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To estimate the prevalence of catastrophic health expenditure due to dental healthcare (CHED) in Spain, quantify its intensity and examine the related sociodemographic household characteristics.Data from the Spanish Household Budget Survey, which addresses more than 20,000 households each year for the period 2008-2015 were included, and the methodology proposed by Wagstaff and van Doorslaer was followed. The prevalence (number of households that devote more than a certain threshold of their income to such payments) and intensity (amount that exceeds a certain percentage of income) were estimated. Ordered logistic regression models were estimated to analyse the sociodemographic factors associated with the prevalence of catastrophic payments.The prevalence and intensity remained stable during the period under analysis. In terms of prevalence, a mean proportion of 7.36% of the population dedicated, in terms of intensity, more than 10% of their resources to dental care payments [mean: €292.75 per year (SD €2144.14)] and 2.05% dedicated more than 40% [mean: €143.02 per year (SD €1726.42)]. This represents 36.32% and 51.34% (for the thresholds of 10% and 40%) of the total catastrophic expenditure derived from out-of-pocket payments for dental healthcare in Spain.This study shows that a significant proportion of catastrophic healthcare payments correspond to dental services. Being male, aged over 40 years, unattached (single, separated, divorced or widowed), having a low level of education, a low household income, being unemployed and living in an urban area are all associated with a greater risk of CHED. This finding highlights the need to establish policies aimed at increasing dental care coverage to mitigate related financial burdens on a large part of the Spanish population.

Objective: To assess the amount of employment generated from the effective development of the Dependency Act in 2012, by evaluating the number of jobs depending on whether in-kind services or cash benefits were applied. Methods: The level and total costs of dependency were obtained by using the Survey on Disability, Personal Autonomy and Dependency Situations of 2008. The consumption of dependent households was collected from the Household Budget Survey of 2012 carried out by the Spanish Statistics Institute. The impact on employment was estimated using an extended Input-Output model based on Symmetric Input-Output Tables and labour data from the Spanish National Accounts Base. Results: The total estimated costs of dependency in 2012 were 4,545 million Euros for in-kind services and 2,662 for cash benefits. One hundred and ninety-five thousand, six hundred and sixty-eight jobs were generated in 2012 from dependency costs, and132,997 were linked to in-kind services and 62,671 to cash benefits. Every million Euros allocated for dependency by the Government returned 53.33 jobs linked to in-kind services and 46.21 to cash benefits. Furthermore, 341,505 jobs would have been created if dependency benefits had been exclusively offered via in-kind services. Conclusions: Dependency benefits were equally distributed between in-kind services and cash benefits in 2012. Given that two out of three job positions generated from dependency benefits are linked to in-kind services, while the remaining third is generated by cash benefits, we conclude that around 146 thousand more jobs would have been generated if benefits had been offered as in-kind services instead of overusing cash benefits. Resumen: Objetivo: Estimar la creación de empleo generada por la implantación de la Ley de Dependencia en 2012, evaluando el número de puestos de trabajo vinculados a servicios y a prestaciones económicas. Métodos: Los grados y los costes totales de la dependencia se han obtenido de la Encuesta sobre Discapacidades, Autonomía Personal y Situaciones de Dependencia de 2008. El consumo de los hogares dependientes proviene de la Encuesta de Presupuestos Familiares realizada por el Instituto Nacional de Estadística en 2012. La creación de empleo se ha estimado con un modelo ampliado input-output basado en las tablas simétricas input-output y en datos de empleo de la Contabilidad Nacional de España. Resultados: Los costes totales de dependencia estimados en 2012 fueron de 4545 millones de euros en servicios y 2662 millones de euros en prestaciones económicas. Se generaron 195.668 empleos vinculados a prestaciones de dependencia en 2012, 132.997 asociados a servicios y 62.671 a prestaciones económicas. Cada millón de euros asignados a prestaciones de dependencia por la Administración generó 53,33 empleos vinculados a servicios y 46,21 a prestaciones económicas. Además, se habrían creado 341.505 empleos si las prestaciones de dependencia hubieran sido asignadas únicamente como servicios. Conclusiones: Los costes de dependencia se distribuyeron por igual entre servicios y prestaciones económicas en 2012. Dado que dos de cada tres empleos generados por las prestaciones de dependencia están vinculados a servicios, mientras que el tercio restante a prestaciones económicas, se habrían generado 146.000 empleos más si todas las prestaciones hubieran sido asignadas como servicios en lugar de la masiva utilización de prestaciones económicas. Keywords: Dependency, Employment, Long-term care, Social services, Spain, Palabras clave: Dependencia, Empleo, Cuidados de larga duración, Servicios sociales, España

Objective An increasing number of persons across the world require long-term care (LTC). In Spain, access to LTC involves individuals incurring out-of-pocket (OOP) expenditure. There is a large body of literature on the incidence of catastrophic OOP payments in access and participation in health systems, but not in the field of LTC nor the determinants of these expenses. Our aim was to analyse the socio-demographic and economic factors associated with different levels of catastrophic LTC expenditure in the form of private out-of-pocket payments among dependent persons in Spain. Materials and methods The study used the Spanish Disability and Dependency Survey (SDDS) conducted by the Spanish National Statistics Institute to obtain the socioeconomic, demographic and health profiles. The households were classified into those below the poverty threshold and those above the threshold of catastrophe, using measures of impoverishment and catastrophe. We estimated two logistic regression models, one binary (impoverishment) and one ordinal (catastrophe). Results The results show that OOP expenditure on LTC increases the probability of impoverishment by 18.90%. The factors associated with higher probability of experiencing catastrophe were age, being single, widowed or separated, lower levels of household income and education, higher level of dependence and living in an autonomous community with lower per capita income. Conclusions These findings highlight the need to include exemptions or insurance in the design of LTC policies to protect dependent persons from the risk of financial burden.

Background: Out-of-pocket (OOP) payments are configured as an important source of financing long-term care (LTC). However, very few studies have analyzed the risk of impoverishment and catastrophic effects of OOP in LTC. To estimate the contribution of users to the financing of LTC and to analyze the economic consequences for households in terms of impoverishment and catastrophism after financial crisis in Spain. Methods: The database that was used is the 2008 Spanish Disability and Dependency Survey, projected to 2012. We analyze the OOP payments effect associated to the impoverishment of households comparing volume and financial situation before and after OOP payment. At the same time, the extent to which OOP payment had led to catastrophism was analyzed using different thresholds. Results: The results show that contribution of dependent people to the financing of the services they receive exceeds by 50% the costs of these services. This expenditure entails an increase in the number of households that live below the poverty. In terms of catastrophism, more than 80% of households dedicate more than 10% of their income to dependency OOP payments. In annual terms, the catastrophe gap generated by devoting more than 10% of the household income to dependent care OOP payment reached &euro, 3955, 1 million (0.38% of GDP). Conclusion: This article informs about consequences of OOP in LCT and supplements previous research that focus on health. Our results should serve to develop strategic for protection against the financial risk resulting from facing the costs of a situation of dependence.

Informal care is a substantial source of support for people with cancer. However, various studies have predicted its disappear ance in the near future. The aim of this study is to analyse the catastrophic effect resulting from the substitution of informal care with formal care in patients with blood cancer throughout the different stages of treatment. A total of 139 haematological neoplasm patients who underwent stem cell transplantation in Spain, completed a longitudinal questionnaire according to the three phases of treatment between 2012 and 2013. The economic value of informal care was estimated using proxy good, opportunity cost, and contingent valuation methods. Catastrophic health expenditure measures with thresholds ranging from 5 to 100% were used to value the financial burden derived from substitution. A total of 88.5% of patients reported having received informal care. In 85.37%, 80.49%, and 33.33% of households, more than 40% of their monthly income would have to be devoted to the replacement with formal care, with monthly amounts of €2105.22, €1790.86, and €1221.94 added to the 40% in the short, medium, and long-term, respectively (proxy good method, value=9 €/h). Informal caregivers are a struc tural support for patients with blood cancer, assuming significant care time and societal costs. The substitution of informal care with formal care would be financially unaffordable by the families of people with blood cancer.

Objectives This study analyses the financial burden associated with the introduction of copayment for long-term care (LTC) in Spain in 2012 for dependent individuals. Material and methods We analyse and identify households for which the dependency-related out-of-pocket payment exceeds the defined catastrophic threshold (incidence), and the gap between the copayment and the threshold for the catastrophic copayment (intensity), for the full population sample and for subsamples based on the level of long-term care dependency and on regional characteristics (regional income and political ideology of party ruling the region). Results The results obtained show there is a higher risk of impoverishment due to copayment among relatively well-off dependents, although the financial burden falls more heavily on less well-off households. Our findings also reveal interesting regional patterns of inequity in financing and access to long-term care services, which appear to be explained by an uneven development of LTC services (monetary transfers versus formal services) and varying levels of copayment across regions. Conclusions The new copayment for long-term care dependency in Spain is an important factor of catastrophic risk, and more attention should be addressed to policies aimed at improving the progressivity of out-of-pocket payments for LTC services within and between regions. In addition, formal services should be prioritised in all regions in order to guarantee equal access for equal need.

healthy eating habits, such as the consumption of fruits and vegetables, allow better health and, consequently, reduce the consumption of health resources. It is important to establish a relationship between fruit and vegetable consumption and the use of health services in the Spanish population to consider the need to intervene.the European Health Survey in Spain for 2014 was used, and the possible existence of differences in access and visit frequency to the family physician, specialist physician and emergency services depending on fruits and vegetables consumption habits was assessed through Hurdle models. Subsequently, two groups were generated through the propensity score matching technique in order to compare the differences in the frequenting of services depending on the consumption of fruits and/or vegetables and other adjustment covariates. Finally, the cost generated by such differences was estimated according to consumption groups.there are differences in access to the emergency services, both in subjects who never consume fruit and in subjects who never consume vegetables. In the first case, there is an increase of 420 visits per year for every 1,000 persons with attributable costs of €75,000, whereas in the second case, an increase of 780 visits per year for every 1,000 persons, with a cost of €139,000, is observed.certain eating habits of the Spanish population, such as never consuming fruits or vegetables, produce important avoidable expenses in the health system. It would be of interest to implement prevention policies to reduce such costs and use resources appropriately.Introducción: los buenos hábitos de alimentación, como el consumo de frutas y verduras, permiten tener una mejor salud y, consecuentemente, minorar el consumo de recursos sanitarios. Es importante establecer una asociación entre consumo de frutas y verduras y el uso de los servicios sanitarios en la población española para considerar la necesidad de intervenir.Métodos: se empleó la Encuesta Europea de Salud en España del año 2014 y, mediante la utilización de modelos Hurdle, se valoró si existían diferencias en el acceso y la frecuentación al médico de familia, especialista y urgencias, dependiendo de los hábitos de consumo de frutas y verduras. Posteriormente, mediante la técnica propensity score matching se generaron dos grupos con los que poder comparar las diferencias en la frecuentación de los servicios sanitarios dependiendo del consumo de frutas y/o verduras y otras covariables de ajuste. Finalmente, se estima el coste de dichas diferencias por grupos de consumo.Resultados: se revela la existencia de diferencias en el acceso al servicio de urgencias, tanto por los sujetos que no consumen nunca fruta como por parte de los sujetos que no consumen nunca verdura. En el primer caso hay un incremento de 420 visitas al año por cada 1.000 personas con un coste atribuible de 75.000 €, mientras que en el segundo caso se observa un incremento de 780 visitas al año por cada 1.000 personas, con un coste equivalente de 139.000 €.Conclusiones: determinados hábitos de alimentación de la población española como no consumir nunca fruta o verdura producen importantes gastos evitables en el sistema sanitario. Es de gran interés implementar políticas de prevención para minorar dichos gastos y emplear los recursos de forma adecuada.

There is a growing interest in incorporating informal care in cost-of-illness studies as a relevant part of the economic impact of some diseases. The aim of this paper was to review the recent literature valuating the costs of informal care in a group of selected diseases from 2005 to 2015. We carried out a systematic review on the economic impact of informal care, focusing on six selected diseases: arthritis or osteoarthritis, cancer, dementia, mental diseases, multiple sclerosis and stroke. We selected 91 cost-of-illness articles. The average weight attributed to the informal care cost over the total cost was highly relevant for dementia, stroke, mental diseases, cancer and multiple sclerosis. The most frequent valuation method applied was the opportunity cost method, followed by the proxy good method. The annual cost of informal care presented a high variability depending on the disease and geographic location. Distinguishing by type of illness, the disease with the highest annual value of informal caregiving was dementia, followed by mental illness and multiple sclerosis. The average hourly unit cost was €11.43 (2015 values), varying noticeably depending on the geographic location. This paper identifies several aspects that should be enhanced to promote comparability between studies and countries, and it sends key messages for incorporating informal care costs to adequately measure the economic impact of diseases.

The objective of this piece of work is to establish the cost of dependency and the cost of financing it. Specifically, we will determine the cost of co-payment for individual users following the modification introduced by the 13th of July 2012 Resolution as well as its allocation by the autonomous regions.The degree and level of dependency was established using the Survey on Disability, Personal Autonomy and Dependency Situations, 2008. The cost of dependency according to degree and level and autonomous regions was established with information from the System for Personal Autonomy and Care of Dependent Persons. The co-payment was established according to applicants' purchasing power. The rating of these services, and the contribution of individual users were done in agreement with 2012 legislation and with common indicators and benchmarks for the whole national territory.The total estimated cost is 10,598.8 million euros (1.03% of GDP), and Andalusia, the Valencian Community and Catalonia are those regions with the greatest costs. The average national co-payment per individual user is 53.54%, with differences due to degrees and levels of disability and autonomous regions, although, generally speaking, all of the users fund more than half of the care they receive.This change in legislation has meant that co-payment is higher than the 33% established by this law and that co-payments prior to 2012 were about 20%. If we add to this the differences in autonomous regions, it would be useful to reflect on the uneven application of the law.

The Law of Dependence keeps the informal caregiver´s role, incorporating a specific economic benefit. The aims of this work are 1) to analyze the effect of the Law on informal care existence, and 2) to value the economic impact in the Law, disaggregated by financier.A cross-section study has been conducted from a representative sample of the dependent population in Cuenca (Spain) in February, 2009. We have obtained information for people with level II and III of dependence. A care service delivery simulation is used to quantify the economic impact of informal care to Cuenca (sample), Castilla-La Mancha and Spain.Informal care delivery is assigned in 81,74% of dependency benefits. Total costs of care service delivery is reduced between 36,51% and 80,53% if informal care exits, disaggregated into savings of 122,97-251,04% for user and 23,30-54,47% for public administration. Average estimated copayment for user is 13,25% for real sample, and it rises to 25,77% when it is supposed informal care extinguishes.Informal care is widespread in the Law, and it implies an important household and public resources saving: for household due to the assumption a smaller copayment that theoretical established, which is assumed by Autonomous Communities; in turn, for public administration, because of the fact economic deliveries require fewer resources.

To analyze the relationship between sociodemographic and health variables (including informal care) and the healthcare service delivery assigned in the individualized care plan.An observational cross-sectional study was conducted in a representative sample of the dependent population in Cuenca (Spain) in February, 2009. Information was obtained on people with level II and III dependency. Four different logistic regression models were used to identify the factors associated with the care service delivery assigned in the individualized care plan. Independent variables consisted of age, gender, marital status, annual income, place of residence, health conditions, medical treatment, and perception of informal care.A total of 83.7% of the sample was assigned economic benefits and 15.3% were assigned services. Eighty percent of the sample received informal care in addition to dependency benefits. People who received informal care were 3239 times more likely to be assigned economic benefits than persons not receiving informal care.For the period analyzed (the first phase of the implementation of the Dependency Act), the variables associated with receiving economic benefits (versus services) were being married, having a high annual income, the place of residence (rural areas versus urban area), and receiving hygiene-dietary treatment and informal care.

The analysis of the effect that different variables have in the probability that dependent people are institutionalized is a topic scantily studied in Spain. The aim of the work is to analyze as certain socio-demographic and health factors can influence probability of dependent person living in a residence.A cross-section study has been conducted from a representative sample of the dependent population in Cuenca (Spain) in February, 2009. We have obtained information for people with level II and III of dependence. A binary logit regression model has been estimated to identify those factors related to the institutionalization of dependent people.People with ages between 65-74 years old are six times more likely to be institutionalized than younger people (65 years old); this probability increases sixteen times for those individuals with ages equal or higher than 95 years. The probability of institutionalization of people who live in an urban area is three times the probability of people who live in a rural area. People who need pharmacological, psychotherapy or rehabilitation treatments have between two and four times more probability of being institutionalized that those who do not need those.Age, marital status, place of residence, cardiovascular and musculoskeletal diseases and four times of medical treatment are the principal variables associated with the institutionalization of dependent people.