Italy's poor go to the hospital more

Despite free public healthcare, Italy's poor are more likely to end up in hospital with avoidable conditions, new research shows. This pattern, reported today in the online open access journal BMC Public Health, mirrors findings from a number of different healthcare systems around the world, although to date fewer studies have been completed in Europe.

A research team led by Nera Agabiti at the Department of Epidemiology, ASL RM/E Rome (Italy) used hospital discharge data from the year 2000 from Rome, Bologna, Turin and Milan. They focussed on patients with six chronic conditions: diabetes, hypertension (without procedures), congestive heart failure (without procedures), angina pectoris (without procedures), chronic obstructive pulmonary disease (COPD), and asthma. These ambulatory care sensitive conditions (ACSCs) are disorders where hospitalisation is potentially preventable with the right care and medication. Hospitalisation rates for ACSCs are also increasingly used as an indicator of primary health care (PHC) efficacy.

The researchers found a statistically significant socio-economic gradient for all medical conditions they investigated. The association was particularly strong for COPD and congestive heart failure, where the poorest had around four times the risk of hospitalisation compared with the well off. Except for asthma, males were more vulnerable to ACSC hospitalisation than females, and the risk increased for those aged 45-64 compared to younger age groups.

"This study provides evidence of higher rates of hospitalisation for ACSC for economically disadvantaged people in Italy, where barriers to health care are not expected to exist because of the universal health care system. This finding highlights the need for improving outpatient care programmes to reduce the excess of unnecessary hospitalisations among poor people," says Agabiti, adding: "Low socio-economic individuals are vulnerable and tend to receive substandard care."

1. Income level and chronic ambulatory care sensitive conditions in adults: a multicity population-based study in Italy
Nera Agabiti, Monica Pirani, Patrizia Schifano, Giulia Cesaroni, Marina Davoli, Luigi Bisanti, Nicola Caranci, Giuseppe Costa, Francesco Forastiere, Chiara Marinacci, Antonio Russo, Teresa Spadea, Carlo A. Perucci and Italian Study Group on Inequalities in Health Care Isgihc
BMC Public Health (in press)

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2. Several studies have documented a relationship between greater access to PHC and lower risk for preventable hospitalisations, although among the less wealthy, exposure to other behavioural and environmental risk factors also count. This effect is well documented in the US, particularly among the elderly, with ethnic minorities and those without medical insurance among groups at greater risk. ACSC hospitalisation rates have been studied in China, New Zealand, Australia and Canada, but to date the only other European health system measured has been Spain.

3. BMC Public Health (http://www.biomedcentral.com/bmcpublichealth/) is an open access journal publishing original peer-reviewed research articles in the epidemiology of disease and the understanding of all aspects of public health. The journal has a special focus on the social determinants of health, the environmental, behavioral, and occupational correlates of health and disease, and the impact of health policies, practices and interventions on the community. BMC Public Health (ISSN 1471-2458) is indexed/tracked/covered by PubMed, MEDLINE, CAS, EMBASE, Scopus, Current Contents, FSTA, Thomson Reuters (ISI) and Google Scholar.

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