An ecological study of trends in medical and surgical hospital admissions in Tuscany over 25 years

Since 1995, hospital admissions in Italy have been classified using diagnosis-related groups (DRGs). Hospital discharge records provide a valuable basis for reconstructing long-term trends in hospital activity and examining these patterns in the context of organizational reforms and the COVID-19 pandemic. We conducted a retrospective ecological study using Tuscany regional healthcare administrative data to examine trends in hospital admissions from 1999 to 2024 and compare them with national Italian trends. Admissions were classified as medical or surgical, and analyzed by care setting, length of stay, age, and case-mix index (CMI). Ordinary and day-case hospitalization rates in Tuscany decreased by 35.8% and 23.1%, respectively. Medical hospitalization rates fell by 47.5%, while outpatient chemotherapy surged by 233.6% (2014–2024). Medical CMI rose from 0.5 to 0.8, and mean patient age reached 66.9 years. Surgical hospitalization rates fluctuated but returned to near-baseline levels, while outpatient surgery increased markedly. Ordinary surgical LOS decreased by 1.3 days, while surgical CMI increased from 0.9 to 1.5. An observed divergence from national trends occurred in 2009, coinciding with regional reforms. Over 25 years, hospital care in Tuscany shifted toward lower medical inpatient and day-case volumes, greater use of outpatient services, and shorter surgical stays. These trends occurred in the context of organizational reform, demographic aging, and administrative reclassifications. Findings reflect a progressive concentration of hospital resources on older patients with higher case-mix complexity. Causal interpretations should remain cautious because the analysis centers on aggregated routinely collected data.