The social cos o ch onic heal h condi ions and hei
po en ial o ehabili a ion owa ds an aging
popula ion
Cumula i e hesis submi ed o he deg ee o
Ph.D. in Heal h Sciences a he Facul y o Healh Sciences and Medicine Uni e si y o Luce ne
Included Pape s in he Cumula i e Thesis
Pape 1
Excess heal hca e u iliza ion and cos s linked o ch onic condi ions. Eu opean Jou nal o Public Heal h.
S a us: Published.
A ailable a : h ps://doi.o g/10.1093/eu pub/cka 012
Pape 2
Ch onic heal h condi ions and hei impac on he labo ma ke . A c oss-coun y compa ison in Eu ope.
Jou nal o Social Sciences and Medicine. S a us: Published
A ailable a : h ps://doi.o g/10.1016/j.ssmph.2024.101666
Pape 3
E ec i e and e icien ehabili a ion. Wha wo ks bes o pe sons wi h SCI du ing (sub)acu e phase o
ehabili a ion? S a us: Submi ed
A ailable a : h ps://doi.o g/10.1016/j.a c .2025.100532
Submi ed by Bo is San iago Polanco Jacome
16-104-622
Supe iso s
P o . Diana Pacheco Ba zallo
P o . Ad ian Ma inez de la To e
Luce ne, 2025
DOI: 10.5281/zenodo.17199873
Acknowledgemen s
I ind his sec ion he pe ec place o e lec on he jou ney I ha e had while wo king on
his hesis and o hank all he people who suppo ed me along he way.
I am ex emely g a e ul o he suppo o all he co-au ho s o he pape s included
in his hesis. Thei eedback p o ided helped me o shape he ideas p esen ed in hese
s udies.1
I would like o hank also o he Velux Founda ion 2 o suppo ing his esea ch.
Thei con ibu ion enabled me o deepen my unde s anding o heal h and aging.
Special hanks o Swiss Pa aplegic Resea ch o hos ing me and gi ing me access o
hei excellen acili ies. This ins i u ion is a wo ld leade in spinal co d inju y esea ch
and I eel o una e o ha e been a pa o i .
I am also e y g a e ul o my supe iso , P o . Diana Pacheco, she has been eally
suppo i e in all he s ages o his esea ch. I hink ha in some way I can unde s and
much be e economy and also his jou ney has igge ed new ideas o u u e po en ial
p ojec s.
I eel also eally glad o ha e been wo king in he Heal h Economics G oup a Swiss
Pa aplegic Resea ch. Big hanks o he g oup. E en hough we a e a new and small
g oup, we a e doing and impo an p og ess p epa ing he g ound and cons uc ing he
ounda ions o heal h economics in SPZ3.
I am also deeply g a e ul o he iendships I o med he e, especially wi h my Ph.D
1A e y special hanks o my co-au ho s: P o . Diana Pacheco Ba zallo, P o . Ca la Saba iego, P o .
A min Gempe li, D . Inge E iks-Hoogland, D . Anke Scheel-Saile , MSc S e an Me zge , and D . Ana
Ona.
2h ps:// eluxs i ung.ch/p ojec s/new-pe spec i es- o -heal hy-ageing/
3Membe s o he Heal h Economics G oup: P o . Diana Pacheco Ba zalo, D . Ana Ona, and my
colleagues S e an Me zge and Nga Chau My Ha
1
colleagues in he PhD oom in No wil. I has been inc edibly en iching o sha e his
expe ience wi h people o di e en academic backg ounds and na ionali ies. Ha ing such
di e se and inspi ing colleagues has made his jou ney e y special.
I also hank he P o esso S e an Boes and D . Michael Ha anek o gi ing me he
oppo uni y o wo k on a eal-wo ld p ojec . Tha expe ience allowed me o explo e
new opics, be e unde s and how esea ch is applied in p ac ical se ings, and g ow
signi ican ly in my p o essional de elopmen .
Be o e men ioning my pe sonal g ow h, I since ely hank all he p o esso s in ol ed
in he PhD p og am and e alua ions. You guidance, eedback and suppo played a key
ole in helping me comple e his hesis and shape my academic pa h.
I mus also hank my amily, who ha e always encou aged my cu iosi y and suppo ed
me in pushing my limi s o achie e my academic goals.
Swi ze land has gi en me mo e han jus academic g ow h, i in oduced me o won-
de ul people who ha e shaped my li e. I wan o hank my iends om he Zug jazz
band, wi h whom I ha e been playing almos e e y weekend o mo e han h ee yea s.
They’ e helped me unde s and, in a e y pe sonal way, wha heal hy aging means h ough
hei passion, discipline, and lo e o music. I will o e e ca y wi h me my passion o
d umming.
2
Chap e 1
In oduc ion
Backg ound and Mo i a ion
The popula ion aging imposes se e al challenges and oppo uni ies o he o ganiza ion
o heal h and social sys ems. As people li e longe and o en in be e heal h, hey can
emain ac i e in he wo k o ce and con ibu e o socie y beyond adi ional e i emen
ages [1]. Howe e , a he same ime, his demog aphic shi is also cha ac e ized by a
ising p e alence o ch onic condi ions, which is cu en ly he leading cause o disabili y
[2]. Globally, ch onic condi ions such as ischemic hea disease, s oke, and ch onic
obs uc i e pulmona y disease (COPD) a e no only he main causes o dea h, bu also
he d i e s o disabili y adjus ed yea s (DALYs) wo ldwide [3, 4, 5].
Ex ensi e li e a u e exis s s udying how speci ic ch onic condi ions impac indi idu-
als, as well as he e ec s on he cos s o he heal hca e sys em. [6, 7]. Howe e , hei
economic bu den ex ends beyond ha due o i s long- e m na u e. In ac , ch onic condi-
ions educe he in insic capaci y o people wi h impo an implica ions o hei ac i i y
and pa icipa ion, being he mos wo isome he e ec s in he labo ma ke . Se e al s ud-
ies ha e shown how people wi h ch onic condi ions ha e highe a es o absen eeism [8],
inc easing demand o disabili y bene i s o ea ly e i emen [9]. In addi ion, ch onic
condi ions a e associa ed wi h highe le els o heal hca e u iliza ion. These esul s a e
pa icula ly p onounced among ulne able popula ions, whe e po e y, limi ed educa ion,
3
and es ic ed access o ca e can exace ba e ad e se heal h and economic ou comes [10].
To quan i y hese impac s, he li e a u e has commonly adop ed he cos -o -illness
(COI) app oach, which conside s di ec and indi ec cos s [11]. Di ec cos s a e ela ed
o he ea men o he ch onic condi ion, which includes cos s such as hospi aliza ion
and medical ca e. Indi ec cos s a ise om he e ec s o he ch onic disease, and include
p oduc i i y losses, dependence on o he s, among o he s. Se e al s udies ha e es ima ed
hese cos s o speci ic condi ions including diabe es [12], s oke [13], ch onic obs uc i e
pulmona y disease (COPD) [14], a h i is [15], men al heal h diso de s [16], kidney dis-
ease [17], and cance [18]. Despi e his g owing a en ion, exis ing s udies mos ly o e
condi ion speci ic esul s, mos ly desc ibing co ela ions, which limi s o cap u e he cu-
mula i e e ec s o ch onic condi ions. This agmen ed e ec makes i ha de o de elop
clea and e ec i e public policies ha deal wi h ch onic condi ions in a comp ehensi e
and las ing way. Mo eo e , ew s udies explo e po en ial solu ions om he heal h sys-
em pe spec i e, such as p e en i e o ehabili a i e ca e, o mi iga e he e ec s o hese
condi ions [19].
While p e en ion is a long- e m goal, i does no add ess he exis ing and g owing
popula ion al eady li ing wi h ch onic condi ions. Fo his g oup, he sole heal h s a egy
ha a ge s people’s unc ioning is ehabili a ion[20]. Rehabili a ion, de ined as he se
o in e en ions designed o op imize unc ioning and educe disabili y, can help people
wi h ch onic condi ions o emain independen o as long as possible, wi h impo an
implica ions o socie y.
This hesis aims o close his gap and con ibu es o he li e a u e by p o iding a
comp ehensi e assessmen o he economic bu den o ch onic condi ions in 9 Eu opean
coun ies. I ocuses on bo h di ec and indi ec cos s and explo es he unde used bu
p omising ole o ehabili a ion. Speci ically, i es ima es he impac o ch onic condi ions
on heal hca e u iliza ion (di ec cos s) and labo ma ke pa icipa ion (indi ec cos s),
and i e alua es he e ec i eness and e iciency o ehabili a ion using an ex eme case o
disabili y, like spinal co d inju y (SCI) as a case s udy.
In addi ion, his hesis implemen s an inno a i e me hodological amewo k, using
4
causal in e ence o panel da a. We apply di e ence-in-di e ences models wi h mul iple
ime pe iods o s udy how he diagnosis o a ch onic condi ion impac s he u iliza ion
o heal hca e se ices and he p oduc i i y o indi iduals. I combine hese es ima es
wi h uni cos s o heal hca e se ices (WHO-CHOICE) and concep s om insu ance
ma hema ics o quan i y he heal hca e cos bu den. Finally, using eal wo ld da a, I
show how ehabili a ion can be an e ec i e s a egy o imp o e independence measu es
o pa ien s wi h high le el o disabili y.
1.1 Resea ch Objec i es and S uc u e
The objec i e o his hesis is o quan i y he e ec o ch onic condi ions on heal hca e
cos s and he labo ma ke . Also, o e alua e he e ec i eness and e iciency o ehabili-
a ion in keeping people independen . This is achie ed h ough he ollowing s udies:
•S udy 1: Ch onic condi ions and hei impac on heal hca e u iliza ion and cos s.
Aim: To es ima e he addi ional use o heal h se ices due o ch onic condi ions
and i s cos .
•S udy 2: Ch onic condi ions and hei impac in he labo ma ke .
Aim: To es ima e he p oduc i i y losses due o ch onic condi ions, assessing hei
impac on he pa icipa ion and economic bu den in he labo ma ke .
•S udy 3: E iciency and e ec i eness o ehabili a ion o pe sons wi h spinal co d
inju y (SCI).
Aim: To es ima e how ehabili a ion imp o es unc ional independence o pe sons
wi h pa aplegia/ e aplegia.
1.2 Da a Sou ces and Me hodological App oach
This hesis is ed wi h da a om se e al sou ces. Fi s , i analyzed da a om he Su -
ey on Heal h, Aging and Re i emen in Eu ope (SHARE)[21]. SHARE is a longi udinal
5
da a se ha co e s Eu opean coun ies. The da a con ain in o ma ion on heal h con-
di ions, u iliza ion o heal hca e ca e se ices, and socioeconomic ac o s in people 50+
yea s o age. Second, I use he WHO-CHOICE da a se . This p og am, de eloped by
he Wo ld Heal h O ganiza ion (WHO), p o ides e idence on he uni cos s o inpa ien
and ou pa ien ca e a coun y le el . Finally, o he hi d s udy, in which we analyze
he ole o ehabili a ion and disabili y, we ha e conside ed ou ine clinical da a om
pa ien s wi h SCI who ecei ed ehabili a ion om Swiss Pa aplegic Cen e , one o he
ou specialized SCI ehabili a ion cen e s in Swi ze land.
To analyze he e ec o ch onic condi ions on p oduc i i y and use o heal hca e se -
ices, we conside he po en ial ou comes amewo k [22],[23] (Rubin’s causal model).
This amewo k iden i ies causal e ec s by compa ing he ou comes ha an indi idual
would expe ience wi h and wi hou a ea men , which in he case o his hesis is he
diagnosis o a ch onic condi ion. Fo each indi idual in he su ey, we ha e wo po en ial
ou comes, bu only one is obse ed. Causal in e ence hen in ol es es ima ing he missing
coun e ac ual using a syn he ic con ol g oup.
The ou comes analyzed we e he numbe o wo king hou s in he las week (S udy
1) and he numbe o doc o isi s and o e nigh hospi al s ays (S udy 2). To es ima e
causal e ec s in his se ing, I implemen ed he Callaway and San ’Anna di e ence in
di e ence es ima o [24], which is speci ically designed o mul iple ime pe iods wi h he
adop ion o s agge ed ea men . This app oach allows o make compa isons be ween
ea ed and un ea ed indi iduals o e ime, p o iding es ima es o he a e age e ec o
ea men .
Fo he las s udy, I employed gene alized addi i e models (GAMs) o es ima e he
e ec i eness and e iciency o specialized ehabili a ion. The ou come measu ed in his
model, was he independence me ic (SCIM III), which is a s anda d measu e collec ed
in clinical se ings. GAMs accoun o he nonlinea ela ionship be ween ehabili a ion
and unc ional independence, pa icula ly wi h espec o leng h o s ay and cos s. This
modeling choice was suppo ed by ela ed e idence on he nonlinea associa ion be ween
heal hca e spending and heal h ou comes, which ypically elies on agg ega e heal h ex-
6
pendi u e da a [25].
In con as , ou s udy ocused on spinal co d inju y (SCI), a condi ion ha , due o
i s complexi y and in ensi e esou ce needs, se es as a ace condi ion o e alua e he
pe o mance o heal h sys ems [26].
SCI becomes highly ele an no only because o i s p o ound and li e-changing impac
on indi iduals, bu also because i in ol es an ini ial pe iod o acu e hospi aliza ion
ollowed by a leng hy p ocess o ehabili a ion and adap a ion o a new way o li e [27].
Impo an ly, SCI ca e equi es a b oad ange o heal h se ices ac oss sec o s, o e ing
aluable insigh s in o he unc ioning o he heal hca e sys em. In his s udy, we ocus
on Swi ze land, as i p o ides de ailed indi idual-le el da a on ehabili a ion and se ice
use, which aligns wi h he o e all objec i es o he hesis.
7
Chap e 2
Excess Heal hca e U iliza ion and
Cos s
DOI h ps://doi.o g/10.1093/eu pub/cka 012
8
con ex , a good unde s anding o ehabili a ion e ec i eness and e iciency is essen ial. Fu u e
simula ions could es di e en scena ios o hese me ics, o example, inc easing o dec eas-
ing ehabili a ion esou ces o see how hese changes would a ec pa ien ou comes and he
inancial p essu e on insu ance sys ems. This could help policymake s o plan how o in es in
ehabili a ion as a way o educe he long- e m impac o ch onic diseases.
5.3 Conclusion
In conclusion, his hesis shows ha ch onic diseases ha e impo an economic consequences,
bo h o indi iduals and heal h sys ems. People wi h ch onic diseases use mo e heal hca e
se ices and ace p oduc i i y losses, especially in he labo ma ke . A he same ime, he
esul s show ha ehabili a ion can play a key ole in helping people eco e hei independence.
This is impo an no only o hei heal h, bu also because i can educe u u e heal hca e
use and p oduc i i y losses. In es ing in ehabili a ion should be seen as pa o he s a egy
o manage he economic impac o ch onic condi ions.
This hesis is one o he ew s udies o p o ide coun y le el causal es ima es on he economic
impac o ch onic diseases, including bo h heal hca e u iliza ion and p oduc i i y losses. These
indings a e e y impo an e idence o suppo he design o policy in e en ions ailo ed o
he speci ic cha ac e is ics o each coun y’s heal h and social sys ems.
15
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