University of Oulu

Satokangas, Markku,; Arffman, Martti; Antikainen, Harri; Leyland, Alastair H.; Keskimäki, Ilmo, Individual and Area-level Factors Contributing to the Geographic Variation in Ambulatory Care Sensitive Conditions in Finland, Medical Care: February 2021 - Volume 59 - Issue 2 - p 123-130 doi: 10.1097/MLR.0000000000001454

Individual and area-level factors contributing to the geographic variation in ambulatory care sensitive conditions in Finland : a register-based study

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Author: Satokangas, Markku1,2; Arffman, Martti2; Antikainen, Harri3;
Organizations: 1Department of General Practice and Primary Health Care, Network of Academic Health Centres, University of Helsinki
2Service System Research Unit, Finnish Institute for Health and Welfare, Helsinki
3Geography Research Unit, University of Oulu, Oulu, Finland
4MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, Scotland
5Faculty of Social Sciences, Tampere University, Tampere, Finland
Format: article
Version: published version
Access: open
Online Access: PDF Full Text (PDF, 0.2 MB)
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Language: English
Published: Wolters Kluwer, 2021
Publish Date: 2021-03-09


Background: Measuring primary health care (PHC) performance through hospitalizations for ambulatory care sensitive conditions (ACSCs) remains controversial—recent cross-sectional research claims that its geographic variation associates more with individual socioeconomic position (SEP) and health status than PHC supply.

Objectives: To clarify the usage of ACSCs as a PHC performance indicator by quantifying how disease burden, both PHC and hospital supply and spatial access contribute over time to geographic variation in Finland when individual SEP and comorbidities were adjusted for.

Methods: The Finnish Care Register for Health Care provided hospitalizations for ACSCs (divided further into subgroups of acute, chronic, and vaccine-preventable causes) in 2011–2017. With 3-level nested multilevel Poisson models—individuals, PHC authorities, and hospital authorities—we estimated the proportion of the variance in ACSCs explained by selected factors at 3 time periods.

Results: In age-adjusted and sex-adjusted analysis of total ACSCs the variances between hospital authorities was nearly twice that between PHC authorities. Individual SEP and comorbidities explained 19%–30% of the variance between PHC authorities and 25%–36% between hospital authorities; and area-level disease burden and arrangement and usage of hospital care a further 14%–16% and 32%–33%—evening out the unexplained variances between PHC and hospital authorities.

Conclusions: Alongside individual factors, areas’ disease burden and factors related to hospital care explained the excess variances in ACSCs captured by hospital authorities. Our consistent findings over time suggest that the local strain on health care and the regional arrangement of hospital services affect ACSCs—necessitating caution when comparing areas’ PHC performance through ACSCs.

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Series: Medical care
ISSN: 0025-7079
ISSN-E: 1537-1948
ISSN-L: 0025-7079
Volume: 59
Issue: 2
Pages: 123 - 130
DOI: 10.1097/MLR.0000000000001454
Type of Publication: A1 Journal article – refereed
Field of Science: 316 Nursing
3142 Public health care science, environmental and occupational health
1171 Geosciences
Copyright information: © 2020 The Author(s). Published by Wolters Kluwer Health, Inc. This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.