Introduction The territorial emergency medical system 118 is a strategic area of the Italian National Health Service, yet it lacks shared models for cost determination and comparison. Article 8-sexies of Legislative Decree 502/1992 provides for standard-cost financing of territorial emergency care, but it has never been fully implemented at national level. A PRISMA systematic review (PubMed, CINAHL, Scopus; 2015-2025) identified six contributions: four international studies on single operational segments and the two FIASO Reports (2015, 2019), the only Italian pilot experiences on ground emergency cost classification. Neither edition included Marche, where the voluntary sector manages approximately 76% of the regional fleet, playing a structural rather than merely supplementary role. Objective To develop a cost analysis and classification model for the 118 system adapted to Marche, through functional benchmarking applied to the Pesaro and Urbino Local Health Authority (AST) as a pilot setting, in order to produce standard costs per Mobile Operational Unit (UOM) across management models and project them to the other four AST. Materials and methods A monocentric pilot study integrating the design of an instrument with a retrospective descriptive observational analysis of accounting and administrative data flows. The five phases of Camp's (1989) functional benchmarking were followed. The FIASO 2015 and 2019 Reports were adapted through a cost matrix per UOM (six production-factor sections, fourteen configurations), adding a section on contractual costs with Voluntary Organisations (OdV), absent from the original model. Data were obtained through a formal request to the AST offices and from the thirteen 2023 economic reports of contracted OdV. The regional projection is based on a census of the 118 PoTES stations (territorial emergency stations) across the five AST. Results A marked informational asymmetry emerged: direct management lacks cost-centre reporting (only aggregate figure: line 2D100 of the 2025 Cost by Care Level Account, €19,072,786.19), whereas the OdV follow a uniform reporting framework. Standard costs per directly managed H24 UOM are €967,132.24-€1,254,372.26 for Advanced Life Support units (MSA) and €316,945.02 for the Intermediate Life Support unit (MSI). Under mixed management they are €837,250.46-€1,174,193.05 (MSA) and €475,242.13-€526,520.35 (MSI); for fully contracted Basic Life Support units (MSB), €143,911.85-€417,442.72. Compared with FIASO, labour remains the central cost factor; nursing (+20.9%) and driver-rescuer (+28.6%) costs reflect the 2015-2025 contractual renewals. The regional projection estimates €56,027,571.49-€62,601,994.45, of which 36.3% is borne by the OdV. Conclusions The study demonstrates the feasibility of adapting the FIASO framework to Marche, integrating direct management and the voluntary sector in a single model. The UOM matrix supports economic governance, transparent contracting with the OdV and network remodelling, enhancing nurse-led units (MSI) in a context of physician shortage in emergency care. Future developments: replication in the other AST with direct data collection, extension to 118 Dispatch Centres and helicopter emergency services, and correlation with clinical outcomes.
Introduzione Il sistema di emergenza sanitaria territoriale 118 è un'area strategica del Servizio Sanitario Nazionale, ma priva di modelli condivisi per la determinazione e il confronto dei costi. L'art. 8-sexies del D.Lgs. 502/1992 prevede il finanziamento a costo standard dell'emergenza territoriale, mai pienamente attuato a livello nazionale. Una revisione sistematica PRISMA (PubMed, CINAHL, Scopus; 2015-2025) ha identificato sei contributi: quattro studi internazionali su singoli segmenti operativi e i due Report FIASO (2015, 2019), uniche esperienze pilota italiane sui costi del soccorso su gomma. Nessuna edizione ha incluso le Marche, dove il Terzo Settore gestisce circa il 76% della flotta regionale con un ruolo strutturale e non meramente integrativo. Obiettivo Costruire un modello di analisi e classificazione dei costi del sistema 118 adattato alle Marche, mediante benchmarking funzionale sull'AST di Pesaro e Urbino (realtà pilota), per produrre costi standard per Unità Operativa Mobile (UOM) nelle diverse modalità gestionali e proiettarli alle altre quattro AST. Materiali e metodi Studio pilota monocentrico che integra la progettazione di uno strumento e l'analisi osservazionale descrittiva retrospettiva dei flussi contabili e amministrativi. Sono state seguite le cinque fasi del benchmarking funzionale di Camp (1989). I Report FIASO 2015 e 2019 sono stati adattati con una matrice dei costi per UOM (sei sezioni di fattori produttivi, quattordici configurazioni), aggiungendo una sezione sugli oneri convenzionali con le Organizzazioni di Volontariato (OdV), assente nel modello originario. I dati provengono da istanza formale agli uffici dell'AST e dalle tredici rendicontazioni economiche 2023 delle OdV convenzionate. La proiezione regionale si basa sul censimento delle 118 postazioni PoTES delle cinque AST. Risultati È emersa una marcata asimmetria informativa: la gestione diretta è priva di rendicontazione per centro di costo (unico dato aggregato: voce 2D100 del Conto dei Costi per Livelli di Assistenza 2025, €19.072.786,19), mentre le OdV seguono uno schema uniforme. I costi standard per UOM a gestione diretta H24 sono €967.132,24-€1.254.372,26 per le MSA e €316.945,02 per la MSI. Nella gestione mista sono €837.250,46-€1.174.193,05 (MSA) e €475.242,13-€526.520,35 (MSI); nelle MSB interamente convenzionate €143.911,85-€417.442,72. Rispetto a FIASO, il fattore lavoro resta centrale; i costi di infermieri (+20,9%) e autisti-soccorritori (+28,6%) riflettono i rinnovi contrattuali 2015-2025. La proiezione regionale stima €56.027.571,49-€62.601.994,45, di cui il 36,3% a carico delle OdV. Conclusioni Lo studio dimostra la fattibilità di adattare il framework FIASO alle Marche, integrando gestione diretta e Terzo Settore in un unico modello. La matrice UOM supporta il governo economico, la contrattazione trasparente con le OdV e la rimodulazione della rete, valorizzando le postazioni a leadership infermieristica (MSI) in un contesto di carenza di medici dell'emergenza. Sviluppi futuri: replica nelle altre AST con raccolta diretta dei dati, estensione a Centrali Operative 118 ed elisoccorso, correlazione con gli esiti clinici.
Il sistema di emergenza sanitaria territoriale nelle Marche: uno studio pilota sull'AST di Pesaro e Urbino, verso un modello di costi standard regionale
LETIZI, ILENIA
2025/2026
Abstract
Introduction The territorial emergency medical system 118 is a strategic area of the Italian National Health Service, yet it lacks shared models for cost determination and comparison. Article 8-sexies of Legislative Decree 502/1992 provides for standard-cost financing of territorial emergency care, but it has never been fully implemented at national level. A PRISMA systematic review (PubMed, CINAHL, Scopus; 2015-2025) identified six contributions: four international studies on single operational segments and the two FIASO Reports (2015, 2019), the only Italian pilot experiences on ground emergency cost classification. Neither edition included Marche, where the voluntary sector manages approximately 76% of the regional fleet, playing a structural rather than merely supplementary role. Objective To develop a cost analysis and classification model for the 118 system adapted to Marche, through functional benchmarking applied to the Pesaro and Urbino Local Health Authority (AST) as a pilot setting, in order to produce standard costs per Mobile Operational Unit (UOM) across management models and project them to the other four AST. Materials and methods A monocentric pilot study integrating the design of an instrument with a retrospective descriptive observational analysis of accounting and administrative data flows. The five phases of Camp's (1989) functional benchmarking were followed. The FIASO 2015 and 2019 Reports were adapted through a cost matrix per UOM (six production-factor sections, fourteen configurations), adding a section on contractual costs with Voluntary Organisations (OdV), absent from the original model. Data were obtained through a formal request to the AST offices and from the thirteen 2023 economic reports of contracted OdV. The regional projection is based on a census of the 118 PoTES stations (territorial emergency stations) across the five AST. Results A marked informational asymmetry emerged: direct management lacks cost-centre reporting (only aggregate figure: line 2D100 of the 2025 Cost by Care Level Account, €19,072,786.19), whereas the OdV follow a uniform reporting framework. Standard costs per directly managed H24 UOM are €967,132.24-€1,254,372.26 for Advanced Life Support units (MSA) and €316,945.02 for the Intermediate Life Support unit (MSI). Under mixed management they are €837,250.46-€1,174,193.05 (MSA) and €475,242.13-€526,520.35 (MSI); for fully contracted Basic Life Support units (MSB), €143,911.85-€417,442.72. Compared with FIASO, labour remains the central cost factor; nursing (+20.9%) and driver-rescuer (+28.6%) costs reflect the 2015-2025 contractual renewals. The regional projection estimates €56,027,571.49-€62,601,994.45, of which 36.3% is borne by the OdV. Conclusions The study demonstrates the feasibility of adapting the FIASO framework to Marche, integrating direct management and the voluntary sector in a single model. The UOM matrix supports economic governance, transparent contracting with the OdV and network remodelling, enhancing nurse-led units (MSI) in a context of physician shortage in emergency care. Future developments: replication in the other AST with direct data collection, extension to 118 Dispatch Centres and helicopter emergency services, and correlation with clinical outcomes.| File | Dimensione | Formato | |
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https://hdl.handle.net/20.500.12075/28951