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  • Indirect impact of the COVID-19 pandemic and its containment measures on social inequalities in hospital utilisation in Italy

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Original research
Indirect impact of the COVID-19 pandemic and its containment measures on social inequalities in hospital utilisation in Italy
  1. Chiara Di Girolamo1,
  2. Roberto Gnavi2,
  3. Tania Landriscina2,
  4. Silvia Forni3,
  5. Manuele Falcone3,
  6. Enrico Calandrini4,
  7. Giulia Cesaroni4,
  8. Antonio Russo5,
  9. Olivia Leoni6,
  10. Caterina Fanizza7,
  11. Alessandra Allotta8,
  12. Giuseppe Costa9,
  13. Teresa Spadea2
  14. the MIMICO-19 working group
    1. 1 Regional Health and Social Care Agency Emilia-Romagna Region, Bologna, Italy
    2. 2 Epidemiology Unit, ASL TO3 Piedmont Region, Turin, Italy
    3. 3 Regional Health Agency of Tuscany Region, Florence, Italy
    4. 4 Department of Epidemiology, Regional Health Service Lazio, Rome, Italy
    5. 5 Epidemiology Unit, Agenzia di Tutela della Salute della Citta Metropolitan di Milano, Milan, Italy
    6. 6 Regional Health Ministry, Milan, Italy
    7. 7 Regional Healthcare Agency of Puglia Region, Bari, Italy
    8. 8 Department of Health and Epidemiological Observatory, Regional Health Authority of Sicily Region, Palermo, Italy
    9. 9 Department of Clinical and Biological Science, University of Turin, Turin, Italy
    1. Correspondence to Dr Chiara Di Girolamo, Regional Health and Social Care Agency Emilia-Romagna Region, Bologna 40127, Italy; chiara.digirolamo{at}regione.emilia-romagna.it

    Abstract

    Background The pandemic may undermine the equity of access to and utilisation of health services for conditions other than COVID-19. The objective of the study is to evaluate the indirect impact of COVID-19 and lockdown measures on sociodemographic inequalities in healthcare utilisation in seven Italian areas.

    Methods In this multicentre retrospective study, we evaluated whether COVID-19 modified the association between educational level or deprivation and indicators of hospital utilisation and quality of care. We also assessed variations in gradients by sex and age class. We estimated age-standardised rates and prevalence and their relative per cent changes comparing pandemic (2020) and pre-pandemic (2018–2019) periods, and the Relative Index of Inequalities (RIIs) fitting multivariable Poisson models with an interaction between socioeconomic position and period.

    Results Compared with 2018–2019, hospital utilisation and, to a lesser extent, timeliness of procedures indicators fell during the first months of 2020. Larger declines were registered among women, the elderly and the low educated resulting in a shrinkage (or widening if RII <1) of the educational gradients for most of the indicators. Timeliness of procedures indicators did not show any educational gradient neither before nor during the pandemic. Inequalities by deprivation were nuanced and did not substantially change in 2020.

    Conclusions The socially patterned reduction of hospital utilisation may lead to a potential exacerbation of health inequalities among groups who were already vulnerable before the pandemic. The healthcare service can contribute to contrast health disparities worsened by COVID-19 through more efficient communication and locally appropriate interventions.

    • COVID-19
    • EPIDEMIOLOGY
    • Health inequalities

    Data availability statement

    Data are available upon reasonable request. The health administrative databases which are the data sources of this study are not publicly available; the unidentifiable aggregated data will be available from the corresponding author upon reasonable request.

    This article is made freely available for personal use in accordance with BMJ’s website terms and conditions for the duration of the covid-19 pandemic or until otherwise determined by BMJ. You may use, download and print the article for any lawful, non-commercial purpose (including text and data mining) provided that all copyright notices and trade marks are retained.

    https://bmj.com/coronavirus/usage

    https://doi.org/10.1136/jech-2021-218452

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      Data availability statement

      Data are available upon reasonable request. The health administrative databases which are the data sources of this study are not publicly available; the unidentifiable aggregated data will be available from the corresponding author upon reasonable request.

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      Footnotes

      • Collaborators The MIMICO-19 working group: Teresa Spadea (Epidemiology Unit ASL TO3, Piedmont Region, Turin, Italy), Roberto Gnavi (Epidemiology Unit ASL TO3, Piedmont Region, Turin, Italy), Tania Landriscina (Epidemiology Unit ASL TO3, Piedmont Region, Turin, Italy), Roberta Onorati (Epidemiology Unit ASL TO3, Piedmont Region, Turin, Italy), Alessandro Migliardi (Epidemiology Unit ASL TO3, Piedmont Region, Turin, Italy), Giuseppe Costa (Epidemiology Unit ASL TO3, Piedmont Region, Turin, Italy), Olivia Leoni (Regional Epidemiological Observatory, Lombardy Region, Milan, Italy), Michele Ercolanoni (Regional Epidemiological Observatory, Lombardy Region, Milan, Italy), Chiara Di Girolamo (Regional Health and Social Care Agency of Emilia-Romagna Region, Bologna, Italy), Elena Berti (Regional Health and Social Care Agency of Emilia-Romagna Region, Bologna, Italy), Nicola Caranci (Regional Health and Social Care Agency of Emilia-Romagna Region, Bologna, Italy), Maria Luisa Moro (Regional Health and Social Care Agency of Emilia-Romagna Region, Bologna, Italy), Silvia Forni (Regional Health Agency of Tuscany Region, Florence, Italy), Valeria Di Fabrizio (Regional Health Agency of Tuscany Region, Florence, Italy), Sara D'Arienzo (Regional Health Agency of Tuscany Region, Florence, Italy), Fabrizio Gemmi (Regional Health Agency of Tuscany Region, Florence, Italy), Paola Colais (Department of Epidemiology, Regional Health Service, Lazio Region, Rome, Italy), Luigi Pinnarelli (Department of Epidemiology, Regional Health Service, Lazio Region, Rome, Italy), Mariangela D'Ovidio (Department of Epidemiology, Regional Health Service, Lazio Region, Rome, Italy), Maria Balducci (Department of Epidemiology, Regional Health Service, Lazio Region, Rome, Italy), Marina Davoli (Department of Epidemiology, Regional Health Service, Lazio Region, Rome, Italy), Caterina Fanizza (Regional Healthcare Agency of Puglia Region, Bari, Italy), Vito Petrarolo (Regional Healthcare Agency of Puglia Region, Bari, Italy), Giulia Piepoli (Regional Healthcare Agency of Puglia Region, Bari, Italy), Lucia Bisceglia (Regional Healthcare Agency of Puglia Region, Bari, Italy), Alessandra Allotta (Department of Health Services and Epidemiological Observatory, Sicily Region, Palermo, Italy), Achille Cernigliaro (Department of Health Services and Epidemiological Observatory, Sicily Region, Palermo, Italy), Salvatore Scondotto (Department of Health Services and Epidemiological Observatory, Sicily Region, Palermo, Italy).

      • Contributors CDG, TS, RG and GCo designed the study. CDG conducted the analysis and drafted the first version of the manuscript and is responsible for the overall content as guarantor. RG and TS contributed to subsequent versions. CDG, TL, SF, MF, EC, GCe, AR, OL, CF and AA were involved in the data collection and preparation at local level. All authors were involved in critically revising the manuscript and approving the final version.

      • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

      • Competing interests None declared.

      • Provenance and peer review Not commissioned; externally peer reviewed.

      • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.