Inter-Regional Hospital Patients' Mobility in Italy

Patient Mobility in the Digital Era: How Online Service Information from Internet Hospitals Shapes Patients' Cross-Regional Healthcare Choices

Background/Objectives: Patients in medically underserved regions often seek cross-regional healthcare for high-quality medical services but face significant barriers due to limited information about providers. Internet hospitals address this gap by offering online consultations, remote diagnoses, and public service information. This study examines how such information shapes patients' cross-regional healthcare choices. Methods: A binary logistic regression model using signaling theory was employed to evaluate the impact of platform-generated signals (e.g., hospital ratings) and patient-generated signals (e.g., review quantity and polarity) on patients' cross-regional healthcare choices. The experimental data were sourced from a leading Chinese online medical platform, comprising 1901 hospitals and 273,884 patient feedback records. Among these, 216,793 patients (79.16%) sought cross-regional treatment, while 57,091 patients (20.84%) opted for local treatment. Results: Platform-generated signals, such as hospital ratings (B = 0.406, p < 0.01) and patient-generated signals, including review quantity (B = 0.089, p < 0.01) and polarity (B = 0.634, p < 0.01), significantly and positively influence patients' cross-regional healthcare choices. Disease severity and local medical resource availability moderated these effects: Patients with severe conditions rely less on hospital ratings (B = -0.365, p < 0.01), while those in resource-limited areas depend more on hospital ratings (B = -0.138, p < 0.01) and review quantity (B = -0.029, p < 0.01) but less on review polarity (B = 0.273, p < 0.01). Conclusions: These findings offer actionable insights for policymakers and platform developers to optimize online healthcare services, facilitating informed cross-regional healthcare decisions and advancing healthcare equity in the digital era.

Is the treatment of ankle osteoarthritis changing over time in Italy? Analysis of temporal trends for fusion and arthroplasty in a population-based study from 2001 to 2022 on the National Hospital Discharge Record database

BACKGROUND

Treatment of ankle osteoarthritis by total ankle replacement (TAR) is increasing worldwide. The aim of the study was to present the overall temporal trends of TAR throughout 22 years (2001-2022) in Italy, analyzing the distributions of hospitals by volume of activity and patients by age and sex, drawing on the National Hospital Discharge Record database. Furthermore, as a secondary aim, we compared these trends with those of ankle fusions.

MATERIALS AND METHODS

International Classification of Diseases, 9th Revision, Clinical Modification (ICD9-CM) codes of interest were identified to browse the Italian National Hospital Discharge Record database. Surgical volumes, trends over time, classes of hospital activity volume, sex and age of patients, and population incidence rates were described. The statistical significance of time series trends was assessed by the Cox-Stuart test with randomness as a null hypothesis.

RESULTS

20,248 ankle procedures (total ankle replacements 8853 and ankle fusions 11,395) were extracted from 231,601,523 admissions registered nationally from 2001 to 2022. The yearly total number of TARs significantly increased almost tenfold from 96 to 996 (p < 0.05), while the number of fusions exhibited a stationary behavior (p > 0.05). The increased trend in TAR procedures was concentrated mostly in the North of Italy, with predominantly males between 55 and 64 years of age. The analysis of the number of procedures performed on inhabitants by region and that performed by all the hospitals in the region showed a different pattern across Italy.

CONCLUSIONS

The substantial increase in TARs may be owing to improved implant designs and innovative surgical technologies, which allow the treatment of more severe cases and deformities, previously untreated or treated by a fusion. This trend highlights the need to invest in implementing high quality registries by promoting surgeons' participation in data collection.

LEVEL OF EVIDENCE

population based study, level 1 evidence.

An Evaluation of Rare Cancer Policies in Europe: A Survey Among Healthcare Providers

Rare cancers, defined as those with an annual incidence of fewer than six cases per 100,000 individuals, are associated with significant health inequalities. This study aimed to assess the knowledge, attitudes, and perceptions of healthcare providers with expertise in rare cancers regarding the effectiveness of enacted or planned rare cancer policies across Europe. Between 25 March 2023 and 5 March 2024, we conducted an online survey targeting 738 healthcare providers affiliated with the European Reference Networks and the Organization of European Cancer Institutes, yielding 92 complete responses from 28 European countries (response rate: 12.5%). While a significant portion of respondents were unaware of their country's legal definitions for rare cancers, 67.4% acknowledged that national cancer plans prioritized rare cancers. These plans received the highest ratings for their evidence-based interventions and monitoring efforts. The integration of rare cancer policies into broader oncology frameworks was the preferred policy model. National cancer registries were highly rated for confidentiality and validity but scored the lowest for cost-effectiveness. Government funding was deemed crucial for cancer screening programs. The disease burden and unmet health needs primarily influenced reimbursement decisions in the field of rare cancers. Respondents rated palliative care as more effective in adults with rare cancers compared to in children, particularly regarding symptom management. We confirmed significant variability in rare cancer policy evaluations across Europe, the necessity for a common EU-level definition for rare cancers, and a shift in reimbursement and policy framework models, highlighting the importance of policy integration and enhanced collaboration. However, given the limitations of the study, such as small sample size and possible unstudied confounding factors, we should interpret our findings with caution. A systematic policy review and multistakeholder assessment in the future could complement our results.

Analysing the intra and interregional components of spatial accessibility gravity model to capture the level of equity in the distribution of hospital services in Italy: do they influence patient mobility?

BACKGROUND

An equal distribution of hospital structures represents an important factor to achieve Universal Health Coverage. Generally, the most diffused approach to measure the potential availability to healthcare is the provider-to-population ratio based on the number of beds or professionals. However, this approach considers only the availability of resources provided at regional or local level ignoring the spatial accessibility of interregional facilities that are particularly accessed by patients living at the borders. Aim of this study is to outline the distribution of the intra and interregional services in Italy to capture the level of equity across the country. Moreover, it explores the impact of the accessibility to these resources on interregional patient's mobility to receive care.

METHODS

To compute spatial accessibility, we propose an alternative approach that applies the enhanced two-step floating catchment area (ESFCA) to capture the level of attraction of intra and interregional hospitals to a given population. Moreover, the adoption of process and outcome indices captured to what extent the quality of structures influenced patients in choosing services located inside or outside their region of residence.

RESULTS

The study confirms that there is an unequal distribution of high-quality resources at regional and national level with a high level of inequality in the availability and accessibility of quality resources between the north and south part of Italy. This is particularly true considering the accessibility of intraregional resources in the southern part of the country that clearly influences patient choice and contribute to a significant cross border passive mobility to northern regions. This is confirmed by an econometric model that showed a significant effect of spatial accessibility with the propensity of patients of travel from the region of residence to receive care.

CONCLUSIONS

The analysis of intra and interregional components of spatial accessibility may contribute to identify to what extent patients are willing to travel outside their region of residence to access to care services. Moreover, it can contribute to gain a deeper understanding of the allocation of health resources providing input for policy makers on the basis of the principles of service accessibility in order to contain patient mobility.

Machine Learning for Evaluating Hospital Mobility: An Italian Case Study

This study delves into hospital mobility within the Italian regions of Apulia and Emilia-Romagna, interpreting it as an indicator of perceived service quality. Utilizing logistic regression alongside other machine learning techniques, we analyze the impact of structural, operational, and clinical variables on patient perceptions of quality, thus influencing their healthcare choices. The analysis of mobility trends has uncovered significant regional differences, emphasizing how the regional context shapes perceived service quality. To further enhance the analysis, SHAP (SHapley Additive exPlanations) values have been integrated into the logistic regression model. These values quantify the specific contributions of each variable to the perceived quality of service, significantly improving the interpretability and fairness of evaluations. A methodological innovation of this study is the use of these SHAP impact scores as weights in the data envelopment analysis (DEA), facilitating a comparative efficiency analysis of healthcare facilities that is both weighted and normative. The combination of logistic regression and SHAP-weighted DEA provides a deeper understanding of perceived quality dynamics and offers essential insights for optimizing the distribution of healthcare resources. This approach underscores the importance of data-driven strategies to develop more equitable, efficient, and patient-centered healthcare systems. This research significantly contributes to the understanding of perceived quality dynamics within the healthcare context and promotes further investigations to enhance service accessibility and quality, leveraging machine learning as a tool to increase the efficiency of healthcare services across diverse regional settings. These findings are pivotal for policymakers and healthcare system managers aiming to reduce regional disparities and promote a more responsive and personalized healthcare service.

A hub and spoke model to supply the Sicilian neurorehabilitation demand: effects on hospitalization rates and patient mobility

Introduction

Cerebrovascular diseases in Sicily have led to high mortality and healthcare challenges, with a notable gap between healthcare demand and supply. The mobility of patients seeking care, both within and outside Sicily, has economic and organizational impacts on the healthcare system. The Hub and Spoke model implemented by the IRCCS Centro Neurolesi "Bonino-Pulejo" of Messina aims to distribute advanced neurorehabilitation services throughout Sicily, potentially reducing health mobility and improving service accessibility.

Methods

The evaluation was based on calculating hospitalization rates, examining patient mobility across Sicilian provinces, and assessing the financial implications of neurorehabilitation admissions. Data from 2016 to 2018, covering the period before and after the implementation of the Hub and Spoke network, were analyzed to understand the changes brought about by this model.

Results

The analysis revealed a significant increase in hospitalization rates for neurorehabilitation in the Sicilian provinces where spokes were established. This increase coincided with a marked decrease in interregional health mobility, indicating that patients were able to receive high-quality care closer to their residences. Furthermore, there was a decrease in both intra-regional and inter-regional escape rates in provinces within the Hub and Spoke network, demonstrating the network's efficacy in improving accessibility and quality of healthcare services.

Discussion

The implementation of the Hub and Spoke network substantially improved neurorehabilitation healthcare in Sicily, enhancing both accessibility and quality of care for patients. The network's establishment led to a more efficient utilization of healthcare resources and balanced distribution of services. These advancements are vital steps toward equitable and effective healthcare delivery in Sicily.

Identifying the Drivers of Inter-Regional Patients' Mobility: An Analysis on Hospital Beds Endowment

BACKGROUND

In a Beveridgean decentralized healthcare system, like the Italian one, where regions are responsible for their own health planning and financing, the analysis of patients' mobility appears very interesting as it has economic and social implications. The study aims to analyze both patients' mobility for hospital rehabilitation and if the beds endowment is a driver for these flows; Methods: From 2011 to 2019, admissions data were collected from the Hospital Discharge Cards database of the Italian Ministry of Health, population data from the Italian National Institute of Statistics and data on beds endowment from the Italian Ministry of Health website. To evaluate patients' mobility, we used Gandy's Nomogram, while to assess if beds endowments are mobility drivers, we created two matrices, one with attraction indexes (AI) and one with escape indexes (EI). The beds endowment, for each Italian region, was correlated with AI and EI. Spearman's test was carried out through STATA software; Results: Gandy's Nomogram showed that only some northern regions had good hospital planning for rehabilitation. A statistically significant correlation between beds endowment and AI was found for four regions and with EI for eight regions; Conclusions: Only some northern regions appear able to satisfy the care needs of their residents, with a positive attractions minus escapes epidemiological balance. The beds endowment seems to be a driver of patients' mobility, mainly for escapes. Certainly, the search for mobility drivers needs further investigation given the situation in Molise and Basilicata.

Factors associated with patients' mobility rates within the provinces of Iran

BACKGROUND

The absence of a referral system and patients' freedom to choose among service providers in Iran have led to increased patient mobility, which continues to concern health policymakers in the country. This study aimed to determine factors associated with patient mobility rates within the provinces of Iran.

METHODS

This cross-sectional study was conducted in Iran. Data on the place of residence of patients admitted to Iranian public hospitals were collected during August 2017 to determine the status of patient mobility within each province. The sample size were 537,786 patients were hospitalized in public hospitals in Iran during August 2017. The patient mobility ratio was calculated for each of Iran's provinces by producing a patient mobility matrix. Then, a model of factors affecting patient mobility was identified by regression analysis. All the analyses were performed using STATA14 software.

RESULTS

In the study period, 585,681 patients were admitted to public hospitals in Iran, of which 69,692 patients were referred to the hospital from another city and 51,789 of them were admitted to public hospitals in the capital of the province. The highest levels of intra-provincial patient mobility were attributed to southern and eastern provinces, and the lowest levels were observed in the north and west of Iran. Implementation of negative binomial regression indicated that, among the examined parameters, the distribution of specialist physicians and the human development index had the highest impact on intra-provincial patient mobility.

CONCLUSION

The distribution of specialists throughout different country areas plays a determining role in patient mobility. In many cases, redistributing hospital beds is impossible, but adopting different human resource policies could prevent unnecessary patient mobility through equitable redistribution of specialists among different cities.

Inter-Regional Patients' Migration for Hospital Orthopedic Intensive Rehabilitation: The Italian Experience

BACKGROUND

Following the introduction of administrative federalism in the Italian National Health Service, inter-regional patients' mobility has become increasingly relevant because, in addition to being an indirect index of the quality of care, it has important economic and financial implications. This study aimed to evaluate the fulfillment of the need for hospital orthopedic intensive rehabilitation on site and care-seeking patients' migration to other regions.

METHODS

From 2011 to 2019, the data of intensive orthopedic rehabilitation extracts from the Hospital Discharge Cards provided by Italian Ministry of Health were analyzed. We studied the hospital networks of every Italian region (catchment areas). The epidemiological flows of inter-regional mobility were analyzed with Gandy's Nomogram, while the financial flows were analyzed through Attraction Absorption and Escape Production Indexes.

RESULTS

Gandy's Nomogram showed that only Piedmont, Lombardy, A.P. of Trento, E. Romagna, Umbria and Abruzzo had good public hospital planning for intensive orthopedic rehabilitation, with a positive balance for all studied periods. Lombardy, E. Romagna, Piedmont, Veneto and Latium have absorbed approximately 70% of all financial flows (about EUR 60.5 million).

CONCLUSIONS

Only six regions appear to be able to satisfy the care needs of their residents, with a positive epidemiological and financial balance for all studied periods.

Where do you live? North versus Central-South differences in relation to Italian patients with oral lichen planus: a cross-sectional study from the SIPMO (Italian Society of Oral Pathology and Medicine)

BACKGROUND

Oral lichen planus (OLP) is an immune-mediated inflammatory chronic disease of the oral mucosa, with different patterns of clinical manifestations which range from keratotic manifestations (K-OLP) to predominantly non-keratotic lesions (nK-OLP). The aim of the study was to analyze the differences in the clinical, psychological profile and symptoms between Italian patients of the North and Central-South with K-OLP and nK-OLP.

METHODS

270 K-OLP and 270 nK-OLP patients were recruited in 15 Italian universities. The Numeric Rating Scale (NRS), Total Pain Rating Index (T-PRI), Hamilton Rating Scales for Depression and for Anxiety (HAM-D and HAM-A), Pittsburgh Sleep Quality Index (PSQI), and Epworth Sleepiness Scale (ESS) were administered.

RESULTS

The Central-South K-OLP (CS-K-OLP) patients reported a higher frequency of pain/burning compared with the K-OLP patients of the North (N-K-OLP) with higher scores in the NRS and T-PRI (p value < 0.001**). The CS-K-OLP and the CS-nK-OLP patients showed higher scores in the HAM-D, HAM-A, PSQI and ESS compared with the Northern patients (p value < 0.001**). Multivariate logistic regression revealed that the NRS and T-PRI showed the greatest increase in the R2 value for the CS-K-OLP (DR2 = 9.6%; p value < 0.001**; DR2 = 9.7% p value < 0.001**; respectively) and that the oral symptoms (globus, itching and intraoral foreign body sensation) and PSQI showed the greatest increase in the R2 value for the CS-nK-OLP (DR2 = 5.6%; p value < 0.001**; DR2 = 4.5% p value < 0.001** respectively).

CONCLUSIONS

Pain and mood disorders are predominant in patients with OLP in the Central-South of Italy. Clinicians should consider that the geographical living area may explain the differences in oral symptoms and psychological profile in OLP.