Addressing chronic diseases: a comparative study of policies towards type-2 diabetes and hypertension in selected European countries

BACKGROUND

Type-2 diabetes (T2D) and hypertension (HTN) are two of the most prevalent non-communicable diseases (NCDs): they both cause a relevant number of premature deaths worldwide and heavily impact the national health systems. This study illustrates the impact of HTN and T2D in four European countries (Albania, Bulgaria, Greece and Spain) and compares their policies towards the monitoring and management of HTN and T2D and the prevention of NCDs as a whole. This analysis is conducted throughout the DigiCare4You Project (H2020)-which implements an innovative solution involving digital tools for the prevention and management of T2D and HTN.

METHODS

The analysis is implemented through desk research, and it is enriched with additional information directly provided by the local coordinators in the four countries, by filling specific semi-structured forms.

RESULTS

The countries exhibit significant differences in the prevalence of HTN and T2D and available policies and programs targeted to these two chronic conditions. Each country has implemented strategies for HTN and T2D, including prevention initiatives, therapeutic guidelines, educational programs and children's growth monitoring programs. However, patient education on proper disease management needs improvement in all countries, registries about patients affected by HTN and T2D are not always available, and not all countries promoted acts to contain the increasing rates of risk factors related to NCDs.

CONCLUSIONS

While political awareness of the risks associated with HTN, T2D and NCDs in general is growing, there is a collective need for countries to strengthen their policies for preventing and managing these chronic diseases.

Evaluating hepatitis C cascade of care surveillance system in Tuscany, Italy, through a population retrospective data-linkage study, 2015-2021

This comprehensive retrospective data-linkage study aimed at evaluating the impact of Direct-Acting Antivirals (DAAs) on Hepatitis C Virus (HCV) testing, treatment trends, and access to care in Tuscany over six years following their introduction. Utilizing administrative healthcare records, our work reveals a substantial increase in HCV tests in 2017, attributed to the decision to provide universal access to treatment. However, despite efforts to eradicate chronic HCV through a government-led plan, the target of treating 6,221 patients annually was not met, and services contracted after 2018, exacerbated by the COVID-19 pandemic. Key findings indicate a higher prevalence of HCV screening among females in the 33-53 age group, influenced by pregnancy-related recommendations, while diagnostic tests and treatment uptake were more common among males. Problematic substance users constituted a significant proportion of those tested and treated, emphasizing their priority in HCV screening. Our paper underscores the need for decentralized HCV models and alternative testing strategies, such as point-of-care assays, especially in populations accessing harm reduction services, communities, and prisons. The study acknowledges limitations in relying solely on administrative records, advocating for improved data access and timely linkages to accurately monitor HCV care cascades and inform regional plans. Despite challenges, the paper demonstrates the value of administrative record linkages in understanding the access to care pathway for hard-to-reach populations. The findings emphasize the importance of the national HCV elimination strategy and the need for enhanced data collection to assess progress accurately, providing insights for future regional and national interventions.

Learning prevalent patterns of co-morbidities in multichronic patients using population-based healthcare data

The prevalence of longstanding chronic diseases has increased worldwide, along with the average age of the population. As a result, an increasing number of people is affected by two or more chronic conditions simultaneously, and healthcare systems are facing the challenge of treating multimorbid patients effectively. Current therapeutic strategies are suited to manage each chronic condition separately, without considering the whole clinical condition of the patient. This approach may lead to suboptimal clinical outcomes and system inefficiencies (e.g. redundant diagnostic tests and inadequate drug prescriptions). We develop a novel methodology based on the joint implementation of data reduction and clustering algorithms to identify patterns of chronic diseases that are likely to co-occur in multichronic patients. We analyse data from a large adult population of multichronic patients living in Tuscany (Italy) in 2019 which was stratified by sex and age classes. Results demonstrate that (i) cardio-metabolic, endocrine, and neuro-degenerative diseases represent a stable pattern of multimorbidity, and (ii) disease prevalence and clustering vary across ages and between women and men. Identifying the most common multichronic profiles can help tailor medical protocols to patients' needs and reduce costs. Furthermore, analysing temporal patterns of disease can refine risk predictions for evolutive chronic conditions.

Driving time drives the hospital choice: choice models for pelvic organ prolapse surgery in Italy

OBJECTIVE

The Italian healthcare jurisdiction promotes patient mobility, which is a major determinant of practice variation, thus being related to the equity of access to health services. We aimed to explore how travel times, waiting times, and other efficiency- and quality-related hospital attributes influenced the hospital choice of women needing pelvic organ prolapse (POP) surgery in Tuscany, Italy.

METHODS

We obtained the study population from Hospital Discharge Records. We duplicated individual observations (n = 2533) for the number of Tuscan hospitals that provided more than 30 POP interventions from 2017 to 2019 (n = 22) and merged them with the hospitals' list. We generated the dichotomous variable "hospital choice" assuming the value one when hospitals where patients underwent surgery coincided with one of the 22 hospitals. We performed mixed logit models to explore between-hospital patient choice, gradually adding the women's features as interactions.

RESULTS

Patient choice was influenced by travel more than waiting times. A general preference for hospitals delivering higher volumes of interventions emerged. Interaction analyses showed that poorly educated women were less likely to choose distant hospitals and hospitals providing greater volumes of interventions compared to their counterpart. Women with multiple comorbidities more frequently chose hospitals with shorter average length of stay.

CONCLUSION

Travel times were the main determinants of hospital choice. Other quality- and efficiency-related hospital attributes influenced hospital choice as well. However, the effect depended on the socioeconomic and clinical background of women. Managers and policymakers should consider these findings to understand how women behave in choosing providers and thus mitigate equity gaps.

Utilisation of primary healthcare services by Sjögren's syndrome patients in the Community of Madrid and associated factors: a population-based cross-sectional study

OBJECTIVES

To describe the utilisation of primary health care (PHC) services and factors associated with its use by patients diagnosed with Sjögren's syndrome (SS).

METHODS

Population-based cross-sectional cohort of SS patients in Madrid, Spain (SIERMA). Sociodemographic, diagnostic, clinical and PHC service utilisation variables were studied by bivariate analyses and regression models.

RESULTS

A total of 4,778 SS patients were included, 65.2% classified as primary SS (pSS), while 34.8% associated with another autoimmune disease (associated SS). Mean age was 64.3 years, and 92.8% of the patients were women. A total of 87.5% used PHC services, with a mean of 19.8 consultations/year. The general practitioner was the most visited health professional, with a mean of 10.9 consultations/year, followed by the nurse, with a mean of 5.7. Characteristics associated with a greater use of PHC services in SS patients were associated SS, higher adjusted morbidity groups (AMG) risk level and older age. Additional factors included symptoms such as dry mouth, fatigue, dry vagina and joint and muscle pain; comorbidities such as atrial fibrillation, diabetes, hypertension, solid malignant neoplasms, coronary heart disease and chronic obstructive pulmonary disease; and treatments such as sterile saline solution, corticosteroids, opioids and biologic disease-modifying anti-rheumatic drugs.

CONCLUSIONS

Most SS patients used PHC services during the study period, and the mean number of consultations was remarkably high. Utilisation was mainly associated with AMG risk level, ageing, glandular and extra-glandular symptoms, substantial comorbidities and various treatments. An optimised design of PHC policies will facilitate early diagnosis, improved management and better quality of life for SS patients.

Prevalence and comorbidities of Sjogren's syndrome patients in the Community of Madrid: A population-based cross-sectional study

OBJECTIVES

To estimate the prevalence, sociodemographic characteristics and comorbidities of Sjogren's syndrome (SS) patients in the Community of Madrid.

METHODS

A population-based cross-sectional cohort of SS patients was derived from the information system for rare diseases in the Community of Madrid (SIERMA) and confirmed by a physician. The prevalence per 10,000 inhabitants among people aged ≥18years in June 2015 was calculated. Sociodemographic data and accompanying disorders were recorded. Univariate and bivariate analyses were performed.

RESULTS

A total of 4,778 SS patients were confirmed in SIERMA; 92.8% were female, with a mean age of 64.3 (standard deviation=15.4) years. A total of 3,116 (65.2%) patients were classified as primary SS (pSS), and 1,662 (34.8%) as secondary SS (sSS). The prevalence of SS among people aged ≥18 years was 8.4/10,000 (95%Confidence interval [CI]=8.2-8.7). The prevalence of pSS was 5.5/10,000 (95%CI=5.3-5.7), and that of sSS was 2.8/10,000 (95%CI=2.7-2.9), with rheumatoid arthritis (20.3%) and systemic lupus erythematosus (8.5%) being the most prevalent associated autoimmune diseases. The most common comorbidities were hypertension (40.8%), lipid disorders (32.7%), osteoarthritis (27.7%) and depression (21.1%). The most prescribed medications were nonsteroidal anti-inflammatory drugs (31.9%), topical ophthalmic therapies (31.2%) and corticosteroids (28.0%).

CONCLUSION

The prevalence of SS in the Community of Madrid was similar to the overall prevalence worldwide observed in previous studies. SS was more frequent in women in their sixth decade. Two out of every three SS cases were pSS, while one-third were associated predominantly with rheumatoid arthritis and systemic lupus erythematosus.

The Function of Bed Management in Pandemic Times-A Case Study of Reaction Time and Bed Reconversion

The last decade was characterized by the reduction in hospital beds throughout Europe. When facing the COVID pandemic, this has been an issue of major importance as hospitals were seriously overloaded with an unexpected growth in demand. The dichotomy formed by the scarcity of beds and the need for acute care was handled by the Bed Management (BM) function. This case study explores how BM was able to help the solidness of the healthcare system, managing hospital beds at best and recruiting others in different settings as intermediate care in a large Local Health Authority (LHA) in central Italy. Administrative data show how the provision of appropriate care was achieved by recruiting approximately 500 beds belonging to private healthcare facilities affiliated with the regional healthcare system and exercising the best BM function. The ability of the system to absorb the extra demand caused by COVID was made possible by using intermediate care beds, which were allowed to stretch the logistic boundaries of the hospitals, and by the promptness of Bed Management in converting beds into COVID beds and reconverting them, and by the timely management of internal patient logistics, thus creating space according to the healthcare demands.

Physical and stressful psychological impacts of prolonged personal protective equipment use during the COVID-19 pandemic: A cross-sectional survey study

BACKGROUND

Healthcare workers (HCWs) caring for COVID-19 infected patients are exposed to stressful and traumatic events with potential for severe and sustained adverse mental and physical health consequences. Our aim was to assess the magnitude of physical and mental health outcomes of HCWs due to the prolonged use of personal protective equipment (PPE) treating COVID-19 patients.

METHODS

This cross-sectional study assessed the symptoms of stress, anxiety, insomnia, and psychological resilience using the Stress and Anxiety to Viral Epidemics (SAVE) scale, Insomnia Severity Index (ISI), and Resilience Scale (RS), respectively, in Italy between 1st February and 31st March 2022. The physical outcomes reported included vertigo, dyspnea, nausea, micturition desire, retroauricular pain, thirst, discomfort at work, physical fatigue, and thermal stress. The relationships between prolonged PPE use and psychological outcomes and physical discomforts were analyzed using Generalized Linear Models (GLMs). We calculated the factor mean scores and a binary outcome to measure study outcomes.

FINDINGS

We found that 23% of the respondents reported stress related symptoms, 33% anxiety, 43% moderate to severe insomnia, and 67% reported moderate to very low resilience. The GLMs suggested that older people (>55 years old) are less likely to suffer from stress compared to younger people (<35 y.o); conversely, HCW aged more than 35 years are more inclined to suffer from insomnia than younger people (<35 y.o). Female HCW reported a lower probability of resilience than males. University employed HCWs were less likely to report anxiety than those who worked in a community hospital. The odds of suffering from insomnia for social workers was significantly higher than for other HCWs. Female HCW>3 years old, enrolled in training programs for nursing, social work, technical training and other healthcare professionals increased the probability of reported physical discomforts. HCW that worked on non COVID-19 wards and used PPE for low-medium exposure level, were at lower risks for lasting physical side effects as compared to the HCW who worked in high-risk PPE intense, COVID-19 environments.

INTERPRETATION

The study suggests that frontline HCWs who had extensive PPE exposure while directly engaged in the diagnosis, treatment, and care for patients with COVID-19 are at significant risks for lasting physical and psychological harm and distress.

The management of healthcare employees' job satisfaction: optimization analyses from a series of large-scale surveys

BACKGROUND

Measuring employees' satisfaction with their jobs and working environment have become increasingly common worldwide. Healthcare organizations are not extraneous to the irreversible trend of measuring employee perceptions to boost performance and improve service provision. Considering the multiplicity of aspects associated with job satisfaction, it is important to provide managers with a method for assessing which elements may carry key relevance. Our study identifies the mix of factors that are associated with an improvement of public healthcare professionals' job satisfaction related to unit, organization, and regional government. Investigating employees' satisfaction and perception about organizational climate with different governance level seems essential in light of extant evidence showing the interconnection as well as the uniqueness of each governance layer in enhancing or threatening motivation and satisfaction.

METHODS

This study investigates the correlates of job satisfaction among 73,441 employees in healthcare regional governments in Italy. Across four cross sectional surveys in different healthcare systems, we use an optimization model to identify the most efficient combination of factors that is associated with an increase in employees' satisfaction at three levels, namely one's unit, organization, and regional healthcare system.

RESULTS

Findings show that environmental characteristics, organizational management practices, and team coordination mechanisms correlates with professionals' satisfaction. Optimization analyses reveal that improving the planning of activities and tasks in the unit, a sense of being part of a team, and supervisor's managerial competences correlate with a higher satisfaction to work for one's unit. Improving how managers do their job tend to be associated with more satisfaction to work for the organization.

CONCLUSIONS

The study unveils commonalities and differences of personnel administration and management across public healthcare systems and provides insights on the role that several layers of governance have in depicting human resource management strategies.

Early Warning Systems for Emerging Profiles of Antimicrobial Resistance in Italy: A National Survey

Antimicrobial resistance (AMR) national surveillance systems in Italy lack alert systems for timely detection of emerging profiles of AMR with potential relevance to public health. Furthermore, the existence of early warning systems (EWS) at subnational level is unclear. This study aims at mapping and characterizing EWS for microbiological threats available at regional level in Italy, focusing on emerging AMR, and at outlining potential barriers and facilitators to their development/implementation. To this end, a three-section, web-based survey was developed and administered to all Italian regional AMR representatives from June to August 2022. Twenty out of twenty-one regions and autonomous provinces (95.2%) responded to the survey. Among these, nine (45%) reported the implementation of EWS for microbiological threats at regional level, three (15%) reported that EWS are in the process of being developed, and eight (40%) reported that EWS are not currently available. EWS characteristics varied widely among the identified systems concerning both AMR profiles reported and data flow: the microorganisms most frequently included were extensively drug-resistant (XDR) Enterobacterales, with the lack of a dedicated regional IT platform reported in most cases. The results of this study depict a highly heterogeneous scenario and suggest that more efforts aimed at strengthening national AMR surveillance systems are needed.

Women's choices of hospital for breast cancer surgery in Italy: Quality and equity implications

This paper employs mixed logit regression to investigate the effects of providers characteristics on women's choice of hospital for breast surgery. Patient level data are used to model choices in Tuscany region, Italy. In particular, we focus on the effects of travel time and hospital quality indicators including quality standard (volumes of breast surgery), measurement of process (waiting times) and quality of surgical procedures. Variation in preferences related to individual characteristics such as age, education and travel distance from the hospital are also considered. Findings show that, on average, women prefer closer hospital with longer waiting times and higher quality (high volumes of interventions). We found preference heterogeneity associated to education: travel distance affects choice especially among less educated women (regardless of age), while among younger women (<65 years), less educated ones prefer shorter waiting times. These results could be used to optimize the allocation of resources toward breast cancer units that meet quality and efficacy standards to increase the efficiency and responsiveness of breast cancer care.

Regional practice variation in pelvic organ prolapse surgery in Tuscany, Italy: a retrospective cohort study on administrative health data

OBJECTIVES

To explore determinants of practice variation in both access, and quality and efficiency of surgical care for pelvic organ prolapse (POP).

DESIGN AND SETTING

A retrospective cohort study employing administrative health data from the Tuscany region, Italy.

PARTICIPANTS

All women over 40 years hospitalised for apical/multicompartmental POP reconstructive surgery (excluding anterior/posterior colporrhaphy without concomitant hysterectomy) from January 2017 to December 2019.

OUTCOMES

We first computed treatment rates just for women residing in Tuscany (n=2819) and calculated the Systematic Component of Variation (SCV) to explore variation in access to care among health districts. Then, using the full cohort (n=2959), we ran multilevel models for the average length of stay and reoperations, readmissions and complications, and computed the intraclass correlation coefficient to assess the individual and hospital determinants of efficiency and quality of care provided by hospitals.

RESULTS

The 5.4-fold variation between the lowest-rate (56/100 000 inhabitants) and the highest-rate (302/100 000) districts and the SCV over 10% confirmed high systematic variation in the access to care. Higher treatment rates were driven by greater provisions of robotic and/or laparoscopic interventions, which showed highly variable usage rates. Both individual and hospital factors influenced quality and efficiency provided by hospitals, but just low proportions of variation were explained by hospital and patient characteristics.

CONCLUSIONS

We found high and systematic variation in the access to POP surgical care in Tuscany and in quality and efficiency provided by hospitals. Such a variation may be mainly explained by user and provider preferences, which should be further explored. Also, supply-side factors may be involved, suggesting that wider and more uniform dissemination of robotic/laparoscopic procedures may reduce variation.

Healthcare costs of diabetic foot disease in Italy: estimates for event and state costs

OBJECTIVE

This study aimed to estimate healthcare costs of diabetic foot disease (DFD) in a large population-based cohort of people with type-2 diabetes (T2D) in the Tuscany region (Italy).

DATA SOURCES/STUDY SETTING

Administrative healthcare data of Tuscany region, with 2018 as the base year.

STUDY DESIGN

Retrospective study assessing a longitudinal cohort of patients with T2D.

DATA COLLECTION/EXTRACTION METHODS

Using administrative healthcare data, DFD were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification codes.

METHODS

We examined the annual healthcare costs of these clinical problems in patients with T2D between 2015 and 2018; moreover, we used a generalized linear model to estimate the total healthcare costs.

PRINCIPAL FINDINGS

Between 2015 and 2018, patients with T2D experiencing DFD showed significantly higher average direct costs than patients with T2D without DFD (p < 0.0001). Among patients with T2D experiencing DFD, those who experienced complications either in 2015-2017 and in 2018 incurred the highest incremental costs (incremental cost of € 16,702) followed by those with complications in 2018 only (incremental cost of € 9,536) and from 2015 to 2017 (incremental cost of € 800).

CONCLUSIONS

DFD significantly increase healthcare utilization and costs among patients with TD2. Healthcare costs of DFD among patients with T2D are associated with the timing and frequency of DFD. These findings should increase awareness among policymakers regarding resource reallocation toward preventive strategies among patients with T2D.

Monitoring Appropriate Monoclonal Antibodies Prescribing via Administrative Data: An Application to Psoriasis

The Italian Medicines Agency (AIFA) and the Italian Regional Health Systems have implemented measures together with data collection and analysis to improve medicines' appropriate prescription. Administrative databases represent rich Real-World Evidence (RWE) sources that may be leveraged for research purposes. Thus, such heritage may allow for appropriate prescription studies to be carried out on complex pharmaceutical molecules, as the appropriateness of prescriptions is essential both for patients' treatment and to ensure healthcare systems' sustainability. This study analyzed the appropriate monoclonal antibodies (mAbs) prescribed in psoriasis treatment across Tuscany, Italy. Data were extracted from several large administrative databases collected by the Tuscan Regional Healthcare System through record linkages. The analysis showed that over 30% of the 2020 cohort of psoriatic patients could be regarded as potentially inappropriate treated, signaling that mAbs are often prescribed as first-line treatment contrary to guidelines. Variation was observed in the appropriate prescription of mAbs, across different types of mAbs and areas. The study revealed potential inappropriate prescription, and its geographic variation should raise awareness among managers about the appropriate use of resources. Despite limitations, this could represent a pilot for future studies to evaluate the appropriate prescription of mAbs in other clinic conditions and across time.

Detection of primary Sjögren’s syndrome in primary care: developing a classification model with the use of routine healthcare data and machine learning

Background

Primary Sjögren’s Syndrome (pSS) is a rare autoimmune disease that is difficult to diagnose due to a variety of clinical presentations, resulting in misdiagnosis and late referral to specialists. To improve early-stage disease recognition, this study aimed to develop an algorithm to identify possible pSS patients in primary care. We built a machine learning algorithm which was based on combined healthcare data as a first step towards a clinical decision support system.

Method

Routine healthcare data, consisting of primary care electronic health records (EHRs) data and hospital claims data (HCD), were linked on patient level and consisted of 1411 pSS and 929,179 non-pSS patients. Logistic regression (LR) and random forest (RF) models were used to classify patients using age, gender, diseases and symptoms, prescriptions and GP visits.

Results

The LR and RF models had an AUC of 0.82 and 0.84, respectively. Many actual pSS patients were found (sensitivity LR = 72.3%, RF = 70.1%), specificity was 74.0% (LR) and 77.9% (RF) and the negative predictive value was 99.9% for both models. However, most patients classified as pSS patients did not have a diagnosis of pSS in secondary care (positive predictive value LR = 0.4%, RF = 0.5%).

Conclusion

This is the first study to use machine learning to classify patients with pSS in primary care using GP EHR data. Our algorithm has the potential to support the early recognition of pSS in primary care and should be validated and optimized in clinical practice. To further enhance the algorithm in detecting pSS in primary care, we suggest it is improved by working with experienced clinicians.

Exploring Cost-Effectiveness of the Comprehensive Geriatric Assessment in Geriatric Oncology: A Narrative Review

Simple Summary

The Comprehensive Geriatric Assessment is a multidimensional and multidisciplinary evaluation designed for elderly patients with the goal of structuring tailored care and follow-up. Despite the known benefits of this approach, the Comprehensive Geriatric Assessment is not universally applied to elderly cancer patients due to economic and practical barriers. This narrative review aims to investigate the cost-effectiveness of the Comprehensive Geriatric Assessment adopted in geriatric oncology. The results revealed a lack of research on the topic, but recurrent cost-saving effects of this approach in geriatric oncology settings were highlighted—suggesting a positive cost-effectiveness ratio. Further structured research with comprehensive economic evaluations is needed to confirm these findings.

Abstract

The Comprehensive Geriatric Assessment (CGA) and the corresponding geriatric interventions are beneficial for community-dwelling older persons in terms of reduced mortality, disability, institutionalisation and healthcare utilisation. However, the value of CGA in the management of older cancer patients both in terms of clinical outcomes and in cost-effectiveness remains to be fully established, and CGA is still far from being routinely implemented in geriatric oncology. This narrative review aims to analyse the available evidence on the cost-effectiveness of CGA adopted in geriatric oncology, identify the relevant parameters used in the literature and provide recommendations for future research. The review was conducted using the PubMed and Cochrane databases, covering published studies without selection by the publication year. The extracted data were categorised according to the study design, participants and measures of cost-effectiveness, and the results are summarised to state the levels of evidence. The review conforms to the SANRA guidelines for quality assessment. Twenty-nine studies out of the thirty-seven assessed for eligibility met the inclusion criteria. Although there is a large heterogeneity, the overall evidence is consistent with the measurable benefits of CGA in terms of reducing the in-hospital length of stay and treatment toxicity, leaning toward a positive cost-effectiveness of the interventions and supporting CGA implementation in geriatric oncology clinical practice. More research employing full economic evaluations is needed to confirm this evidence and should focus on CGA implications both from patient-centred and healthcare system perspectives.

Changes in Acute Myocardial Infarction, Stroke, and Heart Failure Hospitalizations During COVID-19 Pandemic in Tuscany-An Interrupted Time Series Study

Objectives: We evaluate the impact of the COVID-19 pandemic on unplanned hospitalization rates for patients without COVID-19, including their length of stay, and in-hospital mortality, overall, and for acute myocardial infarction (AMI), stroke, and heart failure in the Tuscany region of Italy. Methods: We carried out a population-based controlled interrupted time series study using segmented linear regression with an autoregressive error term based on admissions data from all public hospitals in Tuscany. The primary outcome measure was weekly hospitalization rates; secondary outcomes included length of stay, and in-hospital mortality. Results: The implementation of the pandemic-related mitigation measures and fear of infection was associated with large decreases in inpatient hospitalization rates overall (-182 [-234, -130]), unplanned hospitalization (-39 [-51, -26]), and for AMI (-1.32 [-1.98, -0.66]), stroke (-1.51 [-2.56, -0.44]), and heart failure (-8.7 [-11.1, -6.3]). Average length of stay and percent in-hospital mortality for select acute medical conditions did not change significantly. Conclusion: In Tuscany, Italy, the COVID-19 pandemic was associated with large reductions in hospitalization rates overall, as well as for heart failure, and the time sensitive conditions of AMI and stroke during the months January to July 2020.

Estimating variations in the use of antibiotics in primary care: Insights from the Tuscany region, Italy

BACKGROUND

Practice variation is a well-known phenomenon that affects all aspects of healthcare delivery and leads to suboptimal health outcomes as well as poor resource allocation. Given the global rise of antimicrobial resistance, practice variation is of particular concern when it comes to the prescription of antibiotics. A growing number of healthcare systems are tackling this issue at all levels of healthcare governance.

AIMS AND OBJECTIVES

This study sought to estimate the variation in antibiotic use across different levels of Tuscany's primary care, and assess the extent to which the organization of primary care delivery is responsible for this variation.

METHODS

We analysed the performance and variation for seven indicators related to the use of antibiotics at three levels of healthcare governance: (i) the clinician level (2619 general practitioners [GPs]); (ii) the peer-group level (all 116 GP group practices) and (iii) the institutional level (all 26 health districts). For the statistical analysis, we built three-level mixed effects models that were fitted with 2619 GPs, 116 GP group practices and 26 health districts.

RESULTS

The multi-level models suggested that the grand majority of the variation in antibiotic use was located at the GP level (75% to 97%). However, the percentage of variation associated with GP group practices and health districts ranged from 3% to 25%, depending on the type of indicator analysed.

CONCLUSION

While the variation was found to be in large part due to differences between GPs themselves, the influence exerted by peer groups and institutional mechanisms does have a significant impact as well. Further research needs to be conducted regarding the institutional and contextual factors that prompt GPs to harmonize their prescribing behaviour in line with best practices and lead to not only improved patient outcomes but also large cost-savings.

International survey of COVID-19 management strategies

BACKGROUND

While individual countries have gained considerable knowledge and experience in coronavirus disease of 2019 (COVID-19) management, an international, comparative perspective is lacking, particularly regarding the measures taken by different countries to tackle the pandemic. This paper elicits the views of health system staff, tapping into their personal expertise on how the pandemic was initially handled.

METHODS

From May to July 2020, we conducted a cross-sectional, online, purpose-designed survey comprising 70 items. Email lists of contacts provided by the International Society for Quality in Health Care, the Italian Network for Safety in Health Care and the Australian Institute of Health Innovation were used to access healthcare professionals and managers across the world. We snowballed the survey to individuals and groups connected to these organizations. Key outcome measures were attitudes and information about institutional approaches taken; media communication; how acute hospitals were re-organized; primary health organization; personal protective equipment; and staffing and training.

RESULTS

A total of 1131 survey participants from 97 countries across the World Health Organization (WHO) regions responded to the survey. Responses were from all six WHO regions; 57.9% were female and the majority had 10 or more years of experience in healthcare; almost half (46.5%) were physicians; and all other major clinical professional groups participated. As the pandemic progressed, most countries established an emergency task force, developed communication channels to citizens, organized health services to cope and put in place appropriate measures (e.g. pathways for COVID-19 patients, and testing, screening and tracing procedures). Some countries did this better than others. We found several significant differences between the WHO regions in how they are tackling the pandemic. For instance, while overall most respondents (71.4%) believed that there was an effective plan prior to the outbreak, this was only the case for 31.9% of respondents from the Pan American Health Organization compared with 90.7% of respondents from the South-East Asia Region (SEARO). Issues with swab testing (e.g. delay in communicating the swab outcome) were less frequently reported by respondents from SEARO and the Western Pacific Region compared with other regions.

CONCLUSION

The world has progressed in its knowledge and sophistication in tackling the pandemic after early and often substantial obstacles were encountered. Most WHO regions have or are in the process of responding well, although some countries have not yet instituted widespread measures known to support mitigation, for example, effective swab testing and social control measures.

Looking for the right balance between human and economic costs during COVID-19 outbreak

Since the beginning of Coronavirus 2019 (COVID-19) disease outbreak, there has been a heated debate about public health measures, as they can presumably reduce human costs in the short term but can negatively impact economies and well-being over a longer period.

Materials and methods

To study the relationship between health and economic impact of COVID-19, we conducted a secondary research on Italian regions, combining official data (mortality due to COVID-19 and contractions in value added of production for a month of lockdown). Then, we added the tertiles of the number of people tested for COVID-19 and those of health aids to evaluate the correspondence with the outcome measures.

Results

Five regions out of 20, the most industrialized northern regions, which were affected both earlier and more severely by the outbreak, registered both mortality and economic value loss above the overall medians. The southern regions, which were affected later and less severely, had low mortality and less economic impact.

Conclusions

Our analysis shows that considering health and economic outcomes in the assessment of response to pandemics offers a bigger picture perspective of the outbreak and could allow policymakers and health managers to choose systemic, ‘personalized’ strategies, in case of a feared second epidemic wave.

Fitness for purpose of routinely recorded health data to identify patients with complex diseases: The case of Sjögren's syndrome

Background

This study is part of the EU‐funded project HarmonicSS, aimed at improving the treatment and diagnosis of primary Sjögren's syndrome (pSS). pSS is an underdiagnosed, long‐term autoimmune disease that affects particularly salivary and lachrymal glands.

Objectives

We assessed the usability of routinely recorded primary care and hospital claims data for the identification and validation of patients with complex diseases such as pSS.

Methods

pSS patients were identified in primary care by translating the formal inclusion and exclusion criteria for pSS into a patient selection algorithm using data from Nivel Primary Care Database (PCD), covering 10% of the Dutch population between 2006 and 2017. As part of a validation exercise, the pSS patients found by the algorithm were compared to Diagnosis Related Groups (DRG) recorded in the national hospital insurance claims database (DIS) between 2013 and 2017.

Results

International Classification of Primary Care (ICPC) coded general practitioner (GP) contacts combined with the mention of “Sjögren” in the disease episode titles, were found to best translate the formal classification criteria to a selection algorithm for pSS. A total of 1462 possible pSS patients were identified in primary care (mean prevalence 0.7‰, against 0.61‰ reported globally). The DIS contained 208 545 patients with a Sjögren related DRG or ICD10 code (prevalence 2017: 2.73‰). A total of 2 577 577 patients from Nivel PCD were linked to the DIS database. A total of 716 of the linked pSS patients (55.3%) were confirmed based on the DIS.

Conclusion

Our study finds that GP electronic health records (EHRs) lack the granular information needed to apply the formal diagnostic criteria for pSS. The developed algorithm resulted in a patient selection that approximates the expected prevalence and characteristics, although only slightly over half of the patients were confirmed using the DIS. Without more detailed diagnostic information, the fitness for purpose of routine EHR data for patient identification and validation could not be determined.

Variations in use and access of mental health services in Europe

Background

Mental illnesses comprise a wide range of mental health (MH) conditions -prevalence 3,90%- among European (EU) countries with significant effects on quality of life, life expectancy and disability. They are also related to substantial direct and indirect costs, consequences of inpatient care - not always beneficial for those patients. The main goals of our study are: to report on geographic variations in utilization rates and quality of care for adults MH diseases among 30 EU countries and regions; to explain the determinants of such variations.

Methods

Different data from EUROSTAT regarding healthcare resources, activities and self-perceived health and wellbeing for the years 2013-2015 are combined in a unique database at level of EU countries and NUTS 2 regions to allow for comparisons in utilization rates, perceived conditions and service local supply for MH diseases in Europe.

Results

Preliminary findings show a decline in the global trend of hospitalization rates for mental diseases; however, significant variations were observed among and within countries (High-Low ratio=25 in 2015, at country level). Males were more hospitalized than females (p = 0.40). Women were more likely than men to report depressive symptoms and to access to MH consultations (p &lt; 0.001). Significant and positive correlations were found between resources (hospital beds and psychiatrists per capita) and adjusted hospitalization rates for MH disorders and between self-reported MH consultations and psychiatrists per capita (p &lt; 0.001).

Conclusions

Preliminary findings confirm the presence of wide variations in the care of mental diseases across and within EU countries. Significant correlations between utilization rates and local supply of resources might indicate that part of the variation might be explained by differences in the local organization and availability of resources rather than patients' needs.

Key messages

There is a wide variation in the care of mental diseases across and within EU countries which might be explained by differences in the local organization and resources instead patients’ needs. These results can help policy makers and professionals to identify unwarranted variations that need to be removed and to shift to value-based healthcare.

Influences over Italian nurses' job satisfaction and willingness to recommend their workplace

BACKGROUND

Nurses' perception towards job satisfaction and willingness to recommend their workplace are relevant to a number of areas including the quality of nursing care delivery. Hence, an increasing number of scholars seek to understand the factors that influence these two concepts. Yet, inclusiveness and openness to innovation are under-investigated.

PURPOSE

The paper focuses on the relative importance that factors like propensity towards innovation, working conditions and inclusion have on nurses' job satisfaction and their willingness to recommend their workplace.

METHODS

A large sample of nurses was extracted from the organizational climate survey carried out in all healthcare authorities of nine Italian Regions through the years 2016-2018. Descriptive and multilevel regressions were carried out to investigate the factors that influence nurses' job satisfaction and their willingness to recommend the hospital in which they work in, analysing both overall and in specific age classes.

RESULTS

When recommending a workplace, nurses tend to recommend units showing higher propensity to innovate (OR 2.83), while the most important factor related to job satisfaction is the encouragement after a failure (OR 2.23). Inclusiveness is a key factor for both job satisfaction and willingness to recommend, whilst innovation prone organizations appear to be the most attractive for nurses. The levers mix is slightly different among the age classes. Findings identify the levers to be used in order to attract nurse workforce and increase nurses' job satisfaction. These levers are partially different for young and senior nurses.

Managing the performance of general practitioners and specialists referral networks: A system for evaluating the heart failure pathway

High quality chronic disease management requires coordinated care across different healthcare settings, involving multidisciplinary teams of professionals, and performance evaluation systems able to measure this care. Inter-organizational performance should be measured considering the professional relationships between general practitioners (GPs) and specialists, who are usually linked through informal referral networks. The aim of this paper is to identify and evaluate the performance of naturally occurring networks of GPs and hospital-based specialists providing care for congestive heart failure (CHF) patients in Tuscany, Italy. The analysis focuses on the identification and classification of networks, following CHF patients (n = 15,841) through primary care and inpatient care using administrative data, and on the assessment of process and outcome indicators for CHF patients in these referral networks. We demonstrate the existence of informal links between GPs and hospitals based on patterns of patient flow. These networks which are not geographically based vary in the intensity of relationships and quality of care. Such referral networks may represent the most effective accountability level for chronic disease management, since they encompass the multiple care settings experienced by patients. Overall, an integrated approach to evaluation and performance management that considers the naturally occurring links between professionals working in different settings may enable more efficient, integrated care and quality improvements.

Improving chronic diseases management using Learning from Excellence (LfE) model

Background

Learning from excellence (LfE) model demonstrated to be an effective method in the promotion of quality improvement in healthcare and in the reduction of patient’s harm. We applied LfE to identify the best models that could represent the excellence in the management of chronic heart failure (CHF) patients among the models adopted among 98 healthcare providers across 10 Italian Regions.

Methods

The research consisted of 2 phases: 1) the creation of a 9 indicators set to map CHF pathways and the analysis of these indicators through a quantitative approach using a modified positive deviance model which identified the best performers among our sample of hospitals and local health authorities (H/LHA) grouped in geographical Areas. We transformed 3 indicators (“tracking” indicators) into a 0-5 scale to assure direct comparison. 2) The H/LHA best performers were asked to share their organizational and clinical model during a workshop where every stakeholder involved could take part.

Results

Among the 10 investigated Italian Regions, 42 Areas were ranked and ranged 1,83-3,91. The three best performing areas that ranked above the 3rd quartile and were interested in taking part in this new approach were selected. The results arising from the qualitative analysis of these areas showed that communication, trust and shared goals among healthcare professionals resulted to play a key role among the best performing H/LHA. Indeed, the same role is played by all the policies and practices that enabled Interactions among healthcare workforce and patients, thus representing the ‘integration of care’.

Conclusions

The identification-celebration of best performers LfE implementation model holds the potential to promote quality improvement of processes among healthcare providers. This potential also unlocks in the chronic disease management field, making the sharing of best performers’ experience possible at a Regional and National level.

Key messages

Learning from excellence model demonstrated to be an effective method in the promotion of best models in the management of chronic diseases. Communication, trust and shared goals among healthcare professionals resulted to play a key role among the best performing hospital and local health authority.

Nurse’s job satisfaction and organization’s innovation propensity: organizational climate in Italy

Key messages

nurses’ perception towards job satisfaction is relevant regarding nursing care delivery’s quality, which is directly linked to patients’ safety. Innovation and inclusion can be beneficial to improve workforce experience and care delivery.

Are people's health care needs better met when primary care is strong? A synthesis of the results of the QUALICOPC study in 34 countries

AIM

This article synthesises the results of a large international study on primary care (PC), the QUALICOPC study.

BACKGROUND

Since the Alma Ata Declaration, strengthening PC has been high on the policy agenda. PC is associated with positive health outcomes, but it is unclear how care processes and structures relate to patient experiences.

METHODS

Survey data were collected during 2011-2013 from approximately 7000 PC physicians and 70 000 patients in 34, mainly European, countries. The data on the patients are linked to data on the PC physicians within each country and analysed using multilevel modelling.

FINDINGS

Patients had more positive experiences when their PC physician provided a broader range of services. However, a broader range of services is also associated with higher rates of hospitalisations for uncontrolled diabetes, but rates of avoidable diabetes-related hospitalisations were lower in countries where patients had a continuous relationship with PC physicians. Additionally, patients with a long-term relationship with their PC physician were less likely to attend the emergency department. Capitation payment was associated with more positive patient experiences. Mono- and multidisciplinary co-location was related to improved processes in PC, but the experiences of patients visiting multidisciplinary practices were less positive. A stronger national PC structure and higher overall health care expenditures are related to more favourable patient experiences for continuity and comprehensiveness. The study also revealed inequities: patients with a migration background reported less positive experiences. People with lower incomes more often postponed PC visits for financial reasons. Comprehensive and accessible care processes are related to less postponement of care.

CONCLUSIONS

The study revealed room for improvement related to patient-reported experiences and highlighted the importance of core PC characteristics including a continuous doctor-patient relationship as well as a broad range of services offered by PC physicians.

Using a GIS to support the spatial reorganization of outpatient care services delivery in Italy

BACKGROUND

Studying and measuring accessibility to care services has become a major concern for health care management, particularly since the global financial collapse. This study focuses on Tuscany, an Italian region, which is re-organizing its inpatient and outpatient systems in line with new government regulations. The principal aim of the paper is to illustrate the application of GIS methods with real-world scenarios to provide support to evidence-based planning and resource allocation in healthcare.

METHODS

Spatial statistics and geographical analyses were used to provide health care policy makers with a real scenario of accessibility to outpatient clinics. Measures for a geographical potential spatial accessibility index using the two-step floating catchment area method for outpatient services in 2015 were calculated and used to simulate the rationalization and reorganization of outpatient services. Parameters including the distance to outpatient clinics and volumes of activity were taken into account.

RESULTS

The spatial accessibility index and the simulation of reorganization in outpatient care delivery are presented through three cases, which highlight three different managerial strategies. The results revealed the municipalities where health policy makers could consider a new spatial location, a shutdown or combining selected outpatient clinics while ensuring equitable access to services.

CONCLUSIONS

A GIS-based approach was designed to provide support to healthcare management and policy makers in defining evidence-based actions to guide the reorganization of a regional health care delivery system. The analysis provides an example of how GIS methods can be applied to an integrated framework of administrative health care and geographical data as a valuable instrument to improve the efficiency of healthcare service delivery, in relation to the population's needs.

A turnaround strategy: improving equity in order to achieve quality of care and financial sustainability in Italy

BACKGROUND

Equity, financial sustainability, and quality in healthcare are key goals embraced by universal health systems. However, systematic performance management strategies for achieving equity are still weaker than those aimed at achieving financial sustainability and quality of care. Using a vertical equity perspective, the overarching aim of this paper is to examine how improving equity in quality of care impacts on financial sustainability. We applied a simulation to indicators of the heart failure clinical pathway in Tuscany (central Italy), in order to quantify the equity gaps and financial resources that could be reallocated in the absence of performance inequities.

METHODS

The analysis included all patients hospitalized for heart failure as a principal diagnosis in 2014. We selected five indicators: hospitalization rate, 30-day readmission, cardiology visits, and the utilization of beta-blockers, and ACE inhibitors and sartans. For each indicator, the simulation followed three steps: 1) stratification by socioeconomic status (SES), using education as a proxy for SES; 2) computation of the vertical equity indicator; and 3) assessment of the financial value of the equity gap.

RESULTS

All indicators showed performance gaps regarding inequities across SES-groups. For the hospitalization rate and 30-day readmission, resources could have been reallocated, if the performance of patients with a low SES had been equal to the performance of patients with a high SES, which amounted to €2,144,422 and €892,790 respectively. In contrast, limited additional resources would have been required for prescriptions and cardiology visits.

CONCLUSIONS

Reducing equity gaps by improving the performance of low-SES patients may be a crucial strategy to achieving financial sustainability in universal coverage healthcare systems. Universal healthcare systems, which aim to pursue financial sustainability and quality of care, are thus urged to develop performance management actions to improve equity. This approach should not only include the measurement and public disclosure of equity indicators but be part of a comprehensive evidence-based strategy for the management of chronic conditions along the clinical pathway.

Socio-demographic determinants of women's satisfaction with prenatal and delivery care services in Italy

OBJECTIVE

The aim of this study was to examine the extent to which socio-demographic variables affect women's satisfaction regarding antenatal and perinatal care.

DESIGN

To take into account the role of the context in shaping women's satisfaction, we used multilevel models, with women at the lower level, and the health districts of residence, or the hospitals in which the delivery took place, at the higher level.

SETTING

Tuscany (Italy).

PARTICIPANTS

The study is based on a representative survey focused on the satisfaction and experience of 4598 new mothers who gave birth in one of the 25 hospitals in Tuscany (Italy) in 2012.

MAIN OUTCOME MEASURES

Women's overall satisfaction in the prenatal period and their overall satisfaction during hospitalization for delivery.

RESULTS

Regarding pregnancy, women's satisfaction increased with age, and was generally higher among foreign women coming from non-Western countries and among highly educated women. Regarding delivery, age proved insignificant, whereas citizenship and education maintained the same association with satisfaction. Contrary to our expectations, the number of previous pregnancies turned out to be insignificant.

CONCLUSIONS

Our findings suggest that the quality of maternity services was perceived differently in different socio-demographic groups: women's expectations affected satisfaction, but in different ways, in various socio-demographic groups, both during pregnancy and at delivery. Keeping these socio-demographic factors into account in the analysis of satisfaction may help organisations to identify areas where pregnancy and delivery services can be better targeted and where increasing awareness among professionals in their everyday practice is most needed.

Proximity and waiting times in choice models for outpatient cardiological visits in Italy

We apply mixed logit regression to investigate patients' choice of non-emergency outpatient cardiovascular specialists in Tuscany, Italy. We focused on the effects of travel time and waiting time. Results reveal that patients prefer clinics nearby and with shorter waiting times. Differences in patient choice depend on age and socioeconomic conditions, thus confirming equity concerns in the access of non-acute services. Our results could be used to optimize the allocation of resources, reduce inequities and increase the efficiency and responsiveness of outpatient systems considering patient preferences.

Comparing regional models of congenital bleeding disorders: preliminary steps in the Italian context

Background

Among these diseases, congenital bleeding disorders (CBD) represent a significant societal burden in terms of high morbidity costs and health outcomes. In Italy, the organization and provision of health care is a regional responsibility and regions must assure equity and quality to all their residents. This is also true for CBD care which is provided by 54 multidisciplinary Hemophilia Treatment Centers (HTCs) distributed among the regions. With the present study, we intend to stimulate a debate on the effect that the decentralization process have in the delivery of services to CBD patients across Italy.

Methods

The available comparable measures of caseloads per center and interregional patient mobility, as proxies of quality and responsiveness of the regional network of HTCs, were first analyzed for the using data from the Italian Hemophilia Centers Association for the year 2012.

Results

Nine thousand one hundred and thirty four Italian residents with CBD received care in at least one of the Italian HTC in 2012. Preliminary findings suggested room for improvement in health care delivery for CBD patients. In 2012, 16 HTCs out of 51 (31.4%) treated a number of patients under the minimum requirement for treatment center accreditation (10 severe patients). Moreover, data on interregional patient mobility highlighted differences in the ability of each region to retain its own residents or to attract residents from other regions.

Conclusions

Preliminary study results showed significant disparities among regions in terms of volumes and mobility of residents with CBDs that cannot be completely explained by the different geographical characteristics. Therefore, the central government should consider taking concrete measures to bridge the gap between regions to assure access to quality care for all individuals with CBD independently from where they live and therefore to move toward a more integrated and homogeneous national network of care centers. Typology of disease, patients’ needs, and cost for outcomes, should have high priority on the political agenda. For CBD patients, even in a federal healthcare system, the national government should have the global responsibility to guaranteeing uniform levels of quality care over the country and overcome local institutions when necessary.

Consistency of priorities for quality improvement for nursing homes in Italy and Canada: A comparison of optimization models of resident satisfaction

The paper seeks to identify aspects of care that may be easily modified to yield a desired level of improvement in residents' overall satisfaction with nursing homes, comparing data across Canada and Italy. Using a structured questionnaire, 681 and 1116 nursing home residents were surveyed in Ontario in 2009 and in Tuscany in 2012, respectively. Fourteen items were common to the surveys, including willingness to recommend (WTR), which was used as the dependent variable and measure of global satisfaction. The other analogous items were entered as covariates in ordinal logistic regression models predicting residents' WTR in each jurisdiction separately. Regression coefficients were then incorporated into a constrained nonlinear optimization problem selecting the most efficient combination of predictors necessary to increase WTR by as much as 15%. Staff-related aspects of care were selected first in the optimization models of each jurisdiction. In Ontario, to improve WTR the primary focus should be on staff relationships with residents, while in Tuscany it was the technical skill and knowledge of staff that was selected first by the optimization model. Different optimization solutions might mean that the strategies required to improve global satisfaction in one jurisdiction could be different than those for the other jurisdictions. The optimization model employed provides a novel solution for prioritizing areas of focus for quality improvement for nursing homes.

Patient-perceived responsiveness of primary care systems across Europe and the relationship with the health expenditure and remuneration systems of primary care doctors

BACKGROUND

Health systems are expected to be responsive, that is to provide services that are user-oriented and respectful of people. Several surveys have tried to measure all or some of the dimensions of the responsiveness (e.g. autonomy, choice, clarity of communication, confidentiality, dignity, prompt attention, quality of basic amenities, and access to family and community support), however there is little evidence regarding the level of responsiveness of primary care (PC) systems.

METHODS

This work analyses the capacity of primary care systems to be responsive. Data collected from 32 PC systems were used to investigate whether a relationship exists between the responsiveness of PC systems and the PC doctor remuneration systems and domestic health expenditure.

RESULTS

There appears to be a higher responsiveness of PC when doctors are paid via capitation than when they only receive a fee for services or a mixed payment method. In addition, countries that spend more on health services are associated with higher levels of dignity and autonomy.

CONCLUSION

Quality, as measured from the patient's perspective, does not necessarily overlap with PC performance based on structure and process indicators. The results could also stimulate a new debate on the role of economic resources and PC workforce payment mechanisms in the achievement of quality goals, in this case related to the capacity of PC systems to be responsive.

Educational level and 30-day outcomes after hospitalization for acute myocardial infarction in Italy

Background

There is a growing interest in the factors that influence short-term mortality and readmission after hospitalization for acute myocardial infarction (AMI) since such outcomes are commonly considered as hospital performance measures. Socioeconomic status (SES) is one of the factors contributing to healthcare outcomes after hospitalization for AMI. However, no study has been published on education and 30-day readmission in Europe. The objective of this study is to examine the association between educational level and 30-day mortality and readmission among patients hospitalized for AMI in Tuscany (Italy).

Methods

A retrospective cohort study using data from hospital discharge records was conducted. The analysis included all patients discharged with a principal diagnosis of AMI between January 1, 2011, and November 30, 2014, from all hospitals in Tuscany. Educational level was categorized as low (no middle school diploma), mid (middle school diploma) and high (high school diploma or more). Three multilevel models were developed, sequentially controlling for patient-level socio-demographic and clinical variables and hospital-level variables. Patients were stratified by age (≤75 and >75 years).

Results

Mortality analysis included 23,402 patients, readmission analysis included 22,181 patients. In both unadjusted and full-adjusted models, patients with a high education had lower odds of 30-day mortality compared to those patients with low education (OR age ≤ 75 years 0.67, 95% CI:0.47–0.94; OR age > 75 years 0.72, 95% CI:0.54–0.95). With regard to 30-day readmission, only patients aged over 75 years with a high education had lower odds of short-term readmission compared to those patients with low education (OR age > 75 0.73, 95% CI:0.58–0.93).

Conclusions

Among patients hospitalized in Tuscany for AMI, low levels of education were associated with increased odds of 30-day mortality for both age groups and increased odds of 30-day readmission only for patients aged over 75 years. Our findings suggest that the educational component should not be underestimated in order to improve short-term outcomes, which are considered as performance measures at the hospital level. Hospital managers might consider strategies that are sensitive to patients with low SES, such as providing post-hospitalization support to less-educated patients and promoting a healthier lifestyle, to improve both health equity and performance outcomes.

Basic ICT adoption and use by general practitioners: an analysis of primary care systems in 31 European countries

Background

There is general consensus that appropriate development and use of information and communication technologies (ICT) are crucial in the delivery of effective primary care (PC). Several countries are defining policies to support and promote a structural change of the health care system through the introduction of ICT. This study analyses the state of development of basic ICT in PC systems of 31 European countries with the aim to describe the extent of, and main purposes for, computer use by General Practitioners (GPs) across Europe. Additionally, trends over time have been analysed.

Methods

Descriptive statistical analysis was performed on data from the QUALICOPC (Quality and Costs of Primary Care in Europe) survey, to describe the geographic differences in the general use of computer, and in specific computerized clinical functions for different health-related purposes such as prescribing, medication checking, generating health records and research for medical information on the Internet.

Results

While all the countries have achieved a near-universal adoption of a computer in their primary care practices, with only a few countries near or under the boundary of 90 %, the computerisation of primary care clinical functions presents a wide variability of adoption within and among countries and, in several cases (such as in the southern and central-eastern Europe), a large room for improvement.

Conclusions

At European level, more efforts could be done to support southern and central-eastern Europe in closing the gap in adoption and use of ICT in PC. In particular, more attention seems to be need on the current usages of the computer in PC, by focusing policies and actions on the improvement of the appropriate usages that can impact on quality and costs of PC and can facilitate an interconnected health care system. However, policies and investments seem necessary but not sufficient to achieve these goals. Organizational, behavioural and also networking aspects should be taken in consideration.

Gender difference in diabetes-associated risk of first-ever and recurrent ischemic stroke

OBJECTIVE

To evaluate the effect of diabetes by gender on the peak-risk of first-ever-ischemic stroke and its recurrence.

METHODS

Administrative datasets including all hospital discharges for ischemic stroke (N = 43,332) in the diabetic (N = 207,568) and non-diabetic (N = 2,808,554) population of the Tuscany region, Italy were used to calculate Hazard ratios (HR) after Cox-regression, of first-ever and recurrent ischemic strokes, between 2005 and 2011.

RESULTS

Overall, diabetes increased the HR of first-ever ischemic stroke by about 50% in both genders. However, this risk significantly declined with age and was higher in women aged 55-74 yr than in men of the same age (HR; 95% CI: 1.392; 1.228-1.579 in age-class 55-64 yr and 1.203; 1.110-1.304 in age class 65-74 yr; p < 0.001). Diabetes also increased the adjusted risk of three-year-stroke recurrence (N = 5,998) in women, independently of age, whereas this was the case in men < 70 yr.

CONCLUSIONS

Diabetes is associated with increased risk of ischemic stroke although it declines with age though at lower rate among women than men. Moreover, diabetic women have greater risk of recurrence than in men > 70 yrs old, supporting a high-risk "time-window" in postmenopausal-elderly diabetic women.

Applying discrete choice modelling in a priority setting: an investigation of public preferences for primary care models

OBJECTIVES

The shift toward more innovative and sustainable primary care models in Italy leads policy makers and clinicians to face difficult decisions between options that are all regarded as potentially beneficial. In this study, patient preferences for different primary care models in the Tuscany region of Italy were elicited. The relative importance of different attributes to the surveyed respondents was then examined, as well as the rate at which individuals trade between attributes and the relative value of different service configurations.

METHODS

A discrete choice experiment survey explored the following attributes in a stratified random sample of 6,970 adults: primary care provider, diagnostic facilities and waiting time for the visit.

RESULTS

Respondents (3,263) were likely to prefer a consultation by their own general practitioner (GP) and a practice with many diagnostic facilities. The predicted utilities of different service configurations have shown that a "primary care centre" with many diagnostic facilities was preferable to a "solo GP" model or a "group general practice".

CONCLUSIONS

The study demonstrated how a patient choice model could be used by decision makers for developing successful policies that takes into account different healthcare needs, balancing responsiveness with care continuity, equity and appropriateness. Considering that a primary care centre would perform better than a "solo GP", especially for younger respondents and for those with minor healthcare needs, for a more rapid diffusion of this model policymakers and managers could direct the care of primary care centres towards these targeted subgroups, at least in the first phase.

Height, socioeconomic status and marriage in Italy around 1900

This study examines the role of height in the process of mate selection in two Italian populations at the turn of the twentieth century, Alghero, in the province of Sassari, and Treppo Carnico, in the province of Udine. Based on a linkage between military registers and marriage certificates, this study reveals a negative selection of short men on marriage and a differential effect of tallness by population in the process of mate choice. These findings emerge once SES is taken into account in the risk models of marriage.

Is variation management included in regional healthcare governance systems? Some proposals from Italy

The Italian National Health System, which follows a Beveridge model, provides universal healthcare coverage through general taxation. Universal coverage provides uniform healthcare access to citizens and is the characteristic usually considered the added value of a welfare system financed by tax revenues. Nonetheless, wide differences in practice patterns, health outcomes and regional usages of resources that cannot be justified by differences in patient needs have been demonstrated to exist. Beginning with the experience of the health care system of the Tuscany region (Italy), this study describes the first steps of a long-term approach to proactively address the issue of geographic variation in healthcare. In particular, the study highlights how the unwarranted variation management has been addressed in a region with a high degree of managerial control over the delivery of health care and a consolidated performance evaluation system, by first, considering it a high priority objective and then by actively integrating it into the regional planning and control mechanism. The implications of this study can be useful to policy makers, professionals and managers, and will contribute to the understanding of how the management of variation can be implemented with performance measurements and financial incentives.

How do hospitalization experience and institutional characteristics influence inpatient satisfaction? A multilevel approach

Over the last several years, interest in benchmarking health services’ quality—particularly patient satisfaction (PS)—across organizations has increased. Comparing patient experiences of care across hospitals requires risk adjustment to control for important differences in patient case-mix and provider characteristics. This study investigates the individual-level and organizational-level determinants of PS with public hospitals by applying hierarchical models. The analysis focuses on the effect of hospital characteristics, such as self-discharges, on overall evaluations and on across hospital variation in scores. Sociodemographics, admission mode, place of residence, hospitalization ward and continuity of care were statistically significant predictors of inpatient satisfaction. Interestingly, it was observed that hospitals with a higher percentage of Patients Leaving Against Medical Advice (PLAMA) received lower scores. The latter result suggests that the percentage of PLAMA may provide a useful measure of a hospital’s inability to meet patient needs and a proxy indicator of PS with hospital care.

Measures of quality, costs and equity in primary health care instruments developed to analyse and compare primary care in 35 countries

BACKGROUND

The Quality and Costs of Primary Care in Europe (QUALICOPC) study aims to analyse and compare how primary health care systems in 35 countries perform in terms of quality, costs and equity. This article answers the question 'How can the organisation and delivery of primary health care and its outcomes be measured through surveys of general practitioners (GPs) and patients?' It will also deal with the process of pooling questions and the subsequent development and application of exclusion criteria to arrive at a set of appropriate questions for a broad international comparative study.

METHODS

The development of the questionnaires consisted of four phases: a search for existing validated questionnaires, the classification and selection of relevant questions, shortening of the questionnaires in three consensus rounds and the pilot survey. Consensus was reached on the basis of exclusion criteria (e.g. the applicability for international comparison). Based on the pilot survey, comprehensibility increased and the number of questions was further restricted, as the questionnaires were too long.

RESULTS

Four questionnaires were developed: one for GPs, one for patients about their experiences with their GP, another for patients about what they consider important, and a practice questionnaire. The GP questionnaire mainly focused on the structural aspects (e.g. economic conditions) and care processes (e.g. comprehensiveness of services of primary care). The patient experiences questionnaire focused on the care processes and outcomes (e.g. how do patients experience access to care?). The questionnaire about what patients consider important was complementary to the experiences questionnaire, as it enabled weighing the answers from the latter. Finally, the practice questionnaire included questions on practice characteristics.

DISCUSSION

The QUALICOPC researchers have developed four questionnaires to characterise the organisation and delivery of primary health care and to compare and analyse the outcomes. Data collected with these instruments will allow us not only to show in detail the variation in process and outcomes of primary health care, but also to explain the differences from features of the (primary) health care system.

30-day in-hospital mortality after acute myocardial infarction in Tuscany (Italy): an observational study using hospital discharge data

Background

Coronary heart disease is the leading cause of mortality in the world. One of the outcome indicators recently used to measure hospital performance is 30-day mortality after acute myocardial infarction (AMI). This indicator has proven to be a valid and reproducible indicator of the appropriateness and effectiveness of the diagnostic and therapeutic process for AMI patients after hospital admission. The aim of this study was to examine the determinants of inter-hospital variability on 30-day in-hospital mortality after AMI in Tuscany. This indicator is a proxy of 30-day mortality that includes only deaths occurred during the index or subsequent hospitalizations.

Methods

The study population was identified from hospital discharge records (HDRs) and included all patients with primary or secondary ICD-9-CM codes of AMI (ICD-9 codes 410.xx) that were discharged between January 1, 2009 and November 30, 2009 from any hospital in Tuscany. The outcome of interest was 30-day all-cause in-hospital mortality, defined as a death occurring for any reason in the hospital within 30 days of the admission date. Because of the hierarchical structure of the data, with patients clustered into hospitals, random-effects (multilevel) logistic regression models were used. The models included patient risk factors and random intercepts for each hospital.

Results

The study included 5,832 patients, 61.90% male, with a mean age of 72.38 years. During the study period, 7.99% of patients died within 30 days of admission. The 30-day in-hospital mortality rate was significantly higher among patients with ST segment elevation myocardial infarction (STEMI) compared with those with non-ST segment elevation myocardial infarction (NSTEMI). The multilevel analysis which included only the hospital variance showed a significant inter-hospital variation in 30-day in-hospital mortality. When patient characteristics were added to the model, the hospital variance decreased. The multilevel analysis was then carried out separately in the two strata of patients with STEMI and NSTEMI. In the STEMI group, after adjusting for patient characteristics, some residual inter-hospital variation was found, and was related to the presence of a cardiac catheterisation laboratory.

Conclusion

We have shown that it is possible to use routinely collected administrative data to predict mortality risk and to highlight inter-hospital differences. The distinction between STEMI and NSTEMI proved to be useful to detect organisational characteristics, which affected only the STEMI subgroup.