Variations in avoidable hospital admissions and emergency visits by primary care characteristics: an ecological study in Italy
Keywords:
Primary healthcare; healthcare outcomes; inappropriate hospitalisation; emergency presentationsAbstract
Background. Primary healthcare plays a central role in providing preventive care, managing chronic conditions and reducing inappropriate emergency presentations. The study aimed at providing population-level evidence on the correlation between the characteristics of primary healthcare across Italian regions and health outcomes included in the National Programs Outcomes of the National Agency for Regional Healthcare Services. Study Design. Ecological study
Methods. We analysed healthcare data from the National Agency for Regional Healthcare Services, the public lists of primary care doctors and the National Federation of Surgeons and Dentists and the National Institutes of Statistics referring to the 20 Italian regions. Pearson’s correlation and Spearman’s correlation were used to assess the relationships between primary healthcare characteristics and health outcomes.
Results. Overall, across all Italian regions each general practitioner had on average 1447 patients and was 57.5 years old. The study found positive correlations between the number of patients per general practitioner and non-urgent Emergency Department visits among adult patients (Pearson’s r = 0.58, p = 0.008), the number of residents aged 65+ per general practitioner and the rate of chronic obstructive pulmonary disease admissions (Pearson’s r = 0.49, p = 0.029), and the age of general practitioners and lower-extremity amputations in diabetes patients (Pearson’s r = 0.56, p = 0.011). A negative correlation was observed between the age of general practitioners and urinary tract infection admissions (Pearson’s r = -0.76; p < 0.001). A non-linear negative correlation was found between the age of general practitioners and chronic obstructive pulmonary disease admissions (Spearman’s ρ = -0.46, p = 0.041).
Conclusions. The findings emphasise the importance of guaranteeing sufficient numbers of primary healthcare physicians to meet patients’ needs, and for limiting avoidable hospitalisations and emergency presentations. General practitioners’ age might also influence the provision of care, but more research is needed on possible mechanisms.
References
1. Declaration of Alma-Ata [Internet]. Available from: https:// iris.who.int/bitstream/handle/10665/347879/WHO-EURO1978-3938-43697-61471-eng.pdf [Last accessed: 2023 Dec 1].
2. A vision for primary health care in the 21st century: towards universal health coverage and the Sustainable Development Goals [Internet]. Geneva: World Health Organization and the United Nations Children’s Fund (UNICEF); 2018 (Technical series on primary health care). Available from: https://iris. who.int/bitstream/handle/10665/328065/WHO-HIS-SDS2018.15-eng.pdf [Last accessed: 2023 Dec 1].
3. Signorelli C. Igiene e sanità pubblica. Secrets. Domande e risposte. 3rd ed. SEU; 2021.
4. Berardi D, Ferrannini L, Menchetti M, Vaggi M. Primary care psychiatry in Italy. J Nerv Ment Dis. 2014 Jun;202(6):460–3.
5. ACCORDO COLLETTIVO NAZIONALE PER LA DISCIPLINA DEI RAPPORTI CON I MEDICI PEDIATRI DI LIBERA SCELTA AI SENSI DELL’ART. 8 DEL D.LGS. N. 502 DEL 1992 E SUCCESSIVE MODIFICAZIONI ED INTEGRAZIONI – TRIENNIO 2016-2018 [Internet]. 2022. Available from: https://www.sisac.info/downloadFILE. do?doc_id=www.sisac.info/resources/news/news_2022042 8143637328&nomefile=ACN_28.04.2022_pediatri_di_libera_scelta(2).pdf&serv=nws [Last accessed: 2023 May 18].
6. ACCORDO COLLETTIVO NAZIONALE PER LA DISCIPLINA DEI RAPPORTI CON I MEDICI DI MEDICINA GENERALE AI SENSI DELL’ART. 8 DEL D.LGS. N. 502 DEL 1992 E SUCCESSIVE MODIFICAZIONI ED INTEGRAZIONI – TRIENNIO 2016-2018 [Internet]. 2022. Available from: https://www.sisac.info/downloadFILE. do?doc_id=www.sisac.info/resources/news/news_2022042 8142843635&nomefile=ACN_28.04.2022_medicina_generale.pdf&serv=nws [Last accessed: 2023 May 18].
https://www.sisac.info/downloadFILE.do?doc_id=www.sisac.info/resources/news/news_20220428142843635&nome file=ACN_28.04.2022_medicina_generale.pdf&serv=nws
7. Decreto del Presidente della Repubblica 28 luglio 2000, n. 270. Regolamento di esecuzione dell’accordo collettivo nazionale per la disciplina dei rapporti con i medici di medicina generale. [Internet]. 270/2000 Jul 28, 2000. Available from: https://www.gazzettaufficiale.it/eli/gu/2000/10/02/230/ so/165/sg/pdf [Last accessed: 2023 Jul 30].
8. Regione del Veneto. Definizione e computo dei massimali del MMG e PLS [Internet]. Available from: https://salute.regione. veneto.it/c/document_library/get_file?uuid=89897ab5-737b-4114-b13c-a40271b28e22&groupId=543512 [Last accessed: 2023 Jul 30].
9. AZIENDA USL TOSCANA NORD OVEST. OGGETTO: ACN PER LA MEDICINA GENERALE. RICOGNIZIONE INNALZAMENTO MASSIMALE
INDIVIDUALE A 1800 SCELTE. [Internet]. Available from: https://www.uslnordovest.toscana.it/attachments/ article/10472/20230517_1624%20decreto.pdf [Last accessed: 2023 Jul 30].
10. Programma Nazionale Esiti edizione 2022 [Internet]. Available from: https://pne.agenas.it/main/doc/Report_PNE_2022. pdf [Last accessed: 2023 May 10].
11. Guide to Prevention Quality Indicators: Hospital Admission for Ambulatory Care Sensitive Conditions. Available from: https://www.ahrq.gov/downloads/pub/ahrqqi/pqiguide.pdf [Last accessed: 2023 May 10].
12. TASSO DI ACCESSI IN PS NEI GIORNI FERIALI DALLE ORE 8.00 ALLE ORE 20.00 DI ADULTI CON
CODICE DI DIMISSIONE BIANCO/VERDE. PROTO-
COLLO OPERATIVO [Internet]. Available from: https:// pne.agenas.it/assets/documentation/protocolli/pro_703.pdf [Last accessed: 2023 Nov 22].
13. OSPEDALIZZAZIONE PER AMPUTAZIONE DEGLI
ARTI INFERIORI IN PAZIENTI DIABETICI. PROTOCOLLO OPERATIVO [Internet]. Available from: https:// pne.agenas.it/assets/documentation/protocolli/pro_52.pdf [Last accessed: 2023 Nov 23].
14. OSPEDALIZZAZIONE PER ASMA NEGLI ADULTI. PROTOCOLLO OPERATIVO [Internet]. Available from: https://pne.agenas.it/assets/documentation/protocolli/ pro_47.pdf [Last accessed: 2023 Nov 23].
15. OSPEDALIZZAZIONE PER BRONCOPNEUMOPATIA CRONICO OSTRUTTIVA. PROTOCOLLO OPERATIVO
[Internet]. Available from: https://pne.agenas.it/assets/documentation/protocolli/pro_56.pdf [Last accessed: 2023 Nov 23].
16. OSPEDALIZZAZIONE PER COMPLICANZE A BREVE E LUNGO TERMINE DEL DIABETE. PROTOCOLLO
OPERATIVO [Internet]. [LAST ACCESSED 2023 Nov 23]. Available from: https://pne.agenas.it/assets/documentation/ protocolli/pro_77.pdf [Last accessed: 2023 Nov 23].
17. OSPEDALIZZAZIONE PER DIABETE NON CONTROLLATO (SENZA COMPLICANZE). PROTOCOLLO
OPERATIVO [Internet]. Available from: https://pne.agenas. it/assets/documentation/protocolli/pro_49.pdf [Last accessed: 2023 Nov 23].
18. OSPEDALIZZAZIONE PER INFEZIONI DEL TRATTO URINARIO. PROTOCOLLO OPERATIVO [Internet].
Available from: https://pne.agenas.it/assets/documentation/ protocolli/pro_57.pdf [Last accessed: 2023 Nov 23].
19. OSPEDALIZZAZIONE PER INFLUENZA. PROTOCOL-
LO OPERATIVO [Internet]. Available from: https://pne. agenas.it/assets/documentation/protocolli/pro_44.pdf [Last accessed: 2023 Nov 23].
20. OSPEDALIZZAZIONE PER IPERTENSIONE ARTERIOSA. PROTOCOLLO OPERATIVO [Internet]. Available
from: https://pne.agenas.it/assets/documentation/protocolli/ pro_58.pdf [Last accessed Nov 23].
21. OSPEDALIZZAZIONE PER SCOMPENSO CARDIACO. PROTOCOLLO OPERATIVO [Internet]. Available from: https://pne.agenas.it/assets/documentation/protocolli/ pro_59.pdf [Last accessed Nov 23].
22. OSPEDALIZZAZIONE PER TSO. PROTOCOLLO OPE-
RATIVO [Internet]. Available from: https://pne.agenas.it/ assets/documentation/protocolli/pro_702.pdf [Last accessed 2024 Jan 8].
23. TASSO DI ACCESSI IN PS NEI GIORNI FERIALI DALLE ORE 8.00 ALLE ORE 20.00 DI PAZIENTI PEDIATRICI
CON CODICE DI DIMISSIONE BIANCO/VERDE. PRO-
TOCOLLO OPERATIVO [Internet]. Available from: https:// pne.agenas.it/assets/documentation/protocolli/pro_704.pdf [Last accessed: 2023 Nov 23].
24. OSPEDALIZZAZIONE PER ASMA PEDIATRICO. PRO-
TOCOLLO OPERATIVO [Internet]. Available from: https:// pne.agenas.it/assets/documentation/protocolli/pro_46.pdf [Last accessed: 2023 Nov 23].
25. OSPEDALIZZAZIONE PER GASTROENTERITE PEDIATRICA. PROTOCOLLO OPERATIVO [Internet]. Available from: https://pne.agenas.it/assets/documentation/protocolli/ pro_45.pdf [Last accessed: 2023 Nov 23].
26. Ugolini C, Leucci AC, Nobilio L, Bertè G. Reorganizing territorial healthcare to avoid inappropriate ED visits: does the spread of Community Health Centres make Walk-in-Clinics redundant? BMC Health Serv Res. 2020 Dec;20(1):807. doi: 10.1186/s12913-020-05648-x.
27. Lippi Bruni M, Mammi I, Ugolini C. Does the extension of primary care practice opening hours reduce the use of emergency services? J Health Econ. 2016 Dec;50:144–55.
doi: 10.1016/j.jhealeco.2016.09.011. Epub 2016 Oct 8.
28. Cowling TE, Harris MJ, Watt HC, Gibbons DC, Majeed A. Access to general practice and visits to accident and emergency departments in England: cross-sectional analysis of a national patient survey. Br J Gen Pract. 2014 Jul;64(624):e434–9. doi: 10.3399/bjgp14X680533.
29. Cowling TE, Cecil EV, Soljak MA, Lee JT, Millett C, Majeed A, et al. Access to primary care and visits to emergency departments in England: a cross-sectional, population-based study. PLoS One. 2013;8(6):e66699. doi: 10.1371/journal. pone.0066699.
30. Henricson J, Ekelund U, Hartman J, Ziegler B, Kurland L, Björk Wilhelms D. Pathways to the emergency department - a national, cross-sectional study in Sweden. BMC Emerg Med. 2022 Apr 7;22(1):58. doi: 10.1186/s12873-022-00619-3.
31. Brasseur E, Gilbert A, Servotte JC, Donneau AF, D’Orio V, Ghuysen A. Emergency department crowding: why do patients walk-in? Acta Clin Belg. 2021 Jun;76(3):217–23. doi: 10.1080/17843286.2019.1710040. Epub 2019 Dec 30.
32. McIntyre A, Janzen S, Shepherd L, Kerr M, Booth R. An integrative review of adult patient-reported reasons for nonurgent use of the emergency department. BMC Nurs. 2023 Mar 30;22(1):85. doi: 10.1186/s12912-023-01251-7.
33. Harris MJ, Patel B, Bowen S. Primary care access and its relationship with emergency department utilisation: an observational, cross-sectional, ecological study. Br J Gen Pract. 2011 Dec;61(593):e787–93. doi: 10.3399/ bjgp11X613124.
34. Safiri S, Carson-Chahhoud K, Noori M, Nejadghaderi SA, Sullman MJM, Ahmadian Heris J, et al. Burden of chronic obstructive pulmonary disease and its attributable risk factors in 204 countries and territories, 1990-2019: results from the Global Burden of Disease Study 2019. BMJ. 2022 Jul 27;378:e069679. doi: 10.1136/bmj-2021-069679.
35. Steurer-Stey C, Dalla Lana K, Braun J, Ter Riet G, Puhan MA. Effects of the “Living well with COPD” intervention in primary care: a comparative study. Eur Respir J. 2018 Jan;51(1):1701375. doi: 10.1183/13993003.01375-2017.
36. Jamieson AL, Harries TH, Thornton H, Crichton S, White P. Emergency Admissions for COPD in an Urban Population: The Role of Population and Primary Care Factors. COPD. 2015;12(6):606–12. doi: 10.3109/15412555.2015.1020150. Epub 2015 Aug 11.
37. Pennisi F, Odelli S, Borlini S, Signorelli C, Renzi C. Impact of the Covid pandemic on timely cancer diagnosis across European healthcare settings: a scoping review. Ann Ig. 2024 Jan 18. doi: 10.7416/ai.2024.2596.
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