[Framework for evaluating the performance of local healthcare: international experiences and prospects for Italy.]

The Italian National healthcare service currently lacks a synthetic framework for measuring the primary care legislative reform established by the National recovery and resilience plan and the legislative reform, Decree number 77/2022. This paper explores the existing international and national literature on primary care' monitoring and evaluation systems with the purpose of drawing guidelines to build up a global and systematic framework. The 2022 World health organization framework is the most advanced reference point as a result of more than twenty years of theoretical and field research. Indeed, it can be regarded as the basic model to be adapted to the specificities of the current Italian legislation and organization.

The meta-projects of the new community health centers, community hospitals and local operative centers for the Italian country

BACKGROUND AND AIM

COVID-19 highlighted significant criticalities of the Italian National Healthcare System (NHS) and recently the Italian Government approved the National Recovery and Resilience Plan (NRRP) to relaunch its economy and at the same time to promote health, sustainability and digital innovation. Specifically, M6C1 (Mission 6 Component 1) wants to introduce Community Health Centers (CHCs), Community Hospitals (CHs) and Local Operative Centers (LOCs) to strength territorial healthcare services. Starting from the Italian Ministerial Decree n. 77 (2022), AGENAS (National Agency for Regional Healthcare System) and POLIMI (Politecnico di Milano) working group developed the meta-design guidelines for CHCs, CHs and LOCs facilities with the aim of supporting decision-makers to define spatial features and building performances in order to be responsive to functional issues.

METHODS

The spatial strategies of these facilities have been elicited through three different steps: a) a survey about the current national and international scenario regarding the territorial healthcare; b) a review of all national and regional regulations; c) the development of the meta-design guidelines have been elaborated from the analysis of the a) and b) steps.

RESULTS

The regulatory instructions and scientific indications collected through the literature have been translated into spatial and functional layouts. The services have been organized by homogeneous macro-areas and defined in a synoptic framework which shows the performance approach and their features. Each macro-area, sorted by type of functions, has been subdivided into a list of all its specific spatial units.

CONCLUSIONS

The study conducted aims at supporting the planning of these facilities in relation to the catchment area and their sizing. It will be necessary to define the location by evaluating the possibility of setting them up within existing hospitals, as well as to guarantee a sustainable approach in the realization of these infrastructures.

[Staffing standards in residential facilities: a regional regulatory survey]

. Staffing standards in residential facilities: a regional regulatory survey.

INTRODUCTION

Residential facilities are present in all Regions and several data useful to better understand the activities performed are available through the residential care information flow. To date, some information useful for analysing staffing standards is difficult to capture and very likely in the Italian Regions heterogeneous care modalities and staffing levels are present.

AIM

To investigate the staffing standards of residential facilities in Italian Regions.

METHODS

A review of regional regulations was carried out, between January and March 2022, on the website Leggi d'Italia, searching for documents on staffing standards in residential facilities.

RESULTS

45 documents were analysed and 16 from 13 regions were included. There are important inhomogeneities between regions. For example, Sicily sets unique staffing standards irrespective of the severity/complexity of the residents; the number minutes of nursing care per patient, for residents in intensive residential care may vary from 90 to 148 minutes/day. Standards have been set for nurses but not always for health care assistants, physiotherapists and social workers.

CONCLUSIONS

Only a few regions have defined standards for all the main professions in the community health system. The variability described should be interpreted accounting for the socio-organisational contexts of the region, the organisational models adopted, and the staffing skill-mix.

Does the healthcare system know what to cut under the pandemic emergency pressure? An observational study on geographic variation of surgical procedures in Italy

OBJECTIVES

During 2020 many countries reduced the number of elective surgeries to free up beds and cope with the COVID-19 outbreak. This situation led healthcare systems to prioritise elective interventions and reduce the overall volumes of treatments.The aim of this paper is to analyse whether the pandemic and the prioritisation policies on elective surgery were done considering the potential inappropriateness highlighted by the measurement of geographic variation.

SETTING

The setting of the study is acute care with a focus on elective surgical procedures. Data were analysed at the Italian regional level.

PARTICIPANTS

The study is observational and relies on national hospitalisation records from 2019 to 2020. The analyses refer to the 21 Italian regional health systems, using 48 917 records for 2019 and 33 821 for 2020. The surgical procedures analysed are those considered at high risk of unwarranted variation: coronary angioplasty, cholecystectomy, colectomy, knee replacement, hysterectomy, tonsillectomy, hip replacement and vein stripping.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary measures were the hospitalisation rate and its reduction per procedure, to understand the level of potential inappropriateness. Secondary measures were the SD and high/low ratio, to map the level of geographic variation.

RESULTS

For some procedures, there is a linear negative relationship (eg, tonsillectomy: ρ = -0.92, p<0.01; vein stripping: ρ = -0.93, p<0.01) between the reduction in hospitalisation and its starting point. The only two procedures for which no significant differences were registered are cholecystectomy (ρ = -0.22, p=0.31) and hysterectomy (ρ = -0.22, p=0.33). In particular, in all cases, data show that regions with higher 2019 hospitalisation rates registered a larger reduction.

CONCLUSIONS

The Italian data show that the pandemic seems to have led hospital managers and health professionals to cut surgical interventions more likely to be inappropriate. Hence, these findings can inform and guide the healthcare system to manage unwarranted variation when coming back to the new normal. This new starting point (lower volumes in some selected elective surgical procedures) should be used to plan elective surgical treatments that can be cancelled because of their high risk of inappropriateness.

A novel plot for the early alert of epidemic growth using regional targets: the doubling plot

Background

During the pandemic, restrictions set by the Italian Government were primarily based on the regional level of key parameters including hospitalization and incidence rates. We aimed to build a specific plot to monitor trends and trigger early alerts, with daily updates publicly available on a National Portal.

Methods

A multidisciplinary team conceived and implemented a new composite plot, developing ad hoc R scripts on top of a specialised database, built in collaboration with the Ministry of Health. We calculated the doubling time Td as log(2)/log(1+r/100), where r is the daily change of target parameters and Td ranges between (0,+-infinity), and not determined for constant or missing values. We calculated Td daily, as either doubling (growth) or halving (decrease) time. To visualize trends, we assembled two different types of graphs: a bivariate plot showing the path of each point (Td, target parameter) over time, and a line plot of Td over time. The Y axis was inverted for doubling times, as lower Td indicate higher alert in this case. The two graphs were arranged in lines, using cutoffs for excessive high values for doubling times and low values for halving times. A third line was included to display trends of the target parameter over time.

Results

The plot was successfully realized and published on the Portal for all regions in February 2021 (https://www.agenas.gov.it/covid19/web/index.php?r=english%2Fdoubling&q=ITA&t=0). Since July 2021, we used the doubling plot to monitor the three main parameters adopted to set restrictions for Covid-19: a) occupancy rates in intensive care; b) occupancy rates in medical wards; c) weekly incidence rates. The plot highlighted growth trends and early alerts, particularly in the initial phases of growth.

Conclusions

The doubling plot can provide useful information to trigger early responses for pandemic control in decentralised governance. R code is available open source from AGENAS for free use.

Key messages

• The doubling plot was conceived and implemented on a National Portal to trigger early alerts of Covid-19 progression in Italian Regions and Autonomous Provinces.

• The plot could be rapidly adapted to legislative parameters and can be useful in different situations to monitor epidemic growth and support public health policies.

A novel stream of collaborative National portals to enhance preparedness and informed choices

Issue/problem

AGENAS supports the implementation of health policies in direct collaboration with Italian Regions and Autonomous Provinces. To improve public reporting, we aimed to complement the production of technical reports with new forms of timely communication, using National Portals.

Description of the problem

Between October-December 2020, we designed and implemented the Covid-19 National Portal, including a suite of targeted indicators, fully automated via ad hoc scripts written in php and R on top of a relational database using internal and external data sources. Targeted information was widely communicated and continuously updated. Dedicated sections on forecasting and resilience were delivered in collaboration with specialised academic institutions. In 2021, we deployed the Portal for the Transparency of Health Services, broadly oriented towards health issues, the location of services and performance indicators.

Results

Pre-post comparisons of web analytics for Jan-Apr 2020-2022 showed clear advantages of Covid-19 Portal. By Apr 2020, Italy had introduced national lockdown, while AGENAS covered the topic traditionally, recording 48,122 users overall, with daily peaks below 5,000 sessions. In 2021-2022, the number of users skyrocketed at 436,280, with daily peaks of 100,000 sessions, and 421,123 respectively, with daily peaks of 150,000 sessions. Visits to the Transparency Portal were considerably more limited.

Lessons

To be widely used, public health information needs to be relevant (responding to personal need close to home), understandable, accurate and timely. National Portals can gain efficiency through the mediation of search engines, enhanced by: targeted naming (url), coherent semantic perimeter (third level domain in a highly referenced institutional website), continuous updating, and impact factor (linked by authoritative websites). The Transparency Portal will take stock of these lessons to succeed in a new funded program of NextGenerationEU.

Key messages

• Relevant, understandable, accurate and timely dissemination for different types of audience may be effectively organised through National Portals.

• Productive collaboration between health specialists and communication experts can enhance usability and actionability of National Portals for public health.

The Italian investment in telemedicine: a breakthrough model of care in primary care

Issue/Problem

Aging populations, worsening burden of chronic disease and recent pandemic has accelerated awareness and the importance of telemedicine in providing continuity of healthcare.

Description of the problem

AGENAS is the public body responsible for the implementation of telemedicine investment (€1 billion) in the context of the NextGenerationEU plan. AGENAS has built up a working group expert panel to define the technical and informatics features of the investment. The project consists of the realization of the national telemedicine platform and the regional telemedicine services. Italian regions will implement telemedicine services based on the national guidelines defined by AGENAS, that will also monitor it through key performance indicators outlined on the basis of best practices and scientific evidence of multidimensional evaluation.

Results

National telemedicine platform will improve, optimise and standardise telemedicine services throughout the Country, considering what may already be available in regional and local healthcare contexts. Regarding telemedicine services in regional context, that will be implemented within the NextGenerationEU, they will be focused on the telemonitoring of high prevalence conditions (i.e. cardiological, respiratory, diabetes, neurological and oncological) as well as other services such as televisit, teleconsultation and teleassistance. Connecting patient's home with healthcare system provide benefits for patients and their families, who will be able to interact with healthcare professionals, obtaining consultation and monitoring of their health.

Lessons

The implementation of the investment, aiming at improving equity and integration of care, will contribute to provide real world evidence about usage, benefits and potential risk of the telemedicine in primary care for the management of chronic diseases.

Key messages

• The investment under the Next Generation EU plan it is the lifetime chance to transform Italian healthcare service and draw a new framework to cope with the high demand in telemedicine.

• Improving telemedicine services will determine a breakthrough in management of patient with chronic diseases in the Italian primary care sector.

[Relationship between hospital volumes and health outcomes: epidemiological evidence supporting the revision process of the Ministry of Health Decree no. 70 of 2 April 2015.]

Since its enactment on 2 April 2015, the Decree of the Ministry of Health no.70 has provided a key framework for the reorganization of services to enhance the quality and safety of care. This decree presents the volume thresholds for a series of nosological areas and diagnostic-therapeutic procedures, aiming to improve healthcare outcomes. These thresholds are expected to be periodically updated based on the most recent scientific developments.

AIM

In this perspective, this work intends to establish whether statistical correlations exist between volumes of activity and outcomes of hospital care. The scope is limited to several clinical conditions and therapeutic procedures for which specific indicators are provided by the National Healthcare Outcomes Programme (Programma Nazionale Esiti - PNE).

METHODS

For each condition or procedure, the analysis shows the volume-outcome relationship by hospital centre by means of the Levenberg-Marquardt algorithm (software: XLSTAT). The existence of breakpoints is assessed through the use of segmented models (software: "segmented" R-Package).

RESULTS

The results show a statistical correlation for the following: acute myocardial infarction (breakpoint: 91 hospitalizations per year; 95% CI: 81-101; p<0.0001); repair of an unruptured abdominal aortic aneurysm (breakpoint: 69 procedures per year; 95% CI: 52-86; p=0.146); lung cancer (breakpoint: 96 procedures per year; 95% CI: 60-132; p<0.01); knee arthroplasty (breakpoint: 91 procedures per year; 95% CI: 51-131; p=0.484). Conversely, the statistical analysis did not allow to accurately highlight a breakpoint for the isolated aorto-coronary bypass, percutaneous transluminal coronary angioplasty and hip arthroplasty.

CONCLUSIONS

These results represent a useful knowledge contribution to support the revision process of the above-mentioned Decree. As regards the procedures that may not be currently assessed through this statistical analysis method, literature data is referred to that confirm that the current regulatory thresholds are in the safe range.

[Family nurses in Italy: an explorative survey]

. Family nurses in Italy: an explorative survey.

INTRODUCTION

The Family and Community Nurses (FCN) are unevenly distributed throughout Italy.

AIM

to describe the numbers, functions and work situation of FCNs in Italy.

METHODS

A questionnaire with 24 multiple-choice questions was sent to 60 Nursing and health professions District managers, to explore numerical standards of reference, recruitment methods, training, work environments and methods, hierarchical and functional dependencies, functions performed and level of autonomy.

RESULTS

38 (63%) managers from 14 regions responded. In 26 (68%) districts, FCNs are employed with numbers ranging from 2 to 350 per district (median FCN/inhabitants ratio of approximately 1/16.000 inhabitants (IQR 10.000-40.000). Nurses with at least 2 years of work experience (in home or medical care) were selected, and all have attended or are currently attending a training course (university, regional - 40% of the districts - or internal courses). In almost all Districts FCNs hierarchically depend on the Nurse Manager while functionally from the District Nurse or Medical Director. FCNs mostly work in multidisciplinary teams and in most Districts (21, 80%) perceive good levels of autonomy.

CONCLUSIONS

Although a limited number of managers responded, these data provide a cross-section of the variability of numbers and organization at district level.

Associations between mortality from COVID-19 in two Italian regions and outdoor air pollution as assessed through tropospheric nitrogen dioxide

After the appearance of COVID-19 in China last December 2019, Italy was the first European country to be severely affected by the outbreak. The first diagnosis in Italy was on February 20, 2020, followed by the establishment of a light and a tight lockdown on February 23 and on March 8, 2020, respectively. The virus spread rapidly, particularly in the North of the country in the 'Padan Plain' area, known as one of the most polluted regions in Europe. Air pollution has been recently hypothesized to enhance the clinical severity of SARS-CoV-2 infection, acting through adverse effects on immunity, induction of respiratory and other chronic disease, upregulation of viral receptor ACE-2, and possible pathogen transportation as a virus carrier. We investigated the association between air pollution and subsequent COVID-19 mortality rates within two Italian regions (Veneto and Emilia-Romagna). We estimated ground-level nitrogen dioxide through its tropospheric levels using data available from the Sentinel-5P satellites of the European Space Agency Copernicus Earth Observation Programme before the lockdown. We then examined COVID-19 mortality rates in relation to the nitrogen dioxide levels at three 14-day lag points after the lockdown, namely March 8, 22 and April 5, 2020. Using a multivariable negative binomial regression model, we found an association between nitrogen dioxide and COVID-19 mortality. Although ecological data provide only weak evidence, these findings indicate an association between air pollution levels and COVID-19 severity.

Epidemiology and public health response in early phase of COVID-19 pandemic, Veneto Region, Italy, 21 February to 2 April 2020

Background

Veneto was one of the Italian regions hit hardest by the early phase of the coronavirus disease (COVID-19) pandemic.

Aim

This paper describes the public health response and epidemiology of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections in the Veneto Region from 21 February to 2 April 2020.

Methods

Information on the public health response was collected from regional health authorities’ official sources. Epidemiological data were extracted from a web-based regional surveillance system. The epidemic curve was represented by date of testing. Characteristics of hospitalised COVID-19 cases were described and compared to those never admitted to hospital. Age- and sex-stratified case-fatality ratios (CFRs) were calculated.

Results

Key elements of the regional public health response were thorough case-finding and contact tracing, home care for non-severe cases, creation of dedicated COVID-19 healthcare facilities and activation of sub-intensive care units for non-invasive ventilation. As at 2 April 2020, 91,345 individuals were tested for SARS-CoV-2 and 10,457 (11.4%) were positive. Testing and attack rates were 18.6 per 1,000 and 213.2 per 100,000 population, respectively. The epidemic peaked around 20 to 24 March, with case numbers declining thereafter. Hospitalised cases (n = 3,623; 34.6%) were older and more frequently male compared with never-hospitalised cases. The CFR was 5.6% overall, and was higher among males and people > 60 years of age.

Conclusion

In the Veneto Region, the strict social distancing measures imposed by the Italian government were supported by thorough case finding and contact tracing, as well as well-defined roles for different levels of care.

Evaluating the effects of polices on nursing care as promoted by the Veneto region: the research protocol and its implications for public health

Study design

Multi-centre mixed-method study design organised into several phases.

Background

The Veneto region has recently defined a set of policies on nursing care by determining the needed amount of daily care in minutes and by initiating a systematic measurement of nursing outcomes; also, with a more recent policy, missed nursing care (MNC) has been established as a process measure of interest. To measure the effect of these policies, a research protocol - aimed at evaluating several end points - has been designed, involving a large target population and hospital units. The aim of this manuscript is to briefly present the research protocol and to discuss the public health implications of its expected end-points.

Methods

The endpoints of the protocol are: (a) to describe the frequency of MNC as perceived by nurses; (b) to identify contributing factors; (c) to identify practices adopted in low-occurrence MNC units and to assess the effectiveness of implementing them in units with higher levels of MNC; (d) to explore the relationship between the amount of nursing care provided, MNC, and patient outcomes; and (e) to validate a tool that measures MNC as perceived by patients/caregivers. A total of 3,460 nurses, 5,000 patient/day and 160 nursing coordinators of the medical and surgical units of public hospitals in the Veneto Region will be included.

Conclusions

Measuring the association between the amount of nursing care and patient outcomes, as well as evaluating the role of MNC as perceived by nurses and patients in hindering or increasing the risk of some patient outcomes can provide a body of evidence capable of further informing policies in the field, both at the national and at the international level. Moreover, emerging good practices capable of preventing or minimising MNC, sharing and implementing them in other units where high levels of missed care are reported and evaluating their effectiveness, can also inform public health policies.

Exposure to PFAS and small for gestational age new-borns: A birth records study in Veneto Region (Italy)

BACKGROUND

Perfluoroalkylated substances (PFAS) in serum are inversely associated with fetal growth. Small for gestational age (SGA) is a measure based on birth weight and gestational age at birth and represents a good indicator of fetal growth but it has been used only in a small number of studies. We examined the association between PFAS exposure and the risk of severe SGA in a PFAS contaminated area in the Veneto Region (North-East of Italy).

METHODS

A retrospective cohort study has been developed including all singleton live births reported in the Veneto Region Birth Registry between 2003 and 2018 to mothers living in the contaminated and in a control area. We estimated the association between mothers' area of residence and severe SGA using crude RR (and 95% CI) and stepwise logistic regression, including all the maternal characteristics.

RESULTS

The study included 105,114 singleton live births. The occurence of severe SGA was 3.44% in the contaminated area and 2.67% in the control area. The multivariate analysis confirmed that living in the contaminated area significantly increased the odds of severe SGA (adjusted OR 1.27 (95% C.I. 1.16, 1.39)).

CONCLUSIONS

The findings suggest that living in a contaminated area by PFAS plays a role in affecting fetal growth and support the hypothesis that PFAS exposure is a risk factor for SGA. Individual data on exposure are needed to confirm the direct association.

Serum Levels of Perfluoroalkyl Substances (PFAS) in Adolescents and Young Adults Exposed to Contaminated Drinking Water in the Veneto Region, Italy: A Cross-Sectional Study Based on a Health Surveillance Program

BACKGROUND

In spring 2013, groundwater of a vast area of the Veneto Region (northeastern Italy) was found to be contaminated by perfluoroalkyl substances (PFAS) from a PFAS manufacturing plant active since the late 1960s. Residents were exposed to high concentrations of PFAS, particularly perfluorooctanoic acid (PFOA), through drinking water until autumn 2013. A publicly funded health surveillance program is under way to aid in the prevention, early diagnosis, and treatment of chronic disorders possibly associated with PFAS exposure.

OBJECTIVES

The objectives of this paper are: a) to describe the organization of the health surveillance program, b) to report serum PFAS concentrations in adolescents and young adults, and c) to identify predictors of serum PFAS concentrations in the studied population.

METHODS

The health surveillance program offered to residents of municipalities supplied by contaminated waterworks includes a structured interview, routine blood and urine tests, and measurement of 12 PFAS in serum by high-performance liquid chromatography-tandem mass spectrometry. We studied 18,345 participants born between 1978 and 2002, 14-39 years of age at recruitment. Multivariable linear regression was used to identify sociodemographic, lifestyle, dietary, and reproductive predictors of serum PFAS concentrations.

RESULTS

The PFAS with the highest serum concentrations were PFOA [median 44.4   ng / mL , interquartile range (IQR) 19.3-84.9], perfluorohexanesulfonic acid (PFHxS) (median 3.9   ng / mL , IQR 1.9-7.4), and perfluorooctanesulfonic acid (PFOS) (median 3.9   ng / mL , IQR 2.6-5.8). The major predictors of serum levels were gender, municipality, duration of residence in the affected area, and number of deliveries. Overall, the regression models explained 37%, 23%, and 43% of the variance of PFOA, PFOS, and PFHxS, respectively.

CONCLUSIONS

Serum PFOA concentrations were high relative to concentrations in populations with background residential exposures only. Interindividual variation of serum PFAS levels was partially explained by the considered predictors. https://doi.org/10.1289/EHP5337.

Heart failure in the Veneto region of Italy: analysis of therapeutic pathways and the utilization of healthcare resources

Objectives: Aim of the study was to describe the use and pharmacoutilization profiles of recommended drugs for HF patients, hospital re-admission rates, mortality rates and determine healthcare resource consumption and related costs for HF patients in an Italian region. Methods: We retrospectively analyzed data from the administrative database and included adult patients who were discharged alive with a primary or secondary HF diagnosis between 1 January 2010 and 31 December 2015. We assessed data on HF-related drug prescriptions at discharge and during a 12-month follow-up period, as well as treatment adherence and treatment modification. All-cause mortality, hospital HF re-admission, and mean direct cost per patient were also analyzed during the follow-up period. Results: A total of 69,164 patients were included. One in ten patients had discontinued all treatment initially prescribed by the end of follow-up. In total, 25.9% of patients were re-hospitalized with an HF diagnosis during the follow-up period; the mortality rate at 12 months was 24.3%. The mean annual cost per patient was €6,303.7, with nearly three-fourths attributable to hospitalizations. Conclusions: In our study, we observed an under-prescription of recommended drugs for the treatment of HF. Moreover, one out of four HF patients were re-hospitalized for HF-related causes and the healthcare costs related to hospitalization accounted for the great majority of the total healthcare resource costs.

An overview of future EU health systems. An insight into governance, primary care, data collection and citizens' participation

Background

Health systems in the European Union (EU) are being questioned over their effectiveness and sustainability. In pursuing both goals, they have to conciliate coexisting, not always aligned, realities.

Methods

This paper originated from a workshop entitled 'Health systems for the future' held at the European Parliament. Experts and decision makers were asked to discuss measures that may increase the effectiveness and sustainability of health systems, namely: (i) increasing citizens' participation; (ii) the importance of primary care in providing integrated services; (iii) improving the governance and (iv) fostering better data collection and information channels to support the decision making process.

Results

In the parliamentary debate, was discussed the concept that, in the near future, health systems' effectiveness and sustainability will very much depend on effective access to integrated services where primary care is pivotal, a clearer shift from care-oriented systems to health promotion and prevention, a profound commitment to good governance, particularly to stakeholders participation, and a systematic reuse of data meant to build health data-driven learning systems.

Conclusions

Many health issues, such as future health systems in the EU, are potentially transformative and hence an intense political issue. It is policy-making leadership that will mostly determine how well EU health systems are prepared to face future challenges.

[National survey to verify the implementation of State-Regions agreements introducing the professional profile of health social care worker and instituting a complementary training program for nursing assistants, Italy]

The professional profile of health social care worker (OSS) was introduced in Italy in 2001 and has become a fundamental figure in the Italian healthcare and social-health services system. However, changes have occurred in Italian health, clinical care and social realities since the OSS profile was defined. This article reports the results of a national-level study to investigate the state of application of the State-Regions Agreement of 22 February 2001, establishing the professional profile of OSS and regulating its characteristics and competencies, as that of the agreement of 16 January 2003, regulating the complementary healthcare training for nursing assistants.

[Measuring nursing sensitive outcomes in publicly funded hospitals in the Veneto Region, Italy: the development of a regional policy]

INTRODUCTION

The indicators used in the Italian National Outcome Strategy does not include measurement of nursing care outcomes so these have not yet been assessed systematically in our country but only in the context of specific research projects. Positive and negative outcomes of nursing care have been documented in the literature, the latter associated with missed nursing care, a phenomenon that occurs when conditions are such that nurses are unable to deliver planned care to patients.

OBJECTIVES

To describe the rationale, methodology and main results achieved to date in the development of a regional policy aimed at establishing a panel of indicators for monitoring nursing care-sensitive outcomes hospitals in publicly funded hospitals in the Veneto Region (northern Italy).

METHODS

A plurennial, multi-method project based on [1] identification of selection criteria for a Minimum Data Set of indicators; [2] a rapid review of the literature and of the policies established internationally to measure nursing care-sensitive outcomes; [3] the establishment of an initial panel of indicators and evaluation of any critical issues with the chosen indicators, and [4] identification of the most appropriate tool for measuring missed nursing care.

RESULTS

The medical and surgical units were considered to be the most suitable settings for the pilot study. Following the literature review, indicators that were already being monitored in the current regional information system were chosen, with the intent to prevent an additional administrative burden to nurses. By using a progressive consensus process, five outcome indicators (functional status, falls, pressure sores, urinary tract infections, aspiration pneumonia) and one process indicator (missed nursing care) were selected., and the tools for measuring the above-mentioned indicators and their related risks, were identified. A regional policy was then established to measure these indicators in a pilot phase, with the intent of implementing them as stable indicators to be measured in the new computerized hospital information system.

CONCLUSIONS

An initial panel of nursing-sensitive outcome indicators has been defined to be used in Internal Medicine and General Surgery units of hospitals in Italy's Veneto Region. Despite its limitations, the project represents the first effort to create a regional policy to measure the contribution of nursing care to the health outcomes of patients and that will also the identification of potential relations with other variables such as personnel staffing and/or skill mix.

A case-mix classification system for explaining healthcare costs using administrative data in Italy

BACKGROUND

The Italian National Health Service (NHS) provides universal coverage to all citizens, granting primary and hospital care with a copayment system for outpatient and drug services. Financing of Local Health Trusts (LHTs) is based on a capitation system adjusted only for age, gender and area of residence. We applied a risk-adjustment system (Johns Hopkins Adjusted Clinical Groups System, ACG® System) in order to explain health care costs using routinely collected administrative data in the Veneto Region (North-eastern Italy).

METHODS

All residents in the Veneto Region were included in the study. The ACG system was applied to classify the regional population based on the following information sources for the year 2015: Hospital Discharges, Emergency Room visits, Chronic disease registry for copayment exemptions, ambulatory visits, medications, the Home care database, and drug prescriptions. Simple linear regressions were used to contrast an age-gender model to models incorporating more comprehensive risk measures aimed at predicting health care costs.

RESULTS

A simple age-gender model explained only 8% of the variance of 2015 total costs. Adding diagnoses-related variables provided a 23% increase, while pharmacy based variables provided an additional 17% increase in explained variance. The adjusted R-squared of the comprehensive model was 6 times that of the simple age-gender model.

CONCLUSIONS

ACG System provides substantial improvement in predicting health care costs when compared to simple age-gender adjustments. Aging itself is not the main determinant of the increase of health care costs, which is better explained by the accumulation of chronic conditions and the resulting multimorbidity.

[The process of defining the competence profile of the healthcare professions manager in the Veneto Region]

Presented here is the approach used by a multidisciplinary working group fo the drafting of the "core" competence profile of the healthcare professions manager in the Veneto Region. Defining a competence profile allows for specifying a standard for measuring the skills acquired by a professional and the gap level from what is expected by the organization, as well as orienting the preparatory education to carry out the related role.

Hub-and-spoke stroke network in the Veneto region: a retrospective study investigating the effectiveness of the stroke pathway and trends over time

After recognizing the pivotal role played by stroke unit (SU) admission in reducing mortality and dependency in stroke patients, the need to organize and monitor stroke networks has become an increasingly essential aspect of stroke care. We conducted a retrospective study of stroke patients admitted to hospitals in the Veneto region from 2007 to 2015 in order to evaluate the effectiveness of the stroke pathway and trends over time. Between 2007 and 2015, 61,062 stroke patients were discharged from Veneto hospitals: they were more frequently female, females were older than males, and had higher intrahospital mortality and a lower probability of undergoing systemic thrombolysis. Patients admitted to facilities with a level 2 SU were twice as likely to undergo thrombolytic treatment compared to those admitted to facilities with a level 1 and had a lower intrahospital mortality rate. During the collection period, thrombolytic treatments increased in both level 1 and 2 SUs, as did the number of patients admitted to neurology wards and to facilities with an SU. Our study confirmed that thrombolytic treatment and admission to a facility with an SU are important determinants in improving stroke patient outcome. The increase in the proportion of both SU admissions and thrombolytic treatments demonstrates the effectiveness of the regional hub-and-spoke organization model, suggesting that implementation of highly specialized facilities is an efficient strategy in improving stroke care. The role of the observed sex bias in stroke treatment and outcome needs to be explored.

Intensity of integrated cancer palliative care plans and end-of-life acute medical hospitalisation among cancer patient in Northern Italy

A high hospital utilisation at the end of life (EOL) is an indicator of suboptimal quality of health care. We evaluated the impact of the intensity of different Integrated Cancer Palliative Care (ICPC) plans on EOL acute medical hospitalisation among cancer decedents. Decedents of cancer aged 18-84 years, who were residents in two Italian regions, were investigated through integrated administrative data. Outcomes considered were prolonged hospital stay for medical reasons, 2+ hospitalisations during the last month of life and hospital death. The ICPC plans instituted 90 to 31 days before death represented the main exposure of interest. Other variables considered were gender, age class at death, marital status, recent hospitalisation and primary cancer site. Among 6,698 patients included in ICPC plans, 44.3% presented at least one critical outcome indicator; among these, 76.5% died in hospital, 60.3% had a prolonged (12+ days) medical hospitalisation, 19.1% had 2+ hospitalisations at the EOL. These outcomes showed a strong dose-response effect with the intensity of the ICPC plans, which is already evident at levels of moderate intensity. A well-ICPC approach can be very effective-beginning at low levels of intensity of care-in reducing the percentage of patients spending many days or dying in hospital.

End-of-Life Place of Care, Health Care Settings, and Health Care Transitions Among Cancer Patients: Impact of an Integrated Cancer Palliative Care Plan

CONTEXT

Frequent end-of-life health care setting transitions can lead to an increased risk of fragmented care and exposure to unnecessary treatments.

OBJECTIVES

We assessed the relationship between the presence and the intensity of an Integrated Cancer Palliative Care (ICPC) plan and the occurrence of multiple transitions during the last month of life.

METHODS

Decedents of cancer aged 18-85 years residents in two regions of Italy were investigated accessing their integrated administrative data (death certificates, hospital discharges, hospice, and home care records). The principal outcome was defined as having 3+ health care setting transitions during the last month of life. The ICPC plans instituted 90-31 days before death represented the main exposure of interest.

RESULTS

Of the 17,604 patients, 6698 included in an ICPC, although spending in hospital a median number of only two days (interquartile range 1-2), experienced 1+ (59.8%), 2+ (21.1%), or 3+ (5.9%) health care transitions. Among the latter group, the most common trajectory of care is home-hospital-home-hospital (36.0%). The intensity of the ICPC plan showed a marked protective effect toward the event of 3+ health care setting transitions; the effect is already evident from an intensity of at least one home visit/week (odds ratio 0.73; 95% confidence interval 0.62-0.87).

CONCLUSION

A well-integrated palliative care approach can be effective in further reducing the percentage of patients who spent many days in hospital and/or undergo frequent and inopportune changes of their care setting during their last month of life.

Trend and variability in open and laparoscopic hysterectomies for patients with benign disease: a retrospective cohort study

AIM

The aim of the present analysis on a regional hospital database was to ascertain the variability and 5-year trends of hysterectomy rates and the different surgical approaches used.

METHODS

A retrospective cohort study was conducted in Veneto Region (North-East Italy), based on administrative data collected in 6 years, from 2009 to 2014.

RESULTS

Our study showed an overall decline in the hospitalization rates for hysterectomy from 197.5 to 165.8/100 000 and shorter overall hospital stays for this procedure (from 5.5 to 4.5 days). During the six years analyzed, there was an overall increase in the use of laparoscopic surgery (from 28% to 35% of cases). There was also a marked variability within the region considered in terms of the hysterectomy rates and the type of procedure performed.

CONCLUSIONS

The unwarranted variability in the rates of elective surgical procedures, and the techniques used to perform them, could be monitored by analyzing electronic hospital records.

Isolated rectal cancer surgery: a 2007-2014 population study based on a large administrative database

Rectal resection is technically one of the most demanding laparoscopic procedures, requiring additional training and expertise of both surgeons and institutions. The literature has shown that laparoscopic procedures can be appropriate for the treatment of rectal cancer (RC), in terms of safety, outcome and efficiency, but results may not always be directly transferable to the general population. This study aimed to investigate the use of laparoscopic rectal cancer resections in a north-eastern Italian region (the Veneto) and to see how the characteristics of patients and hospitals are associated with the use of laparoscopy. This was a retrospective cohort study based on administrative data collected from 2007 to 2014 in the Veneto region (north-east Italy). In the period considered (2007-2014), 4953 rectal resections were performed for RC in Veneto hospitals, accounting for 35% of the total 14,243 surgical procedures involving the rectum, and resulting in 76,739 days in hospital [mean length of stay-post-operative (MLOS) 15.5 ± 11.1 days]. Patients were a mean 67.9 ± 11.7 years old (68 ± 12.7 for women, 67.9 ± 11 for men), while the subgroup of patients undergoing laparoscopic procedures was on average 2 years younger (66.5 ± 11.8 vs 68.8 ± 11.5; p < 0.05). The four main findings of this study are: (1) the increasing rates of laparoscopic procedures for RC resection at all the hospitals in our geographical area, rising up to 52% in 2014. This is probably related to not only to availability of better equipment but surely to a growing expertise of surgeons; (2) the esteem of proportion of laparoscopically treated RC; (3) the significant difference between the laparoscopic and open surgical approach in terms of mean length of hospital stay after RC resection, making the laparoscopic approach cost-effective generally speaking; and (4) the disparities in hospitals' use of laparoscopy by patients' age group: Laparoscopic surgery is safe also in the elderly population but it is not so widely offers in Veneto Region hospitals, and it's probably due to the lack of experience about this approach in frail/old patients.

Frequency and trends of hospital discharges against medical advice (DAMA) in a large administrative database

OBJECTIVE

The aim of this research was to characterize hospitalizations associated with discharges against medical advice (DAMA) in a large, population-based data system.

MATERIALS AND METHODS

This was a retrospective cohort study on 11 436 500 hospital admissions. The hospital discharge records for residents of the Veneto region (north-east Italy) discharged from 2001 to 2012, from both public and accredited private hospitals, were considered. The DAMA rate was calculated by type of hospital admission, excluding patients who died. The time trend of the DAMA rate was charted from the average annual percent changes.

RESULTS

During the period considered, 66 549 DAMA were recorded, amounting to an overall DAMA rate of 6.0‰ admissions. Analyzing the diagnostic categories, admissions for substance abuse (drugs or alcohol) and dependence coincided with the highest DAMA rate (83.5‰), followed by poisoning (40.2‰), psychiatric disorders (24.7 ‰), traumas (21.1‰), HIV-related diseases (19.9‰), burns (10.5‰), and - for women - issues relating to pregnancy, childbirth and the postnatal period (11.2‰). The DAMA rate dropped from 6.72 to 5.55 from 2000 to 2008, then remained stable.

CONCLUSION

The DAMA rate dropped slightly over the period considered. Several diagnostic categories are associated with a higher likelihood of patients leaving hospital against their doctor's advice.

Intensity of Integrated Primary and Specialist Home-Based Palliative Care for Chronic Diseases in Northeast Italy and Its Impact on End-of-Life Hospital Access

BACKGROUND

Hospital admissions at the end of life (EOL) represent an established indicator of poor quality of care.

OBJECTIVE

To examine the impact of intensity of integrated primary and specialist home-based palliative care for chronic diseases (HPCCD) plans of care on EOL hospital access.

METHODS

Retrospective population-based study using linked mortality, hospitalization, and home care data. Intensity of HPCCD was measured 90-31 days before death; outcomes were hospital death and prolonged hospital stay for medical reasons in the last month of life. Outcomes were modeled through Poisson and quartile regressions. Adults aged 65-84 years with at least an ordinary hospitalization and a drug treatment in the year before death, who died from nononcological chronic diseases in the Veneto Region, January 2012-December 2013, were included.

RESULTS

Among 2087 patients, 1016 (48.7%) did not receive any HPCCD homecare visit; 860 (41.2%), 152 (7.3%), and 59 (2.8%) had <2, 2-4, and 4-7 homecare visits/week, respectively. Hospital death occurred for 1310 patients (62.8%) and the median hospital stay in the last month of life was five days (interquartile range 0-14). In multivariate analysis, a higher intensity of HPCCD was associated with lower rates of prolonged (≥14 days) EOL hospitalization and hospital death with a dose-response relationship. When no access to HPCCD was compared with 2-4 visits/week, adjusted percentage of hospital death decreased by -18.4% (95% confidence interval [CI] -5.4% to -29.7%) and the length of hospital stay decreased by 37.9% (95% CI 16.7%-56.0%).

CONCLUSIONS

The intensity of integrated HPCCD plans of care was associated with a reduction in EOL hospital stay and in hospital death.

Increased rate of day surgery use for inguinal and femoral hernia repair in a decade of hospital admissions in the Veneto Region (north-east Italy): a record linkage study

BACKGROUND

Worldwide, there has been a marked increase in the number of inguinal and femoral hernia repairs performed as day surgery procedures. This study aimed to outline the epidemiology of the procedures for repairing unilateral inguinal and femoral hernia in the Veneto Region, and to analyze the time trends and organizational appropriateness of these procedures.

METHODS

Drawing from the anonymous computerized database of hospital discharge records for the Veneto Region, we identified all unilateral groin hernia repair procedures completed in Veneto residents between 2000 and 2009 at both public and accredited private hospitals.

RESULTS

A total 141,329 hernias were repaired in the Veneto Region during the decade considered, with an annual rate of 291.2 per 100,000 population for inguinal hernia (IH) repairs and 11.2 per 100,000 population for femoral hernia (FH) repairs. Day surgery was used more for inguinal than for femoral hernia repairs, accounting for 76% and 43% (p< 0.05), respectively, of all hernia repair procedures completed during the period. The % of other than surgery hospital ordinary admissions (day surgery or ambulatory surgery) during the decade considered rose from 61.7% to 86.7% for IH and from 33.0% to 61.8% for FH.

CONCLUSIONS

In the last decade, the Veneto Region has reduced the rate of ordinary hospital admissions for groin hernia repair with a view to improving the efficiency of the hospital network.

Time trend and variability of open versus laparoscopic cholecystectomy in patients with symptomatic gallstone disease

BACKGROUND

The purpose of this study was to compare length of stay, as one of the efficacy indicators, and effectiveness, in terms of operative complications and mortality, between laparoscopic (LC) and open cholecystectomy, and to verify the 10-year temporal trends in the application of the LC technique in a large regional population.

METHODS

This was a retrospective cohort study based on 73,853 hospital discharge records of cholecystectomies for gallstone disease (GD) in residents of the Veneto from 2001 to 2010, at both public and accredited private hospitals. The data are from a regional administrative database. The main epidemiological rates calculated, and expressed per 100,000 residents, were the cholecystectomy rate (CR) for gallstones by surgical technique (laparoscopic or open surgery), and the in-hospital mortality rate (MR), considered as the in-hospital MR regardless of the specific cause of death.

RESULTS

The CR was 139.7 higher in females, with a male-to-female ratio of 1:1.5. LC was performed more frequently in females than in males and in younger than in older patients. From 2001 to 2010, there was a significant linear rising trend in the use of LC, in fact during the period considered, the use of laparoscopic surgery increased significant (χ (2) trend: 316,917; p < 0.05), reaching 93.6% of surgical procedures for gallstones during the year 2010.

CONCLUSIONS

There are still some age- and gender-related disparities in its usage, although LC is an increasingly widely applied, as effective procedure.

Trend, variability, and outcome of open vs. laparoscopic appendectomy based on a large administrative database

The aim of this study was to ascertain the variability and 9-year trends in the use of laparoscopic surgery for appendicitis using data from a large administrative database, to compare the effectiveness and efficiency of laparoscopic (LA) and open appendectomy, and to ascertain whether different choices of surgical approach stem from evidence-based recommendations. This was a retrospective cohort study based on administrative data collected from 2000 to 2008 in the Veneto Region (northeastern Italy). Funnel plots were used to display variability between local health units (LHUs). A total of 38,314 appendectomies were performed from 2000 to 2008 in the Veneto Region, 53% of them in males. The laparoscopic procedure was used more often for females than for males of fertile age. There was a significant rising linear trend in the use of LA, with a higher increment among females. The overall regional standardized appendectomy rate was 82.9/10,000. The mean proportion of LAs (27.3%) ranged from 2.8 to 59.4% at different LHUs, and there was no relationship between the volume of procedures undertaken and the proportion of LAs. The proportion of LAs performed in females of reproductive age also varied considerably, on no apparent evidence-based grounds. The analysis of aggregate clinical data is a powerful tool for supporting regional health management units in efforts to improve the quality of medical care and assess the appropriateness of therapeutic or diagnostic approaches in the light of practical guidelines. Variability in the treatment of a given disease that lacks any evidence-based justification remains an important issue in national health systems.

Veneto Region, Italy. Health system review

The Health Systems in Transition (HiT) profiles are country-based reports that provide a detailed description of a health system and of policy initiatives in progress or under development. This HiT is one of the first to be written on a subnational level of government and focuses on the Veneto Region of northern Italy. HiTs examine different approaches to the organization, financing and delivery of health services and the role of the main actors in health systems; describe the institutional framework, process, content and implementation of health and health care policies; and highlight challenges and areas that require more in-depth analysis. The Veneto Region is one of Italy's richest regions and the health of its resident population compares favourably with other regions in Italy. Life expectancy for both men and women, now at 79.1 and 85.2 years, respectively, is slightly higher than the national average, while mortality rates are comparable to national ones. The major causes of death are tumours and cardiovascular diseases. Under Italy's National Health Service, the organization and provision of health care is a regional responsibility and regions must provide a nationally defined (with regional input) basic health benefit package to all of their citizens; extra services may be provided if budgets allow. Health care is mainly financed by earmarked central and regional taxes, with regions receiving their allocated share of resources from the National Health Fund. Historically, health budget deficits have been a major problem in most Italian regions, but since the early 2000s the introduction of efficiency measures and tighter procedures on financial management have contributed to a significant decrease in the Veneto Regions health budget deficit.The health system is governed by the Veneto Region government (Giunta) via the Departments of Health and Social Services, which receive technical support from a single General Management Secretariat. Health care is provided by 21 local health and social care units, 2 hospital enterprises, 2 national hospitals for scientific research and private accredited providers. Major national health reform legislation in the 1990s started the process of regionalization of the health system and the introduction of managerial methods and quasi-market mechanisms into the National Health Service, a process that has been consolidated since the early 2000s under the framework of fiscal federalism. Future challenges for the Veneto Region include the sustainable provision of the basic health benefit package; the adaptation of services to meet changes in demand, particularly those associated with the ageing population and the incidence of chronic diseases; and the ever-present problem of keeping the regional health budget balanced.

[Risk factors for one year hospitalization and death of 615 home care patients with multidimensional assessment]

INTRODUCTION

The District care activities are often presented as number of patients, interventions or home visits. A better description should render more visible the persons and their clinical problems whose outcomes should be monitored.

AIM

To prospectically monitor the outcomes in a sample of home care patients followed for one year.

METHODS

Six hundred sixty two home care patients of two Local Health Units of Veneto Region with at least two nurses visits per month had a multidimensional assessment and were followed for one year.

RESULTS

At the end of follow-up 32% of patients had died, 3.9% had been admitted to a Nursing home; 41.9% had at least one hospital admission and for 49.7% the number of nursing visits was increased. Closeness to death and inadequate family support were independently associated to an increased risk of hospital admission, while patients with severe cognitive impairment tend to be admitted to hospital less frequently. Of the 216 bedridden patients those with inadequate family support are at higher risk for death and hospital admissions.

CONCLUSIONS

Home care informative systems allow to assess and monitor the more severe patients thus producing information useful for the continuous improvement of caring processes.

[Feasibility of week surgery model in general surgery]

Progress in medical technology and the research in cost-effectiveness have provided an implementation on new general surgery models. Week Surgery model is a maximum 5 days stay surgical unit which represents an important contribution to surgical therapeutic strategies, allowing an excellent compromise between safety, convenience for the patient and economic savings for health care structures. This model represent an excellent compromise between elective and emergency care and thus allow to improve patients flow across the week, a most efficient bed utilisation and reallocating hospital workloads. With the aim of testing the feasibility of the application of Week Surgery model was carried out a seven-years retrospective study (2000-2006) among Veneto Region public hospitals. Results suggest that week surgery model can be considered a valid and achievable alternative organisation compared to conventional hospitalization: 61% of patient undenrwent elective surgery were discharged in less than 5 days.

[The validation of a nursing caseload score of home care patients]

Identifying a measure of community nurses' workload is complicated due to the difficulty of capturing and standardizing the nature of community nursing across health care settings.

AIM

Aim of this paper is to validate a workload/caseload nursing score for home care patients.

METHODS

Patients of health care districts of Veneto region with at least two home care visits per month and a multi-dimensional and professional assessment were assesses with instruments used in routine care, adapted to the scope (a multidimensional assessment scale for frail elderly, that includes assessment of cognitive function, social support, mobility, functional status, health care needs); a list of patients needs. Time required for home care visits (excluded travelling time) was voluntarily registered in 5/8 districts. Uni and multivariate analyses were performed and a robust logistic regression accounting for skewed values. A tree regression analysis with CART Package model to identify conceptual nodes of the proposed classification was used.

RESULTS

A group of 1298 of home care patients of 9 Districts were assessed and in 639 patients the time needed for home care visits was registered. The predictive value of the model on home care visits over 3 months was 44% while 59% for the time needed for nursing home care visits (number and length of nurses visits).

CONCLUSION

A caseload score allows allocating nursing resources. The role of the family and of the overall environment should be accounted for. Patients need to be regularly re-assessed to capture any changes in their overall situation and needs.

[Discharge against medical advice in Veneto Region]

Discharge against medical advice (DAMA) may put patients at risk of adverse health outcomes and often generate hospital readmission. A retrospective case-control study (2000-2004) of all DAMA in Veneto Region hospitals was carried out to determine the baseline characteristics of patients who leaves hospital. During the 5-years study period, the overall DAMA rates were 0.8 from ordinary hospitalization and 0.2 from daily. Prediction of patients at risk of DAMA may be possible with several defined variables and this analysis represent an instrument that should facilitate the development of successful strategies to reduce DAMA for high-risk patients.

Stochastic Modeling of S. cerevisiae Inactivation by Supercritical CO2

Pasteurization of S. cerevisiae in a simple substrate with supercritical CO(2) was performed at 36 degrees C on a laboratory multibatch apparatus of a total volume of 150 mL. The pressure values ranged from 100 to 300 bar. The results show a clear dependence between inactivation ratio and increase of pressure. A mathematical modeling of the process was exploited to fit the experimental evidences: inactivation curves were analyzed using a stochastic model based on the multihit model (1). The nonlinear survival curve shows a shoulder and a tail which represent the lag and the resistant phase, respectively. The meaning of the nonlinear relationship between inactivation ratio and time is also discussed; the effect of pressure on the values assumed by the parameters of the model proposed was investigated.