use of antibacterials among smokers with 12 or more pack-years was 2.32 (95% CI 1.91 to 2.82) in women and 1.45 (95% CI 1.23 to 1.71) in men. The associations remained after adjustment for the following confounding factors: use of alcohol, body mass index, physical activity, socioeconomic status, hard physical work, life satisfaction, disability pension and dyspnoea. CONCLUSIONS: Smoking is associated with increased use of antibacterials. Infectious periods experienced by patients should be used as an opportunity to encourage smoking cessation.
[show abstract][hide abstract] ABSTRACT: Objective: To explore the types of procedures and practices in rehabilitation planning for children with cerebral palsy and how multidisciplinary team members experience them. Design, subjects, and setting: A qualitative research approach was used. Participants were members of multidisciplinary teams in neuropediatric wards at five university hospitals. Methods: In order to explore the rehabilitation planning procedure within multidisciplinary teams, focus group interviews were conducted. The interviews were tape recorded and transcribed. Three content areas guided the interviews: goal setting, the different transition phases, and the use of the International Classification of Functioning, Disability and Health, Child and Youth version (ICF-CY). Qualitative content analysis was used to analyze the results. Results: Three themes arose from the focus group discussions; challenging goal setting, transition without routines, and ICF-CY not in use. A family-centered service model had been adopted, but there was no clear procedure in the collaboration with parents. Goal setting was found to be challenging and the concern arose of how to integrate goals into the child's everyday life. There was a lack of systematic planning of the different transition phases. There was also a general variation in the rehabilitation planning procedures due to local and regional differences in practice. The ICF-CY was familiar, but not in formal use in clinical practice. Conclusion: There is a need to enhance the procedures and to systematize coordination of services in the rehabilitation process. The ICF-CY framework might help to optimize collaborative goal setting and to structure both procedures and documentation of the rehabilitation plans and goals.
Journal of pediatric rehabilitation medicine 01/2012; 5(3):203-15.
[show abstract][hide abstract] ABSTRACT: In order to best meet the needs of both families and their children with cerebral palsy, many rehabilitation service providers have adopted a family-centred service (FCS) approach. In FCS parents are seen as experts on their child's needs, and the family and professionals collaborate in the rehabilitation process. However, parents and service providers might look at FCS from different points of view, i.e. look into the mirror from two different sides. The objective of this study was to explore the degree to which parents experience the service as being family-centred and to which extent the service providers experience their service provision as family-centred.
A translated version of The Measure of Processes of Care 20 (MPOC-20) questionnaire was used to evaluate parents' experience of FCS, and a Measures of Processes of Care for Service Providers (MPOC-SP) questionnaire was used to evaluate the FCS provided by professionals. Parents visiting two university hospital neuropediatric wards (n= 67) during a 2-month period and who were willing to participate received the questionnaire. Also the service providers working on the same wards (n= 49) were invited to participate.
A total of 53 families and 29 service providers completed the questionnaires. Both parents and professionals generally rated the FCS positively. General information was rated lowest and respectful treatment the highest by both parents and professionals. The results revealed that written information about the child's condition, the possibility to choose when to receive information, and contact with other families in the same situation are areas in need of improvement.
The possibility to regularly evaluate services both from the families' and the professionals' perspectives should be part of quality development. Providing general information is a challenge for all service providers. The MPOC questionnaires can be used to highlight important areas of improvement in FCS.
Child Care Health and Development 09/2011; 38(1):79-86. · 1.70 Impact Factor
[show abstract][hide abstract] ABSTRACT: To examine risk and protective factors associated with behavioural problems of children and adolescents following prenatal alcohol exposure.
A total of 73 children and adolescents with foetal alcohol spectrum disorders (FASD) were assessed for internalizing, externalizing and total behavioural problems using the Child Behavior Checklist. Linear regression models were used to determine the effects of diagnostic and environmental risk and protective factors on behaviour, while controlling for age, sex and IQ.
Length of time spent in residential care was the most pervasive risk factor associated with internalizing, externalizing and total behavioural problems. A low dysmorphology score was related to more internalizing and total problems.
Children and adolescents prenatally exposed to alcohol faced greater risk of substantive behavioural problems (i) if they were less visibly alcohol affected and (ii) the longer time they had spent in residential care. The results underscore the clinical importance of appropriate services and care for less visibly affected children with FASD and highlight the need to attend to children with FASD being raised in institutions.
[show abstract][hide abstract] ABSTRACT: Early childhood healthcare utilization, mortality and welfare interventions were studied among children of mothers with identified gestational alcohol and/or substance abuse.
Register-based retrospective cohort study. The exposed cohort consisted of 638 children born to 524 women followed up antenatally 1992-2001 at special outpatient clinics in the capital area of Finland. Nonexposed children (n = 1914) born to control women were matched for maternal age, parity, number of foetuses, month of birth and delivery hospital of the index child. Postnatal data of both cohorts were collected from national registers until 2007.
The exposed cohort displayed twice the amount of in- and outpatient hospital care episodes compared with nonexposed children. Differences attributable to exposure were found in categories of conditions originating in the perinatal period, mental and behavioural disorders, and nonspecific factors influencing health status and contact with health services. This was reflected in amounts of reimbursements for drugs of the central nervous system, as well as special care allowances and rehabilitation for mental and behavioural disorders. The highest degree of healthcare utilization was observed among exposed children placed in out-of-home care. One-third of these children received outpatient care and one-tenth required inpatient care for a mental and behavioural disorder. No significant differences were found in early mortality.
The exposed children displayed significant neonatal and early mental and behavioural healthcare utilization, and need for significant psychosocial support during their first decade of life.
[show abstract][hide abstract] ABSTRACT: Children with cerebral palsy have difficulties in several areas of functioning, and they need long-lasting rehabilitation with a clear focus on the individual's needs. Finnish guidelines emphasize family-centred service. The values of family-centred service are widely known, but how the principles of family-centred service are adopted in clinical practice is not well documented. The objective of this study was to analyse the family-centred behaviour of professionals working with children and adolescents with cerebral palsy.
A translated version of the Measure of Processes of Care for Service Providers (MPOC-SP) questionnaire was used to evaluate the family-centred service. The questionnaire was sent to all the professionals in the multidisciplinary rehabilitation teams at all the hospitals and governmental special schools treating children and adolescents with cerebral palsy in Finland (n= 327). Furthermore, 438 physiotherapy service providers working in the children's home region were invited to participate.
A total of 201 multidisciplinary team members and 311 physiotherapy service providers completed the questionnaire. Both the team members and the service providers generally rated their family-centred behaviour positively. There was statistically significant difference in how the team members in the multidisciplinary teams self-assessed their family-centred service. Physiotherapists working in multidisciplinary teams rated their family-centred service higher than physiotherapy service providers. The professional's apprehension of family-centred service increased with work experience.
Professional background and professional context seem to affect the apprehension of family-centred service. Also work experience and being part of a multidisciplinary team have an influence on how the professionals embrace the family-centred service delivered. The MPOC-SP can be used to identify areas for improvement.
Child Care Health and Development 03/2011; 38(1):70-8. · 1.70 Impact Factor
[show abstract][hide abstract] ABSTRACT: No previous studies on the association of smoking behaviour with disability retirement due to register verified chronic obstructive pulmonary disease (COPD) exist. This 30-yr follow-up study examined how strongly aspects of cigarette smoking predict disability retirement due to COPD. The study population consisted of 24,043 adult Finnish twins (49.7% females) followed from 1975 to 2004. At baseline the participants had responded to a questionnaire. Information on retirement was obtained from the Finnish pension registers. Smoking strongly predicted disability retirement due to COPD. In comparison to never-smokers, age adjusted hazard ratio (HR) for current smokers was 22.0 (95% CI 10.0-48.5) and for smokers with ≥ 12 pack-yrs was 27.3 (95% CI 12.6-59.5). Similar estimates of risk were observed in within-pair analyses of twin pairs discordant for disability retirement due to COPD. Among discordant monozygotic pairs those with disability pension due to COPD were more often current smokers. The effect of early smoking onset (< 18 yrs) on the risk of disability retirement due to COPD remained after adjustment for the amount smoked (HR 1.70, 95% CI 1.08-2.68). Smoking strongly predicts disability retirement due to COPD. Preventive measures against disability retirement and other harmful consequences of tobacco smoking should receive greater emphasis.
European Respiratory Journal 01/2011; 37(1):26-31. · 6.36 Impact Factor
[show abstract][hide abstract] ABSTRACT: Cost-effectiveness of a geriatric rehabilitation programme.
Economic evaluation alongside a randomized controlled trial.
A total of 741 subjects with progressively decreasing functional ability and unspecific morbidity were randomly assigned to either an inpatient rehabilitation programme (intervention group) or standard care (control group). The difference between the mean cost per person for 12 months' care in the rehabilitation and control groups (incremental cost) and the ratio between incremental cost and effectiveness were calculated. Clinical outcomes were functional ability (Functional Independence Measure (FIM(TM))) and health-related quality of life (15D score).
The FIM(TM) score decreased by 3.41 (standard deviation 6.7) points in intervention group and 4.35 (standard deviation 8.0) in control group (p = 0.0987). The decrease in the 15D was equal in both groups. The mean incremental cost of adding rehabilitation to standard care was 3111 euros per person. The incremental cost-effectiveness ratio for FIMTM did not show any clinically significant change, and the rehabilitation was more costly than standard care. A cost-effectiveness acceptability curve suggests that if decision-makers were willing to pay 4000 euros for a 1-point improvement in FIMTM, the rehabilitation would be cost-effective with 70% certainty.
The rehabilitation programme was not cost-effective compared with standard care, and further development of outpatient protocols may be advisable.
Journal of rehabilitation medicine: official journal of the UEMS European Board of Physical and Rehabilitation Medicine 11/2010; 42(10):949-55. · 1.88 Impact Factor
[show abstract][hide abstract] ABSTRACT: A register-based retrospective case-control study to investigate the long-term morbidity, mortality, and welfare among women with alcohol and/or substance misuse identified during pregnancy.
Cohort of 524 women followed-up ante- and perinatally 1992-2001 at special out-patient clinics of maternity hospitals in the capital area of Finland. The control group of 1792 women with no evidence of alcohol or substance misuse was matched for maternal age, parity, date of birth and hospital of index delivery. Both groups were followed-up until end of 2007.
7.9% (42/524) of the cases and 0.2% (4/1792) of the controls had died by the end of the median follow-up of 9 years (OR 38, 95% CI 14-108). The cases displayed significant morbidity requiring in-patient care in the areas of mental disorders (AOR 8.8, 95% CI 6.5-11.9), viral (AOR 23.5, 95% CI 8.8-62.7) and bacterial (AOR 6.1, 95% CI 3.5-10.4) infections, skin diseases (AOR 3.9, 95% CI 2.0-7.8) and injury and poisoning (AOR 4.2, 95% CI 3.1-5.6). The cases displayed more out-patient visits (OR 2.7, 95% CI 2.7-2.8). Their mean length of hospital stay was longer compared to controls (10.3 vs. 4.4 days, p<0.001). The risk of pension granted due to a disorder, disease or disability (OR 8.8, 95% CI 6.0-13.0) and the risk for minimum unemployment benefit were higher compared to controls (OR 2.1, 95% CI 1.8-2.5).
These women display significant long-term morbidity, mortality and loss of productivity after delivery. The results emphasize the importance of adequate postnatal follow-up and treatment for misuse.
Drug and alcohol dependence 10/2010; 111(3):215-21. · 3.60 Impact Factor
[show abstract][hide abstract] ABSTRACT: To identify evidence evaluating the effectiveness of physiotherapy in adolescents (>16 years of age) and adults with cerebral palsy.
Systematic literature search from the earliest available time until March 2009. Additional studies were identified through reference and citation tracking.
Two reviewers independently agreed on eligibility, methodological quality and quality of evidence assessment. Standard methods were used for quality assessments.
Included were 13 studies, two of which were randomized controlled trials. No article met the criteria for high methodological quality. Evidence of moderate quality was found on gait after strength training. Evidence of low quality was found on balance after strength training and workstation interventions. Low-quality evidence was also found on functionality after strength training in four studies evaluating gross motor capacity. There was very low-quality evidence on increased muscle strength and in outcome measures used to evaluate range of motion.
Evidence for the effect of physiotherapy on adolescents and adults with cerebral palsy is sparse, and therefore there is an urgent need for well-designed physiotherapeutic trials for these people.
[show abstract][hide abstract] ABSTRACT: A primary goal of recent research is the development of neurobehavioral profiles that specifically define fetal alcohol spectrum disorders (FASD), which may assist differential diagnosis or improve treatment. In the current study, we define a preliminary profile using neuropsychological data from a multisite study.
Data were collected using a broad neurobehavioral protocol from 2 sites of a multisite study of FASD. Subjects were children with heavy prenatal alcohol exposure and unexposed controls. The alcohol-exposed group included children with and without fetal alcohol syndrome (FAS). From 547 neuropsychological variables, 22 variables were selected for analysis based on their ability to distinguish children with heavy prenatal alcohol exposure from nonexposed controls. These data were analyzed using latent profile analysis (LPA).
The results indicated that a 2-class model best fit the data. The resulting profile was successful at distinguishing subjects with FAS from nonexposed controls without FAS with 92% overall accuracy; 87.8% of FAS cases and 95.7% of controls were correctly classified. The same analysis was repeated with children with heavy prenatal alcohol exposure but without FAS and nonexposed controls with similar results. The overall accuracy was 84.7%; 68.4% of alcohol-exposed cases and 95% of controls were correctly classified. In both analyses, the profile based on neuropsychological variables was more successful at distinguishing the groups than was IQ alone.
We used data from 2 sites of a multisite study and a broad neuropsychological test battery to determine a profile that could be used to accurately identify children affected by prenatal alcohol exposure. Results indicated that measures of executive function and spatial processing are especially sensitive to prenatal alcohol exposure.
Alcoholism Clinical and Experimental Research 09/2010; 34(9):1640-50. · 3.42 Impact Factor
[show abstract][hide abstract] ABSTRACT: The Collaborative Initiative on Fetal Alcohol Spectrum Disorders (CIFASD) was created in 2003 to further understanding of fetal alcohol spectrum disorders. Clinical and basic science projects collect data across multiple sites using standardized methodology. This article describes the methodology being used by the clinical projects that pertain to assessment of children and adolescents. Domains being addressed are dysmorphology, neurobehavior, 3-D facial imaging, and brain imaging.
[show abstract][hide abstract] ABSTRACT: Directional asymmetry, the systematic differences between the left and right body sides, is widespread in human populations. Changes in directional asymmetry are associated with various disorders that affect craniofacial development. Because facial dysmorphology is a key criterion for diagnosing fetal alcohol syndrome (FAS), the question arises whether in utero alcohol exposure alters directional asymmetry in the face. Data on the relative position of 17 morphologic landmarks were obtained from facial scans of children who were classified as either FAS or control. Shape data obtained from the landmarks were analyzed with the methods of geometric morphometrics. Our analyses showed significant directional asymmetry of facial shape, consisting primarily of a shift of midline landmarks to the right and a displacement of the landmarks around the eyes to the left. The asymmetry of FAS and control groups differed significantly and average directional asymmetry was increased in those individuals exposed to alcohol in utero. These results suggest that the developmental consequences of fetal alcohol exposure affect a wide range of craniofacial features in addition to those generally recognized and used for diagnosis of FAS.