Optimizing Territorial Healthcare Networks with a Capacity-Constrained Hub-And-Spoke Allocation Algorithm: The...

Background: Geographic and demographic disparities strongly influence access to community-based healthcare, especially in rural and mountainous areas. In Italy, Ministerial Decree 77/2022 promotes a territorial reorganization based on networked care models, but practical tools for translating policy standards into operational catchment areas remain limited. Methods: We developed a transparent, data-driven allocation framework combining travel-time accessibility and population-based capacity constraints. A case study was conducted in the Province of L'Aquila, within Local Health Authority ASL 1 Avezzano-Sulmona-L'Aquila, a low-density mountainous area including 65 municipalities. Using official ISTAT data, including the 2021 national origin-destination road travel-time matrix, municipalities were allocated to 3 hub nodes and 8 spoke nodes. Population caps of 50,000 residents per hub and 40,000 per spoke were applied. Scenario analyses were performed under 20, 30, and 40 min travel-time thresholds. Results: Under the 30 min scenario, all municipalities were allocated, but the L'Aquila hub exceeded the capacity cap. A cap-compliant 30 min allocation eliminated this violation at the cost of longer upper-tail travel times. Under the 20 min scenario, only 54 municipalities were allocated, leaving 11 mountainous municipalities outside the threshold. Under the 40 min scenario, all municipalities were allocated without capacity violations. Conclusions: The proposed framework provides a reproducible approach for territorial healthcare planning and makes explicit the trade-off between accessibility and capacity compliance in hub-and-spoke network design, particularly in geographically complex mountain settings.