[All-cause mortality from 1970 to 2013 in the municipality of Trino (Piedmont region, Italy), previously home to a nuclear plant]

Mortality studies conducted to date in the area of Trino (Piedmont Region, northern Italy) have been limited to the years from 2000 onwards. These studies have highlighted an increased frequency of brain tumors, leukemia, mesothelioma, peritoneal, prostate, larynx and total tumors in men in the municipality of Trino while for women the increased risk was limited to melanoma. The present study has allowed us to make more robust epidemiological considerations and to analyze the historical trend in mortality in the municipality (starting from 1970) correlating it also to the social and economic changes reported. We calculated the Standard Mortality Ratio (indirect standardization) by retrieving data on observed cases from the years 1980 to 2013 from the Italian national statistics bureau (ISTAT) and the municipal archives, and using regional specific mortality rates in the Piedmont region from 1980 to 2013 for expected cases. Results show a slowly decreasing trend for brain tumors in the last 10-15 years while for leukemia, we observe a sharp increase in the same time period, affecting both men and women indistinctly.

[Evaluating quality and safety in long term care: results from the experimentation of the Smart Star model]

The Smart Star model is a rating system to evaluate the quality of care in nursing homes for the elderly; it uses a five star rating score. We tested the model in a sample of 16 nursing homes in Italy. The Smart Star model showed to be effective in the multidimensional evaluation of the performance of nursing homes. One of the major strengths of the model consisted in its flexibility of application, that suggested its possible adaptation for different areas of healthcare.

Care Pathway Effect on In-Hospital Care for ST-Elevation Myocardial Infarction

OBJECTIVES

To study the care pathway effect on the percentage of patients with ST-elevation myocardial infarction -(STEMI) receiving timely coronary reperfusion and the percentage of STEMI patients receiving optimal secondary prevention.

METHODS

A care pathway was implemented by the Collaborative Model for Achieving Breakthrough Improvement. One pre-intervention and 2 post-intervention audits included all adult STEMI patients admitted within 24 h after onset and eligible for reperfusion. Adjusted (hospital random intercepts and controls for transfer and out-of-office admission) differences in composite outcomes were analyzed by a multilevel logistic regression.

RESULTS

Significant improvements in intervals between the first medical contact (FMC) to percutaneous coronary intervention (PCI) and between the door to PCI were shown between post-intervention audit II and post-intervention audit I. Secondary prevention significantly deteriorated at post-intervention audit I but improved significantly between both post-intervention audits. Six out of nine outcomes were significantly poorer in the case of transfer. The interval from FMC to PCI was significantly poorer for patients admitted during out-of-office hours.

CONCLUSIONS

After care pathway implementation, composite outcomes improved for in-hospital STEMI care. Collaborative efforts exploited heterogeneity in performance between hospitals. Iterative and incremental care pathway implementation maximized performance improvement.

Minimal impact of a care pathway for geriatric hip fracture patients

BACKGROUND

Adherence to guidelines for patients with proximal femur fracture is suboptimal.

OBJECTIVE

To evaluate the effect of a care pathway for the in-hospital management of older geriatric hip fracture patients on adherence to guidelines and patient outcomes.

DESIGN

The European Quality of Care Pathways study is a cluster randomized controlled trial.

SETTING

26 hospitals in Belgium, Italy and Portugal.

SUBJECTS

Older adults with a proximal femur fracture (n = 514 patients) were included.

METHODS

Hospitals treating older adults (>65) with a proximal femur fracture were randomly assigned to an intervention group, i.e. implementation of a care pathway, or control group, i.e. usual care. Thirteen patient outcomes and 24 process indicators regarding in-hospital management, as well as three not-recommended care activities were measured. Adjusted and unadjusted regression analyses were conducted using intention-to-treat procedures.

RESULTS

In the intervention group 301 patients in 15 hospitals were included, and in the control group 213 patients in 11 hospitals. Sixty-five percent of the patients were older than 80 years. The implementation of this care pathway had no significant impact on the thirteen patient outcomes. The preoperative management improved significantly. Eighteen of 24 process indicators improved, but only two improved significantly. Only for a few teams a geriatrician was an integral member of the treatment team.

DISCUSSION

Implementation of a care pathway improved compliance to evidence, but no significant effect on patient outcomes was found. The impact of the collaboration between surgeons and geriatricians on adherence to guidelines and patient outcomes should be studied.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT00962910.

Prevalence and use of clinical pathways in 23 countries – an international survey by the European Pathway Association

Objectives

To give an overview on the use and prevalence of clinical pathways.

Design

Cross-sectional descriptive study.

Study participants

European Pathway Association (E-P-A) contact persons in 23 countries.

Results

Clinical pathways, also known as critical pathways or integrated care pathways, have been used in health care for 20 years. Although clinical pathways are well established, little information exists on their use and dissemination around the world. The E-P-A has performed their first international survey on the use and dissemination of clinical pathways in 23 countries. At present, pathways are used with a minority of patients, mainly in acute hospital trusts. Our survey showed that clinical pathways were predominantly viewed as a multidisciplinary tool to improve the quality and efficiency of evidence-based care. Pathways were also used as a communication tool between professionals to manage and standardize outcome-oriented care.

Conclusions

There is a future for the use of clinical pathways, but there is a need for international benchmarking and knowledge sharing with regard to their development, implementation and evaluation.

Teamwork and Adherence to Recommendations Explain the Effect of a Care Pathway on Reduced 30-day Readmission for Patients with a COPD Exacerbation

This study aimed to increase our understanding of processes that underlie the effect of care pathway implementation on reduced 30-day readmission rate. Adherence to evidence-based recommendations, teamwork and burnout have previously been identified as potential mechanisms in this association. We conducted a secondary data analysis of 257 patients admitted with chronic obstructive pulmonary disease exacerbation and 284 team members caring for these patients in 19 Belgian, Italian and Portuguese hospitals. Clinical measures included 30-day readmission and adherence to a specific set of five care activities. Teamwork measures included team climate for innovation, level of organized care and burnout (emotional exhaustion, level of competence and mental detachment). Care pathway implementation was significantly associated with better adherence and reduced 30-day readmission. Better adherence and higher level of competence were also related to reduced 30-day readmission. Only better adherence fully mediated the association between care pathway implementation and reduced 30-day readmission. Better team climate for innovation and level of organized care, although both improved after care pathway implementation, did not show any explanatory mechanisms in the association between care pathway implementation and reduced 30-day readmission. Implementation of a care pathway had an impact on clinical and team indicators. To reduce 30-day readmission rates, in the development and implementation of a care pathway, hospitals should measure adherence to evidence-based recommendations during the whole process, as this can give information regarding the success of implementation.

Managing in-hospital quality improvement: An importance-performance analysis to set priorities for ST-elevation myocardial infarction care

BACKGROUND

A focus on specific priorities increases the success rate of quality improvement efforts for broad and complex-care processes. Importance-performance analysis presents a possible approach to set priorities around which to design and implement effective quality improvement initiatives. Persistent variation in hospital performance makes ST-elevation myocardial infarction care relevant to consider for importance-performance analysis.

AIMS

The purpose of this study was to identify quality improvement priorities in ST-elevation myocardial infarction care.

METHODS

Importance and performance levels of ST-elevation myocardial infarction key interventions were combined in an importance-performance analysis. Content validity indexes on 23 ST-elevation myocardial infarction key interventions of a multidisciplinary RAND Delphi Survey defined importance levels. Structured review of 300 patient records in 15 acute hospitals determined performance levels. The significance of between-hospital variation was determined by a Kruskal-Wallis test. A performance heat-map allowed for hospital-specific priority setting.

RESULTS

Seven key interventions were each rated as an overall improvement priority. Priority key interventions related to risk assessment, timely reperfusion by percutaneous coronary intervention and secondary prevention. Between-hospital performance varied significantly for the majority of key interventions. The type and number of priorities varied strongly across hospitals.

CONCLUSIONS

Guideline adherence in ST-elevation myocardial infarction care is low and improvement priorities vary between hospitals. Importance-performance analysis helps clinicians and management in demarcation of the nature, number and order of improvement priorities. By offering a tailored improvement focus, this methodology makes improvement efforts more specific and achievable.

Development of a model care pathway for adults undergoing colorectal cancer surgery: Evidence-based key interventions and indicators

RATIONALE, AIMS, AND OBJECTIVES

During the last decades, perioperative care for patients with colorectal cancer has shifted towards more standardized care, so-called "enhanced recovery after surgery." Those programs aim to optimize interventions in perioperative care to decrease the rate of postoperative complications, improve patients' recovery, and shorten hospital stay. The purpose of this literature review is to identify, summarize, and operationalize the clinical content of both key interventions and clinical indicators to develop an evidence-based model pathway for surgical patients with colorectal cancer.

METHODS

A systematic search in 3 databases was conducted to identify key interventions (KIs) and indicators to measure the effect of implementation of care pathways. The KIs from the enhanced recovery after surgery protocol were listed and used as framework to identify and match KIs used in the included studies. The Clinical Pathway Compass was used to categorize the indicators.

RESULTS

Fifteen studies were included. The number of KI used in the study protocols ranged from 9 to 20. In total, 33 KIs were identified. Little information was available concerning the implementation of and compliance to the protocol. Length of stay and complication rate are the most common used indicators (used in 15/15 and 14/15 of the studies), followed by 21 other measures. All but one of the included studies reported a reduction in length of stay.

CONCLUSION

There is a considerable variation in both number of KIs and indicators as well as operationalization of key interventions, for surgical patients with colorectal cancer documented in literature. Therefore, we summarized the input from different studies and developed an evidence-based model pathway, which can serve as a basis for a local/regional care pathway team to build their own pathway.

Key interventions and quality indicators for quality improvement of STEMI care: a RAND Delphi survey

OBJECTIVE

Identification, selection and validation of key interventions and quality indicators for improvement of in hospital quality of care for ST-elevated myocardial infarction (STEMI) patients.

METHODS AND RESULTS

A structured literature review was followed by a RAND Delphi Survey. A purposively selected multidisciplinary expert panel of cardiologists, nurse managers and quality managers selected and validated key interventions and quality indicators prior for quality improvement for STEMI. First, 34 experts (76% response rate) individually assessed the appropriateness of items to quality improvement on a nine point Likert scale. Twenty-seven key interventions, 16 quality indicators at patient level and 27 quality indicators at STEMI care programme level were selected. Eighteen additional items were suggested. Experts received personal feedback, benchmarking their score with group results (response rate, mean, median and content validity index). Consequently, 32 experts (71% response rate) openly discussed items with an item-content validity index above 75%. By consensus, the expert panel validated a final set of 25 key interventions, 13 quality indicators at patient level and 20 quality indicators at care programme level prior for improvement of in hospital care for STEMI.

CONCLUSIONS

A structured literature review and multidisciplinary expertise was combined to validate a set of key interventions and quality indicators prior for improvement of care for STEMI. The results allow researchers and hospital staff to evaluate and support quality improvement interventions in a large cohort within the context of a health care system.

Variation in care for surgical patients with colorectal cancer: protocol adherence in 12 European hospitals

PURPOSE

Surgical care for patients with colorectal cancer has become increasingly standardized. The Enhanced Recovery After Surgery (ERAS) protocol is a widely accepted structured care method to improve postoperative outcomes of patients after surgery. Despite growing evidence of effectiveness, adherence to the protocol remains challenging in practice. This study was designed to assess the adherence rate in daily practice and examine the relationship between the importance of interventions and adherence rate.

METHODS

This international observational, cross-sectional multicenter study was performed in 12 hospitals in four European countries. Patients were included from January 1, 2014. Data was retrospectively collected from the patient record by the local study coordinator.

RESULTS

A total of 230 patients were included in the study. Protocol adherence was analyzed for both the individual interventions and on patient level. The interventions with the highest adherence were antibiotic prophylaxis (95%), thromboprophylaxis (87%), and measuring body weight at admission (87%). Interventions with the lowest adherence were early mobilization-walking and sitting (9 and 6%, respectively). The adherence ranged between 16 and 75%, with an average of 44%.

CONCLUSION

Our results show that the average protocol adherence in clinical practice is 44%. The variation on patient and hospital level is considerable. Only in one patient the adherence rate was >70%. In total, 30% of patients received 50% or more of the key interventions. A solid implementation strategy seems to be needed to improve the uptake of the ERAS pathway. The importance-performance matrix can help in prioritizing the areas for improvement.

Better organized care via care pathways: A multicenter study

An increased need for efficiency and effectiveness in today’s healthcare system urges professionals to improve the organization of care. Care pathways are an important tool to achieve this. The overall aim of this study was to analyze if care pathways lead to better organization of care processes. For this, the Care Process Self-Evaluation tool (CPSET) was used to evaluate how healthcare professionals perceive the organization of care processes. Based on information from 2692 health care professionals gathered between November 2007 and October 2011 we audited 261 care processes in 108 organizations. Multilevel analysis was used to compare care processes without and with care pathways and analyze if care pathways led to better organization of care processes. A significant difference between care processes with and without care pathways was found. A care pathway in use led to significant better scores on the overall CPSET scale (p<0.001) and its subscales, “coordination of care” (p<0.001) and “follow-up of care” (p<0.001). Physicians had the highest score on the overall CPSET scale and the five subscales. Care processes organized by care pathways had a 2.6 times higher probability that the care process was well-organized. In around 75% of the cases a care pathway led to better organized care processes. Care processes supported by care pathways were better organized, but not all care pathways were well-organized. Managers can use care pathways to make healthcare professionals more aware of their role in the organization of the care process.

CT Angiography ASPECTS Predicts Outcome Much Better Than Noncontrast CT in Patients with Stroke Treated Endovascularly

BACKGROUND AND PURPOSE

Noncontrast CT ASPECTS has been investigated as a predictor of outcome in patients with acute ischemic stroke. Our purpose was to investigate whether CTA source images are a better predictor of clinical and radiologic outcomes than NCCT ASPECTS in candidates for endovascular stroke therapy.

MATERIALS AND METHODS

CT scans of patients (n = 124) were independently evaluated by 2 readers for baseline NCCT and CTA source image ASPECTS and for follow-up ASPECTS. An mRS of ≤2 at 3 months was considered a favorable outcome. Receiver operating characteristic curve analysis was used to assess the ability of NCCT and CTA source image ASPECTS to identify patients with favorable outcomes. A stepwise multiple regression analysis was performed to find independent predictors of outcome.

RESULTS

Baseline CTA source image ASPECTS correlated better than NCCT ASPECTS with follow-up ASPECTS (r = 0.76 versus r = 0.51; P for comparison of the 2 coefficients < .001). Receiver operating characteristic curve analysis showed that baseline CTA source image ASPECTS compared with NCCT ASPECTS can better identify patients with favorable outcome (CTA source image area under the curve = 0.83; 95% CI, 0.76-0.91; NCCT area under the curve = 0.67; 95% CI, 0.58-0.77; P < .001). Finally, the stepwise regression analysis showed that lower age, good recanalization, lower time to recanalization, and good baseline CTA source image ASPECTS, not NCCT ASPECTS, were independent predictors of favorable outcome.

CONCLUSIONS

CTA source image ASPECTS predicts outcome better than NCCT ASPECTS; this finding suggests CTA rather than NCCT as a main step in the decision-making process for patients with acute ischemic stroke.

Prevalence and costs of defensive medicine: a national survey of Italian physicians

Objective To identify the prevalence of the practice of defensive medicine among Italian hospital physicians, its costs and the reasons for practising defensive medicine and possible solutions to reduce the practice of defensive medicine. Methods Cross-sectional web survey. Main outcome measures Number of physicians reporting having engaged in any defensive medicine behaviour in the previous year. Results A total of 1313 physicians completed the survey. Ninety-five per cent believed that defensive medicine would increase in the near future. The practice of defensive medicine accounted for approximately 10% of total annual Italian national health expenditure. Conclusions Defensive medicine is a significant factor in health care costs without adding any benefit to patients. The economic burden of defensive medicine on health care systems should provide a substantial stimulus for a prompt review of this situation in a time of economic crisis. Malpractice reform, together with a systematic use of evidence-based clinical guidelines, is likely to be the most effective way to reduce defensive medicine.

Prevalence and costs of defensive medicine: a national survey of Italian physicians

Objective To identify the prevalence of the practice of defensive medicine among Italian hospital physicians, its costs and the reasons for practising defensive medicine and possible solutions to reduce the practice of defensive medicine. Methods Cross-sectional web survey. Main outcome measures Number of physicians reporting having engaged in any defensive medicine behaviour in the previous year. Results A total of 1313 physicians completed the survey. Ninety-five per cent believed that defensive medicine would increase in the near future. The practice of defensive medicine accounted for approximately 10% of total annual Italian national health expenditure. Conclusions Defensive medicine is a significant factor in health care costs without adding any benefit to patients. The economic burden of defensive medicine on health care systems should provide a substantial stimulus for a prompt review of this situation in a time of economic crisis. Malpractice reform, together with a systematic use of evidence-based clinical guidelines, is likely to be the most effective way to reduce defensive medicine.

An International Study of Adherence to Guidelines for Patients Hospitalised with a COPD Exacerbation

Guideline adherence rates for the treatment of chronic obstructive pulmonary disease (COPD) exacerbation are low. The aim of this study is to perform an importance-performance analysis as an approach for prioritisation of interventions by linking guidelines adherence rates to expert consensus rates for the in-hospital management of COPD exacerbation. We illustrate the relevance of such approach by describing variation in guideline adherence across indicators and hospitals. A secondary data analysis of patients with an acute COPD exacerbation admitted to Belgian, Italian and Portuguese hospitals was performed. Twenty-one process indicators were used to describe adherence to guidelines from patient record reviews. Expert consensus on the importance for follow-up of these 21 indicators was derived from a previous Delphi study. Three of the twenty-one indicators had high level of expert consensus and a high level of adherence. Eleven of the twenty-one indicators had high level of expert consensus but a low level of adherence. For none of the 378 patients included in this study were all process indicators adhered to, patients received 41.0% of the recommended care on average, and only 34.1% of the patients received 50% or more of the care they should receive. There was also a large variation within and between hospitals regarding the care received. This study confirms the findings of previous studies, indicating that COPD exacerbations are largely undertreated. Importance-performance analysis provides a decision-making tool for prioritising indicators. All hospitals in this study would benefit from having in place a quality framework for systematic follow-up of these indicators.

Impact of a care pathway for COPD on adherence to guidelines and hospital readmission: a cluster randomized trial

PURPOSE

Current in-hospital management of exacerbations of COPD is suboptimal, and patient outcomes are poor. The primary aim of this study was to evaluate whether implementation of a care pathway (CP) for COPD improves the 6 months readmission rate. Secondary outcomes were the 30 days readmission rate, mortality, length of stay and adherence to guidelines.

PATIENTS AND METHODS

An international cluster randomized controlled trial was performed in Belgium, Italy and Portugal. General hospitals were randomly assigned to an intervention group where a CP was implemented or a control group where usual care was provided. The targeted population included patients with COPD exacerbation.

RESULTS

Twenty-two hospitals were included, whereof 11 hospitals (n=174 patients) were randomized to the intervention group and 11 hospitals (n=168 patients) to the control group. The CP had no impact on the 6 months readmission rate. However, the 30 days readmission rate was significantly lower in the intervention group (9.7%; 15/155) compared to the control group (15.3%; 22/144) (odds ratio =0.427; 95% confidence interval 0.222-0.822; P=0.040). Performance on process indicators was significantly higher in the intervention group for 2 of 24 main indicators (8.3%).

CONCLUSION

The implementation of this in-hospital CP for COPD exacerbation has no impact on the 6 months readmission rate, but it significantly reduces the 30 days readmission rate.

[Evaluating the quality of care in nursing homes: comparison of three International models]

The aim of this observational descriptive study was to identify the main international models evaluating the quality of nursing homes for non self-sufficient elderly persons, and to apply them in the Italian health system. Firstly, a bibliographic search of institutional websites and Pubmed-Medline was performed to identify the main international models. Secondly, three variables were chosen to evaluate the level of implementability of the models: (1) frequency of use of quality indicators in the international models; (2) degree of constructability of the models in two Italian nursing homes; (3) perceived relevance of the indicators used by the chosen models, by nursing home workers. Thirdly, the chosen models were evaluated. Three international models were identified, respectively used in USA, Canada and Australia. About 80% of the indicators used by the three models were constructable in the two Italian nursing homes that were evaluated. The two nursing homes were "promoted" according to the Canadian model, "better than sufficient" according to the Australian model, but "failed" when US model indicators were applied. The poorest performances in the two Italian nursing homes, with respect to international quality standards, were related to indicators of incontinence, physical restraints (1,1% for USA and 13% for Canada and Australia, versus 55% in one of the nursing homes and 30% in the second home), diagnosis of depressive symptoms, and antipneumococcical vaccination (0% in the two nursing homes, in comparison with the 93,8% in the USA). A low level of performance in prevention and safety matters was identified, while performance was higher for aspects warranted by law. The survey also revealed thatnursing home workers' perceptions of the utility of specific indicators were often based on habit rather than on the actual relevance of care indicators. The development of a model of quality of care that offers a multidimensional evaluation of the level of performance of Italian nursing homes is needed.

Psychological impact and recovery after involvement in a patient safety incident: a repeated measures analysis

OBJECTIVE

To examine individual, situational and organisational aspects that influence psychological impact and recovery of a patient safety incident on physicians, nurses and midwives.

DESIGN

Cross-sectional, retrospective surveys of physicians, midwives and nurses.

SETTING

33 Belgian hospitals.

PARTICIPANTS

913 clinicians (186 physicians, 682 nurses, 45 midwives) involved in a patient safety incident.

MAIN OUTCOME MEASURES

The Impact of Event Scale was used to retrospectively measure psychological impact of the safety incident at the time of the event and compare it with psychological impact at the time of the survey.

RESULTS

Individual, situational as well as organisational aspects influenced psychological impact and recovery of a patient safety incident. Psychological impact is higher when the degree of harm for the patient is more severe, when healthcare professionals feel responsible for the incident and among female healthcare professionals. Impact of degree of harm differed across clinicians. Psychological impact is lower among more optimistic professionals. Overall, impact decreased significantly over time. This effect was more pronounced for women and for those who feel responsible for the incident. The longer ago the incident took place, the stronger impact had decreased. Also, higher psychological impact is related with the use of a more active coping and planning coping strategy, and is unrelated to support seeking coping strategies. Rendered support and a support culture reduce psychological impact, whereas a blame culture increases psychological impact. No associations were found with job experience and resilience of the health professional, the presence of a second victim support team or guideline and working in a learning culture.

CONCLUSIONS

Healthcare organisations should anticipate on providing their staff appropriate and timely support structures that are tailored to the healthcare professional involved in the incident and to the specific situation of the incident.

[Second victims in healthcare: the stages of recovery following an adverse event]

A second victim has been defined as "a healthcare worker involved in an unanticipated adverse patient event, medical error and/or a patient related-injury who becomes victimized in the sense that the worker is traumatized by the event". The aim of the present research study was to assess the "second victim" phenomenon in Italy. Fifty interviews were conducted with different health care professionals previously involved in medical errors. All study participants clearly remembered the event. Support obtained by second victims was poor and inefficient. Healthcare workers become second victims every day and, considering that human resources are the most important resource of healthcare organizations, it is fundamental to implement valid programs to support and train these workers about the phenomenon.