In previous longitudinal studies of mortality and morbidity among foreign-born and native-born Swedes, increased mortality and dissimilarities in mortality pattern were found. The aim of this study is to describe, compare, and analyse the utilization of in-hospital care among deceased foreign- and Swedish-born persons during the years 1987–1999 with focus on four diagnostic categories. The study population consisted of 361,974 foreign-born persons aged 16 years and upward who were registered as living in Sweden in 1970, together with 361,974 matched Swedish controls for each person. Data from Statistics Sweden (SCB) and the National Board of Health and Welfare Centre for Epidemiology, covering the period 1970–1999, was used. Persons were selected if they were admitted to hospital during 1987–1999 and the cause of death was in one of four ICD groups. The results indicate a tendency towards less health care utilization among migrants, especially men, as regards
In previous longitudinal studies of mortality and morbidity among 723,948 foreign-born and native-born Swedes during 1970–1999, increased mortality and dissimilarities in mortality pattern were found [
The differences in mortality and morbidity pattern could indicate differences in utilization of health care among foreign and native-born Swedes; this needs to be further studied.
Earlier studies of utilization of health care among immigrants and the native population have had a predominantly cross-sectional design and have shown diverging results. Lower utilization has been explained as lack of economic resources such as access to health insurance, and the higher utilization could be a consequence of poorer health [
Foreign-born persons living in Sweden today constitute 11.5 percent of the total Swedish population, or slightly more than 1 million persons [
The aim of this study is to describe, compare, and analyse the utilization of health care, measured as the number of hospital admissions and days in hospital, among deceased foreign and Swedish-born persons during the years 1987–1999. The study will focus on four diagnostic categories where significant differences in mortality and morbidity have been shown. The pattern will be discussed in relation to gender, year of birth, and country of birth testing the hypothesis that no differences exist in health care utilization in relation to being foreign-born.
This study is a case-control study based on national register data from a large number of subjects. The study population consisted of 361,974 foreign-born persons aged 16 years old and upward who were registered as living in Sweden in 1970, together with 361,974 matched Swedish controls for each person. This database was originally set up by CAFO (Centre for Labour Market Research) at Växjö University. The data came from Statistics Sweden (SCB) and the National Board of Health and Welfare Centre for Epidemiology, covering the period 1970–1999 and including all foreign-born persons registered as living in Sweden in 1970. The control was matched and was similar in age (±3 year), sex, occupation, and type of employment and lived in the same county in 1970
A Swedish matched control could not be found for 20,518 of the foreign-born persons due to the matching criteria.
Exclusion criteria were if no information was available or if a person had emigrated or migrated back (“remigrated”); thus, in total 163,896 persons were excluded from the database. Persons were then also excluded if the information from the control subject was missing due to migration. The database used for analysis finally consisted of 723,948 persons. Causes of death were registered according to the system of International Classification of Diseases (ICD) revision 8 (1969), 9 (1987), or 10 (1998).
From the database, persons were selected if their registered causes of death were in one of the ICD groups of
The rationale for studying the selected ICD groups was an earlier study showing significant higher numbers of deaths among foreign-born than native Swedes in these groups.
The analysis involved, first, a comparison of foreign-born with a selected cause of death with Swedish-born persons with the same cause of death and secondly a comparison of groups of foreign-born from specific countries or regions with the total group of Swedish-born with the same cause of death. Natives from the following countries have been studied in particular: Denmark, Finland, Norway/Iceland, Yugoslavia, Poland, Germany, other European countries, and non-European countries. The rationale for studying the selected countries was that increased mortality and different pattern of causes of death had been shown among these migrant groups in previous analyses and that they constitute the dominant groups (74.9%) of all migrants in Sweden included in the database during the studied period.
Values are given as numbers, means, and percentages. Comparisons were made by tests of significance with Mann-Whitney
All analyses were performed using SPSS (Statistical Package for Social Sciences), version 11,5.
The Ethics Committee of the University of Lund approved the study after all other Swedish University Ethics Committees had reviewed it.
The total number of deceased foreign-born persons was 41,688 persons, of whom 15,372 had
Number of hospital admissions and days in hospital (mean values) for deceased persons 1987–1999 in four ICD groups.
Diagnosis | Foreign-born | Swedish-born | ||||||||
---|---|---|---|---|---|---|---|---|---|---|
In-patient record | Age 1970 |
Hospital |
Total days in hospital |
Days during the two last |
In patient |
Age 1970 |
Hospital |
Days in hospital |
Days during the two last | |
|
15 372 | 46.5** |
7.2 |
81.0 |
33.1 |
16 651 | 46.9 |
7.2 |
84.1 |
33.1 |
| ||||||||||
|
23 837 | 53.2* |
6.0 |
114.8*** |
48.2** |
26 042 | 54.1 |
5.9 |
110.4 |
46.0 |
| ||||||||||
|
1605 | 41.7* |
4.7**** |
90.5* |
32.1* |
1671 | 44.3 |
5.3 |
91.3 |
29.9 |
| ||||||||||
|
874 |
53.0* |
5.4* |
107.6* |
55.5* |
577 | 58.2 |
6.1 |
158.6 |
78.2 |
The number of days in hospital during the two last hospital admissions was similar for foreign-born and native Swedes for persons with
Multiple-linear regression analysis, with age and being foreign-born as independent variables, showed that being a foreign-born person was a significant factor in relation to number of days in hospital during the two last hospital admissions only in the ICD diagnosis group
Multiple linear regression with age at death (constant) and being/not being a foreign-born person adjusted for age in relation to utilization of hospital care.
Diagnosis | Number of hospital admissions | Total number of days | Number of days at the two last hospital admissions | |||
---|---|---|---|---|---|---|
Significance |
|
Significance |
|
Significance |
|
|
|
||||||
Age | 0.000 | −0.613 | NS | — | 0.000 | 0.864 |
Foreign-born person or not | NS | — | NS | — | NS | — |
| ||||||
|
||||||
Age | 0.000 | −0.782 | 0.000 | 0.058 | 0.000 | 0.299 |
Foreign-born person or not | 0.038 | 0.009 | 0.018 | 0.011 | 0.005 | 0.012 |
| ||||||
|
||||||
Age | 0.000 | −1.199 | NS | — | NS | — |
Foreign-born person or not | 0.012 | −0.043 | NS | — | NS | — |
| ||||||
|
||||||
Age | 0.000 | −0.718 | 0.000 | 0.677 | 0.000 | 0.898 |
Foreign-born person or not | 0.006 | −0.072 | 0.040 | −0.054 | NS | — |
The total number of hospital admissions during 1987–1999 was similar for foreign-born and native Swedes with the two exceptions of persons who had
Multiple-linear regression analysis showed that being a foreign-born person adjusted for age was an independent determining factor for a higher number of hospital admissions in the ICD diagnosis groups
Total number of days in hospital differed between foreign- and Swedish-born persons in three ICD groups:
Being a foreign-born person was an independent determining factor for the total number of days in hospital among persons with
An analysis was also performed of the number of days during the last two admissions to hospital with regard to gender and cause of death classified as ICD groups, see Table
Number of days in hospital (mean) at the two latest admissions to a hospital for deceased persons 1987–1999 in four ICD groups stratified for gender.
Foreign-born men | wedish-born men | Foreign-born women | Swedish-born women | |||||||
---|---|---|---|---|---|---|---|---|---|---|
Diagnosis |
|
|
||||||||
|
Days in hospital |
|
Days in hospital |
|
Days in hospital |
|
Days in hospital |
|||
|
7646 |
30.6 |
8424 | 30.8 |
0.313 | 7726 | 35.5 |
8227 | 35.6 |
0.362 |
|
11 614 | 33.4 |
13 156 | 34.8 |
0.000 | 12 222 | 62.3 |
12 886 | 57.5 |
0.297 |
|
933 | 27.2 |
996 | 26.2 |
0.000 | 672 | 38.9 |
675 | 35.3 |
0.001 |
|
426 | 26.3 |
214 | 41.0 |
0.001 | 448 | 83.3 |
362 | 100.1 |
0.014 |
In relation to gender, foreign-born men had fewer hospital admissions (4.5 versus 5.4,
Number of hospital admissions (mean) in relation to gender for deceased persons 1987–1999 in four ICD groups.
Diagnosis | Foreign-born men | Swedish-born men | Foreign-born women | Swedish-born women | ||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|
Age |
Admissions |
|
Age |
Admissions |
|
|
Age |
Admissions |
|
Age |
Admissions |
|
|
|
7646 | 46.0* |
7.0 |
8424 | 47.8 |
7.0 |
0.717 | 7726 | 47.0 |
7.4 |
8227 | 47.0 |
7.3 |
0.488 |
| ||||||||||||||
|
11 615 | 49.6* |
6.0 |
13 156 | 51.0 |
6.0 |
0.776 | 12 753 | 56.6* |
5.9 |
13 426 | 57.2 |
5.8 |
0.746 |
| ||||||||||||||
|
933 | 38.5* |
4.5 |
996 | 41.0 |
5.4 |
0.024 | 672 | 46.1** |
4.9 |
675 | 49.3 |
5.1 |
0.641 |
| ||||||||||||||
|
426 | 46.1* |
5.3 |
214 | 51.5 |
6.5 |
0.003 | 448 | 59.5*** |
5.5 |
363 | 62.1 |
5.9 |
0.034 |
*
When multiple linear regression analysis was performed separately for men and women, it was found that being a foreign-born person was an independent determining factor for hospital admissions adjusted for age for men in the ICD groups
Analysis of the number of days during the last two admissions to hospital in relation to age revealed a clear tendency, with increasing number of days in hospital with increasing age. A separate analysis of three death age intervals (25–44, 45–64, and 65–84 years) during the period 1992–1999 showed significantly fewer days in hospital in the age interval 65–84 years for foreign-born persons with
Days in hospital during the two latest admissions stratified for age groups among foreign and Swedish-born persons with deceased in four different diagnose groups 1992–1999.
Age (years) | Foreign-born | Swedish-born |
|
||||
---|---|---|---|---|---|---|---|
|
Days in hospital mean | Range |
|
Days in hospital mean | Range | ||
|
|||||||
65–84 | 6294 | 28.8 | 0, 1625 | 7011 | 28.7 | 0, 1305 | 0.889 |
45–64 | 2849 | 26.9 | 0, 528 | 2880 | 26.6 | 0, 902 | 0.621 |
25–44 | 73 | 26.2 | 2, 106 | 71 | 33.5 | 1, 873 | 0.305 |
| |||||||
|
|||||||
65–84 | 9588 | 35.6 | 0, 2532 | 10 636 | 34.7 | 0, 2253 | 0.265 |
45–64 | 2184 | 19.4 | 0, 1477 | 1882 | 17.3 | 0, 1254 | 0.026 |
25–44 | 45 | 12.5 | 0, 188 | 27 | 15.3 | 0, 143 | 0.903 |
| |||||||
|
|||||||
65–84 | 283 | 32.3 | 0, 2054 | 349 | 32.4 | 0, 832 | 0.011 |
45–64 | 365 | 24.8 | 0, 2474 | 354 | 25.5 | 0, 1091 | 0.509 |
25–44 | 71 | 39.7 | 0, 1738 | 47 | 17.1 | 1, 159 | 0.630 |
| |||||||
|
|||||||
65–84 | 275 | 26.5 | 0, 922 | 109 | 32.7 | 1, 539 | 0.015 |
45–64 | 144 | 13.2 | 0, 136 | 64 | 39.8 | 0, 1671 | 0.307 |
25–44 | 2 | 8.5 | 7, 10 | 2 | 8.0 | 4, 12 | 1.00 |
Country/region of birth was not an independent determining factor for number of days in hospital during the two last hospital admissions when multiple-linear regression analysis was performed. Age was an independent determining factor for number of days during the two last hospital admissions in the ICD group
The main finding in the study was the differences in utilization of hospital care between foreign-born and Swedish-born persons in three out of four selected ICD diagnosis groups.
No differences were found for persons with
Differences in days in hospital during the two last admissionswas not influenced by specific country/region of birth.
The similarities in number of admissions, total number of days, and number of days in hospital during the last two admissions, especially in diagnosis groups
An earlier study in Sweden of equity in access to health care for migrants has not indicated any gross pattern of inequity in the utilization of health care [
The studied foreign-born population was mainly persons from the Nordic countries and Europe with a long stay in Sweden and labour migrant background, but it also included refugees. Adaptation to Swedish society and hence adaptation to the same utilization of health care could also explain similarities between foreign- and Swedish-born persons [
The number of days during the last two admissions and thetotal number of days in hospital was higher among foreign-born persons than native Swedes in the ICD group
Migrants showed shorter total time in hospital and for migrant men also fewer admissions to hospital in the ICD diagnosis group
Fewer days in hospital could also be explained if more care among migrants than native Swedes was carried out within the families or close social networks, but this study does not allow for this type of analysis. However, immigrant families have been described as providers of more care, especially for the aged [
Gender differences could explain why foreign-born men but not women had fewer hospital admissions. Gender differences have been discussed, such as that more women have more contacts with physicians, more ability to recall minor health problems, and give more details about symptoms [
Fewer hospital admissions were also found among foreign-born men in the ICD group
In two ICD diagnosis groups,
Previous studies have shown increased mortality and a lower mean age at time of death among foreign-born persons living in Sweden than among native Swedes [
The study of utilization of hospital care among deceased foreign-born and native Swedes 1987–1999 in four selected causes of death was based on data from Statistics Sweden and from the National Board of Health and Welfare Centre for Epidemiology. Causes of death were registered according to the system of International Classification of Diseases (ICD) revision 9 (1997) or 10 (1998).
The four selected cause-of-death groups—
The time period for the study is limited to 12 years (1987–1999) because no data on hospital care was nationally registered before 1987. One important change has been made in the Swedish health care system during this period that can influence the number of total days and days during the two last admissions in hospital. Before 1992 the days elderly persons spent in nursing homes was registered as days in hospital. In 1992 the responsibility for elderly care was transferred from the counties to the local authorities and care in a nursing home was no longer regarded as hospital care. Due to this change the analysis of days during the two last admissions in hospital stratified for age was limited to the period 1992–1999. There are still no national data available in Sweden on care outside of hospital settings such as visits to GP or visits to nurses in primary care centres.
The data used to establish the database originated from the Population and Housing Census of 1970, which is considered to be a total census as it was compulsory by law to take part in the census. No number of dropouts has been estimated for the total census, only for some of the variables such as “occupation,” and Statistics Sweden estimates the dropout on this variable to be 3.5–4.5%. It can only be speculated whether participation in the census is related to health problems and whether there were a number of migrants that did not take part as well as a number of Swedes. Other reasons for migrants not participating in the census could be language problems.
Persons were excluded from the database if they had emigrated, migrated back (remigrated), or if the control subject had migrated or if no information about the person was available. A followup of Finns who had remigrated was performed and showed no differences in mortality from the group of Finns included in the study [
The diagnosis given at death is in most cases not based on autopsy. The autopsy frequency in Sweden has varied during the period and has decreased from 41% for men and 31% for women (1987) to 22% for men and 13% (1998) (The National Board of Health and Welfare, 1998). There could be a bias in diagnosing the right cause death because of a low autopsy frequency. Studies of cancer incidence indicate about 10% higher incidence when autopsy is performed [
In conclusion, the study indicates a tendency towards less health care utilization among migrants, especially men, as regards
This work was supported by grants from the research profile AMER (labour market and ethnic relations) Växjö University, Sweden, the KP Pension & Försäkring (The Pension Insurance Institute of the Co-operative Societies), Sweden, and Rådet för Hälso och-sjukvårdsforskning i södra Sverige HSF (the Council for Health and Health Care Research in Southern Sweden).