In . J. En i on. Res. Public Heal h 2014, 11, 8743-8754; doi:10.3390/ije ph110908743
In e na ional Jou nal o
En i onmen al Resea ch and
Public Heal h
ISSN 1660-4601
www.mdpi.com/jou nal/ije ph
A icle
Does P ima y Ca e Men al Heal h Resou cing A ec he Use
and Cos s o Seconda y Psychia ic Se ices?
Minna Sadeniemi 1,2,*, Sami Pi kola 2,3,4, Maiju Pankakoski 2 , G igo i Jo e 3 , Raija Kon io 5,
Maili Malin 2, Taina Ala-Nikkola 2,3 and K is ian Wahlbeck 2
1Depa men o Psychia y, Hospi al Dis ic o Helsinki and Uusimaa, Po oo Heal h Ca e A ea,
Po oon psykia ian poliklinikka, Kai oka u 37, FI-06100 Po oo, Finland
2Depa men o Men al Heal h and Subs ance Abuse Se ices, Na ional Ins i u e o Heal h and Wel a e,
Manne heimin ie 170, FI-00270 Helsinki, Finland; E-Mails: maiju.pankakoski@ hl. i (M.P.);
[email p o ec ed] (M.M.); [email p o ec ed] (K.W.)
3Depa men o Psychia y, Uni e si y Hospi al Region, Hospi al Dis ic o Helsinki and Uusimaa,
Välskä inka u 12, PL 590, FI-00029 HUS, Finland; E-Mails: [email p o ec ed] (S.P.);
[email p o ec ed] (G.J.); [email p o ec ed] (T.A.-N.)
4 School o Heal h Sciences, Uni e si y o Tampe e, Medisiina inka u 3, FI-33014 Tampe e, Finland;
E-Mail: [email p o ec ed]
5Depa men o Psychia y, Hospi al Dis ic o Helsinki and Uusimaa, Hy inkää Hospi al Region,
Vanha Val a ie 198, FI-04500 Kellokoski, Finland; E-Mail: [email p o ec ed]i
*Au ho o whom co espondence should be add essed; E-Mail: [email p o ec ed];
Tel.: +358-503-368-414.
Recei ed: 25 June 2014; in e ised o m: 13 Augus 2014 / Accep ed: 14 Augus 2014 /
Published: 26 Augus 2014
Abs ac : Collabo a i e ca e models o ea men o dep ession and anxie y diso de s in
p ima y ca e ha e been shown o be e ec i e. The aim o his s udy was o in es iga e a
he municipal le el o wha ex en in es men in men al heal h pe sonnel a p ima y ca e
heal h cen es in he s udy a ea is e lec ed in he cos s and use o seconda y psychia ic
se ices. Fu he mo e, we analysed whe he he se ice p o ision and use o seconda y
psychia ic ca e co ela es wi h he socioeconomic indica o s o need. We ound signi ican
a ia ion in he amoun o men al heal h pe sonnel p o ided a he heal h cen es,
unco ela ed wi h he indica o s o need no wi h he cos s o seconda y psychia ic ca e.
The amoun o men al heal h nu ses a he heal h cen es co ela ed in e sely wi h he
numbe o seconda y psychia ic ou pa ien isi s, whe eas i s ela ion o inpa ien days and
OPEN ACCESS
In . J. En i on. Res. Public Heal h 2014, 11 8744
admission was posi i e. The cos s o seconda y psychia ic ca e co ela ed wi h le el o
psychia ic mo bidi y and socioeconomic indica o s o need. The esul s sugges ha when
aiming a equal access o ca e and cos -e iciency, he p ima y and seconda y ca e should
be o ganized and planned wi h in eg a i e collabo a ion.
Keywo ds: cos s and cos analysis; p ima y heal h ca e; nu ses; psychia ic hospi als
1. In oduc ion
Men al heal h se ices ha e been ans o med om hospi al-cen ed o a balanced model o in eg a ed
communi y-based se ices suppo ed by psychia ic hospi al ca e in mos de eloped coun ies [1].
Since 1970, he numbe o psychia ic hospi al beds in Finland has dec eased by 80% [2]. The amoun o
inpa ien days in psychia ic hospi als has dec eased by 29% be ween 2002 and 2012. The numbe o
psychia ic ou pa ien isi s has inc eased be ween 2006 and 2012 by 30% [3]. Deins i u ionaliza ion
has no esul ed in poo e ou comes [4], on he con a y, well de eloped communi y men al
heal h se ices a e associa ed wi h lowe suicide a es han se ices o ien ed owa ds inpa ien
ea men p o ision [5,6].
In Finland, only app oxima ely one-hal o hose su e ing e en om se e e and como bid mood
diso de s in he gene al popula ion use heal h se ices o hem [7]. Fo milde o ms o diso de s,
he p opo ion o hose ecei ing ea men may be e en lowe [8]. Acco ding o in e na ional s udies,
mos o he pa ien s wi h anxie y, mood and subs ance use diso de s a e diagnosed and ea ed in
p ima y ca e [8,9]. In Finland, he ole o p ima y ca e has been less p ominen . In an ea lie Finnish
s udy, specialized men al heal h se ices accoun ed o wo- hi ds o he se ices ha we e used by
people su e ing om majo dep ession and anxie y diso de s [7].
In o de o enhance he quali y o ca e o psychia ic diso de s in he p ima y ca e se ing,
e ec i e models o collabo a i e ca e (CCM) o dep ession and anxie y ha e been de eloped [10–13].
These models ypically include nu se ca e managemen and a g ea e deg ee o in eg a ion be ween
p ima y and seconda y ca e, and hey a e e ec i e in imp o ing pa ien ou come [13]. Acco ding o
some s udies, he CCM o ea ing dep ession is mo e e ec i e han usual ca e bu also esul s in
g ea e ea men cos s [14]. Howe e , when indi ec heal h ca e cos s o p oduc i i y losses a e also
aken in o accoun , he e idence seems o indica e, ha CCM does no lead o a ne inc ease in o al
heal h ca e cos s [11,15].
In Finland, he municipali ies p o ide p ima y heal h ca e a heal h cen es, which o m he poin o
sys em en y o people wi h men al heal h p oblems. Heal h cen es p o ide p e en ion, diagnosis and
ea men o common men al diso de s, such as dep ession, anxie y diso de s and alcohol use
diso de s. The heal h cen es ha e a ga ekeepe ole, and access o specialized ca e is usually by
e e ence om p ima y ca e only. Fo specialized public heal h se ices, including specialized men al
heal h ca e, he municipali ies o m hospi al dis ic s.
Du ing he las ew yea s in Finland, men al heal h nu ses ha e been inc easingly included in
p ima y heal h cen e s a , mos ly o ea ing dep ession [16,17]. This kind o collabo a i e ca e
model has been ecommended by he Na ional Plan o Men al Heal h and Subs ance Abuse Wo k o
In . J. En i on. Res. Public Heal h 2014, 11 8745
be implemen ed in heal h cen es na ionwide [18]. The pa ien s mee he nu se o e alua ion,
psychoeduca ion and suppo , and some imes sho - e m psycho he apy like in e pe sonal
psycho he apy. Some imes collabo a ion wi h a psychia is is also included in he ca e model.
Acco ding o he Finnish Cu en Ca e Guideline o T ea men o Dep ession [19], complica ed o
ea men - esis an mode a e episodes and se e e dep essi e episodes should be ea ed in seconda y
psychia ic ca e. The deg ee o which heal h cen es in Finland ha e special men al heal h ca e s a ,
as men al heal h nu ses and psychologis s, has no been s udied p io o his s udy. Low socioeconomic
s a us is gene ally associa ed wi h highe psychia ic mo bidi y [20–22]. I is no known whe he his is
aken in o accoun when o ganizing p ima y ca e psychosocial se ices in Finland.
This s udy is a pa o he Eu opean REsea ch on FINancing sys ems’ E ec on he quali y o
MENTal heal h ca e (REFINEMENT) p ojec [23]. The aim o his s udy was o: (1) in es iga e he
associa ion o he amoun o men al heal h pe sonnel p o ided a heal h cen es wi h he use and cos s
o seconda y psychia ic se ices in he s udy a ea and (2) in es iga e whe he he in es men in
psychosocial esou ces a p ima y ca e le el, and he use and cos s o seconda y psychia ic ca e
e lec he needs o he popula ion as measu ed by socioeconomic indica o s. The i s hypo hesis:
(1) was ha he mo e esou ces he e a e o men al heal h ca e in he p ima y ca e heal h cen es,
he less need he e is o psychia ic se ices a he seconda y le el, as measu ed by psychia ic
hospi al admissions, inpa ien days and ou pa ien isi s, and he e will be less cos s o he
municipali y o seconda y psychia ic ca e. We also hypo hesized: (2) ha ce ain indica o s o social
disad an age and psychia ic mo bidi y would associa e wi h highe se ice esou cing a he p ima y
ca e le el, and highe use o seconda y psychia ic ca e.
2. Expe imen al Sec ion
In he i s phase o he REFINEMENT p ojec men al heal h se ices we e classi ied in nine
Eu opean coun ies, one s udy a ea in each coun y, by using he Eu opean Se ice Mapping
Schedule—Re ised (ESMS-R) se ice mapping ool [24–28]. In Finland, addic ion se ices we e also
mapped. The mapping was es ic ed o adul se ices. The mapping was done a he beginning o 2012.
The s udy a ea is one o he hospi al dis ic s in Finland, i.e., he Hospi al Dis ic o Helsinki and
Uusimaa (HUS). I is owned and go e ned by 26 municipali ies in he sou he nmos pa o Finland,
he Uusimaa dis ic . The o al popula ion in he HUS a ea is 1.5 million people (adul popula ion
(18+) is 1.2 million), which is o e a qua e o he en i e popula ion o Finland. The adul popula ion
in indi idual municipali ies a ies om 1200 o 490,000. The e a e 18 municipal heal h cen es in he
HUS a ea. Smalle municipali ies ha e join heal h cen es. The heal h cen e in Helsinki also o e s
inpa ien psychia ic ca e. Wi h some excep ions, he o he municipali ies pu chase inpa ien se ices
om he HUS hospi al dis ic .
The amoun o p ima y ca e psychia ic pe sonnel was exp essed as he numbe o nu ses,
psychologis s, o he men al heal h wo ke s and psychia is s loca ed a he heal h cen es pe 10,000
adul inhabi an s o he municipali y. Al hough we looked a he o al amoun o pe sonnel, he men al
heal h nu ses we e he mos ele an and p e alen occupa ional g oup.
To de ine he use o seconda y psychia ic ca e in 2012, o each municipali y he numbe o
psychia ic ou pa ien isi s, he numbe o hospi al admissions, he a e age leng h o he hospi al s ay
In . J. En i on. Res. Public Heal h 2014, 11 8746
and he o al numbe o inpa ien days we e collec ed om Ecomed, he HUS hospi al dis ic egis e .
The municipali y o Hy inkää p o ides seconda y psychia ic ou pa ien ca e as a pa o i s own
unc ion, and he capi al ci y o Helsinki has a majo psychia ic uni p o iding bo h ou pa ien and
inpa ien seconda y le el psychia ic ca e. Bo h o hese municipali ies also buy psychia ic se ices
om HUS. The ca e gi en a hei own psychia ic uni s we e added o he HUS s a is ics.
The o al cos s o he psychia ic seconda y ca e p o ided by HUS in 2012 o each municipali y
we e collec ed om he HUS inancial managemen da abase, HUS-To al. The cos s we e exp essed as
eu os pe adul inhabi an in he yea 2012. The cos s o psychia ic ca e in he Hy inkää and Helsinki
municipal seconda y psychia ic uni s we e asked sepa a ely om hei adminis a ion, and hen added
o he cos s o psychia ic ca e p o ided by HUS o hese municipali ies. Thus, o seconda y
psychia ic se ices, he esul s e lec he psychia ic se ices p o ided by he Hospi al Dis ic HUS
and he se ices p o ided by he Hy inkää and Helsinki municipal seconda y psychia ic uni s.
Socioeconomic indica o s o need o psychia ic se ices, as he unemploymen a e, he a e age
income pe adul , he le el o educa ion and he pe cen age o single households we e collec ed om
he Finnish S a is ics and Indica o Bank (SOTKA-ne ) [29] using da a om 2011.
As a likely indica o o psychia ic mo bidi y, a c ude men al heal h index (MHI) o each
municipali y is p o ided by he Na ional Ins i u e o Heal h and Wel a e. The index is based on he
incidence o suicides and suicide a emp s, he numbe o pe sons eligible o special eimbu semen
o an ipsycho ic medica ion, and he numbe o pe sons on disabili y pension due o men al diso de s
in a gi en a ea [30]. Each o he indica o s is gi en equal weigh . The MHI is coun ed as an a e age
o e h ee yea s. The MHI ep esen s an e o o u ilize na ional s a is ics, and he Na ional Ins i u e o
Heal h and Wel a e p omo es i s’ use in na ional policy making and esou ce alloca ion. Howe e , he MHI
has no p e iously been s udied. Simila bu no iden ical measu es ha e been p esen ed and s udied in
o he coun ies [31].
Because o he small numbe o municipali ies, Spea man co ela ions we e used o in es iga e he
associa ion be ween he indica o s o need, he MHI, he amoun o psychia ic pe sonnel, he numbe
o nu ses a p ima y ca e le el and he use and cos s o seconda y psychia ic ca e. Linea eg ession
was used in assessing he join e ec o mo e han one a iable (MHI, numbe o p ima y ca e men al
heal h nu ses, seconda y ca e psychia ic ou pa ien isi s) on psychia ic inpa ien days and admission
a e. Analyses we e pe o med using SPSS e sion 21 (IBM Co p., A monk, NY, USA).
3. Resul s and Discussion
3.1. Resul s
The e was signi ican a ia ion be ween he municipali ies in he amoun o men al heal h pe sonnel
in he heal h cen es (Figu e 1). The smalles amoun o pe sonnel was obse ed in he Po oo heal h
cen e, wi h only one psychologis o he en i e adul popula ion o app oxima ely 38,000. The highes
amoun o men al heal h pe sonnel was in Raasepo i p ima y heal h ca e.
In he analysis o he s udy a iables (Table 1), he numbe o men al heal h nu ses in p ima y ca e
co ela ed nega i ely wi h he numbe o ou pa ien isi s in seconda y psychia ic ca e (Figu e 2).
The e is a signi ican nega i e co ela ion (Spea man co ela ion coe icien −0.39, p = 0.050) be ween
In . J. En i on. Res. Public Heal h 2014, 11 8747
he numbe o p ima y ca e men al heal h nu ses pe 10,000 adul s and he numbe o ou pa ien isi s
pe 1000 adul s pe yea in seconda y psychia ic ca e. The municipali y o Jä enpää is an ou lie ,
ha ing bo h hea y s a ing o nu ses in p ima y ca e and a g ea numbe o ou pa ien isi s in seconda y
psychia ic ca e. I i is le ou o he analysis, he co ela ion coe icien is la ge (−0.56, p = 0.003).
The o al amoun o men al heal h pe sonnel did no show any co ela ion wi h he o he a iables.
Figu e 1. The numbe o men al heal h nu ses, psychologis s, auxilia y nu ses (aux nu se),
o he men al heal h wo ke s (o he ) and psychia is s in he p ima y ca e heal h cen es o
municipali ies pe 10,000 adul inhabi an s.
No es: Join municipal au ho i ies co e ing he ollowing municipali ies: * Män sälä,
Po nainen, ** Lohja, Siun io, Inkoo, Ka jalohja, *** Ka kkila, Nummi-Pusula, Vih i.
Table 1. Co ela ions be ween he a iables.
Va iable
P ima y
Ca e
Men al
Heal h
Nu ses
Ou pa ien
Visi s
Inpa ien
Days
Admission
Ra e
Leng h
o S ay
Cos s
MHI
Unemploymen
Ra e
A e age
Income
Single
Households
P ima y ca e men al
heal h nu ses
1
Ou pa ien isi s in
seconda y psychia ic ca e
−0.39 *
1
Psychia ic inpa ien days
0.19
0.41 *
1
Psychia ic hospi al
admissions
0.074
0.36
0.68 **
1
Leng h o hospi al s ay
0.07
−0.007
0.21
−0.55 **
1
Cos s o seconda y
psychia ic ca e
−0.075
0.63 **
0.83 **
0.73 **
−0.041
1
MHI
−0.22
0.29
0.39
0.62 **
−0.39 *
0.69 **
1
Unemploymen a e
−0.19
0.06
0.37
0.54 **
−0.31
0.46 *
0.64 **
1
A e age income
−0.079
0.17
−0.065
−0.43 *
0.57 **
−0.18
−0.45 *
−0.66 **
1
Pe cen age o single
households
−0.056
0.11
0.47 *
0.51 **
−0.16
0.61 **
0.75 **
0.82 **
−0.49 *
1
Educa ion
−0.096
0.17
−0.088
−0.44 *
0.56 **
−0.13
−0.37
−0.66 **
0.95 **
−0.41
No es: * Co ela ion is signi ican a he 0.05 le el; ** Co ela ion is signi ican a he 0.01 le el.
0
1
2
3
4
5
6
Helsinki
Espoo
Kauniainen
Ki kkonummi
Ke a a
Van aa
Tuusula
Jä enpää
Mus ijoki*
Hy inkää
Nu mijä i
LOST**
Ka iainen***
Raasepo i
Hanko
Askola
Lo iisa+Lap
Po oo
Sipoo
psychia is
o he
aux nu se
psychologis
nu se

In . J. En i on. Res. Public Heal h 2014, 11 8748
Figu e 2. P ima y ca e men al heal h nu ses and ou pa ien isi s in seconda y psychia ic
ca e. Each do ep esen s a municipali y. Jä enpää was excluded om he calcula ion o
he eg ession line.
A signi ican posi i e co ela ion o he numbe o seconda y psychia ic ca e ou pa ien isi s wi h
he numbe o psychia ic inpa ien days was obse ed. Mul i a ia e analysis was used o con ol o
con ounding ac o s in in es iga ing associa ions wi h hospi aliza ions. A linea eg ession model
adjus ed wi h seconda y psychia ic ou pa ien isi s and MHI shows a posi i e associa ion be ween
numbe o p ima y ca e men al heal h nu ses and inpa ien days (Table 2). Adjus ed wi h he same
a iables, a posi i e associa ion be ween numbe o p ima y ca e men al heal h nu ses and hospi al
admissions was seen. In he bi a ia e analyses, hese associa ions be ween he numbe o nu ses and
inpa ien days and hospi al admissions we e no seen.
Table 2. Reg ession models explaining inpa ien days and admission a e by MHI,
numbe o p ima y ca e psychia ic nu ses and seconda y ca e psychia ic ou pa ien isi s.
Independen Va iables
Inpa ien Days
Admission Ra e
B
se
p
B
se
p
In e cep
−23.27
53.23
0.666
−5.06
3.13
0.12
MHI
1.23
0.67
0.077
0.15
0.04
0.001
P ima y ca e men al heal h nu ses
44.23
17.94
0.022
2.29
1.06
0.041
Ou pa ien isi s in seconda y psychia ic ca e
0.16
0.08
0.074
0.00
0.01
0.485
The numbe o men al heal h nu ses in p ima y ca e did no co ela e wi h he o al cos s o
seconda y psychia ic ca e no wi h he socioeconomic indica o s o he MHI. The o al cos s o
In . J. En i on. Res. Public Heal h 2014, 11 8749
seconda y psychia ic ca e co ela ed signi ican ly wi h he MHI (Figu e 3), as well as wi h he
unemploymen a e, he pe cen age o single households, and expec edly he numbe o psychia ic
admissions, inpa ien days and ou pa ien isi s. The admission a e signi ican ly co ela ed posi i ely
wi h he unemploymen a e, he p opo ion o single households and he MHI. A signi ican nega i e
co ela ion was ound be ween he admission a e and he a e age income, he le el o educa ion and
he a e age leng h o he hospi al s ay. No ecip ocal ela ionship wi h ou pa ien isi s and inpa ien
days, admission a es o leng h o hospi al s ay was ound.
Figu e 3. The cos s o seconda y psychia ic ca e in ela ion o he Men al Heal h Index
(MHI). Each do ep esen s a municipali y. Cos s a e exp essed as eu os pe adul
inhabi an . The co ela ion is signi ican (c = 0.69, p < 0,001).
3.2. Discussion
In his s udy in in es iga ing he men al heal h se ice sys em in an u ban, semi-u ban egion in
Finland, we ound signi ican a ia ion in p ocesses and cos s o o ganizing se ices. We ound ha a
highe p o ision o men al heal h nu ses, bu no he o al amoun o men al heal h pe sonnel,
a p ima y ca e le el associa es wi h dec eased use o specialized psychia ic ou pa ien isi s.
In e es ingly, highe numbe o p ima y ca e psychia ic nu ses a heal h cen es associa es wi h
inc eased use o psychia ic inpa ien ca e. This may pa ly explain why, con adic o y o ou
hypo hesis, highe p ima y ca e men al heal h esou ces did no associa e wi h lowe o al cos s o
seconda y psychia ic ca e. In addi ion, ou analyses a e sugges ing ha he Men al Heal h Index,
de i ed om s a is ics da a on suicides, psychia ic medica ion eimbu semen s and disabili y pension due
o men al diso de s, may be a alid and easible indica o o cos d i e s o seconda y psychia ic ca e.
In . J. En i on. Res. Public Heal h 2014, 11 8750
P e ious s udies on collabo a i e ca e ha e mos ly been clinical s udies. Ou sys em-le el s udy
shows ha models o using men al heal h pe sonnel in p ima y ca e ha e been qui e widely
implemen ed in e e yday clinical p ac ice in he s udy a ea, despi e he lack o an o e all in eg a ed
policy s a egy. Wide, mo e han en old, a ia ion in pe capi a p ima y ca e psychosocial esou ces
was ound in he s udy a ea. Municipali ies ha e independen ly de eloped se ice p o ision pa e ns
and sys ems o hei own. The di e ences in he amoun o s a ing does no seem o de i e om need
o se ices, a leas no as measu ed by he men al heal h index o he socioeconomic indica o s.
P ima y ca e psychia ic esou cing does no seem o ela e o he o al cos s o specialized
psychia ic ca e in he s udy a ea. Ra he , he cos s o specialized psychia ic ca e associa e wi h he
MHI, he unemploymen a e and he pe cen age o single households. Acco ding o his s udy,
men al heal h nu ses a e he mos p e alen and ele an occupa ional g oup in p ima y ca e.
Inc easing hei numbe dec eases he use o seconda y psychia ic ou pa ien ca e. Howe e , i seems ha
in es men in p o ision o men al heal h se ices in p ima y ca e is linked o an inc ease o psychia ic
inpa ien ca e, which is he main cos d i e in men al heal h ca e p o ision. Pe haps, wi hou
in eg a ion wi h seconda y le el psychia ic se ices, he p ima y le el men al heal h nu ses ha e a
po en ial o ecognize needs ha in a mo e in eg a ed con ex could be me also in ou pa ien se ing.
I may also be ha men al heal h se ices in p ima y ca e ca e o a di e en clinical pa ien popula ion
han inpa ien psychia ic se ices. Ou s udy indica es a need o u he de elop men al heal h se ices
in p ima y ca e o he mos ulne able g oups, as simply adding esou ces o p ima y ca e seems o be
an ine icien way o educe psychia ic inpa ien ca e needs.
The posi i e independen associa ion o highe numbe o p ima y ca e men al heal h nu ses and
psychia ic hospi al admissions and inpa ien days is in e es ing and somewha su p ising. I may indica e
ha he p ima y ca e le el, in con as o seconda y le el o psychia ic ou pa ien se ices, lacks he
capaci y o espond o mo e complex and ad anced needs o pa ien s. In some cases his may lead o
inc eased hospi al use. Thus, quali y and con en o ca e may be an issue in p ima y ca e se ings,
especially in small heal h cen es. A small uni canno p o ide specialized se ices. Ano he explana ion
would be ha mo e p ima y ca e psychia ic nu ses means inc eased ecogni ion o unme needs o
inpa ien ca e.
To ensu e ho izon al equi y in access o men al heal h ca e, e alua ion o men al heal h policy
should be based on concu en e idence-based assessmen o he o ganiza ion and use o se ices in
ela ion o indica o s o social dep i a ion [32]. The psychia ic hospi al admission a es ha e,
in s udies om No he n Eu ope, been ound o di e conside ably acco ding o he le el o
socioeconomic dep i a ion [33]. In some s udies, he leng h o s ay has been ound o co ela e
nega i ely wi h socioeconomic dep i a ion [34]. Acco ding o ou s udy, he cos s o psychia ic
seconda y ca e co ela e clea ly wi h MHI, which seems unde s andable and may be in e p e ed as a
necessi y. In he municipali ies wi h a high MHI and high unemploymen , he e a e mo e admissions
and he hospi al s ays a e sho e , which is in line wi h p e ious indings. In he mo e p ospe ous
municipali ies wi h a lowe MHI, he e a e less admissions bu he s ays a e longe . This may poin o a
le el o inequali y in inpa ien ca e, which migh me i u he in es iga ion. In some cases,
he a ailabili y o esou ces may also o some ex en de e mine se ice u iliza ion. As o p ima y ca e
men al heal h esou ces, i is wo h asking whe he hey should be e e lec he socioeconomic indica o s
o need and be o ganized in la ge uni s a he han small municipali ies. To assu e cos -e iciency,
In . J. En i on. Res. Public Heal h 2014, 11 8751
p ima y ca e and seconda y psychia ic ca e should be de eloped as a whole. This would ensu e
ci izens equal access o bo h low h eshold ca e and specialized psychia ic ca e.
3.3. S eng hs and Limi a ions
The s eng h o his s udy is ha i is he i s s udy whe e he p ima y ca e men al heal h se ice
sys em has been sys ema ically mapped in a ela i ely la ge and di e se a ea in e ms o se ice
se ings. I is also he i s s udy whe e he cos s and use o seconda y psychia ic ca e has been s udied
in ela ion o he MHI and socioeconomic indica o s.
Since his s udy was a c oss-sec ional s udy o a gi en men al heal h ca e sys em and no ou come
measu es o quali y o ca e measu es we e used, i is no possible o compa e he ac ual cos -e ec i eness
o ca e. Also, no analysis o he ype o ca e ac ually p o ided by he p ima y ca e psychia ic nu ses was
included in his s udy. So, he deg ee o which he ca e mee s he c i e ia o CCM emains unknown.
Wi h his complex, c oss-sec ional and na u alis ic s udy se ing we a e unable o make di ec causal
conclusions, bu a he p esen signi ican and possibly impo an associa ions. Howe e , need o
esea ch da a o he use o se ice de elopmen is eme ging and ou indings implica e u he
ou come s udies.
4. Conclusions
P o iding p ima y ca e men al heal h nu ses, in an a emp o collabo a i e ca e, associa es wi h
dec eased use o psychia ic ou pa ien ca e and inc eased psychia ic hospi al use. Regional socioeconomic
disad an age o psychia ic mo bidi y associa e wi h highe cos s, bu does no seem o ela e o
planning o collabo a i e ca e models. On he basis o complex and non-con e gen e ec s,
a mo e in eg a ed managemen o se ice p o ision model seems jus i ied.
Acknowledgmen s
This esea ch has ecei ed unding om he Eu opean Union Se en h F amewo k P og amme
unde g an ag eemen No. 261459 (REFINEMENT P ojec ). The con en s o his publica ion a e he
sole esponsibili y o he REFINEMENT G oup and can in no way be aken o e lec he iews o he
Eu opean Union’. This esea ch has ecei ed unding om Helsinki and Uusimaa Hospi al Dis ic s
De elopmen and esea ch g an s. We a e pleased o acknowledge he con ibu ion played by p ojec
coo dina o Ma ju Vas amäki in he se ice sys em mapping, he con ibu ion played by planne
Ka oliina Jouh en in supplying he da a o he cos s o seconda y psychia ic ca e, and de elopmen
manage Maa i Be gman in supplying he da a o use o seconda y psychia ic ca e.
Au ho Con ibu ions
Minna Sadeniemi had he idea o he s udy ques ions and ca ied ou he design wi h all co-au ho s.
Minna Sadeniemi an he s a is ical analysis ad ised by Maiju Pankakoski. Maili Malin p o ided da a
o he socioeconomic indica o s. Minna Sadeniemi and Sami Pi kola d a ed he manusc ip ,
which was e ised by all o he au ho s.