Erosion of universal health coverage and trend in the frequency of physician consultations in Spain

Background: We studied the frequency of physician visits in the native and immigrant populations in Spain before and after implementation of a governmental measure to restrict the use of public healthcare services by undocumented immigrants beginning in 2012. Methods: Data were taken from the 2009 and 2014 European Health Surveys carried out in Spain. We investigated any physician consultation in the last 4 weeks before the interview, as well as visits to a family physician, public specialist physician and private specialist physician. We estimated the frequency of visits in 2009 and in 2014 in the native and immigrant populations and the difference in the frequency between the two populations, by calculating the percentage ratio estimated by binomial regression and adjusted for different confounders that are indicators of the need for assistance. Results: The percentage of persons who consulted any physician in 2009 and 2014 was 31.7 and 32.9% in the native population, and 25.6 and 30.1% in the immigrant population, respectively. In the immigrant population, the frequency of visits to the general practitioner and public specialist physician increased, whereas in the native population only public specialist physician visits increased. The frequency of private specialist visits remained stable in both populations. After adjusting for the indicators of need for healthcare, no significant differences between the immigrant and native populations were seen in the frequency of visits, except for private specialist consultations, which were less frequent among immigrants. Conclusion: The restriction of universal healthcare coverage in Spain did not reduce the frequency of physician visits between 2009 and 2014, as the frequency of these consultations was seen to increase in both the native and immigrant populations.This study was supported by a grant from the “Plan Estatal de I + D, Ministry of Science, Innovation and Universities of Spain (no. CSO2017–83180-P)

Rural–urban disparities in the reduction of avoidable mortality and mortality from all other causes of death in Spain, 2003–2019

Aim This study aims to evaluate the trend of avoidable mortality and of mortality from all other causes of death in urban and rural areas in Spain, throughout the first 2 decades of the twenty-first century. Methods Data deaths and population by age and sex, according to the area of residence, were obtained from the National Institute of Statistics. Avoidable mortality refers to premature deaths (≤ 75 years old) for which there is reasonable scientific consensus that they should not occur in the presence of timely health care. In large urban, small urban, and rural areas, annual age-standardized mortality rates from avoidable causes and from all other causes of death were calculated from 2003 to 2019. The annual percentage change (APC) in the mortality rate in each area was estimated using linear regression models and taking age-standardized mortality rates as dependent variable. Results Mortality rates decreased between the beginning and the end of the period analysed. Large urban areas and rural areas showed the largest and smallest reduction in mortality rate respectively. The APC in avoidable mortality was −3.5% in men and −3.0% in women in large urban areas, and −2.7% in men and −2.6% in women in rural areas. The APC in the mortality rate from all other causes of death was −2.4% in men and −1.2% in women in large urban areas, and −1.4% in men and −1.0% in women in rural areas. Conclusion In Spain, avoidable mortality and mortality from other causes of death in rural and urban areas show similar trends, which suggests the presence of a common factor responsible for such findings.Open Access funding provided by Universidad Pública de Navarra. This study was supported by the Universidad Complutense de Madrid (grant No UCM 2022-920743)

Trends and equity in the use of health services in Spain and Germany around austerity in Europe

Background: Following the 2008 economic crisis many countries implemented austerity policies, including reducing public spending on health services. This paper evaluates the trends and equity in the use of health services during and after that period in Spain – a country with austerity policies – and in Germany – a country without restriction on healthcare spending. Methods: Data from several National Surveys in Spain and several waves of the Socio-Economic Panel in Germany, carried out between 2009 and 2017, were used. The dependent variables were number of doctor’s consultations and whether or not a hospital admission occurred. The measure of socioeconomic position was education. In each year, the estimates were made for people with and without pre-existing health problems. First, the average number of doctor’s consultations and the percentage of respondents who had had been hospitalized were calculated. Second, the relationship between education and use of those health services was estimated by calculating the difference in consultations using covariance analysis – in the case of number of consultations – and by calculating the percentage ratio using binomial regression – in the case of hospitalization. Results: The annual mean number of consultations went down in both countries. In Spain the average was 14.2 in 2009 and 10.4 in 2017 for patients with chronic conditions; 16.6 and 13.5 for those with a mental illness; and 6.4 and 5.9 for those without a defined illness. In Germany, the averages were 13.8 (2009) and 12.9 (2017) for the chronic group; 21.1 and 17.0 for mental illness; and 8.7 and 7.5 with no defined illness. The hospitalization frequency also decreased in both countries. The majority of the analyses presented no significant differences in relation to education. Conclusion: In both Spain and Germany, service use decreased between 2009 and 2017. In the first few years, this reduction coincided with a period of austerity in Spain. In general, we did not find socioeconomic differences in health service use.This study was supported by a grant from the “Plan Estatal de Investigación Científica y Técnica y de Innovación”, Ministry of Economy, Industry and Competitiveness of Spain (no. CSO2017–83180-P)

Cardiovascular mortality and risk behaviours by degree of urbanization before, during and after the economic crisis in Spain

BACKGROUND: To estimate the relationship of the degree of urbanization to cardiovascular mortality and to risk behaviours before, during and after the 2008 economic crisis in Spain. METHODS: In three areas of residence - large urban areas, small urban areas and rural areas - we calculated the rate of premature mortality (0-74 years) from cardiovascular diseases before the crisis (2005-2007), during the crisis (2008-2010 and 2011-2013) and after the crisis (2014-2016), and the prevalence of risk behaviours in 2006, 2011 and 2016. In each period we estimated the mortality rate ratio (MRR) and the prevalence ratio, taking large urban areas as the reference. RESULTS: In men, no significant differences were observed in mortality between the two urban areas, while the MRR in rural areas went from 0.92 [95% confidence interval, 0.90-0.94) in 2005-2007 to 0.94 (0.92-0.96) in 2014-2016. In women, no significant differences were observed in mortality between the rural and large urban areas, whereas the MRR in small urban areas decreased from 1.11 (1.08-1.14) in 2005-2007 to 1.06 (1.02-1.09) in 2014-2016. The rural areas had the lowest prevalence of smoking, obesity and physical inactivity in men, and of obesity in women. No significant differences were observed in smoking or physical inactivity by area of residence in women. CONCLUSION: The pattern of cardiovascular mortality by degree of urbanization was similar before and after the crisis, although in women the excess mortality in small urban areas with respect to large urban areas was smaller after the crisis. The different pattern of risk behaviours in men and women, according to area of residence, could explain these findings.This work was supported by the Instituto de Salud Carlos III (PI16/00455) y el European Regional Development Fund. The funders had neither role in study design, data collection, analysis, decision to publish, nor preparation of the manuscript.S

Mortality in working-age population during the Great Recession and austerity in Spain

OBJECTIVE: To analyze the mortality trend in Spain before, during and after the economic crisis and austerity policies in the working-age population. METHODS: From 2005 to 2016 we calculated the annual all-cause mortality rate and the annual mortality rate from the main causes of death in the population aged 15 to 64. We also estimated the linear trends in mortality rates during four time intervals-2005-2007 (before crisis), 2008-2010 (first part of the crisis), 2011-2013 (second part of the crisis and implementation of austerity policies) and 2014-2016 (after the crisis)- by the annual percentage change (APC). RESULTS: The all-cause mortality rate in men and women showed the greatest decline in 2008-2010 and the smallest decline in 2014-2016. The decline in 2011-2013 was higher than in 2014-2016. The APCs in 2005-2007, 2008-2010, 2011-2013 and 2014-2016 were -2.8, -4.1, -3.0 and -1.5 in men and -1.0. -2.1, -1.1 and -0.6 in women, respectively, although the APC in 2014-2016 in women was not significant. In 2014-2016, cancer mortality showed the largest decrease, mortality from cardiovascular diseases (men), respiratory diseases and traffic accidents reversed and showed an upward trend, and the downward trend in mortality from infectious diseases and digestive diseases was equal to or greater than that observed before the crisis. CONCLUSION: The decline in all-cause mortality in the working-age population during the economic crisis and the introduction of austerity measures was greater than that observed before and after the economic crisis. The slowing of the decline after the crisis was due to the reversal of the trend in mortality from cardiovascular and respiratory diseases.This work was supported by the Instituto de Salud Carlos III (PI16/00455) and the European Regional Development Fund.S

Use of health services according to income before and after elimination of copayment in Germany and restriction of universal health coverage in Spain

Background: In Germany copayment for medical consultation was eliminated in 2013, and in Spain universal health coverage was partly restricted in 2012. This study shows the relationship between income and the use of health services before and after these measures in each country. Methods: Data were taken from the 2009 and 2014 Socio-Economic Panel conducted in Germany, and from the 2009 and 2014 European Health Surveys in Spain. The health services investigated were physician consultations and hospital admissions, and the measure of socioeconomic position used was household income. The magnitude of the relationship between socioeconomic position and the use of each health service in people from 16 to 74 years old was estimated by calculating the percentage ratio using binary regression. Results: In Germany, after adjusting for age, sex, and need for care, in the model comparing the two lower income categories to the two higher categories, the percentage ratio for physician consultation was 0.97 (95% CI 0.96–0.99) in 2009 and 0.98 (95% CI 0.97–0.99) in 2014, and the percentage ratio for hospitalization was 1.01 (95% CI 0.93–1.10) in 2009 and 1.16 (95% CI 1.08–1.25) in 2014. In Spain, after adjusting for age, sex, and self-rated health, the percentage ratio for physician consultation was 0.99 (95% CI 0.94–1.05) in 2009 and 1.08 (95% CI 1.03–1.14) in 2014, and the percentage ratio for hospitalization was 1.04 (95% CI 0.92–1.18) in 2009 and 0.99 (95% CI 0.87–1.14) in 2014. Conclusion: The results suggest that elimination of the copayment in Germany did not change the frequency of physician consultations, whereas after the restriction of universal health coverage in Spain, subjects with lower incomes had a higher frequency of physician consultations.This study was supported by a grant from the “Plan Estatal de I + D + I”, Ministry of Economy and Competitiveness of Spain (no. CSO2013–40877-P)

Socioeconomic position and health services use in Germany and Spain during the Great Recession.

The relationship of socioeconomic position with the use of health services may have changed with the emergence of the economic crisis. This study shows that relationship before and during the economic crisis, in Germany and in Spain.Data from the 2006 and 2011 Socio-Economic Panel carried out in Germany, and from the 2006 and 2011 National Health Surveys carried out in Spain were used. The health services investigated were physician consultations and hospitalization. The measures of socioeconomic position used were education and household income. The magnitude of the relationship between socioeconomic position and the use of each health services was estimated by calculating the percentage ratio by binary regression.In Germany, in both periods, after adjusting for age, sex, type of health insurance and need for care, subjects belonging to the lower educational categories had a lower frequency of physician consultations, while those belonging to the lower income categories had a higher frequency of hospitalization. In the model comparing the two lower socioeconomic categories to the two higher categories, the percentage ratio for physician consultation by education was 0.97 (95%CI 0.96-0.98) in 2006 and 0.96 (95%CI 0.95-0.97) in 2011, and the percentage ratio for hospitalization by income was 1.14 (95%CI 1.05-1.25) in 2006 and 1.12 (95%CI 1.03-1.21) in 2011. In Spain, no significant socioeconomic differences were observed in either period in the frequency of use of these health services in the fully adjusted model.The results suggest that the economic crisis did not alter accessibility to the health system in either country, given that the socioeconomic pattern in the use of these health services was similar before and during the crisis in both countries

Categories included in each indicator of socioeconomic position.

<p>Categories included in each indicator of socioeconomic position.</p