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open, Improving the quality of care is a leading priority for national health systems, consistent with the aim of improving population health, while maintaining the sustainability of the whole health system, especially for the mental health system, since it is composed by a complex network of community mental health teams of professionals and a wide range of community-based treatment, rehabilitation, day-care and residential care facilities. The quality of routine mental healthcare is still far from optimal, worldwide and in Italy, because it is not always delivered in accordance with evidence-based mental health standards and it can vary greatly among providers. Indeed, the construct of process indicators in the field of mental health is often not completely consistent with recommendations in evidence-based guidelines, where existing. To date, only few studies have analyzed this issue in Italy, despite the quality of mental health care has become a frequent subject of international evaluations. Given these premises, the QUADIM Project (“Clinical pathways in patients with severe mental disorders in Italy”), an Italian multi-regional project funded in 2016 by the Italian Health Ministry, was conducted with the aim to assess the quality of healthcare pathways provided to patients with serious mental illnesses (SMI) assisted by regional Departments of Mental Health (DMHs) in a real-world setting, using a set of process indicators developed by a panel of experts starting from a document approved by the italian Unified State-Regions Conference (2014). The main aim of this thesis was the conduction and the management of this project, which constituted my thesis project during the PhD. For each of the four SMI investigated (i.e., schizophrenic, depressive, bipolar and personality disorders), from the regional Healthcare Utilization (HCU) databases were identified the cohorts of adult patients affected by this specific mental disorder and taken in care by regional DMHs during the, Improving the quality of care is a leading priority for national health systems, consistent with the aim of improving population health, while maintaining the sustainability of the whole health system, especially for the mental health system, since it is composed by a complex network of community mental health teams of professionals and a wide range of community-based treatment, rehabilitation, day-care and residential care facilities. The quality of routine mental healthcare is still far from optimal, worldwide and in Italy, because it is not always delivered in accordance with evidence-based mental health standards and it can vary greatly among providers. Indeed, the construct of process indicators in the field of mental health is often not completely consistent with recommendations in evidence-based guidelines, where existing. To date, only few studies have analyzed this issue in Italy, despite the quality of mental health care has become a frequent subject of international evaluations. Given these premises, the QUADIM Project (“Clinical pathways in patients with severe mental disorders in Italy”), an Italian multi-regional project funded in 2016 by the Italian Health Ministry, was conducted with the aim to assess the quality of healthcare pathways provided to patients with serious mental illnesses (SMI) assisted by regional Departments of Mental Health (DMHs) in a real-world setting, using a set of process indicators developed by a panel of experts starting from a document approved by the italian Unified State-Regions Conference (2014). The main aim of this thesis was the conduction and the management of this project, which constituted my thesis project during the PhD. For each of the four SMI investigated (i.e., schizophrenic, depressive, bipolar and personality disorders), from the regional Healthcare Utilization (HCU) databases were identified the cohorts of adult patients affected by this specific mental disorder and taken in care by regional DMHs during the, No, open, MONZIO COMPAGNONI, M

Improving the quality of care is a leading priority for national health systems, consistent with the aim of improving population health, while maintaining the sustainability of the whole health system, especially for the mental health system, since it is composed by a complex network of community mental health teams of professionals and a wide range of community-based treatment, rehabilitation, day-care and residential care facilities. The quality of routine mental healthcare is still far from optimal, worldwide and in Italy, because it is not always delivered in accordance with evidence-based mental health standards and it can vary greatly among providers. Indeed, the construct of process indicators in the field of mental health is often not completely consistent with recommendations in evidence-based guidelines, where existing. To date, only few studies have analyzed this issue in Italy, despite the quality of mental health care has become a frequent subject of international evaluations. Given these premises, the QUADIM Project (“Clinical pathways in patients with severe mental disorders in Italy”), an Italian multi-regional project funded in 2016 by the Italian Health Ministry, was conducted with the aim to assess the quality of healthcare pathways provided to patients with serious mental illnesses (SMI) assisted by regional Departments of Mental Health (DMHs) in a real-world setting, using a set of process indicators developed by a panel of experts starting from a document approved by the italian Unified State-Regions Conference (2014). The main aim of this thesis was the conduction and the management of this project, which constituted my thesis project during the PhD. For each of the four SMI investigated (i.e., schizophrenic, depressive, bipolar and personality disorders), from the regional Healthcare Utilization (HCU) databases were identified the cohorts of adult patients affected by this specific mental disorder and taken in care by regional DMHs during the, Improving the quality of care is a leading priority for national health systems, consistent with the aim of improving population health, while maintaining the sustainability of the whole health system, especially for the mental health system, since it is composed by a complex network of community mental health teams of professionals and a wide range of community-based treatment, rehabilitation, day-care and residential care facilities. The quality of routine mental healthcare is still far from optimal, worldwide and in Italy, because it is not always delivered in accordance with evidence-based mental health standards and it can vary greatly among providers. Indeed, the construct of process indicators in the field of mental health is often not completely consistent with recommendations in evidence-based guidelines, where existing. To date, only few studies have analyzed this issue in Italy, despite the quality of mental health care has become a frequent subject of international evaluations. Given these premises, the QUADIM Project (“Clinical pathways in patients with severe mental disorders in Italy”), an Italian multi-regional project funded in 2016 by the Italian Health Ministry, was conducted with the aim to assess the quality of healthcare pathways provided to patients with serious mental illnesses (SMI) assisted by regional Departments of Mental Health (DMHs) in a real-world setting, using a set of process indicators developed by a panel of experts starting from a document approved by the italian Unified State-Regions Conference (2014). The main aim of this thesis was the conduction and the management of this project, which constituted my thesis project during the PhD. For each of the four SMI investigated (i.e., schizophrenic, depressive, bipolar and personality disorders), from the regional Healthcare Utilization (HCU) databases were identified the cohorts of adult patients affected by this specific mental disorder and taken in care by regional DMHs during the

open, The burden of a condition, illness or risk factor on the population is a fundamental issue in Public Health and evaluating this burden appears to be necessary to improve health systems and policies, and to help decision makers for a better allocation of public resources. The population attributable fraction, a measure used to assess the burden of disease, allows to determine the number of disease’s cases that would be avoided or prevented if a risk factor was eliminated. Clinical Pathways are composed by several evidence-based healthcare intervention and are considered both as tool for patients’ care and as a way to describe the structure of a care process that is worldwide used to make care processes transparent and to improve the efficiency and quality of health care. However, the real impact of these pathways on several clinical outcomes, in particular in outpatient settings, is a little explored field. If we consider the subject’s adherence to recommendations contained in Clinical Pathways as a ‘gold standard’ of healthcare to avoid adverse clinical events/complications, the condition of ‘non-adherence’ represents a risk factor that could be controlled and limited, if not even removed. The aim of this thesis is to assess the impact of healthcare interventions for specific health conditions, from the Public Health point of view, in terms of (i) size of the problem, (ii) process of care and (iii) association between process and outcomes. To this purpose, my thesis is composed of four parts that lead to explore the main issue of this work and to understand how we can measure the impact of some healthcare interventions on subjects affected by several chronic conditions. After an introduction to the concept of Burden of Disease and its possible application in the assessment of impact of healthcare interventions, Clinical Pathways and their current use are presented. In this part an Italian project aimed to assess the impact of several pathways on patients’ clinical o, Il concetto di Burden of Disease è molto usato nella letteratura internazionale per indicare il peso, l’impatto che una condizione, una malattia o un fattore di rischio possono avere sulla popolazione. Misurare questo burden sembra essere necessario per migliorare i sistemi sanitari e per aiutare i decisori politici nell’allocare adeguatamente le risorse pubbliche. Una misura molto usata nella valutazione del Burden of Disease è la frazione attribuibile di popolazione, che misura il numero di casi di malattia che si potrebbero evitare o prevenire se il fattore di rischio venisse eliminato. I percorsi clinici, o PDTA (percorsi diagnostico-terapeutico-assistenziali), sono composti da un insieme di interventi clinici basati sulle evidenze e vengono considerati sia come uno strumento per una miglior cura del paziente sia come un modo per descrivere la struttura di un processo di cura, ed è uno strumento utilizzato in tutto il mondo per rendere trasparenti i processi stessi e per migliora l’efficacia e la qualità dell’assistenza. Tuttavia, il reale impatto di questi percorsi di cura sugli outcome clinici dei pazienti, soprattutto in ambino extra-ospedaliero, rappresentano un campo della ricerca ancora poco esplorato. Se consideriamo, inoltre, l’aderenza alle raccomandazioni contenute nei PDTA come un gold standard da perseguire per evitare diversi outcome clinici o complicanze, una condizione di non-aderenza rappresenta un fattore di rischio che può essere controllato e limitano, se non additìrittura eliminato. L’obiettivo di questa tesi è quello di valutare l’impatto degli interventi sanitari per specifiche patologie dal punto di vista della salute pubblica, e cioè in termini di (i) dimensione del problema, (ii) processo di cura e (iii) associazione tra il processo stesso gli outcome in esame. Con queso fine, la tesi è formata da quattro parti che conducono ad esplorare il quesito principale di questi lavoro di ricerca e a capire come si possa misurare l’impatto di alcu, No, open, Comoretto, R

Il concetto di Burden of Disease è molto usato nella letteratura internazionale per indicare il peso, l’impatto che una condizione, una malattia o un fattore di rischio possono avere sulla popolazione. Misurare questo burden sembra essere necessario per migliorare i sistemi sanitari e per aiutare i decisori politici nell’allocare adeguatamente le risorse pubbliche. Una misura molto usata nella valutazione del Burden of Disease è la frazione attribuibile di popolazione, che misura il numero di casi di malattia che si potrebbero evitare o prevenire se il fattore di rischio venisse eliminato. I percorsi clinici, o PDTA (percorsi diagnostico-terapeutico-assistenziali), sono composti da un insieme di interventi clinici basati sulle evidenze e vengono considerati sia come uno strumento per una miglior cura del paziente sia come un modo per descrivere la struttura di un processo di cura, ed è uno strumento utilizzato in tutto il mondo per rendere trasparenti i processi stessi e per migliora l’efficacia e la qualità dell’assistenza. Tuttavia, il reale impatto di questi percorsi di cura sugli outcome clinici dei pazienti, soprattutto in ambino extra-ospedaliero, rappresentano un campo della ricerca ancora poco esplorato. Se consideriamo, inoltre, l’aderenza alle raccomandazioni contenute nei PDTA come un gold standard da perseguire per evitare diversi outcome clinici o complicanze, una condizione di non-aderenza rappresenta un fattore di rischio che può essere controllato e limitano, se non additìrittura eliminato. L’obiettivo di questa tesi è quello di valutare l’impatto degli interventi sanitari per specifiche patologie dal punto di vista della salute pubblica, e cioè in termini di (i) dimensione del problema, (ii) processo di cura e (iii) associazione tra il processo stesso gli outcome in esame. Con queso fine, la tesi è formata da quattro parti che conducono ad esplorare il quesito principale di questi lavoro di ricerca e a capire come si possa misurare l’impatt, The burden of a condition, illness or risk factor on the population is a fundamental issue in Public Health and evaluating this burden appears to be necessary to improve health systems and policies, and to help decision makers for a better allocation of public resources. The population attributable fraction, a measure used to assess the burden of disease, allows to determine the number of disease’s cases that would be avoided or prevented if a risk factor was eliminated. Clinical Pathways are composed by several evidence-based healthcare intervention and are considered both as tool for patients’ care and as a way to describe the structure of a care process that is worldwide used to make care processes transparent and to improve the efficiency and quality of health care. However, the real impact of these pathways on several clinical outcomes, in particular in outpatient settings, is a little explored field. If we consider the subject’s adherence to recommendations contained in Clinical Pathways as a ‘gold standard’ of healthcare to avoid adverse clinical events/complications, the condition of ‘non-adherence’ represents a risk factor that could be controlled and limited, if not even removed. The aim of this thesis is to assess the impact of healthcare interventions for specific health conditions, from the Public Health point of view, in terms of (i) size of the problem, (ii) process of care and (iii) association between process and outcomes. To this purpose, my thesis is composed of four parts that lead to explore the main issue of this work and to understand how we can measure the impact of some healthcare interventions on subjects affected by several chronic conditions. After an introduction to the concept of Burden of Disease and its possible application in the assessment of impact of healthcare interventions, Clinical Pathways and their current use are presented. In this part an Italian project aimed to assess the impact of several pathways on patients’ clinical o