Emergency Department Departures: Untangling the Complexities of Early Exits in a Large Italian region
DOI:
https://doi.org/10.54103/2282-0930/28754Keywords:
Emergency Department, Early Emergency Department Departure, Healthcare Access, Patient Decision-making, Emergency Department EfficiencyAbstract
Leaving Emergency Departments (ED) early is an important failure of these structures, constituting a risk for the health of the people who renounce the benefits of such healthcare, and a cost to the countries that finance healthcare service for their citizens. In order to implement actions to reduce the extent of this failure, an understanding of the characteristics of patients who leave EDs early is needed. This research scrutinizes the determinants of early ED departure in the hospitals of the region of Campania, Italy, where around a tenth of the Italian population lives. We adopt a quantitative framework, utilizing a novel robust dataset of about 1,000,000 observations, employing both Probit and Logit estimators. Our analysis reveals that factors including being a woman, having Italian citizenship, arriving by ambulance, severity of condition, and reporting a trauma, are associated with decreased probability of premature ED departure, while residing in high-income municipalities and being under 65 correlate with an increased likelihood of early leaving. The value of this information for policymakers and healthcare providers is discussed.
Downloads
References
1. Scaletti, A. (2014). Evaluating investments in health care systems: health technology assessment. Springer. DOI: https://doi.org/10.1007/978-3-319-02544-5
2. Hardin, G. (1968). The Tragedy of the Commons. Science, 162(3859): 1243–1248. http://www.jstor.org/stable/1724745 DOI: https://doi.org/10.1126/science.162.3859.1243
3. Wendt, C., Frisina, L., Rothgang, H. (2009). Healthcare system types: A conceptual framework for comparison. Social Policy & Administration, 43(1): 70–90. DOI: https://doi.org/10.1111/j.1467-9515.2008.00647.x
4. Böhm, K., Schmid, A., Götze, R., Landwehr, C., Rothgang, H. (2013). Five types of OECD healthcare systems: Empirical results of a deductive classification. Health Policy, 113(3): 258–269. DOI: https://doi.org/10.1016/j.healthpol.2013.09.003
5. France, G., Taroni, F., Donatini, A. (2005). The Italian Healthcare System. Health Economics, 14 (S1): S187-S202. DOI: https://doi.org/10.1002/hec.1035
6. Hangoma, P., Robberstad, B., Aakvik, A. (2018). Does Free Public Health Care Increase Utilization and Reduce Spending? Heterogeneity and Long Term Effects. World development, 101: 334-350. DOI: https://doi.org/10.1016/j.worlddev.2017.05.040
7. Xu, K., Evans, D. B., Kawabata, K., Zeramdini, R., Klavus, J., Murray, C. J. (2003). Household catastrophic health expenditure: a multicountry analysis. The lancet, 362(9378): 111-117. DOI: https://doi.org/10.1016/S0140-6736(03)13861-5
8. Azzani, M., Roslani, A.C., Su, T.T. (2019). Determinants of Household Catastrophic Health Expenditure: A Systematic Review. Malaysian Journal of Medical Science, 26(1): 15-43. DOI: https://doi.org/10.21315/mjms2019.26.1.3
9. Griffin, C.C. (1988). User Charges for Health Care in Principle and Practice, An EDI discussion paper, 37, World Bank, Washington DC.
10. Hurley, J. (2013). User charges for health care services: some further thoughts. Health Economics, Policy and Law, 8: 537-541. DOI: https://doi.org/10.1017/S1744133113000297
11. Gwatkin, D.R. (2004). Are free government health services the best way to reach to poor? Health, Nutrition and Population (HNP) discussion paper, World Bank, Washington, DC. DOI: https://doi.org/10.1596/13720
12. Hsia, R. Y., Asch, S. M., Weiss, R. E., Zingmond, D., Liang, L. J., Han, W., McCreath, H., Sun, B. C. (2011). Hospital determinants of emergency department left without being seen rates. Annals of emergency medicine, 58(1): 24-32. DOI: https://doi.org/10.1016/j.annemergmed.2011.01.009
13. Mataloni, F., Colais, P., Galassi, C., Davoli, M., Fusco, D. (2018) Patients who leave Emergency Department without being seen or during treatment in the Lazio Region (Central Italy): Determinants and short term outcomes. PLoS ONE 13(12): e0208914. DOI: https://doi.org/10.1371/journal.pone.0208914
14. Carmel, A., Amital, H., Shemer, Y., Sahar, A. (1998). Why do they leave? Clinical characteristics of patients who leave the emergency room against medical advice. Harefuah, 134(6): 445-449, 503.
15. Fernandes, C.M., Daya, M.R., Barry, S., Palmer, N. (1994). Emergency department patients who leave without seeing a physician: the Toronto Hospital experience. Annals of emergency medicine, 24(6): 1092-6. DOI: https://doi.org/10.1016/S0196-0644(94)70238-1
16. Fry, M., Thompson, J., Chan, A.C. (2004). Patients regularly leave emergency departments before medical assessment: A study of did not wait patients, medical profile and outcome characteristics. Australian Emergency Nursing Journal, 6: 21-26. DOI: https://doi.org/10.1016/S1328-2743(04)80111-1
17. Lee, K.M., Wong, T.W., Chan, R.P., Lau, C.C. (1998). A study of patients who leave without notice in an A & E department. Accident and emergency nursing, 6(2): 118-121. DOI: https://doi.org/10.1016/S0965-2302(98)90012-1
18. Lerner, B.H. (1992). Patients leaving emergency departments without being seen by a physician. JAMA, 267 2, 231-2. DOI: https://doi.org/10.1001/jama.1992.03480020041016
19. Weiss, S. J., Derlet, R., Arndahl, J., Ernst, A. A., Richards, J., Fernández-Frackelton, M., ... Levy, D. (2010). Estimating the degree of emergency department overcrowding in academic medical centers: Results of the National ED Overcrowding Study (NEDOCS). Academic Emergency Medicine, 11(1): 38–50. DOI: https://doi.org/10.1197/j.aem.2003.07.017
20. Rowe, B. H., Channan, P., Bullard, M., Blitz, S., Saunders, L. D., Rosychuk, R. J., ... Holroyd, B. R. (2006). Characteristics of patients who leave emergency departments without being seen. Academic Emergency Medicine, 13(8): 848–852. DOI: https://doi.org/10.1197/j.aem.2006.01.028
21. Mohsin, M., Forero, R., Ieraci, S., Bauman, A. E., Young, L., Santiano, N., ... Jorm, L. (2007). A population follow-up study of patients who left an emergency department without being seen by a medical officer. Emergency Medicine Journal, 24(3): 175–179. DOI: https://doi.org/10.1136/emj.2006.038679
22. Mahmoudian-Dehkordi, A., Sadoughi, F., Sheikhtaheri, A. (2020). Reasons for patients leaving emergency departments against medical advice: A cross-sectional study in Iran. BMJ Open, 10(1): e031240.
23. Liao, H.C., Liaw, S.J., Hu, P., Lee, K., Chen, C., Wang, F. (2002). Emergency department patients who leave without being seen by a doctor: the experience of a medical center in northern Taiwan. Chang Gung medical journal, 25(6): 367-373.
24. Khanna, R., Chaudhry, M., Prescott, M.V. (1999). Emergency department patients who leave the department without being seen by a doctor. European journal of emergency medicine: official journal of the European Society for Emergency Medicine, 6(3): 233-235. DOI: https://doi.org/10.1097/00063110-199909000-00011
25. Campagna, S., Borraccino, A., Politano, G., Benso, A., Dalmasso, M., Dimonte, V., Gianino, M.M. (2021). Determinants Associated With the Risk of Emergency Department Visits Among Patients Receiving Integrated Home Care Services: A 6-Year Retrospective Observational Study in a Large Italian Region. International Journal of Health Policy Management, 10 (10): 605-612. DOI: https://doi.org/10.34172/ijhpm.2020.79
26. Di Laura, D., D’Angiolella, L., Mantovani, L., Squassabia, G., Clemente, F., Santalucia, I., Improta, G., Triassi, M. (2021). Efficiency measures of emergency departments: an Italian systematic literature review. BMJ Open Qual., 10(3): e001058. DOI: https://doi.org/10.1136/bmjoq-2020-001058
27. Agovino, M., Musella, G., Pisano, S., Scaletti, A. (2021). Assessing the impact of tourist flows on emergency department treatment speed for residents and tourists. The case of Sorrento. Socio-Economic Planning Science, 77: 101004. DOI: https://doi.org/10.1016/j.seps.2020.101004
28. Cameron, A. C., Trivedi, P. K. (2010). Microeconometrics Using Stata. Rev. ed. College Station, TX: Stata Press.
29. Long, J. S. (1997). Regression Models for Categorical and Limited Dependent Variables. Thousand Oaks, CA: SAGE.
30. Pampel, F. C. (2000). Logistic Regression: A Primer. Thousand Oaks, CA: SAGE. DOI: https://doi.org/10.4135/9781412984805
31. Powers, D. A., Xie, Y. (2008). Statistical Methods for Categorical Data Analysis. 2nd ed. Bingley, UK: Emerald.
32. Eckel, C. C., Grossman, P. J. (2008). Men, women and risk aversion: Experimental evidence. Handbook of experimental economics results, 1: 1061-1073. DOI: https://doi.org/10.1016/S1574-0722(07)00113-8
33. Palumbo, R., Annarumma, C., Adinolfi, P., Musella, M., Piscopo, G. (2016a). The Italian Health Literacy Project: Insights from the assessment of health literacy skills in Italy, Health Policy, 120 (9): 1087-1094. DOI: https://doi.org/10.1016/j.healthpol.2016.08.007
34. Cognetti, G., Poltronieri, E., De Castro, P., Scarinci, V., Perilli, R. (2019). Searching health information on the Internet: results of a survey in a cohort of 414 elderly people in Italy, Journal Medical Internet Research Preprints. 04/08/2019:15760
35. Velasco, V., Gragnano, A., Gruppo Regionale HBSC Lombardia 2018, Vecchio, L.P. (2021). Health Literacy Levels among Italian Students: Monitoring and Promotion at School. International Journal Environmental Research and Public Health, 18: 9943. DOI: https://doi.org/10.3390/ijerph18199943
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2025 Vincenzo Alfano, Alessandro Scaletti

This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.
Accepted 2025-05-22
Published 2025-06-09


