Effect of centralization on geographic accessibility of maternity hospitals in Finland.

BACKGROUND: In the past two decades, the number of maternity hospitals in Finland has been reduced from 42 to 22. Notwithstanding the benefits of centralization for larger units in terms of increased safety, the closures will inevitably impair geographical accessibility of services. METHODS: This study aimed to employ a set of location-allocation methods to assess the potential impact on accessibility, should the number of maternity hospitals be reduced from 22 to 16. Accurate population grid data combined with road network and hospital facilities data is analyzed with three different location-allocation methods: straight, sequential and capacitated p-median. RESULTS: Depending on the method used to assess the impact of further reduction in the number of maternity hospitals, 0.6 to 2.7% of mothers would have more than a two-hour travel time to the nearest maternity hospital, while the corresponding figure is 0.5 in the current situation. The analyses highlight the areas where the number of births is low, but a maternity hospital is still important in terms of accessibility, and the areas where even one unit would be enough to take care of a considerable volume of births. CONCLUSIONS: Even if the reduction in the number of hospitals might not drastically harm accessibility at the level of the entire population, considerable changes in accessibility can occur for clients living close to a maternity hospital facing closure. As different location-allocation analyses can result in different configurations of hospitals, decision-makers should be aware of their differences to ensure adequate accessibility for clients, especially in remote, sparsely populated areas.

Inter-rater reliability of medication error classification in a voluntary patient safety incident reporting system HaiPro in Finland.

BACKGROUND: Medication errors are common in healthcare. Medication error reporting systems can be established for learning from medication errors and risk prone processes, and their data can be analysed and used for improving medication processes in healthcare organisations. However, data reliability testing is crucial to avoid biases in data interpretation and misleading findings informing patient safety improvement. OBJECTIVE: To assess the inter-rater reliability of medication error classifications in a voluntary patient safety incident reporting system (HaiPro) widely used in Finland, and to explore reported medication errors and their contributing factors. METHOD: The data consisted of medication errors (n = 32 592), including near misses, reported by 36 Finnish healthcare organisations in 2007-2009. The reliability of the original classifications was tested by an independent researcher reclassifying a random sample of errors (1%, n = 288) based on narratives. The inter-rater reliability of agreement (κ) of the classifications was calculated to describe the degree of conformity between the researcher and the original data classifiers. Descriptive statistics were used to describe the medication errors. RESULTS: The inter-rater reliability between the researcher and the original data classifiers was acceptable (κ ≥ 0.41) in 11 of 42 (26%) medication error classes. Thus, these errors could be pooled from different healthcare units for the exploration of medication errors at the level of all reporting organisations. Contributing factors were identified in 48% (n = 137) of the medication error narratives in the random sample (n = 288). The most commonly reported errors were dispensing errors (34%, n = 10 906), administration errors 25% (n = 7972), and documentation errors 17% (n = 5641). CONCLUSIONS: The data classified by different classifiers can be pooled for some of the medication error classes. Consistency of the classification and the quality of narratives need improvement, as well as reporting and classification of contributing factors to provide high quality information on medication errors.

Accessibility of tertiary hospitals in Finland: A comparison of administrative and normative catchment areas.

The determination of an appropriate catchment area for a hospital providing highly specialized (i.e. tertiary) health care is typically a trade-off between ensuring adequate client volumes and maintaining reasonable accessibility for all potential clients. This may pose considerable challenges, especially in sparsely inhabited regions. In Finland, tertiary health care is concentrated in five university hospitals, which provide services in their dedicated catchment areas. This study utilizes Geographic Information Systems (GIS), together with grid-based population data and travel-time estimates, to assess the spatial accessibility of these hospitals. The current geographical configuration of the hospitals is compared to a normative assignment, with and without capacity constraints. The aim is to define optimal catchment areas for tertiary hospitals so that their spatial accessibility is as equal as possible. The results indicate that relatively modest improvements can be achieved in accessibility by using normative assignment to determine catchment areas.

High hospital burden in overlap syndrome of asthma and COPD.

BACKGROUND: Overlap syndrome of asthma and chronic obstructive pulmonary disease (COPD) is a common condition, which is not well understood. This study describes the characteristics and hospital impact of patients suffering from this condition. METHODS: The data are comprised of the hospital discharge registry data maintained by National Institute for Health and Welfare [Terveyden ja hyvinvoinnin laitos (THL)] between 1972 and 2009 covering the entire Finnish population (5.35 million inhabitants in 2009). In THL, treatment periods for patients with the primary or secondary diagnosis of asthma or COPD were selected. From that data, patients over 34 years and their treatment periods starting and ending 2000-2009 with a principal or secondary diagnosis of asthma [International Classification of Diseases (ICD) 10: J45-J46] or COPD (ICD 10: J41-J44) were picked up. There were 105 122 such patients who had 343 420 treatment periods altogether. RESULTS: Patients with asthma were younger than patients with COPD and overlap syndrome, while COPD and overlap syndrome patients' age distribution was very similar. Patients with both asthma and COPD had 30.4% of all treatment periods, even though the percentage of all patients in this group was only 16.1%. These patients had an increased number of hospitalisation episodes across all age groups. Average number of treatment periods during 2000-2009 was 2.1 in asthma, 3.4 in COPD and 6.0 in overlap syndrome. Hospital impact of the same period in asthma was 939 900 days in COPD 1 517 308 and 1 000 724 days in overlap syndrome. CONCLUSION: Overlap syndrome of asthma and COPD is a common condition with high hospital impact for patients with this condition.

Effect of smoking on use of antibacterials: a 9-year follow-up study of 24 000 working-aged Finns.

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.

[HaiPro--what was learned from patient safety incidents in Finnish health care units in 2007 to 2009?]. / HaiPro--millaisista vaaratapahtumista terveyden- huollon yksiköissä opittiin vuosina 2007-2009?

Reports of the HaiPro reporting system are described and the role of reporting procedure aiming at internal development of the units and the possibilities of national development and monitoring of patient safety are discussed. The study material consisted of 64,405 reports of patient safety incidents accumulated from May 5, 2007 to December 31, 2009 to the HaiPro database from 36 user organizations. Of the reported incidents, 51% were associated with medicaments and the process of medication. The most common incidents were errors in registration, dispensing and administration of the drugs.

Differences in COPD-related readmissions to primary and secondary care hospitals.

OBJECTIVE: To study differences in readmissions to primary and secondary care hospitals for exacerbations of chronic obstructive pulmonary disease (COPD). DESIGN: A register-based study. SUBJECTS: The data were gathered from the hospital admissions register of the Finnish National Research and Development Centre for Welfare and Health. The data included all acute periods of treatment received by COPD patients aged over 44 years in 1996-2004 who had a principal or subsidiary diagnosis of COPD (ICD 10: J41-J44), respiratory infection (ICD 10: J00-J39, J85-J86) or cardiac insufficiency (ICD 10: I50), followed by an emergency readmission. Treatment had to have taken place in either a primary care hospital or a specialized ward for respiratory diseases or internal medicine in a secondary care hospital. MAIN OUTCOME MEASURES: The risk of readmission within a week of discharge, analysed by site of care. RESULTS: The risk of readmission within seven days of discharge is 1.74-fold for a patient treated in primary care compared with a patient treated in secondary care. CONCLUSIONS: COPD patients discharged from primary care hospitals have a greater risk of readmission, particularly within a week, than those discharged from secondary care. This risk may be attributed to differences in treatment procedures and arrangement of subsequent care. Thus, in the future, more attention should be paid to primary healthcare resources and staff training.

A bronchiectatic patient's risk of pneumonia and prognosis.

The objective of this study was to define the morbidity and mortality of bronchiectatic patients. All records from the years 1993-2004 of patients with asthma, chronic obstructive pulmonary disease (COPD) and bronchiectasis as the primary diagnosis were extracted from the Finnish Hospital Discharge Register. The data of these patients' deaths until the end of the year 2004 were acquired from Statistics Finland. These materials were analyzed in order to find each bronchiectatic patient of this period an asthma or COPD control subject who was of the same age and sex and had also been hospitalized in the same year. Their numbers of pneumonia and prognoses were compared with each other during the study period. 59.4% of all bronchiectasis treatment periods in absolute numbers were for people aged 65 years or over. The occurrence of pneumonia in bronchiectatic patients was 1.03 (95% CI 0.82-1.24) per follow-up year, while the corresponding rate in the COPD control subjects was 1.22 (95% CI 0.92-1.53) and in the asthma control subjects 0.38 (95% CI 0.22-0.54). The mean survival times for the bronchiectatic patients were 8.33 (95% CI 8.16-8.50), for the COPD control subjects 6.26 (95% CI 6.07-6.45) and for the asthma patients 8.93 (95% CI 8.76-9.10) years. Bronchiectasis-related hospitalization in Finland is primarily focused on aged people. A bronchiectatic patient has a higher risk of pneumonia and a worse prognosis than an asthmatic, while the situation is opposite when compared to a COPD patient.

Increased patient safety with an Internet-based reporting system.

An efficient, goal-directed and positive approach allows learning from medical errors. The systematic analysis of patient safety incidents increases initiative and innovation in problem solving. In Finland, a nationally implemented Internet-based, voluntary reporting system provides a tool for the development of patient safety. The system is used by over 40 health care organisations. Vaasa Hospital District includes over 100 units and 3500 employees from specialty wards to primary care clinics and ambulances. All employees may submit reports which are processed by the chief medical officer and head nurse of each unit. The processing officers are able to intervene immediately to problems underlying a patient safety incident immediately. Classifying incidents according to an agreed structure creates an electronic database that serves as a tool for hospital management. The strength of an Internet-based reporting system is its simplicity and usability. It can help in promoting safety culture in health care.

Does place of treatment affect prognosis for chronic obstructive pulmonary disease (COPD)?

BACKGROUND: It has been shown previously that mortality from acute chronic obstructive pulmonary disease (COPD) is higher at small hospitals than at large teaching hospitals. OBJECTIVE: To examine mortality at this acute stage and referral for further treatment by specialities in Finland, and trends in these between the 1990s and 2000s. METHODS: Data on all periods of treatment for patients over 44 years of age with a principal or subsidiary diagnosis of COPD beginning and ending in 1995-2004 were extracted from the Finnish hospital discharge register. Particular attention was paid to acute-stage treatment periods managed by a general practitioner, pulmonary specialist, or specialist in internal medicine that had begun as emergency admissions and had a principal diagnosis of COPD, and to any further treatment immediately following these. RESULTS: General practitioners referred 5.1% of their acute-stage patients to a specialist in secondary care in 1995-2004. Of the total of 77,445 acute-stage treatment periods, 3% (2328) ended in the death of the patient, implying the loss of 8.3% of the patients involved. The age- and sex-adjusted risk of death attached to treatment periods managed by a general practitioner relative to those managed by a pulmonary specialist was 0.83 (95% CI 0.75-0.91). CONCLUSION: It is quite possible to treat acute exacerbations of COPD efficiently and safely in a health centre hospital ward. New treatment modalities and health service structures seem to have led to a decrease in acute exacerbations of COPD since the year 2000, even though the number of patients with this disease has increased as a consequence of ageing of the population. Further research is required on the efficacy of treatment by a general practitioner, e.g., with data on re-hospitalization.

The COPD-induced hospitalization burden from first admission to death.

BACKGROUND: Hospitalization periods at the exacerbation stage of COPD place a major burden on the health services and entail substantial costs. Little is known, however, about the corresponding burden on hospitals as the disease advances. We therefore set out to determine from hospital discharge and cause of death registers the overall burden on hospital resources occasioned by a COPD patient on a relative time scale from first admission to death, differentiated by age group, prognosis and sex. METHODS: Data on all subsequent hospital treatment periods after the first for patients with COPD who were over 44 years of age on admission were gathered from the Finnish National Research and Development Centre for Welfare and Health for the period 1991-2001. The actual material for this study consisted of the data on those patients who were alive after the first treatment period but had died by 2001. These were divided into three survival groups. RESULTS: The 8325 patients in this material had a total of 35,814 hospitalization periods in 1991-2001, of which men accounted for 73.6%. A total of 1895 of the patients (22.8%) had died within a year, 4257 (51.1%) within 1-5 years and 2173 (26.1%) after more than 5 years. Of those dying within a year, 20.9% had been in hospital care, while of those who lived on for over a year, 4.5% were in hospital when two-thirds of their remaining lifetime was still ahead of them and 7.3% when one-tenth of that time was still ahead. CONCLUSIONS: Almost one-fourth of the COPD patients had died within a year of first hospital admission for the disease. This group with a poor prognosis made abundant use of hospital services. The burden imposed on such services by severe COPD patients is U-shaped, with hospital use increasing towards the end of their lives.

Is the treatment of acute COPD exacerbations in Finland shifting to general practitioners?

OBJECTIVE: To examine changes in the numbers of inpatient episodes and inpatient days and length of stay in acute exacerbations of COPD (chronic obstructive pulmonary disease) by specialization and by age group and sex distribution relative to the total population in the years 1995-2001. DESIGN: A register-based study. SUBJECTS: Data on inpatient episodes for patients aged 45 years or over with a principal diagnosis of COPD beginning in 1995-2001 and lasting less than 90 days were extracted from the hospital discharge register of the Finnish National Research and Development Centre for Welfare and Health. MAIN OUTCOME MEASURES: Numbers of inpatient episodes and days by age and sex in the specialties of general practice, pulmonary medicine, and internal medicine. RESULTS: The annual number of inpatient episodes increased by 10.9% from 1995 to 2001. The number of emergency treatment episodes supervised by a general practitioner increased by 36.8% during the same period and the number of such episodes supervised by a pulmonary specialist by 17.8%. The increase in age-adjusted emergency treatment episodes for men was 0.8% and that for women 18.5%. The average hospital stay shortened from 8.0 (SD 8.0) to 6.5 (SD 6.2) for men and from 8.7 (SD 8.5) to 7.3 (SD 6.8) for women. CONCLUSIONS: The greater increase in inpatient episodes for exacerbations of COPD in relation to the total population among women than among men may be attributed to differences in smoking habits and ageing between the sexes. Responsibility for COPD cases is clearly shifting to general practitioners. This is due partly to the national programme for the treatment of obstructive pulmonary diseases and the associated in-service training provided for general practitioners and partly to financial reasons. More detailed investigations should be made into the quality of the treatment.

Length of stay and interval to readmission in emergency hospital treatment of COPD.

BACKGROUND: increasing attention has recently been attached to the length of hospital stay and related factors in the treatment of COPD. OBJECTIVES: to assess the trend in the duration of inpatient episodes following emergency admissions for COPD by age and sex, and the frequency of readmissions, as well as the correlations between the frequency and duration of inpatient episodes. DESIGN: retrospective study. SETTING: the Finnish hospital discharge register. SUBJECTS: the 72,672 inpatient episodes following emergency admissions of patients aged over 44 years that ended in 1993-2001 and had COPD as the principal diagnosis. RESULTS: the mean duration of inpatient episodes was 8.5 days (SD 8.2) in 1993, but 6.8 days (SD 6.6) in 2001. The figure for 45- to 64-year-old men was 6.5 days (SD 6.6) and that for men aged >64 years, 7.8 days (SD 6.8). The corresponding figures for women were 7.1 days (SD 6.8) and 8.8 days (SD 8.4). The average interval between the end of one inpatient episode and the beginning of the next was 195.4 days (SD 327.7). This interval was longest when the inpatient episode lasted for 7 days (interval 215 days). CONCLUSIONS: the length of hospital stay for COPD exacerbation seems to be decreasing, and elderly women have the longest inpatient episodes. With the current treatment modalities, a 1-week stay in hospital results in the longest interval to readmission. The situation may change if supported home care at exacerbation can be increased.

Regional and seasonal variation in the length of hospital stay for chronic obstructive pulmonary disease in Finland.

Notable regional and seasonal variation has been reported in the rate of hospital admissions for chronic obstructive pulmonary disease (COPE). The aim of this study was to assess the variation in the length of hospital stay for COPD in Finland on the north south axis and by season. For this purpose, the patient records of subjects aged over 45 hospitalised altogether 153,401 times with COPD as their primary diagnosis during 1987 - 1998 were retrieved from the Finnish Hospital Discharge Register maintained by the National Research and Development Centre for Welfare and Health. During this period, the average length of hospital episodes was 9.8 (SD) 47.8) days in northern Finland and 11.9 (SD 54.5) days in southern Finland (p = 0.001). Throughout Finland, the mean duration of hospital stay was longest in the winter, 12.3 (SD) 62.3) days, and shortest in the summer, 11.0 (SD) 42.3) days (p = 0.001). The mean duration of hospital stay in northern Finland was also longest in the winter, 10.6 (SD 56.7) days, and shortest in the summer, 8.8. (SD) 26.7) days (p = 0.015). Hospital episodes for COPD vary in duration in Finland, probably mainly due to regional differences in health care resources and treatment routines. The light and warm northern summer may also speculatively serve to shorten hospital episodes.