Our study showed that there are significant differences in odds of receiving home health care, depending on age, gender and multimorbidity level. Being a woman was associated with significantly higher odds of receiving home health care, especially if aged above 80 years. Increasing multimorbidity level increased the odds of receiving home health care to a similar degree in both genders.
Interestingly, we found that a number of patients receiving home health care had a low level of multimorbidity or no morbidity at all. Most of them were older people, and there were a higher number of women in this group.
Our study included all individuals receiving home health care in the county during 1 year. The strength of our study is that we could analyse multimorbidity of all individuals aged 65 and above on an individual level. It enabled us to discover that a large number of individuals without morbidity or with low morbidity used home health care services. The weakness of our study is that in order to see the effects of the PHC centres we had to exclude about 12 % of individuals over 65 years who changed PHC centre or died (most of them) during the period under study. Another weakness is that ACG Case-mix is dependent on diagnoses. Although we have used all the patients’ PHC and SHC diagnoses, if the diagnosis made is not correct, the multimorbidity level assigned might not be valid. In this case home health care might be based on morbidity, even if we did not find any morbidity for this patient in our data set. We did not validate the diagnosis. However, making a diagnosis during the consultations is mandatory, but how complete it is may vary between physicians. An earlier study from Sweden has, however, shown that 75 % of inhabitants had a diagnosis in PHC, and about 90 % of consultations resulted in a diagnosis . In Blekinge County ACG was not used for reimbursement at the time of study, but in other counties a clear increase in diagnosis prevalence, especially at the physician level, was observed when ACG was introduced as a part of reimbursement system . Other earlier studies from different countries have shown that ACG is a good instrument for measuring multimorbidity [13, 18, 19]. However, ACG based multimorbidity level is limited only to diagnosis, so other factors like functional ability level are not included. It is a limitation of our study, as some of the patients with lower functional ability can have more home health care, even if they do not have diagnoses. On the other hand, functional ability is to a certain extent associated with morbidity and should be seen in higher RUB.
Home health care is an integral part of PHC, and it has significance for older patients who cannot come to the PHC centre. In a study from Stockholm patients who had regular home health care provided by district nurses did not need to consult the GPs as often as other patients . Home health care is also used in order to prevent deterioration of their health. A study in Germany showed for example that preventive home visits significantly decreased the number of patient falls . With increasing age the risk of injury connected with falls increases, and a high percentage (more than 40 %) of falls result in hospitalisation . The problem for the elderly with multimorbidity is hospitalisation, but also increased need of institutionalisation.
Our study shows that higher age and higher multimorbidity level were associated with higher odds of receiving home health care both for men and women. However, a higher proportion of elderly women than elderly men received home health care, although they had same multimorbidity level. Earlier studies have shown that older men more often than women identify their spouses as caregivers . This can partly explain why older women more often receive home health care. As women live longer than men, they often take care of their spouses and can help them with contacts to PHC centres, so home health care is unnecessary. The situation for the elderly women might be different when they need health care, as they more often do not have help from a spouse. Elderly women are more often hospitalised, have longer stays at hospitals and have higher rates of most chronic diseases than men . Other studies from Blekinge County showed that multimorbidity level is positively correlated with number of consultations in PHC , and that women and individuals with higher multimorbidity level were more often actively listed at PHC [23, 24]. In our study we found that even home health care utilisation is associated with multimorbidity level and gender, especially in older women.
The fact that women use more health care, especially PHC, has previously been reported in other studies [25, 26]. Women also more often feel that their health is poor . We found that women have a higher level of multimorbidity than men, especially the older ones. It is well-known that with increasing age the utilisation of healthcare increases, but the increase is higher for women . Older women have more doctor visits to PHC and generally more visits to PHC, but older men have more visits to specialists . Our results show that older women have higher odds of receiving home health care than older men, even after adjusting for age. Our study has shown, however, that many individuals receiving home health care have no or very low level of multimorbidity. We have not found any direct answer to this in our study. One option may be that there are factors other than diseases, like higher age, perceived subjective health, functional ability level or isolation, which require the necessity of home health care. Further studies are needed in order to identify these factors, in order to be able to provide the whole picture of home health care use.