








































This is an open access article under the terms of a license that permits non-commercial use, provided the original work is properly cited.  
© 2023 The Authors. Société Internationale d'Urologie Journal, published by the Société Internationale d'Urologie, Canada.

SIUJ.ORG SIUJ  •  Volume 4, Number 4  •  July 2023

Key Words Competing Interests Article Information

Bladder cancer, population registry, 
epidemiology, medical insurance, trends

None declared. Received on January 25, 2023 
Accepted on April 5, 2023 
This article has been peer reviewed.

Soc Int Urol J. 2023;4(4):265–272

DOI: 10.48083/ZNKI7577

265

ORIGINAL RESEARCH

Public Policies and Type of Insurance Are Associated 
With the Burden of Bladder Cancer – Related 
Inpatient Health Care in Chile: A Two-Decade Analysis
Ignacio Eltit,1 Joaquín Cristi,1 Iris Delgado,2 Paula Huerta,1 Sergio Fuentes,1 Alberto Bustamante,1,3  
Mario I. Fernández3,4

1 Facultad de Medicina Clínica Alemana Universidad del Desarrollo, Santiago, Chile 2 Centro de Epidemiología y Políticas de Salud, Facultad de Medicina Clínica Alemana 
Universidad del Desarrollo, Santiago, Chile 3 Servicio de Urología, Clínica Alemana de Santiago, Chile 4 Centro de Genética y Genómica, Facultad de Medicina Clínica 
Alemana Universidad del Desarrollo, Santiago, Chile

Abstract

Objective To quantify changes in the burden of bladder cancer (BC) inpatient health care in Chile between  
2001 and 2019, focusing on the impact of public policies and the type of medical insurance (public or private)  
held by patients.

Methods We retrospectively collected national data on hospital discharges and calculated raw and adjusted 
hospitalization rates for the period of 2001 to 2019 categorized by sex and age. Additionally, we analyzed length of 
hospital stays, outcomes of surgical interventions, and discharge conditions based on the type of medical insurance 
— public: FONASA; private: ISAPRE. We also evaluated the impact of public policies such as the GES (“garantías 
explícitas en salud”) program, which ensures opportunities and access to medical attention, financial protection, and 
quality of care for a subset of diseases.

Results A total of 34 100 hospital discharges were analyzed. Most patients were men (71%), and median age was 69 
years. Of the patients, 91.3% had some kind of medical insurance, either private or public. Within this subset, 71.3% 
had public medical insurance (FONASA) and 23.2% had private medical insurance (ISAPRE). Patients on FONASA 
had significantly higher levels of overall surgery-related mortality (0.83% vs. 0.2%) and significantly longer median 
hospital stays (4 days vs. 2 days) compared to patients on ISAPRE. Following the implementation of the GES program 
in 2013, we observed an increase in transurethral resections and a reduction in radical cystectomies among publicly 
insured patients.

Conclusions The type of medical insurance has a significant impact on the burden of BC-related inpatient health 
care in Chile, reflecting a significant disparity in terms of health care. The implementation of public policies such 
as the GES program can play a key role in reducing this gap between public and private medical insurance systems, 
especially in underdeveloped countries.

Introduction
Bladder cancer (BC) is the seventh most common malignancy worldwide, with a global incidence of 7.4/100 000[1]. 
Incidence rates of BC are higher in high-income countries, particularly among men and associated with age.  
The main risk factor for BC is tobacco use, accounting for 50% to 60% of cases[2]. Previous studies have demonstrated 
that socioeconomic status, ethnicity, and health coverage are independent prognostic factors of clinical outcomes for 
the common malignancies, including BC (CIE-10 – c67)[3,4]. Among these factors, health coverage is particularly 

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Regression Software, v.4.6.0.0 Statistical Research and 
Applications Branch, National Cancer Institute, US, 
2018). This test quantifies the annual percentage change 
(APC) adjusted by autocorrelation, with a statistical 
significance set at P < 0.05.

All patient information was obtained and handled 
using encrypted codes for ID, strictly adhering to the 
privacy regulations and use of sensitive data (Chilean 
Act #19628).

Results
A total of 29 724 hospital discharges with BC as the 
primary diagnosis were recorded during the period 
from 2001 to 2019. As expected, most patients (71%; 
n = 21 113) were men, with a median of 69 years. The age 
range for 90% of patients (10th to 90th percentile) in this 
sample fell between 51 and 83 years. Almost half of them 
(45.9%; n  =  13 635) underwent surgery. Additionally, 
86.1% of the patients (n  =  25 606) had some type of 
medical insurance, either public or private. Among this 

subset, 75.8% were hospital discharges of patients with 
FONASA (public insurance, n  =  19 403), while 24.2% 
were ISAPRES (private insurance, n = 6203).

Over the study period, we observed a steady increase 
of overall hospital discharges, along with changes 
in their distribution according to insurance type. 
Interestingly, the proportion of ISAPRE users increased 
from 17.3% in the period from 2001 to 2003 to 23.9% 
in the period from 2017 to 2019. Table 1 and Figure 1 
summarize the number of annual discharges and the 
changes in discharge rates by insurance type over time, 
respectively.

Regarding clinical outcomes, the overall inpatient 
mortality rate was 3.7%. When analyzed by insurance 
type, the mortality rate was higher among FONASA 
patients (4.4%; 95% CI 4.0 to 4.8]) compared with 
ISAPRE patients (2.7%; 95% CI 2.2 to 3.2; P  <  0.001). 
However, we observed a significant decrease in inpa-
tient mortality for FONASA patients (-1.74% APC) over 
the period from 2001 to 2019 (Figure 2). Additionally, 

TABLE 1. 
Annual hospital discharges, population, and crude hospital discharge rates per 100 000

Hospital discharges (n) Population (n) Crude hospital 
discharge rates 

FONASA 

Crude hospital 
discharge rates

ISAPREYear
FONASA
(public)

ISAPRE
(private)

Total
FONASA
(public)

ISAPRE
(private) 

2001 791 12 803 10 156 364 2 940 795 7.7 0.4

2002 673 152 825 10 327 218 2 828 228 6.5 5.3

2003 871 317 1188 10 580 090 2 729 088 8.2 11.6

2004 808 346 1154 10 910 702 2 678 432 7.4 12.9

2005 846 325 1174 11 120 094 2 660 338 7.6 12.2

2006 811 225 1036 11 479 384 2 684 554 7 8.3

2007 777 161 938 11 740 688 2 776 912 6.6 5.7

2008 714 223 937 12 248 257 2 780 396 5.8 8

2009 759 259 1018 12 504 226 2 776 572 6 9.3

2010 748 271 1019 12 731 506 2 825 618 5.8 9.5

2011 801 227 1028 13 202 753 2 925 973 6 7.7

2012 1015 313 1328 13 377 082 3 064 719 7.5 10.2

2013 1058 413 1471 13 451 188 3 206 312   7.8   12.8

2014 1146 448 1594 13 468 265 3 308 927 8.5 13.5

2015 1338 475 1813 13 256 173 3 410 487 10 13.9

2016 1309 489 1798 13 598 639 3 427 665 9.6 14.2

2017 1414 467 1881 13 926 475 3 393 662 10.1 13.7

2018 1734 569 2303 14 242 655 3 404 896 12.1 16.7 

2019 1790 511 2301 14 841 577 3 431 126 12 14.9

Total 19 403 6203 25 606

relevant due to the high costs associated with BC 
diagnosis, treatment, and follow-up[5]. Population-
based studies conducted in the United States (US) have 
revealed that the type of medical insurance can partially 
explain differences in BC patient survival[6]. Indeed, 
US-based studies report lower overall survival and 
cancer-specific survival in BC patients without medical 
insurance or with public medical insurance[7].

In Chile, the health care system uses a mixed 
model that consists of a public medical insurance 
fund (FONASA: “Fondo Nacional de Salud ”) and 
private medical insurance providers (collectively 
called ISAPRES: “Instituciones de Salud Previsional”). 
According to official figures from 2018, FONASA 
covers 78% of the Chilean population whereas ISAPRES 
provides coverage for 18%. Both insurance systems are 
regulated by the Chilean Ministry of Health (MINSAL). 
The remaining 4% is covered by the armed forces and 
other specific insurance providers[9]. To date, private 
and public medical insurance systems operate inde-
pendently, without formal coordination[10]. In 2005, 
Chile implemented the Explicit Guarantees in Health 
(“garantías explícitas en salud”; GES). This system 
ensures timely access to quality health care for a prior-
itized set of diseases. Since GES was introduced, it is 
mandatory to report the diseases incorporated into this 
system. BC was incorporated into the GES program in 
2013, guaranteeing the staging, treatment, and follow-up 
for this disease. When a primary care physician suspects 
BC, the GES system is activated, setting the time frame 
by which health providers must deliver care (up to 30 
days for staging and up to 45 days for treatment). The 
GES program also provides financial coverage for both 
private and publicly insured patients[11,12].

The objective of our study was to quantify changes in 
the burden of BC inpatient health care in Chile between 
2001 and 2019, aiming to assess the impact of public 
policies and the type of medical insurance (public or 
private) held by patients.

Methods
This descriptive population-based study analyzed 
hospital discharges related to BC between 2001 and 
2019. The publicly available databases were obtained 
from the Department of Health Statistics (DEIS) at the 
MINSAL. The collected variables included individual/
patient identification number (ID), sex, age, type of 
medical insurance, year, and condition at discharge 
(alive or deceased), length of hospital stay (in days), 
surgical intervention (yes or no), and type of surgery. 
All patients with diagnoses belonging to the ICD-10 c67 
classification were identified.

We only included the hospital discharges of FONASA 
(public insurance) and ISAPRE (private insurance), 
which represented 95% of the total of individuals with 
health care coverage[9]. Hospital discharge rates were 
calculated as annual discharge rate per 100 000, with a 
confidence interval (CI) of 95% and categorized by type 
of insurance. The overall rate was calculated by dividing 
the total number of annual BC discharges by the esti-
mated total population obtained from the INE-CELADE 
and the 2017 national census. To calculate the rate 
according to type of medical insurance, we divided the 
total of discharges for each type of insurance by the total 
population of individuals with private and public medi-
cal insurance (ISAPRE and FONASA, respectively). 
These calculations were based on data obtained from 
national surveys and administrative bulletins.

The primary outcome of this study was to analyze 
the changes in the burden of BC inpatient health care in 
Chile from 2001 to 2019, according to type of insurance 
and relative to the implementation of the GES program. 
The secondary outcomes were inpatient mortality and 
length of stay of BC patients according to type of insur-
ance for the aforementioned period.

The hospitalization burden was estimated using the 
annual bed-days, obtained by multiplying the number of 
days of hospital stays by the absolute frequency for each 
year and categorized by the type of insurance. To avoid 
registration bias of this variable, we excluded outliers 
(0.2% of outliers when considering length of stay < 100 
days). Differences in length of stay (days) were calculated 
as annual median and overall values by insurance type 
and type of BC surgery, and they were compared over 
time using 3-year periods (triennial). Given the incorpo-
ration of BC into the GES program in 2013, we consid-
ered the period from 2001 to 2012 as the pre-GES period 
and the period from 2013 to 2020 as post-GES period.

For perioperative and overall hospital mortality, 
we only included BC-related surgical interventions 
(associated with treatment). The evolution of overall 
inpatient mortality over time by insurance type was 
analyzed using a joinpoint regression model (Joinpoint 

Abbreviations 
BC Bladder cancer
CI Confidence Interval
FONASA Fondo Nacional de Salud
GES  Garantías explícitas en salud;  

Explicit Guarantees in Health
ID Identification number 
ISAPRES Instituciones de Salud Previsional
TUR Transurethral resection 
TURBT Transurethral resection of bladder tumor
US United States

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TABLE 2. 
Mean length of hospital stay (days) by medical 
insurance type.

Type of medical insurance

FONASA (public) ISAPRE (private)

Surgery Mean Mean

Radical cystectomy 23* 15

TUR 6* 3

*P < 0.001 by ANOVA (FONASA vs. ISAPRE). TUR: Transurethral resection.

*P < 0.05. APC: annual percentage change; JP: Joinpoint regression model\*P < 0.05. APC: annual percentage change;  
JP: Joinpoint regression model.

FIGURE 2. 
Annual inpatient mortality by medical insurance type during the period of 2001–2019 

In
pa

tie
nt

 M
or

ta
lit

y 
%

10

8

6

4

2

0

20
01

20
02

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17

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19

Year

JP FONASA, APC: -1.74*

FONASA (public)

ISAPRE (private)

JP ISAPRE, APC: 7.33

3000

2500

2000

1500

1000

500

0

N
um

be
r o

f s
ur

ge
rie

s

FONASA
(public)

TUR

Radical
cystectomy

N
um

be
r o

f s
ur

ge
rie

s

ISAPRE
(private)

Triennium

2004–2006 2007–2009 2010–2012 2014–2016 2017–2019

2004–2006 2007–2009 2010–2012 2014–2016 2017–2019

TUR

Radical
cystectomy

0

500

1000

1500

2000

2500

3000

BC: bladder cancer; TUR: transurethral resection.

FIGURE 3. 
Trends in BC-related surgeries by medical 
insurance type during the period of 2001–2019.

among FONASA patients observed in our study, regard-
less of surgery.

Notably, we observed a trend toward lower mortal-
ity rates following the incorporation of BC into the GES 
program in 2013, particularly among FONASA patients. 
This was accompanied by an increase in the number 
of TURBTs and a reduction in the proportion of radi-
cal cystectomies within the same subset of FONASA 
patients. These results are aligned with international 
reports. In 2010, the US Congress approved the expan-
sion of the Medicaid program under the Affordable 
Care Act (ACA), which delivered health care coverage to 

inpatient mortality for patients undergoing BC-related 
surgical interventions was 0.6% compared to 6.5% for 
those not undergoing surgery (P < 0.001). After adjust-
ing for insurance type, the overall postoperative mortal-
ity rate for BC patients was 0.8% for FONASA (public) 
patients and 0.2% ISAPRE (private) patients (P < 0.001).

Among patients undergoing surgery, we observed a 
significant increase in transurethral resection of bladder 
tumors (TURBTs) and radical cystectomies over time in 
newly diagnosed cases, particularly following the intro-
duction of the GES program. The total number of these 
procedures reached up to 2289 in the period from 2017 
to 2019. This trend persisted after adjusting for type of 
insurance (Figure 3).

Median values for hospital stay also differed accord-
ing to insurance, with a median of 4 days for FONASA 
patients and 2 days for ISAPRE patients. Table 2 
compares length of hospital stays by type of surgery, 
showing significantly longer stays for patients with 
public insurance across almost all types of surgery. 
Finally, Figure 4 shows a sustained increase in annual 
hospital bed-days over time, starting in 2010, particu-
larly for FONASA patients.

Discussion
To our k nowledge, this study provides the f irst 
descriptive analysis of the burden of BC-related hospital 
discharges in Chile, while examining the impact of 

medical insurance and public policies such as the 
GES program. Furthermore, we found a significant 
association between the type of medical insurance and 
BC clinical outcomes. Most Chileans are enrolled in 
FONASA (public medical insurance), and only a fraction 
uses private health coverage (ISAPRE). However, the 
number of ISAPRE users has progressively increased in 
recent years. Our study found that the incorporation of 
BC into the GES program in 2013 was associated with 
an increase in the number of hospital discharges and 
bed-days. We also found a doubling in the number of 
TURBTs over the 2001–2019 period. While our findings 
indicate higher mortality rates among FONASA 
patients, these rates decreased over time, particularly 
after the incorporation of BC into the GES program, 
suggesting a positive effect of this public policy.

Patients undergoing BC-related surgery exhibited 
lower inpatient mortality compared with those without 
surgery, regardless of their medical insurance. However, 
our results also highlight the contrasting realities of 
the public and the private health care systems in Chile. 
A previous study by Castillo-Laborde et al. showed 
that FONASA mainly serves the elderly and lower-to-
mid–income individuals. The public medical insurance 
provides coverage for a large proportion of the Chilean 
population, including a high proportion of women and 
individuals with a higher prevalence of risk factors [10], 
which may explain the higher inpatient mortality rates 

Cr
ud

e 
ho

sp
ita

l d
is

ch
ar

ge
 ra

te
 (p

er
 1

00
 0

00
)

20

18

16

14

12

10

8

6

4

2

0

20
01

20
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Year

CR ISAPRE (private)

CR FONASA (public)

CR: crude rate.

FIGURE 1. 
Annual hospital discharge rates by medical insurance type during the period of 2001–2019.  
Rates per 100 000 in FONASA and ISAPRE patients

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Latin America, given the presence of similar (mixed) 
health care systems and comparable socioeconomic 
conditions.

Conclusions
Our study identified a significant increase in BC-related 
surgical interventions and admissions over the period 
from 2001 to 2019. This increase was more pronounced 
following the incorporation of BC into the GES program, 
which aimed to ensure access to health care for cancer 
patients. However, our findings highlight that there are 
significant differences in the burden BC admissions 
according to type of medical insurance (public versus 
private), ref lecting a significant disparity in terms of 

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health care. The implementation of public policies such 
as the GES program may help to reduce this gap between 
public and private health care systems.

Acknowledgements 

Funding statement
This research was funded by ANID Anillo ACT210079.

Author contributions
All authors contributed to the study conception, 
design, and analysis. Ignacio Eltit and Mario Fernández 
wrote the first draft of the manuscript and all authors 
commented on previous versions of the manuscript.  
All authors read and approved the final manuscript.

low-income individuals. Consequently, cancer patients 
diagnosed after the expansion exhibited 15% less prob-
ability of having metastatic disease compared with 
patients diagnosed before the expansion, suggesting a 
major impact of health care coverage on the outcomes in 
low-income communities[14]. Uninsured individuals in 
the US have been reported to have a 2-fold risk of being 
diagnosed with metastatic BC and a 60% higher risk of 
being diagnosed with locally advanced BC compared 
with individuals enrolled in Medicaid[13].

Regarding inpatient mortality by type of surgery, we 
observed a marked increase in mortality associated with 
radical cystectomies in FONASA patients compared 
with ISAPRE patients, particularly in the period from 
2017 to 2019 (2.9% vs. 0.4%). While this difference 
aligns with the length of stay based on insurance type, 
it is based on a multifactorial phenomenon that must 
be further investigated, including more detailed local 
data. Studies in the US indicate that individuals with-
out health care coverage tend to ignore their symptoms 
and are less likely to seek medical attention because they 
mistrust the health system[15]. On the other hand, a lack 
of social support or means of transportation, along with 
other cultural behaviors (such as of physicians) further 
contribute to delayed treatments[16]. Timely treatments 
and medical care are also affected by the availabil-
ity of medical providers, especially in remote or rural 
areas[17]. All these factors contribute to late diagnoses 
and the emergence of more comorbidities in patients, 
leading to longer hospital stay and potentially increased 
inpatient mortality burden.

Another relevant issue to discuss is the cost of BC 
treatments and management, which impact health 
care systems. In the US, annual BC-related costs were 
estimated at approximately US $4000 million in 2010 
and projected to reach US $5000 million in 2020[18]. 
Worldwide studies have consistently reported elevated 
costs associated with advanced-stage BC mainly because 
of the aggressive therapies patients undergo. Moreover, 
non–muscle-invasive tumors usually involve even higher 
costs due to extended treatments and follow-up sched-
ules[19]. Our study revealed longer hospital stays for 
FONASA patients who underwent TURBT compared to 
ISAPRE patients (4 vs. 2 bed-days). Additionally, hospi-
tal discharge rates increased over time in both FONASA 
and ISAPRE patients, imposing a major economic 
burden on the public system, which accounted for 76.1% 
of the total discharges during the 2017–2019 period.

It is important to acknowledge the imitations of our 
study, including potential registration bias leading to 
missing data for certain variables in our database, such 
as performance status, other comorbidities, tumor stage, 
and postoperative care. Approximately 14% of patients 
did not have registered medical insurance between 2001 
and 2019. Additionally, some registries lacked associ-
ated IDs, preventing assessment of whether they repre-
sented new cases or readmissions of the same patient. 
Furthermore, we were unable to obtain clinical details 
for all patients, and some hospital stays may have been 
misdiagnosed as BC. Finally, our analyses were limited 
to Chilean patients, making it difficult to extrapolate 
these findings to other countries. However, these results 
may reflect the situation of low-income countries within 

FIGURE 4. 
Annual length of hospital stay by medical insurance type during the period of 2001–2019

Le
ng

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15. Lillie-Blanton M, Brodie M, Rowland D, Altman D, McIntosh M. 
Race, ethnicity, and the health care system: public perceptions and 
experiences. Med Care Res Rev.2000;57(Suppl 1):218–235. doi: 
10.1177/1077558700057001S10. PMID: 11092164.

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