Considering that hospitalizations in internal medicine wards are around one million a year and that at least half of these are over 70. And also taking into account that well over 50% of these extend their hospitalization by a week on average beyond what is necessary health care, in total there would be 2.1 million excess days of hospitalisation. A number which significantly affects the clogging of hospitals and which, considering the average cost of a day of hospitalisation, equal to 712 euros according to OECD data, make a total of one and a half billion a year of expenditure that could have been invested in real health care
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It is the burden that unduly falls on public health due to the shortcomings of the social assistance system, but also of the territorial health services that are poorly equipped to take care of these patients. The survey conducted in 98 facilities indicates that from the date of discharge indicated by the doctor to the actual date of exit, more than a week passes in 26.5% of cases, from 5 to 7 days in 39.8% of patients, while another 28, 6% stay two to four days longer than necessary.
The reason? 75.5% of elderly patients remain in hospital improperly because they have no family member or caregiver able to assist them at home, while for 49% there is no possibility of entering an RSA. 64.3% extend hospitalization beyond what is necessary because there are no intermediate health facilities in the area while 22.4% have difficulty activating the Adi. And all this has a cost for the NHS of around one and a half billion a year.
Our hospitals are so full that patients in stretchers pile up in the emergency rooms for days without finding a place in the ward. Because beds and staff have been cut over the years. But also due to the fact that half of the hospitalizations concern patients over 70 and in over 50% of cases they stay in the ward about a week longer than necessary, given that they do not have a family member who can assist them and that they do not even have such a pension rich enough to be able to pay the approximately two thousand euros of monthly tuition for an RSA. Not to mention the fact that in most cases there is a lack of intermediate healthcare structures in the area, and that in one out of four cases it is difficult to activate the ADI, the integrated home assistance.
A survey conducted by Fadoi, the scientific society of internal medicine, on 98 hospital facilities scattered along the all Italy.
Considering that hospitalizations in internal medicine wards are around one million a year and that at least half of these are over 70. And also taking into account that well over 50% of these extend their hospitalization by a week on average beyond what is necessary health care, in total there would be 2.1 million excess days of hospitalisation. A number which significantly affects the clogging of hospitals and which, considering the average cost of a day of hospitalisation, equal to 712 euros according to OECD data, make a total of one and a half billion a year of expenditure that could have been invested in real health care.
Let’s start with the age of the patients. In the Internal Medicine departments – but the situation does not change much in the other departments – more than half of the over 70s are in 87.8% of the structures. There are also many people over eighty, who are over half in 17.3% of the structures, between 40 and 50% in 20.4% of cases, between 30 and 40% in 24.5% of wards. However, do not think of internal medicines as parking lots for the elderly alone. Those who are hospitalized are in fact complex patients, who in 80.6% of cases still require more than seven days of hospitalization to be adequately treated, so much so that they require a high intensity of care in 28.6% of cases, the average for 69.4%. Numbers that should make us think about the classification of internal medicines as low-intensity care departments. The problem is that when the same doctor arranges for the patient to be discharged, that date never corresponds with the actual discharge date. In fact, these last for more than a week in 26.5% of cases, from 5 to 7 days in 39.8% of patients, while another 28.6% stay longer than necessary for two to four days.
The same survey launched by Fadoi shows why. 75.5% of elderly patients remain in hospital improperly because they have no family member or caregiver able to assist them at home, while for 49% there is no possibility of entering an RSA. 64.3% extend hospitalization beyond what is necessary because there are no intermediate health facilities in the area while 22.4% have difficulty activating the Adi. In other words, a mix between a lack of social assistance and a failure to take charge of local health services and structures.
Once discharged, 24.5% of patients over 70 go directly home, 41.8% however having at least activated home assistance. 15.3% end up in an RSA, 18.4% in an intermediate structure.
“What the survey reveals is what we unfortunately experience first-hand on a daily basis, i.e. the need to take on social problems that end up weighing unduly on hospitals and internal medicine departments in particular”, he comments Francesco Dentali, who from 1 January became the new President of Fadoi. “It is a picture that should make us reflect on our social assistance system, which according to the Cnel Observatory for services employs just 0.42% of GDP, while according to INPS data over 25 billion are disbursed in the form of allowances, such as carer’s or disability allowances. This without considering the 3.4 billion disbursed directly by the Municipalities. An inverse system to that adopted by many countries, above all in Northern Europe, where the optimization of available resources passes through a greater investment in personal assistance services. It being understood – concludes Dentali – that there is also an evident lack of intermediate territorial health services, because we are still talking about patients who, at the time of admission to our wards, need a medium or high intensity of care”.
In this regard, the new Ministerial Decree 77 on the reform of primary care should intervene, which identifies these intermediate structures in community hospitals, places where those patients who no longer need ordinary hospitalization but who cannot be assisted at home should be assisted.
For the outgoing president of Fadoi, Dario Manfellotto, “recipes like community houses and community hospitals are old. These are models that we have already defined and tested but which often don’t work and we have seen it for example with Covid. They had also been present for years in some regional health plans, such as that of Lazio for example. And it doesn’t seem to me that there was a greater ability to deal with the pandemic, for example, where the Health Homes were present. Strengthening the territory does not mean disseminating Italy with other bureaucratic structures, such as the more than 600 territorial operations centres, envisaged within the current districts.
Above all, we must aim to bring together the forces already in the field, which are many but without a director. It is necessary to have clear and simplified assistance pathways, avoiding creating additional obstacle courses for citizens and healthcare professionals, precisely in that “territory” which should facilitate treatment. And then, as usual, there is a bet on appropriateness, a reduction in hospitalizations and fewer visits to the emergency room. But it is a film already seen. For example, the home-territory-hospital-post-acute-rehabilitation-home connection should be well specified with strict and rigorous rules of engagement. The direction cannot be done by the bureaucrat of the territorial operations center but by a team of competent doctors and operators. And then a community hospital with almost total nursing management cannot work. In this Recovery, among other things, there is a reduction in the number of doctors and a ‘diminutio’ in the role of the doctor: this cannot be the future of healthcare”.
January 16, 2023
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