Objectives

Waiting times in healthcare are a major policy concern in many OECD countries. As healthcare systems suffer from long waits in key areas, the relationship between waiting times for medical treatments and patient outcomes is widely debated in the literature. High levels of crowding at Emergency Departments (EDs), long waiting lists for elective hospital treatments, specialist visits or diagnostic tests may all lead to delays in treatment with potentially harmful consequences on patients' health, particularly for time-sensitive surgical conditions.

However, the identification of a causal relationship between treatment delays and patient outcomes is hard to establish. The challenge arises from the endogeneity of individual waiting times, which are determined by patient prioritization based on severity. This creates a spurious negative correlation between waiting times and mortality, as more severe patients receive priority treatment while having higher mortality risk. Consequently, naive regression approaches would incorrectly suggest that longer waiting times are protective of patients’ health, which is clinically implausible.

Methods

We analyze 170,332 patients requiring urgent surgical intervention admitted to EDs in Emilia-Romagna over 2018-2019. To identify time-sensitive cases, we employ the Timing in Acute Care Surgery (TACS) classification, which provides standardized priority levels based on the available clinical evidence. We focus on patients with TACS classifications indicating conditions requiring surgery within 6 hours at the latest.

To address the endogeneity problem, we develop an instrumental variables strategy that exploits quasi-random variation in emergency department congestion at the time of patient arrival. We construct two congestion measures at the ED-time slot level, relative to their averages: (i) the number of patient arrivals, and (ii) aggregate waiting times. These instruments capture the imbalance between patient demand and available resources while being exogenous to individual patient characteristics. We examine mortality outcomes across multiple time horizons.

Results and discussion

Our study reveals a striking reversal when addressing endogeneity. While naive estimates suggest waiting times reduce mortality, properly instrumented estimates show that longer waiting times significantly increase mortality. The results are robust to multiple validation tests. Placebo tests using future congestion measures as instruments yield statistically insignificant estimates, while analysis of low-severity patients shows no effect of waiting times on mortality, as expected. An analysis of patients over 65 years yields qualitatively similar results to the main findings.

These findings provide causal evidence on the relationship between emergency department waiting times and patient mortality for urgent surgical case and bear important policy implications for hospital resource allocation, highlighting the critical importance of minimizing treatment delays for time-sensitive medical conditions in the context of public healthcare systems.

Acknowledgements

The research is funded by the European Union-NextGenerationEU within the Italian project Age-It.

Italy, with one of the highest aging rates in the world, is facing increasing pressure on its care and assistance systems. The sustainability of the aging population care is a complex issue that may benefit from a systemic approach that takes into account the wide variety of phenomena at play and their interrelationships in an articulated manner. Future Literacy and growing awareness of Foresight offer a framework for strategic thinking and proactive action, and has the potential to address this issue with an innovative and forward-looking perspective. Backcasting, which starts from a desired vision of the future and works backwards to identify the actions needed to achieve it, may be a useful tool to address this challenge. In this work, I will present the process and results of a Backcasting exercise carried out with a group of experts involved in various aspects of population aging, exploring the theme of Aging in Place. A common theme emerging from these future-oriented exercises is the need for a cultural shift toward social and cultural accountability for the future and the adoption of renewed social practices.

This study investigates the determinants of municipal welfare expenditure for elderly across Italian municipalities between 2014 and 2020—a period marked by accelerated population ageing, evolving welfare priorities, and persistent territorial inequalities. While total welfare spending increased nationally, the share allocated to the elderly declined despite a growing population over 65. Notably, Inner Areas—though initially more dedicated to elder care—experienced the sharpest reductions. The analysis focuses on two key indicators: (i) the share of welfare spending directed to older adults, and (ii) per capita expenditure on elder services. These outcomes are examined in relation to demographic, socioeconomic, geographical, and political-institutional factors, including mayoral characteristics and the composition of the local executive. Using a novel panel dataset, the study employs recent Difference-in-Differences methods for staggered treatments to explore causal relationships. By focusing on age-related welfare spending at a granular spatial level, the study offers new insights into how political leadership and local contexts shape the prioritization of elder care, contributing to the broader discourse on welfare equity and decentralization in Italy.

This paper proposes a qualitative methodological tool to analyze and compare local policies supporting informal caregivers of non-self-sufficient elderly people, highlighting the local dimension of welfare provision. The methodology is based on the use of vignettes within semi-structured interviews conducted with a variety of public and third-sector actors. The analytical framework includes six key dimensions: financial support, respite care, training support, psychological support, communication, and scalability. Applied in an exploratory manner to four Italian metropolitan cities – Milan, Bologna, Rome, and Bari – the method is used to investigate territorial disparities in the six dimensions, highlighting significant differences across contexts. Bologna emerges as a city with robust and well-developed support across all key dimensions also thanks to its integrated network between public and third-sector actors; Rome and Milan rely more heavily on regional measures; Bari offers examples of hybrid innovation. Nonetheless, even in the most advanced contexts, some recurring limitations remain, such as challenges in communication, limited psychological support services, and access criteria that may be perceived as restrictive. This paper demonstrates the potential of vignette-based interviews to explore realistic scenarios, stimulate reflection among a diverse array of public and third-sector actors, and enable cross-context comparisons. These findings carry important implications for both researchers and policymakers, highlighting the need not only to standardize essential services and improve the integration of actors, but also to increase the visibility and fairness of support measures for family caregivers. Crucially, efforts should focus on strengthening more innovative forms of support – such as psychological and educational services – moving beyond a sole reliance on financial aid.

The rising prevalence of chronic conditions among the aging population has driven the development of various care models for chronic disease management, all of them enhancing interprofessional collaboration, particularly between general practitioners (GPs) and primary care nurses (PCNs).

In response to the burden of type 2 diabetes, one of the leading chronic causes of deaths and disability in older population, the Italian region Emilia-Romagna introduced a Diabetes Management Program (DMP) in 2010. This program adopts an integrated proactive approach managed by GPs. In addition, GPs have the opportunity to collaborate with Nursing Outpatient Clinics (NOCs) for chronic care run by PCNs. Access to NOC varies by GP practice location: those working within Community Health Centers (CHCs) have onsite access, whereas external GPs benefit from nursing support if they practice in groups who share the same premise.

We estimate the impact of these alternative settings for diabetes management on older patient outcomes using a panel of individual-level administrative data from the largest Local Health Authority in the Emilia-Romagna region from 2017 to 2023. We leverage variation in treatment timing by using a staggered difference-in-differences approach. This design allows us to exploit variation in the timing of treatment by allowing for treatment effect heterogeneity.

Our preliminary results suggest that involving nurses in the diabetes management significantly improves patient outcomes, especially for patients whose GP operates inside the local CHC. These findings offer important insights for policymakers aiming to design effective diabetes care strategies