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Background: More and more countries have been implementing chronic care programs, such as the Chronic Care Model (CCM) to manage non-acute conditions of diseases in a more effective and less expensive way. Often, these programs aim to provide care for single conditions instead of the sum of diseases. This paper analyzes the satisfaction and better management of single and multiple chronic patients with the core elements of chronic care programs in Siena, Italy. In addition, the paper also considers whether the CCM introduced in Siena has any influence on satisfaction and better self-management., Methods: Survey data from patients with single chronic (N = 500) and multiple chronic diseases (N = 454), assisted by the Local Health Authority in Siena (Tuscany, Italy), were considered for the analysis. Variables on education, monitoring system, proactivity, relational continuity, model of care (CCM versus no CCM) and patient demographics were used to detect which strategies are associated with a higher patient-reported ability to better self-manage the disease and overall patient satisfaction. Logistic and ordinary logistic models were executed on data related to patients with both single and multiple chronic diseases., Results: The results showed that monitoring was the sole strategy associated with overall satisfaction and better self-management for both single and multiple chronic patients. Relational continuity also showed a significant positive association with better self-management perception for both patient groups, but had a positive association with patient satisfaction only for single chronic patients. Enrolment in the CCM was not associated with both overall satisfaction and better management for the two patient groups., Conclusions: Strategies that are significantly associated with satisfaction and perception of better disease self-management were the same for both single and multiple chronic patients. The delivery of care based on the Siena CCM does not seem to make a difference in the perception of better self-management and overall satisfaction for all the patients. Other concurrent strategies implemented by the regional government in Tuscany on primary care monitoring and health promotion could partially explain why CCM does not have a significant influence.

This paper analyzes migrant access to health care by comparing hospitalizations of native and immigrant population with respect the Tuscany Region (Italy). In the analyses, a critical gap both for legal and undocumented migrant population is highlighted. Indeed, we found some key differences between the migrant and native populations related to the use of specific hospital services in Tuscany and, indirectly, of community and primary care services. Moreover, especially for undocumented migrants, hospitals seem to be the only point of access to the health-care system for migrant populations. The results suggest that the Italian health-care system is unable to ensure an equitable access to health services. In this context, maternity care could be a key point of access to the welfare system that allows participation in the health system not only for mothers but also for all migrant family members., (Copyright © 2018 John Wiley & Sons, Ltd.)

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., (Copyright © 2017 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: The main objective of the paper is to identify the governance system related to policies to reduce health inequalities in the European regions. Considering the Action Spectrum of inequalities and the check list of health equity governance, we developed a survey in the framework of the AIR Project - Addressing Inequalities Intervention in Regions - was an European project funded by the Executive Agency of Health and Consumers., Methods: A web-based qualitative questionnaire was developed that collected information about practiced strategies to reduce health inequalities. In total 28 questionnaires from 28 different regions, related to 13countries, were suitable for the analysis., Results: Progress in health equity strategies at the national and regional levels has been made by countries such as France, Portugal, Poland, and Germany. On the other hand, Spain, Italy, and Belgium have a variable situation depending on the region. However, the results of the survey indicate that the governance system for health equity different in terms of commitment, resources and tools., Conclusions: The survey highlights a weakness of governance system for the majority of countries in terms of evaluation actions and of impact of interventions in reducing inequalities, and the difficulties in having a clear and integrated vision between the national and regional levels.

Disparities in health between social groups have been documented all over Europe. We summarize the methods and results of the Addressing Inequalities in Regions (AIR) project, which identified illustrative interventions and policies developed in European regions to reduce inequalities at the primary health care level. The first phase was a systematic review of the published literature. The second phase was a survey of European regions, collecting information on policies aiming at reducing health inequalities through primary health care and identifying regional, innovative and evaluated interventions. The third phase assessed interventions through methods defined by a formal consensus, and selected illustrative practices considered good practices for several of nine evaluation criteria. The review included 98 evaluations of interventions and 10 reviews; 80% of interventions were from North-America. Three main pathways to reduce health inequalities were identified: providing health promotion, improving financial access to care and modifying care provision. The first survey identified 90 interventions. Most national strategies included health inequalities issues. Education was the most frequently identified targeted determinant. Most interventions were health promotion general or targeted at specific health determinants, conditions or groups. The second survey assessed 46 interventions. Many involved the population in planning, implementation and evaluation. We also identified the multidisciplinary of interventions, and some who had an impact on empowerment of the targeted population. The AIR project documented that policies and actions can be implemented at the regional level through primary care providers. Policies and interventions are seldom evaluated., (© The Author 2015. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Background: Several countries have co-located General Practitioners (GPs) in Primary Care Centres (PCCs) with other health and social care professionals in order to improve integrated care. It is not clear whether the co-location of a multidisciplinary team actually facilitates a positive patient experience concerning GP care. The aim of this study was to verify whether the co-location of GPs in PCCs is associated positively with patient satisfaction with their GP when patients have experience of a multidisciplinary team. We also investigated whether patients who frequently use health services, due to their complex needs, benefitted the most from the co-location of a multidisciplinary team., Methods: The study used data from a population survey carried out in Tuscany (central Italy) at the beginning of 2015 to evaluate the patients' experience and satisfaction with their GPs. Multilevel linear regression models were implemented to verify the relationship between patient satisfaction and co-location. This key explanatory variable was measured by considering both the list of GPs working in PCCs and the answers of surveyed patients who had experienced the co-location of their GP in a multidisciplinary team. We also explored the effect modification on patient satisfaction due to the use of hospitalisation, access to emergency departments and visits with specialists, by performing the multilevel modelling on two strata of patient data: frequent and non-frequent health service users., Results: A sample of 2025 GP patients were included in the study, 757 of which were patients of GPs working in a PCC. Patient satisfaction with their GP was generally positive. Results showed that having a GP working within a PCC and the experience of the co-located multidisciplinary team were associated with a higher satisfaction (p < 0.01). For non-frequent users of health services on the other hand, the co-location of multidisciplinary team in PCCs was not significantly associated with patient satisfaction, whereas for frequent users, the strength of relationships identified in the overall model increased (p < 0.01)., Conclusion: The co-location of GPs with other professionals and their joint working as experienced in PCCs seems to represent a greater benefit for patients, especially for those with complex needs who use primary care, hospitals, emergency care and specialized care frequently.

Background: Scientific and public interest in the use of the Internet for health-related purposes has grown considerably. Concerns regarding its impact on patient-doctor relationship and risks for patients have inflamed the debate. Literature provides scarce evidence in this field. This paper investigates whether a patient's decision to use the web also depends on previous experience and satisfaction with healthcare., Method: Statistical analyses were conducted using data from a survey of more than 1700 citizens in Tuscany (Italy). The Andersen behavioural model was adopted as framework for investigating two patient behaviours: Internet use for health-related purposes; discussion of online findings with the physician. Two separate multivariate logistic models were performed to verify whether satisfaction and experience with healthcare system and general practitioners were associated with the e-health behaviours., Results: Age, education and dissatisfaction with the healthcare system are the main determinant factors of e-health use. The behaviour of sharing the e-health experience with general practitioners is more diffused among those patients who are more satisfied with physicians for the involvement in the decision-making process and suggestions on life-style., Implications: Whether patients choice to share information found online with the doctor depends on the ability of the doctor to engage patients in decision-making, e-health can produce a 'double-empowerment' process: experienced by the patient on the Internet, and legitimated by the doctor during encounters., (Copyright © 2016 The Authors. Published by Elsevier Ireland Ltd.. All rights reserved.)

Background: The current social and political context is generating socio-economic inequalities between and within countries, causing and widening health inequalities. The development and implementation of interventions in primary health care (PHC) settings seem unavoidable. Attempts have been made to draw up adequate criteria to guide and evaluate interventions but none for the specific case of PHC. This methodological article aims to contribute to this field by developing and testing a set of criteria for guiding and evaluating real-life interventions to reduce health inequalities in PHC settings in European regions., Methods: A literature review, nominal group technique, survey and evaluation template were used to design and test a set of criteria. The questionnaire was answered by professionals in charge of 46 interventions carried out in 12 European countries, and collected detailed information about each intervention. Third-party experts scored the interventions using the set of evaluation criteria proposed., Results: Nine criteria to guide and evaluate interventions were proposed: relevance, appropriateness, applicability, innovation, quality assurance, adequacy of resources, effectiveness in the process, effectiveness in results and mainstreaming. A working definition was drawn up for each one. These criteria were then used to evaluate the interventions identified., Conclusions: The set of criteria drawn up to guide the design, implementation and evaluation of interventions to reduce health inequalities in PHC will be a useful instrument to be applied to interventions under development for culturally, politically and socio-economically diverse PHC contexts throughout Europe., (© The Author 2014. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.)

The main objective of this paper is to describe how indicators of the equity of access to health care according to socioeconomic conditions may be included in a performance evaluation system (PES) in the regional context level and in the planning and strategic control system of healthcare organisations. In particular, the paper investigates how the PES adopted, in the experience of the Tuscany region in Italy, indicators of vertical equity over time. Studies that testify inequality of access to health services often remain just a research output and are not used as targets and measurements in planning and control systems. After a brief introduction to the concept of horizontal and vertical equity in health care systems and equity measures in PES, the paper describes the 'equity process' by which selected health indicators declined by socioeconomic conditions were shared and used in the evaluation of health care institutions and in the CEOs' rewarding system, and subsequently analyses the initial results. Results on the maternal and child path and the chronicity care path not only show improvements in addressing health care inequalities, but also verify whether the health system responds appropriately to different population groups., (Copyright © 2013 John Wiley & Sons, Ltd.)

To assess whether delaying puberty may improve final height in GH-deficient children with a poor height prediction at early puberty, we studied 24 girls with isolated GH deficiency until they reached their final height, in a controlled trial. Patients were taking recombinant human GH (r-hGH) substitutive therapy from 2.1 +/- 0.5 yr (0.1 IU/kg.day sc) before entering the study, without showing any improvement in height prediction (149.6 +/- 2.9 vs.150.3 +/- 2.2 cm) on entering puberty. Fourteen girls agreed to add a GnRH agonist (GnRHa) to r-hGH, whereas the remaining 10 decided against it and served as controls. At the start of the study, girls treated with or without GnRHa had similar auxological characteristics (bone age, 10.9 +/- 0.6 vs. 10.7 +/- 1.3 yr; height SD score for chronological age, -1.87 +/- 0.3 vs. -1.82 +/- 0.2), including pubertal development. The GnRHa (long-acting D-Trp-6-GnRH) was given at 60 microg/kg im every 28 days for 1.9 +/- 0.9 yr, then patients continued the r-hGH at the same dosage (3.1 +/- 0.7 yr). At the end of the study, bone age was 16.2 +/- 0.3 yr in GnRHa-treated girls and 16.6 +/- 0.9 yr in controls. Bone maturation was significantly slower during GnRHa (1.4 +/- 0.2 yr), and height SD score for bone age improved (-0.31 +/- 0.3) in comparison with controls (2.6 +/- 0.4 yr and -1.35 +/- 0.3 SD score; P < 0.001 and P < 0.0001, respectively). As a result, girls given the combined therapy reached a final height higher than that of controls (height SD score, -0.39 +/- 0.5 vs. -1.45 +/- 0.2; P < 0.0001) and also higher than their midparental height (-1.1 +/- 0.5; P < 0.0005). Controls reached their midparental height. In conclusion, our results demonstrate that slowing pubertal development with the administration of GnRHa for a limited time may improve final height in GH-deficient girls selected because of a poor height prediction at early puberty.

The pubertal growth spurt accounts for approximately one-eighth of adult height and is regulated by complex hormonal interactions involving the somatotropic and gonadal axes. The observation that children with growth hormone deficiency (GHD) may fail to achieve an appropriate pubertal growth spurt led to the development of strategies to optimize GH therapy during puberty. In one strategy the dosage of GH is increased during puberty to support pubertal growth and in keeping with the physiological increase in serum levels of the hormone seen at that age. A different approach is to combine a GnRH analog (GnRHa) to GH to stop pubertal development, delaying epiphyseal fusion and prolonging peripubertal growth. Both strategies require caution. As regards the first strategy, too high doses of GH may shorten the pubertal time for growth; we found a small, nonsignificant, improvement in final height by increasing the dose by less than half. Preliminary results on the second strategy are more encouraging. However, manipulation of puberty should be limited to selected patients who show a statural height SDS for bone age unfavorable in terms of height prognosis.

X-linked hypophosphatemic rickets (XLHR) is frequently associated with growth retardation and short adult stature, even with an appropriate conventional treatment associating phosphate and calcitriol or 1 alpha-hydroxyvitamin D. Its pathogenesis is unclear; growth hormone (GH) secretion is usually normal. Six children with XLHR and growth retardation were treated with GH during 6 years. In addition, they received the conventional treatment. At the beginning of the treatment mean age was 7.8 +/- 1.8 years, and height mean Z score was -3.4 +/- 0.5. A control group was composed of six children with XLHR (age: 7.9 +/- 2.5 years) receiving the conventional treatment only. Under GH treatment statural growth was improved, with significant increase in Z score and predicted adult height; the height gain was significantly higher in the GH treated group as compared with the group receiving the conventional treatment only. In addition, radial bone mineral density increased significantly under GH treatment. GH treatment thus appears to be a useful treatment to improve statural growth in children with XLHR.

To improve final adult height, we treated with growth hormone (0.65 +/- 0.07 (mean +/- SD) IU.kg-1.wk-1) and gonadotropin-releasing hormone analogs (66 +/- 9 micrograms.kg-1 every 28 days) a group of seven short normal girls in early puberty with a chronologic age (CA) of 11.50 +/- 0.95 years, predicted adult height (PAH) lower (0.003 < p < 0.001) than mean target height, and without any endocrine abnormalities. The results were compared with those obtained in a similar group of seven untreated girls considered as control subjects. The mean period of combined therapy was 2.01 +/- 0.52 years; in two subjects treatment is still in progress. The value of height standard deviation score for bone age (BA) improved from -1.69 +/- 0.47 to -1.04 +/- 0.56 (p = 0.001); height age (HA)/BA ratio also increased from 0.83 +/- 0.05 to 0.90 +/- 0.04 (p < 0.01), as did PAH (from 146.8 +/- 4.4 to 152.9 +/- 3.6 cm; p < 0.002). The ratio of gain in HA to gain in BA was 2.08 +/- 0.78. Pubertal stages showed an arrest in five cases and a regression in the other two girls. After administration of gonadotropin-releasing hormone analogs was interrupted, in four of five girls growth hormone was administered alone for a further period of 6 to 18 months to improve their physiologic growth spurt. The present height in five girls is higher than PAH before therapy. In the treated girls the height values for BA, for BA/CA and HA/BA ratios, and for PAH were higher (0.002 < p < 0.04) than those in control subjects. This preliminary study demonstrates that combination therapy with growth hormone and gonadotropin-releasing hormone analogs in short, endocrinologically normal girls may be useful in improving both height prognosis and predicted adult height. Further studies are necessary to reach definitive conclusions regarding the efficacy of this kind of therapy.