REGIONAL INEQUALITIES IN TIMELY ACCESS TO THE SPANISH NHS: EVIDENCE FROM A COMPOSITE INDEX (ISAT), 2023-2025
Author(s)
Carlos Calvo-Fernández, MD1, Lucía Pedrosa Pérez, PhD2, Montserrat Carmona, BSc, MSPH, PhD2, Esther-Elena Garcia-Carpintero, PhD2, Carlos Sanchez-Piedra, PhD2.
1Hospital General Universitario Gregorio Marañón, Madrid, Spain, 2Instituto de Salud Carlos III- Health Technology Assessment Agency (AETS), Madrid, Spain.
1Hospital General Universitario Gregorio Marañón, Madrid, Spain, 2Instituto de Salud Carlos III- Health Technology Assessment Agency (AETS), Madrid, Spain.
OBJECTIVES: To develop and validate a Composite Index of Timely Access (ISAT) to the Spanish NHS; to quantify regional and sociodemographic inequalities; and to assess the relative contribution of population composition versus health system factors.
METHODS: Cross-sectional secondary analysis of pooled Spanish Health Barometer microdata 2023-2025 (N=22,580; analytical sample N=16,045). The ISAT (0-100; higher scores indicate worse access and longer waits) was built following the OECD ten-step protocol: log(x+1) transformation, min-max normalization and 50-50 weighting; robustness was assessed using alternative weighting and normalization schemes. External validation used a random-intercept linear multilevel model with 11 Spanish NHS Key Indicators (INCLASNS) across 17 autonomous communities.
RESULTS: Mean ISAT was 36.6 (95% CI 36.2-36.9), with a wide regional gap from Navarre (23.0) to Andalusia (44.3). Only 34.8% of Primary Care visits met the 48-hour target; specialist care compliance with the 60-day benchmark fell from 61.3% (2023) to 46.1% (2025), a 15.2-percentage-point drop. Factors associated with better access, in decreasing magnitude of association: residence in municipalities under 2,000 inhabitants (β=−12.75), age over 75 years (β=−4.79), and foreign nationality (β=−2.77); in contrast, higher ISAT scores were associated with very poor self-rated health (β=+5.03), female sex (β=+1.71), and chronic illness (β=+1.71), all p<0.05. Nine of eleven INCLASNS indicators showed associations in the expected direction (binomial p=0.033) and three remained statistically significant after adjustment for multiple comparisons (FDR correction). Sequential variance decomposition attributed 13.4% of between-region variance to composition and 58.0% to system-level indicators.
CONCLUSIONS: The Spanish NHS consistently fails to meet waiting-time benchmarks, with persistent regional inequalities. Between-region variation is driven primarily by modifiable health system factors, suggesting that improvements in system organization could reduce inequalities.
METHODS: Cross-sectional secondary analysis of pooled Spanish Health Barometer microdata 2023-2025 (N=22,580; analytical sample N=16,045). The ISAT (0-100; higher scores indicate worse access and longer waits) was built following the OECD ten-step protocol: log(x+1) transformation, min-max normalization and 50-50 weighting; robustness was assessed using alternative weighting and normalization schemes. External validation used a random-intercept linear multilevel model with 11 Spanish NHS Key Indicators (INCLASNS) across 17 autonomous communities.
RESULTS: Mean ISAT was 36.6 (95% CI 36.2-36.9), with a wide regional gap from Navarre (23.0) to Andalusia (44.3). Only 34.8% of Primary Care visits met the 48-hour target; specialist care compliance with the 60-day benchmark fell from 61.3% (2023) to 46.1% (2025), a 15.2-percentage-point drop. Factors associated with better access, in decreasing magnitude of association: residence in municipalities under 2,000 inhabitants (β=−12.75), age over 75 years (β=−4.79), and foreign nationality (β=−2.77); in contrast, higher ISAT scores were associated with very poor self-rated health (β=+5.03), female sex (β=+1.71), and chronic illness (β=+1.71), all p<0.05. Nine of eleven INCLASNS indicators showed associations in the expected direction (binomial p=0.033) and three remained statistically significant after adjustment for multiple comparisons (FDR correction). Sequential variance decomposition attributed 13.4% of between-region variance to composition and 58.0% to system-level indicators.
CONCLUSIONS: The Spanish NHS consistently fails to meet waiting-time benchmarks, with persistent regional inequalities. Between-region variation is driven primarily by modifiable health system factors, suggesting that improvements in system organization could reduce inequalities.
Conference/Value in Health Info
2026-11, ISPOR Europe 2026, Vienna, Austria
Value in Health, Volume 29, Issue 12S
Code
HSD123
Topic
Epidemiology & Public Health, Health Service Delivery & Process of Care
Disease
No Additional Disease & Conditions/Specialized Treatment Areas