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La sindrome da affaticamento cronico/encefalomielite mialgica (CFS/ME) descrive una condizione di debolezza cronica che non può essere alleviata dal riposo ed è associata a una minore qualità della vita e ad un maggior ricorso all’assistenza sanitaria. Nei paesi occidentali, la sua prevalenza oscilla tra lo 0,2 e l’1%. Nonostante i numerosi sforzi compiuti negli ultimi decenni per indagare sulla natura di questa sindrome, ci sono ancora incertezze e controversie riguardo alla sua definizione, diagnosi e trattamento. Alcuni autori suggeriscono che, a causa della difficoltà nell’identificare correttamente i suoi sintomi, potrebbe esservi una percentuale non trascurabile di pazienti a cui non è stata ancora diagnosticata questa patologia. Di conseguenza, l’onere economico della malattia non è chiaro: i costi da essa determinati sono principalmente legati alla perdita di produttività da parte di chi ne soffre. La presente rassegna della letteratura esamina gli studi condotti sull’argomento, adottando inizialmente una prospettiva cronologica. Lo studio evidenzia come il peso economico della CFS/ME sia stato gradualmente e in misura sempre maggiore preso in considerazione dai ricercatori e menziona gli aspetti che dovrebbero meritare maggiore attenzione nel prossimo futuro. Parole chiave. CFS/ME, diagnosi, onere economico della malattia, costi indiretti., Chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) describes a condition of chronic weakness that cannot be alleviated by rest and it is associated with lower quality of life and higher health care utilization. In western countries, its prevalence ranges from 0.2 to 1%. Despite the many efforts carried out during the last decades to investigate the nature of this syndrome, there are still uncertainties and controversies with respect to its definition, diagnosis, and treatment. Some authors suggest that there may be a non-negligible percentage of patients that are not yet diagnosed with this pathology, due to the difficulty in identifying the symptoms. Henceforth, the economic burden of the disease is still unclear, though it is highly recognized that costs are mainly related to productivity loss. The present literature review investigates this topic, by considering, through a chronological perspective, the most relevant contributions focused on the economic costs and consequences of CFS/ME. It describes how the economic burden of CFS has been gradually and increasingly considered through the years by researchers and addresses the aspects that should deserve more attention in the next future.

Durante gli ultimi decenni, il calo delle nascite e il contestuale allungamento della vita media hanno mutato l’equilibrio demografico dell’Europa e di buona parte dei Paesi industrializzati. Il nuovo assetto comporta una riduzione nella consistenza delle coorti di giovani generazioni, più che compensata da un incremento nel numero di anziani. L’invecchiamento è associato ad un progressivo deterioramento dello stato di salute delle persone e conseguentemente ad un accresciuto bisogno di cure. Queste possono essere fornite per via formale, cioè da personale qualificato e remunerato, oppure per via informale, da parenti, amici o vicini di casa che dedicano il proprio tempo per assistere la persona non autosufficiente. Il termine utilizzato per designare chi offre cure informali è caregiver, ovvero “donatore di cure”. All’interno del nucleo familiare sono prevalentemente le donne a farsi carico della cura dei soggetti più fragili. In particolare, per quanto riguarda la cura degli anziani, la categoria più rappresentata è quella delle figlie femmine, spesso schiacciate fra le responsabilità verso i figli non ancora autonomi e l’assistenza ai genitori anziani e per questo definite, insieme ai loro coetanei, “generazione sandwich. Il capitolo prende spunto da queste considerazioni per analizzare, tramite il contributo della letteratura, le scelte allocative individuali e famigliari nel fornire assistenza a genitori o parenti anziani in Europa e nei Paesi occidentali. In particolare si studiano gli effetti sul piano lavorativo e le possibili ricadute sulla salute relative alla categoria maggiormente rappresentata di caregiver, quella delle figlie femmine.

Background and Objectives: The socioeconomic working group of the European myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) Research Network (EUROMENE) has conducted a review of the literature pertaining to GPs’ knowledge and understanding of ME/CFS; Materials and Methods: A MEDLINE search was carried out. The papers identified were reviewed following the synthesis without meta-analysis (SWiM) methodology, and were classified according to the focus of the enquiry (patients, GPs, database and medical record studies, evaluation of a training programme, and overview papers), and whether they were quantitative or qualitative in nature; Results: Thirty-three papers were identified in the MEDLINE search. The quantitative surveys of GPs demonstrated that a third to a half of all GPs did not accept ME/CFS as a genuine clinical entity and, even when they did, they lacked confidence in diagnosing or managing it. It should be noted, though, that these papers were mostly from the United Kingdom. Patient surveys indicated that a similar proportion of patients was dissatisfied with the primary medical care they had received. These findings were consistent with the findings of the qualitative studies that were examined, and have changed little over several decades; Conclusions: Disbelief and lack of knowledge and understanding of ME/CFS among GPs is widespread, and the resultant diagnostic delays constitute a risk factor for severe and prolonged disease. Failure to diagnose ME/CFS renders problematic attempts to determine its prevalence, and hence its economic impact.

The ageing of European population has been rapidly increasing during the last decades, and the problem of elderly care financing has become an issue for policy-makers. Long-term care (LTC) financing is considered a suitable proxy of the resources committed to elderly care by each government, but the preciseness of this approximation depends on the extent to which LTC is representative of elderly care within each country. Since there is a broad heterogeneity in LTC funding, organization and setting among European States, it is difficult to find a common parameter representing the public resources destined to the elderly care. We address these topics employing as a case study an Italian region, Lombardy, which in terms of population, dimension, healthcare organization and economic development could be compared to other European countries. The method we suggest, which consists basically in a careful estimate of all the public resources employed in the provision of services exclusively destined to the elderly, could be applied, with the due differences, to other European countries or regions.

In recent years, there has been a growing interest among scholars on Information and Communication Technologies (ICT) and their beneficial effects on elderly wellbeing; almost all contributions support the positive impact of ICT on the older population because their use has been demonstrated to enhance social participation and psychosocial wellbeing.This study contributes to the extant literature by using a specific and comprehensive measure of quality of life, the WHOQol-Bref, on a sample of 341 individuals attending the University of Third Age in an Italian town. Three different model specifications were built in order to test the impact of different aspects of ICT use on elderly’s quality of life, respectively: i) frequency of ICT use, ii) location of ICT use and iii) kind of ICT used. Results corroborate the findings of existing literature and provide insights on policy measures aimed at favoring a process of active ageing across western countries.

This is a brief note in response to some commentaries on a previous article by the author.

L’Europa nel corso degli ultimi decenni ha sperimentato una caduta nel tasso di fertilità, cui si è accompagnata una crescente longevità, due fattori demografici che indicano il progressivo invecchiamento della sua popolazione. Il calo delle nascite ha ridotto la consistenza delle coorti di giovani generazioni, mentre l’allungamento della speranza di vita ha posticipato il momento del decesso. La percentuale di anziani (over 65) su tutta la popolazione è più alta in Europa che in qualsiasi altro continente, e il fenomeno dell’invecchiamento è un problema che si imporrà per tutto il secolo. Le previsioni per il 2060 sulla dinamica demografica europea sono preoccupanti: per quell’anno circa metà della popolazione dei Paesi UE sarà ultracinquantenne e gli over 65 aumenteranno dall’attuale 18% (dati 2013) al 28% (Eurostat, 2015). All’interno del gruppo over 50 la “generazione sandwich”, vale a dire la generazione di individui impegnati simultaneamente sul duplice fronte delle responsabilità di cura verso i figli non ancora autonomi e i genitori anziani, giocherà un ruolo fondamentale nel fornire assistenza informale alle generazioni di anziani più fragili., Over the past few decades in Europe, and particularly in Italy, progressive ageing of the population has been recorded. This is due to two parallel phenomena: an increase in life expectancy and a declining birth rate. The growing need of elderly care has been faced by European countries with different strategies that follow a North-South gradient and stem from social, cultural, religious and institutional factors. In particular European countries from the Mediterranean basin, including Italy, rely on “family centred” models of welfare, where historically the family has shouldered the burden of looking after its older parents, both financially and in terms of assistance. Similarly, it is still the family that supports the new generations facing the lack of job opportunities, even if these generations have already left the family nucleus, in a reciprocal pact that reflects the structural absence of institutional answers. In northern Europe prevails a “non family centered” model: here, for the past few decades, elderly care has been managed through reforms that involve institutions taking charge of those who are not self-sufficient: the need of care is satisfied by the public sector, mainly through the supply of formal services (care provided to the elderly by paid and qualified personnel) and, residually, through the financial support of activities by informal caregivers (care provided for free by relatives, neighbors, friends).

Background: In recent years, accreditation of private hospitals followed by decentralisation of the Italian National Health Service (NHS) into 21 regional health systems has provided a good empirical ground for investigating the Tiebout principle of “voting with their feet”. We examine the infra-regional trade-off between greater patient choice (due to an increase in hospital services supply) and financial equilibrium, and we relate it to the significant phenomenon of Cross-Border Mobility (CBM) between Italian regions. Focusing on the rules supervising the financial agreements between regional authorities and providers of hospital care, we find incentives for private accredited providers in attracting patient inflows. Methods: The analysis is undertaken from an institutional, regulatory and empirical perspective. We select a sample of five regions with higher positive CBM balance and we examine regional regulations governing the contractual agreements between purchasers and providers of hospital care. According to this sample, we provide a statistical analysis of CBM and apply a Regional Attraction Ability Index (RAAI), aimed at testing patient preferences for private/public accredited providers. Results: We find that this index is systematically higher for private providers, both in the case of distance/boundary patients and of excellence/general hospitals. Conclusion: Conclusions address both financial issues regarding the coverage of regional healthcare systems and equity issues on patient healthcare access. They also raise concerns on the new European Union (EU) directive inherent to patient mobility across Europe.

In the last decades, both the lengthening of life expectancy and an accentuated decline in birth rates have reduced the consistency of the younger generational cohorts. Due to an ageing population, the burden of caregiving is expected to intensify in the next quarter of the century in Europe, especially for mature women. This paper investigates the impact of the provision of constant care for older parents on the mental health of adult daughters, between the ages of 50 and 75, living in different European countries. Data is drawn from the Survey of Health,Ageing and Retirement in Europe. Information on mental health status is provided by Euro-D depression scale, a measure of depression standardized across European countries. We focus on differences in the effects according to the North–South gradient: we test whether the relationship between informal caregiving and mental health differs across European macro-regions. Our results, robust under different specifications of the propensity score model, reveal a clear North–South gradient: the provision of informal care has a negative and significant impact on daughters’ mental health in the Mediterranean countries only, where the amount of resources allocated to the Long Term Care is minimal and the local system of health and social services for the elderly lacks the necessary structures to meet the increasing demand for eldercare

Obiettivi Lo studio analizza le modalità con cui in Lombardia viene finanziata la spesa sociale e sociosanitaria per gli anziani non autosufficienti. In particolare si concentra su tre punti: i) i flussi di finanziamento per la spesa dedicata agli anziani e gli organi di competenza dedicati alla loro gestione; ii) i servizi erogati rispettivamente dai Comuni e dalla Regione e la spesa da essi generata; iii) le peculiarità del modello lombardo, i meriti e le criticità. L’obiettivo finale è duplice: analizzare il trend della spesa per gli anziani negli ultimi anni e delineare un quadro generale sulla sua allocazione rispettivamente fra area sociale e area sociosanitaria e fra le diverse tipologie di servizi. In base a questi risultati è possibile fornire alcune indicazioni in termini di appropriatezza degli interventi e di soddisfacimento del bisogno da parte degli anziani non autosufficienti. Metodo e aspetti discussi L’analisi viene sviluppata sul piano istituzionale e quantitativo. Dopo aver individuato i principali organi istituzionali che gestiscono i flussi finanziari per l’assistenza agli anziani, si ricostruiscono i dati numerici (finanziamento e spesa) facendo uso di diverse fonti: la banca dati dell’Istat per la spesa sociale dei Comuni (2011), il Bilancio Sociale e il Piano degli Indicatori di Bilancio 2013 per la spesa sociosanitaria gestita dalla Regione. Esistono difficoltà oggettive nella ricostruzione dei dati regionali riguardanti la spesa per gli anziani, dovute a tre cause principali: i) l’eterogeneità delle fonti di finanziamento che si schierano sui tre diversi livelli di governo, centrale, regionale e comunale ii) la frequente sovrapposizione fra area sociale e area sociosanitaria, fattore che rende difficile la corretta individuazione delle voci di spesa, iii) la coesistenza di diverse categorie di utenti finanziati dalla spesa sociale e sociosanitaria (ad es. minori, immigrati, anziani), fatto che comporta frequenti variazioni nella ripa

Background: Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (CFS/ME) describes a condition of chronic weakness that cannot be alleviated by rest and which is associated with lower quality of life and higher healthcare utilization. In Western countries, its prevalence ranges from 0.2% to 1%. Despite the many efforts carried out during recent decades to investigate the nature of this syndrome, there are still uncertainties and controversies with respect to its definition, diagnosis and what constitutes optimal treatment. Some authors suggest that there may be a significant percentage of patients that are not yet diagnosed with this illness, due to the difficulty in identifying the symptoms. Thus, the economic burden of the disease remains unclear, although it is well recognized that the costs associated with CFS are mainly related to productivity loss. Methods: A literature review was conducted to investigate this topic, by considering, with a chronological perspective, the most relevant contributions focussed on the economic costs and consequences of CFS/ME. Results: The literature review describes how the economic burden of CFS has been increasingly considered over recent decades and addresses the aspects of CFS that deserve more attention as this field of study moves forward. Conclusion: The economic burden of CFS has not been well studied, but recent research demonstrates an increasing interest in the direct and indirect costs of CFS on individuals and Society. The need to establish an optimal, person-centered approach to the diagnosis, management and follow-up of CFS, is an imperative for modern medicine, given the relationship between the nature of clinical practice and the costs incurred by CFS. Further research is required to explore this relationship and to define its policy implications.

Di fronte al progressivo invecchiamento della popolazione, l’assistenza informale ai soggetti anziani può rappresentare un problema per i caregiver, tipicamente donne ultracinquantenni, occupate sul duplice fronte della cura ai genitori anziani e ai figli ancora giovani (da cui il termine “generazione sandwich”). L’obiettivo dello studio consiste nello stimare l’impatto delle cure ai genitori anziani, naturali o acquisiti, sulla salute mentale delle donne ultracinquantenni residenti in Europa. I dati utilizzati provengono dall’indagine SHARE (Survey of Health, Ageing and Retirement in Europe) e l’indice di depressione impiegato è l’EURO-D depression scale, una misura standardizzata della depressione riconosciuta da tutti i Paesi europei. I risultati sono resi particolarmente interessanti dalla suddivisione per macro-aree geografiche, rispettivamente Nord, Centro e Sud Europa, che è funzionale all’individuazione di due elementi ritenuti significativi ai fini della ricerca: i) la tipologia di sistema di welfare, e in particolare di Long Term Care (LTC), maggiormente sviluppata al Nord, con una progressiva riduzione nello spostamento verso i Paesi del Sud Europa; ii) il contesto sociale e culturale condizionante i legami familiari all’interno delle tre zone europee. I risultati rivelano la presenza di un gradiente Nord-Sud sull’impatto che l’assistenza ai genitori anziani provoca sulla salute mentale delle caregiver. Le indicazioni di policy suggeriscono un progressivo sviluppo dei sistemi di LTC nei Paesi dell’Europa mediterranea sulla base dei modelli implementati nelle regioni del Nord Europa, al fine di sgravare i familiari, in particolare le donne, da un peso assistenziale che è molto impegnativo in termini di tempo e di risorse fisiche e psicologiche., In the ageing societies, caring for the elderly is becoming an issue for the possible adverse effects on their caregivers, who are typically women in their late midlife. The aim of this study is to estimate the impact of caring for an old parent (natural and in-law) on the mental health of mature women living in Europe. The individual-level data employed in the analysis is drawn from the Survey of Health, Ageing and Retirement in Europe (share). Specifically, we use data from Wave 1 and Wave 2, which was collected by personal interviews in 2004 and 2006/07 respectively. Information on caregivers’ mental health status is provided by euro-d depression scale developed and validated by the eurodep Concerted Action Programme as standardized measure of depression across European countries. The analysis is particularly interesting as the sample has been subdivided geographically into three macro-regions, namely, Northern, Central and Southern Europe, which is consistent with two elements: i) the amount of resources devoted to Long Term Care (ltc) systems, and ii) the social and cultural context conditioning family ties in these three European regions. Our results reveal the presence of a North-South gradient in the effect of caring on women’s mental health. Policy implication suggest the need for a revision of the ltc systems in Southern Europe on the model of Northern ones, in order to alleviate the psychological burden carried by over-50 Mediterranean women.

Di fronte al progressivo allungamento della vita media e al contestuale incremento delle malattie croniche e degenerative, l’assistenza primaria, e in particolare il ruolo del medico di medicina generale (MMG)1, assumono un’importanza cruciale per il contenimento della spesa sanitaria e per l’appropriatezza delle cure. In diversi Paesi europei, primo fra tutti il Regno Unito, storicamente attivo nel riordino dell’assistenza primaria, ma anche in Spagna, Paesi Bassi, Germania e Francia, sono stati implementati diversi interventi tesi a riformare il settore. In Italia da più di un decennio l’assistenza primaria è oggetto di studio, ma una riforma strutturale dei modelli assistenziali, accompagnata da un processo di reale valorizzazione e responsabilizzazione del MMG, stenta a decollare.

The Basaglia law, enacted in 1978, decreed the closing down of mental hospitals in order to start a model of psychiatric care according to which patients would have been part of the society, without being relegated. Each Region reacted to this law by implementing its own model of mental health: some Regions invested in community-based services, while others increased the number of beds in the psychiatric departments of hospitals. The result is that the model of care for psychiatric patients in general, and schizophrenic ones in particular, is very heterogeneous at regional level, and seems to depend more on the services supplied than on the need of care. This paper focuses on three regional models – implemented respectively by Lombardy, Lazio and Sicily – and analyses the resource allocation for hospital admissions of schizophrenic patients. Results show disparities among regions in the provision of care and in the resource allocation between community-based and hospital services.

In the very recent past, the Lombardy health care system – established in 1997 on the quasi market model – has caught the interest of researchers and politicians in different OECD countries1. Its merits, compared to other Italian regional systems, are the control of health care spending and the balanced budget, in a frame of good quality of services and patient choice. From the theoretical point of view, an appealing aspect of the Lombardy model is its gradual shift from a quasi market (QM) to a “quasi administered” system, which maintains all the typical features of the QM orientation – separation between purchasers and providers, the co-presence of public, not for profit and public providers, and patient free choice – but has deliberately sacrificed competition in order to control health expenditure. Another aspect of the Lombardy model is the sharp presence of private providers: the evidence that private sector is mainly concentrated in the long term care, where risks of complications are lower and financial remuneration is higher, suggests that a closer control should be exerted on hospital activity. Furthermore, possible distortions such as cream skimming and cherry picking by the private providers need more consideration. Another concern is linked to health spending control: equity issues could arise when observing a still relatively high share of private (out of pocket) health care expenditure. The paper stems from a literature review and tries to analyse the evolution of this regional system, the institutional path that brought to the implementation of the model, its theoretical basis, its merits and criticism. The period considered ranges from 1997, when the reform was enacted, to 2010.

In the very recent past, the Lombardy health care system - established on the quasi-market model – has caught the interest of researchers and politicians in different OECD countries1. The merits of the model, compared to other Italian regional models, are the control of health care spending and the balanced budget, in a frame of good quality of services and patient choice. This paper stems from a literature review and tries to analyse the evolution of this regional system, the institutional path that brought to the implementation of the model, its theoretical basis, its merits and criticism. The period considered ranges from 1997, when the reform was enacted, to 2010.

This paper tries to analyse the way of financing hospital admissions in Lombardy Region. With the help of a case study, it attempts to verify if the governance model approved in 1997, which enables local Health Authority (ASL) to contract with providers about number, typology and prices of hospital admissions, is achieved. The findings show that till 2003 it was the Region who controlled for these parameters and who regulated hospital expenses, while ASL had a marginal position. If Region doesn’t let more autonomy to ASL, and continues financing deficit ex-post, it will be very difficult to program and control hospital expenses.

Empirical evidence shows that health need and health care access depend, among other factors,on socioeconomic variables.Weighting the healthcare capitation system with a deprivation index would achieve equity in resource allocation in the Italian Nhs. The Scottish Nhs healthcare funding allocation formula includes a recently approved deprivation index, named Arbuthnott index, which allows for differentials in health care access due to relative poverty. Following the Scottish experience, this paper proposes a deprivation index based on regional data for weighting the Italian capitation formula. Key words. Deprivation indices, health care need, resource allocation, weighted capitation

A circa un decennio dall’introduzione dei Diagnosis Related Groups (DRG) come strumento di finanziamento prospettico degli ospedali italiani, permane il problema della scarsa sensibilità della tariffa alla gravità clinica dei pazienti ricoverati. Per controllare la variabilità dei ricoveri afferenti al medesimo DRG alcune Regioni hanno utilizzato in via sperimentale un metodo di classificazione ad impostazione prevalentemente clinica, in grado di definire l’eziologia e il livello di severità clinica della patologia di ogni singolo caso trattato, il Disease Staging (DS). Il presente lavoro intende descrivere ed analizzare questo metodo di stadiazione dei ricoveri, evidenziandone le possibili applicazioni. Le conclusioni si concentrano sull’opportunità di affiancare ai DRG un sistema isogravità, come il DS, capace di fornire informazioni rilevanti in tema di appropriatezza dei ricoveri e di composizione delle casistiche ospedaliere, al fine di limitare il fenomeno dell’inappropriatezza dei ricoveri ospedalieri., Ten years after the Diagnosis Related Groups (DRG) implementation within the Italian hospital sector, the relevant problem is represented by the scarce sensitivity of the tariffs to the different degrees of admissions’ severity. While some excellence hospitals are financially penalised by severe case-mix indices, others show high rates of inappropriateness. The paper investigates the use of a new clinical method of admissions staging, the “Disease Staging” system, able to define the aetiology and the severity of each disease. This method can easily be integrated with the DRG prospective payment, in order to avoid the phenomenon of inappropriateness of admissions and contextually help the Local Health Authorities in identifying the amount of resources required by each admissions.

In the 90’s in a number of Western countries, the reorganisation of primary care centred on the role of the general practitioner. This occurred later in Italy, but the country has now caught up with other countries. New organisational models of primary care (Utap) have been implemented and stronger incentives have been introduced to encourage General practitioners to assume more responsibility for quality of care and spending control. This paper looks at the relationship link between the more efficient organisation of primary care, more appropriate care and expenditure control. It begins with a description of organisational models of primary care used in Great Britain. It then gives details of arrangements for primary care in Italy and of most recent trade union contract for General practitioners. The new organisational model known as Utap is also discussed. Finally the first results of a reorganisation of primary care in a local health authority in the region of Veneto are presented.

Il presente lavoro intende in prima istanza fornire una panoramica della letteratura riguardante le connessioni fra variabili socioeconomiche e salute nei Paesi industrializzati e, successivamente, analizzare le implicazioni in termini di politiche sanitarie che i diversi approcci interpretativi comportano. In particolare vengono individuate tre diverse scuole di pensiero: la prima si attiene alla teoria del reddito assoluto, secondo la quale le variabili socioeconomiche influiscono positivamente sugli indici di salute; la seconda esprime il parere degli economisti in senso stretto che indicano lo stock iniziale di salute come variabile causale in un modello dove reddito e ricchezza familiare sono variabili dipendenti; il terzo approccio, in contrapposizione con la teoria del reddito assoluto, viene denominato teoria del reddito relativo in quanto indica, non tanto nel reddito procapite, quanto nella distribuzione del reddito all'interno delle società, la causa principale delle variazione negli indici di salute. Naturalmente a diverse interpretazioni corrispondono differenze, anche di notevole entità, nelle misure di politica sanitaria da adottare per migliorare gli indici di salute delle popolazioni. Il lavoro si conclude con alcune osservazioni riguardanti l¿opportunità di sviluppare le politiche sanitarie indicate dalle diverse scuole di pensiero.

This work, based on an empirical analysis carried out by the Poison Centre of Milan, is an attempt to estimate the direct costs of acute intoxication due to pesticide use in Italy. From the analysis undertaken, it is possible to demonstrate that the number of incidents of acute intoxication registered every year in Italy is not negligible and that it causes a cost of nearly Lit 2 000 000 000. The investigation, supported also by empirical studies from other countries, suggests that, in order to reduce the incidence of this pathology, greater attention should be paid to prevention, regulation and education. Key words: cost analysis, health expenditure, acute intoxication.