[Morbidity for congenital malformations. From 2005 to 2009 in Vercelli and neighboring countries]

Special attention is now placed in the diagnosis of congenital malformations, MC, and several recent studies attest to the role of indicators of injury is inherent is extrinsic to the environmental component. In the Vercelli area recognize different sources of environmental pressure can result in damage potential direct and indirect effects on community residents; about, identify plants with high environmental impact on health including a MSW incinerator off in March 2014. The study refers to the morbidity derived from SDO from 2005 to 2009 than the specific rates ASL VC. The main concern the excess female for the area south and central ages 50-69 years old for the rest of the areas considered. Worthy of investigation is the excess of males in the group 5-19 years. Events have been of important insights, but in light of its limitations is certainly worth a discussion in terms expansion is as period of observation that as more data sources for the precise and reliable diagnosis of CD.

Cancer risk among farmers in the Province of Vercelli (Italy) from 2002 to 2005: an ecological study

BACKGROUND

As the link between agricultural pesticides and numerous types of human cancers is wellknown. Farmers living in the Province of Vercelli (Italy) were observed to verify if they have a higher cancer risk than the rest of the local employed population. Literature showed a well-known excess of cancer morbidity and mortality in the Province of Vercelli, but only few studies focused on cancer incidence in local farmers. Studying farmers could allow to assess the causal importance respectively of environmental pressure and professional exposure factors in explaining cancer excesses in the above-mentioned area.

MATERIALS AND METHODS

The present ecological study considered all cancer new cases recorded among the mean employed population with a range of age from 25 to 84 years and resident in the Province of Vercelli during the four-year period 2002-2005. Cancer odds ratios, by gender and type of cancer, between farmers and non-farmers were calculated.

RESULTS

Farmers showed a higher risk for the following tumors: colorectal (OR 2.38, IC95%: 1,76-2,87), leaukaemia (OR 2.65, IC95%:2,12-2,89), digestive system (OR 2.16, IC95% 1,92-2,33), lymphoma OR 2.08, IC95%:1,99-2,23), melanoma (OR 2.90, IC95%:2,54-3,15), myeloma OR 3.55, IC95%:3,23-3,70), pancreas OR 3.38, IC95%:3,14-3,61), lung (1.59, IC95%:1,12-2,38) and kidney (2.70, IC95%:2,41-2,99). Males showed a higher risk for lung cancer, females for liver neoplasm, melanoma and lymphoma.

CONCLUSIONS

Farmers showed a higher risk for several cancers. Further studies are needed, in order to examine in detail the issue, to encourage the use of personal protective equipment and to promote a more responsible pesticides use.

Involvement of health-care professionals in an adverse event: the role of management in supporting their workforce

INTRODUCTION

 After an adverse event, not only patients and family members but also health-care professionals involved in the event become victims. More than 50% of all health-care professionals suffer emotionally and professionally after being involved in an adverse event. Support is needed for these "second victims" to prevent a further negative impact on patient care.

OBJECTIVES

 The aim of the study was to evaluate the prevalence and content of organizational‑level support systems for health-care professionals involved in an adverse event.

METHODS

 A survey was sent to 109 Belgian hospitals regarding 2 aspects: first, the availability of a protocol for supporting second victims; and, second, the presence of a contact person in the organization to provide support. A total of 59 hospitals participated in the study. Hospitals were asked to submit their protocols for providing support to second victims. A content analysis based on an Institute for Healthcare Improvement's white paper and the Scott Model was performed to evaluate the protocols.

RESULTS

 Thirty organizations had a systematic plan to support second victims. Twelve percent could not identify a contact person. The chief nursing officer was seen as one of the main contact people when something went wrong. In terms of the quality of the protocols, only a minority followed part of the international resources.

CONCLUSIONS

 A minority of hospitals are somewhat prepared to provide support for health-care professionals. Management should take a leadership role in establishing support protocols for their health-care professionals in the aftermath of an adverse event.

Geographical and epidemiological analysis of oncological mortality in a Municipality of North-Western Italy Vercelli years 2000-2009

BACKGROUND

We performed a geographic analysis study on mortality in the town of Vercelli, in order to respond to the concerns of the population and some local administrators. Main reason to carry out a detailed and sophisticated study for a city of medium-small size was represented by the presence of various sources of environmental and industrial pressure (i.e. old-generation incinerator for solid urban waste, industrial site for chemicals production, intense agricultural activity of rice production…).

METHODS

The study analyzed census, ISTAT death cards, both from the epidemiological point of view with admirers that SMR standardized spatial analysis using Bayesian models.

RESULTS

Overall, both approaches highlighted major risks for the area south of the capital for major cancers such as colorectal and lung and increases worthy of investigation for the young-adult age groups in both genders. And being processed a similar study that considers the incidence oncology.

CONCLUSIONS

The imminent elaboration of the cartography by oncological incidence will allow us to confirm, or less, the areas in excess for the death data, and in the meanwhile observe any excesses for low mortality pathologies (e.g., thyroid) or neoplasies whose present therapies allowed complete recovery and/or very long survivals (e.g. leukaemia, lymphomas and testicle).

Intraclass correlation coefficients for cluster randomized trials in care pathways and usual care: hospital treatment for heart failure

BACKGROUND

Cluster randomized trials are increasingly being used in healthcare evaluation to show the effectiveness of a specific intervention. Care pathways (CPs) are becoming a popular tool to improve the quality of health-care services provided to heart failure patients. In order to perform a well-designed cluster randomized trial to demonstrate the effectiveness of Usual care (UC) and CP in heart failure treatment, the intraclass correlation coefficient (ICC) should be available before conducting a trial to estimate the required sample size. This study reports ICCs for both demographical and outcome variables from cluster randomized trials of heart failure patients in UC and care pathways.

METHODS

To calculate the degree of within-cluster dependence, the ICC and associated 95% confidence interval were calculated by a method based on analysis of variance. All analyses were performed in R software version 2.15.1.

RESULTS

ICCs for baseline characteristics ranged from 0.025 to 0.058. The median value and interquartile range was 0.043 [0.026-0.052] for ICCs of baseline characteristics. Among baseline characteristics, the highest ICCs were found for admission by referral or admission from home (ICC = 0.058) and the disease severity at admission (ICC = 0.046). Corresponding ICCs for appropriateness of the stay, length of stay and hospitalization cost were 0.069, 0.063, and 0.001 in CP group and 0.203, 0.020, 0.046 for usual care, respectively.

CONCLUSION

Reported values of ICCs from present care pathway trial and UC results for some common outcomes will be helpful for estimating sample size in future clustered randomized heart failure trials, in particular for the evaluation of care pathways.

[Second victims of medical errors: a systematic review of the literature]

"Second victims" are health care providers who remain traumatized and suffer at the psycho-physical level after being involved in a patient adverse event. A systematic review of the literature was conducted to: a) estimate the prevalence of second victims among healthcare workers, b) describe personal and work outcomes of second victims, c) identify coping strategies used by second victims to face their problems, and d) describe current support strategies. Findings reveal that the prevalence of "second victims" of medical errors is high, ranging in four studies from 10.4% to 43.3%. Medical errors have a negative impact on healthcare providers involved, leading to physical, cognitive and behavioural symptoms including the practice of defensive medicine. Managers of health organizations need to be aware of the "second victim" phenomenon and ensure adequate support is given to healthcare providers involved. The best strategy seems to be the creation of networks of support at both the individual and organizational levels. More research is needed to evaluate the efficacy of support structures for second victims and to quantify the extent of the practice of defensive medicine following medical error.

The Care Process Self-Evaluation Tool: a valid and reliable instrument for measuring care process organization of health care teams

Background

Patient safety can be increased by improving the organization of care. A tool that evaluates the actual organization of care, as perceived by multidisciplinary teams, is the Care Process Self-Evaluation Tool (CPSET). CPSET was developed in 2007 and includes 29 items in five subscales: (a) patient-focused organization, (b) coordination of the care process, (c) collaboration with primary care, (d) communication with patients and family, and (e) follow-up of the care process. The goal of the present study was to further evaluate the psychometric properties of the CPSET at the team and hospital levels and to compile a cutoff score table.

Methods

The psychometric properties of the CPSET were assessed in a multicenter study in Belgium and the Netherlands. In total, 3139 team members from 114 hospitals participated. Psychometric properties were evaluated by using confirmatory factor analysis (CFA), Cronbach’s alpha, interclass correlation coefficients (ICCs), Kruskall-Wallis test, and Mann–Whitney test. For the cutoff score table, percentiles were used. Demographic variables were also evaluated.

Results

CFA showed a good model fit: a normed fit index of 0.93, a comparative fit index of 0.94, an adjusted goodness-of-fit index of 0.87, and a root mean square error of approximation of 0.06. Cronbach’s alpha values were between 0.869 and 0.950. The team-level ICCs varied between 0.127 and 0.232 and were higher than those at the hospital level (0.071-0.151). Male team members scored significantly higher than females on 2 of the 5 subscales and on the overall CPSET. There were also significant differences among age groups. Medical doctors scored significantly higher on 4 of the 5 subscales and on the overall CPSET. Coordinators of care processes scored significantly lower on 2 of the 5 subscales and on the overall CPSET. Cutoff scores for all subscales and the overall CPSET were calculated.

Conclusions

The CPSET is a valid and reliable instrument for health care teams to measure the extent care processes are organized. The cutoff table permits teams to compare how they perceive the organization of their care process relative to other teams.

[Survey of the perceived quality of healthcare in some countries of the former Soviet block]

The health systems of countries of the Former Soviet Union are all based on Semashko's system, which is no longer active since 1991 when the fall of communism occurred. Post-soviet states have tried to create new healthcare systems that maintain universal access to care. The goal of this descriptive study, conducted from August 2009 to June 2012, was to investigate the perceived quality of healthcare services in selected post-Soviet states. A questionnaire was administered by trained staff, to samples of adult healthcare service users in five countries (Belarus, Moldova, the Baltic States, Romania, and Ukraine), to investigate different aspects of the health care systems in these countries. Results were analysed by gender, profession, age and country of origin. Overall, 470 subjects participated in the study. Perceived quality of healthcare varied among different countries but an overall negative and pessimistic view of the future was identified. Gender, age group and profession were found to be determinants of perceived quality (p <0.05). The observed variations do not seem to be directly explained by the model of healthcare system adopted, rather by respondents' different socioeconomic and demographical standings.

Important variations in the content of care pathway documents for total knee arthroplasty may lead to quality and patient safety problems

AIM

Reducing variations by standardizing the key interventions in clinical processes is an effective tool to minimize the probability of medical errors. Thus, we determined whether variations exist in the key interventions included in care pathway documents (CPDs) of different organizations and in the timing of these interventions during the care process.

METHODS

We invited members of the Belgian Dutch Clinical Pathway Network to send their CPDs for external review. We analysed 19 CPDs for total knee arthroplasty. International guidelines were consulted for definition of key interventions. Documentation of these interventions in the pathway documents was checked.

RESULTS

From the 19 CPDs analysed, we retrieved 18 key interventions. Nine of these key interventions appeared in at least 80% of the care pathways. Only two key interventions appeared in all pathway documents. Nine out of 12 interventions that appeared in at least 80% of the pathway documents showed a variation of 1 day in the timing of care from the median timing.

CONCLUSION

We conclude that important variation exists in the included interventions and in their timing. The results of this study suggest that, before use in daily patient care, CPDs should be reviewed by peers and checked to ensure that all evidence-based key interventions are included and properly planned. Only in this way can pathways documents be used interprofessionally during the entire perioperative period in the search for optimal quality and patient safety.

[Cancer survival in a local health district in Piemonte (Italy): follow up to 2007]

The objectives of this study were to compare, in a standardized manner, survival of cancer patients residing in this area and to further verify the quality of baseline incidence and mortality data. The survival analysis presented here refers to cases of primary malignant tumors diagnosed for the first time from 2002 to 2004 and followed until 31 December 2007. Women were found to have lower survival rates for gastric, laryngeal and lung cancer with respect to men while good survival rates were found for cancers for which organized screening programs are available. Overall, results show that women in this health district have substantially lower survival than men, indicating that major efforts in terms of primary prevention and awareness should be geared at this population.

Eight-step method to build the clinical content of an evidence-based care pathway: the case for COPD exacerbation

BACKGROUND

Optimization of the clinical care process by integration of evidence-based knowledge is one of the active components in care pathways. When studying the impact of a care pathway by using a cluster-randomized design, standardization of the care pathway intervention is crucial. This methodology paper describes the development of the clinical content of an evidence-based care pathway for in-hospital management of chronic obstructive pulmonary disease (COPD) exacerbation in the context of a cluster-randomized controlled trial (cRCT) on care pathway effectiveness.

METHODS

The clinical content of a care pathway for COPD exacerbation was developed based on recognized process design and guideline development methods. Subsequently, based on the COPD case study, a generalized eight-step method was designed to support the development of the clinical content of an evidence-based care pathway.

RESULTS

A set of 38 evidence-based key interventions and a set of 24 process and 15 outcome indicators were developed in eight different steps. Nine Belgian multidisciplinary teams piloted both the set of key interventions and indicators. The key intervention set was judged by the teams as being valid and clinically applicable. In addition, the pilot study showed that the indicators were feasible for the involved clinicians and patients.

CONCLUSIONS

The set of 38 key interventions and the set of process and outcome indicators were found to be appropriate for the development and standardization of the clinical content of the COPD care pathway in the context of a cRCT on pathway effectiveness. The developed eight-step method may facilitate multidisciplinary teams caring for other patient populations in designing the clinical content of their future care pathways.

[Perceived quality of care in a nursing home in Piedmont (Italy)]

A cross-sectional study was conducted in the years 2003, 2005 and 2006, to assess client satisfaction in a nursing home in Piedmont (Italy). A structured questionnaire was used to evaluate three dimensions of care: interpersonal relationships, clinical care received and room comfort. Six-hundred eighty-four patients participated in the study. Of these, 33.6% were surgical patients, 33.6% were rehabilitation patients and 32.8% were medical patients. Overall, quality of care was reported as being "excellent" by 85% of patients in 2003, 85.3% of patients in 2005 and 66.1% in 2006. The study has made it possible to give a general description of client satisfaction regarding quality of services provided in a nursing home, and to identify the major critical areas. These should be analyzed in more detail, in order to identify which factors are most relevant to the patient and to implement corrective actions.

Cancer morbidity of residents living near an oil refinery plant in North-West Italy

Cerano is a municipality of the Province of Novara (North-West Italy). To assess the morbidity associated to its proximity to a petrochemical plant, standardized incidence ratios (SIRs) of oncological pathologies in the period 2003-2009 were calculated based on age-sex specific rates for the district of the Local Health Authority of Novara (ASL13) and the main regional city of Turin. For all cancers combined, men showed a significant higher risk (SIR: 1.21; 95% CI: 1.02-1.40) compared to the ASL13 population; significantly lower risks for both men and women were observed in comparison to the Turin population. Among women, a significant excess of mesothelioma cancers was reported; a significantly higher risk for lympho-haematopoietic pathologies was also observed compared to the Turin population only. Several other cancers have significantly lower rates in Cerano for both men and women. Despite some studies' limitations, these findings could suggest potential chemical risk factors and need further investigation.

Effects of care pathways on the in-hospital treatment of heart failure: a systematic review

BACKGROUND

Care pathways have become a popular tool to enhance the quality of care by improving patient outcomes, promoting patient safety, increasing patient satisfaction, and optimizing the use of resources. We performed a disease specific systematic review to determine how care pathways in the hospital treatment of heart failure affect in-hospital mortality, length of in-hospital stay, readmission rate and hospitalisation cost when compared with standard care.

METHODS

Medline, Cinahl, Embase and the Cochrane Central Register of Controlled Trials were searched from 1985 to 2010. Each study was assessed independently by two reviewers. Methodological quality of the included studies was assed using the Jadad methodological approach for randomised controlled trials, controlled clinical trials and the New Castle Ottawa Scale for case-control studies, cohort studies and time interrupted series.

RESULTS

Seven studies met the study inclusion criteria and were included in the systematic review with a total sample of 3,690 patients. The combined overall results showed that care pathways have a significant positive effect on mortality and readmission rate. A shorter length of hospital stay was also observed compared with the standard care group. No significant difference was found in the hospitalisation costs. More positive results were observed in controlled trials compared to randomized controlled trials.

CONCLUSION

By combining all possible results, it can be concluded that care pathways for treatment of heart failure decrease mortality rates and length of hospital stay, but no statistically significant difference was observed in the readmission rates and hospitalisation costs. However, one should be cautious with overall conclusions: what works for one organization may not work for another because of the subtle differences in processes and bottlenecks.

Health care professionals as second victims after adverse events: a systematic review

Adverse events within health care settings can lead to two victims. The first victim is the patient and family and the second victim is the involved health care professional. The latter is the focus of this review. The objectives are to determine definitions of this concept, research the prevalence and the impact of the adverse event on the second victim, and the used coping strategies. Therefore a literature research was performed by using a three-step search procedure. A total of 32 research articles and 9 nonresearch articles were identified. The second victim phenomenon was first described by Wu in 2000. In 2009, Scott et al. introduced a detailed definition of second victims. The prevalence of second victims after an adverse event varied from 10.4% up to 43.3%. Common reactions can be emotional, cognitive, and behavioral. The coping strategies used by second victims have an impact on their patients, colleagues, and themselves. After the adverse event, defensive as well as constructive changes have been reported in practice. The second victim phenomenon has a significant impact on clinicians, colleagues, and subsequent patients. Because of this broad impact it is important to offer support for second victims. When an adverse event occurs, it is critical that support networks are in place to protect both the patient and involved health care providers.

[An update on several indicators of the quality of data flow in a cancer registry in Vercelli (Piedmont, Italy)]

The first estimates of cancer incidence in the city of Vercelli in Piedmont (Italy) are now available for the years 2002 to 2005 and preliminary data are also available up to 2009. With respect to previously published results, the cancer database has been integrated with information from additional data sources to ensure that it will become, in the near future, a sound basis of information upon which to build an accredited cancer registry. An evaluation was therefore performed of two indicators of the quality of data flow: the proportion of cases with histological confirmation of diagnosis and cancer mortality to incidence (M/I) ratios. Both show an improvement with respect to 2005 but need to be significantly improved to reach the levels of excellence and accuracy that a registry must necessarily possess. Local health authorities will need to ensure staff availability and facilitate access to key data sources to fully evaluate cancer epidemiology in the area.

A cluster randomized trial to assess the effect of clinical pathways for patients with stroke: results of the clinical pathways for effective and appropriate care study

BACKGROUND

Clinical pathways (CPs) are used to improve the outcomes of acute stroke, but their use in stroke care is questionable, because the evidence on their effectiveness is still inconclusive. The objective of this study was to evaluate whether CPs improve the outcomes and the quality of care provided to patients after acute ischemic stroke.

METHODS

This was a multicentre cluster-randomized trial, in which 14 hospitals were randomized to the CP arm or to the non intervention/usual care (UC) arm. Healthcare workers in the CP arm received 3 days of training in quality improvement of CPs and in use of a standardized package including information on evidence-based key interventions and indicators. Healthcare workers in the usual-care arm followed their standard procedures. The teams in the CP arm developed their CPs over a 6-month period. The primary end point was mortality. Secondary end points were: use of diagnostic and therapeutic procedures, implementation of organized care, length of stay, re-admission and institutionalization rates after discharge, dependency levels, and complication rates.

RESULTS

Compared with the patients in the UC arm, the patients in the CP arm had a significantly lower risk of mortality at 7 days (OR = 0.10; 95% CI 0.01 to 0.95) and significantly lower rates of adverse functional outcomes, expressed as the odds of not returning to pre-stroke functioning in their daily life (OR = 0.42; 95 CI 0.18 to 0.98). There was no significant effect on 30-day mortality. Compared with the UC arm, the hospital diagnostic and therapeutic procedures were performed more appropriately in the CP arm, and the evidence-based key interventions and organized care were more applied in the CP arm.

CONCLUSIONS

CPs can significantly improve the outcomes of patients with ischemic patients with stroke, indicating better application of evidence-based key interventions and of diagnostic and therapeutic procedures. This study tested a new hypothesis and provided evidence on how CPs can work.

TRIAL REGISTRATION

ClinicalTrials.gov ID: [NCT00673491].

The effect of care pathways for hip fractures: a systematic review

We performed a systematic review for primary studies on care pathways (CPs) for hip fracture (HF). The online databases MEDLINE-PubMed, Ovid-EMBASE, CINAHL-EBSCO host, and The Cochrane Library (Cochrane Central Register of Clinical Trials, Health Technology Assessment Database, NHS Economic Evaluation Database) were searched. Two researchers reviewed the literature independently. Primary studies that met predefined inclusion criteria were assessed for their methodological quality. A total of 15 publications were included: 15 primary studies corresponding with 12 main investigations. Primary studies were evaluated for clinical outcomes, process outcomes, and economic outcomes. The studies assessed a wide range of outcome measures. While a number of divergent clinical outcomes were reported, most studies showed positive results of process management and health-services utilization. In terms of mortality, the results provided evidence for a positive impact of CPs on in-hospital mortality. Most studies also showed a significantly reduced risk of complications, including medical complications, wound infections, and pressure sores. Moreover, time-span process measures showed that an improvement in the organization of care was achieved through the use of CPs. Conflicting results were observed with regard to functional recovery and mobility between patients treated with CPs compared to usual care. Although our review suggests that CPs can have positive effects in patients with HF, the available evidence is insufficient for formal recommendations. There is a need for more research on CPs with selected process and outcome indicators, for in-hospital and postdischarge management of HF, with an emphasis on well-designed randomized trials.

[Health status of residents of the town of Trino Vercellese (Italy): cancer mortality from 2000 to 2010 and other epidemiological indicators]

The authors evaluated the health status of the population of Trino, a town in the province of Vercelli (Piedmont region, northern Italy) that houses several industries such as cement plants and foundries and that in the past (1964-1987) has been the site of a nuclear power plant. In detail, cancer mortality data for the years 2000 to 2010 was analyzed and the excess mortality with respect to cancer deaths registered in the city of Torino (also in the Piedmont region) from 2006 to 2008 was calculated. Significantly more deaths were observed than expected for cancers of the nervous system, leukemia, mesothelioma and peritoneal cancer. Additional indicators such as standardized years of life lost and the cumulative risk of mortality from birth to 74 years highlight several epidemiological anomalies when compared to the European population, that will be investigated in the future through case-control studies and spatial analyses.