Frequent User in Pronto Soccorso e Bed Blocker nei reparti di degenza: analisi del profilo e strategie preventive sul territorio attraverso le nuove piattaforme digitali e le COT distrettuali

Background In recent decades, the progressive aging of the population and the higher levels of urbanisation and pollution are increasing the number of patients suffering from chronic diseases, which has a significant impact on the use of health care services, in particular Emergency Departments (EDs). In Italy, despite significant improvements in the emergency care system, the cuts in numbers of hospital beds over the last 30 years and the increase in numbers of fragile patients (adults and children) have led to a rise in ED attendances. Published evidence from many countries shows that frequent ED use increases the risk of adverse effects such as hospitalisation, functional decline, and complications related to treatment and procedures. A significant proportion of hospital attendances are inappropriate and the respective ailments could be managed by non-acute health care services outside the hospital setting; such inappropriate attendances, therefore, drive up costs and increase inefficiency. The causes of frequent ED use are multifactorial: although many patients have chronic medical problems, these are often combined with marked psychosocial morbidity. Against this backdrop, the Covid-19 pandemic caused a significant fall in overall ED utilisation, with reduced volumes of up to 50% in some countries. The largest proportional reduction in ED users was in preventable ED attendance, including accident and traumatic injuries, probably as a result of a reduction in motor vehicle travel and fewer work activities, but also to time-dependent illnesses such as stroke or cardiac complaints among the oldest age groups, possibly due to concerns about Covid-19 acquisition in hospital. In Italy and in other countries, the Covid-19 pandemic also influenced the usage of Emergency Medical Services (EMSs). Despite a copious international literature on the frequent use of EDs, there is no single definition of a Frequent User (FU). The choice of threshold values is often subjective, generally based on previous literature or the distribution of ED attendances in a given period. More often a FU is considered a user with ≥4 or 5 attendances at the hospital, with both physical and mental issues, but various alternatives, from 2 to 12 attendances per year or six-month period, have also been chosen. Similar studies have also been conducted in Italy and the Netherlands showing that FUs represent a small percentage of hospital attendances, but nevertheless form a high proportion of the total ED costs. Among children, available studies conducted in Italy report that non-urgent attendances account for 27.6% of ED users and 58.2% of total paediatric attendance episodes. Non-urgent attendances have been negatively associated with crowding and costs, causing longer waiting times and greater dissatisfaction among both parents and health workers. The Italian National Health Service (NHS) is structured on three levels: the first includes the Central Government and the Ministry of Health, the second comprises the twenty Regional Governments and the third consists of the Local Health Authorities (LHAs) together with independent hospitals. The NHS is primarily funded through public taxation and is guided by the principles of universal coverage, solidarity, and human dignity. Each LHA includes at least one non-independent hospital and one or more Local Health Districts (LHDs), which provide primary care services (vaccination and screening, specialist consultations, family planning counselling, home care) and coordinates General Practitioners (GPs) and Primary Care Paediatricians (PCPs). Primary care physicians may work individually or in operational and multidisciplinary associations to ensure full ac-cess to care, 24 hours a day, 7 days a week. The availability of beds in hospital for acute patients and outside hospital for post-acute assistance is a major issue for the Italian NHS, especially in metropolitan areas like Rome, the most populous municipality in Italy, where three large LHAs administer health care services. Various Italian studies have explored the problem by analysing some of the characteristics of the adults and children FU but there is still insufficient consideration in the literature of the following points: number of attendances, usage of EMS, level of urgency, and appropriateness of attendance, geographical distribution and social-clinical characteristics. Covid-19 diagnosis was also investigated for a possible influence on ED attendances. The first study of this project investigates ED attendances in Rome; it describes the characteristic of the FU population and defines a FU profile (for adults and children), which highlights the differences between FUs and non-FUs, and identifies factors linked to FU status and appropriate ED attendance. The second analysis was aimed to identify the clinical and social characteristics of FUs and to quantify and compare the variation in the probability of being FU attributable to GPs and LHDs. The third part of the study described an example of strategic interventions of FU case management in a pilot phase carried out between 2023 and 2024. Materials and methods Study design and data collection A retrospective cohort study was carried out during 2022 of the ED attendances in 2021 for adults and the ED attendances in 2022 for children. The LHA Roma 1 geographical area in Rome was chosen for the analysis as it is one of the most populous areas in Italy, containing 13 EDs (of 22 in the Rome metropolitan area), including 8 paediatric EDs, with an aging index (number of population aged >64 years per 100 individuals aged