Associations between Primary Health Care- and Hospital Utilization among Elderly People in Norway

Summary Background: Geographical variations in health-care utilization in many countries have been an area of debate. Health-care supply factors, population and/or environmental need factors might explain the so-called small-area variations (SAVs). Demographic forecasts indicated a significant increase in the elderly population over the next few decades, with a resulting increased need for health services. The Norwegian Coordination reform and health policies in many western countries suggested that a strengthening of primary health care (PHC) could improve the sustainability of health-care budgets and decrease pressure on hospital services. Studies were however inconsistent in their conclusions regarding whether a higher PHC-utilization can reduce hospital utilization. Aims and study designs: In three papers we have aimed to explore the association between PHC-utilization and utilization of specialized health care (SHC) among elderly people in Norway. In papers 1 and 2 we used a linear multiple regression model, whereas in paper 3 we used a multilevel model. We adjusted for variables known to influence health-care use. Results: We found no or a weak positive association between PHC and SHC use in all three papers. Age, sex, mortality, and a composite of hospital status and municipality population size were identified as effect modifiers, whereas travel time to a local hospital was an important confounder. Socioeconomic variables had little influence on the associations studied. In the multilevel study we found that higher municipality LTC volume was associated with less unplanned medical admissions among the oldest, whereas we found a modest geographical variability in risk for unplanned medical admissions at both the municipality level and the local hospital area level. Conclusions: In a universal health-care system with well-functioning PHC it was not obvious that increased PHC utilisation alone will reduce the pressure on hospital services.