Understanding how older adults use outpatient care is central to planning services and safeguarding access after major disruptions. Longitudinal data from the Survey of Health, Ageing and Retirement in Europe tracked 147,116 people aged 50 years or older across 27 European countries from 2004 to 2022, generating 505,607 observations. Outpatient visits were defined as seeing or talking to a medical doctor or qualified nurse, excluding dentists and hospital stays. Using a Bayesian spatiotemporal approach, the analysis separated pre-pandemic trends (2004–2019), the pandemic period (2021) and the post-pandemic period (2022) and examined differences by sex, age and chronic conditions. The results show marked cross-country variation before COVID-19, a sharp and heterogeneous decline during the pandemic, and a broad recovery by 2022, with notable and persistent gaps for people living with chronic noncancer conditions.
Cross-Country Utilisation Before the Pandemic
Before COVID-19, outpatient utilisation among older adults varied substantially across Europe even after accounting for age and health conditions. For a reference individual aged 75 years with no chronic conditions, the expected annual visit rate in 2019 was highest in Luxembourg for both women and men at 5.60 and 4.62 visits respectively (95% uncertainty interval [UI]: women 5.20–5.97; men 4.30–4.90). Belgium, Italy, Austria and Germany followed with similarly elevated rates. At the other end of the range, Finland recorded some of the lowest 2019 rates, at 2.20 visits for women and 1.96 for men (UI: women 2.07–2.34; men 1.84–2.12), with Cyprus and Malta also on the lower side. The lowest rates observed across the entire period occurred in Sweden in 2004, at 1.82 for women and 1.52 for men (UI: women 1.74–1.89; men 1.45–1.61).
Across countries there was a slight overall increase in visits between 2004 and 2019, accompanied by evidence of convergence: countries with higher initial rates tended to grow more slowly than those with lower starting points. Within many countries, women consistently had higher visit rates than men, though this gap narrowed over time in places such as Italy, Spain, France and Czechia. These pre-pandemic patterns provide a baseline for interpreting the shock that followed.
Pandemic Shock and Varying Recovery
During COVID-19, outpatient visits dropped sharply in all 27 countries relative to the rates expected from pre-pandemic trends. Germany experienced the smallest relative decline, with men and women registering 0.45 and 0.42 of the expected rate. In contrast, utilisation nearly halted in several countries. In Italy, the relative rate was 0.06 for both sexes (UI: women 0.05–0.06; men 0.06–0.07), with similarly extreme reductions in Croatia, Estonia and Hungary. These differences reflect heterogeneous system responses and behavioural changes that constrained access and demand for routine care.
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By 2022, most countries had returned to approximately pre-pandemic levels, with rates typically between 0.90 and 1.10 of the expected baseline. Recovery was uneven, however. Slovakia remained low at 0.64 for men and 0.71 for women. Luxembourg and Poland also stayed below baseline, while Cyprus rose above, at 1.36 for men and 1.15 for women. A cross-country correlation linked smaller pandemic declines with higher domestic government health expenditure as a share of gross domestic product in 2019: each 1 percentage point increase in this measure was associated with a 0.05 higher relative visit rate during the pandemic for both sexes. No clear association emerged between changes in utilisation and cumulative COVID-19 deaths, the average stringency of restrictions, physician density or population density. Excluding Luxembourg as an outlier, higher per-capita income correlated with larger declines during the pandemic.
Age, Chronic Conditions and Remaining Gaps
Before COVID-19, visit rates rose with age, more steeply for men, consistent with greater screening and chronic care needs in later life. During the pandemic, this relationship reversed at older ages, forming an inverse U-shape: visits increased with age from 50 to about 75 years, then declined among the very old. After COVID-19, the positive age gradient re-emerged for both sexes but with flatter slopes, particularly among women, suggesting a partial, not complete, return to previous utilisation patterns across age groups.
Chronic conditions were associated with higher outpatient use throughout, but the intensity and trajectory differed by diagnosis and period. Compared with those without the condition, people with cancer exhibited the largest relative increase in visit rates, and this association strengthened after the pandemic for both sexes. By contrast, for several noncancer chronic conditions the association weakened post-pandemic. Among men, the post-pandemic relative risks remained lower than pre-pandemic for prior heart attack, hypertension, diabetes and chronic lung disease. A similar pattern appeared among women for heart attack, hypertension, stroke, diabetes and chronic lung disease. These shifts indicate that although overall utilisation largely recovered, people living with common chronic conditions continued to interact with outpatient services at levels below pre-pandemic expectations.
Taken together, the age-specific reversal during the pandemic and the persistent attenuation of visit rates linked to prevalent chronic conditions point to a dual challenge. Ensuring the very old can safely maintain routine care during crises remains essential, as does restoring consistent, longitudinal contact for those requiring regular monitoring and treatment adjustments. The observed increase in visit intensity linked to cancer after the pandemic aligns with a pattern of decreased attendance during lockdowns followed by heightened demand, whereas the opposite tendency for other chronic conditions suggests lingering disengagement from routine care.
Across 27 European countries, outpatient visits among adults aged 50 years or older fell sharply during COVID-19, then mostly rebounded to pre-pandemic levels by 2022. Yet recovery was uneven across countries, attenuated at the oldest ages during the pandemic and incomplete for people with common chronic noncancer conditions, whose visit rates stayed below pre-pandemic associations. For healthcare leaders, the findings underline the value of monitoring utilisation as an access signal through and beyond system shocks and the need to design measures that protect routine care for the very old and re-engage patients with chronic conditions swiftly after disruption.
Source: The Lancet Regional Health - Europe
Image Credit: iStock
