It is well known that older people use more health and social services than younger people, but the exact determinants of service use still remain unclear. More information is needed on whether the high use of services among older people is associated with their high age or the closeness of death, for instance. The aim of this study was to shed light on health and social service use among older people living their last two years of life and among controls who lived longer. Special consideration was given to how age, closeness of death, municipality of residence and dementia diagnosis are associated with service use and to how service use in the last two years of life has changed from 1996 to 2003.
The services in focus were (1) hospital inpatient care (2) long-term institutional care (3) regular home care (at least once a week) and (4) use of prescribed medicines. Hospital care included care provided at university hospitals, general hospitals (central, district and private) and health centre inpatient wards if length of stay was less than 90 days. Long-term care included care in residential homes for older people, sheltered housing with 24-hour assistance and health centre inpatient wards if length of stay was 90 days or over. The analysis determined the probability of using each of the services in the two-year study period and the number of days in care.
The data were derived from registers of Statistics Finland, National Institute for Health and Welfare and Social Insurance Institute. The study population consisted of all persons in Finland who died in 1998, 2002 or 2003 at the age of 70 years or over and a 40% random sample of those who died in 1999-2001 at the age of 70 years or over. The total population numbered 145,944 persons. For decedents who died in 1998-2000, a matched control was selected who lived at least two years longer. There were 56,001 case-control pairs, matched for age, gender and municipality of residence.
Closeness of death was a strong determinant of hospital and long-term care use. In all age groups decedents used these services more often than their matched survived controls. The difference between decedents and survivors was smaller in older than younger age groups. Age was also an important determinant of service use. Younger people used hospital care more often than older people, but older people used long-term care more often.
Overall hospital use varied between municipalities and hospital districts less than the use of different types of hospital. Use of university hospital varied most, and there was also much variation in the use of general hospital services. The use of long-term care and home care did not vary between hospital districts. Municipal differences in the use of home care services were greater than in the use of long-term institutional care. The proportion of service users varied more than the number of days in care among users. Municipal level variables did not explain much of the differences.
Older people with a dementia diagnosis were more than nine times more likely to use long-term care than people without a dementia diagnosis. The use of hospital care, on the other hand, was more common among older people without dementia, even when comorbidity was adjusted for. Among users the number of days in care was higher for people with a dementia diagnosis. The use of university hospital and long-term care increased during the study period from 1996 to 2003, while the use of general hospital and home care decreased. The number of days in care increased on health centre inpatient wards and in long-term care, but decreased in general hospitals.
In conclusion, closeness of death is an important determinant of health and social service use among older people. However, the effect of closeness of death varies with age and between different services. Age also has an impact on service use among older people at the end of life. Further research is needed to determine whether older people living in different municipalities as well as those with and without a dementia diagnosis have equal access to care.
