Risk factors, awareness of disease and use of medications in a deprived population: differences between indigent natives and undocumented migrants in Italy

A Cohort Study on Diabetic Undocumented Migrants in Italy: Can Charitable Organizations Contribute to Higher Adherence?

The increasing presence of documented and undocumented migrants increases the commitment of the Italian National Health Service to their health needs, following its founding principle of equity. In particular, chronic diseases, such as diabetes, represent a crucial area where patients' health is affected by their adherence to care pathways, for which the recent literature has reported alarming low levels. In the case of migrants, obstacles to adherence, such as language or organizational barriers, could be overcome thanks also to charitable organizations providing healthcare services. In this study, we aimed to compare the adherence among documented and undocumented migrants who received healthcare services in Milan, Italy, either from the National Health Service (NHS) or from a charitable organization. We identified a cohort of newly taken into care diabetic patients composed of two groups: (i) documented migrants that attend the NHS; and (ii) undocumented migrants that attend a charity. Information was tracked by merging two datasets: the regional healthcare information system of Lombardy, and a unique dataset that collects data on specialistic visits and pharmaceutical prescriptions for all people visiting one of the most prominent charitable organizations in Italy. The annual diabetologist visit was used as the measure of adherence. The probability of being adherent was compared among the two groups by using a multivariate log-binomial regression model, considering a set of personal characteristics that may impact health behaviors. The cohort comprised 6429 subjects. The percentage of adherence was 52% among the documented migrants, and 74% among the undocumented. Regression results confirmed this pattern: undocumented patients have an increased probability of being adherent by 1.19 times (95% CI: 1.12 to 1.26) compared to documented ones. Our study revealed the potentiality of charitable organizations in guaranteeing continuity of care to undocumented migrants. We argue that this mechanism would benefit from central coordination by the government.

Healthcare Services for Undocumented Migrants: Organisation and Costs from the Italian NHS Perspective

Based on the principle of health equity, the Italian National Health Service is known worldwide for being a universalistic system that guarantees healthcare services for all its population, among which there are undocumented migrants. A commitment for their health needs is further motivated by their lower utilisation rates of healthcare services, which becomes even more crucial when considering chronic conditions such as diabetes that require adherence and continuity of care. However, the need for more official data has resulted in little research documenting these healthcare usage patterns. For this reason, our objective has been to deepen, from the Italian NHS perspective, the quantity, costs, type, preventability and organisation of healthcare services directed to undocumented migrants. We used official healthcare data from the Lombardy Region, which enable the identification of people receiving the STP code (undocumented migrants) and of people with foreign citizenship (documented migrants). After quantifying the average annual amount and expenditure for healthcare services grouped by Italian citizens, documented migrants and undocumented migrants for all clinical conditions (quantity and costs), we performed three primary investigations where we enlightened differences between the three mentioned groups focusing on the diagnosis of diabetes: (i) mapping the types of healthcare services used and their characteristics (type); (ii) quantifying the impact of preventable hospital admissions (preventability); (iii) examining the healthcare patterns linking pharmaceutical prescriptions with hospital accesses (organisation). Our results reveal significant differences among the three groups, such as more urgent hospital admissions, more preventable complications, and a higher recurrence in terms of access and costs to hospital services rather than pharmaceutical prescriptions for undocumented migrants. These findings can represent the leverage to raise awareness toward the emerging challenges of the migrant health burden.

Effects of SARS-CoV-2 pandemic on follow-up and pharmacological treatment of chronic diseases in undocumented migrants

Background

All over the world, the COVID-19 pandemic, not unlikely other epidemics, has hit harder people in low socioeconomic conditions.

In Western countries, undocumented migrants are a growing component of this disadvantaged segment of the population.

Their health conditions are frequently burdened by a number of chronic conditions, and they experience many difficulties in accessing public health services. Frequently, the only medical assistance they can get is provided by non-governmental organisations.

Methods

We studied the medical records (including pharmacological treatments) of all patients attending the outpatient clinics of Opera San Francesco (OSF; a big charity in Milano, Italy), in the first 5 months of 2020. These comprise the outbreak of the pandemic and the lockdown period. The 1914 patients (1814 undocumented migrants and 100 Italians) seen during the lockdown were compared with those seen in the same period of 2019 and with those seen in the preceding months of 2020. We especially focused on three chronic conditions: cardiovascular diseases, diabetes and psychiatric disorders.

Results

The number of consultations during the first 5 months of 2020 was much smaller than that of the same period of 2019. During the lockdown, we found 4048 consultations for 1914 patients, while they were 8051 in the same period of 2019 and 5681 in the first 2 months of 2020.

The quantity of medicines dispensed by OSF showed a marked decrease in the period of the study and mainly during the lockdown.

The decrease in consultations and dispensation of medicines was most evident for psychiatric patients and almost not existent for patients with diabetes. Female patients suffered a more pronounced reduction.

Conclusions

Western countries need strategies to better assist the very poor during epidemics.

Differences among different groups of disadvantaged persons should be taken into account when designing recovery plans.

Current Pharmacological Treatment of Type 2 Diabetes Mellitus in Undocumented Migrants: Is It Appropriate for the Phenotype of the Disease?

Type 2 diabetes is increasingly recognized as a spectrum of metabolic disorders sharing chronic hyperglycaemia. In Europe, the continually growing number of migrants from developing countries could affect diabetes phenotypes. We evaluated a population of 426 Italians and 412 undocumented migrants. Using 17 variables (with the exclusion of ethnic origin) we performed a multiple component analysis to detect potential clusters, independently from ethnicity. We also compared the two groups to evaluate potential ethnicity associated differences. We found five clusters of patients with different disease phenotypes. Comparing Italians with undocumented migrants, we noted that the first had more often cardiovascular risk factors and neurologic involvement, while the latter had a higher frequency of diabetic ulcers and renal involvement. Metformin was used in a comparable percentage of patients in all clusters, but other antidiabetic treatments showed some differences. Italians were more often on insulin, due to a larger use of long acting insulin, and received a larger number of oral antidiabetics in combination. Pharmacological treatment of comorbidities showed some differences too. We suggest that type 2 diabetes should be considered as a spectrum of diseases with different phenotypes also in heterogeneous populations, and that this is not due only to ethnic differences.