From the cost of hospital days to the endless emergency room times, the Agenas analysis photographs a fragmented healthcare system. Hospitals with expenses tripled compared to others and hospitals where one in four patients abandons the facility even before the visit.
The most recent development by Agenas (National Agency for Regional Health Services) confirms an inconvenient truth for the Italian healthcare system: the average cost of one “acute hospital day” it varies substantially from region to region — and very often it is higher in the South. The gap is impressive: while in some structures in the North, indicated as models of efficiency, hospitalization weighs relatively little on resources, in some hospitals in the South the cost per admission can reach figures worthy of five-star suites. “A high value of the indicator – says Agenas – is evaluated negatively, as it represents higher operating costs connected to each day of hospitalisation”. In concrete terms, for example, the L.Vanvitelli University Hospital of Naplesproved to be the “worst” in Italy, and recorded a cost per day of hospitalization in acute care, weighted by complexity, equal to approximately 1,326 euros. On the contrary, the most virtuous “Papa Giovanni XXIII” Hospital in Bergamo reaches costs of “only” 374 euros for the same type of hospitalization. In second place in terms of spending, after Vanvitelli, we find the Giaccone Polyclinic in Palermo (881.6 euros per day)followed by G. Martino of Messina (735.8 euros) and from Renato Dulbecco from Catanzaro (727.8 euros). Among non-university hospitals the most expensive isCosenza Hospitalwhich records an average cost of 827.6 euros. They follow the Papardo of Messina (728.7 euros) and the Civico-Benfratelli of Palermo (728.1 euros). Among the “best”, in addition to the aforementioned Pope John XXIII, we find the Moscati of Avellino and the Niguarda of Milanin addition to San Matteo of Pavia and the Brotzu of Cagliari.
Emergency-urgency: endless waits
If the hospital stay gives an idea of how much each day of treatment “weighs”, the other side of the coin concerns the waiting times and emergency management. Here too, the Agenas data do not leave room for much optimism. Let’s start by saying that, in 2023 alone, Italian emergency rooms recorded approximately 18.27 million hits. Of these, a significant part – according to the medical literature cited by Agenas – concerns “non-urgent” codes: it is estimated that approximately 73% of emergency room visits are used to manage low clinical priority conditionsthen green and white codes. The indicator examined by Agenas concerns the “percentage of visits to the emergency room with waiting times between entry and discharge from the emergency room (and therefore also hospitalization, ed.) greater than or equal to eight hours”. In the ranking of critical performances, the Emergency room of the Tor Vergata Polyclinic in Rome: where one in four patients (25%) wait longer before leaving the emergency stretchers. Obviously, in general for all hospitals (even the most virtuous), the waits, as the news often reminds us, can even exceed 24-48 hours especially in certain periods of the year such as the flu peak. Al Giaccone Polyclinic of Palermo the percentage of those who stay in the ward for more than 8 hours is 21.9%, according to Ospedali Riuniti Villa Sofia–Cervello, also in the Sicilian capitalis at 20.7%, at Cardarelli in Naples at 20.4%. The quickest to discharge or admit are. The most virtuous are the S. Carlo di Potenza and thePerugia HospitalThe Renato Dulbecco of Catanzaro and thePadua hospitalall with percentages below 6%
There are also too many “abandonments” in the emergency room“
In Sicily, always at the PS of the Villa Sofia–Cervello Hospitals of Palermo 24.7% of users abandon the facility before completing the treatment process – a rate that reveals the severity of the expectations and pressure on the departments. Even theDei Colli Hospital in Naples appears among the most suffering, with 23.1% of voluntary abandonments to the ED even before the visit. In the Centre-North, at Papa Giovanni XXIII in Bergamo, voluntary abandonments stop at 9.9%, at S.Giovanni Addolorata in Rome at 9.3% and at San Camillo Forlanini we are at 9.2%. The emergency roomNiguarda Hospital in Milan records a 5% dropout rate and thePerugia Hospital it is 4%. The AGENAS document clearly shows that the emergency-urgency network is today under stress and profoundly uneven: in many metropolitan areas and in the South the emergency rooms are collapsing. Even among university hospitals the situation varies greatly from region to region. The emergency room with the most worrying abandonment rate is still that of Giaccone Polyclinic of Palermowhere abandonments are 18.8% of users. They still follow Tor Vergata (Rome) with 15.7% of patients who leave the facility before the visit and the G. Martino of Messina (13.3%). The most virtuous in terms of number of abandonments are the Hospital of Padua (1.0%), the San Matteo of Pavia (1.2%) and Verona (1.9%).
A system problem–hospital
However, it would be unfair and incorrect to limit ourselves to listing the best and worst and attribute the responsibility for abandonments only to the inefficiency of the emergency departments: indicators relating to abandonmentin fact, express different meanings and mainly denote a inappropriate use of the care settingmore than an operational insufficiency of the Emergency Department. It’s a cauldron where very different realities end up: there are patients who leave even before the visit, and who are in fact nothing more than inappropriate access; there are abandonments during the diagnosis and treatment process and there are patients who refuse observation. It is a heterogeneous group: those who went to the emergency room without any real urgency leave as soon as they realize that they will not immediately receive what they expected, perhaps the CT scan or the tests that they were unable to obtain due to waiting lists too long. Then there are those who behave opportunistically, and who after a certain amount of tests reassure themselves – or are reassured – about their conditions and decide to leave. And there are also those who, despite having a just cause for staying, prefer to leave the emergency room, just because they feel better. The fact that the data mainly involves PS from the South correlates with a greater inefficiency of local medicine and greater difficulty in accessing care. Translated: often not finding adequate answers from the general practitioner or in the clinics, citizens turn to the emergency room even for extremely banal problems that could easily be solved without any urgency. Also the data relating to “expectations”, where we mean the length of stay in the emergency room before admission or discharge, is in turn attributable, in the first case, to the availability of the bed or the operational efficiency of the hospital system: relating to services such as diagnostics, consultancy and transport made available to the EDs in the second case. The data from Agenas and the news are not mere alarmism: they are signs of a crisis that affects the right to health and the actual possibility of treatment. When a patient decides to leave the ED before the visit or during the procedure – as happens with rates higher than 20–25% in some hospitals – it is therefore not an individual problem, but a severe indicator of systemic failure. Waiting times for hospitalization that exceed 8 hours, 24 or even 48 hours they drastically reduce the quality of care, increase clinical risk and erode citizens’ trust in the public system. The inequalities between structures and territories, but also within the same metropolitan areas, show that “equal public healthcare for all” too often remains a promise, not a reality. For these reasons they are needed urgent and structural interventions: strengthening of staff, strengthening of local assistance (to avoid having to resort to the ED for non-urgent problems), improvement of governance, data transparency and periodic checks. Only in this way can we hope that the problems are not just reported, but resolved.
In today’s emergency rooms, waiting is healing. Often excellent
However, if we want to delve deeper into the concept that Agenas defines – in a reductive way – “waiting”, we need to clarify. In fact, one should not think that during the (often) too many hours in which the patient is in the emergency room he will simply come parked in a corner to -precisely- await his fate of hospitalization or discharge. In today’s emergency rooms, especially in level II DEAs which are also points of reference for time-dependent networks that treat heart attacks and strokes (and which work very well in Italy) the time spent by patients is used for a great deal of diagnosis and therapy, aimed at establishing a safe discharge or appropriate hospitalization. And all this, today, given the reduction in beds, is more necessary than ever: therefore if once the emergency room was little more than a sorting and filtering centre, it has now become a place where excellent diagnoses and treatments are carried out. It means that a diagnostic activity is carried out which previously, when there was ample availability of beds, was the exclusive prerogative of specialist departments, and which is now increasingly carried out in the emergency departments, where they work specialists trained specifically for this activity. Not taking this into account would be a mistake, at least a superficial one.
In the end, the emergency room remains the place where time takes on different forms: minutes that weigh like hours before taking charge, hours that expand into necessary or merely prudent observationspaths that are interrupted and others that are completed to the end. It is a suspended space, poised between urgency and system, between what should be there and what really is. And within this imperfect time, made of choices, uncertainties, fear and responsibilitythe distance – often silent – between the need for care and the ability to offer it is measured every day.
