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Background: Social mobility among patients with schizophrenia or major affective disorder was compared with that among the general population.Method: Mobility was studied retrospectively from 1970 to 1987. Socio-economic status (SES) was defined by occupation as in the population census (upper white-collar, lower white-collar, blue-collar, entrepreneur, farmer, unemployed). All patients aged 30-60 years at discharge (2901 men and 3620 women) in 1987-88 in Finland were included in the study. The SES structure of the general population was used for comparisons.Results: Among patients with schizophrenia there was a constant downward drift, commonly to unemployment. This risk was higher among men than women. In the youngest age group a marked decline from the parents' social status was observed. Among patients with major affective disorder the distribution of SES in 1970 was similar to that of the general population. By 1987, a downward drift was again observed, mainly to unemployment regardless of the initial SES group. The number of patients in occupational categories were usually 30-50% lower than expected.Conclusions: Schizophrenic patients had a high risk of social drop-out. Among patients with major affective disorder the downward drift was much less. [ABSTRACT FROM AUTHOR]

To explore variations in rates for hysterectomy in relation to social class, education, and family income. Retrospective analysis of the 1988 Finnish hospital discharge register linked individually to the 1987 population census. Finland. All women living in Finland aged 35 and over were the denominator population. The numerators were the 8663 women who underwent hysterectomy in 1988. The overall rate for hysterectomy was 63.5/10,000 women aged 35 and over. There was a marked positive correlation between disposable family income and hysterectomy rates even after age, hospital catchment area, education, and occupational status were adjusted for. However, no linear trend for overall hysterectomy rates was observed in relation to social class or education. Procedures due to myomas, accounting for 48% of all hysterectomies, were more frequent among women of high socioeconomic status according to all socioeconomic indicators. Larger proportions of hysterectomies for myoma were also performed in patients in private hospitals and in pay beds in public hospitals than in women in worse off groups. Unlike the findings in earlier studies from other countries, there was a positive correlation between income and hysterectomy rates as a result of the high numbers of hysterectomies performed to treat myoma in the well off women. The findings are discussed in terms of socioeconomic differences in the use of private gynaecological services, and factors, such as parity and use of hormonal replacement therapy, that affect the growth of myomas. [ABSTRACT FROM AUTHOR]

Background: The objective of our study was to investigate the incidence of hysterectomy by age, indication and surgical method employed during 1987-1989 in Finland, corrected by 'uteri or cervix at risk' population.Methods: Three years (1987-1989) of patient discharges from the Finnish Hospital Discharge Register, which covers all Finnish hospitals including the few private ones, was used. Patients represented all Finnish adult women (approximately 2,000,000).Results: Approximately 9000 hysterectomies are performed annually in Finland. The annual incidence of hysterectomy was 348/100,000 women (most among women aged 45-49), and after correction for 'uteri or cervix at risk' this rose by 11% to 390/100,000. The most frequent indications were leiomyoma (50%) and endometriosis (11%). Prolapse, menstrual disorders and cancer each accounted for 7-8% of all hysterectomies. The most common surgical approach was total abdominal hysterectomy (36%), while hysterectomy with bilateral oophorectomy and partial hysterectomy each accounted for 20% of operations. Differences in the rates by indication or surgical approach between 'uteri or cervix at risk' corrected and uncorrected estimates varied between 0% and 22%.Conclusions: The incidence of, and indications for hysterectomy in Finland are approximately the same as in other European countries, but partial hysterectomy is more common in Finland. Because the correction for the 'uteri or cervix at risk' population produced changes in the rates of hysterectomy, correction should be considered when calculating hysterectomy rates or incidences of cervical or endometrial cancer. [ABSTRACT FROM AUTHOR]

Abstract Background Chronic conditions such as coronary heart disease (CHD) challenge health care to provide systematic and long-lasting disease management. In this study of patients who were revascularized, we examine whether treatment pathways leading to coronary revascularisation differ between patients with and without diabetes. Methods This retrospective, nationwide register-based study in Finland in 1998-2007 describes temporal trends in the proportions of 1) revascularisations performed at the first treatment period, and 2) suboptimal treatment pathways to revascularisations, i.e. pathways containing several cardiac emergency hospitalisations. Differences between patient groups were examined using a logistic regression model adjusting for age, comorbidity, and region. Results Among patients who underwent revascularisation, upward trends were found in the proportions of revascularisations performed during first hospital admission: among men with CHD alone, the percentages were 28% in 1998 and 77% in 2007; among men with insulin-dependent diabetes (IDD) they were 16% vs. 58% for the respective years; and among men with non-insulin dependent diabetes (NIDD) they were 25% vs. 69%, respectively. Among women the percentages were for non-diabetic group 32% vs. 77%; for IDD group 36% vs. 64%; and for NIDD group 33% vs. 73% for the respective years. Patients with diabetes were less likely to undergo revascularisation during the first hospital admission, in 2005-2007, the odds ratio (OR) for IDD among men was 0.52 (95% confidence interval 0.42-0.64) and for NIDD among men it was 0.79 (95% CI 0.73-0.86) compared to patients with CHD alone. The respective ORs among women were 0.59 (95% CI 0.44-0.78), and 0.83 (95% CI 0.74-0.93). Conclusions Treatment practices changed substantially during the study period to favour performing revascularisation during the first hospital admission. The large increase in coronary angioplasty operations is likely to be an important factor behind these changes. However, fewer operations are performed during the first CHD hospitalisation of diabetic patients who undergo coronary revascularisation and they experience more often emergency hospital admissions before the operation than patients without diabetes. To avoid adverse cardiac events, more attention is needed in managing diabetic CHD patients' referral pathways to revascularisation.

Abstract Background Earlier studies have mainly reported the use of antithrombotic drugs, beta-blockers and statins among hospital patient populations or MI patients. This study aimed to describe the use of these drugs among middle-aged Finnish coronary patients and to identify patient groups in risk of being prescribed inadequate medication for secondary prevention of coronary heart disease. Methods One-year follow-up survey data from a random sample of a cohort of coronary patients were used along with register data linked to the survey. The response rate was 54% (n = 2650). The main outcome measures were use of antithrombotic drugs, beta-blockers and statins and the data were analysed using logistic regression analysis. Results Among men and women, respectively, 82% and 81% used beta-blockers, 95% and 89% used antithrombotic drugs, and 62% and 59% used statins. Younger men and men from higher socioeconomic groups were more likely to use statins, even after controlling for disease severity and comorbidity. In women, the age trend was reversed and no socioeconomic differences were found. Drug use increased with increased disease severity, but diabetes had only a slight effect. Conclusion The use of antithrombotic drugs and beta-blockers among Finnish coronary patients seemed to be rather appropriate and, to some extent, prescription practices of preventive medication varied according to patients' risk of coronary events. However, statin use was remarkably low among men with low socio-economic status, and there is need to improve preventive drug treatment among diabetic coronary patients.

Background: The integration of information systems in health care and social welfare organizations has brought significant changes in patient and client care. This integration is expected to offer numerous benefits, but simultaneously the implementation of health information systems and client information systems can also introduce added stress due to the increased time and effort required by professionals., Objective: This study aimed to examine whether professional groups and the factors that contribute to successful implementation (participation in information systems development and satisfaction with software providers' development work) are associated with the well-being of health care and social welfare professionals., Methods: Data were obtained from 3 national cross-sectional surveys (n=9240), which were carried out among Finnish health care and social welfare professionals (registered nurses, physicians, and social welfare professionals) in 2020-2021. Self-rated stress and stress related to information systems were used as indicators of well-being. Analyses were conducted using linear and logistic regression analysis., Results: Registered nurses were more likely to experience self-rated stress than physicians (odds ratio [OR] -0.47; P>.001) and social welfare professionals (OR -0.68; P<.001). They also had a higher likelihood of stress related to information systems than physicians (b=-.11; P<.001). Stress related to information systems was less prevalent among professionals who did not participate in information systems development work (b=-.14; P<.001). Higher satisfaction with software providers' development work was associated with a lower likelihood of self-rated stress (OR -0.23; P<.001) and stress related to information systems (b=-.36 P<.001). When comparing the professional groups, we found that physicians who were satisfied with software providers' development work had a significantly lower likelihood of stress related to information systems (b=-.12; P<.001) compared with registered nurses and social welfare professionals., Conclusions: Organizations can enhance the well-being of professionals and improve the successful implementation of information systems by actively soliciting and incorporating professional feedback, dedicating time for information systems development, fostering collaboration with software providers, and addressing the unique needs of different professional groups., (© Janna Nadav, Anu-Marja Kaihlanen, Sari Kujala, Ilmo Keskimäki, Johanna Viitanen, Samuel Salovaara, Petra Saukkonen, Jukka Vänskä, Tuulikki Vehko, Tarja Heponiemi. Originally published in JMIR Medical Informatics (https://medinform.jmir.org).)

Purpose: The worldwide prevalence of diabetes mellitus (DM) continues to increase. As DM is linked to various ophthalmological comorbidities, it is crucial to understand the incidence and the treatment patterns of these complications to minimise the treatment burden for the patient and the healthcare system. This study aims to evaluate the incidence and prevalence of diabetic macular oedema (DME) and proliferative diabetic retinopathy (PDR) and to analyse intravitreal (IVT) treatment patterns and responses in the Finnish population with diabetes., Methods: A nationwide data register containing details of over 20-year-old individuals with diabetes was used in the analyses., Results: The incidence and prevalence of DME and PDR among the Finnish population with diabetes either declined or remained stable during 2007-2017 (Incidence rate: DME -40.8%, PDR -65.3%; prevalence rate: DME +4.7%, PDR -11.2%). During the same period, number of persons suffering from diabetes increased by +58.3%. The total number of IVT injections increased by 261.7%; the number of patients receiving IVT treatments increased by 133.6% from 2011 to 2017, reflecting changes in patient numbers in the ophthalmology departments. Furthermore, irrespective of the rising number of patients with diabetes, the numbers with visual impairment declined by 75.8% among DME and by 75.7% among PDR patients in 2007-2017., Conclusions: Regardless of the considerable increase in the workload of ophthalmology departments, the healthcare system has been able to reduce both the age and sex standardised incidence of DME and PDR among the diabetic population suffering from a visual impairment associated with this disease., (© 2024 The Authors. Acta Ophthalmologica published by John Wiley & Sons Ltd on behalf of Acta Ophthalmologica Scandinavica Foundation.)

As part of the European Semester, Finland received country-specific recommendations (CSRs) in 2013-2020 that encouraged the reform of national social and health services. These recommendations were part of efforts to balance public finances and implement public-sector structural reforms. Finland has been struggling to reform the national social and health care system since 2005. Only on 1 January 2023 did the new wellbeing services counties become liable for organizing social, health, and rescue services. Studying the CSRs for Finland enables us to understand better what genuinely occurs at the EU member state level. This data-driven case study aims to disclose the relevance of the European Semester for Finland in the pursuit of a national social and health system reform. The mixed-method approach is based on the research tradition of governance, and the study contains features of data sourcing and methodological triangulation. Empirically, the research material consists of Finland's official policy documents and anonymous semi-structured elite interviews. The study highlights that although the received CSRs on the need to restructure social and health services corresponded to Finland's views, their influence to national reform efforts was limited. The CSRs were administered according to the established formal routines, but separately from the national reform preparations. The CSRs, however, delivered implicit steering, which were considered to affect social and health policy making in various ways., Competing Interests: Declaration of competing interest The first author has a permanent post at the Finnish Ministry of Finance. The first two authors have in the past worked for the Finnish government on EU affairs., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

Aim: To outline the organisation and responsibility for health and social care provided to older people in Denmark, Finland and Sweden., Methods: Non-quantifiable data on the care systems were collated from the literature and expert consultations. The responsibilities for primary healthcare, specialised healthcare, prevention and health promotion, rehabilitation, and social care were presented in relation to policy guidance, funding and organisation., Results: In all three countries, the state issues policy and to some extent co-funds the largely decentralised systems; in Denmark and Sweden the regions and municipalities organise the provision of care services - a system that is also about to be implemented in Finland to improve care coordination and make access more equal. Care for older citizens focuses to a large extent on enabling them to live independently in their own homes., Conclusions: Decentralised care systems are challenged by considerable local variations, possibly jeopardising care equity. State-level decision and policy makers need to be aware of these challenges and monitor developments to prevent further health and social care disparities in the ageing population., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Aim: To outline and discuss care transitions and care continuity following hospital discharge of older people with complex care needs in three Nordic cities: Copenhagen, Tampere and Stockholm., Methods: Data on potential pathways following hospital discharge of older people were obtained from existing literature and expert consultations. The pathways for each system were outlined and presented in three figures. The hospital discharge process of the systems was then compared., Results: In all three care systems, the main care path from hospital is to home. Short-term intermediate healthcare can be provided in all three systems, possibly creating additional care transitions; however, once home, extensive home healthcare may prevent further care transitions. Opportunities for continuity of care include needs assessments (all cities) and meetings with the patient about care upon return home (Copenhagen, Stockholm). Yet this is challenged by lack of transfer of information (Tampere) and patients' having to apply for some services themselves (Tampere, Stockholm)., Conclusions: Comparisons of the discharge processes studied suggest that despite individual care planning and short- and long-term care options, transitional care and care continuity are challenged by limited access as some services need to be applied for by the older person themselves., Competing Interests: Declaration of conflicting interestsThe authors have no conflicts of interest to declare.

Background: Denmark, Finland and Sweden pursue equity in health for their citizens through universal health care. However, it is unclear if these services reach the older adult population equally across different socioeconomic positions or living areas. Thus, we assessed geographic and socioeconomic equity in primary health care (PHC) performance among the older adults in the capital areas of Denmark (Copenhagen), Finland (Helsinki) and Sweden (Stockholm) in 2000-2015. Hospitalisations for ambulatory care sensitive conditions (ACSC) were applied as a proxy for PHC performance., Methods: We acquired individual level ACSCs for those aged ≥ 45 in 2000-2015 from national hospitalisation registers. To identify whether the disparities varied by age, we applied three age groups (those aged 45-64, 65-75 and ≥ 75). Socioeconomic disparities in ACSCs were described with incidence rate ratios (IRR) and annual rates by education, income and living-alone; and then analysed with biennial concentration indices by income. Geographic disparities were described with biennial ACSC rates by small areas and analysed with two-level Poisson multilevel models. These models provided small area estimates of IRRs of ACSCs in 2000 and their slopes for development over time, between which Pearson correlations were calculated within each capital area. Finally, these models were adjusted for income to distinguish between geographic and socioeconomic disparities., Results: Copenhagen had the highest IRR of ACSCs among those aged 45-64, and Helsinki among those aged ≥ 75. Over time IRRs decreased among those aged ≥ 45, but only in Helsinki among those aged ≥ 75. All concentration indices slightly favoured the affluent population but in Stockholm were mainly non-significant. Among those aged ≥ 75, Pearson correlations were low in Copenhagen (-0.14; p = 0.424) but high in both Helsinki (-0.74; < 0.001) and Stockholm (-0.62; < 0.001) - with only little change when adjusted for income. Among those aged ≥ 45 the respective correlations were rather similar, except for a strong correlation in Copenhagen (-0.51, 0.001) after income adjustment., Conclusions: While socioeconomic disparities in PHC performance persisted among older adults in the three Nordic capital areas, geographic disparities narrowed in both Helsinki and Stockholm but persisted in Copenhagen. Our findings suggest that the Danish PHC incorporated the negative effects of socio-economic segregation to a lesser degree., (© 2023. BioMed Central Ltd., part of Springer Nature.)

In Finland, descriptive performance indicators point towards increasing and sustained use of the national Kanta Services among adults from May 2010 to December 2022. Adult users have accessed the web-based My Kanta, sent electronic prescription renewal requests to healthcare organizations, and caregivers and parents have acted on behalf of their children. Furthermore, adult users have recorded consents, consent restrictions, organ donation testaments and living wills. In this register study, 11% of the young person cohorts (<18-year-olds) and over 90% of the working age cohorts had used the My Kanta portal in 2021, whereas 74% of the 66-75-year-olds and 44% of the at least 76-year-olds.

The COVID-19 pandemic has plagued health systems in an unprecedented way and challenged the traditional ways to respond to epidemics. It has also revealed several vulnerabilities in countries' health systems and preparedness. In this paper we take the Finnish health system as an example to analyse how pre-COVID-19 preparedness plans, regulations, and health system governance were challenged by the pandemic and what lessons can be learned for the future. Our analysis draws on policy documents, grey literature, published research, and the COVID-19 Health System Response Monitor. The analysis shows how major public health crises often reveal weaknesses in health systems, also in countries which have been ranked highly in terms of crisis preparedness. In Finland, there were apparent regulative and structural problems which challenged the health system response, but in terms of epidemic control, the results appear to be relatively good. The pandemic may have long-term effects on the health system functioning and governance. In January 2023, an extensive health and social services reform has taken place in Finland. The new health system structure needs to be adjusted to take on board the legacy of the pandemic and a new regulatory frame for health security should be considered., Competing Interests: Declaration of Competing Interests The first author has worked in Ministry of Social Affairs and Health from March 2020 to May 2021. The other authors declare that they have no competing interests., (Copyright © 2023. Published by Elsevier B.V.)

Nationwide implementation and adoption of the Prescription Centre and the Patient Data Repository services required 5.5 years since May 2010 in Finland. The Clinical Adoption Meta-Model (CAMM) was applied in the post-deployment assessment of the Kanta Services in its four dimensions (availability, use, behavior, clinical outcomes) over time. The CAMM results on the national level in this study suggest 'Adoption with Benefits' as the most appropriate CAMM archetype.

Aims: Type 1 diabetes has been associated with a significant reduction in life expectancy. Major advances in treatment of type 1 diabetes have been associated with improved survival. However, life expectancy for type 1 diabetes under contemporary care is not known., Methods: Health care registers were used to obtain data on all people with type 1 diabetes in Finland in 1964-2017 and their mortality in 1972-2017. Survival analyses were used to study long-term trends in survival and abridged period life table methods to calculate life expectancy estimates. Causes of death were examined to consider development., Results: Study data included 42,936 persons with type 1 diabetes and 6,771 deaths. Kaplan-Meier curves showed improved survival during the study period. In 2017, the remaining life expectancy at the age of 20 for a person diagnosed for type 1 diabetes was estimated to be 51.64 (95% CI: 51.51, 51.78) years which was 9.88 (9.74, 10.01) years lower than for the general Finnish population., Conclusions: We found improved survival among persons with type 1 diabetes during the last decades. However, their life expectancy remained significantly below that of the general Finnish population. Our results call for further innovations and improvements in diabetes care., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 The Authors. Published by Elsevier B.V. All rights reserved.)

Power and politics are both critical concepts to engage with in health systems and policy research, as they impact actions, processes, and outcomes at all levels in health systems. Building on the conceptualization of health systems as social systems, we investigate how power and politics manifested in the Finnish health system during COVID-19, posing the following research question: in what ways did health system leaders and experts experience issues of power and politics during COVID-19, and how did power and politics impact health system governance? We completed online interviews with health system leaders and experts (n = 53) at the local, regional, and national level in Finland from March 2021 to February 2022. The analysis followed an iterative thematic analysis process in which the data guided the codebook. The results demonstrate that power and politics affected health system governance in Finland during COVID-19 in a multitude of ways. These can be summarized through the themes of credit and blame, frame contestation, and transparency and trust. Overall, political leaders at the national level were heavily involved in the governance of COVID-19 in Finland, which was perceived as having both negative and positive impacts. The politicization of the pandemic took health officials and civil servants by surprise, and events during the first year of COVID-19 in Finland reflect recurring vertical and horizontal power dynamics between local, regional, and national actors. The paper contributes to the growing call for power-focused health systems and policy research. The results suggest that analyses of pandemic governance and lessons learned are likely to leave out critical factors if left absent of an explicit analysis of power and politics, and that such analyses are needed to ensure accountability in health systems., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Purpose: The purpose of this study was to elucidate facilitators and barriers to health system resilience and resilient responses at local and regional levels during the first year of the COVID-19 pandemic in Finland., Design/methodology/approach: The authors utilized a qualitative research approach and conducted semi-structured interviews ( n  = 32) with study participants representing five different regions in Finland. Study participants were recruited using purposive and snowball sampling. All study participants had been in management and civil servant positions during the first year of the pandemic, representing municipalities, municipalities' social and healthcare services, hospital districts and regional state administrative agencies. All interviews were completed remotely from April to December 2021 and the recordings transcribed verbatim. The authors coded the transcripts in ATLAS.ti 9.1 using directed content analysis., Findings: The findings highlighted a wide range of localized responses to the pandemic in Finland. Facilitators to health system resilience included active networks of cooperation, crisis anticipation, transitioning into crisis leadership mode, learning how to incorporate new modes of operation, as well as relying on the competencies and motivation of health workforce. The authors found several barriers to health system resilience, including fragmented organization and management particularly in settings where integrated health care systems were not in place, insufficient preparedness to a prolonged crisis, lack of reliable information regarding COVID-19, not having plans in place for crisis communication, pandemic fatigue, and outflux of health workforce to other positions with better compensation and working conditions., Originality/value: Factors affecting health system resilience are often studied at the aggregate level of a nation. This study offers insights into what resilient responses look like from the perspective of local and regional actors in a decentralized health system. The results highlight that local capacities and context matter greatly for resilience. The authors call for more nuanced analyses on health systems and health system resilience at the sub-national level., (© Emerald Publishing Limited.)

Background: Diabetes is a major public health issue. Because lifetime risk, life expectancy, and years of life lost are meaningful metrics for clinical decision making, we aimed to estimate these measures for type 2 diabetes in the high-income setting., Methods: For this multinational, population-based study, we sourced data from 24 databases for 23 jurisdictions (either whole countries or regions of a country): Australia; Austria; Canada; Denmark; Finland; France; Germany; Hong Kong; Hungary; Israel; Italy; Japan; Latvia; Lithuania; the Netherlands; Norway; Scotland; Singapore; South Korea; Spain; Taiwan; the UK; and the USA. Our main outcomes were lifetime risk of type 2 diabetes, life expectancy in people with and without type 2 diabetes, and years of life lost to type 2 diabetes. We modelled the incidence and mortality of type 2 diabetes in people with and without type 2 diabetes in sex-stratified, age-adjusted, and calendar year-adjusted Poisson models for each jurisdiction. Using incidence and mortality, we constructed life tables for people of both sexes aged 20-100 years for each jurisdiction and at two timepoints 5 years apart in the period 2005-19 where possible. Life expectancy from a given age was computed as the area under the survival curves and lifetime lost was calculated as the difference between the expected lifetime of people with versus without type 2 diabetes at a given age. Lifetime risk was calculated as the proportion of each cohort who developed type 2 diabetes between the ages of 20 years and 100 years. We estimated 95% CIs using parametric bootstrapping., Findings: Across all study cohorts from the 23 jurisdictions (total person-years 1 577 234 194), there were 5 119 585 incident cases of type 2 diabetes, 4 007 064 deaths in those with type 2 diabetes, and 11 854 043 deaths in those without type 2 diabetes. The lifetime risk of type 2 diabetes ranged from 16·3% (95% CI 15·6-17·0) for Scottish women to 59·6% (58·5-60·8) for Singaporean men. Lifetime risk declined with time in 11 of the 15 jurisdictions for which two timepoints were studied. Among people with type 2 diabetes, the highest life expectancies were found for both sexes in Japan in 2017-18, where life expectancy at age 20 years was 59·2 years (95% CI 59·2-59·3) for men and 64·1 years (64·0-64·2) for women. The lowest life expectancy at age 20 years with type 2 diabetes was observed in 2013-14 in Lithuania (43·7 years [42·7-44·6]) for men and in 2010-11 in Latvia (54·2 years [53·4-54·9]) for women. Life expectancy in people with type 2 diabetes increased with time for both sexes in all jurisdictions, except for Spain and Scotland. The life expectancy gap between those with and without type 2 diabetes declined substantially in Latvia from 2010-11 to 2015-16 and in the USA from 2009-10 to 2014-15. Years of life lost to type 2 diabetes ranged from 2·5 years (Latvia; 2015-16) to 12·9 years (Israel Clalit Health Services; 2015-16) for 20-year-old men and from 3·1 years (Finland; 2011-12) to 11·2 years (Israel Clalit Health Services; 2010-11 and 2015-16) for 20-year-old women. With time, the expected number of years of life lost to type 2 diabetes decreased in some jurisdictions and increased in others. The greatest decrease in years of life lost to type 2 diabetes occurred in the USA between 2009-10 and 2014-15 for 20-year-old men (a decrease of 2·7 years)., Interpretation: Despite declining lifetime risk and improvements in life expectancy for those with type 2 diabetes in many high-income jurisdictions, the burden of type 2 diabetes remains substantial. Public health strategies might benefit from tailored approaches to continue to improve health outcomes for people with diabetes., Funding: US Centers for Disease Control and Prevention and Diabetes Australia., Competing Interests: Declaration of interests SKP is currently a full-time employee of AstraZeneca. All other authors declare no competing interests., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Introduction: The study explores regional approaches to integrated care, focusing on regions with regular municipality-based and integrated unified health and social care administration. The aim is to describe a governance approach that supports care integration in the regions., Methods: The study draws on analysis of integrated care governance using an extensive collection of administrative documents ( n = 176) on regional health and social services within 20 specialised care authorities. The document data were supplemented with interviews of national health and social system evaluation officers. In our analysis, we used deductive content analysis and identified conceptual approaches of social and health care integration according to elements of integrated care governance., Results: Overall, integrated care governance was relatively well advanced. All regional authorities had established at least some preconditions for integrated governance. The stage of integration varied in the different elements of integrated care governance. The regions with unified integrated administrations enabled the more advanced models of integrated care., Conclusions: Various models for cooperation between regional health and social care authorities have emerged in the regions to identify good integrated care practices. The study suggests that the applied theoretical framework and presented elements of integrated care governance can be used to monitor development of care integration., Competing Interests: The authors have no competing interests to declare., (Copyright: © 2022 The Author(s).)

Background: A persistent research finding in industrialised countries has been regional variation in medical practices including elective primary hip and knee arthroplasty. The aim of the study was to examine regional variations in elective total hip and knee arthroplasties over time, and the proportions of these variations which can be explained by individual level or area-level differences in need., Methods: We obtained secondary data from the Care Register for Health Care to study elective primary hip and knee arthroplasties in total Finnish population aged 25 + years between 2010 and 2017. Two-level Poisson regression models - individuals and hospital regions - were used to study regional differences in the incidence of elective hip and knee arthroplasties in two time periods: 2010 - 2013 and 2014 - 2017. The impact of several individual level explanatory factors (age, socioeconomic position, comorbidities) and area-level factors (need and supply of operations) was measured with the proportional change in variance. Predictions of incidence were measured with incidence rate ratios. The relative differences in risk of the procedures in regions were described with median rate ratios., Results: We found small and over time relatively stable regional variation in hip arthroplasties in Finland, while the variation was larger in knee arthroplasties and decreased during the study period. In 2010 - 2013 individual socioeconomic variables explained 10% of variation in hip and 4% in knee arthroplasties, an effect that did not emerge in 2014 - 2017. The area-level musculoskeletal disorder index reflecting the need for care explained a further 44% of the variation in hip arthroplasties in 2010 - 2013, but only 5% in 2014 - 2017 and respectively 22% and 25% in knee arthroplasties. However, our final models explained the regional differences only partially., Conclusions: Our results suggest that eligibility criteria in total hip and knee arthroplasty are increasingly consistent between Finnish hospital districts. Factors related to individual level and regional level need both had an important role in explaining regional variations. Further study is needed on the effect of health policy on equity in access to care in these operations., (© 2022. The Author(s).)

Objectives: To analyze the vaccination strategy as part of wider public governing of the COVID-19 pandemic in Finland., Methods: The study provides a synthesis of vaccination strategy and health policy measures, as well as economic challenges, in the COVID-19 pandemic in Finland. The analysis is based on the systematic collection and reviewing of documents and reports. The review was complemented with relevant pandemic and vaccination monitoring data from Finland., Results: The vaccination strategy approved by the Finnish Government in December 2020 prioritised various risk groups and health and social care professionals attending to COVID-19 patients. The Government has purchased COVID-19 vaccines through the EU joint procurement programme. Vaccinations were organised by municipalities and offered free of charge. The Government recommends universal vaccinations, including foreign residents and undocumented migrants. In 2021, the Government adopted a revised COVID-19 hybrid strategy, which aimed to dismantle wide restrictions as a means to control the epidemic. Despite high vaccination coverage, the Omicron variant became widespread in the population. The economic consequences of the pandemic have been less severe than expected., Conclusions: In the approach to manage the pandemic, the vaccination strategy has a central role. Finland has probably benefitted from the EU joint vaccine procurement programme. The rapid launch of the vaccinations was supported by the existing vaccination capacity in municipalities. High vaccine coverage was seen as a key in opening society. Although a relatively high vaccination rate was not able to stop the spread of Omicron in late 2021, it has efficiently curbed serious cases and kept the death rate low., Competing Interests: None declared., (© 2022 Fellowship of Postgraduate Medicine. Published by Elsevier Ltd.)

Provider payment mechanisms were adjusted in many countries in response to the COVID-19 pandemic in 2020. Our objective was to review adjustments for hospitals and healthcare professionals across 20 countries. We developed an analytical framework distinguishing between payment adjustments compensating income loss and those covering extra costs related to COVID-19. Information was extracted from the Covid-19 Health System Response Monitor (HSRM) and classified according to the framework. We found that income loss was not a problem in countries where professionals were paid by salary or capitation and hospitals received global budgets. In countries where payment was based on activity, income loss was compensated through budgets and higher fees. New FFS payments were introduced to incentivize remote services. Payments for COVID-19 related costs included new fees for out- and inpatient services but also new PD and DRG tariffs for hospitals. Budgets covered the costs of adjusting wards, creating new (ICU) beds, and hiring staff. We conclude that public payers assumed most of the COVID-19-related financial risk. In view of future pandemics policymakers should work to increase resilience of payment systems by: (1) having systems in place to rapidly adjust payment systems; (2) being aware of the economic incentives created by these adjustments such as cost-containment or increasing the number of patients or services, that can result in unintended consequences such as risk selection or overprovision of care; and (3) periodically evaluating the effects of payment adjustments on access and quality of care., (Copyright © 2021. Published by Elsevier B.V.)

This paper explores and compares health system responses to the COVID-19 pandemic in Denmark, Finland, Iceland, Norway and Sweden, in the context of existing governance features. Content compiled in the Covid-19 Health System Response Monitor combined with other publicly available country information serve as the foundation for this analysis. The analysis mainly covers early response until August 2020, but includes some key policy and epidemiological developments up until December 2020. Our findings suggest that despite the many similarities in adopted policy measures, the five countries display differences in implementation as well as outcomes. Declaration of state of emergency has differed in the Nordic region, whereas the emphasis on specialist advisory agencies in the decision-making process is a common feature. There may be differences in how respective populations complied with the recommended measures, and we suggest that other structural and circumstantial factors may have an important role in variations in outcomes across the Nordic countries. The high incidence rates among migrant populations and temporary migrant workers, as well as differences in working conditions are important factors to explore further. An important question for future research is how the COVID-19 epidemic will influence legislation and key principles of governance in the Nordic countries., (Copyright © 2021 The Authors. Published by Elsevier B.V. All rights reserved.)

Population ageing with an increasing number of people experiencing complex health and social care needs challenges health systems. We explore whether and how health system reforms and policy measures adopted during the past two decades in Finland and Sweden reflect and address the needs of the older people . We discuss health system characteristics that are important to meet the care needs of older people and analyse how health policy agendas have highlighted these aspects in Finland and Sweden. The analysis is based on "most similar cases". The two countries have rather similar health systems and are facing similar challenges. However, the policy paths to address these challenges are different. The Swedish health system is better resourced, and the affordability of care better ensured, but choice and market-oriented competition reforms do not address the needs of the people with complex health and social care needs, rather it has led to increased fragmentation. In Finland, the level of public funding is lower which may have negative impacts on people who need multiple services. However, in terms of integration and care coordination, Finland seems to follow a path which may pave the way for improved coordination of care for people with multiple care needs. Intensified monitoring and analysis of patterns of health care utilization among older people are warranted in both countries to ensure that care is provided equitably., (© The Author(s) 2022.)

Background: Although the COVID-19 pandemic has significantly boosted the implementation of digital services worldwide, it has become increasingly important to understand how these solutions are integrated into professionals' routine work. Professionals who are using the services are key influencers in the success of implementations. To ensure successful implementations, it is important to understand the multiprofessional perspective, especially because implementations are likely to increase even more., Objective: The aim of this study is to examine health and social care professionals' experiences of digital service implementations and to identify factors that support successful implementations and should be considered in the future to ensure that the services are integrated into professionals' routine work., Methods: A qualitative approach was used, in which 8 focus group interviews were conducted with 30 health and social care professionals from 4 different health centers in Finland. Data were analyzed using qualitative content analysis. The resulting categories were organized under the components of normalization process theory., Results: Our results suggested 14 practices that should be considered when implementing new digital services into routine work. To get professionals to understand and make sense of the new service, (1) the communication related to the implementation should be comprehensive and continuous and (2) the implementation process should be consistent. (3) A justification for the service being implemented should also be given. The best way to engage the professionals with the service is (4) to give them opportunities to influence and (5) to make sure that they have a positive attitude toward the service. To enact the new service into professionals' routine work, it is important that (6) the organization take a supportive approach by providing support from several easy and efficient sources. The professionals should also have (7) enough time to become familiar with the service, and they should have (8) enough know-how about the service. The training should be (9) targeted individually according to skills and work tasks, and (10) it should be diverse. The impact of the implementation on the professionals' work should be evaluated. The service (11) should be easy to use, and (12) usage monitoring should happen. An opportunity (13) to give feedback on the service should also be offered. Moreover, (14) the service should support professionals' work tasks., Conclusions: We introduce 14 practices for organizations and service providers on how to ensure sustainable implementation of new digital services and the smooth integration into routine work. It is important to pay more attention to comprehensive and continuing communication. Organizations should conduct a competence assessment before training in order to ensure proper alignment. Follow-ups to the implementation process should be performed to guarantee sustainability of the service. Our findings from a forerunner country of digitalization can be useful for countries that are beginning their service digitalization or further developing their digital services., (©Janna Nadav, Anu-Marja Kaihlanen, Sari Kujala, Elina Laukka, Pirjo Hilama, Juha Koivisto, Ilmo Keskimäki, Tarja Heponiemi. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 01.12.2021.)

Background: Registries and data sources contain information that can be used on an ongoing basis to improve quality of care and outcomes of people with diabetes. As a specific task of the EU Bridge Health project, we carried out a survey of diabetes-related data sources in Europe., Objectives: We aimed to report on the organization of different sources of diabetes information, including their governance, information infrastructure and dissemination strategies for quality control, service planning, public health, policy and research., Methods: Survey using a structured questionnaire to collect targeted data from a network of collaborating institutions managing registries and data sources in 17 countries in the year 2017., Results: The 18 data sources participating in the study were most frequently academic centres (44.4%), national (72.2%), targeting all types of diabetes (61.1%) covering no more than 10% of the target population (44.4%). Although population-based in over a quarter of cases (27.8%), sources relied predominantly on provider-based datasets (38.5%), fewer using administrative data (16.6%). Data collection was continuous in the majority of cases (61.1%), but 50% could not perform data linkage. Public reports were more frequent (72.2%) as well as quality reports (77.8%), but one third did not provide feedback to policy and only half published ten or more peer reviewed papers during the last 5 years., Conclusions: The heterogeneous implementation of diabetes registries and data sources hampers the comparability of quality and outcomes across Europe. Best practices exist but need to be shared more effectively to accelerate progress and deliver equitable results for people with diabetes., Competing Interests: SL is the Director of the RCGP RSC, as part of his academic work. He has received grants through his institution from AstraZeneca, Eli Lilly, Novo, and Sanofi, for diabetes related research. SC is employed by My Digital Health. CI is employed by Serectrix snc. SP was employed by Telemedica Consulting. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Carinci, Štotl, Cunningham, Poljicanin, Pristas, Traynor, Olympios, Scoutellas, Azzopardi, Doggen, Sandor, Adany, Løvaas, Jarosz-Chobot, Polanska, Pruna, de Lusignan, Monesi, Di Bartolo, Scheidt-Nave, Heidemann, Zucker, Maurina, Lepiksone, Rossing, Arffman, Keskimäki, Gudbjornsdottir, Di Iorio, Dupont, de Sabata, Klazinga and Benedetti.)

Background: A persistent research finding in Finland and elsewhere has been variation in medical practices both between and within countries. Variation seems to exist especially if medical decision making involves discretion and the best treatment cannot be identified unambiguously. This is true for hysterectomy when performed for benign causes. The aim of the current study was to investigate regional trends in hysterectomy in Finland and the potential convergence of rates over time., Methods: We used hospital discharge register data on hysterectomies performed, diagnoses, age, and region of residence to examine hospital discharges for women undergoing hysterectomy in 2001-2018 among total female population aged 25 years or older in Finland. We examined hysterectomy rates among biannual cohorts by indication, calculated age-standardised rates and used multilevel models to analyse potential convergence over time., Results: Altogether 131,695 hysterectomies were performed in Finland 2001-2018. We found a decreasing trend, with the age-adjusted overall hysterectomy rate decreasing from 553/100,000 person years in 2001-2002 to 289/100,000 py in 2017-2018. Large but converging regional differences were found. The correlations between hospital district intercepts and slopes in time ranged from - 0.71 to - 0.97 (p < 0.001) suggesting diminishing variation., Conclusions: Our findings demonstrate that change in hysterectomy practices and more uniformity across regions are achievable goals. Regional variation still exists suggesting differences in medical practices.

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., Competing Interests: The authors declare no conflict of interest., (Copyright © 2020 The Author(s). Published by Wolters Kluwer Health, Inc.)

Objectives: The objective of this study was to describe and analyze the impact of the coronavirus disease COVID-19 on health policy, social- and health system, and economic and financing system to prevent, treat, contain and monitor the virus in Finland., Methods: This study provides early outcomes of health policy measures, social- and health system capacity as well as economic challenges in COVID-19 pandemic in Finland. This paper is based available documents and reports of different ministries and social, health and economic authorities collected online. This was complemented by other relevant pandemic data from Finland., Results: The impact of COVID-19 pandemic on the Finnish society has been unpredictable although it has not been as extensive and massive than in many other countries. As the situation evolved the Government took strict measures to stop the spread of the virus (e.g. Emergency Powers Act). Available information shows that the economic consequences will be drastic also in Finland, albeit perhaps less dramatic than in large industrial economies., Conclusions: Finland has transferred gradually to a "hybrid strategy", referring to a move from extensive restrictive measures to enhanced management of the epidemic. However, health system must be prepared for prospective setback. It is possible, that COVID-19 pandemic has accelerated the development of digital health services and telemedicine in Finnish healthcare system., (© 2020 Fellowship of Postgraduate Medicine. Published by Elsevier Ltd. All rights reserved.)

Aims: Hospitalisations for ambulatory care sensitive conditions are used as an outcome indicator of access to and quality of primary care. Evidence on mortality related to these hospitalisations is scarce. This study analysed the effect of ambulatory care sensitive condition hospitalisations to subsequent mortality and time or geographical trends in the mortality indicating variations in ambulatory care sensitive conditions outcomes. Methods: This retrospective cohort study used individual-level data from national registers concerning ambulatory care sensitive condition hospitalisations. Crude and age-adjusted 365-day mortality rates for the first ambulatory care sensitive condition-related admission were calculated for vaccine-preventable, acute, and chronic ambulatory care sensitive conditions separately, and for three time periods stratified by gender. The mortality rates were also compared to mortality in the general Finnish population to assess the excess mortality related to ambulatory care sensitive condition hospitalisations. Results: The data comprised a total of 712,904 ambulatory care sensitive condition hospital admissions with the crude 365-day mortality rate of 14.2 per 100 person-years. Mortality for those hospitalised for vaccine-preventable conditions was approximately 10-fold compared to the general population and four-fold in chronic and acute conditions. Of the 10 most common ambulatory care sensitive conditions, bacterial pneumonia and influenza and congestive heart failure were associated with highest age-standardised mortality rates. Conclusions: Hospitalisations for ambulatory care sensitive conditions were shown to be associated with excess mortality in patients compared to the general population. Major differences in mortality were found between different types of ambulatory care sensitive condition admissions. There were also minor differences in mortality between hospital districts. These differences are important to consider when using preventable hospital admissions as an indicator of primary care performance.

Women with a history of severe mental illness (SMI) have elevated breast cancer mortality. Few studies have compared cancer-specific mortality in women with breast cancer with or without SMI to reveal gaps in breast cancer treatment outcomes. We compared breast-cancer specific mortality in women with or without SMI and investigated effects of stage at presentation, comorbidity, and differences in cancer treatment. Women with their first breast cancer diagnosis in 1990-2013 (n = 80,671) were identified from the Finnish Cancer Registry, their preceding hospital admissions due to SMI (n = 4,837) from the Hospital Discharge Register and deaths from the Causes of Death Statistics. Competing risk models were used in statistical analysis. When controlling for age, year of cancer diagnosis, and comorbidity, breast cancer mortality was significantly elevated in patients with SMI. Relative mortality was highest in breast cancer patients with non-affective psychosis, partly explained by stage at presentation. Mortality was also significantly elevated in breast cancer patients with a substance use disorder and mood disorder. Patients with SMI received radiotherapy significantly less often than patients without SMI. Our findings emphasize the need to improve early detection of breast cancer in women with SMI and the collaboration between mental health care and oncological teams., Competing Interests: Declaration of Competing Interest This work was partly funded by the Cancer Society in Finland. The Finnish Cancer Society had no involvement in the study design, data collection, findings, or decision to publish. The authors declare that they have no conflict of interest in relation to the subject of this study., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Objective: Individuals with severe mental disorders have an impaired ability to work and are likely to receive income transfer payments as their main source of income. However, the magnitude of this phenomenon remains unclear. Using longitudinal population cohort register data, the authors conducted a case-control study to examine the levels of employment and personal income before and after a first hospitalization for a serious mental disorder., Methods: All individuals (N=50,551) who had been hospitalized for schizophrenia, other nonaffective psychosis, or bipolar disorder in Finland between 1988 and 2015 were identified and matched with five randomly selected participants who were the same sex and who had the same birth year and month. Employment status and earnings, income transfer payments, and total income in euros were measured annually from 1988 to 2015., Results: Individuals with serious mental disorders had notably low levels of employment before, and especially after, the diagnosis of a severe mental disorder. Their total income was mostly constituted of transfer payments, and this was especially true for those diagnosed as having schizophrenia. More than half of all individuals with a serious mental disorder did not have any employment earnings after they received the diagnosis., Conclusions: The current study shows how most individuals in Finland depend solely on income transfer payments after an onset of a severe mental disorder.

Finnish alcohol policy has aimed for decades years to mitigate alcohol-related harm by using high taxation and restrictions on the physical availability of alcohol. The state monopoly on the retail of alcohol has played a central role in reducing the availability of alcohol. In 2011, preparations began for a comprehensive reform of the Alcohol Act 1994. Over time, the issue became highly politicised, lobbied and divisive. It took intense work of two consecutive governments to finalise the reform. The new Alcohol Act came into force in 2018. It expanded the rights of grocery stores to sell alcohol and reduced the administrative burden for on-premise sales. As a result, the state monopoly on the retail of alcohol was weakened, but it still has an important impact on the physical availability of alcohol. The Finnish public health community expected an increase in alcohol sales following the reform because of greater alcohol availability and expected price reductions related to greater competition of sales in grocery stores. However, prices decreased less than expected in 2018, partly due to a simultaneous increase in alcohol taxes. It is difficult to evaluate the impact of the reform at this early stage. However, after the reform, the 10-year (2008-2017) downward trend in the total per capita alcohol consumption was discontinued despite the tax increase. According to preliminary analyses, the change in the law may have slightly increased recorded alcohol sales but the effect was not statistically significant., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: Due to stagnating resources and an increase in staff workload, the quality of Finnish primary health care (PHC) is claimed to have deteriorated slowly. With a decentralised PHC organisation and lack of national stewardship, it is likely that municipalities have adopted different coping strategies, predisposing them to geographic disparities. To assess whether these disparities emerge, we analysed health centre area trajectories in hospitalisations due to ambulatory care sensitive conditions (ACSCs)., Methods: ACSCs, a proxy for PHC quality, comprises conditions in which hospitalisation could be avoided by timely care. We obtained ACSCs of the total Finnish population aged ≥20 for the years 1996-2013 from the Finnish Hospital Discharge Register, and divided them into subgroups of acute, chronic and vaccine-preventable causes, and calculated annual age-standardised ACSC rates by gender in health centre areas. Using these rates, we conducted trajectory analyses for identifying health centre area clusters using group-based trajectory modelling. Further, we applied area-level factors to describe the distribution of health centre areas on these trajectories., Results: Three trajectories - and thus separate clusters of health centre areas - emerged with different levels and trends of ACSC rates. During the study period, chronic ACSC rates decreased (40-63%) within each of the clusters, acute ACSC rates remained stable and vaccine-preventable ACSC rates increased (1-41%). While disparities in rate differences in chronic ACSC rates between trajectories narrowed, in the two other ACSC subgroups they increased. Disparities in standardised rate ratios increased in vaccine-preventable and acute ACSC rates between northern cluster and the two other clusters. Compared to the south-western cluster, 13-16% of health centre areas, in rural northern cluster, had 47-92% higher ACSC rates - but also the highest level of morbidity, most limitations on activities of daily living and highest PHC inpatient ward usage as well as the lowest education levels and private health and dental care usage., Conclusions: We identified three differing trajectories of time trends for ACSC rates, suggesting that the quality of care, particularly in northern Finland health centre areas, may have lagged behind the general improvements. This calls for further investments to strengthen rural area PHC.

In 2015 Finland received an unprecedented number of asylum seekers, ten times more than in any previous year. This surge took place at a time the Finnish Government was busily undergoing a wide-range health and social care reform amid growing nationalist and populist sentiments. Our aim is to explore the governance of a parallel health system for asylum seekers with a right-to-health approach. We concentrated on three right to health features most related to the governance of asylum seeker health care, namely Formal recognition of the right to health, Standards and Coordination mechanisms. Through our qualitative review, we identified three major hurdles in the governance of the system for asylum seekers: 1) Ineffectual and reactive national level coordination and stewardship; 2) Inadequate legislative and supervisory frameworks leading to ineffective governance; 3) Discrepancies between constitutional rights to health, legal entitlements to services and guidance available. This first-time large-scale implementation of the policies exposed weaknesses in the legal framework and the parallel health system. We recommend the removal of the parallel system and the integration of asylum seekers' health services to the national public health care system., (Copyright © 2019 The Authors. Published by Elsevier B.V. All rights reserved.)