Search

Interest in chronic conditions reflects their role as the first cause of death and disability in developed countries; improving the management of these conditions is a priority for health care services. The aim of this study was to establish which sociodemographic factors influence adherence to standards of care for chronic heart failure (CHF). A generalized multilevel structural equation model was developed and applied to a sample of patients with CHF obtained from administrative data flows in six Italian regions to ascertain any associations between adherence to standards of care for CHF and sociodemographic variables. Indicators of compliance were adherence to beta-blocker therapy (BB-A) and Angiotensin Convertin Enzime inhibitor/Angiotensin Receptor Blocker therapy (ACE-A), and creatinine and electrolyte testing (CNK-T). All indicators were computed over a one-year follow-up. Among a cohort of 24,997 patients, the BB-A rate was 40.4%, the ACE-A rate 61.1%, and the CNK-T rate 57.0%. Factors found associated with adherence were gender, age, and citizenship. Our study shows an inadequate adherence to standards of care for CHF, particularly associated with certain sociodemographic characteristics. This suggests the need to improve the role of primary care in managing this chronic condition. The measures considered only apply to patients with a reduced Left Ventricular Ejection Fraction, hence a limitation of this analysis is the lack of information on left ventricular ejection.

Introduzione. L’interesse per le patologie croniche riflette il loro ruolo di prima causa di morte e disabilità nei paesi sviluppati: prioritario è migliorarne la gestione, affidata in primis alle cure primarie. Obiettivo. Definire un modello che identifichi il contributo dei diversi determinanti socio-demografici all’aderenza alle linee guida dello scompenso cardiaco, al netto della variabilità delle performance dei singoli MMG e dell’attività di governance dei distretti. Metodi. La fonte dei dati sono i flussi amministrativi correnti aziendali raccolti in 21 distretti appartenenti a 6 regioni italiane (Progetto Valore). Su un campione di 23.805 pazienti con scompenso cardiaco e’ stato implementato un modello a Equazioni strutturali Generalizzato (GSEM) per misurare l’aderenza alle linee guida dello scompenso cardiaco che, nel modello GSEM rappresenta la variabile latente, determinata da quattro indicatori di processo (terapia con: ACE-inibitori, beta-bloccanti, il monitoraggio semestrale della creatinina, Na e K ed ecocardiografia annuale) che sono indicativi della qualità delle cure dei pazienti con insufficienza cardiaca. Sono state verificate le relazioni causali delle variabili sociodemografiche [genere, età (gruppo di riferimento 65-74), nazionalità), Indice di Charlson e durata della malattia] con la variabile latente. L’analisi è stata effettuata mediante l’utilizzo del software STATA14. Risultati. Dalle stime ottenute risulta che le variabili demografiche, età, genere e nazionalità, siano significativamente associate all’aderenza alle linee guida dello scompenso cardiaco. Conclusione. I risultati del modello evidenziano che alcune caratteristiche socio-demografiche del paziente incidono significativamente sulla aderenza ed i percorsi assistenziali di gestione della patologia. Questo dovrebbe sollecitare un differenziale contributo di educazione ed empowerment del paziente in funzione di queste caratteristiche.

Background There has been an increasing interest and necessity to measure Long term care - LTC services for dependent elderly. The LUNA study conducted by the National Agency for regional healthcare services aimed to contribute to the development and implementation of a governance tool to monitor and improve LTC services. Methods A set of indicators for evaluating care delivered to disabled elderly in local areas of five Italian regions – Lombardy, Veneto, Tuscany, Apulia, Emilia Romagna was defined and a report was developed as governance tool. All records relative to residents in Brescia Local Health Unit (LHU), Vicenza LHU, Tuscany, Taranto LHU, Bologna LHU aged 65years, assisted at least one day between Jan, 1 2012 and June, 30 2013 were extracted from national home and residential care databases. These records were linked with hospital discharges and emergency room access databases. The outcome measures were ratios, arithmetic means, incidence rates, Odds Ratio (CI 95%) adjusted for the main confounders. Independent audit and coordinated focus groups were performed across the LHU involved to test the utility of the report as governance tool. Results 33 indicators on access, multidimensional evaluation, tempestivity, continuity, efficacy were calculated. An example of appropriateness regards the Emergency Access rate with white or green code of elderly in home care. The rates were 28% person-years at Brescia, 80% person-years at Empoli, 38% at Bologna, 37% at Vicenza and 19% person-years at Taranto. 8 focus groups were performed involving 87 professionals and stakeholders of LTC services. Qualitative concerns reveal that despite the high validity of the set of indicators developed, less technicality and a deeper bottom up approach in the set of indicators design and selection would have been recommended from the health care professionals and governors involved in the implementation of the report as governance tool. The report was appreciated as tool for integrat

BACKGROUND: An aging population means that chronic illnesses, such as diabetes, are becoming more prevalent and demands for care are rising. Members of primary care teams should organize and coordinate patient care with a view to improving quality of care and impartial adherence to evidence-based practices for all patients. The aims of the present study were: to ascertain the prevalence of diabetes in an Italian population, stratified by age, gender and citizenship; and to identify the rate of compliance with recommended guidelines for monitoring diabetes, to see whether disparities exist in the quality of diabetes patient management. METHODS: A population-based analysis was performed on a dataset obtained by processing public health administration databases. The presence of diabetes and compliance with standards of care were estimated using appropriate algorithms. A multilevel logistic regression analysis was applied to assess factors affecting compliance with standards of care. RESULTS: 1,948,622 Italians aged 16+ were included in the study. In this population, 105,987 subjects were identified as having diabetes on January 1st, 2009. The prevalence of diabetes was 5.43% (95%CI 5.33-5.54) overall, 5.87% (95%CI 5.82-5.92) among males, and 5.05% (95%CI 5.00-5.09) among females. HbA1c levels had been tested in 60.50% of our diabetic subjects, LDL cholesterol levels in 57.50%, and creatinine levels in 63.27%, but only 44.19% of the diabetic individuals had undergone a comprehensive assessment during one year of care. Statistical differences in diabetes care management emerged relating to gender, age, diagnostic latency period, comorbidity and citizenship. CONCLUSIONS: Process management indicators need to be used not only for the overall assessment of health care processes, but also to monitor disparities in the provision of health care.

Background Our interest in chronic conditions is due to the fact that, worldwide, chronic diseases have overtaken infectious diseases as the leading cause of death and disability, so their management represents an important challenge for health systems. The aim of this study was to compare the performance of primary health care services in managing diabetes, congestive heart failure (CHF) and coronary heart disease (CHD), by age group. Methods This population-based retrospective cohort study was conducted in Italy, enrolling 1,948,622 residents ≥16 years old. A multilevel regression model was applied to analyze compliance to care processes with explanatory variables at both patient and district level, using age group as an independent variable, and adjusting for sex, citizenship, disease duration, and Charlson index on the first level, and for District Health Unit on the second level. Results The quality of chronic disease management showed an inverted U-shaped relationship with age. In particular, our findings indicate lower levels for young adults (16–44 year-olds), adults (45–64), and oldest old (+85) than for patients aged 65–74 in almost all quality indicators of CHD, CHF and diabetes management. Young adults (16–44 y), adults (45–64 y), the very old (75–84 y) and the oldest old (+85 y) patients with CHD, CHF and diabetes are less likely than 65–74 year-old patients to be monitored and treated using evidence-based therapies, with the exceptions of echocardiographic monitoring for CHF in young adult patients, and renal monitoring for CHF and diabetes in the very old. Conclusion Our study shows that more effort is needed to ensure that primary health care systems are sensitive to chronic conditions in the young and in the very elderly.

Background Access and continuity of care for elderly disable people is becoming a priority for disabled elderly care in Western countries. This study aimed at defining and using a set of indicators for evaluating care delivered to disabled elderly accordingly a process approach in local areas of three Italian regions – Lombardy, Veneto, Tuscany. Methods Access, multidimensional evaluation/care planning, providers coordination/case management, and monitoring composed the care process phases. Secondary data from home care and residential care national information systems were used. All records relative to residents in Milano Local Health Unit (LHU), Vicenza and Alto vicentino LHUs, Societa` della Salute (SdS) of Firenze and Pisa, aged ≥65years, assisted at least one day between July, 1 2010 and June, 30 2011 were extracted from national databases. These records were linked with hospital discharges and emergency room access databases. The outcome measures were ratios, arithmetic means, incidence rates, Odds Ratio (CI 95%) adjusted for the main confounders. Results Of 7.237 disable elderly 65% were women and 47% ≥85 years old. Concerning access to the system and services delivered in residential or home care, the coverage rates ranged from 82% in Milano LHU to 15% in Tuscany SdS. With regard to care planning, the mean waiting time between multidimensional evaluation and first access at elderly’s home was 2 days in Milano LHU, 90 days in Tuscany Sds, 31 days in Veneto LHUs. The mean waiting time before being institutionalized was around 54 days in Tuscany and 45 days in Veneto LHUs. Aggregate Bed Day Rate for home care elderly ranged from 13.5/person-years in Milano LHU to 3.8/person-years in Tuscany Sds; while for institutionalized elderly it ranged from 2.5/person-years in Milano LHU to 0.8/person-years in Veneto LHUs. If social network is absent the odd of being institutionalized vs being assisted at home increased (OR 4.86, CI 2.84-8.32 in Tuscany Sds, OR 45.10, CI 2

Background Access and continuity of care for elderly disable people is becoming a priority for disabled elderly care in Western countries. This study aimed at defining and using a set of indicators for evaluating care delivered to disabled elderly accordingly a process approach in local areas of three Italian regions – Lombardy, Veneto, Tuscany. Methods Access, multidimensional evaluation/care planning, providers coordination/case management, and monitoring composed the care process phases. Secondary data from home care and residential care national information systems were used. All records relative to residents in Milano Local Health Unit (LHU), Vicenza and Alto vicentino LHUs, Societa` della Salute (SdS) of Firenze and Pisa, aged ≥65years, assisted at least one day between July, 1 2010 and June, 30 2011 were extracted from national databases. These records were linked with hospital discharges and emergency room access databases. The outcome measures were ratios, arithmetic means, incidence rates, Odds Ratio (CI 95%) adjusted for the main confounders. Results Of 7.237 disable elderly 65% were women and 47% ≥85 years old. Concerning access to the system and services delivered in residential or home care, the coverage rates ranged from 82% in Milano LHU to 15% in Tuscany SdS. With regard to care planning, the mean waiting time between multidimensional evaluation and first access at elderly’s home was 2 days in Milano LHU, 90 days in Tuscany Sds, 31 days in Veneto LHUs. The mean waiting time before being institutionalized was around 54 days in Tuscany and 45 days in Veneto LHUs. Aggregate Bed Day Rate for home care elderly ranged from 13.5/person-years in Milano LHU to 3.8/person-years in Tuscany Sds; while for institutionalized elderly it ranged from 2.5/person-years in Milano LHU to 0.8/person-years in Veneto LHUs. If social network is absent the odd of being institutionalized vs being assisted at home increased (OR 4.86, CI 2.84-8.32 in Tuscany Sds, OR 45.10, CI 2

Objectives In family medicine contrasting evidence exists on the effectiveness of team practice compared with solo practice on chronic disease management. In Italy, several experiences of team practice have been introduced since the late 1990s but few studies detail their impact on the quality of care. The aim of this paper is to evaluate the impact of team practice in family medicine in six Italian regions using chronic disease management process indicators as a measure of outcome. Methods Cross-sectional studies were performed to assess impact on quality of care for diabetes, congestive heart failure and ischaemic heart disease. The impact of team vs. solo practice was approximated through performance comparison of general practitioners (GPs) adhering to a team with respect to GPs working in a solo practice. Among the 2082 practitioners working in the 6 regions those assisting 300+ patients were selected. Quality of care towards 164,267 patients having at least one of three chronic conditions was estimated for the year 2008 using administrative databases. Quality indicators (% of patients receiving appropriate care) were selected (4 for diabetes, 4 for congestive heart failure, 3 for ischaemic heart disease) and a total score was computed for each patient. For each disease the response variable associated to each physician was the average score of the patients on his/her list. A multilevel model was estimated assessing the impact of team vs. solo practice. Results No impact was found for diabetes and heart failure. For ischaemic heart disease a slightly significant impact was observed (0.040; 95% CI: 0.015, 0.065). Conclusions No significant difference was found between team practice and solo practice on chronic disease management in six Italian regions.

BACKGROUND: For chronic conditions, disparities can take effect cumulatively at various times as the disease progresses, even when care is provided. The aim of this study was to quantify the prevalence of diabetes, congestive heart failure (CHF) and coronary heart disease (CHD) in adults by citizenship, and to compare the performance of primary care services in managing these chronic conditions, again by citizenship. METHODS: This is a population-based retrospective cohort study on 1,948,622 people aged 16 years or more residing in Italy. A multilevel regression model was applied to analyze adherence to care processes using explanatory variables at both patient and district level. RESULTS: The age-adjusted prevalence of diabetes was found higher among immigrants from high migratory pressure countries (HMPC) than among Italians, while the age-adjusted prevalence of cardiovascular disease was higher for Italians than for HMPC immigrants or those from highly-developed countries (HDC). Our results indicate lower levels in all quality management indicators for citizens from HMPC than for Italians, for all the chronic conditions considered. Patients from HDC did not differ from Italian in their adherence to disease management schemes. CONCLUSION: This study revealed a different prevalence of chronic diseases by citizenship, implying a different burden of primary care by citizenship. Our findings show that more effort is needed to guarantee migrant-sensitive primary health care.

N/A

L’Organizzazione mondiale della sanità e la Co- munità Europea sostengono l’adozione di stra- tegie volte ad assicurare l’accesso all’assistenza per tutti, un elevato grado di qualità e la soste- nibilità finanziaria del sistema e, inoltre, la va- lorizzazione del ruolo della famiglia e della co- munità nell’ambito delle politiche di long term care. In diverse regioni italiane sono stati recentemen- te sviluppati alcuni modelli organizzativi con lo scopo di facilitare l’accesso ai servizi territoriali di persone con bisogni sociosanitari complessi e di garantirne la continuità nell’assistenza. Il Pun- to Unico d’Accesso o la Porta Sanitaria di Ac- cesso alla rete dei servizi territoriali, le Unità ter- ritoriali di assistenza primaria, sono esempi di spe- rimentazioni condotte in alcune regioni (ad esem- pio FriuliVenezia Giulia, Puglia,Toscana,Veneto, Sardegna). Risulta necessario e inderogabile il ricorso tanto alla funzione di programmazione quale strumen- to per governare, per decidere, per gestire il siste- ma sanitario ai vari livelli istituzionali, quanto al- la funzione di monitoraggio attraverso un siste- ma unico riproducibile di indicatori che controlli e verifichi i risultati in termini di produzione di salute, salvaguardando in tal modo la garanzia del- la tutela della salute dei cittadini, l’uniformità ed equità di accesso ai servizi che ne consegue. L’obiettivo generale della ricerca è stato definire e sperimentare un sistema di indicatori per mo-nitorare il processo organizzativo di presa in ca- rico di persone di età pari o superiore a 65 anni con bisogno sociosanitario complesso, ossia di per- sone anziane con condizione di non autosuffi- cienza4 rilevata da una valutazione multidimen- sionale5, attraverso l’utilizzo integrato di flussi in- formativi correnti afferenti al Nuovo Sistema In- formativo Sanitario (NSIS), da quelli più tradi- zionali e consolidati (scheda di dimissione ospe- daliera - SDO, pronto soccorso - PS) a quelli di p

OBJECTIVE: To assess the predictive factors of influenza vaccination among Italian adults, focusing on socioeconomic differences. METHODS: A cross-sectional study was carried out using interview and self-reported data on 102,095 subjects aged 25-89 years from the national survey "health conditions and health care services use" conducted in Italy in 1999-2000. Analyses were stratified by age and multiple logistic regression models were used to estimate odds ratios (OR) of influenza vaccination. RESULTS: Approximately one in six individuals (17.3%) received an influenza vaccine in the previous 12 months. Older age, poor health status and former smoking were all positively associated with influenza vaccination (P-value<0.05). Lower educated individuals and subjects with manual occupations were less likely to be vaccinated than those better off, with an OR ranging from 0.65 (95% CI 0.55, 0.77) to 0.82 (95% CI 0.71, 0.93). Among individuals aged 65-89 there was no apparent influence of both variables on the likelihood of receiving the influenza vaccine. CONCLUSIONS: Socioeconomic inequalities in influenza vaccine uptake were present among the adults but not among the elderly. Because in Italy the National Health Service provides influenza vaccination to the elderly free of charge, it is possible that this policy attenuated the socioeconomic differential.