Lucia Leporatti

Targeting frequent users of emergency departments: Prominent risk factors and policy implications

This study investigates the characteristics of frequent users of accident and emergency departments (AEDs) and recommends alternative medical services for such patients. Prominent demographic and clinical risk factors for individuals accessing seven AEDs located in the metropolitan area of Genoa, Italy are identified and analysed. A truncated count data model is implemented to establish the determinants of access, while a multinomial logistic regression is used to highlight potential differences among different user categories. According to previous studies, empirical findings suggest that despite the relevance of demographic drivers, vulnerability conditions (e.g. abuse of alcohol and drugs, chronic conditions, and psychological distress) are the main reasons behind frequent AED use; the analysis seems to confirm an association between AED frequent use and lower level of urgency. Since frequent and highly frequent users are found responsible for disproportionate resource absorption with respect to total amount of AED costs (they represent roughly 10% of the total number of patients, but contribute to more than 19% of the total annual AED cost), policies aiming to reduce frequent use of AEDs could bring significant savings in economic resources. Thus, efficient actions could be oriented toward extending primary care services outside AED and toward instituting local aid services specifically addressed to people under the influence of substances or in conditions of mental distress.

The spatial configuration of urban crime environments and statistical modeling

The aim of this paper is to discuss the representation of space in statistical models of urban crime. We argue that some important information represented by the properties of space is either lost or hardly interpretable if those properties are not explicitly introduced in the model as regressors. We illustrate the issue commenting on the shortcomings of the two standard approaches to modeling the dispersion of crime in a city: using local attributes of places as regressors, and defining a catch-all spatial component to neutralize the effect of latent spatial factors from the model. As an alternative to the current methods, the metrics of spatial configuration, including those devised by the technique called Space Syntax Analysis, provide useful variables that can be introduced as regressors. Such regressors offer interpretable information on space, behavior, and their interactions, that would otherwise be lost. We therefore consider a set of three configurational variables that represent different forms of centrality and that are thought to have influence on a wide range of human activities. We propose an innovative procedure to adapt these variables to most urban graphs and then, using data from a large area in the city of Genoa (Italy), we show that the three variables are well defined, consistent, noncollinear indicators, with evident spatial meanings. Then we build two sets of Hierarchical Bayesian count models of different urban crime types (“property crime” and “arson and criminal damage”) around some known covariates of crime and we show that the overall quality of the models is improved (with the size of improvement depending on the type of crime) when the three configurational variables are included. Furthermore, we show that what the three variables explain of the overall variability of crime is a sizeable part of what would be the spatial error term of a traditional spatial model of urban crime. While the configurational variables alone cannot provide a goodness of fit as high as the one obtained with a generic spatial term, they have a relevant role for the interpretation of the results, which is ultimately the objective of urban crime modeling.

POSET Analysis of Panel Data with POSAC

In the last two decades, data-driven policymaking has gained more and more importance due to the larger availability of data (and, more recently, Big Data) for designing proper and timely economic and social policies. This larger availability of data has let decision makers have a deeper insight of complex socio-economic phenomena (e.g. unemployment, deprivation, crime, social care, healthcare) but, at the same time, it has drastically increased the number of indicators that can be used to monitor these phenomena. Decision makers are now often in the condition of taking decisions with large batteries of indicators whose interpretation is not always easy or concordant. In order to simplify the decisional process, a large body of literature suggests to use synthetic indicators to produce single measures of vast, latent phenomena underlying groups of indicators. Unfortunately, although simple, this solution has a number of drawbacks (e.g. compensation between components of synthetic indicators could be undesirable; subjective weighting of the components could lead to arbitrary results; mixing information about different phenomena could make interpretation harder and decision-making opaque). Moreover, with operational decisions, it is necessary to distinguish between those situations when decisions can be embedded in automated processes, and those that require human intervention. Under certain conditions, the use of synthetic indicators may bring to a misleading interpretation of the real world and to wrong policy decisions. In order to overcome all these limitations and drawbacks of synthetic indicators, the use of multi-indicator systems is becoming more and more important to describe and characterize many phenomena in every field of science, as they keep the valuable information, inherent to each indicator, distinct (see, for a review: Bruggemann and Patil 2011).

Popular initiatives in 2014–2016 call for the introduction of mandatory dental care insurance in Switzerland: The contrasting positions at stake ☆

Switzerlands mandatory health insurance system provides coverage for a standard benefits package for all residents. However, adult dental care is covered only in case of accidents and inevitable dental illnesses, while routine dental care is almost completely financed out-of-pocket. In general, unmet health needs in Switzerland are low, but unmet dental needs are significant, when compared with other countries in Europe. Recent popular initiatives in Switzerland have aimed to introduce a mandatory insurance model for dental care through a mandatory contribution of 1% of gross salaries toward dental care insurance. In three cantons, the proposals have collected the required number of signatures and a public referendum is expected to be held in 2017/2018. If implemented, the insurance system is expected to have a significant impact on the dental profession, dental care demand, and the provision of dental services. The contrasting positions of stakeholders for and against the reform reflect a rare situation in which dental care policy issues are being widely discussed at all levels. However, such a discussion is of crucial relevance not only for Switzerland, but also for the whole of Europe, which has significant levels of unmet needs for dental care, especially among vulnerable and deprived individuals, and new solutions to expand dental care coverage are required.

Robustness and Effectiveness of the Triage System in the Pediatric Context

BackgroundThe increasing use of emergency departments (EDs) potentially compromises their effectiveness and quality. The evaluation of the performance of the triage code system in a pediatric context is important because waiting time affects the quality of care for acutely ill patients.ObjectiveIn this study, we aimed to assess the effectiveness and robustness of the triage code system in a pediatric context and identify the determinants of waiting times for urgent and non-urgent patients.MethodsData regarding 37,767 pediatric patients who accessed the ED of a major Italian pediatric hospital in 2015 were investigated in order to study patient numbers and waiting times. The determinants of waiting times for urgent and non-urgent patients, as well as variables referring to the “supply side,” such as periods of staff shortage, were analyzed using a survival analysis framework.ResultsFor urgent patients, the waiting time between triage and the first physician assessment is generally below the standard threshold of 15 min and this is not affected by the number of non-urgent patients waiting for care. Conversely, the waiting time for non-urgent patients is affected by ED flow, periods of staff shortage, and non-clinical variables (age and nationality).ConclusionOur results suggest that the triage level assignation system is effective in terms of safety for urgent patients. The current ED organization adequately fulfills its primary goal of providing healthcare for acutely ill patients.

What should we expect from Switzerland’s compulsory dental insurance reform?

BackgroundA vast and heated debate is arising in Switzerland as a result of some recent citizens’ initiatives aimed at introducing compulsory dental health care insurance. The Grand Conseils of the Vaud, Geneva, and Neuchâtel cantons recently approved three public initiatives and their citizens are expected to vote on the proposal in 2018. The process of collecting signatures has begun in several other cantons and the discussion has now moved to a national level.DiscussionAt present, there is no scientific research that can help policy-makers and citizens to understand the main economic implications of such reform. We attempt to fill this gap by analysing three critical issues: the level and determinants of unmet needs for dental care in Switzerland; the protection of vulnerable individuals; and the economic sustainability of reform.Results and short conclusionsThe results show that income is not a unique determinant of barriers to access to dental care but rather, cultural and socio-demographic factors impact the perceived level of unmet dental care needs. The reform might only partially, if at all, improve the equity of the current system. In addition, the results show that the 1% wage-based contribution that the reform promoters suggest should finance the insurance is inadequate to provide full and free dental care to Swiss residents, but is merely sufficient to guarantee basic preventive care, whereas this could be provided by dental hygienists for less.

Analisi socio-economica degli accessi ripetuti al pronto soccorso pediatrico: il caso dell’Istituto G. Gaslini di Genova

The use of Emergency Departments (EDs) is continuously increasing and the challenge of guaranteeing an efficient and effective service is threatened by the phenomena of inappropriate and frequent use. Most of the literature on the topic focuses on adult population; in this study we analyse the issue of frequent use of ED among paediatric patients, with the aim of detecting the most significant socio-demographic and clinical predictors of frequent use of emergency services. Results, based on data collected from the ED of one of the most important paediatric Italian Hospital, show that children aged less than 12 months, foreign and chronic patients (particularly those suffering from mental illness, respiratory diseases and circulatory system problems) have a higher risk of becoming frequent and highly frequent ED users. It emerges that frequent users, although they only represent the 8% of total number of accesses, they account for 19% of total costs.

The Impact of Demographic Change on Sustainability of Emergency Departments

The progressive ageing of the population and the increasing migration flows are affecting the population structure in most of the western countries. Because of this demographic change, the demand for public services is expected to rise, creating potential problems to the economic sustainability of major public services. Our paper is focused on Accident and Emergency Departments (AEDs) services and it aims at estimating how the AED demand and costs will change adapting to the demographic trend in a specific Italian administrative region (Liguria) in the next decades (2012–2065). This is done as follows: first, we split the patients assisted over a whole year by one of the most relevant Italian AEDs into several categories per severity level (i.e., triage colour) and demographic characteristics (age span, gender, and nationality); using actual accounting data we estimate the average assistance cost per typology of patient; after we derive an estimate of the probability for each category of patient to ask for emergency assistance; finally we use official ISTAT 2012 – 2065 residential population forecasts to provide an estimate of the expected number of accesses per patient category and the overall expected AEDs’ cost of the whole Liguria region. Our results suggest that, although immigration seems to be a more relevant aspect for future AEDs’ sustainability than ageing, the inappropriate use of emergency departments by nonurgent patients is the biggest threat which policymakers will really have to deal with.