The district operation centres in one of the largest local health authorities in Italy to manage COVID-19 surveillance and homecare: first implementation and results of a survey addressed to general practitioners

BACKGROUND

COVID-19 pandemic represented a shock for healthcare systems. Italy was one of the first country to deal with a huge number of patients to be diagnosed, isolated, and treated with scarce evidence-based guidelines and resources. Several organizational and structural changes were needed to face the pandemic at local level. The article aims at studying the perceived impact of the newly implemented District Operation Centres (DOCs) of Local Health Authority (LHA) Roma 1 in managing active surveillance and home care of COVID-19 patients and their close contacts in cooperation with general practitioners (GPs).

METHODS

A questionnaire, developed according to Delphi methodology, was validated by 7 experts and administered to a randomized sample of GPs and family paediatricians (FPs). All medical doctors selected received a phone interview between December 2020 and January 2021. The questionnaire investigated general characteristics of the sample, relations with DOC and its usefulness, and potential developments. A descriptive analysis was performed and inferential statistical tests were used to assess differences.

RESULTS

In April 2020 the LHA Roma 1 implemented one DOCs in each local health district. 215 medical doctors were interviewed, reaching the sample target for health districts (80% CL and 10% MOE) and the whole LHA (90% CL and 5% MOE). Several aspects in the management of COVID-19 cases and close contacts of COVID-19 cases, and of the support of DOCs to GPs/FPs were investigated. More than 55% of the GPs and FPs interviewed found the DOCs useful and more than 78% would recommend a service DOC-like to other LHAs. The medical professionals interviewed would use DOCs in the future as support in treating vulnerable patients, utilizing digital health tools, enlisting specialist doctors, establishing networks, and facilitating professional counselling by nurses.

CONCLUSIONS

This study is an attempt to evaluate an organizational change happened during COVID-19 pandemic. DOCs were created to support GPs and FPs as a link between primary healthcare and public health. Although several difficulties were disclosed, DOCs' experience can help to overcome the fragmentation of the systems and the duality between primary care and public health and make the system more resilient.

Demographic and epidemiological characteristics of Ukrainian refugees in an Italian Local Health Authority

BACKGROUND

The Russian invasion of Ukraine caused millions of Ukrainian refugees to flee to other nations. To provide the most appropriate assistance, host nations necessitate up-to-date information regarding Ukrainian refugee's demographic and epidemiological conditions. We aim to investigate the demographic composition, the COVID-19 vaccinations performed, specialist care provided and the prevalence of non-communicable diseases (NCDs) in refugees assisted by an Italian Local Health Authority (LHA).

METHODS

We conducted a retrospective cross-sectional analysis from March to June 2022, analyzing the demographic and epidemiological status of Ukrainians. Statistical analyses were carried out to assess possible associations between NCDs distribution, age and gender.

RESULTS

LHA Roma 1 assisted 9349 Ukrainian refugees. Of these, 2784 (29.8%) were males and 6565 (70.2%) were females, with a median age of 25 years. Two thousand four hundred and eighty-five Ukrainian refugees were vaccinated against COVID-19. Among them, 401 (16.1%) had at least one NCD. The most frequent groups of diseases were related to the circulatory system (50.6%), the endocrine system (24.9%), and mental and behavioral disorders (6.5%).

CONCLUSION

Refugees need healthcare services targeted mainly towards minors and females. It is essential to analyze and monitor the demographic and epidemiological conditions to provide evidence about patient management and the best care integrated into the health service of host countries.

Ukrainian refugee crisis management in the Local Health Authority Roma 1: the challenges of implementing public health policies and lessons learned

BACKGROUND

The conflict between Russia and Ukraine has strained the health systems of countries that welcome war refugees on all levels, from national to local. Despite the Public Health guidelines regarding assistance being published on the topic, the scientific literature currently lacks evidence on the experience of applying theory in practice. This study aims to describe evidence-based practices that were implemented and to provide a detailed description of emerging problems and solutions pertaining Ukrainian refugee assistance in the context of one of the biggest Local Health Authorities in Italy (LHA Roma 1).

METHODS

LHA Roma 1 developed a strategic plan based on local expertise, national and international guidelines to ensure infectious disease prevention and control, as well as continuity of care for non-communicable diseases and mental health.

RESULTS

The insertion of Ukrainian refugees in the National Health System through an identification code assignment and other services such as COVID-19 swab and vaccination were provided either in one of the three major assistance hubs or in local district level ambulatories spread throughout the LHA. Many challenges were faced during the implementation phase of the outlined practice guidelines, which required sensible and timely solutions. These challenges include the necessity of rapid resource provision, overcoming linguistic and cultural barriers, guaranteeing a standard of care across multiple sites and coordination of interventions. Public Private Partnerships, the creation of a centralized multicultural and multidisciplinary team and the mutually beneficial collaboration with the local Ukrainian community were essential to guarantee the success of all operations.

CONCLUSIONS

The experience of LHA Roma 1 helps shed light on the importance of leadership in emergency settings and how a dynamic relationship between policy and practice would allow each intervention to be modulated according to the local environment, to better realize the potential of local realities to provide appropriate health interventions to all those in need.

The "Lazio ADVICE" telemedicine platform: First results of general practitioners' usage, facilitators and barriers in the Local Health Authority Roma 1

Background

Telemedical approaches represent a valuable tool for the management of coronavirus disease 2019 patients, allowing daily clinical assessment, monitoring of vital parameters, remote visits, and prescription of treatment or hospitalization in case of clinical worsening. This cross-sectional study aims to evaluate the use, barriers and facilitators of the "Lazio ADVICE" telemedical platform, a regional system for remote assistance for coronavirus disease 2019 patients at home, according to General Practitioners and Family Pediatricians of the Local Health Authority Roma 1, during the coronavirus disease 2019 pandemic.

Methods

An interview-based survey was performed between December 2020 and January 2021. The survey investigated the demographic information of General Practitioner and Family Pediatricians, the knowledge of the platform, frequency of utilization, usefulness, strengths and weaknesses, and hypothesis of future implementation proposed.

Results

We interviewed 214 physicians and 89 (41.6%) were classified as users and 125 (58.4%) as non-users. Older age and working in District 1, 14 and 15 (vs. District 13) significantly reduced the probability of using the platform physician. Among the 89 users, 19 (21.3%) used the platform every day or even several times a day, 40 (44.9%) several times a week but less than one access per day, 30 (33.7%) used the platform several times a month up to one entry per week. Most of them (92.3%) consider the platform useful. Barriers were poor integration with software and work routine (76.4%), and usability issues (53.9%). Among the 125 non-users, 14 (11.2%) didn't know the existence of the platform, 60 (48.0%) never tried it and 51 (40.8%) tried to use it. Reported reasons for the interruption of use were not very user-friendly (45.1%), perceived useless (37.3%), non-optimal functioning (23.5%), and lack of time (19.6%).

Conclusion

The pandemic accelerated the implementation of telemedicine services around Lazio Region, starting a positive and continuous exchange of experiences, activities and best practices among physicians.

POS1251 INCIDENCE AND OUTCOMES OF SARS-CoV-2 INFECTION IN PATIENTS WITH SYSTEMIC AUTOIMMUNE RHEUMATIC DISEASES: A POPULATION-BASED STUDY OF MORE THAN FOUR MILLION INHABITANTS IN THE LAZIO ITALIAN REGION

Background

The impact of the severe acute respiratory syndrome Coronavirus 2 disease (COVID-19) pandemic on people with systemic autoimmune rheumatic diseases (SARDs) remains to be fully established. It is unclear whether SARDs are an independent risk factor for COVID-19 infection and poor outcome.

Objectives

The aim of our study is to assess the incidence and prognosis of test-proven SARS-CoV-2 infection during the first COVID-19 wave in a large population of SARD patients of the Lazio Italian region.

Methods

We retrospectively evaluated in a cohort of 4.716.119 subjects aged over 18 years and affiliated to the health system of the Lazio Italian Region, the incidence and 30-day outcomes of COVID-19 infection in 40.490 SARD pts and compared to the affiliated population as incidence rate ratio adjusted for demographics and comorbidities (adjIRR). SARD diagnosis and comorbidities were derived from medical administrative records using the Chronic Related Group classification system. Data on COVID-19 infection were derived from a dedicated regional digital network.

Results

The risk of COVID-19 infection was increased in patients with Psoriatic Arthritis (adjIRR=1.21, 95% CI 1.10-1.33) and Undifferentiated Connective Tissue Disease (adjIRR=1.26, 95% CI 1.03-1.54). The risk of hospitalisation was higher in patients with Axial Spondylarthritis (adjIRR=2.16, 95% CI 1.45-3.22), and Systemic Vasculitis (adjIRR=1.81, 95% CI 1.07-3.06) while the risk of Intensive care unit admission was higher in Systemic Erythematous Lupus (adjIRR=3.67, 95% CI 1.52-8.83) and primary Sjögren Syndrome (adjIRR=4.13, 95% CI 1.71-9.96) patients. An increased COVID-19 mortality was reported in patients with Rheumatoid Arthritis (adjIRR=1.50, 95% CI 1.04-2.17), Systemic Erythematous Lupus (adjIRR=2.67, 95% CI 1.10-6.44), primary Sjögren Syndrome (adjIRR=2.51, 95% CI 1.12-5.62), and Scleroderma (adjIRR=4.60, 95% CI 2.06-10.29).

Conclusion

The incidence of severe COVID-19 is not increased in the same percentage in SARDs. Each SARD presents a peculiar pattern in terms of increased risk of COVID-19 incidence, hospitalisation, intensive care unit admission and death, that is not linked to the immunosuppressive behaviour of the disease.

Disclosure of Interests

None declared

Organisational Model and Coverage of At-Home COVID-19 Vaccination in an Italian Urban Context

The COVID-19 pandemic called for a reorganisation of the methods for providing health services. The aim of this paper is to describe the organisational model implemented by one of Rome’s Local Health Units (LHU), ASL Roma 1, for the “at-home COVID-19 vaccination campaign” dedicated to a target population and to outline data related to vaccination coverage stratified by health districts. A cross-sectional study was designed to describe the strategies implemented by LHU to deliver at-home vaccination programmes. People eligible for the at-home vaccination programme included patients living in the area of the LHU, being assisted by the district home care centre or not transportable or individuals with social situations that make traveling difficult. Priority for vaccination was given to (I) age > 80 years, (II) ventilated patients with no age limit, (III) very seriously disabled people with no age limit. Patients’ data were acquired from regional and LHU databases. From 5 February until the 16 May, 6127 people got at least one dose of Pfizer-Biontech Comirnaty^® vaccine, while 5278 (86.14%) completed the necessary two doses. The highest number of vaccines was administered during the first week of April, reaching 1296 doses overall. The number of vaccines administered were similar across the districts. The average number of people vaccinated at home was 6 per 1000 inhabitants in the LHU. This model proved to be extremely complex but effective, reaching satisfying results in terms of vaccination coverage.

A dynamic GIS space-time diffusion model to tackle COVID-19 emergency

Background

Surveillance and containment of the spread of COVID-19 requires the use of advanced geographic information science and technology (GIS&T) to map the spread and eventually to guide interventions. A dynamic space-time diffusion model in a GIS environment was developed and succesfully tested in Rome, Italy.

Methods

Information on cases of SARS-CoV-2 infection confirmed by molecular diagnostics from Feb 25 to Sep 26 2020 (collected by a large Local Health Unit of Rome, Italy) was used to test a GIS simulator model able to monitor the spatial diffusion and temporal evolution of the spread of the disease. Data included information on: sex, date and place of birth, healthcare facility of hospitalization, date of notification, start date and end date of isolation, date of recovery (both clinical and laboratory confirmed), residence address.

Results

Globally, 3,056 cases were geocoded and analysed. The spatio-temporal analysis of the first 45 days since 25 Feb 2020 shows that the spread of COVID-19 was very fast (1,230 cases recorded on 11 Apr) and spatially widespread. Number of cases was highest in the city centre with clusters, thickets and axes in different sub-municipal areas. A slowdown occurred the following month, confirming the positive effect of the lockdown. This effect continued until 11 Jun with a small increase in the number of cases (+10.9%). The period up to 26 Sep is paradigmatic of the second wave, with a continuous increase in cases that spread from the city centre to the suburbs.

Conclusions

Using geocoding process and a detailed GIS mapping it is possible to identify streets, buildings and census sections where the number of cases is high and tends to increase rapidly and, at the same time, it is possible to distinguish clusters and axes that should be kept immediately under special observation as potential pools of super-diffusion. Development of its use in near-real time could bring significant advantages in controlling the spread of COVID-19.

Key messages

The use of GIS technology is fundamental for mapping the spread of COVID-19.

A greater effort should be made by institutions to increase the digitisation of health data and the possibility of using them for both research and surveillance purposes.

Do Degree Programs Affect Health Profession Students' Attitudes and Opinions Toward Vaccinations? An Italian Multicenter Study

Background

Healthcare workers' attitudes toward vaccination have been widely described in the literature, but a restricted amount of studies assessed healthcare students' knowledge, attitudes, and opinions on this issue. This study aimed to estimate the influence of a degree course on knowledge and immunization behavior among healthcare students and to compare medical students with students from other health profession degree programs to identify possible differences.

Methods

A multicenter, cross-sectional study was performed in 2018 in 14 Italian Universities (3,131 students were interviewed). A validated questionnaire was used to assess knowledge, attitudes, and opinions toward vaccinations, with a specific focus on influenza vaccine and attitudes toward mandatory vaccination policies. Statistical software STATA® 14 was used.

Results

Significant differences were recorded between medical students and other healthcare students. The intention to get vaccinated against influenza during the next season and having been vaccinated in the previous season was higher in the medical group (p < 0.001). In the group of students of other health professions, we registered a lower probability of identifying themselves as a high-risk group for contracting infectious diseases as a consequence of their profession and health status (aOR 0.49; CI95%: 0.40–0.60) and an increased likelihood of defining their level of knowledge on vaccine-preventable diseases and related vaccinations as “insufficient/sufficient/fair” (aOR 1.31; CI95%: 1.11–1.56).

Conclusions

Results show several differences between medical students and students of other health professions when it comes to vaccination knowledge, attitudes, and perceptions, as well as a general low tendency to be vaccinated against influenza.

The Impact of Digital Patient Portals on Health Outcomes, System Efficiency, and Patient Attitudes: Updated Systematic Literature Review

Background

Patient portals are becoming increasingly popular worldwide even though their impact on individual health and health system efficiency is still unclear.

Objective

The aim of this systematic review was to summarize evidence on the impact of patient portals on health outcomes and health care efficiency, and to examine user characteristics, attitudes, and satisfaction.

Methods

We searched the PubMed and Web of Science databases for articles published from January 1, 2013, to October 31, 2019. Eligible studies were primary studies reporting on the impact of patient portal adoption in relation to health outcomes, health care efficiency, and patient attitudes and satisfaction. We excluded studies where portals were not accessible for patients and pilot studies, with the exception of articles evaluating patient attitudes.

Results

Overall, 3456 records were screened, and 47 articles were included. Among them, 11 studies addressed health outcomes reporting positive results, such as better monitoring of health status, improved patient-doctor interaction, and improved quality of care. Fifteen studies evaluated the impact of digital patient portals on the utilization of health services with mixed results. Patient characteristics were described in 32 studies, and it was reported that the utilization rate usually increases with age and female gender. Finally, 30 studies described attitudes and defined the main barriers (concerns about privacy and data security, and lack of time) and facilitators (access to clinical data and laboratory results) to the use of a portal.

Conclusions

Evidence regarding health outcomes is generally favorable, and patient portals have the potential to enhance the doctor-patient relationship, improve health status awareness, and increase adherence to therapy. It is still unclear whether the use of patient portals improves health service utilization and efficiency.

Assessment of the healthcare managerial skills offered by the Italian post-graduate schools of public health

BACKGROUND

The Italian National Health Service (Servizio Sanitario Nazionale, SSN) is facing relevant challenges due to decreased financing and increased healthcare costs (1). In this complex framework, most of the Italian Medical Doctors, after obtaining their Specialization degree in Public Health, develop their careers in organizational and managerial roles in public and private health organizations, i.e. hospitals, local health units, health districts or national and international agencies (1, 2). Public health technical competencies, in particular policy and management, are of crucial importance to develop, run and support healthcare services. However, some gaps exist between current public health needs and the extent to which Public Health Residents are trained in the above fields (3, 4).

STUDY DESIGN

The study is a cross-sectional cognitive survey carried out through a questionnaire sent by e-mail to Residents and Directors of the Italian Schools of Public Health, from May to November 2018. The questionnaire was sent only to the accredited Schools which had all four years of the course running.

METHODS

The questionnaire investigated 35 managerial topics divided into 4 macro-areas. It was sent to both Directors of the SPHs and the Residents of 32 Schools. The latter were asked to provide a single collective answer per School. Respondents could assign a score from 1 (topic not addressed at all) to 4 (topic addressed extensively and linked to other related topics) to each item, also taking into account the skills acquired through internships, seminars, etc. that involved all the Residents.

RESULTS

Answers were received from the Residents of 30/32 (93.8%) SPHs and from 15/32 (46.9%) of the Directors. Scores given by the Directors were higher than the ones of the Residents for every topic, and for 17 out of 35 items (48.6%) a statistically significant difference has been obtained. In the overall score of 3 macro-areas out of 4 (General issues, Managerial tools and macro-organisational Models) there are statistically significant differences. In Soft skills macro-area, the single scores of all topics are generally low for both Directors and Residents.

CONCLUSION

The study shows that the Residents declare a strong need for training improvement in the field pf healthcare organization and management: the median score is equal to or greater than 3 (topic addressed extensively) in only a few answers. The comparison between Directors' and Residents' scores highlights a different perception of the training offered in these areas. The study results could be pivotal for the improvement of the managerial skills provided to the Residents in Public Health of the Country.

Nose-pharyngeal swabs as a screening test for SARS-CoV-2 infection in patients with scheduled elective surgery: the experience of the Hygiene Service of the Local Health Authority Roma 1

ABSTRACT

The COVID-19 (COrona Virus Disease 2019), due to the SARS-COV-2 (Severe Acute Respiratory Syndrome Corona Virus 2) has been an unprecedented global challenge for the healthcare systems (1).

Increasing HPV Vaccination Uptake among Adolescents: A Systematic Review

Human Papillomavirus (HPV) vaccination is a well-known fundamental strategy in the prevention of cervical cancer, as it is always caused by HPV infection. In fact, primary prevention of the infection corresponds to primary prevention of HPV-related cancers and other diseases. Since an effective prevention at the population level is the final goal, it is mandatory for healthcare systems to achieve a high HPV vaccination coverage among the adolescents to reduce the circulation of the virus and the burden of HPV-related diseases. This research identified, through a systematic literature review, 38 papers on strategies adopted to increase HPV vaccination coverage among adolescents. The evaluated strategies targeted adolescents/parents and/or healthcare providers and could be grouped in three main types: (1) reminder-based, (2) education, information, and communication activities, and (3) multicomponent strategies. Several types of strategy, such as those relied only on reminders and integrating different interventions, showed a positive impact on vaccination coverage. Nonetheless, the heterogeneity of the interventions suggests the importance to adapt such strategies to the specific national/local contexts to maximize vaccination coverage.

Global health challenges: Are future physicians prepared? The results of a 4 years training experience

Background

Current health challenges are highlighting as Global Health (GH) is a discipline of growing importance for future physicians. Although its training is globally recommended, it has not universally entered the curricula of degree courses in Medicine and Surgery. A cycle of 6 seminars in global health has been promoted by researchers and public health residents of the Center for Research and Studies in GH of the Università Cattolica del Sacro Cuore (UCSC) in Rome, and offered for 4 consecutive years to medical students attending the UCSC.

Objectives and Methods

Main goal was increasing students knowledge and awareness in global health issues exploring their needs and perceptions about the impact of the topic on their future career. Two-hours frontal lessons held by experts and practical sessions (PBL) facilitated by promoters were planned on topics as determinants and inequalities in health, UHC, fragile and vulnerable population as migrants and victims of violence, SDGs, AIDS and emerging infectious diseases,international cooperation, maternal-child health. A pre-course, single event and post-course questionnaire was administered to participants.

Results

A mean of 48 students (± 15.7SD), 66.7% females, attending mainly the second(40.4%) and the third year (39%), joined each event. The analysis of the pre-course questionnaire has highlighted students' interest in healthcare inequalities, pandemics, migration, health in developing countries, healthcare systems. At the end, 92% of participants has considered the course interesting, 87% stated that the topic should be part of the degree course and 78% that it will influence their career. The methodology was considered adequate in 94% of cases underlining its strong incentive to work in team.

Conclusions

The strong interest of medical students in acquiring skills in global health seems to firmly encourage its inclusion and strengthening in study plans to prepare them properly to face the future challenges in health.

Key messages

Medical students consider the global health training relevant for their career encouraging its inclusion in the Medicine and Surgery curriculum. Practical sessions and team work could be useful tools to adequately train the future health workforce.

Leadership in Public Health: an Italian learning experience

Background

The “Public Health Leadership” Working Group of Italian Society of Public Health (S.It.I.) organized a two-days Workshop in Verona in January 2020. Leadership is linked to capacity of inspiring people to craft and achieve vision and goals, to provide mentoring, coaching and recognition and to encouragement empowerment, allowing other leaders to emerge and high quality of care. As in others country, in Italy investing in new generations is fundamental and far-sighted to create Leadership culture in tomorrow's professionals.

Objectives

The Workshop aim was to immerse Public Health residents into Health Leadership. Two types of practical/interactive experiences (Design thinking and Barometer strategy) and three speakers' interventions aroused curiosity, suggesting innovative ways to manage emerging local and global healthcare problems. Are residents interested in Leadership? Do they think Leadership could influence, motivate and enable to contribute to organization effectiveness?

Results

100 residents (Male 52, Female 48), from 72% of Public Health Schools (26), attended Workshop: 46 of 1st, 23 of 2nd, 18 of 3rd and 13 of residency program last year. Satisfaction questionnaire was completed by 58 residents (7 points Likert scale from 1 [dissatisfied/not useful] to 7 [satisfied/useful]). 5.91 pts result in interventions satisfaction, increasing from 1st (5.84) to last year (6.00); interventions topics deepening results in 5.38 pts, decreasing from 1st (5.52) to last year (5.00). Overall satisfaction on practical/interactive activities was 5.89 and 5.83 pts results in these methodologies usefulness.

Conclusions

Health Leadership is a hot topic for residents; during residency program Leadership in not a main theme and residents want to improve non-technical skills to realise organization high quality of care. The practical/interactive activities were a winning choice to capture attention and cultivate mutual trust. This experience could be adapted in other countries.

Key messages

Teaching Leadership in Public Health is a main topic that needs to be strengthened in Public Health agenda. Italian Public Health residents are very interested in Health Leadership improvement during their trainings.

FLUChallenge: an innovative strategy to increase flu vaccination in two Italian Teaching Hospitals

In Europe flu vaccination among healthcare workers (HCWs) is strongly recommended even though not mandatory such as elsewhere (USA). Despite this, vaccination coverage in EU countries is usually low: 30.2% in 2016-17. In Italy, at the end of the same season it was 15.6%. Aim of this study is to describe and evaluate the new strategy adopted by Gemelli and Humanitas Research Hospitals, two Italian Teaching Hospitals (THs) part of the MIRO Public Health Center, to increase the vaccination coverage among their HCWs.

Before the 2019-20 campaign, experts of the two THs met up to identify a common strategy to promote flu vaccination among HCWs in addition to the ones already implemented. It was decided to launch a FLUChallenge: a platform of monitoring updated bi-weekly and available on the THs' internal websites with the vaccination coverage overall and stratified by job category and macro-areas of activity. Descriptive and inferential analysis were performed.

Preliminary Results

6673 HCWs included (4241 Gemelli, 2432 Humanitas). The overall flu vaccination coverage at the end of the 2019-20 campaign was 28.4% (1026 HCWs vaccinated Gemelli, equal to 24.2%; 869 HCWs vaccinated Humanitas, 35.7%). Both THs significantly increased the vaccination coverage compared to the previous year (+10% Gemelli, 22% in 2018-19, p = 0.01; +45.7% Humanitas, 24.5% in 2018-19, p &lt; 0.001). Physicians had the highest coverage both in Gemelli (483/1320, 36.6%) and Humanitas (443/979, 45.2%), while the lowest was registered among nurses in Gemelli (357/2017, 17.7%) and other HCWs in Humanitas (134/605, 22.1%). Infectious disease was the macro-area with highest coverage in Gemelli (32.3%), while in Humanitas the emergency department (63.9%).

The FLUChallenge intervention was an effective strategy to increase flu vaccination coverage in the two TH. The website platform was useful for the purpose of accountability and able to create a positive challenge between the HCWs working in the two THs involved.

Key messages

Flu vaccination among healthcare workers (HCWs) is recommended to prevent influenza and to avoid its transmission. It is important to promote new engagement and innovative strategies to increase flu vaccination coverage among HCWs, when it is not mandatory.

A shared battle against cancer: overcoming screening uptake differences within European countries

Cancer is the second leading cause of dead in Europe and it is responsible of more than 30% of all deaths. For this reason, European Union (EU) identified the battle against cancer as a priority for the European Research Program 2021-2027.About 40% of total deaths for cancers could be prevented with screening.Validated screening test are available for breast (BC), cervical (CC) and colorectal cancers (CRC).

In 2003 the Recommendation of the European Council indicated the right timing and the population target but, nowadays, the percentage of screening within EU is low and consistent differences persist among States.In 2020 there are still countries that don't have population-based screening programs. Last data available for all 28 EU countries are referred to 2014. Data were retrieved from “Osservasalute” reports and Global Burden of Disease database.Pearson test and a paired t test were used to describe correlation between mortality and screening coverage rates.

In 2014 the mean percentage of screening was 70.7% for CC, 68.7% for BC and 31.3% for CRC and the mean of mortality rate was of 2.1, 10.4 and 17.2 for 100,000, respectively.The rate of mortality did not change significantly in 2017 (2, 10 and 16 for 100,000 respectively).The median coverage is 67 for BC [IR: 43-91], 21.4 for CRC [IR: -3-46] and 70.6 for CC [IR: 54-87]. Pearson test resulted in a negative correlation for all three cancers equal to -0.045, -0.060 and -0.561, respectively.A higher adherence to screening programs is significantly associated to lower mortality rates in all the three types of cancer (p &lt; 0.01).

Even if many factors determine the rate of cancer mortality, screening represents the best method to early diagnosis and treatment.Up-to-date data are needed to correctly monitor progress towards the common goal of reaching the entire target population with screenings.A strong leadership at international level is necessary to improve screening programs all over EU and support screening campaigns.

Key messages

Screening is one of the most efficient and life-saving way to prevent cancer. It is needed to improve screening adherence through population-based programmes both at international and national level. Last data available for all EU countries are referred to 2014. It is necessary to update the data in order to enhance the understanding of screening efficiency.

Core competencies for public health medicine: protocol for an Italian inter-society Delphi consensus

Background

Developing core competencies is crucial for the quality of educational curricula in Public Health Medicine (PHM). The postgraduate medical School of Public Health of the University of Pisa developed a core curriculum for PHM specialists (CCV0), adapted from the list of core competencies promoted by the Association of Schools in Public Health of the European Region (ASPHER).

Objectives

We will apply the Garavalia method, a three-round step-wise Delphi consensus, for adapting the CCV0 to the Italian context. Participants will be enrolled through purposive sampling among the members of the Italian Society of Hygiene, Public Health and Preventive Medicine, aiming at the best possible balance between geographical distribution and professional profiles (PHM residents, academics, and Public Health operators). A sample of representatives of other PHM-related Italian Societies will also be included.

Results

We will invite 139 participants through e-mail invitations. During round zero, we will collect additional suggested competencies through an open-ended question. We will analyze data qualitatively and integrate the most relevant suggestions with the CCV0, resulting in the CCV1. A subgroup of 64 experts (among PHM residents, academics, and representatives of the included Societies) will participate in the following rounds. The first round will use Likert scales to measure agreement on the appropriateness of the CCV1 competencies. Consensus and agreement will be computed using the RAND/UCLA criteria. The final round will reach out for consensus repeating the same ratings for competencies classified as uncertain, with the help of quali-quantitave summaries of the answers of the first round. The final document (CC2) will report competencies classified as consensus or uncertain, with the corresponding level of consent.

Conclusions

The CC2 will enable current courses to be assessed and inform the design of future educational programs for Italian PHM residents.

Key messages

The Delphi method ensures anonymity and a balanced involvement of all stakeholders –including medical residents- in the development of a core curriculum for Public Health Medicine specialists. A consensus on core competencies in Public Health Medicine will enable the evaluation of current training curricula and the development of future educational programs.

Flu vaccination coverage among healthcare workers: the example of younger generations

Flu vaccination is highly recommended among Healthcare Workers (HCWs). The low coverage in Italy among HCWs (mean 15.6% for 2016/17 flu season, ECDC) calls for new approaches. The aim of this study was to evaluate in which measure the vaccination coverage among HCWs registered during the 2019-2020 flu vaccination campaign in a large Teaching Hospital in Rome was affected by age and education.

A retrospective observational quasi-experimental study was conducted. Descriptive and inferential statistical analysis (chi-square test, significance level of 0.05) were performed. The 2019-2020 flu vaccination campaign was aimed at more than 4000 employed HCWs (total coverage 24.2%). Vaccination was also extended to not-employed HCWs such as Medical Residents (MRs) and Medical Students (MSs) in clinical training. The coverage in this groups was higher (46.0% and 63.2% respectively) and the difference between them and the coverage among employed HCWs was statistically significant (p &lt; 0.05); Further analysis was performed comparing MRs / MSs in clinical training with their respective professional group of employed HCWs, with a percentage of vaccinated Medical Doctors (MD) of 36.6%. MRs / MSs in clinical training coverage was higher than MDs coverage and the difference still proved to be statistically significant (p &lt; 0.05).

The higher coverage among MRs / MSs in clinical training could be explained, in general, in light of the more open-mindedness to prevention and to healthy lifestyles that characterizes young people with an up-to-date education. It could also be explained considering the specific culture and sense of responsibility of Medical Students and Medical Residents towards their high-demanding educational path and clinical training as an incentive not to get ill.

Flu vaccination is highly recommended among HCWs. Younger generations, who represent the future of Healthcare, prove to be more open-minded and responsible towards good prevention practices such as this.

Key messages

Flu vaccination is highly recommended among HCWs. Younger generations, who represent the future of Healthcare, prove to be more open-minded and responsible towards good prevention practices.

Evaluation of a food safety training intervention in an asylum-seeking population in Rome

The integration of asylum seekers is a public health issue in various contexts, including food, where they often work. According to European legislation, every food operator is obliged to follow training courses on food safety knowledge in order to prevent food-borne diseases. This study aims to evaluate a food safety training intervention in a population of asylum seekers in Rome through the use of a specific tool validated by the WHO, to introduce them in of catering.

The 'Five Key Points for Safer Food' manual was used to deliver the course. An evaluation test for participants to assess the impact of the food safety training is included, divided into 4 categories: General Information, Knowledge (11 items), Attitudes (10) and Behavior (10). The involved food handlers received the same test before and after training. In order to evaluate the effectiveness of the training intervention, the difference in the average of correct pre and post-test answers, overall and by category, was analyzed.

Overall, the 69 food handlers comprised 34 (49.3%) females and 35 (50.7%) males, from different continents (36.2% from Africa, 30.5% Central-South America and 33.3% Asia). The 57.3% has previously worked as cook or waiter. The average age was 36.6 (±12.5) with 11.4 (±3.9) years of education. Overall, the average of correct answers increases of 11.6% (from 76.4% to 88.0% correct answers pre and post-test; p &lt; 0.0001). Knowledge pre test was 7.7 (±1.4), while post test was 8.9 (±1.7) (p &lt; 0.0001). Attitude pre test was 8.3 (±2.2), post test was 9.6 (±0.9) (p &lt; 0.0001). Behavior pre test was 7.7 (±2.2), post test 8.8 (±1.9) (p &lt; 0.0001).

Despite cultural and linguistic differences, our training intervention has been effective in improving knowledge, attitudes and behaviors on food safety in the target population. The food safety in these contexts cannot be understood only as the fulfilment of a regulatory obligation, but also as an opportunity for aggregation and social integration.

Key messages

Food cooking represents a social integration tool: asylum seekers from the most disadvantaged countries could prepare safe multi-ethnic dinners based on the typical courses of their country of origin. WHO training intervention on food safety was effective in improving knowledge, attitudes and behaviors in the target population.

The impact of tumor board on cancer care: evidence from an umbrella review

Background

Tumor Boards (TBs) are Multidisciplinary Team (MDT) meetings in which different specialists work together closely sharing clinical decisions in cancer care. The composition is variable, depending on the type of tumor discussed. As an organizational tool, MDTs are thought to optimize patient outcomes and to improve care performance. The aim of the study was to perform an umbrella review summarizing the available evidence on the impact of TBs on healthcare outcomes and processes.

Methods

Pubmed and Web of Science databases were investigated along with a search through citations. The only study design included was systematic review. Only reviews published after 1997 concerning TBs and performed in hospital settings were considered. Two researchers synthetized the studies and assessed their quality through the AMSTAR2 tool.

Results

Five systematic reviews published between 2008 and 2017 were retrieved. One review was focused on gastrointestinal cancers and included 16 studies; another one was centered on lung cancer and included 16 studies; the remaining three studies considered a wide range of tumors and included 27, 37 and 51 studies each. The main characteristics about format and members and the definition of TBs were collected. The decisions taken during TBs led to changes in diagnosis (probability to receive a more accurate assessment and staging), treatment (usually more appropriate) and survival (not unanimous improvement shown). Other outcomes less highlighted were quality of life, satisfaction and waiting times.

Conclusions

The study showed that the multidisciplinary approach is the best way to deliver the complex care needed by cancer patients; however, it is a challenge that requires organizational and cultural changes and must be led by competent health managers who can improve teamwork within their organizations. Further studies are needed to reinforce existing literature concerning health outcomes. Evidence on the impact of TBs on clinical practices is still lacking for many aspects of cancer care. Further studies should aim to evaluate the impact on survival rates, quality of life and patient satisfaction. Regular studies should be carried out and new process indicators should be defined to assess the impact and the performance of TBs more consistently.

Ischemic stroke: clinical pathway impact

PURPOSE

A clinical pathway for patients with acute ischemic stroke was implemented in 2014 by one Italian teaching hospital multidisciplinary team. The purpose of this paper is to determine whether this clinical pathway had a positive effect on patient management by comparing performance data.

DESIGN/METHODOLOGY/APPROACH

Volume, process and outcome indicators were analyzed in a pre-post retrospective observational study. Patients' (admitted in 2013 and 2015) medical records with International Classification of Diseases, ICD-9 code 433.x (precerebral artery occlusion and stenosis), 434.x (cerebral artery occlusion) and 435.x (transient cerebral ischemia) and registered correctly according to hospital guidelines were included.

FINDINGS

An increase context-sensitive in-patient numbers with more severe cerebrovascular events and an increase in patient transfers from the Stroke to Neurology Unit within three days (70 percent, p=0.25) were noted. Clinical pathway implementation led to an increase in patient flow from the Emergency Department to dedicated specialized wards such as the Stroke and Neurology Unit (23.7 percent, p<0.001). Results revealed no statistically significant decrease in readmission rates within 30 days (5.7 percent, p=0.85) and no statistically significant differences in 30-day mortality.

RESEARCH LIMITATIONS/IMPLICATIONS

The pre-post retrospective observational study design was considered suitable to evaluate likely changes in patient flow after clinical pathway implementation, even though this design comes with limitations, describing only associations between exposure and outcome.

ORIGINALITY/VALUE

Clinical pathway implementation showed an overall positive effect on patient management and service efficiency owing to the standardized application in time-dependent protocols and multidisciplinary/integrated care implementation, which improved all phases in acute ischemic stroke care.

Increasing HPV vaccination uptake among adolescents: A Systematic Review

Background

Human Papillomavirus (HPV) is responsible for the development of several pathologies besides the cervical cancer and HPV vaccination is a key strategy for primary prevention. The aim of this research was to identify strategies adopted to increase HPV vaccination coverage among the adolescents.

Methods

A systematic review was carried-out by searching electronic databases (Pubmed, Scopus, and Web of Science) using selected keywords as “papillomavirus vaccine”, “vaccination strategy” and “efficacy”. Articles conducted in high-income countries and evaluating the impact of one or more strategies on vaccination coverage (initiation e/o completion) in adolescents were included.

Results

Out of 3571 single citations screened, 42 papers (2011-2018) were included. Study size ranged from 50 to 325229 individuals. The major part of the studies was from the United States (n = 35; 83,3%) and conducted with an experimental design (n = 17; 40,5%). The evaluated outcomes included first dose uptake, schedule completion, vaccination timeliness and the number of administered doses. Identified strategies included reminds (9), education activities (9), multicomponent strategies (22) and others (2) and were focused on adolescents/parents and/or healthcare providers. Significant positive results were reported in seven studies (77,8%) evaluating the impact of reminds, four studies (44,4%) on education strategies, and in 12 studies (54,5%) on multicomponent strategies. Offering vaccination in “bundle” or during any medical visit was also reported as significantly effective.

Conclusions

Increasing the vaccination coverage is essential to achieve HPV-related diseases control. Several types of strategies are available and showed a positive impact on vaccination uptake, in particular those relied on reminds. Nonetheless, the heterogeneity of interventions suggests the importance to adapt such initiatives to the specific context in order to maximize the improvement in vaccination uptake.

Key messages

Several types of strategies to increase vaccination uptake are available at international level and showed a positive impact among adolescents. These interventions are heterogeneous suggesting the importance of their adaptation to the specific context in order to gain the maximum improvement in vaccination uptake.

Flu vaccination coverage in a large Italian teaching hospital: the example of the leaders

Key messages

Annual flu vaccination among healthcare workers (HCWs) is recommended to prevent influenza and to avoid its transmission especially to frail patients. This study shows the growing flu vaccination coverage rate in our teaching hospital and the effectiveness of the example given by the vaccinated leaders in increasing the coverage among all HCWs.

An automatic platform to monitor Web 2.0 presence of Healthcare Providers in Italy

Background

Healthcare providers (HP) need to involve the population to spread correct and useful health information and to gather feedback on the perceived quality of the service. Web 2.0, based on the use of Social Networks (SN), allows direct communication between the HP and the population. We built an automatic platform which monitors Web 2.0 usage by Italian public and private HP.

Methods

For each HP the platform finds the relative website using Google searches and extracts the links to SN. For Facebook and Twitter, it retrieves one year of content and identifies common topics via natural language processing. Finally, it compares the Web 2.0 usage patterns and topics with the type of HP and geographical position.

Results

In 2017, on 540 HP screened 97.8% had a website (309 unique sites, many HP have a common site). 37.5% of the websites had links to SN in the homepage: Youtube (YT) was the most common (74.1%), then Facebook (FB, 72.4%) and Twitter (TW, 51.7%). The presence of SN was lower in the south (OR: 0.63; p &lt; 0.001) while is higher for research centers (OR: 5.12; p &lt; 0.001) and private hospitals (OR: 2.12; p = 0.004). Local Health Trusts were the most active on FB (1.86 more posts, p = 0.004) but research centers had more fans RR: 5.32; p = 0.003) and likes per post (RR: 4.95; p &lt; 0.001). On TW private hospitals had the most followers (RR: 3.35; p = 0.002) and likes per tweet (RR: 3.95; p &lt; 0.001). The most posted topics were on healthy behaviors and organizational changes, while a lower number of posts were on healthy food and vaccines. Posts on specific pathologies information and healthy behaviors received more likes.

Conclusions

We propose an automatic platform that monitors the internet presence of HP in Italy, helping to define the best strategies for effective health communication. We found that in the south and in the public sector the importance of this tool is less perceived, with a lower SN presence and a gap between posted topics and those appreciated by the public.

Key messages

We propose an automatic platform that reports and monitors the web 2.0 presence and usage by HP in Italy, helping to define the best strategies to spread effective health communication. In Italy the presence of SN among HP is lower in the south and in the public, while is higher for research centers. HP have to engage the population maximizing the potentiality of web 2.0.

Strategies to achieve HPV-related disease control in Italy: results from an integrative approach

Background

Vaccination against Human Papilloma Virus (HPV) might allow controlling HPV-related diseases but coverage in Italy is far from the optimal goal. This project aimed at identifying strategies to promote HPV vaccination in Italy.

Methods

an integrative approach including a systematic review and a two-step panel consultation was used to identify strategies for improving coverage among adolescents who are already target of the national campaign and promote vaccination in further targets. The systematic review followed PRISMA recommendations and the panel consultation relied on the administration of questionnaires in the first step and on a televoting system during a consensus conference in the second one. Ten experts were involved belonging to Gynecology, Public Health, General Practice, Pediatrics and Consumers. Recommendations relied on a set of criteria drawn from the Evidence to Decision framework.

Results

The systematic review led the identification of three main strategies to improve coverage respectively based on reminds, education and multicomponent approaches. Following the evaluation of selected criteria, namely relevance of benefits, evidence strength, feasibility, equity, acceptability and costs, a strong recommendation was formulated on the use of reminds tailored to vaccine recipients or their parents whereas a moderate one was developed on the use of reminds directed to health professionals. A moderate recommendation was released on the implementation of multicomponent interventions. The panel consultation also supported the elaboration of a strong recommendation on the promotion of vaccination among women treated for HPV-related diseases, fertile women not yet vaccinated and 25 years old women. Catch-up initiatives, in particular among women and men 18 years old, were also identified as strongly recommendable.

Conclusions

This project led to identify several valuable strategies to strengthen HPV vaccination at national level.

Key messages

Using reminds tailored to vaccine recipients or their parents is strongly recommended while using reminds directed to health professionals and multicomponent interventions are moderately recommended. It is strongly recommended to promote HPV vaccination among women treated for HPV-related diseases, fertile women not yet vaccinated and 25 years old women.

Monitoring of Particle Environmental Pollution and Fungal Isolations During Hospital Building-Work Activities in a Hematology Ward

Building-work activities could cause dust contamination and fungal spores' dissemination. A significant relationship was found between building-work activities and the incidence of invasive aspergillosis, in profoundly immunocompromised patients. Renovation-works activities were carried out by four building sites of the hematology ward in a Teaching Hospital without the interruption of clinical activities. These sites were monitored by environmental sampling to determine the particles and fungi count. Clinical surveillance was made using galactomannan antigen test as a proxy for invasive aspergillosis diagnosis. A definitive diagnosis of IA was confirmed by clinical and radiological features. The galactomannan antigen test showed no significant difference between presence (2,75%) and absence (5,03%) of renovation work activities (p=0,522). During the renovation activities, an increment of IA cases with respect to the control period was not recorded. The particle counts showed higher values of small and big-diameter particles before the renovation works if compared to the end of the activities. It was probably due to the containment measures implemented during and immediately after the final phases of the building site. The Fungi counts showed no significant differences between the phase before and after the renovation activities. Our findings show that is possible to perform renovation work, during clinical activities, by increasing clinical and environmental surveillance.

Seasonal influenza vaccination among health-care workers: the impact of different tailored programs in four University hospitals in Rome

Seasonal influenza vaccination (SIV) of health-care workers (HCWs) is recommended in most countries to protect them and their patients from infection. Although SIV can reduce the risk of influenza complications among vulnerable patients, vaccination uptake is generally unsatisfactory. The present study aimed to assess the impact of different programs in promoting SIV uptake among HCWs during the season 2017/2018 in four teaching hospitals in Rome. A multicentric cross-sectional study was carried out, in order to describe the four different campaigns and to assess their impact by identifying and developing a set of indicators that provide information about the vaccination services, the percentage of invited HCWs, the vaccinators' workforce and the vaccination coverage rates.The hospitals organized different strategies: Hospital 1, 3 and 4 organized educational courses for HCWs and actively invited every single HCW through e-mail. All the hospitals organized a dedicated unit for influenza vaccination, and Hospital 1 added on-site vaccination sessions that required a large number of staff. Hospital 1 and hospital 4 registered a comparable vaccination coverage rate, 12.97% and 12.76%, respectively, while it was 6.88% in Hospital 2 and 4.23% in Hospital 3. Our indicators demonstrated to be effective and useful for analyzing the different SIV campaigns. The results suggest that the best practice to promote SIV among HCWs should include multiple approaches. Among those, an easy access to the vaccination site seems to play a key role in determining a higher vaccination coverage.

Improving Nursing Staff Attitudes toward Vaccinations through Academic Detailing: The HProImmune Questionnaire as a Tool for Medical Management

Vaccinations remain the most effective way of preventing infection, disease, and mortality. Public health institutions consequently recommend vaccines to target groups, including healthcare workers, who are considered to be more at risk of exposure and transmission. The aim of this cross-sectional study is to assess, through the administration of a questionnaire, the nursing staff’s knowledge and attitude towards recommended vaccinations, and to explore the effects of a training course (carried out according to the academic detailing methodology) aimed at increasing operators’ knowledge and outreach on recommended vaccinations among healthcare workers. A total of 85 HCWs (30 nursing coordinators and 55 nurses) completed the questionnaire. Results demonstrate a higher rate of agreement towards vaccinations in nursing staff answers (75%), if compared with results of other studies (62–63%). Statistically significant differences between nursing coordinators and nurses can be found. Regarding vaccination attitudes, nursing coordinators agreed in 86% of the answers on healthcare workers’ vaccination vs 70% of nurses (p < 0.001). Considering immunization for influenza, 57% of nursing coordinators vs 18% of nurses reported for vaccination (p < 0.001). Educational programs, carried out according to academic detailing methods, could impact on vaccination attitudes and raise awareness about recommended vaccinations among healthcare workers. The questionnaire is a useful tool for investigating nursing staff knowledge and attitudes towards vaccinations, and to implement strategies to promoting vaccinations among healthcare workers.

Highly-integrated programs for the prevention of obesity and overweight in children and adolescents: results from a systematic review and meta-analysis

BACKGROUND

Since overweight and obesity has become epidemic in children and adolescents, the aim of this study was to determine the role of highly-integrated programs in preventing and reducing prevalence of children and adolescent obesity and overweight, even evaluating if this approach has properly been effective in communities with different determinants as in the Pacific Area.

METHODS

According to PRISMA guidelines, a systematic review of literature was conducted and a meta-analysis was performed to compare obese/overweight prevalence between the intervention and the control group.

RESULTS

We identified 23 studies describing 14 programs. For 11 out of 14 programs, obese/overweight prevalence changing from baseline were definable and meta-analysis of them showed a significant change of obese/overweight prevalence (-0.03; 95% CI = -0.04 to -0.01; P < 0.0001). Secondary outcomes as dietary (such as vegetable intake, carbonated beverages, fruit juice, drinks, healthful food consumption), physical activity and TV-time-spent was analyzed in many of the studies to define community readiness and behavioral changes. Macro-interventions, based on what was observed in our systematic review have a high potential to reach the entire population.

CONCLUSION

Adoption of coordinated cross-sectoral, multi-component and multi-stakeholder initiatives to oppose obesity remains a challenge, but it is also desirable as one of the possible solutions to this major public health issue.

[Vaccination among healthcare workers in Italy: a narrative review]

Vaccination of healthcare workers (HCWs) is a public health tool of the utmost importance and the Italian National Vaccine Prevention Plan (PNPV) 2017-2019 recommends several vaccinations in this population group. Nevertheless, vaccine hesitancy is influencing HCWs' attitude towards vaccination. Moreover, a large number of measles cases have been reported in Italy among HCWs in 2017 and 2018. In Italy there is no national registry for vaccinations, so data on vaccine coverage among HCWs are not readily accessible. The aim of this literature review is to describe the most recent data about vaccination coverage among HCWs in Italy. We also report studies that evaluated the effectiveness of strategies to increase influenza vaccine uptake. We included all studies conducted in Italy and published between 2008 and 2018, regarding vaccines recommended by the PNPV 2017-2019 (hepatitis B, influenza, pertussis, measles, mumps, rubella, varicella, and tuberculosis). Our findings confirm that low vaccination coverage levels among HCWs exist in several Italian regions and cities, highlighting a relevant gap towards targets set by the PNPV. Studies that evaluated the effectiveness of multicomponent interventions to increase vaccination coverage found only minimal to moderate increases in uptake levels. It is therefore crucial to tackle vaccine hesitancy in HCWs, by identifying effective strategies able to significantly increase vaccine coverage, in order to decrease the risk of nosocomial infections, prevent transmission of preventable diseases to patients, and reduce indirect costs related to HCW absenteeism due to illness.

Impact evaluation of a Critical Pathway for patients with Clostridium difficile infection: A pre-post analysis in a Third Level Referral Center

BACKGROUND

Clostridium Difficile Infections (CDIs) have been increasing both in incidence and in severity, representing a big public health concern.

AIM

The aim of this study was to evaluate the impact of a recently implemented Critical Pathway (CP) focused on patients with CDI in an Italian Teaching Hospital.

METHODS

The CP implementation consisted of intervention aimed to faster diagnosis and appropriateness in admission and discharge point of care; activation of a multidisciplinary team; staff training; information to patients and caregivers. In a pre-post retrospective observational study, volume, process and outcome indicators were analyzed.

FINDINGS

A total of 228 patients (128 in 2013 and 100 in 2016) were included. A decrease in the absolute number of access to the Emergency Department (p=0.02) and an increase in hospitalization in more appropriate ward (ie gastroenterology ward, p<0.001) were found. The median hospital length of stay decreased from 20.5 (12.5-31) days in 2013 to 16.5 (7-31) days in 2016 (p=0.05). With regards to outcome indicators, an increase of discharge to home and a decrease of discharge to long term facilities were showed (p=0.01 both). Despite a reduction, no statically significant differences in mortality between 2013 and 2016 were revealed by the analysis.

CONCLUSION

In conclusion, we found quality improvement in patient hospital management. Our experience confirms that the implementation of the CP increases the appropriateness in hospital quality of care.

A campaign aimed at increasing seasonal influenza vaccination coverage among post graduate medical residents in an Italian teaching hospital

We analysed the impact of several strategies aimed at increasing influenza immunisation rates among Medical Residents (MRs) of an Italian teaching Hospital. During the 2015-16 and 2016-17 influenza seasons we carried out several interventions: ambulatory doubling where vaccination was offered, ambulatory opening hour extension, email invitations, informative materials, forum theatre and vaccination campaign conference. In addition, during the 2016-17 the OSV was carried out: MRs who go to specific wards where they perform influenza immunisation counselling and eventually vaccinate the personnel. 99/1041 (9.5%) and 184/1013 (18.2%) MRs received the vaccine in 2015-16 and in 2016-17 respectively (p < 0.0001). Significant difference was found among three specialisation areas (medicine, surgery, "services"; p < 0.001) and among years of residency (p < 0.001). The highest coverage was found among Infectious Diseases, Paediatrics, Haematology and Hygiene MRs (80%, 67%, 52% and 52% respectively) in 2016-2017 season. The highest coverage increase was found among MRs in Pneumology and Geriatrics (566% and 268%, respectively). The coverage rate has increased even though important differences among specialties persist. The study shows a significant increase in immunisation rate among MRs after the implementation of these strategies.

[Use of the Lean methodology in the management of cancer patients in a University Hospital, Italy: First results]

AIM

The aim of this study was to map a patient's journey along all stages of his daily care path in an Oncology outpatient department, to identify and eliminate &quot;bottleneck&quot; situations that interfere with the patient's flow of care. The main key performance indicators used in the study were: waiting times for each stage of the care process, time required for each activity, and resources used.

METHODS

The study was conducted from 17-30 January 2018 at the medical oncology clinic of a large university teaching and research hospital in Italy. We analyzed all the healthcare services provided during the monitoring period, dividing them into: first appointments, therapy, visits for adjustments of the therapeutic plan, visits for i.v. therapy, visits for oral therapy, follow-up visits, other visits (e.g. for positioning of peripherally inserted central catheter). Data collection was performed by administering two questionnaires: a Patient Journey (PJ) questionnaire to patients and a Medical Journey (MJ) questionnaire to clinicians. This project employed Lean principles in order to: view the process and specify value through the patient's point of view, identify waste in processes and eliminate any steps lacking any added value, reduce variation of and leveling workload to improve quality and ?ow of care, engage patients and staff to redesign the process.

RESULTS

The response rate in 1351 outpatients who were invited to participate was 63%; for doctors it was 81%. The mean waiting time for first visits and follow up visits performed in a single day was 50 minutes. An audit process was thus performed and a series of quality improvement measures were defined and shared with health professionals.

CONCLUSIONS

The Lean methodology could provide a robust framework for improved understanding and management of complex system constraints in outpatient oncology clinics, and could result in improved access to treatment and reduced waiting times for patients.

[Control of antimicrobial resistance in the food chain: a narrative review]

A poor environmental management and the deterioration of health and hygiene conditions (lack of awareness and attention to hygienic standards, to measures for preventing transmission of infection, and to appropriate use of antimicrobial therapies) facilitate the selection, release and diffusion of resistant pathogens in the environment, which can very easily contaminate the food chain. Antimicrobial resistance is a major problem worldwide, involving many sectors: medicine, veterinary medicine, breeding, agriculture, economy and commerce. In addition, the expanding globalization and increasing movements of both goods and people across countries and continents have drastically exacerbated the situation. In this difficult context, professionals of both the food and health sectors have an important role to play and their active participation is essential, together with that of citizens and patients themselves. For this very reason, national programs to combat antimicrobial resistance are needed, with a special focus on surveillance, antimicrobial stewardship, training of professionals and citizens, all the while assuring the availability of economic resources to achieve these goals. The "One Health" initiative is intended to strengthen the link between different scientific disciplines, such as human and veterinary medicine, since the phenomenon of antimicrobial resistance may be further aggravated by microbial transmission from animals to humans, directly or indirectly through the consumption of food. The aim of this narrative review is to give an overview of what is known about antimicrobial resistance related to food chain, to illustrate its extent and epidemiology in Italy, in Europe and globally, and to discuss the measures required to fight antimicrobial resistance including good practices on the use of antibiotics.

[Resident physicians' participation to the activities of the hospital hygiene unit in a teaching hospital: a pilot study]

INTRODUCTION

The Hospital Hygiene Unit ensures hospital patient safety, through surveillance and control of environmental conditions of risk. In this context, resident physicians in Hygiene and Preventive Medicine of the Catholic University of the Sacred Heart (UCSC) are required to attend the unit to acquire professional skills, for two months (four weeks in the first year of residency and four weeks in the second year). In the initial phase of the rotation, residents are acquainted with the organization and assigned activities. Ongoing meetings with the tutor take place to verify the progress of activities in which they are involved; verification of acquired skills is performed at the end of the period of attendance. The aim of the study was to evaluate resident doctors' opinions about their training experience, in order to assess the perceived quality and pursue continuous improvement of the training program.

MATERIALS AND METHODS

A questionnaire was administered to resident physicians attending the first three years of residency; the survey consisted of 11 multiple choice questions on organization, attendance, training and overall satisfaction and 3 open-ended questions on strengths, weaknesses and proposals for improvement.

RESULTS

Fourteen of 15 residents (93.3%) completed the questionnaire: seven were male, five were first-year residents, five were second-year and four were third-year residents. Overall, 78% gave a positive assessment of the quality of training; in particular, 11 of 14 residents reported that the experience was very relevant to their training in Hygiene and Preventive Medicine. Responses regarding the training organization were also mostly positive (75%), as were those regarding attendance (57%) and overall satisfaction (67%). Fifty percent reported difficulties in combining this internship with the other activities planned with their tutor.

CONCLUSIONS

Positive opinions prevail in all areas of assessment, although there are some aspects that can be improved, including the possibility to extend the period of attendance. Overall, training activities at the Operative Unit of Hospital Hygiene are appreciated by resident physicians, who consider them an important opportunity for professional growth.

[A health promotion campaign to improve flu vaccination adherence among medical residents in an Italian Teaching Hospital]

INTRODUCTION

In Italy annual flu vaccination for health care workers is recommended but coverage is usually unsatisfying. The compliance is even worse among medical residents (MRs) both in literature, both in our experience: in the flu season 2014/ 15 only 0.6% of MRs enrolled at the Università Cattolica del Sacro Cuore (UCSC) were vaccinated. For this reason, during the influenza season 2015/16, the Institute of Public Health of the UCSC, in collaboration with the Health Management of the "Agostino Gemelli" Teaching Hospital (FPG) and with the directive board of the Medical Specialization Schools (SSM) present at the University has tested several strategies to improve awareness and adherence to flu vaccination campaign by its staff. This study aims to analyze the impact of the strategies used during the 2015/16 campaign on flu vaccination coverage among MRs of an important Italian Teaching Hospital.

METHODS

The study was conducted among MRs enrolled at the UCSC - FPG in 2015/16. The data was collected by the Occupational Medicine which, during the influenza seasons, immunize MRs against influenza free of charge. For each variable - vaccination, area of specialization (surgical, medical, clinical services), typology of SSM - was measured the absolute and percentage frequency. In order to compare the flu vaccination coverage between seasons 2014/15 and 2015/16 and between areas of specialization in 2015/16 chi-square test was used (statistical significance level of 0.05). The data were analyzed using STATA Software.

RESULTS

Were included in the analysis 42 SSM with a total of 1041 MRs. During the vaccination campaign 2015/16, flu vaccine was administered to 99 MRs (9.5%), 8.9% more than in the previous season (p&lt;0.001). There is also a significant difference in vaccine coverage between surgical, medical and clinical services areas in 2015/16 (p &lt;0.001). The highest vaccination coverage was recorded among MRs of Hematology and Urology (54.5%). However, no one MRs had undergone flu vaccination in about 40% of SSM.

CONCLUSIONS

Seasonal flu vaccination among HCWs is important to protect patients as well as them self and their family members. Considering that MRs represent the next generation of HCWs, they should be sensitized about the importance of preventing the spread of influenza in hospital population, becoming an active part of the necessary cultural change. This study highlights a first and promising, although insufficient, increase in flu vaccination coverage among MRs enrolled at the UCSC - FPG after introducing simple strategies to promote vaccination itself and, more generally, positive and proactive behaviors. The study summarizes the results in the short term, but it is well known that cultural changes require time and constancy. Therefore, it will be useful to monitor the improvement over time and extend the assessment to all health care professionals.

Developing a two-sided intervention to facilitate shared decision-making in haemophilia: decision boxes for clinicians and patient decision aids for patients

BACKGROUND

People with haemophilia face many treatment decisions, which are largely informed by evidence from observational studies. Without evidence-based 'best' treatment options, patient preferences play a large role in decisions regarding therapy. The shared decision-making (SDM) process allows patients and health care providers to make decisions collaboratively based on available evidence, and patient preferences. Decision tools can help the SDM process. The objective of this project was to develop two-sided decision tools, decision boxes for physicians and patient decision aids for patients, to facilitate SDM for treatment decisions in haemophilia.

METHODS

Development of the decision tools comprised three phases: topic selection, prototype development and usability testing with targeted end-users. Topics were selected using a Delphi survey. Tool prototypes were based on a previously validated framework and were informed by systematic literature reviews. Patients, through focus groups, and physicians, through interviews, reviewed the prototypes iteratively for comprehensibility and usability.

RESULTS

The chosen topics were: (i) prophylactic treatment: when to start and dosing, (ii) choosing factor source and (iii) immunotolerance induction: when to start and dosing. Intended end users (both health care providers and haemophilia patients and caregivers) were engaged in the development process. Overall perception of the decision tools was positive, and the purpose of using the tools was well received.

CONCLUSIONS

This study demonstrates the feasibility of developing decision tools for haemophilia treatment decisions. It also provides anecdotal evidence of positive perceptions of such tools. Future directions include assessment of the tools' practical value and impact on clinical practice.

Abstract P6-05-16: p53 and BCL2 expression across molecular subtypes: Correlation with disease progression, response to therapy and site of relapse in 1099 early breast cancer patients

Background: The management of early breast cancer (BC) continues to be challenging because of the heterogeneity of the disease and a limited number of clinical/pathological factors are currently used to guide therapy and prognosis. Recently, p53, a tumor suppressor and BCL2, an antiapoptotic protein have been proposed as additional prognostic markers, although their relationship with conventional parameters and patient prognosis remains uncertain. In particular, there are few data concerning p53 and BCL2 distribution within the molecular BC subtypes, luminal A (LA), luminal B/HER2- (LB/HER2-), luminal B/HER2+ (LB/HER2+), HER2-like (H), and triple negative (TN).

Methods: We conducted a retrospective study using immunohistochemistry to evaluate p53 and BCL2 expression in 1099 early BC patients (median age 56 yrs [21-92], N+ 487 [45%]) surgically treated at our Institute between 2000 and 2006 with at least 5 yrs follow-up data. None of the HER2+ patients, included in our series, received trastuzumab in the adjuvant setting. Associations among p53 and BCL2, T, N, G and molecular subtypes were analyzed by multiple correspondence analysis (MCA), while Kaplan-Meier method was applied to determine their impact on disease-free survival (DFS).

Results: p53 and BCL2 differently distribute across the 5 molecular subtypes (p-value&lt;0.0001). p53 is highly positive in LB-H+ (38%), H (50%) and TN (33%), conversely, BCL2 is more frequently expressed in LA (71%) and LB-H- (75%) BC. The relationships among bio-pathological factors, analyzed by MCA, confirmed that p53 positive and BCL2 negative BC are located in the quadrant containing more aggressive conventional tumor phenotypes (H and TN subtypes, T3/T4, N+, G3 and presence of relapse). Kaplan-Meier curves identified BCL2 negativity as a significant discriminating factor for DFS (p = 0.024) while p53 does not discriminate BC patients independent of molecular subtypes. Of interest, in the subset of 595 N0 patients p53 positivity and BCL2 negativity were significantly associated to the lack of response to anthracycline (AC ± taxanes) based chemotherapy (p&lt;0.0001). Focusing on the 345 BC who relapsed (132 visceral and 213 non visceral metastases) we observed that visceral metastases are significantly less frequent in LA (30%), LB HER2- (37%) and TN (29%) BC as compared to H (52%) and LB-HER2+ (58%) BC (p = 0.004).

Conclusions: Our data indicated that lack of BCL2, in contrast to p53 positivity, appears to be a biomarker related to a more aggressive clinical course across BC molecular subtypes although both biomarkers may affect AC-based chemotherapy response in the subset of N0 patients. Visceral metastases are more frequent in H and LB-HER+ subtypes as compared to the other groups.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P6-05-16.

Non-resonant and non-enhanced Raman correlation spectroscopy

We present the first non-resonant and non-enhanced Raman correlation spectroscopy experiments. They are conducted on a confocal microscope combined with a Raman spectrometer. The thermal fluctuations of the Raman intensities scattered by dispersions of polystyrene particles of sub-micrometric diameters are measured and analysed by deriving the autocorrelation functions (ACFs) of the intensities. We show that for particles of diameter down to 200 nm, RCS measurements are successfully obtained in spite of the absence of any source of amplification of the Raman signal. For particles of diameter ranging from 200 to 750 nm, the ACFs present a time-decay behaviour in accordance with the model of free Brownian particles. For particles of 1000 nm in diameter, the AFCs present a different behaviour with a much smaller characteristic time. This results from the dynamics of a single-Brownian particle trapped in the confocal volume by the optical forces of the focus spot.

Orexins/hypocretins control bistability of hippocampal long-term synaptic plasticity through co-activation of multiple kinases

AIM

Orexins/hypocretins (OX/Hcrt) are hypothalamic neuropeptides linking sleep-wakefulness, appetite and neuroendocrine control. Their role and mechanisms of action on higher brain functions, such as learning and memory, are not clear.

METHODS

We used field recordings of excitatory post-synaptic potentials (fEPSP) in acute mouse brain slice preparations to study the effects of orexins and pharmacological inhibitors of multiple kinases on long-term synaptic plasticity in the hippocampus.

RESULTS

Orexin-A (OX-A) but not orexin-B (OX-B) induces a state-dependent long-term potentiation of synaptic transmission (LTP(OX)) at Schaffer collateral-CA1 synapses in hippocampal slices from adult (8- to 12-week-old) mice. In contrast, OX-A applied to slices from juvenile (3- to 4-week-old) animals causes a long-term depression (LTD(OX)) in the same pathway. LTP(OX) is blocked by pharmacological inhibition of orexin receptor-1 (OX1R) and plasticity-related kinases, including serine/threonine- (CaMKII, PKC, PKA, MAPK), lipid- (PI3K), and receptor tyrosine kinases (Trk). Inhibition of OX1R, CaMKII, PKC, PKA and Trk unmasks LTD(OX) in adult animals.

CONCLUSION

Orexins control not only the bistability of arousal states and threshold for appetitive behaviours but, in an age- and kinase-dependent manner, also bidirectional long-term synaptic plasticity in the hippocampus, providing a possible link between behavioural state and memory functions.