[A data-driven approach to optimizing the management of chronic patients within the framework of DM77]

to develop tools to identify the most appropriate and/or prioritized sets of patients with stable chronic conditions who are eligible for management by territorial services, to be included in a dedicated care pathway within Community Health Centers (CdC), as outlined in Italian Ministerial Decree 77/2022.

retrospective observational study.

subjects residing in the territory of the Health Protection Agency of Milan (ATS Milano) in the year 2023.

prevalence of hospitalizations, visits to the Emergency Room (ER) and patients receiving polytherapy, defined by specific criteria, to select chronic condition and cohort with potential territorial management. Duration of the disease and visits to the general practitioner (GP) clinic for the chronic population eligible for care in Community Houses provided for by the Italian Ministerial Decree No. 77 (DM77).

starting from a population of 3.5 million inhabitants in the ATS Milano, 35% suffer from at least one chronic condition. The most represented pathologies are arterial hypertension (254,232 cases) and hypercholesterolemia (156,314 cases). Applying selection criteria on hospital discharge, access in emergency room, and therapy, 16 chronic pathologies of interest for territorial assistance were identified. The 15% of patients had the disease for less than 1 year while the 36,2% for over 10 years. Over 60,000 patients (10,2%) included in the cohort with potential territorial management did not even make one visit to the GP clinic during 2023.

through this model, approximately 600,000 subjects were identified as eligible for territorial care, based on the integration between the GP and the Community House, to be managed preferably within a Territorial Operations Center. This work represents a proposal for the application of a model to the information system available in a structure of the Italian National Health System for the planning of the care of the population affected by chronic diseases, as indicated by the DM77. The possibility of validating and developing similar approaches at a national level could represent a significant step towards better management of chronic conditions.