Hrev_master [page 22] [Emergency Care Journal 2014; 10:1896] Emergency department utilization rates and modalities among immigrant population. A 5-year survey in a large Italian urban emergency department Marcello Zinelli,1 Valentina Musetti,1 Ivan Comelli,1 Giuseppe Lippi,2 Gianfranco Cervellin1 1Emergency Department, Parma University Hospital; 2Laboratory of Clinical Chemistry and Hematology, Parma University Hospital, Italy Abstract The rates and modalities of healthcare serv- ices utilization for migrant population may dif- fer from natives, since the health needs of the former are influenced by some factors such as health status, self-perceived needs, health- seeking behavior, language barriers and cul- tural differences. Only scarce and often con- flicting data have been published so far on migrants’ utilization of healthcare services in Europe, and even less data are available on emergency departments (EDs). The aim of this cross-sectional study was to compare utiliza- tion rates and modalities of presentation to the large urban ED of the University Hospital of Parma, Italy (averaging 85,000 visits per year), by Italian native and foreign-born populations during 2008-2012. Throughout the study peri- od 424,466 ED visits were recorded, 64,435 (15.4%) of which by foreign-born patients. A significant difference between utilization rates was observed for all the triage-codes, with higher rates for foreign-born low-acuity codes (green plus white codes: 87.5 vs 73.9, P<0.0001) and lower rates for high-acuity codes (yellow plus red codes: 12.5 vs 26.1%, P<0.0001). The utilization rate was 253.9 vis- its per 1000 inhabitants for the Italian-native group and 309.7 per 1000 for the foreign-born group (odds ratio 1.23; 95% CI: 1.01-1.48; P=0.034). Different modalities of presentation were also observed, with a high rate of self- referrals (82.3 vs 71.4%, P<0.001). The results of this study suggest that a better knowledge of available Italian healthcare services among immigrants is advisable and should be encour- aged. Introduction The migrants currently account for approx 3% of the worldwide population. In Europe, the number of migrants has increased to 64.1 mil- lions between 1990 and 2005, and now accounts for nearly 9% of the entire popula- tion.1 One of the greatest challenges of migra- tion is represented by effective management of migrants’ health needs according to well estab- lished criteria of equity and appropriateness, since this increasing population represents a potentially vulnerable subset, which is exposed to a number of health risks before, during and after migration. For migrant populations, the rates and modalities of utilization of health- care services may significantly differ from natives, since the health needs of the former are influenced by a variety of factors, including health status, self-perceived needs, health- seeking behaviors, language barriers and cul- tural differences. This represents a substantial problem for first-generation migrants, where- as their offspring are usually more comfortable with the new social and healthcare organiza- tions. Italy has historically been a country of emi- gration since its birth, in 1861. After that year, in the first century, more than 24 million peo- ple have left the country searching better eco- nomic conditions, especially in United States of America and Latin America. In the 1913 only, nearly 900,000 people left Italy. A second emi- gration wave was recorded after the second world war, especially toward countries of mid- dle and northern Europe.2,3 Compared to other European countries like France and Great Britain, which experienced the immigration phenomenon during the early 1950s after the dissolution of their colonial empires, immigra- tion in Italy is a relatively recent phenomenon, which has began in 1970 and has constantly increased during the 1990s until its current predominant importance in the national sce- nario, with a foreign-born population of approx 4 million, thus representing nearly 7% of the entire Italian population.4 This process has been mainly propelled by the collapse of the Soviet Union, and the political instability in Northern Africa. Immigrants typically come to Italy as asylum seekers, legal immigrants, refugees, and irregular arrivals. It is obviously challenging to accurately estimate this last group, which predictably ranges between 10 to 18% of legally immigrant population. Figure 1 represents the main paths of immigration in Italy from different countries. The town of Parma (190,522 residents) and its province (447,251 inhabitants)5 is located in the Region of Emilia Romagna, in the north- western part of Italy, and is one of the richest and most economically developed areas of the country, which makes it a rather attractive site for many immigrants who are employed in industry, agriculture and services (i.e., espe- cially in the home care of the elderly). In the province of Parma the foreign-born population represents almost 13.5% (almost 15.7% in the town), of overall residents,5 and there are cur- rently immigrants from 137 countries living in the city area. The most important community is Moldavian, followed by Albanian, Rumanian, Moroccan and Tunisian.5 The Italian National Healthcare System (NHS), mainly funded by taxes, provides com- prehensive and uniform health care for the entire population, regardless of ability to pay and citizenship. In our Region the access to care is free for children under the age of 14, and for the poorest part of population, whereas co-payments (so-called tickets) are required for the general population. Emergency care is typically free of charge, although co-payments are issued for minor healthcare problems. However, the utilization of primary and spe- cialist care might present several challenges for immigrants, mainly including language barriers6,7 and lack of knowledge of the sys- tem’s organization (i.e., how to access these services).8 At present, only scarce and often contradictory data has been published on migrant’s utilization of healthcare services in Europe,9 and even less information is available on migrant’s utilization of Emergency Departments (EDs). In Copenhagen, for exam- ple, a higher ED utilization rate by persons born in Somalia, Turkey and ex-Yugoslavia has been reported, but not by other non-Western- native people.10 In the same region of Spain (i.e., Catalunya), two studies almost simulta- neously showed conflicting figures, i.e., an overall lower ED utilization rate by foreign- born residents was described in Barcelona (attributed to the so-called healthy immigrant effect),11 whereas immigrants from low- income countries used EDs more than the Spanish-born population in Lleida, with larger differences for Maghrebi populations and sub- Saharan women.12 In a rather different social context such as Israel, a lower rate of ED uti- Emergency Care Journal 2014; volume 10:1896 Correspondence: Gianfranco Cervellin, Emergency Department, Parma University Hospital, Via Gramsci 14, 43126 Parma, Italy. Tel. +39.0521.703800 - Fax: +39.0521.703144. E-mail: gcervellin@ao.pr.it Key words: immigrants, migrants, emergency department, triage, crowding. Received for publication: 27 August 2013. Revision received: 25 November 2013. Accepted for publication: 12 December 2013. This work is licensed under a Creative Commons Attribution 3.0 License (by-nc 3.0). ©Copyright M. Zinelli et al., 2014 Licensee PAGEPress, Italy Emergency Care Journal 2014; 10:1896 doi:10.4081/ecj.2014.1896 Non -co mmerc ial us e o nly [Emergency Care Journal 2014; 10:1896] [page 23] lization and hospitalization by immigrants was found, even after 10 years from migration.13 In Norway, work immigrants from Germany and Poland had a considerably lower use of the ED, while asylum seekers from Somalia and Iraq use these services more than Norwegians.14 Although high rates of ED use among migrants have been related to inadequate access to other services, a German study failed to find that migrant status was a predictor of inappro- priate utilization.15 Not surprisingly, the rela- tionships between migrants and health have been considered a cultural dilemma.16 In Italy, a retrospective survey based on 2005 Italian Health Conditions Survey, carried out by the Italian National Statistical Office (Istituto Nazionale di Statistica; ISTAT), showed a higher ED utilization rate by immi- grants, most notably from those born in Morocco, other African countries and Albania.17 The aim of the present study was to compare utilization rates and modalities of presenta- tion to the large urban ED of the University Hospital of Parma, Italy, by the Italian-native and foreign-born populations. Materials and Methods A cross-sectional study was planned to assess the utilization rates of Italian-native and foreign-born subjects, who visited the ED of the Academic Hospital of Parma (i.e., a 1250 bed, tertiary academic referral institution, averaging 85,000 visits per year), during the years 2008 to 2012, in a catchment area of about 325.000 inhabitants. The information source was the electronic database of the ED, containing information about age, gender, and country of birth, as well as triage color-coding (see below) and modality of presentation (i.e., self-referred vs referred by physician) to the ED. The Obstetric and Gynecology Department in our Hospital offers open access emergency care for pregnancy-related problems, and the Pediatric Department offers emergency care for children under age of 14, provided that they do not show trauma-related problems. The study population was divided into Italian- native and foreign-born, and then categorized according to the color-coding triage system. Large age groups were also partitioned. Immigrants (foreign-born) were defined as persons born outside Italy, whose parents were either foreign citizens or born outside the national territory. Both regular and irregular immigrants have been included. In accord with international and national criteria, all the patients were codified by a triage, nurse-driv- en, system.18-20 In our Region the triage system involves a color-coding protocol using red (level 1), yellow (level 2), green (level 3), and white (level 4) tags. To compare the difference of distributions between Italian-native and for- eign-born emergency accesses by color-code, as well as by modalities of presentation, a chi- squared test was used. Statistical analysis was performed with Mathematica 7® software (Wolfram, Champaign, IL, USA). Results A total of 424,466 visits were recorded in the ED between years 2008 and 2012, 64,435 (15.4%) of which by foreign-born patients coming from as many as 137 different coun- tries. A small group of patients coming from European Economic Community countries and North America (i.e., USA, Canada), accounting for 1676 subjects, and obviously not carriers of the aforementioned problems, does not impact on the accuracy of evaluation. The distribution of ED visits among Italian-born and foreign- born subjects by color tags in years 2008-2012 is shown in Table 1. A significant difference between utilization rates by Italian-born and foreign-born was observed for all the triage- codes considered, with higher rate by foreign- born low-acuity codes (green plus white codes: 87.5 vs 73.9%, P<0.0001) and lower for high- acuity codes (yellow plus red codes: 12.5 vs 26.1%, P<0.0001). The difference was substan- tially the same when considering the younger age groups (i.e., age group 15-50 y, green plus white codes: 75.8% Italians vs 88.6% foreign- born; yellow plus red codes: 24.2% Italians vs 11.4% foreign-born; age group 50-64 y, green plus white codes: 71.7% Italians vs 85.9% for- eign-born; yellow plus red codes: 28.3% Italians vs 14.1% foreign-born), whereas in the age group of 65 y or older the differences were smaller (i.e., green plus white codes: 68.6% Italians vs 72.3% foreign-born; yellow plus red codes: 31.4% Italians vs 27.7% foreign-born). It is noteworthy, however, that very few foreign- born patients aged 65 y or older were visited, when compared with the Italian citizens of the same age group, thus reflecting the consisten- cy of the migrant population. Considering a catchment area of 325,000 Article Table 1. Distribution of emergecy department visits among Italian-native and foreign- born subjects by color tags in 2008-2012. Color tags Total (%) Italian-native (%) Foreign-born (%) Chi squared test Total 424,466 359,031 (84.6) 65,435 (15.4) Red 13,986 (3.3) 13,292 (3.7) 694 (1.1) 1212.08 P<0.0001 Yellow 87,770 (20.7) 80,282 (22.4) 7488 (11.4) 4021.92 P<0.0001 Green 291,940 (68.8) 243,685 (67.9) 48,255 (73.7) 88.71 P<0.0001 White 30,770 (7.2) 21,779 (6.1) 8991 (13.7) 789.50 P<0.0001 Figure 1. Migration routes to Italy. Non -co mmerc ial us e o nly [page 24] [Emergency Care Journal 2014; 10:1896] inhabitants, the ratio of total number of ED visits divided by total population produced an overall utilization rate for the entire popula- tion of 261.2 emergency contacts per 1000 per- sons per year throughout the observational period. The utilization rate was 253.9 visits per 1000 inhabitants for the Italian-native group, and 309.7 per 1000 for the foreign-born group (odds ratio 1.23; 95% CI: 1.01-1.48; P=0.034). The modality of presentation to the ED was also assessed after clustering the study popula- tion into two large categories, the former including subjects who were referred by a physician (i.e. general practitioner), and the latter consisting of self-referrals. The results, which are presented in Table 2, show a signif- icantly difference in modalities of presentation of foreign-born immigrants and Italian- natives, being 82.3 vs 71.4% for self-referral, and 17.6 vs 28.6% (P<0.001) for physician- referral, respectively. The distribution of ED visits among Italian- native and foreign-born subjects, divided by age groups, is shown in Table 3, and displays a large prevalence, among the immigrants, of younger people, and a very poor representation of the oldest group. During night shifts (i.e., 10 p.m. to 6 a.m.) we recorded an average of 28.3% of all visits, with a peak between 10 p.m. and 1 a.m. (i.e., 93% of the entire group). The zenith of night- shift visits was recorded during Sunday nights (32%), and the nadir during Monday nights (25.1%). There were no significant differences between percentages of immigrants and resi- dents attending ED during day shifts and night shifts (i.e., day shifts: 85.4% residents vs 14.6% immigrants; night shifts: 84.1% resi- dents vs 15.9% immigrants; P, not significant). Discussion An equal, safe and appropriate utilization of healthcare resources are paradigms of all mod- ern NHSs. To the best of our knowledge, this is the first study that has assessed ED utilization rate and modality among immigrant popula- tion in Italy. Other reports have focused on specific populations or problems such as pedi- atric EDs or women and contraception.17,21 One of the most relevant information that has emerged from this cross-sectional investi- gation is represented by the high rate of access to our ED for non-urgent or semi-urgent med- ical problems (i.e., green and white codes), for both the Italian-native and the foreign-born population, despite a significantly greater uti- lization for the latter. In recent years, EDs have evolved to provide not only acute emer- gency care, but also safety net care for a grow- ing population and situations that were previ- ously managed by primary healthcare facili- ties. The obvious consequence is an over- crowding of EDs, with an increased risk for patient safety, delays in providing treatment and compromised privacy, amongst others.22-26 Indeed, one limitation of this study is the selection of the study population, where migrants have been only defined according to the Country of birth. This information is prob- ably insufficient to describe such a multifac- eted population and other aspects should be considered, such as type of migration (e.g., forced versus voluntary), citizenship, socio- economic and demographic status along with duration of stay in Italy, all factors that may impact on health needs and access issues.9,27,28 In our study, we classified the number of visits and not the number of subjects, since there is a number of frequent users of ED (the so- called frequent-attenders), who are typically homeless people, drug and alcohol abusers, and those with complex medical and social conditions, and this may be another limitation. Due to the characteristics of our database, which recognizes the Country of birth, there is a inherent under-estimation of immigrants group, because the subjects born in Italy from foreign parents, the so-called second genera- tion immigrants, are inevitably lost. Data derived from instruction institutions indicate that subjects born in Parma from foreign par- ents represent about 75% of foreign pupils in nursery school and 47% in primary school.29 In their study Grassino et al. observed that 51.2% of foreign patients seen in a pediatric ED were born in Italy.21 It is also acknowledged that some groups, in particular Chineses, prefer to obtain healthcare in an out-of-hospital con- text, most notably from traditional Chinese medicine,9,27 although the Parma Chinese pop- ulation accounts for less than 1% of the immi- grant population, and does not represent a sta- tistical confounding factor. In analogy with other reports,11 our data seems to confirm the existence of the so-called healthy immigrant effect. It is clear that a young population is usually unaffected by chronic diseases that more typically character- ize the elderly (i.e. cardiovascular and respira- tory disorders, malignancies, and other chron- ic conditions). On the other hand, we have also observed the so called family rejoining phe- nomenon in recent years, with arrival of immi- grants’ spouses and children, but also parents, thus increasing the median age and generat- ing a previously unknown elderly immigrant population. We also observed a statistically sig- nificant difference between the two groups regarding the color-code tags and the modality of access to the ED. We can explain this obser- vation by a poor knowledge by immigrants of how to access primary healthcare services in Italy, with consequent under-utilization of resources different from the ED. This is clear- ly reflected by the modality of presentation to the ED, wherein a very high rate of self-refer- rals was found in the immigrant group, maybe due to the lack of knowledge about access to primary and specialist care services. Overall, this aspect may account for the large percent- age of minor color-codes (i.e., white and green) among this population. Conclusions In conclusion, we observed a higher rate of utilization of the ED by the immigrant popula- tion, with a consequent increasing risk of over- crowding. The most reasonable solution entails a better knowledge of access to servic- es offered by the Italian NHS, along with other different areas of potential intervention, including educational leaflets about the health Article Table 2. Distribution of emergency department visits among Italian-native and foreign- born subjects, divided by modality of presentation in years 2008-2012. Modality Total Italian-native Foreign-born Chi squared of presentation (%) (%) (%) test Self-referral 310100 (73.06) 256213 (71.4) 53887 (82.5) 3395 P<0.0001 Referred by physician 114366 (26.94) 102818 (28.6) 11548 (17.6) Total 424466 359031 (84.6) 65435 (15.4) Table 3. Distribution of emergecy department visits among Italian-native and foreign- born subjects, divided by age groups, in 2008-2012. Age tags Italian-native (%) Foreign-born (%) Chi squared test Total (%) 0-14 (only trauma) 21,658 (6.0) 3560 (5.4) 34.69 P<0.0001 25,218(5.9) 15-50 157,644 (43.9) 53,965 (82.5) 32,923.33 P<0.0001 211,609 (49.8) 51-64 51,926 (14.5) 5621 (8.6) 1628.75 P<0.0001 57,547 (13.6) >65 127,803 (35.6) 2289 (3.5) 26,829.03 P<0.0001 130,092 (30.6) Non -co mmerc ial us e o nly [Emergency Care Journal 2014; 10:1896] [page 25] system placed in schools, places of worship, shops owned by immigrants, and meetings with different communities, which should be encouraged to promote better knowledge through education. Translators and multilin- gual leaflets concerning health problems should also be available in the ED, to help resolve the language and cultural barriers, along with the use of multilingual displays. References 1. United Nations. International migration and development. Report of the Secretary- General. New York, NY: United Nations ed.; 2006. 2. Bevilacqua P, De Clementi A, Franzina E. 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J Health Serv Res Po 2005;10:77-83. 29. Public School Administration of Emilia- Romagna Region. Available from: http: //www.scuolaer.it/scuola_cifre/default.aspx Article Non -co mmerc ial us e o nly