Use of hospital and long-term institutional care services in relation to proximity to death among older people in Finland.

Using nationally-representative register data for older people in Finland in period 1998-2003 we study how the number of days in acute hospital and long term institutional care services varies by age and proximity to death and how these use patterns change as mortality improves. Acute health care use depends more on proximity to death than on age, a finding often interpreted as showing that the need for care services among older people will be substantially less than would be expected based on the likely increase in population numbers. We show that this assumption is too optimistic for three reasons: (1) the increase in population numbers will be concentrated mainly among the "old old" where use of services is substantial; (2) earlier findings of much lower use of acute care services by older than younger people who are close to death are not observed; and (3) any savings in acute care are more than offset by greater use of residential long-term care (LTC). The main consequences of improving mortality are: (1) to postpone rather than to reduce overall demand for health care; (2) to shift the balance of care from acute to long-term care services; and (3) to increase considerably the average age of time spent in care. We further construct a new indicator "care-free life expectancy" based on number of days in hospital and long-term care to summarise care use patterns for cohorts under a range of plausible mortality assumptions. As mortality improves, lifetime use of acute hospital and long-term care after age 65 and the proportion of life spent in LTC increases for later cohorts, but the proportion spent in acute care decreases slightly.