RESEARCH ARTICLE Open Access
T ends in he use and cos s o ound- he-
clock long- e m ca e in he las wo yea s
o li e among old people be ween 2002
and 2013 in Finland
Leena Fo ma
1*
, Ma ja Jylhä
1
, Ju a Pulkki
1
, Ma i Aal onen
1,2
, Jani Rai anen
1,3
and Pekka Rissanen
1
Abs ac
Backg ound: The s uc u e o long- e m ca e (LTC) o old people has changed: ca e has been shi ed om ins i u ions
o he communi y, and dea h is being pos poned o inc easingly old age. The aim o he s udy was o analyze how he
use and cos s o LTC in he las wo yea s o li e among old people changed be ween 2002 and 2013.
Me hods: Da a we e de i ed om na ional egis e s. The s udy popula ion con ains all hose who died a he age o
70 yea s o olde in 2002–2013 in Finland (N= 427,078). The cos s we e calcula ed using na ional uni cos in o ma ion.
Bina y logis ic eg ession and Cox p opo ional haza d models we e used o s udy he associa ion o yea o dea h wi h
use and cos s o LTC.
Resul s: The p opo ion o hose who used LTC and he sum o days in LTC in he las wo yea s o li e inc eased
be ween 2002 and 2013. The mean numbe o days in ins i u ional LTC dec eased, while ha o shel e ed housing
inc eased. The cos s o LTC pe use dec eased.
Conclusions: Use o LTC in he las wo yea s o li e inc eased, which was explained by he pos ponemen o dea h o
inc easingly old age. Cos s o LTC dec eased as shel e ed housing eplaced ins i u ional LTC. Howe e , an accu a e
compa ison o cos s o di e en ypes o LTC is di icul , and he socie al cos s o shel e ed housing a e no well known.
Keywo ds: Long- e m ca e, Use and cos s, Las yea s o li e, Time end
Backg ound
The use o long- e m ca e (LTC) among old people is
concen a ed in o he las yea s and mon hs o li e, and
he use o LTC a he end o li e is highe in olde old
han younge old age [1–4]. Dea hs a e inc easingly
pos poned o la e old age: in Finland in 1994 ca. 32,500
dea hs occu ed a he age o 70+ and 4100 (12.6%) a
he age o 90+, while in 2014 he co esponding igu es
we e 38,800 and 9500 (24.5%) espec i ely (S a is ics
Finland 2016). Thus he las yea s o li e a e being li ed
a an olde age han be o e, and consequen ly he use o
LTC nea he end o li e will p obably g ow [5].
A numbe o poli ical p og ams in Finland ha e
a emp ed o change highly ins i u ionalized LTC p ac ices
and ha e ecommended communi y-based se ices in-
s ead [6, 7], as has also happened in many o he coun ies
[8, 9]. In p ac ice, he p opo ion o old people using LTC
has emained close o 10% since he 1990s, bu he use o
ins i u ional ca e has dec eased, and ha o shel e ed
housing (se ice housing, classi ied as non-ins i u ional
ca e) has inc eased in Finland [10–12]. Ea lie s udies on
ends in LTC use ha e ocused on old people in gene al,
bu ends in LTC use among hose who use he se ices
mos , old people a he end o li e, a e no known. As he
numbe o such people is inc easing in many coun ies,
knowing he ends is impo an o unde s anding he
dis ibu ion o se ice use and o planning how o e-
spond o inc easing needs in he nea u u e.
* Co espondence: [email p o ec ed]
1
Facul y o Social Sciences (heal h sciences) and Ge on ology Resea ch
Cen e (GEREC), Uni e si y o Tampe e, 33014 Tampe e, Finland
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Fo ma e al. BMC Heal h Se ices Resea ch (2017) 17:668
DOI 10.1186/s12913-017-2615-3
The e a e h ee ypes o ound- he-clock LTC in
Finland: inpa ien ca e in heal h cen e wa ds (p ima y
ca e hospi als, which also p o ide sho - e m ca e), esi-
den ial homes, and shel e ed housing wi h 24-h assis -
ance ( e e ed o he ea e as shel e ed housing). O
hese, heal h cen e s and esiden ial homes a e ins i u-
ional se ings, and shel e ed housing p o ides housing
and closely ela ed se ices. In he pas , hese LTC acil-
i ies we e p esen ed as o ming a hie a chy: people wi h
he smalles ca e needs we e p edominan ly ca ed o in
shel e ed housing, and hose wi h he g ea es needs in
heal h cen e s [13]. Howe e , his hie a chy has been e-
modeled, and nowadays esiden ial homes and shel e ed
housing gene ally espond o simila needs. Those wi h
he highes needs o in need o medical ca e a e ca ed
o in heal h cen e s. Howe e , he clien p o iles in
hese se ices o e lap o some ex en .
Municipali ies a e esponsible o p o iding LTC o
hei ci izens in Finland [14]. The la ges p opo ion o
cos s is paid o by municipal axes (84% o heal h cen-
e s and 72% o esiden ial homes), and he use s o se -
ices pay he es ou o hei own pocke s [15]. Na ional
in o ma ion on he unding o shel e ed housing is no
a ailable, bu in hese se ings esiden s pay o a a ie y
o day- o-day commodi ies, e.g. medicines, ou o hei
own pocke s. Since hey a e en i led o apply o eim-
bu semen s o medical and housing expenses om he
Social Insu ance Ins i u ion (SII), esponsibili y o he
unding o LTC is being shi ed om local- o na ional-
le el wel a e sys ems, and o se ice use s hemsel es
[16]. The uni cos s o heal h cen e s a e highes and
hose o shel e ed housing lowes (Table 1), bu hese
cos s do no include all he same cos i ems, and he e-
o e he di e ences in cos a e no clea a he socie al
le el. F om he iewpoin o municipali ies, shel e ed
housing has been ound o be 22% cheape han ins i u-
ional ca e, bu when SII eimbu semen is aken in o
accoun , he o al cos s o shel e ed housing a e 9%
cheape han hose o ins i u ional ca e [17]. S ill, he e
is a lack o in o ma ion abou cos s paid by clien s, and
consequen ly abou o al socie al cos s.
We desc ibe and analyze he use and socie al cos s o
ound- he-clock LTC among old people du ing he las
wo yea s o li e, and how hose uses and cos s changed
be ween 2002 and 2013. These we e analyzed o long-
e m ca e in o al, and sepa a ely o heal h cen e in-
pa ien wa ds, esiden ial homes, and shel e ed housing.
Du ing he s udy pe iod he s uc u e o LTC con inued
o change so ha ca e was shi ed om ins i u ions o
he communi y, and dea h was being pos poned o in-
c easingly old age. These changes a e cu en in many
coun ies, and he esul s o his s udy add knowledge
abou LTC use in a g oup wi h he highes ca e needs.
This s udy was conduc ed as pa o he p ojec en i led
“New Dynamics o Longe i y and he Changing Needs
o Se ices”(COCTEL).
Me hods
S udy popula ion
The s udy popula ion was d awn om he Causes o
Dea h Regis e (S a is ics Finland). I consis s o all hose
who died a he age o 70 yea s o o e in 2002–2013 in
Finland. The cu o age o 70 was chosen because bo h he
isk o dea h (S a is ics Finland) and heal hca e expendi-
u es pe esiden s a o inc ease a a ound 70 yea s o
age in Finland [18]. Use o LTC was examined o he las
730 days o li e. Thus he da a include deceden s o
12 yea s and se ice use o 14 yea s since 2000.
Da a sou ces
The da a on LTC use we e de i ed om he Ca e Regis-
e o Heal hca e and Ca e Regis e o Social Wel a e
(Na ional Ins i u e o Heal h and Wel a e). The in o -
ma ion om hese egis e s was linked using unique Pe -
sonal Iden i ica ion Codes. A mo e de ailed desc ip ion
o he da a collec ion has been gi en elsewhe e [19].
Table 1 Uni cos s o di e en ypes o LTC
Cos i ems €2011
b
€2013
c
To al cos s in €2013
Heal h cen e S a , adminis a ion, meals, clo hes, ca e
supplies, housing, medicines,
a
TVs, hygiene
p oduc s, phones
257 271 271
Residen ial home S a , adminis a ion, meals, clo hes, ca e
supplies, housing, medicines,
a
TVs, hygiene
p oduc s, phones
185 195 195
Shel e ed housing S a , meals, ca e supplies
a
131 138 156
+ housing cos s 13.60
d
+ medicine cos s 4.00
e
a
[21] The uni cos s o he ca e o old people epo ed by Kapiainen e al. [20] a e mainly based on his epo
b
Cos s pe day in LTC p o ided by municipali y [20]
c
Cos s we e con e ed o hei 2013 equi alen alues acco ding o he p ice index o public expendi u e o heal h and social se ices (S a is ics Finland)
d
[22]
e
COCTEL da a: medicine cos s pe day in he las wo yea s o li e among hose who died in 2013 and we e communi y-dwelling o a leas one day
Fo ma e al. BMC Heal h Se ices Resea ch (2017) 17:668 Page 2 o 9
Days in ca e we e calcula ed o each indi idual on he
basis o da es o admission o and discha ge om ca e.
Pe mission o access and use he egis e da a was ob-
ained om bo h egis e au ho i ies. The esea ch plan
was app o ed by he Pi kanmaa Hospi al Dis ic E hics
Commi ee.
Measu es
Use and cos s o ound- he-clock LTC we e analyzed in
o al and sepa a ely o h ee ypes o LTC: (1) heal h
cen e inpa ien wa ds, i he pe son had a con inuous
leng h o s ay o 90 days o o e ; (2) esiden ial homes;
(3) shel e ed housing wi h 24-h assis ance. The LTC in
o al is he sum o hese h ee ypes o LTC.
Th ee ou come a iables we e c ea ed o LTC in o al
and o each ype o LTC: (1) any use, whe e 1 = used a
leas once in he las 730 days o li e, and 0 = did no
use in he las 730 days o li e; (2) days in ca e ( o
heal h cen e s days a y om 90 o 730 and o o he
se ice ypes om 1 o 730); (3) cos s o ca e in he las
730 days o li e.
We mul iplied he numbe o days in di e en ypes o
LTC by hei daily uni cos s, de i ed om a na ional e-
po [20] (Table 1). The uni cos s o esiden ial homes
and heal h cen e s a e g oss cos s caused by he use o
se ices. We used he uni cos s o he yea 2013 o all
yea s. Cos s we e con e ed om yea 2011 alues o
hei 2013 equi alen alues acco ding o he p ice index
o public expendi u e o heal h and social se ices (S a-
is ics Finland).
The uni cos o shel e ed housing included s a ,
meals, and ma e ials, bu excluded housing, medicines,
and some pu chased se ices [21]. Ins ead, hese we e
included in he uni cos s o heal h cen e s and esiden-
ial homes (cos i ems a e desc ibed in Table 1). We es i-
ma ed he cos o housing (an a e age o €13.60 pe day
in shel e ed housing) using s a is ics om he SII [22].
The mean cos o p esc ibed ou pa ien medicines was
de i ed om he SII’s indi idual-le el egis e da a. This
was €4 pe day among hose who died in 2013 and who
we e communi y-dwelling
1
o a leas one day in he
las wo yea s o li e. We added hese cos i ems o he
uni cos o shel e ed housing o make i mo e compa -
able wi h o he ypes o LTC and o ep esen he soci-
e al cos s, like he cos s o o he ypes o LTC do.
None heless, many o he cos s paid by use s o shel e ed
housing we e excluded, such as o clo hing, TVs, hy-
giene p oduc s, and phones. In esiden ial homes and
heal h cen e s hese cos s a e co e ed (see Table 1). The
uni cos o shel e ed housing is an unde es ima ion,
bu i is he bes es ima ion a ailable, and his limi a ion
mus be kep in mind when in e p e ing he esul s. The
uni cos s o shel e ed housing a e di icul o es ima e,
since he e is a ia ion in he con en o se ice packages
o e ed o clien s.
Analyses
Analyses we e pe o med o he whole s udy popula ion
and by age g oup (70–79, 80–89 and 90+ yea s). Chi-
squa e es s we e used o es he di e ences in he p o-
po ions o se ice use s and gende s be ween he yea s
o dea h. One-way ANOVA was used o assess he
change in he mean age a dea h du ing he s udy
pe iod. Independen samples median es s we e used o
es he di e ences in he numbe o days in ca e, and in
he cos s be ween hose who died in di e en yea s. The
numbe o days in and cos s o LTC we e analyzed
among he use s o se ices. In addi ion, he sum o days
in LTC is p esen ed. Bina y logis ic eg ession analyses
we e pe o med o assess he p obabili y o using LTC
by yea o dea h. Age and gende we e adjus ed o .
The cos s o LTC in ou da a include a lo o ze oes, and
he dis ibu ions a e U-shaped, meaning ha he e we e
many indi iduals wi h ew o no days in ca e ( o heal h
cen e s 0 o ≥90) and many who we e in ca e o 730 o al-
mos 730 days. Su i al me hods such as Cox p opo ion
haza d models may be employed when he da a a e skewed
o mul imodal, ha e hea y ails, o consis o excess ze oes
[23]. These models ha e been used e en when he censo -
ing does no ha e o be co ec ed [24]. In compa isons o
di e en eg ession models o analyzing he cos da a,
p opo ional haza d models ha e been shown o pe o m
well [25] when he p opo ional haza ds assump ion is me
[24].The p opo ional haza ds assump ion means ha he
su i al cu es o wo di e en le els o a co a ia e a e
p opo ional o e ime (i.e. cons an ela i e haza d) [26].
We employed Cox p opo ional haza d models o
analyze he de elopmen o he cos s o LTC pe use be-
ween 2002 and 2013. Cos s we e conside ed a “su i al
ime” a iable, and hose who did no ha e “su i al ime”,
i.e. whose cos s we e 0, we e d opped om he models.
None o he obse a ions was ea ed as censo ed, as o
all he end poin was dea h. Age, gende , and yea o dea h
we e independen a iables. In addi ion, models including
an in e ac ion e m (age * yea o dea h) we e un o ind
ou whe he he e ec o age on cos s di e ed be ween
he yea s. The nega i e coe icien es ima e (haza d a io
(HR) <1.00) o he p opo ional haza d model indica es a
dec eased haza d o eaching o al cos s, hence an in-
c ease in o al cos [25]. The e o e, we p esen he in e ses
o HRs o make he in e p e a ion easie , i.e. a highe alue
means highe cos s.
Resul s
Desc ip i es
The da a included 427,078 pe sons. The mean age a
dea h inc eased om 82.3 o 83.8 yea s be ween 2002
Fo ma e al. BMC Heal h Se ices Resea ch (2017) 17:668 Page 3 o 9
and 2013 (p< .001), and he p opo ion o women de-
c eased om 59.1% o 56.5% (p< .001). The numbe o
people who died a he age o 70–79 yea s dec eased
and ha o olde people inc eased du ing he s udy
pe iod (Fig. 1).
The p opo ion o LTC use s
The p opo ion o hose who used LTC in o al in-
c eased (p< .001) o e he s udy pe iod among hose
who died a he age o 70+. I inc eased in younge age
g oups, bu dec eased (p< .001) among he oldes (90+)
(Fig. 2). The use o ins i u ional ca e (heal h cen e s and
esiden ial homes) dec eased (p< .001), while he use o
shel e ed housing inc eased (p< .001) in all age g oups.
The likelihood o using LTC in o al emained app oxi-
ma ely a he same le el be ween 2002 and 2013 when
age was adjus ed o (s epwise analyses no shown)
(Table 2). The dec ease in he use o ins i u ional ca e
and he inc ease in use o shel e ed housing we e also
shown in hese analyses. Use o all ypes o LTC was
mo e common among olde han younge deceden s
and among women han men (Table 2).
The numbe o days in, and he cos s o , long- e m ca e
The numbe o dea hs a he age o 70+ dec eased om
2002 o 2005, and inc eased ema kably om 2006 o
2013. The e o e he sum o days in LTC in o al i s de-
c eased and hen inc eased (Fig. 1). The sum o days in
LTC dec eased among he younges (70–79) bu in-
c eased in he olde age g oups.
Among hose who used LTC, he numbe o days in
LTC in o al inc eased sligh ly (mean 450 in 2002 and
448 in 2013, median 540 and 549 espec i ely, p< .001)
in he s udy pe iod, bu he cos s pe use dec eased
(p< .001) (Fig. 2). The numbe o days, as well as he
cos s o ca e in heal h cen e s and esiden ial homes, de-
c eased (p< .001) om 2002 o 2013. Con e sely, he
numbe o days in and cos s o shel e ed housing in-
c eased (p< .001).
We an Cox p opo ional haza d models o ind ou
how he cos s o LTC de eloped du ing he s udy pe iod
among se ice use s. The cos s o LTC in o al dec eased
sys ema ically om 2002 o 2013 (Table 3). The cos s o
heal h cen e s dec eased, and he cos s o shel e ed
housing inc eased. The cos s o esiden ial homes did
no change du ing he s udy pe iod. Olde people and
women had a highe p obabili y o highe cos s o each
ype o LTC han younge people and men (Table 3).
We also an Cox p opo ional haza d models includ-
ing he in e ac ion e m (age * yea o dea h) o ind ou
whe he he e ec o age on LTC cos s changed du ing
he s udy pe iod (analyses no shown). The e ec o his
in e ac ion e m was s a is ically signi ican ly associa ed
wi h he cos s o LTC in o al o he yea s 2010–2013
( o all yea s in e se o HR 0.996, 95% con idence in e -
als (CIs) 0.993, 0.999), and wi h he cos s o esiden ial
homes in 2012 and 2013 ( o bo h yea s in e se o HR
0.993, 95% CIs 0.989, 0.998). This indica es ha in hese
yea s he e ec o age on LTC cos s was 0.4% and on
esiden ial home cos s 0.7% weake han in 2002.
Discussion
The aim o his s udy was o desc ibe and analyze how
he use and cos s o ound- he-clock LTC among old
people in he las wo yea s o li e changed be ween
2002 and 2013. We ound ha he p opo ion o LTC
Fig. 1 The sum o days in LTC in he las wo yea s o li e and he numbe o deceden s by age g oup om 2002 o 2013: N= 427,078
Fo ma e al. BMC Heal h Se ices Resea ch (2017) 17:668 Page 4 o 9
Fig. 2 The p opo ion o LTC use s ou o all deceden s, and he mean cos s o LTC (€2013) among use s by age g oup om 2002 o 2013 ( he
cos s o heal h cen e s a e highe han hose o LTC in o al, since he numbe o days in a heal h cen e a ies om 90 o 730 and o o he
ypes o LTC om 1 o 730)
Fo ma e al. BMC Heal h Se ices Resea ch (2017) 17:668 Page 5 o 9

use s inc eased among hose who died a he age o
70 yea s o o e , bu he inc ease was no clea when
age was adjus ed o . This implies ha he inc ease was
due o he change in he age s uc u e o old people, i.e.
he pos ponemen o dea h o olde ages. Use and cos s
o LTC a e highe among olde old han younge old
people, and he e ec o age on use and cos s o LTC
did no change much du ing he s udy pe iod. As he
las yea s o li e a e being li ed a a g ea e age han be-
o e, unc ional and cogni i e disabili y is p obably
Table 2 The associa ion o age, gende , and yea o dea h wi h any use o LTC, logis ic eg ession analyses: N= 427,078
LTC Heal h cen e Residen ial home Shel e ed housing
OR (95% CIs) OR (95% CIs) OR (95% CIs) OR (95% CIs)
Age 1.10 *** (1.10, 1.10) 1.04 *** (1.04, 1.04) 1.07 *** (1.07, 1.07) 1.06 *** (1.06, 1.06)
Gende ( e . man) 1.54 *** (1.52, 1.56) 1.48 *** (1.45, 1.51) 1.23 *** (1.21, 1.25) 1.29 *** (1.27, 1.31)
Yea o dea h
2002 ( e .)
2003 0.98 (0.95, 1.01) 0.97 (0.93, 1.00) 0.93 *** (0.90, 0.97) 1.22 *** (1.16, 1.29)
2004 0.94 *** (0.91, 0.97) 0.92 *** (0.89, 0.96) 0.88 *** (0.85, 0.91) 1.33 *** (1.27, 1.41)
2005 0.95 *** (0.92, 0.98) 0.92 *** (0.88, 0.96) 0.83 *** (0.80, 0.86) 1.58 *** (1.50, 1.66)
2006 0.98 (0.95, 1.01) 0.93 *** (0.90, 0.97) 0.81 *** (0.79, 0.84) 1.73 *** (1.64, 1.82)
2007 1.02 (0.99, 1.05) 0.92 *** (0.89, 0.96) 0.84 *** (0.81, 0.87) 1.98 *** (1.89, 2.08)
2008 1.03 (1.00, 1.06) 0.91 *** (0.87, 0.95) 0.77 *** (0.75, 0.80) 2.27 *** (2.17, 2.38)
2009 1.04 ** (1.01, 1.08) 0.86 *** (0.83, 0.90) 0.78 *** (0.76, 0.81) 2.51 *** (2.40, 2.64)
2010 1.03 * (1.00, 1.07) 0.82 *** (0.79, 0.85) 0.75 *** (0.72, 0.78) 2.88 *** (2.75, 3.01)
2011 1.04 (1.00, 1.07) 0.74 *** (0.71, 0.77) 0.71 *** (0.68, 0.73) 3.33 *** (3.18, 3.49)
2012 1.03 * (1.00, 1.06) 0.66 *** (0.63, 0.69) 0.66 *** (0.64, 0.68) 3.77 *** (3.60, 3.95)
2013 1.04 (1.00, 1.07) 0.57 *** (0.54, 0.59) 0.61 *** (0.59, 0.63) 4.38 *** (4.19, 4.58)
Nagelke ke R
2
0.151 0.039 0.069 0.091
*p< .05, **p< .01, ***p< .001
LTC long- e m ca e, OR odds a io, CI con idence in e al
Table 3 The associa ion o age, gende , and yea o dea h wi h cos s o LTC among use s, Cox p opo ion haza d analyses
LTC in o al Heal h cen e Residen ial home Shel e ed housing
N 196,461 69,958 96,722 71,404
iHR (95% CIs) iHR (95% CIs) iHR (95% CIs) iHR (95% CIs)
Age 1.01 *** (1.01, 1.01) 1.01 *** (1.01, 1.01) 1.02 *** (1.02, 1.02) 1.02 *** (1.02, 1.02)
Man ( e . woman) 1.26 *** (1.25, 1.27) 1.17 *** (1.15, 1.19) 1.29 *** (1.27, 1.31) 1.25 *** (1.23, 1.27)
Yea o dea h ( e . 2002)
2003 0.97 ** (0.95, 0.99) 0.97 (0.94, 1.01) 0.99 (0.96, 1.02) 0.99 (0.94, 1.04)
2004 0.97 ** (0.95, 0.99) 0.98 (0.94, 1.01) 1.00 (0.97, 1.03) 1.04 (0.99, 1.09)
2005 0.95 *** (0.93, 0.98) 0.96 * (0.92, 0.99) 1.00 (0.97, 1.03) 1.04 (0.99, 1.09)
2006 0.96 *** (0.94, 0.98) 0.95 ** (0.92, 0.99) 1.02 (0.99, 1.05) 1.05 (1.00, 1.10)
2007 0.93 *** (0.91, 0.95) 0.94 *** (0.91, 0.98) 0.99 (0.96, 1.02) 1.04 (0.99, 1.09)
2008 0.93 *** (0.91, 0.95) 0.94 *** (0.91, 0.97) 1.01 (0.98, 1.05) 1.06 ** (1.02, 1.11)
2009 0.91 *** (0.89, 0.93) 0.93 *** (0.90, 0.96) 1.05 ** (1.02, 1.08) 1.06 * (1.01, 1.11)
2010 0.87 *** (0.85, 0.89) 0.87 *** (0.84, 0.90) 1.02 (0.99, 1.05) 1.07 *** (1.03, 1.12)
2011 0.82 *** (0.81, 0.84) 0.83 *** (0.80, 0.86) 1.02 (0.99, 1.05) 1.12 *** (1.07, 1.17)
2012 0.79 *** (0.77, 0.81) 0.77 *** (0.75, 0.80) 1.04 ** (1.01, 1.08) 1.20 *** (1.15, 1.26)
2013 0.73 *** (0.71, 0.74) 0.71 *** (0.68, 0.74) 0.99 (0.96, 1.02) 1.28 *** (1.23, 1.33)
*p< .05, **p< .01, ***p< .001
LTC long- e m ca e, iHR in e se o haza d a io, CI con idence in e al
Fo ma e al. BMC Heal h Se ices Resea ch (2017) 17:668 Page 6 o 9
g ea e han p e iously [27], and he pe iod du ing
which ca e is needed may be longe [28].
The composi ion o LTC changed du ing he s udy
pe iod. The use o ins i u ional LTC (heal h cen e s and
esiden ial homes) dec eased, and he use o shel e ed
housing inc eased. The numbe o days in LTC in o al
among use s did no change much, bu he cos s o LTC
in o al pe use dec eased. This was mainly due o he
eplacemen o ins i u ional LTC wi h shel e ed housing,
he cos s o which a e lowe han hose o ins i u ional
LTC. Howe e , he uni cos s o shel e ed housing a e
di icul o es ima e, as he cos s and con en s o se ices
a y be ween shel e ed housing uni s. In pa icula , he
cos s ha clien s pay ou o hei own pocke s a e no
well known, and no all o hem a e included in he uni
cos s used he e. We used he na ional uni cos s, bu
since hese do no include he cos s o medicines and
housing, we es ima ed hei impac on cos s. Conse-
quen ly, he di e ence be ween he daily cos s o esi-
den ial homes and shel e ed housing diminished om
€57 o €39. Howe e , he uni cos o shel e ed housing
is p obably an unde es ima ion.
The cos s o LTC na u ally depend hea ily on he uni
cos s used. We used he same uni cos s (2013) o all
yea s, al hough cos s may ha e changed du ing he s udy
pe iod. Fu he mo e, i he e we e signi ican changes in
he con en o ca e, o in he need o ca e among use s,
his may also ha e led cos s o change. The uni cos s
used he e a e he na ional a e age cos s, while he ac ual
cos s a y somewha be ween municipali ies and se ice
p o ide s [29].
The ole o shel e ed housing clea ly inc eased du ing
he s udy pe iod in he ca e o old people in hei las
wo yea s o li e, as in he ca e o old people in gene al
[10–12, 30]. This shi is mainly due o changes in he
supply o se ices, a he han o he p e e ences o old
people. I an indi idual in shel e ed housing needs as
much ca e and as many se ices as someone in a esi-
den ial home, he cos s o hei ca e a e likely o in-
c ease, becoming nea o equal o he cos s o ca e in a
esiden ial home [16]. Ea lie s udies ha e epo ed e-
ma kable di e ences in ca e needs be ween esiden s in
di e en ypes o LTC [30], bu in ou da a people using
di e en ypes o LTC did no di e much in e ms o
age, gende , o demen ia diagnosis (da a no shown).
Acco ding o ou p e ious analyses, old people a e no
li ing un il hei dea hs in shel e ed housing as o en as
in esiden ial homes. Also, he numbe o ansi ions o
di e en ca e acili ies (commonly hospi als) in he las
yea o li e has been highe om shel e ed housing han
om esiden ial homes [31, 32]. In addi ion o possible
p oblems in he con inui y o ca e, mul iple admissions
o hospi al ca e also inc ease end-o -li e ca e cos s. We
also analyzed he a ia ion in he o al cos s o social
and heal h se ices be ween hose li ing in esiden ial
homes and hose in shel e ed housing, and no di e ence
was ound [33].
The use o egis e s, which a e conside ed eliable
[34, 35], is a s eng h o his s udy. In analyzing he
cos s o LTC we employed Cox p opo ional haza d
models, which a e no a e y es ablished way o make
such an analysis. Howe e , acco ding o p e ious
econome ic compa isons, i is a sui able me hod o
he analysis o complex cos dis ibu ions, al hough an
essen ial equi emen is ha he p opo ional haza ds
assump ion be me [23, 25]. We examined his assump-
ion by conside ing he “su i al cu es”o cos s be-
ween yea s o dea h, and ound ha hey we e
p opo ional (pa allel) a all poin s o he cos dis ibu-
ion. In addi ion, Cox eg ession has been ound o be
alid o analyzing cos s when he da a a e no censo ed
[36]; his was he case in ou s udy, whe e he ollow-
up was wo yea s o all.
The ocus o his s udy was on ound- he-clock LTC;
hus home ca e and in o mal ca e, which a e impo an
pa s o LTC, we e no included. The p opo ion o
home ca e use s in he las wo yea s o li e inc eased
om 19% in 2002 o 21% in 2008 in Finland [37]. Al-
hough he e is a policy emphasis on li ing a home o
as long as possible, he s abili y o he numbe o days in
LTC among he use s in his s udy sugges s ha old
people may no be able o li e longe in hei own
homes wi h he cu en le el o home ca e.
Indi idual cha ac e is ics, o he han age and gende ,
we e no con olled o in ou analyses, al hough disease
and disabili y [38, 39], li ing a angemen s and socio-
economic s a us [40, 41], and a ailabili y o in o mal
ca e [42, 43] a e known o be impo an de e minan s o
he use and cos s o LTC. In his s udy, howe e , he
ocus was on ime ends in he use and cos s o LTC,
no on indi idual de e minan s.
Conclusions
A ema kable change in he a angemen o ound- he-
clock LTC o old people in he las wo yea s o li e
ook place in Finland be ween 2002 and 2013. The num-
be o days in LTC inc eased sligh ly, bu he cos s o
LTC in o al pe use dec eased du ing he s udy pe iod.
The e was a shi om ins i u ional ca e o shel e ed
housing. Howe e , eliably compa ing he cos s o di e -
en ypes o LTC is di icul , because hey do no include
he same cos i ems. We es ima ed he socie al cos s o
shel e ed housing, bu s ill could no include hem all. In
pa icula , he cos s paid by he se ice use s a e di icul
o es ima e. The inc eased use o shel e ed housing
aises conce ns abou shi ing he inancial esponsibili y
on o clien s. Use o LTC in o al inc eased, as he age
s uc u e o he deceden s changed. As dea h con inues
Fo ma e al. BMC Heal h Se ices Resea ch (2017) 17:668 Page 7 o 9
o be pos poned o olde ages, he need o , and he use
and cos s o , LTC will p obably inc ease. Choices should
be made abou how o supply good ca e o old people
in ways ha will sha e he cos s o LTC equi ably.
Endno es
1
People we e conside ed communi y-dwelling i hey
li ed in a p i a e home o shel e ed housing, which is
classi ied as non-ins i u ional ca e.
Abb e ia ions
CI: Con idence in e al; COCTEL: New Dynamics o Longe i y and he
Changing Needs o Se ices p ojec ; HR: Haza d a io; iHR: in e se o haza d
a io; LTC: Long- e m ca e; OR: Odds a io; SII: Social Insu ance Ins i u ion o
Finland
Acknowledgemen s
No applicable.
Funding
This wo k was suppo ed by a g an o Leena Fo ma om he Academy o
Finland (276189), a g an o P o esso Pekka Rissanen om he Founda ion
o Municipal De elopmen and g an s o P o esso Ma ja Jylhä om he
Academy o Finland (250602 and 287372). The unding bodies did no in luence
any aspec o he design o he s udy, analysis o in e p e a ion o da a.
A ailabili y o da a and ma e ials
The indings o his s udy a e based on egis e da a a ailable om S a is ics
Finland and he Na ional Ins i u e o Heal h and Wel a e. The da a used a e
co e ed by he pe mission g an ed o he cu en s udy, and a e no
publicly a ailable.
Au ho s’con ibu ions
All au ho s con ibu ed o he s udy design, in e p e a ion, w i ing and/o
e ision o his publica ion. LF and JR pe o med he s a is ical analyses. LF
d a ed he manusc ip . MJ and PR o iginally planned he COCTEL s udy. All
au ho s ead and app o ed he inal manusc ip .
E hics app o al
The esea ch plan was app o ed by he Pi kanmaa Hospi al Dis ic E hics
Commi ee.
Consen o publica ion
No applicable.
Compe ing in e es s
The au ho s decla e ha hey ha e no compe ing in e es s.
Publishe ’sNo e
Sp inge Na u e emains neu al wi h ega d o ju isdic ional claims in published
maps and ins i u ional a ilia ions.
Au ho de ails
1
Facul y o Social Sciences (heal h sciences) and Ge on ology Resea ch
Cen e (GEREC), Uni e si y o Tampe e, 33014 Tampe e, Finland.
2
Ins i u e o
Ad anced Social Resea ch, Uni e si y o Tampe e, Tampe e, Finland.
3
UKK-Ins i u e o Heal h P omo ion, Tampe e, Finland.
Recei ed: 30 Ma ch 2017 Accep ed: 12 Sep embe 2017
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