Demand for Use of Hospital and
Long-term Residential Care Services
in Relation to Proximity to Death
among Older People in Finland
Mike Murphy, London School of Economics
Pekka Martikainen, University of Helsinki
Prepared for Experts' Seminar on Ageing and
Long-Term Care Needs London School of
Economics, Friday 20 May 2011
Number of people projected to live to
age 100, United Kingdom
Males
Age in
2010
Total aged
under 100
Number
Population to reach
in 2010 age 100
(000s)
(000s)
Females
Proportion Population
reaching
in 2010
100 (%)
(000s)
Number
to reach
age 100
(000s)
Proportion
reaching
100 (%)
30,607
4,441
14.5%
31,604
6,315
20.0%
0-15
5,926
1,359
22.9%
5,649
1,720
30.4%
16-50
15,025
2,272
15.1%
14,884
3,197
21.5%
51-65
5,444
512
9.4%
5,654
818
14.5%
66-99
4,211
299
7.1%
5,416
579
10.7%
Table 1, Department for Work and Pensions, Ed Price (ed.price@dwp.gsi.gov.uk),
Number of Future Centenarians, December 2010
Projections of National Long-term Care
Expenditures for the Elderly: US
Year
Billion Dollars (2000 levels)
2000
123
2020
207
2030
295
2040
346
Source: "Projections of expenditures for long-term care services for the elderly," CBO 1999.
Future demand for long-term care in the
UK: Summary of projections of longterm care finance for older people to
2051
Long-term care expenditure in the UK would
need to rise by around 317 per cent in real
terms between 2000 and 2051 to meet
demographic pressures and allow for real
rises in care costs of 1 per cent per year for
social care and 1.5 per cent per year for
health care (central base case assumptions £12.9 billion to £53.9 billion). (Wittenberg et al Sept
2004)
The Background: e.g.
Wanless
• People’s health care needs are higher as they
approach death.
o Acute health care costs are strongly associated with proximity to death.
o More than a quarter of all acute health care costs are incurred in the last
year of life
• Part of older age groups’ higher cost reflects the
greater number of people close to death as well
as age related health care needs.
• Demographic changes have had less of an
impact on health spending than often thought as
proximity to death has a larger impact on health
care costs than age.
The Background: (contd)
• The costs of acute care are strongly associated with
proximity to death, regardless of age at death, i.e.
health costs for older people are higher mainly
because they are closer to death.
• Analysis of demographic pressures that ignores
specific costs in the last year of life (i.e. the costs of
death) risks overstating its impact. So, need to
consider people in their last year of life (decedents)
and those not (survivors)
• Social care costs increase with proximity to death,
but also increase with age.
(Wanless Chapter 3 p 43)
Wanless (p. 21)
• “It is therefore possible that the effect of an
ageing population will be to postpone rather than
increase health service costs. Previous studies
have suggested that demographic change will
add less than 1 per cent a year to costs. If
ageing postpones costs the impact on costs
could be lower.” BUT the evidence suggests that
the need for social care services rises sharply
with age. (McGrail et al 2000)
• Need to consider all use of services in relation to
age, proximity to death & other factors
Background to long-term
institutional care
• LTC c. 1.5% of GDP in OECD countries 2008
(http://www.oecd.org/dataoecd/31/8/46458681.xls
>3% Sweden & Netherlands)
• With population ageing the demand and costs of
long-term care are expected to grow rapidly
• At the proximate level entry to institutions is
determined by health and cognitive and physical
functional status, but distal socio-demographic
factors are also important
Total expenditures (Hoover et
al US$)
65-74
75-84
85+
Non-terminal
year
5719
7832
13895
Last year of life
37043
38529
36985
“As Chart 2.7 shows, the cost of the
last year of life does not rise with
age; if anything, it appears to fall.”
Average HRG costs for decedents and survivors (all population)
8000
7000
Survivors
Costs(£s)
6000
Decedents
5000
4000
3000
2000
1000
88
85
82
79
76
73
70
67
64
61
58
55
52
49
46
43
40
0
Age (years)
Graham, B & Normand, C (2001) Proximity to death and acute health care utilisation in Scotland.
Demographic change and health
service and social care use
• Although having clear implications for patients’
quality of life, care costs and mix, and clinicians’
end-of-life care decisions, few studies investigating
the contribution of age and proximity to death to
service use have:
o Looked simultaneously at health and social care
use
o Included socio-demographic information
o Assessed the impact of changing patterns of
disease and cause of death
Annual number of deaths, EU−27
(000s)
Data & Methods
• Few countries have good data on LTC (and sometimes
on joint use of community and hospital facilities –
incompatible record systems, confidentiality issues
regarding linkage of records etc)
• Some countries have good integrated longitudinal record
systems such as Finland
Data source
• A 40 % random sample of the Finnish population aged
65 and older at the end of 1997 drawn from population
registers with information on socio-demographic factors
at baseline was followed to death by cause in 1998–
2003 or to the end of 2003. The use of hospital and longterm institutional care was assessed in 1995–2003 up to
seven years prior to death or end of follow-up.
• The outcome measure is days spent in hospital/long
term care (not costs)
Study data (40% sample of those 65+)
STAKES
Institutional care:
Care episodes
Date of entry
Date of exit
Type of institution
STAKES
Sociodemographic
factors:
Sex
Marital status
Living
arrangements
Education
Social class
Income
Housing
Partner
Region
Date/cause of
death
Statistics
Finland
Use of homecare
services
STAKES
Supply of care:
Regional coverage of
institutional care
Health:
Medication
Hospital
discharge
STAKES
Pension
institute
Definitions of long-term
institutional care & hospital care
• Days in long-term care includes days spent in nursing
homes, service homes with 24-hour assistance, and
rehabilitation care (lasting for over 90 days or confirmed
by a long-term care decision).
• Hospital care refers to days spent in either a hospital or
a health centre, and included both overnight stays and
day surgery.
• Total care refers to the sum of the two groups above.
Average Number of Days in Hospital/LTC, by Sex
& Survival status Finland
Average Number of Days in Hospital/LTC by
Marital Status, Finland
Age-adjusted average number of hospital, long-term & total
care days in the each of the previous seven years by
survival status and sex
Age-adjusted average number of hospital, long-term and total
care days in the previous seven years before death by cause
of death and sex
Age-adjusted average number of total care days in
the previous seven years before death from
dementia
Total care, men
Total care, women
250
250
200
200
Days
Days
150
100
50
150
100
50
0
1
2
3
4
5
6
7
Year before death / end of follow-up
Kuolleet, naimattomat
Deceased, married
Deceased, non-married
0
1
2
3
4
5
6
Year before death / end of follow-up
Kuolleet,
avioliitossaSurvivors, married
Survivors,
non-married
7
Summary of key results
• Use of residential long term care increases more with
age than for hospital stays
• For the “young old”, decedents use much more hospital
care than survivors
• For the “old old” differences are less
• For long term care, the difference at any age between
decedents and survivors is less than for hospital use, but
still substantial
Socio-economic
differentials
• Education, social class etc are generally
small at any age
• Differential survival is more important
• Lifetime experiences differ
Marital status differentials
• Marital status differentials are more substantial
than educational ones
• Marriage provides more protection for men than
for women
• Differentials are smaller for decedents than for
survivors
Cause-specific mortality
differentials
• Dementia is associated with particularly
substantial use of care services (even
after age-adjustment)
• Cancers are is associated with lower use
of care services
Percentage of people using social care
and inpatient care in the last months of
life (N=16,479)
Figure 6a in Martin Bardsley, Theo Georghiou, Jennifer Dixon (2010)
Social care and hospital use at the end of life www.nuffieldtrust.org.uk/publications
Monthly costs per user in
last 12 months of life
Figure 6b in Martin Bardsley, Theo Georghiou, Jennifer Dixon (2010)
Social care and hospital use at the end of life www.nuffieldtrust.org.uk/publications
Average cost per person in last
12 months of life by age group
Figure 8 in Martin Bardsley, Theo Georghiou, Jennifer Dixon (2010)
Social care and hospital use at the end of life www.nuffieldtrust.org.uk/publications
authority‐funded social care in the months
before death by site
Figure 28 in Martin Bardsley, Theo Georghiou, Jennifer Dixon (2010)
Social care and hospital use at the end of life www.nuffieldtrust.org.uk/publications
Summary
• Proximity to death is important for acute care, but
age is more important for long-term care
o cost saving similar to those expected for acute care can not be obtained
for LTC in the coming decades
• Socio-economic differentials in long-term care use
(e.g. by education level) are relatively modest
• Marital status differentials are more substantial and
future changes in marital status distributions may be
important for future projections of elderly use of
health and social services.
Summary continued …
• The population will age considerably in
future decades, especially for the oldestold from about 25 years time, & other
things being equal:
o increasing longevity coupled with a rising trend of dementia
is likely to mean a major shift towards higher nursing home
care use in the future
o the optimistic view that needs may not increase in line with
numbers of older people because of the “proximity to death”
effect will not occur since the implied additional long-term
care needs (bed days in our case) overwhelm these
o LTC needs likely to grow more quickly than acute care
needs for older people
o More need to consider interfaces between
• long-term and acute care
• institutional and community care .