1. the case of five large hospitals in Rome, Italy
Appropriateness of ER utilization and emergency admissions of Romanians before and after their entry into European Union:
the case of five large hospitals in Rome, Italy
Di Paolo C, Migliara G, Mele A, Paglione L, Prencipe GP, Salvatori LM, Bertazzoni G, Villari P, Marceca M, De Vito C

2. Background (I) Non-EU Citizens access to NHS in Italy
Non-EU citizens with regular stay permits are entitled with registration to the National Health Service (NHS) and to the same treatment as Italian Citizens
Non-EU population without a stay permit may encounter difficulties to access the NHS services
Regardless of legal status, immigrants are guaranteed urgent and essential care
Immigrants who become citizens have the resources to overcome barriers that they may face in accessing health care, which include: socioeconomic, linguistic, cultural, and knowledge-related barriers. (Cofie, Leslie E., et al. "HPV Vaccination Among Foreign-Born Women: Examining the National Health Interview Survey 2013–2015." American journal of preventive medicine, 2018)
According to Italian law, Non-EU citizens with regular stay permit are registered with the National Health Service and receive the same treatment as Italian Citizens
However, regardless of legal status, immigrants are ensured urgent and essential care.
Moreover, it as been shown that immigrants who become citizens have the resources to overcome barriers in accessing health care like linguistic and cultural barriers

3. Foreign Citizens in Rome
Background (II)
Foreign Citizens in Rome
Non-Italian residents in Rome at 2014:
363,563 people
12.7% of residents in Rome
Romanians: 24,1 % of the resident foreign population
At the end of 2014, there were more than three hundred thousand foreign resident people in Rome overall about 12% of all residents in the city
About a quarter (24,1%) of the them was represented by Romanians
Source: Data processing by Bureau of Statistics of Roma Capitale

4. In five large hospitals in Rome
Objective
Compare the characteristics of Romanians access to emergency rooms (ERs) before and after their entrance in the EU in 2007 and to Italians
In five large hospitals in Rome
The objective of this study was to compare the characteristics of Romanians access to emergency rooms (ERs) before and after their entrance in the EU in 2007 and to compare that with Italians analyzing access to the ERs from 5 large hospitals in Rome.

5. Materials and Methods
Data on the access to ERs of the five hospitals from 1999 to 2014
Description of the clinical and demographic features of the ER access by Romanians and by Italians
Poisson regression model to assess the incidence rate ratios (IRRs) of Romanians compared to Italians and of Romanians before and after 2007 for:
inappropriateness of ER utilization (measured as white codes resulting in discharge to home);
emergency admissions (EAs) for ambulatory care sensitive conditions (ACSCs) “conditions for which good outpatient care can potentially prevent the need for hospitalization or for which early intervention can prevent complications or more severe disease”. (Agency for Healthcare Research and Quality)
In order to do this, we collected clinical and demographic features of the ER access by citizenship form 1999 to 2014 from those hospitals.
A multivariate analysis through Poisson regression model was performed to assess the incidence rate ratios (IRRs) adjusted for confounding variables such as age, gender, ICD-9 codes, triage code, for:
inappropriateness of ERs utilization (measured as white codes resulting in discharge to home) and for emergency admissions (EAs) for ambulatory care sensitive conditions (ACSCs) that are those conditions that can potentially prevent hospitalizations or the complications of more severe diseases.

6. Results (I) Frequencies of ER access by citizenship, 1999-2014
Overall, in the 15 years under study there were about 6 million ER admissions and the access rate increased from 3 to 10% .
Of particular note is the decrease of non-EU citizens in 2007, and subsequent rise of European citizens, that are mainly due to the entry of Romania into the European Union
Since the early 2000s the access of Romanians to ERs in Rome has greatly increased.

7. Results (II) - Descriptive analysis
Age distribution
< 2007
> 2007 F M
Romanians
48,36
51,64
Italians
48,72
51,28 F M
Romanians
50,61
49,39
Italians
49,71
50,29
Gender distribution
The Romanians in Italy are on average younger than Italians and this may be a reflection of their status as economic migrants.
Over the years, the percentage of older age ranges shows that Romanians have become a stable population in Italy.
Comparing the gender distribution both before and after 2007 and with the Italian population shows no notable differences.

8. Within Romanian Population
Results (III) - Poisson Regression for inappropriateness
Before 2007
Variable
IRR Pv
95% CI
Italians
Ref.
---
Romanians
1.30
<0.001
Age
0,9976
0,9974-0,9978
Gender
0.947
After 2007
1.38
0.9989 0,
0,896
0,887-0,904
Within Romanian Population --
0.80
1.004
0.97
0.07
The results of Poisson regression for inappropriateness show that Romanians have an higher risk of inappropriate utilization of ERs both before and after 2007 compared to Italians.
But comparing the Romanian population before and after 2007, the IRR of inappropriateness significantly decreased.
Results adjusted for principal diagnoses codes

9. Results (IV) - Poisson Regression for EAs for ACSCs
Before 2007
After 2007
Within Romanians
About emergency admissions for ACSCs, the Poisson regression shows that before 2007, overall risk for EAs was high compared to Italians and that after 2007, the overall risk decreased significantly and decreased significanty for Angina and largely for Other vaccine preventable conditions.
It is significant, however, for the Other vaccine preventable conditions within Romanian population.
Results adjusted for age, gender, triage codes

10. Conclusions
Romanians have an higher risk to use inapprorpiately ER compared to Italians both before and after 2007 but the risk decreased within Romanians
The overall risk of Emegency Admissions for Ambulatory care sentitive conditions decreased after 2007 in particular for Angina and Other vaccine preventable conditions
These results point out an overall improved health of Romanians and a better use of primary care services after their entry in the EU
This last point suggests the importance of developing specific prevention programs and health policies to reach migrant populations
In conclusion, although the risk of inappropriateness remained higher than Italians after 2007, it decreased within romanians.
Moreover the overall risk of Emegency Admissions for Ambulatory care sentitive conditions decreased after 2007 in particular for Angina and Other vaccine preventable conditions
These results suggest an overall improved health of Romanians and a better use of primary care services after their entry in the EU