Does improved survival lead to a more fragile population: time trends in second and third hospital admissions among men and women above the age of 60 in Sweden

Rethinking morbidity compression

Studies of morbidity compression routinely report the average number of years spent in an unhealthy state but do not report variation in age at morbidity onset. Variation was highlighted by Fries (1980) as crucial for identifying disease postponement. Using incidence of first hospitalization after age 60, as one working example, we estimate variation in morbidity onset over a 27-year period in Denmark. Annual estimates of first hospitalization and the population at risk for 1987 to 2014 were identified using population-based registers. Sex-specific life tables were constructed, and the average age, the threshold age, and the coefficient of variation in age at first hospitalization were calculated. On average, first admissions lasting two or more days shifted towards older ages between 1987 and 2014. The average age at hospitalization increased from 67.8 years (95% CI 67.7-67.9) to 69.5 years (95% CI 69.4-69.6) in men, and 69.1 (95% CI 69.1-69.2) to 70.5 years (95% CI 70.4-70.6) in women. Variation in age at first admission increased slightly as the coefficient of variation increased from 9.1 (95% CI 9.0-9.1) to 9.9% (95% CI 9.8-10.0) among men, and from 10.3% (95% CI 10.2-10.4) to 10.6% (95% CI 10.5-10.6) among women. Our results suggest populations are ageing with better health today than in the past, but experience increasing diversity in healthy ageing. Pensions, social care, and health services will have to adapt to increasingly heterogeneous ageing populations, a phenomenon that average measures of morbidity do not capture.

Thirty-year trends in dementia: a nationwide population study of Swedish inpatient records

Background

The continuous growth of the current dementia epidemic is contingent on the stability of age- and sex-specific trends over time. However, recent evidence suggests declining or stable trends. The aim of this study was to evaluate the real-world changes in the burden of dementia in older adults in Sweden from 1987 to 2016 by estimating age- and sex-specific incidence of dementia diagnosis in hospital inpatient records (dementia incidence). Differences in trends by sex, age, and educational levels were also examined.

Methods

The entire Swedish population aged 65 years and older was followed up from 1987 to 2016. Age-, sex-, and education-stratified dementia incidence rates for every follow-up year were estimated using the National Patient Register. Hazard ratio of receiving a dementia diagnosis in the inpatient records per 1 calendar year increase was estimated with discrete time logistic models with a complementary log–log link.

Results

After increase, especially in those >85 years of age, dementia incidence started to decrease in the last 5 years of the study period. After 2011, 1 calendar year increase was associated with lower hazard ratio of receiving a hospital diagnosis of dementia. The decrease had the highest magnitude in 70–74-year-olds (−5.5%), followed by 75–79-year-olds (−4.5%) and 80–84-year-olds (−4.0%). The decrease was present in both sexes and at all educational levels up to 90 years of age. Age was associated with the level of dementia incidence, and the trends differed by age group. Educational gradient was observed. University-educated older adults had the lowest rates of dementia. However, the trend over time did not substantially differ by sex or educational level.

Conclusion

Our results provide more evidence that dementia incidence may be declining. They also suggest that at least in hospitals, the number of new patients with dementia may decrease in the future.

Sex differences in the 1-year risk of dying following all-cause and cause-specific hospital admission after age 50 in comparison with a general and non-hospitalised population: a register-based cohort study of the Danish population

OBJECTIVES

We examine the mortality of men and women within the first year after all-cause and cause-specific hospital admission to investigate whether the sex differences in mortality after hospitalisation are higher than in the corresponding general and non-hospitalised population.

DESIGN

This is a population-based, longitudinal study with nationwide coverage. The study population was identified by linking the National Patient Register with the Central Population Register using a 5% random sample of the Danish population.

SETTING

The population born between 1898 and 1961, who was alive and residing in Denmark after 1977, was followed up between 1977 and 2011 with respect to hospital admissions and mortality while aged 50-79.

PRIMARY OUTCOME MEASURES

The absolute sex differences in the 1-year risk of dying after all-cause and cause-specific hospital admission. The hospitalised population sex differentials were then compared with the sex differences in a general and a non-hospitalised population, randomly matched by age, sex and hospitalisation status.

RESULTS

The risk of dying was consistently higher for hospitalised men and women. At all ages, the absolute sex differences in mortality were largest in the hospitalised population, were smaller in the general population and were smallest in the non-hospitalised population. This pattern was consistent across all-cause admissions, and with respect to admissions for neoplasms, circulatory diseases and respiratory diseases. For all-cause hospital admissions, absolute sex differences in the 1-year risk of dying resulted in 43.8 excess male deaths per 1,000 individuals within the age range 50-79, while the levels were lower in the general and the non-hospitalised population, at levels of 13.5 and 6.6, respectively.

CONCLUSIONS

This study indicates a larger male disadvantage in mortality following hospitalisation, pointing towards an association between the health status of a population and the magnitude of the female advantage in mortality.

Recent hip fracture trends in Sweden and Denmark with age-period-cohort effects

This study used nationwide hip fracture data from Denmark and Sweden during 1987-2010 to examine effects of (birth) cohort and period. We found that time trends, cohort, and period effects were different in the two countries. Results also indicated that hip fracture rates may increase in the not so far future.

INTRODUCTION

The reasons for the downturn in hip fracture rates remain largely unclear but circumstances earlier in life seem important.

METHODS

We ascertained hip fractures in the populations ≥50 years in Denmark and Sweden in national discharge registers. Country- and sex-specific age-period-cohort (APC) effects during 1987-2010 were evaluated by log-likelihood estimates in Poisson regression models presented as incidence rate ratios (IRR).

RESULTS

There were 399,596 hip fractures in SE and 248,773 in DK. Age-standardized hip fracture rate was stable in SE men but decreased in SE women and in DK. Combined period + cohort effects were generally stronger in SE than DK and in women than men. IRR per period ranged from 1.05 to 1.30 in SE and 0.95 to 1.21 in DK. IRR per birth cohort ranged from 1.07 to 3.13 in SE and 0.77 to 1.67 in DK. Relative period effects decreased with successive period in SE and described a convex curve in DK. Relative cohort effects increased with successive birth cohort in both countries but with lower risks for DK women and men and SE women born around the 1930s (age 75-86 years today and responsible for most hip fractures) partly explaining the recent downturn. Men and women born thereafter however seem to have a higher hip fracture risk, and we expect a reversal of the present decline in rates, with increasing hip fracture rates in both Denmark and Sweden during the upcoming decade.

CONCLUSIONS

Time trends, cohort, and period effects were different in SE and DK. This may reflect differences in general health as evident in known differences in life expectancy, healthcare organization, and prevention such as use of anti-osteoporosis drugs. Analyses indicate that hip fracture rates may increase in the not so far future.

Trend study on the association between hospital admissions and the health of Dutch older adults (1995-2009)

OBJECTIVES

An increase in hospital admission rates in older people may reflect improved access to healthcare, but also declining health trends in the older population. Owing to a lack of individual-level data, the latter possibility has received little attention. The current study examines associations between health status and hospitalisation rates of older adults in the Netherlands.

DESIGN

Observational individual-level data linked to hospital register data.

SETTING

Data from 1995 to 2009 from the nationally representative Longitudinal Aging Study Amsterdam were linked to the Dutch Hospital Discharge Register.

PARTICIPANTS

A total of 5681 observations of 2520 respondents across 4 measurement points (each with a follow-up of 36 months; ages 65-88 years).

OUTCOME MEASURES

The contribution of health, demographic, psychosocial and lifestyle characteristics to time trends in hospitalisation was assessed in multivariate models.

RESULTS

Between 1995 and 2009, the percentage with 1 or more overnight admissions (planned or acute) increased slightly from 38.1% to 39.7%. This was due to an increase in acute admission only (22.2-27.0%). Increased prevalences of chronic diseases, functional limitations and polypharmacy accounted for part of the observed increase in acute admissions. In addition, a more than doubled prevalence of day admissions over time was observed (12.3-28.3%), a trend that was unrelated to changes in individual characteristics.

CONCLUSIONS

This trend study showed a contribution of declines in population health to increases in acute hospital admissions. Since these declines did not provide a full explanation, healthcare reforms and increases in treatment possibilities in this period are likely to have contributed as well.

Does a hospital admission in old age denote the beginning of life with a compromised health-related quality of life? A longitudinal study of men and women aged 65 years and above participating in the Stockholm Public Health Cohort

OBJECTIVES

The objective of this study was to analyse how hospitalisation after the age of 60 affected individuals' health-related quality of life (HRQoL). The main hypothesis was that a hospital admission in old age can be seen as a proxy of ill health and possibly as a health divider, separating life into a healthy and an unhealthy part. The extent to which this is true depends on which disease individuals face and how functional ability and HRQoL are affected.

SETTINGS

This was a longitudinal study, based on an older cohort of individuals who participated in the Stockholm Public Health Cohort (SPHC) survey in 2006; the survey took place in Stockholm, Sweden. Information regarding hospitalisations and deaths, which is available through Swedish administrative registers, was linked to the survey from the National Patient Register and Cause of Death Register.

PARTICIPANTS

2101 individuals, 65+ years old at inclusion, with no previous hospitalisations at baseline (2006), were followed for 4 years until 2010 (end of follow-up).

PRIMARY AND SECONDARY OUTCOME MEASURES

HRQoL was assessed through a utility index derived from the EuroQol 5D questionnaire, at baseline and at 2010. The change in HRQoL after admission(s) to the hospital was estimated as the difference between the 2010 and 2006 levels using linear regression, also considering several covariates.

RESULTS

A single hospitalisation did not reduce individuals' HRQoL, either for men or women. On the other hand, multiple any-cause hospitalisations reduced HRQoL between 3.2% and 6.5%. When looking into hospitalisations for specific causes, such as hip fractures, a decrease in HRQoL was observed as well; however, conclusions regarding this were impeded by the small sample size.

CONCLUSIONS

Hospital admissions in old age may indicate a shift from a healthy life to a life of compromised health when considering their frequency and cause over a period of time.

Four Decades of Educational Inequalities in Hospitalization and Mortality among Older Swedes

BACKGROUND

The inverse association between education and mortality has grown stronger the last decades in many countries. During the same period, gains in life expectancy have been concentrated to older ages; still, old-age mortality is seldom the focus of attention when analyzing trends in the education-mortality gradient. It is further unknown if increased educational inequalities in mortality are preceded by increased inequalities in morbidity of which hospitalization may be a proxy.

METHODS

Using administrative population registers from 1971 and onwards, education-specific annual changes in the risk of death and hospital admission were estimated with complimentary log-log models. These risk changes were supplemented by estimations of the ages at which 25, 50, and 75% of the population had been hospitalized or died (after age 60).

RESULTS

The mortality decline among older people increasingly benefitted the well-educated over the less well-educated. This inequality increase was larger for the younger old, and among men. Educational inequalities in the age of a first hospital admission generally followed the development of growing gaps, but at a slower pace than mortality and inequalities did not increase among the oldest individuals.

CONCLUSIONS

Education continues to be a significant predictor of health and longevity into old age. That the increase in educational inequalities is greater for mortality than for hospital admissions (our proxy of overall morbidity) may reflect that well-educated individuals gradually have obtained more possibilities or resources to survive a disease than less well-educated individuals have the last four decades.

Observations on quality senior health business: success patterns and policy implications

OBJECTIVE

Population ageing is a global issue that affects almost every country. Most ageing researches focused on demand side and studies related to supply side were relatively scarce. This study selected quality enterprises focus on ageing health and analysed their patterns on providing quality services successfully.

DESIGN

Our study selected quality senior health enterprises and explored their success patterns through face-to-face semi-structured in-depth interviews with CEO of each enterprise in 2013.

SETTING

Thirty-three quality senior health enterprises in Taiwan.

PARTICIPANTS

Thirty-three CEO's of enterprises were interviewed individually.

INTERVENTION

None.

MAIN OUTCOME MEASURES

Core values and vision, historical development, organization structure, services/products provided, delivering channels, customer relationships and further development strategies.

RESULTS

Our results indicated success patterns for senior enterprises that there were meeting diversified lifestyles and substitutive needs for the elderly and their caregivers, providing a total solution for actual/virtual integration and flexible one-stop shopping services. We classified these enterprises by used degree of clicks-and-mortar of services and residing situation of the elderly. Industry characteristics and policy implications were summarized.

CONCLUSIONS

Our observations will serve as a primary evidenced base for enterprises developing their senior market, and also for opening dialogue between customers and enterprises to facilitate valuable opportunities for co-creation between the supply and demand sides.

Declining incidence trends for hip fractures have not been accompanied by improvements in lifetime risk or post-fracture survival--A nationwide study of the Swedish population 60 years and older

BACKGROUND

Hip fracture is a common cause of disability and mortality among the elderly. Declining incidence trends have been observed in Sweden. Still, this condition remains a significant public health problem since Sweden has one of the highest incidences worldwide. Yet, no Swedish lifetime risk or survival trends have been presented. By examining how hip fracture incidence, post-fracture survival, as well as lifetime risk have developed between 1995 and 2010 in Sweden, this study aims to establish how the burden hip fractures pose on the elderly changed over time, in order to inform initiatives for improvements of their health.

MATERIAL AND METHODS

The entire Swedish population 60 years-old and above was followed between 1987 and 2010 in the National Patient Register and the Cause of Death Register. Annual age-specific hip fracture cumulative incidence was estimated using hospital admissions for hip fractures. Three-month and one-year survival after the first hip fracture were also estimated. Period life table was used to assess lifetime risk of hip fractures occurring from age 60 and above, and the expected mean age of the first hip fracture.

RESULTS

The age-specific hip fracture incidence decreased between 1995 and 2010 in all ages up to 94 years, on average by 1% per year. The lifetime risk remained almost stable, between 9% and 11% for men, and between 18% and 20% for women. The expected mean age of a first hip fracture increased by 2.5 years for men and by 2.2 years for women. No improvements over time were observed for the 3-month survival for men, while for women a 1% decrease per year was observed. The 1-year survival slightly increased over time for men (0.4% per year) while no improvement was observed for women.

CONCLUSIONS

The age-specific hip fracture incidence has decreased over time. Yet the lifetime risk of a hip fracture has not decreased because life expectancy in the population has increased in parallel. Overall, survival after hip fracture has not improved.