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INTRODUCTION: Clinical Networks are complex interventions that enable healthcare professionals from various disciplines to work in a coordinated manner in the context of multiple care settings, to provide a high quality response to a specific disease. The aim of this study was to evaluate if clinical networks are able to improve effectiveness, efficiency, patients' satisfaction and professionals' behavior in the health care settings, namely the "quadruple aim" quality goals. MATERIALS AND METHODS: A systematic review of documents published until February 28, 2018, in Medline, Embase and CINAHL was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses approach. A specific research strategy was created to identify studies evaluating effectiveness, efficiency, patient satisfaction and professionals well-being obtained through clinical networks implementation. RESULTS: 14249 studies were identified; 12 of these were eligible to the evaluation of "Quadruple Aim" outcomes. 9 studies focused on patients' outcomes improvement and 4 on network efficiency. Professionals' and patients' experience were not considered in any study. CONCLUSIONS: There are some evidences that clinical network can improve patients' outcomes and health funds allocation in a small number of moderate-low quality studies. Further rigorous studies are needed to confirm these findings and to evaluate patients' and professionals' experience, taking into account also networks' structural features that could influence outcomes achievement. ispartof: Journal of Healthcare Quality Research vol:34 issue:1 pages:29-39 ispartof: location:Spain status: published

INTRODUCTION: Defensive medicine (DM) is used when a doctor deviates from good practices to prevent complaints from patients or caregivers. This is a structured phenomenon that may not only affect the physician, but all healthcare personnel. The aim of this review was to determine whether DM is also performed by Non-Medical Health Professionals (NMHP), and the reasons, features, and effects of NMHP-DM. MATERIALS AND METHODS: The review was conducted according to PRISMA guidelines, and specific inclusion criteria were used to search for relevant documents published up to 12 April 2018 in the main biomedical databases. RESULTS: A total of 91 potentially relevant studies were identified. After the removal of duplicates, 72 studies were screened for eligibility, separately by two of the authors. Finally, 14 qualitative and quantitative studies were considered relevant for the purpose of the present review. These last studies were assessed for their methodological quality. CONCLUSIONS: NMHP-DM is quite similar to DM practiced by doctors, and is mainly caused by fear of litigation. Midwives and nursing personnel practiced both active and passive DM, such as over-investigation, over-treatment, and avoidance of high-risk patients. NMHP-DM could increase risks for patient health, costs, risk of burnout for healthcare employees. Further studies are needed to better understand prevalence and features of NMHP-DM in all health professional fields, in order to apply appropriate preventive strategies to contrast DM among health care personnel. ispartof: Journal of Healthcare Quality Research vol:34 issue:2 pages:97-108 ispartof: location:Spain status: published

Background: Hospital treatment of heart failure (HF) frequently does not follow published guidelines, potentially contributing to HF high morbidity, mortality and economic cost. The Experimental Prospective Study on the Effectiveness and Efficiency of the Implementation of Clinical Pathways was undertaken to determine how clinical pathways (CP) for hospital treatment of HF affected care variability, guidelines adherence, in-hospital mortality and outcomes at discharge. Methods/design: Two-arm, cluster-randomised trial. Fourteen community hospitals were randomised either to the experimental arm (CP: appropriate therapeutic guidelines use, new organisation and procedures, patient education) or to the control arm (usual care). The main outcome was in-hospital mortality; secondary outcomes were length and appropriateness of the stay, rate of unscheduled readmissions, customer satisfaction, usage of diagnostic and therapeutic procedures during hospital stay and quality indicators at discharge. All outcomes were measured using validated instruments available in literature. Results: In-hospital mortality was 5.6% in the experimental arm (n = 12); 15.4% in controls (n = 33, p = 0.001). In CP and usual care groups, the mean rates of unscheduled readmissions were 7.9% and 13.9%, respectively. Adjusting for age, smoking, New York Heart Association score, hypertension and source of referral, patients in the CP group, as compared to controls, had a significantly lower risk of in-hospital death (OR 0.18; 95% CI 0.07 to 0.46) and unscheduled readmissions (OR 0.42; 95% CI 0.20 to 0.87). No differences were found between CP and control with respect to the appropriateness of the stay, costs and patient’s satisfaction. Except for electrocardiography, all recommended diagnostic procedures were used more in the CP group. Similarly, pharmaceuticals use was significantly greater in CP, with the exception of diuretics and anti-platelets agents. Discussion: The introduction of a specifically tailored CP for the hospital treatment of HF was effective in reducing in-hospital mortality and unscheduled readmissions. This study adds to previous knowledge indicating that CP should be used to improve the quality of hospital treatment of HF. Trial registration number: NCT00519038

Background Defensive medicine affects healthcare systems worldwide. The concerns and perception about medical liability could lead practitioners to practise defensive medicine. Second victim is a healthcare worker involved in an unanticipated adverse patient event. The role of being second victim and the other possible determinants for defensive medicine is mostly unclear. Objective To study the condition of being second victim as a possible determinants of defensive medicine among Italian hospital physicians. Design, setting and participants A secondary analysis of the database of the national survey study on the prevalence and the costs of defensive medicine in Italy that was carried out between April 2014 and June 2014 in 55 Italian hospitals was performed for this study. The demographic section of the questionnaire was selected including the physician's age, gender, specialty, activity volume, grade and the variable being a second victim after an adverse event. Results A total sample of 1313 physicians (87.5% response rate) was used in the data analyses. Characteristics of the participants included a mean age 49.2 of years and 19.4 average years of experience. The most prominent predictor for practising defensive medicine was the physicians’ experience of being a second victim after an adverse event (OR = 1.88; 95%CI, 1.38–2.57). Other determinants included age, years of experience, activity volume and risk of specialty. Conclusions Malpractice reform, effective support to second victims in hospitals together with a systematic use of evidence-based clinical guidelines, emerged as possible recommendations for reducing defensive medicine.

Objective. To test clinical pathways in a variety of Italian health care organizations in 2000–2002 to measure performance in decreasing process and outcome variations. Design. Creation of indicators, specific for each clinical pathway, to measure variations in the care processes and outcomes. Pre- and post-analysis model to evaluate the possible effect of the clinical pathways on each indicator. Setting. We tested the clinical pathways in six sites, each with different clinical pathways. Results. Reductions in health care macro-variation phenomena (length of stay, patient pathways, etc.) and in performance micro-variation (variations in diagnostic and therapeutic prescriptions, protocol implementation, etc.) were shown in sites where pathways were implemented successfully. A significant improvement in outcome for patients who were treated according to the clinical pathway for heart failure was also demonstrated. Conclusions. The overall purpose of clinical pathways is to improve outcome by providing a mechanism to coordinate care and to reduce fragmentation, and ultimately cost. Our results demonstrated that it is possible to achieve this goal. Although controversial elements still exist, we think that clinical pathways can have a positive impact on quality in health care.

Currently, more than one instrument has been found to be reliable and valid for the assessment of hospital admission appropriateness. However; data on the level of agreement among these methodologies are extremely scarce. The study was aimed at evaluating whether the percentages of organizational (in)appropriateness resulting from some of the most diffused instruments (Italian Appropriateness Evaluation Protocol--AEP/PRUO; Disease Staging; Essential Levels of Care--LEA, version 2001 and 2008) are substantially concordant, or they largely depend upon the methodology. For each public hospital of Abruzzo, Italy, the amount of inappropriateness has been computed using six indicators: inappropriate days of care (PRUO1); totally inappropriate admissions (PRU02); early admissions DRGs according to the first Law on Italian LEA (LEA01); admissions assigned to one of the 108 potentially inappropriate DRGs according to the second Law on Italian LEA, currently inactive (LEA08). The sample was composed by all ordinary admissions made in 2006 in the Region, with the exception of PRUO indicators, which were based upon the manual revision of 2% of all admissions that could be assessed using PRUO methodology. We found a good correlation among most indicators based upon administrative discharge data (DS1, DS2 and LEA01), whereas the results obtained using PRUO and new LEA (LEA08) were discordant, and marked differences were observed also between the two PRUO indicators. Although the limitations of the study permit only preliminary conclusions, in future appropriateness evaluations it may be reasonable to use more than one indicator--allowing the creation of combined scores--and rank hospitals in large categories--avoiding excessively precise scores--as such rankings might relevantly differ depending upon the used instrument.

Using a multidisciplinary questionnaire containing items from previously validated instruments (i.e. CAGE), during the year 2007 a survey (Valentino Project) was carried out on 4024 young workers (18-35 y) from Abruzzo, Italy to investigate the prevalence of use/abuse of alcohol, food, smoking, and drugs in different types of job categories, and to evaluate the potential association between occupational class and type of use/abuse. With the exception of cannabis use/abuse (13.5%), the prevalence of incorrect behaviours was higher than the young-adult general population (workers and non-workers) from Central-South Italy: overweight/obesity = 30.8%; current smoking = 45.7%; alcohol addiction = 17.3%; use/abuse of psychotropic legal drugs = 4.7%; cocaine = 4.5%; opiates = 1.0%;1 illegal drug (multiple abuse) = 3.9%. This negative scenario is accentuated by a probableor = 25% underestimation of illegal drug use/abuse, and because drug use/abuse is inversely associated with age. Using logistic regression analyses (controlling for age, gender marital status, education, job-strain, self-reported health, and all other types of use/abuse), a significant independent association was found for the first time between specific types of use/abuse and some job categories (i.e. cocaine for traders/consultants; legal psychoactive drugs and cannabis for unqualified professions such as itinerants or precarious workers; smoking for Call-Center operators; overweight/obesity for farmers/artisans). These findings should be used to maximize the efficacy of substance use/abuse preventive strategies, which could be more precisely targeted to different professions, and raise the need to control for job category in future multivariate analyses investigating substance use/abuse predictors.

In the context of a wide healthcare system reorganization, the Abruzzo Region of Italy used the Appropriateness Evaluation Protocol (AEP) to carry out a systematic evaluation of the appropriateness of the admissions performed during 2006 in all public hospitals. After specific training courses, a sample representative of all ordinary admissions was assessed twice: first by regional investigators (external assessment) then by the local personnel (internal assessment). Random-effect logistic regression was used to evaluate potential inappropriateness predictors. On a total of 13081 hospital days (2393 hospitalizations), 39.7% (95% Confidence interval: 38.9%-40.6%) were inappropriate at the regional assessment; 39.5% at the internal assessment, with high correlation between the two controls (K = 0.73). Another 10.4% of admissions, excluded by the evaluation, was assigned to DRGs at high risk of inappropriateness and should be considered. In single hospitals, the inappropriateness ranged between 17.9% and 57.9%, with large variation across wards. Additional significant predictors of inappropriateness were the day and hour of admission and hospital size, with lower inappropriateness in bigger ones. In 2006, there was a large degree of hospital misuse in public hospitals in the Abruzzo Region. The approach used in the survey may have contributed to the drastic reduction of the number of ordinary admissions observed in the Region between 2006 and 2007.

The aim of this study was to evaluate a model of analysis of the work environment in a healthcare setting in Italy and its potential utility as tool for improving the quality of care and safeguarding the health of users. The experimental model was generated in a publicly funded hospital and in a healthcare district of a local healthcare organisation. A questionnaire was used to evaluate the work environment and its constituents. Sixty-eight percent of those interviewed were aware of the objectives of the organisation, and 74% of the organisational structure. Only 34% however admitted feeling satisfied with the organisation's communication strategies and integration processes. Overall, most workers (84%) reported being highly satisfied with their work even though only half (52%) reported feeling part of the organisation, 34% of being satisfied with the organisation's current career advancement opportunities and 29% of being satisfied with the professional training opportunities offered. Nurses reported the lowest level of satisfaction, especially those working in healthcare districts. The results of this study show that healthcare workers' perception of the work environment are varied in both hospitals and healthcare districts. They also show that the proposed model is useful for evaluating the work environment in a healthcare setting.

Our study was undertaken to determine how the use of care pathways in hospital affected the quality of the care of the patients. We performed a cluster-randomized trial. The use of diagnostic procedures and of medical treatments was more appropriate in the care pathways group, as well as the discharge process. As a consequence the outcomes indicators adopted in our study showed better performances in the care pathways group when compared to the usual care group. Our study added evidences on the value of clinical pathways that can be effectively used to improve the quality of hospital care. The use of CP helped to create a constant dialogue within the clinicians, ensured that important areas of treatment were not overlooked and unnecessary delays were prevented by timely interventions. We think that our results are reliable because we adopted a cluster-randomized controlled trial design that is widely accepted as the most reliable method of determining effectiveness of complex interventions in healthcare.

The study was aimed at evaluating whether the degree of hospital admission inappropriateness and timeliness was improved in the Abruzzo Region of Italy between the year 2001 and 2005. All hospital admissions for the year 2001 (n = 286,924) and 2005 (n = 280,761) in the Region were analysed (SDO discharge data), and three diseases were in-depth reviewed: diabetes mellitus; cholecystitis/cholelithiasis; and bacterial pneumonia. Using Disease Staging methodology, the timeliness of hospitalisation was assessed by grouping admissions in three categories: premature or medically unnecessary, timely, and late. Overall, the rate of medically unnecessary admissions for diabetes mellitus was 72.3% in 2001 and 73.4% in 2005. The percentage of late hospitalizations for the same disease was still 20.2% in 2005, when the rate of late admissions for cholelithiasis/cholecystitis was 53.3% (+10.5% compared to 2001);for bacterial pneumonia 14.5%. The rate of early admissions did not improve for any disease, and any of the six local health units in Abruzzo showed an improvement in all the measures evaluated. In the period 2001 and 2005, in the Abruzzo Region there is no evidence of an improvement in the rates of inappropriate hospital admission, both early and late, which are still excessively high for all diseases examined excepted bacterial pneumonia. Interventions to address this issue are strongly needed.

To evaluate the annual distribution of personal exposure to NO2 in a sample of school children and to study the determinants of such exposure.Exposure to NO2 has been evaluated using Palmes Tubes in 310 school-children (aged 5-14) in Novara. The possible differences in personal measurements by means of ANOVA and Tuckey test were evaluated. Information on the sources of potential exposure and on respiratory symptoms have been collected through a questionnaire and a clinical diary. The relative risk for these variables has been assessed using a multiple regression model (Logit).The annual mean of the 6,200 measurements was 42.3 microgram/m3, with a significant difference among seasons and with higher values in winter. The only factor associated with a high exposure was identified for maternal school children living in houses close to high traffic density roads. Respiratory symptoms were non-related to NO2.The use of gas cookers and heaters is not enough to explain the variability of personal exposure. Between other specific determinants, the importance of living along busy streets, of ETS and of seasons explains the level of personal exposure. The opportunity of personal, rather than environmental, monitoring is confirmed, even if we stress the necessity of studying the short-term exposure to rapidly find clinical damages in the general population.

Objectives Seasonal influenza represents a major threat to public health but vaccination campaigns are strongly recommended to reduce the risks of serious complications and mortality among community-dwelling elderly persons. We investigated on potential social predictors of influenza vaccination among older adults in Italy. Methods Data analysis was based on the national survey “Health and use of health care,” which was carried out in 2004/2005 and reached a sample of 25,183 elderly persons. After initial univariate and bivariate statistics, we used multivariate logistic regression to evaluate potential independent predictors of influenza immunization. Results 62.6% of the recruited subjects declared to be vaccinated against influenza. At bivariate analysis, significative differences in immunization rates arose by each socioeconomic variable investigated. Logistic regressions confirmed that individuals in lower social classes have higher chances of being vaccinated. Moreover, older age and chronic disease were associated with higher likelihood of immunization. Conversely, reporting good health predicted a lower uptake. Conclusion In our analysis we found several independent predictors of influenza vaccination. Surprisingly, individuals belonging to lower social classes have higher chances of being vaccinated. These results suggest that vaccination policies have a positive effect in preventing socioeconomic inequalities in access to this service in Italy.

Autopsies are a fundamental moment of clinical audit that have been progressively decaying.The autoptic rates of 6 hospitals of Piedmont Region (1639 autopsies, years 1995-97) were calculated. The Positive Predictive Value and Sensitivity (indicators of concordance between clinical and autoptic diagnosis) were calculated for each diagnosis; all discrepancies were classified as type I (adverse impact on patient's survival) and type II (uncertain impact) clinical errors. The diagnostic performance of medical, surgical and emergency staffs were compared with one another.Autopsies are rarely performed on the patients who died in hospital (7.13%). Independently from the diagnosis, the global concordance expresses a Positive Predictive Value of 37.22% and a Sensitivity of 47.71%. 401 type I errors and 307 type II errors were found. The best performance is reached by emergency staff.To evaluate the use and the meaning of autopsies in today's Italian healthcare organisations.

The prognostic meaning of the routine use of the methods of temporary clipping of the afferent vessel in patients with intracranial aneurysm (Grading 0-III) was the aim of the analysis in this study. In the period 1 January, 1991-31 December 1997, 304 patients underwent surgery for non-giant intracranial aneurysm and a follow-up angiography. 157 patients were operated by routinely using the temporary clipping of the afferent vessel, whereas in 147 patients the surgical procedure was performed by traditional methods. The statistical analysis showed a significant reduction (p0.001) in terms of risk of surgical complications in the patients who underwent surgery with the temporary clip method compared to those operated with the traditional method, with a relative risk of such complications about three times greater in the latter. The routine use of temporary clipping offers, therefore, the possibility of a significant improvement of the surgical results, not influenced by a further involvement for the structure, due to the short application time.

The results of a serosurvey for leptospiral antibodies in a random sample of healthy subjects are reported. The study was carried out in an area where a waterborne outbreak of leptospirosis, due to leptospires of serogroup Australis, had occurred a month before. Sera were tested with the microagglutination technique. Leptospiral agglutinins were found in 13.8% of tested subjects, mostly in adult females. The highest prevalence rate was observed for serovar lora belonging to serogroup Australis. The leptospires of this group have a relevant spread in the study area in keeping with other surveys carried out in Italy.

SUMMARYIn one locality in Italy where the incidence of psittacosis has increased rapidly since 1980, a hospital-based study and a seroepidemiological survey were carried out in order to define the clinical and epidemiological features of psittacosis in that area.Registers of the Virology Unit of the University of Ancona, Italy, were reviewed and all hospitalized patients with a serological diagnosis of psittacosis were identified. A total of 76 cases were found and studied. A presumptive bird source was identified in 80% of 62 patients, on whom a detailed investigation had been possible. Poultry represented the most frequent probable source of infection. Clinically, the predominant pattern of illness was a moderately severe lower respiratory tract infection, with chest X-rays showing pulmonary shadowings in 68 patients (89%).In the seroepidemiological study, 51 out of 143 subjects were exposed to birds (35·7%), but only 7 out of 90 urban adult blood donors (7·3%) were positive for chlamydial antibodies using the microimmunofluorescence test.