Eu opean Jou nal o Public Heal h, Vol. 35, No. 2, 216–227
© The Au ho (s) 2025. Published by Ox o d Uni e si y P ess on behal o he Eu opean Public Heal h Associa ion.
This is an Open Access a icle dis ibu ed unde he e ms o he C ea i e Commons A ibu ion-NonComme cial License (h ps://c ea i ecommons.
o g/licenses/by-nc/4.0/), which pe mi s non-comme cial e-use, dis ibu ion, and ep oduc ion in any medium, p o ided he o iginal wo k is p ope ly
ci ed. Fo comme cial e-use, please con ac [email p o ec ed] o ep in s and ansla ion igh s o ep in s. All o he pe missions can be ob ained
h ough ou Righ sLink se ice ia he Pe missions link on he a icle page on ou si e— o u he in o ma ion please con ac jou nals.pe mis-
[email p o ec ed].
h ps://doi.o g/10.1093/eu pub/cka 012 Ad ance Access published on 11 Feb ua y 2025
...............................................................................................................
Excess heal hca e u iliza ion and cos s linked o
ch onic condi ions: a compa a i e s udy o nine
Eu opean coun ies
Bo is Polanco
1,2
, Ana O~
na
2
, A min Gempe li
1,3
, Diana Pacheco Ba zallo
1,2,4,
�
1
Facul y o Heal h Sciences and Medicine, Uni e si y o Luce ne, Luce ne, Swi ze land
2
Heal h Economics G oup, Swiss Pa aplegic Resea ch, No wil, Swi ze land
3
Cen e o P ima y and Communi y Ca e, Uni e si y o Luce ne, Luce ne, Swi ze land
4
Cen e o Rehabili a ion in Global Heal h Sys ems, Uni e si y o Luce ne, Luce ne, Swi ze land
�Co esponding au ho . Facul y o Heal h Sciences and Medicine, Uni e si y o Luce ne, F ohbu gs asse 3, 6002 Luze n,
Swi ze land. E-mail: [email p o ec ed]
Abs ac
The inc easing p e alence o ch onic condi ions is a signi ican challenge o heal hca e sys ems wo ldwide, no
only om a public heal h pe spec i e bu also o he agg ega e cos ha hese ep esen . This pape es ima es
he addi ional use o heal hca e se ices due o ch onic heal h condi ions and hei associa ed cos s in nine
Eu opean coun ies. We analyzed inpa ien and ou pa ien heal hca e u iliza ion using longi udinal da a
(Su ey o Heal h, Ageing and Re i emen in Eu ope [SHARE]). We implemen ed a di e ence-in-di e ences ap-
p oach ac oss mul iple ime pe iods. Mone a y es ima es we e de i ed using WHO-CHOICE heal hca e se ice
cos s. To compa e coun ies, we calcula ed he heal hca e cos bu den o ch onic condi ions as a pe cen age o
o al heal h expendi u e. People wi h ch onic condi ions equi e signi ican ly mo e heal hca e se ices han hose
wi hou such condi ions, a e aging h ee addi ional ou pa ien isi s and one ex a o e nigh inpa ien s ay
annually. These pa e ns a y ac oss coun ies. In Ge many, ou pa ien ca e usage is pa icula ly high, wi h an
a e age o ou addi ional isi s, while Swi ze land leads in inpa ien ca e wi h wo ex a o e nigh s ays. The
associa ed cos s also di e widely, in luenced by a ia ions in heal hca e demand, se ice p icing, and he p e a-
lence o ch onic condi ions in each coun y. Ch onic condi ions signi ican ly inc ease heal hca e u iliza ion,
and demog aphic ends sugges his demand will con inue o g ow s eadily. This ising p essu e poses se ious
challenges o heal hca e sys ems, necessi a ing a shi owa d mo e e icien se ice deli e y models.
...............................................................................................................
In oduc ion
The p e alence o ch onic condi ions is a challenge o heal hca e
sys ems. Since 1990, he bu den o non-communicable diseases
has isen by 60% [1], meaning mo e people will ace long- e m
heal h condi ions. Heal hca e sys ems mus expand se ices o
mee hese needs, adding p essu e o a sys em al eady consuming
abou 10% o he g oss domes ic p oduc (GDP) in indus ialized
economies [2]. Wi hou p ope planning, ising heal hca e cos s
could become a signi ican economic bu den o indi iduals, ami-
lies, and he heal hca e sys em [3]. Unde s anding heal hca e ex-
pendi u e is key o managing budge s and designing cos -e ec i e
in e en ions.
To al heal hca e expendi u es a e d i en by he p ice and u iliza-
ion o se ices. While he p ice depends on a coun y’s weal h [4],
new echnologies [5], and he supply o heal h se ices, he u iliza-
ion o heal hca e se ices is in luenced by demog aphic dynamics,
se ice p o ide s, disease bu den, and ca e p e e ences [6]. The la -
e is being p essu ed by he ise in non-communicable diseases,
especially among olde popula ions, which implies mo e equen
ca e o ex ended pe iods [7]. Rela ed s udies ha e examined he
ising cos o speci ic condi ions like ch onic pain [8], cance [9],
and diabe es[10], bu he e a e no es ima es on he o e all impac o
ch onic condi ions on heal hca e u iliza ion.
This pape es ima ed how much heal hca e u iliza ion changed
a e a pe son was diagnosed wi h a ch onic condi ion and he
co esponding cos s. Using longi udinal da a om nine Eu opean
coun ies, we applied a di e ence-in-di e ences (DiD) app oach o
es ima e he addi ional u iliza ion due o new diagnoses. We ocused
on inpa ien and ou pa ien ca e, as hese wo consume he la ges
po ions o heal hca e expendi u e [11–13]. Ou indings o e
insigh s in o popula ion heal hca e needs and he cos implica ions
o decision-making on se ice p o ision o manage he economic
impac o ch onic condi ions.
Me hods
Da a sou ces
This s udy used h ee da a sou ces: (i) he Su ey o Heal h, Ageing
and Re i emen in Eu ope (SHARE) [14] o es ima e he heal hca e
se ice u iliza ion o people wi h ch onic heal h condi ions com-
pa ed o hose wi h simila cha ac e is ics in he gene al popula ion,
(ii) he WHO-CHOICE [15] o es ima e he cos associa ed wi h he
excess use o heal h se ices, and (iii) he Wo ld Bank and WHO
Global Heal h Expendi u e Da abase [16] o es ima e he heal h-
ca e cos s.
SHARE includes da a on indi iduals aged 50þ om 28 Eu opean
coun ies [14], co e ing heal h, socioeconomic s a us, and well-
being. The su ey collec ed egula da a in mul iple yea s since
2004, 2006/2007, 2008/2009, 2011/2012, 2013, 2015, 2017, 2019/
2020, and 2021/2022. Da a was collec ed ace- o- ace wi h physical
and bioma ke es s, swi ching o phone in e iews o end-o -li e
cases and du ing COVID-19. The su ey a ge s people li ing in
Downloaded om h ps://academic.oup.com/eu pub/a icle/35/2/216/8009071 by ZHB Zen al- und Hochschulbiblio hek Luze n use on 25 No embe 2025
p i a e households and excludes hose inca ce a ed, hospi alized,
ou o he coun y, unable o speak a local language, o mo ed o
an unknown add ess. All esponden s a e included in he longi u-
dinal sample. SHARE aims o ep esen each coun y’s popula ion,
hough ep esen a i eness may a y o some coho s, especially
among olde g oups, due o esponse a es and sampling di e ences
[17]. We analyzed in o ma ion on heal hca e se ice u iliza ion
(ou pa ien and inpa ien ) om he su ey ac oss eigh wa es.
Since no all coun ies pa icipa ed in e e y wa e, we ocused on
he coun ies wi h consis en da a ac oss wa es, enabling panel da a
analysis: Aus ia, Belgium, Denma k, F ance, Ge many, I aly, Spain,
Sweden, and Swi ze land.
The WHO-CHOICE p og am, de eloped by he Wo ld Heal h
O ganiza ion, p o ides e idence on he uni cos s o inpa ien and
ou pa ien ca e a he coun y le el a pu chase powe pa i y (PPP)
[15]. Fo compa ison pu poses, we adjus ed he cos es ima es o
in la ion in ou calcula ions [18].
Da a analysis
Pa 1: Excess equency in heal hca e se ice
u iliza ion
To es ima e he excess in heal hca e se ices u iliza ion, we conside ed
Popula ion A, o he ea ed g oup, diagnosed wi h a ch onic condi ion
in any o he T pe iods, whe e T¼1;2;3;...;8 and Popula ion B,
o he con ol g oup, which has all people who ne e epo ed ha ing a
ch onic condi ion. Once diagnosed, we expec ed he ea ed g oup o
inc ease hei u iliza ion o heal hca e se ices compa ed o he con ol
g oup, which we es ima ed using a DiD wi h mul iple ime pe iods,
applying he po en ial ou comes amewo k [19].
In o mal e ms, he DiD is de ined as ollows:
•T¼8, he numbe o ime pe iods ha indi iduals in he sample
we e obse ed.
•D
i
is he ea men indica o equals 1 i indi idual i was diagnosed
wi h a ch onic condi ion in ime pe iod , and 0 o he wise.
•G
i
is he i s ime pe iod whe e indi idual i epo ed being diag-
nosed wi h a ch onic condi ion, and 0 o he wise.
•Y
i
is he u iliza ion o heal hca e se ices o indi idual i a ime
pe iod , whe e Y is measu ed by:
1. Ou pa ien ca e: epo ed numbe o isi s o a doc o in he
las 12 mon hs.
2. Inpa ien ca e: numbe o o e nigh s ays in a hospi al in he
las 12 mon hs.
•Y
i
(g) is he ea ed po en ial ou come, which is he heal hca e se -
ice u iliza ion ha indi idual i would expe ience a ime pe iod
i hey we e diagnosed wi h a ch onic condi ion in pe iod g.
•Y
i
¼Y
i
(0) is he un ea ed po en ial ou come, which is he heal h-
ca e se ice u iliza ion ha indi idual i would expe ience in ime
pe iod i i has ne e been diagnosed wi h a ch onic condi ion.
•Fo all indi iduals iand ime pe iods <Gi;we ha e ha
Yi ¼Yi 0
ð Þ ðno an icipa ionÞand Yi ¼Yi Gi
ð Þ when ≥Gi.
Following his app oach, he uni -le el ea men e ec is gi en by
he di e ence in heal hca e se ice u iliza ion be ween ea ed and
con ol g oups:
τi ¼Yi g
ð ÞYi 0
ð Þ
The uni -le el a e age ea men e ec on he ea ed (ATT) is
gi en by:
τi
(g
ð Þ ¼1
Tgþ1X
T
¼Gi
Yi g
ð ÞYi 0
ð Þ
� �
The sample ATT is gi en by:
ATT g;
ð Þ ¼E Y g
ð ÞY 0
ð ÞjG¼g
h i
ATT is he a e age ea men e ec on he ea ed o he g oup g
in he ime pe iod , which se es as he building block o o he
agg ega ed ea men e ec s wi h a ying weigh unc ions w g;
ð Þ.
These weigh s depend on he g oup size among all g oups ha e e
pa icipa ed in he ea men and he numbe o pos - ea men ime
pe iods o a pa icula g oup. These pa ame e s a e o he ollow-
ing o m:
θ¼X
g2GX
T
¼2
w g;
ð ÞATT g;
ð Þ
The e en s udy es ima o can be cons uc ed by he g oup- ime
a e age ea men e ec s as ollows:
ATTES e
ð Þ ¼X
g2G
wES g;e
ð ÞATT g;gþe
ð Þ
We conside ed h ee pa ame e s: he o e all a e age ea men
e ec , g oup- ime a e age ea men e ec s, and he e en s udy
es ima o . The DiD app oach elies on he pa allel end assump-
ion, ma ching ea ed and con ol g oups based on he ollowing
cha ac e is ics: age, gende , coun y, household size, ci il s a us, sel -
pe cei ed heal h, inancial s a us, and educa ion le el be o e ea -
men . To ensu e exchangeabili y, we used in e se p obabili y
weigh ing and calcula ed s anda d e o s wi h he mul iplie boo -
s ap me hod (1000 i e a ions). The analysis was conduc ed in R
( e sion 4.2.2) using he did package ( e sion 2.1.2). The
Supplemen a y Appendix includes a sensi i i y analysis o assess
he obus ness o ou es ima es.
Pa 2: Cos o he excess equency
We used WHO-CHOICE da a o es ima e heal hca e se ice cos s,
adjus ed o in la ion using he Ha monized Index o Consume
P ices (HICP) o heal hca e se ices [18, 20]. The WHO-
CHOICE epo s he es ima ed a e age cos pe isi , excluding
medica ion, and is indica ed in PPP o allow compa ison ac oss
coun ies. To accoun o he a ia ion and compu e he s anda d
de ia ion o he cos es ima es, we implemen ed a wo-pa model
o equency [21]. As heal hca e cos s a y by p o ide , we analyzed
di e en cos scena ios:
•Heal h cen e s exclusi ely o ou pa ien se ices (no beds).
•Heal h cen e s wi h beds.
•P ima y-le el hospi als ha ea simple cases and ha e ew special ies.
•Seconda y-le el hospi als ha ea e e al cases (special-
ized hospi als).
•Te ia y-le el hospi als wi h highly specialized s a and ech-
nical equipmen .
Fo inpa ien ca e, we used only he las h ee ca ego ies.
C oss-coun y compa ison: heal hca e cos bu den
To compa e ou esul s ac oss coun ies, we calcula ed he heal hca e
cos bu den (HcB). HcB was calcula ed using he excess se ice u il-
iza ion (ATT), es ima ed in Pa I, and he uni cos es ima es om
Pa II. To ge agg ega e es ima es, we used he po en ial o al demand
o heal hca e se ices by people wi h ch onic condi ions using he
p e alence da a om he Rehabili a ion Needs Es ima o p ojec [22,
23]. Fo mally, HcB is he sha e o he o al heal hca e expendi u e a
coun y incu s o se ices u iliza ion o pe sons wi h ch onic con-
di ions:
HcBcoun y
¼#People wi h ch onic condi ionscoun y ×ATTcoun y ×P icecoun y
To al heal h expendi u ecoun y
In he supplemen , we inco po a ed he HcB esul s using inci-
dence es ima es o ch onic condi ions in each coun y. Howe e , as
incidence es ima es a e inexis en o all ch onic condi ions, we
Excess heal hca e u iliza ion and ch onic condi ions cos s 217
Downloaded om h ps://academic.oup.com/eu pub/a icle/35/2/216/8009071 by ZHB Zen al- und Hochschulbiblio hek Luze n use on 25 No embe 2025
es ima ed incidence a es in ou sample, which se e only as a e -
e ence, as we lack mo ali y da a.
Resul s
Desc ip i e s a is ics
Table 1 displays he cha ac e is ics o he sample (eigh wa es)
ac oss he nine coun ies. Belgium has he la ges sample wi h
34 722 obse a ions (14.5%), ollowed by Spain wi h 29 253
(12.2%), Ge many wi h 29 084 (12.2%), I aly wi h 29 031 (12.2%),
and Swi ze land con ibu ing 18 116 obse a ions (7.6%) o he
o e all da ase . The p opo ion o male indi iduals in he sample
anged om 41.9% in Aus ia o 47.1% in Ge many, wi h an a e age
o 45% ac oss all coun ies. The a e age age anged om 66.4 in
Denma k and Sweden o 69.8 yea s. Sel -pe cei ed heal h a ied
ac oss he sample. Spain had he highes p opo ion o people
epo ing “poo ” heal h (15%), while Denma k and Sweden had
he mos epo ing “excellen ” heal h (19.4% and 15.9%, espec i e-
ly). In con as , Spain had he leas people epo ing “excellen ”
heal h (3.7%). On a e age, households had wo membe s ac oss all
coun ies. Pa ne ship s a us also a ied, wi h I aly ha ing he high-
es pe cen age o indi iduals li ing wi h a pa ne (77.2%) and
Aus ia he lowes (64%). Educa ion le els di e ed signi ican ly,
wi h Denma k ha ing he highes p opo ion o indi iduals wi h
e ia y educa ion (42.5%), while I aly had he lowes (7.7%).
Pa 1: Excess equency o heal h ca e se ices
u iliza ion
The e en s udy plo s (Fig. 1A and B) display he es ima ed ATT o
ch onic condi ions on he u iliza ion o heal hca e se ices. A able
wi h he es ima es is epo ed in Supplemen a y Table S1. Be o e
diagnosis, ea ed and con ol g oups show no signi ican di e ences
in heal hca e u iliza ion, con i ming hei compa abili y. In con as ,
pos -diagnosis, ou pa ien , and inpa ien ca e ises in all coun ies
wi h a ying e ec sizes.
Fo ou pa ien ca e (Fig. 1A), Ge many exhibi ed he highes ex-
cess u iliza ion, wi h an ATT o 3.96 mo e doc o isi s (95% CI:
1.49–6.43). Belgium and Aus ia ollowed closely, wi h ATT alues
o 3.93 (95% CI: 2.62–5.24) and 3.88 (95% CI: 2.24–5.52) mo e isi s,
espec i ely. I aly and Spain also showed no able e ec s, wi h 3.37
(95% CI: 2.53–4.21) and 3.32 (95% CI: 2.39–4.25) mo e isi s, e-
spec i ely. Swi ze land and F ance ollowed, wi h ATT o 3.31 (95%
CI: 1.59–5.02) and 3.09 (95% CI: 2.35–3.82) mo e isi s, espec i ely.
Denma k and Sweden had he lowes es ima es, wi h ATT alues o
2.56 (95% CI: 1.83–3.29) and 1.46 (95% CI: 0.90–2.03) mo e isi s,
espec i ely. No ably, he excess u iliza ion o ou pa ien ca e was
s a is ically signi ican o all coun ies.
Fo inpa ien ca e (Fig. 1B), Swi ze land showed he highes ex-
cess u iliza ion, wi h an ATT o 2.29 mo e o e nigh s ays o indi-
iduals diagnosed wi h a ch onic condi ion (95% CI: 0.70–3.88).
Aus ia ollowed wi h an ATT o 1.94 mo e s ays (95% CI: 0.42–
3.46). Belgium and Ge many epo ed mode a e e ec s, wi h ATT o
0.93 (95% CI: 0.48–1.38) and 0.96 (95% CI: −0.03 o 1.95), espec -
i ely. F ance showed a simila ATT o 0.89 mo e s ays (95% CI:
0.39–1.40). Smalle e ec s we e obse ed o Spain (0.58, 95% CI:
0.22–0.93) and I aly (0.52, 95% CI: 0.19–0.85). Sweden and
Denma k p esen ed he lowes e ec s, wi h ATT o 0.42 (95% CI:
0.08–0.76) and 0.33 (95% CI: −0.17 o 0.83) mo e isi s, espec i ely.
Ne e heless, Denma k and Ge many’s con idence in e al included
ze o, indica ing non-signi ican e ec s.
Pa 2: Cos o se ices
Tables 2 and 3 p esen he es ima ed uni cos s o heal hca e se ices
and hei a ia ion (s anda d de ia ion) ac oss se ice p o ide s in
di e en coun ies. As expec ed, ou pa ien ca e cos s a e subs an-
ially lowe han inpa ien ca e cos s. On a e age, he highes uni
cos s o ou pa ien and inpa ien se ices a e obse ed in Aus ia,
Swi ze land, and Denma k. In con as , I aly, Spain, and F ance
consis en ly exhibi lowe cos s ac oss all p o ide s. The o he coun-
ies demons a e compa able cos le els.
Pa 3: Heal hca e cos bu den
Figu e 2A (ou pa ien ) and B (inpa ien ) display he es ima ed HcB
in he analyzed coun ies. The x-axis displays he excess in heal h-
ca e u iliza ion (ATT), and he y-axis shows he cos pe isi .
In e es ingly, e en when p ices a e in PPP e ms, some a ia ion
emains, especially in inpa ien ca e, which sugges s ha se ices
a e no homogeneous ac oss coun ies. The size o he bubbles
e lec s he p e alence o ch onic condi ions.
Fo ou pa ien ca e, he esul s indica e ha I aly had he highes
HcB, anging om 2% in heal h cen e s o 2.9% in seconda y/ e -
ia y hospi als. This is p ima ily a ibu ed o he coun y’s high
p e alence o ch onic condi ions. Spain ollows, wi h a bu den ang-
ing om 1.6% o 2.3%. Despi e ha ing simila cos s and u iliza ion
le els o I aly, Spain’s bu den is lowe due o a smalle p e alence o
ch onic condi ions. Belgium (1.3%–1.9%) and Ge many (1.2%–
1.8%) exhibi bu dens d i en by highe u iliza ion o ou pa ien
se ices combined wi h a high p e alence o ch onic condi ions.
Aus ia shows a simila bu den (1.3%–1.8%), explained by ele a ed
heal hca e u iliza ion and high se ice p ices. F ance epo s a ela-
i ely lowe bu den (0.9%–1.2%), p ima ily due o lowe heal hca e
p ices and less excessi e u iliza ion o ou pa ien se ices. A he
lowe end o he spec um a e Sweden (0.4%–0.6%), Swi ze land
(0.6%–0.9%), and Denma k (0.7%–1%). Despi e ha ing ela i ely
simila heal hca e p ices, hese coun ies epo ed a smalle p e a-
lence o ch onic condi ions. Sweden, in pa icula , s ands ou wi h
he smalles bu den in he sample.
Fo inpa ien ca e, he highes HcBs we e epo ed in Aus ia (9.1%–
12.8%) and Swi ze land (6.4%–8.6%), d i en by ela i ely highe p ices
and g ea e heal hca e u iliza ion. Belgium (4.5%–5.9%) and Ge many
(4.2%–5.5%) ollowed, wi h lowe p ices and less u iliza ion o e all. In
Ge many, howe e , he high p e alence o ch onic condi ions accoun s
o a signi ican sha e o he es ima ed HcB.
I aly (4.2%–5.6%), Spain (3.7%–4.9%), and F ance (3.3%–4.5%)
showed a lowe bu den, mainly due o educed p ices and u iliza-
ion. No ably, I aly s ands ou o i s highe p e alence o ch onic
condi ions despi e i s lowe o e all cos s. Finally, despi e high
heal hca e p ices, Sweden (1.5%–2.03%) and Denma k (1.2%–
1.61%) had he smalles HcB in he sample. In bo h coun ies, his
is a ibu ed o educed u iliza ion o heal hca e se ices and a lowe
p e alence o ch onic condi ions, pa icula ly in Sweden.
Discussion
This s udy es ima ed he inc eased u iliza ion o heal hca e se ices
and he associa ed cos s esul ing om ch onic condi ions ac oss
nine Eu opean coun ies. Fo ou pa ien ca e, indi iduals diagnosed
wi h a ch onic condi ion expe ience an a e age o ou addi ional
isi s pe yea in Ge many, Belgium, and Aus ia. In I aly, Spain,
Swi ze land, F ance, and Denma k, his igu e d ops o 3, while
Sweden sees jus one addi ional isi annually. Fo inpa ien ca e,
Swi ze land and Aus ia epo an a e age o wo ex a o e nigh
hospi al s ays pe yea , ollowed by Ge many, Belgium, and F ance
wi h one addi ional s ay. In con as , Spain, I aly, and Sweden eco d
less han 1 ex a o e nigh s ay annually, while Denma k shows no
signi ican e ec . These indings highligh a subs an ial inancial
bu den on heal hca e sys ems. I aly, Belgium, Spain, Aus ia, and
Ge many ace he highes cos s o ou pa ien se ices, while
Swi ze land and Aus ia incu he mos signi ican expenses o in-
pa ien ca e.
Ou indings align wi h ela ed li e a u e highligh ing he s eady
ise in heal hca e spending d i en by non-communicable diseases
[24]. While much o he exis ing esea ch ocuses on o al heal hca e
218 Polanco e al.
Downloaded om h ps://academic.oup.com/eu pub/a icle/35/2/216/8009071 by ZHB Zen al- und Hochschulbiblio hek Luze n use on 25 No embe 2025
Table 1. Desc ip i e s a is ics o he sample
Va iable Aus ia Belgium Denma k F ance Ge many I aly Spain Sweden Swi ze land
Sample size (N) 23 623 (9.9%) 34 722 (14.5%) 21 962 (9.2%) 28 917 (12.1%) 29 084 (12.2%) 29 031 (12.2%) 29 253 (12.2%) 24 201 (10.1%) 18 116 (7.6%)
Gende
Male (%) 9891 (41.9%) 15 690 (45.2%) 10 160 (46.3%) 12 538 (43.4%) 13 712 (47.1%) 13 108 (45.2%) 13 092 (44.8%) 11 210 (46.3%) 8260 (45.6%)
Female (%) 13 732 (58.1%) 19 032 (54.8%) 11 802 (53.7%) 16 379 (56.6%) 15 372 (52.9%) 15 923 (54.8%) 16 161 (55.2%) 12 991 (53.7%) 9856 (54.4%)
Age (mean) 68.5 66.8 66.4 67.8 66.8 68.1 69.7 69.8 68.1
Sel -pe cei ed heal h s a us
Excellen (%) 1814 (7.7%) 2528 (7.3%) 4254 (19.4%) 1878 (6.5%) 1 461 (5%) 1 809 (6.2%) 1066 (3.7%) 3841 (15.9%) 1996 (11%)
Ve y good (%) 5421 (23%) 7085 (20.5%) 7197 (32.8%) 4097 (14.3%) 4346 (15%) 4054 (14%) 4277 (14.7%) 5651 (23.4%) 5167 (28.6%)
Good (%) 8433 (35.8%) 14 887 (43%) 5243 (23.9%) 12 306 (42.9%) 11 639 (40.1%) 10 530 (36.3%) 10 875 (37.3%) 8298 (34.4%) 7498 (41.5%)
Fai (%) 5999 (25.5%) 7923 (22.9%) 3957 (18.1%) 7324 (25.5%) 8785 (30.3%) 9345 (32.3%) 8565 (29.4%) 4929 (20.4%) 2760 (15.3%)
Poo (%) 1879 (8%) 2217 (6.4%) 1263 (5.8%) 3089 (10.8%) 2786 (9.6%) 3237 (11.2%) 4369 (15%) 1426 (5.9%) 647 (3.6%)
Income g oup
Low (%) 6345 (30.3%) 9510 (30.2%) 6135 (30.6%) 8133 (30.4%) 7887 (30.2%) 7901 (30.3%) 7825 (30.3%) 6670 (30.2%) 4986 (30.3%)
Medium (%) 8389 (40%) 12 600 (40.1%) 8036 (40.1%) 10 720 (40.1%) 10 487 (40.1%) 10 406 (39.9%) 10 370 (40.1%) 8834 (40%) 6580 (39.9%)
High (%) 6215 (29.7%) 9332 (29.7%) 5863 (29.3%) 7912 (29.6%) 7759 (29.7%) 7784 (29.8%) 7671 (29.7%) 6583 (29.8%) 4912 (29.8%)
Household size
Small (%) 20 154 (85.3%) 28 294 (81.5%) 19 533 (88.9%) 24 555 (84.9%) 24 793 (85.2%) 18 719 (64.5%) 19 590 (67%) 22 447 (92.8%) 15 562 (85.9%)
Medium (%) 2244 (9.5%) 3944 (11.4%) 1540 (7%) 2629 (9.1%) 2937 (10.1%) 6089 (21%) 5647 (19.3%) 1222 (5%) 1476 (8.1%)
La ge (%) 208 (0.9%) 186 (0.5%) 47 (0.2%) 188 (0.7%) 94 (0.3%) 310 (1.1%) 395 (1.4%) 24 (0.1%) 67 (0.4%)
In pa ne ship (%) 15 118 (64%) 23 855 (68.7%) 16 108 (73.3%) 19 246 (66.6%) 22 234 (76.4%) 22 414 (77.2%) 21 774 (74.4%) 17 606 (72.7%) 13 020 (71.9%)
Educa ion
P ima y (%) 5675 (24.3%) 13 847 (40.3%) 4003 (18.3%) 12 076 (42.6%) 3486 (12.1%) 20 269 (70.4%) 22 874 (80.1%) 9179 (38.7%) 3954 (22.2%)
Seconda y (%) 11 594 (49.7%) 9331 (27.2%) 8543 (39.2%) 9915 (34.9%) 16 266 (56.3%) 6315 (21.9%) 2829 (9.9%) 7470 (31.5%) 10 822 (60.7%)
Te ia y (%) 6048 (25.9%) 11 157 (32.5%) 9271 (42.5%) 6383 (22.5%) 9121 (31.6%) 2207 (7.7%) 2839 (9.9%) 7059 (29.8%) 3042 (17.1%)
Numbe s in equencies and pe cen ages in pa en heses.
Excess heal hca e u iliza ion and ch onic condi ions cos s 219
Downloaded om h ps://academic.oup.com/eu pub/a icle/35/2/216/8009071 by ZHB Zen al- und Hochschulbiblio hek Luze n use on 25 No embe 2025
expendi u es—including cos s o medica ions, p e en ion, assis i e
de ices, in as uc u e, and adminis a ion [10, 25, 26]—ou s udy
p o ides causal es ima es speci ically ela ed o inc eased heal hca e
se ice u iliza ion ollowing ch onic condi ion diagnoses.
Consequen ly, ou cos es ima es a e smalle han hose in he
b oade li e a u e, as hey ep esen only a subse o o al
expendi u es o non-communicable diseases. A compa able s udy
es ima ed ha inpa ien se ice u iliza ion o some ch onic condi-
ions in Swi ze land con ibu ed be ween 1.3% and 6.2% o he o al
a ia ion o cos s, which is close o ou indings [12].
Gi en ha heal hca e ep esen s one o he la ges ca ego ies o
public expendi u e, he g owing demand o ca e poses signi ican
Figu e 1. (A) Ou pa ien ca e: es ima ed e ec o being diagnosed wi h a ch onic condi ion on se ice u iliza ion. (B) Inpa ien ca e:
es ima ed e ec o being diagnosed wi h a ch onic condi ion on se ice u iliza ion. ATT is he a e age es ima ed excess u iliza ion o
heal hca e se ices by pe sons diagnosed wi h a ch onic condi ion compa ed o a con ol g oup.
220 Polanco e al.
Downloaded om h ps://academic.oup.com/eu pub/a icle/35/2/216/8009071 by ZHB Zen al- und Hochschulbiblio hek Luze n use on 25 No embe 2025
challenges o public inances [8]. Thus, o add ess he inc easing ca e
needs o he popula ion e ec i ely, i is essen ial o unde s and he
implica ions o heal hca e sys em o ganiza ion. These a e shaped by
se e al key ac o s: (1) he cos o heal hca e se ices, (2) he pa e ns o
se ice u iliza ion, and (3) he o e all heal h s a us o he popula ion.
In ou pa ien ca e, ou indings sugges ha he p ima y d i e o
he HcB is he p e alence o ch onic condi ions. While some a ia-
ions in p ices and u iliza ion we e obse ed, he e a e no ma ked
di e ences ac oss coun ies excep o Sweden. Sweden s ands ou
wi h he smalles bu den in he sample, a ibu ed o i s compa a-
i ely low se ice u iliza ion and p e alence o ch onic condi ions.
In con as , inpa ien ca e e ealed mo e p onounced a ia ions
ac oss coun ies. E en a e adjus ing o p ice di e ences, no able
dispa i ies pe sis , sugges ing ma ked di e ences in how inpa ien
se ices a e o ganized and deli e ed ac oss na ions. Swi ze land and
Aus ia exhibi ed he highes bu dens, d i en by ela i ely highe
Figu e 1. Con inued.
Excess heal hca e u iliza ion and ch onic condi ions cos s 221
Downloaded om h ps://academic.oup.com/eu pub/a icle/35/2/216/8009071 by ZHB Zen al- und Hochschulbiblio hek Luze n use on 25 No embe 2025
p ices o inpa ien ca e and ele a ed le els o heal hca e u iliza ion.
Belgium, Ge many, I aly, Spain, and F ance showed a mid- ange
bu den, p ima ily explained by he high p e alence o ch onic con-
di ions despi e lowe p ices and heal hca e u iliza ion le els. Like
ou pa ien ca e, Sweden and Denma k expe ienced he lowes bu -
den due o hei educed heal hca e u iliza ion and lowe p e alence
o ch onic condi ions.
Ou indings highligh c i ical a eas o imp o ing he o ganiza-
ion o heal hca e se ices o add ess he g owing ca e needs o he
popula ion. Fi s , heal hca e p ices a e highly complex. Ou esul s
demons a e ha e en a e p ice adjus men s, di e ences pe sis ,
pa icula ly in inpa ien ca e. This e lec s he he e ogenei y o
heal hca e se ices ac oss coun ies [27]. These di e ences sugges
ha ac o s beyond in la ion, such as echnological ad ancemen s,
popula ion p e e ences, o s uc u al composi ion e ec s, may con-
ibu e o highe cos s. Fo ins ance, Swi ze land and Aus ia exhibi
ela i ely mo e expensi e se ices, likely in luenced by hese exogen-
ous ac o s [27]. To mi iga e inancial p essu es, al e na i e models
ha minimize eliance on cos ly and po en ially unnecessa y se ices
should be explo ed. Many ch onic condi ions, pa icula ly in hei
Table 2. Ou pa ien ca e: es ima ed cos s by ype o acili y [numbe s in USD (PPP)]
WHO-CHOICE Es ima es Cos es ima es due o excess u iliza ion o heal hca e se ices
A B C B × C D
Coun y Type o acili y Mean
es ima ed
uni cos s
(USD
pe isi )
SD UB
es ima e
LB
es ima e
Mean
indi idual
cos s (USD
pe pe son
o e a yea )
UB
es ima e
LB
es ima e
Numbe
o people
wi h ch onic
condi ions
50+ yo.
To al
es ima ed
cos s (in
USD
millions)
Heal hca e
cos
bu den
(HcB)
Aus ia Heal h cen e (no beds) 58.32 42.87 174.63 12.36 226.28 963.96 27.69 3 338 346 755.41 1.3%
Seconda y hospi al 82.83 64.15 257.83 16.71 321.38 1423.22 37.43 1072.88 1.8%
Te ia y hospi al 82.42 64.36 238.98 16.22 319.79 1319.17 36.33 1067.57 1.8%
P ima y hospi al 80.12 58.99 242.18 15.84 310.87 1336.83 35.48 1037.78 1.8%
Heal h cen e (wi h beds) 70.89 55.33 219.45 14.55 275.05 1211.36 32.59 918.22 1.6%
Belgium Te ia y hospi al 70.55 51.74 206.02 15.56 277.26 1079.54 40.77 4 507 303 1249.70 1.9%
Seconda y hospi al 68.42 48.57 205.44 14.96 268.89 1076.51 39.20 1211.97 1.8%
Heal h cen e (wi h beds) 61.98 48.65 192.66 12.95 243.58 1009.54 33.93 1097.90 1.7%
P ima y hospi al 66.91 51.82 202.92 13.64 262.96 1063.30 35.74 1185.22 1.8%
Heal h cen e (no beds) 49.20 37.68 150.00 9.84 193.36 786.00 25.78 871.51 1.3%
Denma k Te ia y hospi al 76.45 60.41 227.76 16.33 195.71 749.33 29.88 2 167 188 424.14 1.0%
Heal h cen e (wi h beds) 63.73 51.08 202.33 14.38 163.15 665.67 26.32 353.57 0.8%
Seconda y hospi al 76.65 59.04 240.83 14.99 196.22 792.33 27.43 425.25 1.0%
P ima y hospi al 52.48 57.96 225.49 14.76 134.35 741.86 27.01 291.16 0.7%
Heal h cen e (no beds) 52.48 38.15 153.63 10.86 134.35 505.44 19.87 291.16 0.7%
F ance Seconda y hospi al 61.58 49.16 182.38 12.63 190.28 696.69 29.68 24 406 554 4644.13 1.3%
Heal h cen e (no beds) 42.80 34.93 147.43 8.72 132.25 563.18 20.49 3227.82 0.9%
P ima y hospi al 42.80 41.63 171.99 11.87 132.25 657.00 27.89 3227.82 0.9%
Te ia y hospi al 58.64 46.38 179.62 11.86 181.20 686.15 27.87 4422.41 1.2%
Heal h cen e (wi h beds) 52.12 42.92 164.40 9.98 161.05 628.01 23.45 3930.70 1.1%
Ge many Seconda y hospi al 70.68 53.72 212.84 14.72 279.89 1368.56 21.93 35 636 697 9974.45 1.8%
Te ia y hospi al 70.11 53.55 212.73 13.48 277.64 1367.85 20.09 9894.02 1.8%
P ima y hospi al 48.31 50.18 207.39 13.56 191.31 1333.52 20.20 6817.57 1.2%
Heal h cen e (wi h beds) 57.40 41.17 171.71 12.15 227.30 1104.10 18.10 8100.36 1.5%
Heal h cen e (no beds) 48.31 36.88 148.35 9.92 191.31 953.89 14.78 6817.57 1.2%
I aly Te ia y hospi al 65.58 50.87 204.46 12.71 221.00 860.78 32.16 26 297 584 5811.89 2.9%
Seconda y hospi al 63.27 49.47 185.65 13.56 213.22 781.59 34.31 5607.17 2.8%
P ima y hospi al 44.23 47.68 193.96 13.13 149.06 816.57 33.22 3919.79 2.0%
Heal h cen e (no beds) 44.23 32.95 132.48 8.83 149.06 557.74 22.34 3919.79 2.0%
Heal h cen e (wi h beds) 57.44 48.04 179.74 11.03 193.57 756.71 27.91 5090.50 2.6%
Spain Te ia y hospi al 60.66 44.59 182.80 12.84 201.39 776.90 30.69 17 497 926 3523.93 2.3%
P ima y hospi al 42.60 47.57 180.72 12.05 141.43 768.06 28.80 2474.77 1.6%
Heal h cen e (wi h beds) 52.20 39.01 150.26 11.29 173.30 638.61 26.98 3032.46 2.0%
Seconda y hospi al 62.62 48.80 192.26 13.35 207.90 817.11 31.91 3637.79 2.4%
Heal h cen e (no beds) 42.60 33.91 129.78 8.19 141.43 551.57 19.57 2474.77 1.6%
Sweden Te ia y hospi al 75.23 59.57 236.49 14.77 109.84 480.07 13.29 3 680 911 404.30 0.6%
P ima y hospi al 49.49 57.24 217.77 14.80 72.26 442.07 13.32 265.97 0.4%
Seconda y hospi al 74.80 57.14 234.67 14.52 109.21 476.38 13.07 401.98 0.6%
Heal h cen e (wi h beds) 65.93 52.18 197.76 12.15 96.26 401.45 10.94 354.32 0.5%
Heal h cen e (no beds) 49.49 37.58 146.40 10.51 72.26 297.19 9.46 265.97 0.4%
Swi ze land Seconda y hospi al 74.94 58.52 228.71 16.21 248.05 1148.12 25.77 3 277 658 813.03 0.9%
P ima y hospi al 51.69 56.34 231.47 13.92 171.09 1161.98 22.13 560.79 0.6%
Heal h cen e (no beds) 51.69 38.21 154.99 10.83 171.09 778.05 17.22 560.79 0.6%
Heal h cen e (wi h beds) 64.97 52.27 199.97 13.57 215.05 1003.85 21.58 704.86 0.7%
Te ia y hospi al 76.53 60.55 237.37 15.55 253.31 1191.60 24.72 830.28 0.9%
The alues a e in 2021 USD, adjus ed o heal hca e in la ion. UB and LB a e he 95% con idence in e als a ound he es ima ed cos s. The
UB and LB indica e he ange o unce ain y in he es ima ed cos s. SD ¼s anda d de ia ion; yo. ¼yea s old; UB ¼uppe bound es ima e;
LB ¼lowe bound es ima e.
A: Uni cos es ima es (pe isi o a heal hca e p o ide ). Da a comes om he WHO-CHOICE p ojec . B: Mean indi idual cos s a e he uni
cos o a isi o inpa ien ca e imes he es ima ed excess u iliza ion (ATT) o heal hca e se ices. C: Numbe s calcula ed om he
p e alence o ch onic condi ions es ima ed by he Rehabili a ion Needs Es ima o om he Ins i u e o Heal h Me ics (IHME). To al
es ima ed cos s a e he associa ed cos s due o he excess u iliza ion o heal hca e se ices among people wi h ch onic condi ions.
D: HcB is he p opo ion o excess heal hca e u iliza ion cos s ela i e o a coun y’s o al heal hca e expendi u e.
222 Polanco e al.
Downloaded om h ps://academic.oup.com/eu pub/a icle/35/2/216/8009071 by ZHB Zen al- und Hochschulbiblio hek Luze n use on 25 No embe 2025
ea ly s ages, can be managed e ec i ely and a a signi ican ly lowe
cos wi hin p ima y ca e se ings, a he han h ough di ec in-
pa ien ea men [28, 29]. Howe e , expanding p ima y ca e se -
ices p esen s challenges, pa icula ly in Eu ope, whe e heal hca e
sys ems a e al eady s ained by wo k o ce sho ages [30].
Second, he unnecessa y u iliza ion o heal hca e se ices is mo e
p e alen in sys ems lacking ga ekeeping s uc u es o hose ha do
no equi e copaymen s. Some heal hca e sys ems p o ide b oad
access o se ices while inco po a ing e e al sys ems o specialis
ca e as a mechanism o con ol o e use [31]. This app oach may
accoun o he indings in Spain and F ance, whe e excess u iliza-
ion is ela i ely low. Howe e , po en ial ade-o s mus be ca e ully
e alua ed, pa icula ly when conside ing inc eased ou -o -pocke
paymen s. Such measu es can disp opo iona ely a ec lowe -
income households, po en ially exace ba ing heal h dispa i ies and
leading o pe asi e nega i e e ec s on o e all heal h ou comes [32].
Thi d—and pe haps mos c i ical—is add essing he ising p e a-
lence o ch onic condi ions. E ec i e public heal h in e en ions
mus p io i ize wo key s a egies: p e en ion and ehabili a ion.
Enhancing p e en i e measu es, such as p omo ing heal hy nu i ion
and egula physical ac i i y om an ea ly age, ep esen s one o he
mos cos -e ec i e app oaches o managing non-communicable dis-
eases [33]. These measu es can signi ican ly educe he incidence o
ch onic condi ions and alle ia e long- e m heal hca e bu dens.
Equally impo an is in eg a ing ehabili a ion se ices in o s anda d
ca e o indi iduals al eady li ing wi h ch onic condi ions.
Rehabili a ion no only aids pa ien s in egaining independence
and imp o ing hei quali y o li e bu also helps p e en complica-
ions ha could lead o cos ly hospi al admissions [34].
Finally, i is impo an o acknowledge he limi a ions o his
s udy. A key assump ion in ou model is ha once an indi idual
is diagnosed wi h a ch onic condi ion, hei heal hca e u iliza ion
inc eases because o need. Howe e , some o he obse ed inc ease
may also be supply-d i en, esul ing om o e diagnosis— o in-
s ance, iden i ying asymp oma ic condi ions du ing ou ine sc een-
ings [35]. Fu u e esea ch should ocus on accu a ely iden i ying
o e diagnosis and assessing i s impac on heal hca e cos s.
Ad anced isk models could play a pi o al ole in his a ea by
analyzing cos da a o iden i y cos d i e s and acili a e simula ions
o heal h economic e alua ions [36].
Ano he limi a ion is ha ou es ima es e lec changes in heal h-
ca e u iliza ion ollowing a diagnosis, meaning he o al e ec pe -
ains only o new cases (i.e. he incidence o ch onic condi ions).
Since incidence da a is cu en ly una ailable, we calcula ed o al
e ec s using p e alence da a, he eby cap u ing he impac on all
indi iduals wi h ch onic condi ions. As a e e ence, we e-es ima ed
ou esul s in he Supplemen a y sec ion by compu ing incidence
wi hin ou sample, wi h some simpli ica ions.
Table 3. Inpa ien ca e: es ima ed cos s by ype o acili y [numbe s in USD (PPP)]
WHO-CHOICE Es ima es Cos es ima es due o excess u iliza ion o heal hca e se ices
A B C B × C D
Coun y Type o acili y Mean
es ima ed
uni cos s
(USD pe
o e nigh
s ay)
SD UB
es ima e
LB
es ima e
Mean
indi idual
cos s (USD
pe pe son
o e a yea )
UB
es ima e
LB
es ima e
Numbe o
people wi h
ch onic
condi ions
50+ yo.
To al
es ima ed
cos s
(in USD
millions)
Heal hca e
cos
bu den
(HcB)
Aus ia P ima y hospi al 820.4 396.4 1854.6 300.3 1591.6 6417.0 126.1 33 383 46 5313.4 9.1%
Seconda y hospi al 863.1 395.0 1857.5 339.1 1674.5 6427.0 142.4 5590.0 9.6%
Te ia y hospi al 1144.4 537.7 2487.9 410.5 2220.2 8608.2 172.4 7411.8 12.8%
Belgium P ima y hospi al 926.9 417.3 2042.7 352.9 862.0 2818.9 169.4 45 073 03 3885.2 5.9%
Seconda y hospi al 698.0 314.6 1446.0 274.3 649.1 1995.5 131.7 2925.9 4.5%
Te ia y hospi al 707.8 307.1 1466.5 280.4 658.3 2023.8 134.6 2967.0 4.5%
Denma k P ima y hospi al 1006.3 460.0 2141.0 393.4 332.1 1777.1 . 21 671 88 719.7 1.7%
Seconda y hospi al 788.9 375.5 1731.8 311.1 260.3 1437.4 . 564.2 1.3%
Te ia y hospi al 754.2 346.0 1677.8 284.8 248.9 1392.5 . 539.4 1.3%
F ance P ima y hospi al 546.7 267.5 1196.6 211.5 486.6 1675.3 82.5 244 065 54 11 876.0 3.3%
Seconda y hospi al 590.8 271.6 1292.8 227.8 525.8 1809.9 88.8 12 832.6 3.5%
Te ia y hospi al 758.5 347.8 1693.4 302.5 675.1 2370.8 118.0 16 476.7 4.5%
Ge many P ima y hospi al 709.9 327.7 1545.0 268.0 681.5 3012.7 . 35 6366 97 24 287.9 4.4%
Seconda y hospi al 890.9 422.1 1979.1 329.5 855.2 3859.2 . 30 477.8 5.5%
Te ia y hospi al 671.4 308.4 1475.1 265.8 644.5 2876.4 . 22 968.1 4.2%
I aly P ima y hospi al 819.4 375.5 1730.1 306.7 426.1 1470.6 58.3 26 2975 84 11 204.5 5.6%
Seconda y hospi al 611.9 281.2 1342.0 220.9 318.2 1140.7 42.0 8368.1 4.2%
Te ia y hospi al 621.5 293.4 1369.5 227.0 323.2 1164.1 43.1 8498.2 4.3%
Spain P ima y hospi al 738.5 325.3 1511.5 295.3 428.3 1405.7 65.0 17 4979 26 7494.5 4.9%
Seconda y hospi al 603.0 278.9 1317.0 235.4 349.7 1224.8 51.8 6119.7 4.0%
Te ia y hospi al 551.7 254.4 1182.9 206.7 320.0 1100.1 45.5 5599.0 3.7%
Sweden P ima y hospi al 744.9 331.5 1542.5 291.5 312.9 1172.3 23.3 36 809 11 1151.6 1.6%
Seconda y hospi al 991.8 474.1 2184.3 373.6 416.6 1660.0 29.9 1533.3 2.1%
Te ia y hospi al 732.2 330.3 1622.0 288.9 307.5 1232.7 23.1 1131.9 1.6%
Swi ze land P ima y hospi al 799.5 370.5 1793.8 294.5 1830.7 6960.1 206.1 32 776 58 6000.5 6.4%
Seconda y hospi al 835.4 398.6 1871.5 311.7 1913.1 7261.5 218.2 6270.4 6.6%
Te ia y hospi al 1080.7 503.0 2370.0 408.3 2474.8 9195.6 285.8 8111.7 8.6%
The alues a e in 2021 USD, adjus ed o heal hca e in la ion. UB and LB a e he 95% con idence in e als a ound he es ima ed cos s. The
UB and LB indica e he ange o unce ain y in he es ima ed cos s. SD ¼s anda d de ia ion; yo. ¼yea s old; UB ¼uppe bound es ima e;
LB ¼lowe bound es ima e.
A: Uni cos es ima es (pe isi o a heal hca e p o ide ). Da a comes om he WHO-CHOICE p ojec . B: Mean indi idual cos s a e he uni
cos o a isi o inpa ien ca e imes he es ima ed excess u iliza ion (ATT) o heal hca e se ices. C: Numbe s calcula ed om he
p e alence o ch onic condi ions es ima ed by Rehabili a ion Needs Es ima o om he Ins i u e o Heal h Me ics (IHME). To al es ima ed
cos s a e he associa ed cos s due o he excess u iliza ion o heal hca e se ices among people wi h ch onic condi ions. D: HcB is he
p opo ion o excess heal hca e u iliza ion cos s ela i e o a coun y’s o al heal hca e expendi u e.
Excess heal hca e u iliza ion and ch onic condi ions cos s 223
Downloaded om h ps://academic.oup.com/eu pub/a icle/35/2/216/8009071 by ZHB Zen al- und Hochschulbiblio hek Luze n use on 25 No embe 2025
Conclusion
This s udy es ima es how much people wi h ch onic condi ions
inc ease hei u iliza ion o inpa ien and ou pa ien heal hca e
se ices. This excess u iliza ion imposes a subs an ial economic
bu den on heal hca e sys ems, wi h impo an a ia ions ac oss
coun ies. These di e ences can be a ibu ed o each coun y’s
dis inc o ganiza ion o heal hca e sys ems, social s uc u es,
Figu e 2. (A) Ou pa ien ca e: es ima ed cos s by ype o acili y [numbe s in USD (PPP)]. (B) Inpa ien ca e: es ima ed cos s by ype o
acili y [numbe s in USD (PPP)]. The numbe s e lec he heal hca e cos bu den (HcB), de ined as he p opo ion o excess heal hca e
u iliza ion cos s ela i e o a coun y’s o al heal hca e expendi u e. The size o he bubbles indica es he p e alence o ch onic condi ions.
224 Polanco e al.
Downloaded om h ps://academic.oup.com/eu pub/a icle/35/2/216/8009071 by ZHB Zen al- und Hochschulbiblio hek Luze n use on 25 No embe 2025
