The impact of the COVID-19 pandemic on the use of Emergency Departments in Italy
Keywords:
COVID-19, Emergency department, Italy, Age-class, Educational level, GenderAbstract
Background. During 2020, COVID-19 had a diversified distribution in Italy, the first nation in Europe to experience the outbreak of the epidemic. This was linked to geographical differences in population density and distribution of healthcare facilities, including Emergency Departments (EDs). This study aims to assess the impact of the pandemic on ED utilization in 2020 across different subpopulations and geographical locations in Italy.
Methods. We used anonymized data from a survey conducted by the Italian National Institute of Statistics on 25,000 families to analyze the yearly rate of people who used EDs from 2015 to 2020. The rate of persons who accessed ED services in 2020 per 1,000 population was compared with those of the previous non-pandemic years.
Results. The number of people accessing EDs in 2020 was 32.3% lower, although this reduction was not uniform across the 21 regions / autonomous provinces. People aged 0–14 years experienced the highest reduction in ED visits. In 2020, low educational level people exhibited a steeper reduction in the use of EDs.
Conclusions. This study shows a significant drop in EDs use especially by children; the population section mostly affected by the effects of the pandemic. This study also confirms that education and socio-economic status are important determinants of ED use. The heterogeneous reduction in ED use across the regions of Italy highlights the need to further investigate the impact of this pattern on the health of the population, as well as to define adequate preparedness strategies to face future emergencies.
References
1. COVID-19 Excess Mortality Collaborators. Estimating excess mortality due to the COVID-19 pandemic: a systematic analysis of COVID-19related mortality, 2020-21. Lancet. 2022 Apr 16; 399(10334):1513-36. doi: 10.1016/S0140-6736(21)02796-3. Epub 2022 Mar 10. Erratum in: Lancet. 2022 Apr 16; 399(10334): 1468. PMID: 35279232; PMCID: PMC8912932.
2. Signorelli C, Odone A, Gianfredi V, et al. COVID-19 mortality rate in nine high-income metropolitan regions. Acta Biomed. 2020 Jul 20; 91(9-S): 7-18. doi: 10.23750/abm. v91i9-S.10134. PMID: 32701911; PMCID: PMC8023097.
3. Sanmarchi F, Golinelli D, Lenzi J, et al. Exploring the Gap Between Excess Mortality and COVID-19 Deaths in 67 Countries. JAMA Netw Open. 2021; 4(7): e2117359. doi:10.1001/jamanetworkopen.2021.17359. PMID: 34269809; PMCID: PMC8285734
4. Odone A, Vitale M, Signorelli C. The identity of public health in COVID-19 times. Acta Biomed. 2020 2020; 91(9-S): 5-6. doi: 10.23750/abm. v91i9-S.10200. PMID: 32701910; PMCID: PMC8023088.
5. Reno C, Sanmarchi F, Stoto MA, Fantini MP, Lenzi J, Golinelli. The impact of health policies and vaccine rollout on the COVID-19 pandemic waves in Italy. Health Policy Technol. 2022 Jun; 11(2): 100604. Epub 2022 Feb 15. doi: 10.1016/j.hlpt.2022.100604. PMID: 35186670; PMCID: PMC8843325.
6. Manica M, Guzzetta G, Riccardo F, et al. Impact of tiered restrictions on human activities and the epidemiology of the second wave of COVID-19 in Italy. Nat Commun. 2021 Jul 27; 12(1): 4570. doi:10.1038/s41467-021-24832-z.
7. Remuzzi A, Remuzzi G. COVID-19 and Italy: what next?. Lancet. 2020 Apr 11; 395(10231): 1225-8. doi:10.1016/S0140-6736(20)30627-9. Epub 2020 Mar 13. PMID: 32178769; PMCID: PMC7102589.
8. Berardi C, Antonini M, Genie MG, et al. The COVID-19 pandemic in Italy: Policy and technology impact on health and non-health outcomes. Health Policy Technol. 2020 Dec;
9(4): 454-87. doi: 10.1016/j.hlpt.2020.08.019. Epub 2020 Sep 3. PMID: 32895626; PMCID: PMC7467905.
9. Odone A, Delmonte D, Gaetti G, Signorelli C.
Doubled mortality rate during the COVID-19 pandemic in Italy: quantifying what is not captured by surveillance. Public Health. 2021 Jan; 190: 108-15. doi: 10.1016/j.puhe.2020.11.016. Epub 2020 Nov 30. PMID: 33412438; PMCID: PMC7703200.
10. Torri E, Sbrogiò LG, Rosa ED, CF, Cinquetti S, Francia F, Ferro A. Italian Public Health Response to the COVID-19 Pandemic: Case Report from the Field, Insights and Challenges for the Department of Prevention. Int J Environ Res Public Health. 2020 May 22; 17(10): 3666. doi: 10.3390/ijerph17103666. PMID: 32456072; PMCID: PMC7277676.
11. Gibertoni D, Adja KYC, Golinelli D, et al. Patterns of COVID-19 related excess mortality in the municipalities of Northern Italy during the first wave of the pandemic. Health Place. 2021 Jan; 67: 102508. doi: 10.1016/j. healthplace.2021.102508. Epub 2021 Jan 11. PMID: 33476843; PMCID: PMC7834600.
12. Panarello D, Tassinari G. One year of COVID19 in Italy: are containment policies enough to shape the pandemic pattern?. Socioecon Plann Sci. 2022 Feb; 79: 101120. doi: 10.1016/j. seps.2021.101120. Epub 2021 Jul 3. PMID: 34248212; PMCID: PMC8253667.
13. Santi L, Golinelli D, Tampieri A, et al. NonCOVID-19 patients in times of pandemic: Emergency department visits, hospitalizations and cause-specific mortality in Northern Italy. PLoS One. 2021 Mar 22; 16(3): e0248995. Published 2021 Mar 22. doi: 10.1371/journal. pone.0248995. PMID: 33750990; PMCID: PMC7984614.
14. Perlini S, Canevari F, Cortesi S, et al. Emergency Department and Out-of-Hospital Emergency System (112-AREU 118) integrated response to Coronavirus Disease 2019 in a Northern Italy centre. Intern Emerg Med. 2020 Aug; 15(5): 825-33. doi: 10.1007/s11739-020-02390-4. Epub 2020 Jun 8. PMID: 32507926; PMCID: PMC7276336.
15. Raffaldi I, Castagno E, Fumi I, et al. Pediatric admissions to emergency departments of NorthWestern Italy during COVID-19 pandemic: A retrospective observational study. Lancet Reg Health Eur. 2021 Jun; 5: 100081. doi: 10.1016/j. lanepe.2021.100081. Epub 2021 Mar 18. PMID: 34104902; PMCID: PMC7969147.
16. Poletto M, Perri G, Malacarne F, et al. Effect of COVID-19 outbreak on emergency department attendances in an Italian academic hospital. Eur J Public Health. 2020 Sep; 30(Suppl 5): ckaa165.207. doi: 10.1093/eurpub/ckaa165.207. PMCID: PMC7543584.
17. Yasin YJ, Grivna M, Abu-Zidan FM. Global impact of COVID-19 pandemic on road traffic collisions. World J Emerg Surg. 2021 Sep 28; 16(1): 51. doi: 10.1186/s13017-021-00395-8. PMID: 34583713; PMCID: PMC8478263.
18. Sekadakis M, Katrakazas C, Michelaraki E, Kehagia F, Yannis G. Analysis of the impact of COVID-19 on collisions, fatalities and injuries using time series forecasting: The case of Greece. Accid Anal Prev. 2021 Nov; 162: 106391. doi: 10.1016/j.aap.2021.106391. Epub 2021 Sep 4. PMID: 34525414; PMCID: PMC8426576.
19. Golinelli D, Campinoti F, Sanmarchi F, et al. Patterns of Emergency Department visits for acute and chronic diseases during the two pandemic waves in Italy. Am J Emerg Med. 2021 Dec; 50: 22-6. doi: 10.1016/j.ajem.2021.07.010. Epub 2021 Jul 9. PMID: 34271231.
20. Venkatesh AK, Janke AT, Shu-Xia L, et al. Emergency Department Utilization for Emergency Conditions During COVID-19. Ann Emerg Med. 2021 Jul; 78(1): 84-91. doi: 10.1016/j. annemergmed.2021.01.011. Epub 2021 Jan 13. PMID: 33840512; PMCID: PMC7805390.
21. Bardin A, Buja A, Barbiellini Amidei C, et al. Elderly People’s Access to Emergency Departments during the COVID-19 Pandemic: Results from a Large Population-Based Study in Italy. J Clin Med. 2021 Nov 26; 10(23): 5563. doi: 10.3390/jcm10235563. PMID: 34884265; PMCID: PMC8658732.
22. Misra S, Barron E, Vamos E, et al. Temporal trends in emergency admissions for diabetic ketoacidosis in people with diabetes in England before and during the COVID-19 pandemic: a population-based study. Lancet Diabetes Endocrinol. 2021 Oct; 9(10): 671-80. doi: 10.1016/ S2213-8587(21)00208-4. Epub 2021 Sep 2. PMID: 34481558.
23. Naouri D, Ranchon G, Vuagnat A, et al. French Society of Emergency Medicine. Factors associated with inappropriate use of emergency departments: findings from a cross-sectional national study in France. BMJ Qual Saf. 2020 Jun; 29(6): 449-64. doi: 10.1136/bmjqs-2019009396. Epub 2019 Oct 30. PMID: 31666304; PMCID: PMC7323738.
24. Riva B, Clavenna A, Cartabia M, et al. Emergency department use by paediatric patients in Lombardy Region, Italy: a population study. BMJ Paediatr Open. 2018 May 30; 2(1): e000247. doi: 10.1136/bmjpo-2017-000247. PMID: 29942865; PMCID: PMC6014225.
25. Lenzi J, Rucci P, Franchino G, et al. Regional and gender variation in mortality amenable to health care services in Italy. J Hosp Adm. 2013; 2(3): 28-37. doi: 10.5430/jha.v2n3p28.
26. Istituto Nazionale di Statistica (ISTAT). Indagine multiscopo sulle famiglie: aspetti della vita quotidiana. 2022. Available on: https://www.istat.it/ it/archivio/91926 [Last accessed: 2022 August 21].
27. R Core Team. A language and environment for statistical computing. Vienna, Austria: R Foundation for Statistical Computing; 2021. Available on: https://www.R-project.org/ [Last accessed: 2022 August 21].
28. Siegel DA, Reses HE, Cool AJ, et al. Trends in COVID-19 Cases, Emergency Department Visits, and Hospital Admissions Among Children and Adolescents Aged 0-17 Years - United States, August 2020-August 2021. Morb Mortal Wkly Rep. MMWR Morb Mortal Wkly Rep. 2021 Sep 10; 70(36): 1249-54. doi:10.15585/ mmwr.mm7036e1. Erratum in: MMWR Morb Mortal Wkly Rep. 2021 Sep 24; 70(38):1355. PMID: 34499628; PMCID: PMC8437056.
29. Ghaderi H, Stowell JR, Akhter M, Norquist C, Pugsley P, Subbian V. Impact of COVID-19 Pandemic on Emergency Department Visits: A Regional Case Study of Informatics Challenges and Opportunities. AMIA Annu Symp Proc. 2022 Feb 21; 2021: 496-505. PMID: 35308996; PMCID: PMC8861727.
30. Pines JM, Zocchi MS, Black BS, et al. The effect of the COVID-19 pandemic on emergency department visits for serious cardiovascular conditions. Am J Emerg Med. 2021 Sep; 47: 42-51. doi: 10.1016/j.ajem.2021.03.004. Epub 2021 Mar 9. PMID: 33770713; PMCID: PMC7939976.
31. Çıkrıkçı Iık G, Çevik Y. Impact of COVID19 pandemic on visits of an urban emergency department. Am J Emerg Med. 2021 Apr; 42: 78-82. doi: 10.1016/j.ajem.2021.01.011. Epub 2021 Jan 14. PMID: 33493832; PMCID: PMC7807170.
32. Boserup B, McKenney M, Elkbuli A. The impact of the COVID-19 pandemic on emergency department visits and patient safety in
the United States. Am J Emerg Med. 2020 Sep;
38(9): 1732-6. doi: 10.1016/j.ajem.2020.06.007. Epub 2020 Jun 6. PMID: 32738468; PMCID: PMC7274994.
33. Alicandro G, Remuzzi G, La Vecchia C. Italy’s first wave of the COVID-19 pandemic has ended: no excess mortality in May, 2020. Lancet. 2020 Sep 12; 396(10253): e27-e28. doi: 10.1016/
S0140-6736(20)31865-1. Epub 2020 Sep 3. PMID: 32891216; PMCID: PMC7470816.
34. Odone A, Delmonte D, Scognamiglio T, Signorelli C. COVID-19 deaths in Lombardy, Italy: data in context. Lancet Public Health. 2020 Jun; 5(6): e310. doi: 10.1016/S2468-2667(20)30099-2. Epub 2020 Apr 25. Erratum in: Lancet Public Health. 2020 Jun; 5(6): e315. PMID: 32339478; PMCID: PMC7182509.
35. Herranz-Larrañeta J, Klein-Rodríguez A, Menéndez-Riera M, et al. ENT emergencies during the first wave of COVID-19 pandemic in Spain: Our experience. Am J Otolaryngol. 2021 Mar-Apr; 42(2): 102865. doi: 10.1016/j. amjoto.2020.102865. Epub 2021 Jan 9. PMID: 33450479; PMCID: PMC7794058.
36. Vedovetto A, Soriani N, Merlo E, Gregori D. The burden of inappropriate emergency department pediatric visits: why Italy needs an urgent reform. Health Serv Res. 2014 Aug; 49(4): 1290-305. doi:10.1111/1475-6773.12161. Epub 2014 Feb 5. PMID: 24495258; PMCID: PMC4239850.
37. Terraneo M, Sarti S, Tognetti Bordogna M. Social inequalities and pharmaceutical cost sharing in Italian regions. Int J Health Serv. 2014; 44(4): 761-85. doi: 10.2190/HS.44.4.e. PMID: 25626227.
38. Berry A, Brousseau D, Brotanek JM, TomanyKorman S, Flores G. Why Do Parents Bring Children to the Emergency Department for Nonurgent Conditions? A Qualitative Study. Ambul Pediatr. 2008 Nov-Dec; 8(6): 360-7. Epub 2008 Oct 5. PMID: 19084785.
39. Carret ML, Fassa AC. Domingues MR. Inappropriate Use of Emergency Services: A Systematic Review of Prevalence and Associated Factors.
Cad Saude Publica. 2009 Jan; 25(1): 7-28. doi: 10.1590/s0102-311x2009000100002. PMID: 19180283.
40. Stockwell MS, Findley SE, Irigoyen M, Martinez RA, Sonnett M. Change in Parental Reasons for Use of an Urban Pediatric Emergency Department in the Past Decade. Pediatr Emerg Care. 2010 Mar; 26(3): 181-5. doi: 10.1097/ PEC.0b013e3181d1dfc7. PMID: 20179661.
41. Fieldston ES, Alpern ER, Nadel FM, Alessandrini EA. A Qualitative Assessment of Reasons for Nonurgent Visits to the Emergency Department: Parent and Health Professional Opinions. Pediatr Emerg Care. 2012 Mar; 28(3): 220-5. doi: 10.1097/PEC.0b013e318248b431. PMID: 22344210.
42. Iozzi L, Brambilla I, Foiadelli T, Marseglia GL, Ciprandi G. Paediatric emergency department visits fell by more than 70% during the COVID-19 lockdown in Northern Italy. Acta Paediatr. 2020 Oct;109(10): 2137-8. doi: 10.1111/apa.15458. Epub 2020 Jul 22. PMID: 32623774; PMCID: PMC7361573.
43. Hamill JK, Sawyer MC. Reduction of childhood trauma during the COVID-19 Level 4 lockdown in New Zealand. ANZ J Surg. 2020 Jul; 90(7-8):
1242-3. doi: 10.1111/ans.16108. Epub 2020 Jun 26. PMID: 32536014; PMCID: PMC7323325.
44. Malige A, Deemer A, Sobel AD. The Effect of COVID-19 on Pediatric Traumatic Orthopaedic Injuries: A Database Study. J Am Acad Orthop Surg Glob Res Rev. 2022 Feb 11;
6(2): e22.00012. doi: 10.5435/JAAOSGlobalD-22-00012. PMID: 35148285; PMCID: PMC8843388.
45. Raitio A, Ahonen M, Jääskelä M, et al. Reduced Number of Pediatric Orthopedic Trauma Requiring Operative Treatment during COVID-19 Restrictions: A Nationwide Cohort Study. Scand J Surg. 2021 Jun; 110(2): 254-7. doi:10.1177/1457496920968014. Epub 2020 Oct 26. PMID: 33100133; PMCID: PMC8258724.
46. Shi Y, Kvasnovsky C, Khan S, et al. Impact of the COVID-19 pandemic on trauma activations at a pediatric level 1 trauma center in New York.
Pediatr Surg Int. 2021 Oct; 37(10): 1409-14. doi:
10.1007/s00383-021-04962-7. Epub 2021 Jul
15. PMID: 34264357; PMCID: PMC8280274.
47. McDermott KW, Stocks C, Freeman WJ. Overview of Pediatric Emergency Department Visits, 2015: Statistical Brief #242. 2018 Aug 7. In: Healthcare Cost and Utilization Project (HCUP) Statistical Briefs (Internet). Rockville (MD): Agency for Healthcare Research and Quality (US); 2006 Feb-. Available on: https://www.ncbi. nlm.nih.gov/books/NBK526418/ [Last accessed: 2022 August 21].
48. Barbiellini Amidei C, Buja A, Bardin A, et al. Pediatric emergency department visits during the COVID-19 pandemic: a large retrospective population-based study. Ital J Pediatr. 2021 Nov 4; 47(1): 218. doi: 10.1186/s13052-021-01168-4. PMID: 34736514; PMCID: PMC8567132.
49. Kurt F, Bede F, Ouz S, Suskan E. How Important Are Parental Age and Educational Level in Nonurgent Admissions to the Pediatric Emergency Department?. Pediatr Emerg Care. 2020 Sep; 36(9): 414-8. doi: 10.1097/ PEC.0000000000001886. PMID: 31464877.
50. Pianori D, Maietti E, Lenzi J, et al. Sociodemographic and health service organizational factors associated with the choice of the private versus public sector for specialty visits: Evidence from a national survey in Italy. PLoS One. 2020 May 7; 15(5): e0232827. doi: 10.1371/journal. pone.0232827. PMID: 32379839; PMCID: PMC7205245.
51. Marmot M. Health equity in England: the Marmot review 10 years on. BMJ. 2020 Feb 24;
368: m693. doi: 10.1136/bmj.m693. PMID: 32094110.
52. Nana-Sinkam P, Kraschnewski J, Sacco R, et al. Health disparities and equity in the era of COVID-19. J Clin Transl Sci. 2021 Mar 16; 5(1): e99. doi: 10.1017/cts.2021.23. PMID: 34192054; PMCID: PMC8167251.
53. Frølich A, Ghith N, Schiøtz M, Jacobsen R, Stockmarr A. Multimorbidity, healthcare utilization and socioeconomic status: A register-based study in Denmark. PLoS One. 2019 Aug 1; 14(8): e0214183. doi: 10.1371/journal.pone.0214183. PMID: 31369580; PMCID: PMC6675513.
54. Filc D, Davidovich N, Novack L, Balicer RD. Is socioeconomic status associated with utilization of health care services in a singlepayer universal health care system?. Int J Equity Health. 2014 Nov 28; 13: 115. doi: 10.1186/ s12939-014-0115-1. PMID: 25431139; PMCID:
PMC4260253.
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