Chronic Diseases and Inpatient Care among the Middle-Aged and Chronic Diseases and Inpatient Care among the Middle-Aged and Elderly People in Indonesia Elderly People in Indonesia

Background : The prevalence of chronic diseases contributes to an increase in healthcare utilization that results in increased vulnerability in middle and old age. This study aims to determine the factors that in ﬂ uence in-patient care among the middle-aged and elderly. Methods : We conducted a repeated cross-sectional study using the Indonesia Family Life Survey 4 (IFLS 4) in 2007 (10,754 participants) and IFLS 5 in 2014 (12,058 participants). Chronic diseases include hypertension, diabetes mellitus, tuberculosis, asthma, coronary heart diseases, liver diseases, cancer, arthritis, gout, high cholesterol, prostate illness, kidney diseases, and digestive diseases. We used the frequency distribution, and logistic regression to analyze the data. Results : The chronic disease that had the highest prevalence was hypertension among 11.7% ¡ 12.2% of the middle-aged and 18.7% e 20.6% of the elderly. The prevalence of diabetes mellitus increased almost twice among the elderly (3.4% e 6.1%). In 2007, the main predictors of in-patient care among the middle-aged were liver diseases. For the elderly, the main predictors were strokes. In 2014, the main predictors of inpatient care among the middle-aged were heart diseases. However, among the elderly, the main predictors were cancers. Conclusion : The number of chronic diseases and the utilization of inpatient care increased among the middle-aged and the elderly. The main predictors of inpatient care were different between both age groups. This study supports the appropriate methods used for chronic disease prevention programs for middle-aged and elderly in Indonesia.


Introduction
W orldwide, chronic diseases are the leading cause of mortality and have become a global burden.The increase in chronic diseases is related to poor lifestyles, such as lack of exercise, consuming unhealthy food, tobacco use, poverty, and excessive alcohol consumption [1,2].Such a lifestyle contributes to the prevalence of chronic diseases in the community.However, the increase in the aging population has contributed to the higher number of people with chronic diseases [3].
In Indonesia, chronic diseases are shifting from communicable diseases to non-communicable diseases.In 1990, the leading cause of mortality was communicable diseases at approximately 56% and non-communicable diseases at approximately 37%.Since 2000, non-communicable diseases have become the leading cause of mortality contributing to 49% of cases [4].Since 2016, mortality caused by non-communicable diseases has increased to 73% [5].Chronic diseases have significant health-related impacts, such as premature death, disability, poor self-rated health [2,6] decreased quality of life, and economy-related impacts, such as increased health expenditure due to increased demand for medication and access to healthcare services, including outpatient and inpatient care, work loss, and reduced labor market participation [7].
A previous study on the trend of chronic diseases in the United States from 1998 to 2008 found that the percentage of elderly people with one or more chronic diseases increased from 86.9% in 1998 to 92.2% in 2008, and the percentage of elderly people with 4 or more chronic diseases increased from 11.7% in 1998 to 17.4% in 2008 [8].Similarly, a study in The Netherlands from 2004 to 2011 found that the prevalence of chronic diseases observed by the general practice registration increased from 34.9% to 41.8% and the prevalence of chronic diseases based on self-reported diseases increased from 41.0% to 46.6% in 2001e2011 [9].
Access to healthcare services, including inpatient and outpatient care, is needed to treat diseases.Some researchers studied the relationship between chronic diseases and healthcare utilization among adults and the elderly.Hospital admissions due to Congestive Heart Failure (CHF) were the highest, followed by secondary diseases, such as Chronic Obstructive Pulmonary Disease (COPD) [10].
There are insufficient studies related to chronic diseases and inpatient care in the middle-aged.The benefit of this study is to increase awareness of suffering from chronic diseases in order to improve lifestyles and manage health status.Besides that, the government can develop a prevention program for chronic diseases.Therefore, it is important to study the prevalence of chronic diseases among people of these ages.This study aims to know the trend of chronic diseases and inpatient care and to determine the factors influencing inpatient care among the middle-aged and elderly.

Study design
This was a repeated cross-sectional study using secondary data taken from the Indonesia Family Life Survey 4 (IFLS 4) performed in 2007/2008 and IFLS 5 performed in 2014/2015.The 5th wave is the newest IFLS survey.This longitudinal survey represents 83% of the Indonesian population.However, only 13 provinces are involved in the survey.Detailed information about the study design of the IFLS can be obtained at http://www.rand.org/labor/FLS/IFLS.html.The first process of data collection was conducted by identifying the possibility of the number of eligible participants from IFLS 4 and IFLS 5.The study sample only selected participants who were 40 years old and above.In each survey, the participants were divided into two groups: middle-aged and elderly.In the second process, the study identified the availability of variables in each participant.As a result, the study excluded 406 (3.1%) participants from IFLS 4 and 1853 (13.3%) from IFLS 5 because of missing data.Finally, the total number of participants in IFLS 4 was 10,754: 7781 were middle-aged (40e59 years old) and 2973 were elderly (60 years old and above).The total number of participants in IFLS 5 was 12,056 (9273 were middle-aged and 28,733, were elderly).

Measurements
The outcome of this study was to assess inpatient care.The operational definition of inpatient care was the participant's experience of receiving patient care at a hospital, Puskesmas (Public Health Care), clinic during the previous 12 months.The participant who experienced inpatient care was categorized as "yes" and the participant with no experience was categorized as "no".
The type of chronic diseases for each participant was diagnosed by a doctor.In IFLS 4, ten types of chronic diseases were included including hypertension, diabetes mellitus, tuberculosis, asthma, coronary hearth diseases, liver diseases, stroke, cancer, arthritis, and gout.As for IFLS 5, thirteen chronic diseases were included, namely: hypertension, diabetes mellitus, tuberculosis, asthma, coronary hearth diseases, liver diseases, stroke, cancer, arthritis, high cholesterol, prostate illness (only for male), kidney diseases, and digestive diseases.Each type of chronic disease was categorized into "yes" and "no".
The basic recorded characteristics of participants included gender, educational background, marital status, religion, and socioeconomic status (SES).SES identified the value of their house, land, livestock, and vegetation of economic value, vehicles, household appliances, household furniture, saving or deposits, receivables, jewelry, and other assets.The total values were divided into four quartiles.The first third quartile were categorized into low SES and the fourth quartile were categorized into high SES.
For health status, the variables included self-rated health (SRH), depression, fall experience, traffic accidents, and chronic diseases.SRH was assessed by the question "in general, how is your health?"This variable was presented by "healthy" and "unhealthy."Depression was assessed by the Center of Epidemiological Studies Depression Scale-10 (CESD-10) tool.This tool has 10 items with a total score of 30.A score greater than 10 indicated depression [11].

Data analysis
The basic characteristics of the participants were stratified by age group: middle-aged and elderly in each wave.The trend of chronic diseases was presented by disease prevalence.The trend of inpatient care utilization was presented based on the type of diseases and period of survey time.The results were presented by bar graph in each wave for the prevalence of the disease type and inpatient care.The basic characteristics of participants, trend of chronic diseases, and inpatient care were analyzed using descriptive analysis.The chi-square test was used to determine the inpatient care differences between the middle-aged and elderly in each wave.For the multivariate analysis, we used logistic regression to determine the type of diseases that contributed to increased inpatient care among the middle-aged and elderly groups in each wave.The references for multivariate analysis were people who did not have the type of disease.In this analysis, prostate illness was excluded since it occurs only in men.The 95% confidence interval (CI) was used to report the percentage of odds ratio.All statistical analyses were performed using SPSS version 19.00 for Windows operating systems.

Ethical approval
The author analyzed the secondary data from the IFLS 4 and IFLS 5.The dataset is freely accessible after registering on the website of RAND Labor and Population at http://www.rand.org/labor/FLS/IFLS. html.The questionnaires and procedures were reviewed and approved by the Institutional Review Board (IRB) at the RAND Corp. in the United States and Universitas Gadjah Mada (UGM) in Indonesia.Written informed consent was obtained from all participants in the first interview.All personal records from the participants were anonymous and confidential.

Results
The basic characteristics of the participants are shown in Table 1.The number of men and women in each group is almost similar.In both surveys, the highest educational background among the middleaged and elderly was elementary school.Regarding marital status, among the middle-aged, more than 80% were married, among the elderly, more than 60% were married, and around 30% were widow or widower.This study did not explore the reasons and cause for being a widow or widower.
In this study the majority of participants (more than 87%) were Muslim.More than 70% participants indicated that they were of a low socioeconomic status.
In Fig. 2, the third rank of inpatient care utilization based on the type of chronic disease among the middle-aged in ILFS 4 were liver, stroke, and hearth diseases.However, among the middle-age in ILFS 5, the rank was shifting to stroke, heart diseases, and cancer.For the third rank of inpatient care utilization among the elderly in IFLS 4, there were stroke, heart diseases, and diabetes mellitus.In the last survey IFLS 5, it changed to cancer, tuberculosis, and liver diseases.In IFLS 5, in men, prostate illness had the highest percentage in inpatient care utilization.Surprisingly, elderly patients with tuberculosis had an increase in inpatient care utilization by more than 100% (from 7.7% to 18.8%).
In IFLS 4(2007), the following variables had significant differences in terms of inpatient care utilization between the middle-aged and elderly: SRH, fall experience, hypertension, diabetes mellitus, coronary heart diseases, stroke, and gout (p < 0.05).For depression, accidents, liver diseases, cancer, and arthritis variables, had significant differences in terms of inpatient care utilization in the middleaged group.
In IFLS 5 (2014), the variables that had significant differences with inpatient care utilization for middle age and elderly groups were SRH, fall experience, accident, hypertension, diabetes mellitus, coronary heart diseases, liver diseases, stroke, cancer, high cholesterol, prostate illness, and digestive diseases.However, depression and asthma had a significant difference with the inpatient care utilization in the middle-aged group and only tuberculosis and arthritis had a significant difference in the elderly group (Table 2).
Table 3 shows that in 2007, the main predictor of inpatient care among the middle-aged was liver disease (OR: 6.25; CI 95%: 2.85e13.75).Contrarily, patients with diabetes mellitus had reduced inpatient care utilization (OR: 0.24; CI 95%: 0.14e0.39).As for the elderly, the main predictor of inpatient care was gout (OR: 1.97; CI 95%: 1.06e3.69).However, gout disease was not available in the last survey, so when compared to the survey in 2014, hypertension become the main predictor of inpatient care for the elderly (OR: 1.66; CI 95%: 1.04e2.65).In 2014, coronary heart diseases were the main predictor of inpatient care among the middleaged (OR: 3.66; CI 95%: 2.44e5.50).However, among the elderly, the main predictor of inpatient care was cancer (OR: 4.17; CI 95%: 1.34e13.04).Overall, the predictors of inpatient care utilization have changed over time.Among the middle-aged, the predictors have changed from liver diseases to heart diseases and from gouts to cancers in the elderly.

Discussion
This study showed the trend of prevalence of chronic diseases in the middle-aged and elderly.In each wave, the prevalence of chronic diseases increased in both groups.Overall, the list of chronic diseases is dominated by non-communicable diseases.A previous study found that the increasing risks of cardiovascular diseases (CVD), lung and gastric cancers, type 2 diabetes, and chronic obstructive pulmonary diseases (COPD) were associated with people who had low socioeconomic status (SES) and/or lived in low and middle income countries (LMIC) [12].However, The Ministry of Health, Republic of Indonesia stated that the prevalence of non-communicable diseases in Indonesia were related to reduced consumption of vegetables and fruits, but high consumption of calories, natrium, and tobacco use.Moreover, the diseases were also related to insufficient physical activity [4].A previous study found that smoking status significantly contributed to the increased prevalence of heart disease [13].Communicable diseases were successfully reduced by vaccination program, vector control, improved water sanitation, surveillance,   change of behavior, and case management of the diseases [14].Prevalence of hypertension was the highest in all groups.This study is consistent with a previous study that showed that hypertension had the highest prevalence in the elderly (60.5%) [3,15].Hypertension is a unique disease which can be an early symptom for other diseases or a complication arising from other diseases.The main risk factor for stroke and heart diseases is hypertension [16].
This study shows that the utilization of inpatient care increased in the middle-aged and elderly.This study is consistent with a previous study that showed that, in the elderly, the inpatient care utilization increased with age [17,18].However, the number of utilization of inpatient care in Indonesia (less than 6%) is lower than that of some countries in ASEAN such as Malaysia (more than 8.2%) [19] and Vietnam (15.5%) [20].The possible reason is that the ability to access health care services are lower due to low coverage of health care insurance in 2014 [11].
Usually, Indonesian people consider themselves to be healthy if they have no disease.However, a previous study among the elderly people found this demographic had multiple conditions including multimorbidity, disability, and geriatric syndrome.However, disability was the main predictor for hospital admission (AOR: 2.03; CI 95%: 1.64e2.51)[21].Even though the trend of chronic diseases changed from communicable diseases to non-communicable diseases, the highest percentage of inpatient care utilization was the elderly who suffered from tuberculosis.The first reason is related to the decline of immunology protection.The second one is that the clinical symptoms of tuberculosis in the elderly is non-specific [22].The increase in inpatient care utilization is associated with multidrug-resistant tuberculosis (MDR-TB) as well as extensively drugresistant tuberculosis (XDR-TB) [23].
In IFLS 4, the main predictor of inpatient care in the middle-aged was liver diseases.This is consistent with the distribution frequency that showed that patients with liver diseases had the highest percentage of inpatient care utilization.In IFLS 5, the predictors of inpatient care have changed from liver diseases to strokes and cancers.In IFLS 5, heart diseases were still dominant as a predictor for inpatient care.A study by Husaini et al., in 2016, found that the precursors of heart diseases were hypertension, chronic obstructive pulmonary disease, chronic kidney disease, atrial fibrillation, and coronary artery diseases [24].Those diseases appear in ages starting from 35 to 40 years [25].All types of diseases need more complex management and treatment.
In the elderly, gout was a predictor of inpatient care utilization.The symptoms of gout include severe pain, redness, tenderness, warmth, and swelling.Sometimes, it will follow trauma or injury.Such symptoms encourage the elderly to use inpatient care.Unfortunately, in cases that need prolonged treatments, inpatient care costs too much and becomes an economic burden [18].For the next period in IFLS 5, the main predictor of inpatient care utilization in the elderly was cancer.In a previous study on predicting inpatient readmission in the elderly by Lin et al., in 2016, it was found that metastatic cancer is associated with a five times higher risk of inpatient readmission, while non metastatic cancer is associated with a two times higher risk of inpatient readmission [26].Utilization of inpatient care is needed not only for chemotherapy but also for relieving uncontrolled symptoms.

Strength and limitation
This is the first study to explore the trend of inpatient and chronic diseases study in the middleaged and elderly groups.The limitation is this study only focused on type of chronic diseases and study disregarded other risk factor such as demographic variables, social support, healthy life style, and health status as a whole.Finally, this cross-sectional study design cannot identify a causal relationship between chronic diseases and inpatient care.
The implication of this study is to predict the prevalence of chronic diseases in the future so the government can develop appropriate prevention programs, and healthcare providers can prepare the facilities and increase the skills of care providers to offer health services of a high quality.
Overall, this result is an alarm call for middleaged people to be aware of the potential of suffering chronic diseases.Especially for elderly people with chronic diseases, they can maintain their health condition and improve their quality of life.However, it is not only middle-age and elderly people responsible but also their families.For prevention programs, based on this study, the government should focus on non-communicable diseases.For elderly people, health education about tuberculosis is still important.
Regarding inpatient care, the results can help advise hospital management on suitable services in accordance with existing disease trends.It also provides basic information for developing health promotion and prevention programs related to the diseases.In the future, the government will be able to develop services related to the type of disease in various circumstances such as the normal, emergency, or Covid-19 pandemic situation.Future research should consider examining the health impact of chronic diseases among the middle-aged and elderly in Indonesia.

Conclusions
The number of chronic diseases and the utilization of inpatient care increased in the middle-aged and the elderly.The main predictors of inpatient care were different between both of the age groups.Among the middle-aged, the predictors have changed from liver diseases to heart diseases and from hypertension to cancers among the elderly.Therefore, this study supports the appropriate methods used for chronic disease prevention programs for the middle-aged and elderly in Indonesia.

Table 1 .
Characteristics of the participants.

Table 2 .
Bivariate analysis of health status and inpatient care utilization.

Table 3 .
Multivariate logistic regression analysis of inpatient care utilization.