Disparities in the potentially avoidable use of emergency services by citizenship: a two-year cross-sectional study in Italy

Avoidable emergency department (ED) access, though inconsistently defined and measured, is a major driver of both overcrowding and opportunity costs for healthcare systems. Among numerous factors associated with avoidable ED access, foreign citizenship has been increasingly recognized as an important predictor. Indeed, structural and administrative hurdles may prevent foreign citizens from accessing primary healthcare, making the ED a primary entry point for medical advice. This study aimed to investigate disparities in avoidable ED visits among foreign and Italian citizens in Liguria, the oldest region in Europe in terms of population age. In this cross-sectional study, all adult (≥ 18 years) ED visits registered in Liguria during 2023 and 2024 were eligible. Considering the lack of a standardized definition of avoidable ED visits, for the main analysis, we used both narrow (non-urgency only) and broad (non-urgency plus minor urgency) definitions based on the 5-level triage priority codes. Discharge severity codes were used in the sensitivity analysis. The association between citizenship and avoidable ED visits was quantified via modified Poisson regression. After adjusting for confounders, interaction terms were tested to evaluate effect variations. Of 916,568 ED visits recorded during the study period, 14.08% involved foreign citizens. Across both definitions, foreign citizens had higher prevalence ( P < 0.001) of potentially avoidable ED visits, with the narrow definition showing a nearly two-fold difference (9.97% vs. 4.40%) and the broad definition similarly reflecting a significant disparity (54.22% vs. 41.58%). In the multivariable analysis, the prevalence ratio for foreign versus Italian citizenship was 1.669 (95% CI: 1.600–1.741) for the narrow outcome definition and 1.073 (95% CI: 1.062–1.085) for the broad definition of avoidable ED access. Furthermore, there was a significant three-way interaction between citizenship, sex, and age, with younger foreign males showing the highest prevalence. These results were robust in the sensitivity analysis. Foreign citizens, especially younger males, are at higher risk of avoidable ED access. To mitigate these disparities, policymakers should move beyond generalized approaches towards migrant-sensitive interventions tailored to specific socio-demographic intersections.