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

Background 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, systemic and socioeconomic barriers 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. Methods 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 discharge severity codes. Entry priority codes assigned at triage were used in the sensitivity analysis. The effect of citizenship on avoidable access was quantified via logistic regression. After adjusting for confounders, interaction terms were tested to evaluate effect variations. Results Of 916,568 ED visits recorded during the study period, 14.08% involved foreign citizens. Across both definitions, foreign citizens were at higher risk ( P  < 0.001) of potentially avoidable ED access, with the narrow definition showing a nearly two-fold increase (7.00% vs. 3.70%) and the broad definition similarly reflecting a significant disparity (67.88% vs. 54.71%). In the fully adjusted models, the odds ratio for foreign versus Italian citizenship was 1.628 (95% CI: 1.542–1.719) for the narrow outcome definition and 1.174 (95% CI: 1.143–1.205) for the broad definition of avoidable ED access. Furthermore, there was a significant ( P  < 0.001) three-way interaction, indicating that the difference by citizenship was moderated by both sex and age, with younger foreign males being at the highest risk. These results were robust in the sensitivity analysis. Conclusion 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.