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Purpose This study aims to systematically review the literature on the use of customer value for the evaluation of inter-organizational performance, with a wide perspective embracing different contexts and settings. Design/methodology/approach Searching within the Scopus and ISI Web of Science databases, a systematic literature review has been conducted analyzing 41 papers published between 1991 and 2020. Findings Categorization of customer value and inter-organizational performance measures were developed and the main differences among different settings were discussed. Practical implications The results presented in this study may be helpful for practitioners and managers who, in the completion of their activities, have to maintain strong and frequent relationships with other organizations. In fact, practitioners and managers interested in enhancing customer value and measuring inter-organizational performance may find an innovative perspective linking the two dimensions. They could find the categorizations presented in this study as a starting point for developing a performance evaluation framework suitable for evaluating their present business relationships. In fact, the categorizations provide a panorama of how scholars have measured until now inter-organizational performance through customer value, and therefore, they could choose the measures more appropriate for their situation. Originality/value No systematic literature review of the use of customer value for assessing inter-organizational performance has previously been undertaken, especially considering different settings.

Evidence on the effectiveness of health promotion interventions is mixed, especially in terms of the magnitude of their impact and long-term adherence. This paper proposes a comprehensive approach informed by behavioural economics of developing behavioural change programmes, which is designed to educate, activate, engage and empower people by taking into consideration individual and social mechanisms. Three applied pilots and their results are presented in order to illustrate the approach using cognitive and social mechanisms to lead to better health outcomes, individually and community-wide. More research is needed to explore levers and barriers for the systemic adoption of this framework in implementing health promotion interventions.

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.

One of the goals of immediate breast reconstruction (IBR) is to satisfy the patient's outcome. Recent studies therefore tended to focus on the patient's perception of the care and on the impact on quality of life using patients-reported-outcome-measures (PROMs), able to measure the health status directly without the clinician's interposition. We present a preliminary prospective study on 333 patients who underwent mastectomy with IBR in a two-year period, in a single Italian centre, using a dedicated PROMs, the BREAST-Q™, to determine the patient's satisfaction. We studied two groups of IBR: Group A (two-step with tissue-expander) and Group B (one-step: prosthesis/mesh) and conducted a pre- and post-operative comparison for each group to evaluate score-gain over time, and a group-score comparison to determine whether differences were significant between reconstruction types. Two-hundred-and-nine were actually enrolled and 132 completed all the questionnaires. The response rate was 62.8% and the compliance rate (completion of all the questionnaires) was 63.1%. In both groups all the analyzed domains worsened comparing the pre and post-operative period; the differences were statistically significant only for physical and sexual-wellbeing. In the comparison between the two groups, none of the detected differences reached the statistical significance. According to our experience, we can state that PROMs could improve the health concept redefining the variables to be monitored even if data is still insufficient to draw any definitive conclusion. PROMs can help surgeons and patients decide the most appropriate surgery for a particular patient-profile and to identify those who require further support.

Supportive and palliative care at the end of life (EOL) is a core component of health systems. Providing care at the EOL may require the interaction of several care providers working in different settings including nursing homes, home care, hospices, and hospitals. This work aims to (a) provide evidence on the performance of EOL care for cancer patients across healthcare organizations, with a focus on the place of care, aggressive treatments, opioids, and the place of death and (b) analyze factors associated with dying in hospital. A population-based retrospective study was performed using administrative data from Tuscany region (Italy). Thirteen thousand sixty-six cancer patients who died in 2016 were considered. There is a marked variability in EOL care within regional areas, with the multilevel logistic regression highlighting a greater likelihood of dying in hospital for patients who were admitted to intensive care units or previously hospitalized. There is a lower probability of dying in acute care setting for patients assisted in hospices and in both hospital and hospices/home care and for patients treated with opioids. This intraregional variation highlights the need to improve EOL planning and rethink the delivery of supportive/palliative care. Further investigations on the preferences of patients may lead to more understanding.

Aim: This article synthesises the results of a large international study on primary care (PC), the QUALICOPC study. Background: Since the Alma Ata Declaration, strengthening PC has been high on the policy agenda. PC is associated with positive health outcomes, but it is unclear how care processes and structures relate to patient experiences. Methods: Survey data were collected during 2011–2013 from approximately 7000 PC physicians and 70 000 patients in 34, mainly European, countries. The data on the patients are linked to data on the PC physicians within each country and analysed using multilevel modelling. Findings: Patients had more positive experiences when their PC physician provided a broader range of services. However, a broader range of services is also associated with higher rates of hospitalisations for uncontrolled diabetes, but rates of avoidable diabetes-related hospitalisations were lower in countries where patients had a continuous relationship with PC physicians. Additionally, patients with a long-term relationship with their PC physician were less likely to attend the emergency department. Capitation payment was associated with more positive patient experiences. Mono- and multidisciplinary co-location was related to improved processes in PC, but the experiences of patients visiting multidisciplinary practices were less positive. A stronger national PC structure and higher overall health care expenditures are related to more favourable patient experiences for continuity and comprehensiveness. The study also revealed inequities: patients with a migration background reported less positive experiences. People with lower incomes more often postponed PC visits for financial reasons. Comprehensive and accessible care processes are related to less postponement of care. Conclusions: The study revealed room for improvement related to patient-reported experiences and highlighted the importance of core PC characteristics including a continuous doctor–patient relationship as well as a broad range of services offered by PC physicians.

IntroductionMonitoring how patients feel and what they experience during the care process gives health professionals data to improve the quality of care, and gives health systems information to better design and implement care pathways. To gain new insights about specific gaps and/or strengths in breast cancer care, we measure patient-reported outcomes (PROs) and patient-reported experiences (PREs) for women receiving immediate breast reconstruction (iBR).Methods and analysisProspective, multicentre, cohort study with continuous and systematic web-based data collection from women diagnosed with breast cancer, who have an indication for iBR after mastectomy treated at any Breast Unit (BU) in Tuscany Region (Italy). Patients are classified into one of two groups under conditions of routine clinical practice, based on the type of iBR planned (implant and autologous reconstruction). Patient-reported information are obtained prior to and after surgery (at 3-month and 12-month follow-up). We estimate that there are around 700 annual eligible patients.Descriptive analyses are used to assess trends in PROs over time and differences between types of iBR in PROs and PREs. Additionally, econometric models are used to analyse patient and BU characteristics associated with outcomes and experiences. PREs are evaluated to assess aspects of integrated care along the care pathway.Ethics and disseminationThe study has been reviewed and obtained a nihil obstat from the Tuscan Ethics Committees of the three Area Vasta in 2017. Dissemination of results will be via periodic report, journal articles and conference presentations.

Patient experience should be the starting point to achieve a high quality of care. Coherently, healthcare performance evaluation systems, driving the change in line with the main strategic goals, should be designed considering the patient perspective. Instead, they are traditionally defined according to the healthcare service provider's point of view. Consequently, they reproduce a "silo-vision" characterized by a clear separation of responsibilities limited to a specific setting of care or to a single organization. This commentary discusses the importance of using patient-reported measures together with indicators based on administrative data to evaluate cross-setting healthcare services within a multidimensional healthcare performance evaluation system. The experience of the Tuscany regional healthcare Performance Measurement System (PMS), implemented more than 10 years ago and in continuous evolution, represents an innovative example of how to measure the quality of the whole care pathway including patient experience. This new approach is based on a systematic, systemic and standardized collection of patient-reported experience measures in several healthcare pathways and evaluating them using a coherent graphical representation. Targets, incentives and other managerial tools are fixed, overcoming organizational boundaries and integrating the patient point of view with the goal of moving the healthcare system towards a patient-centredness approach to care.

The increasing prevalence of type 2 diabetes has highlighted the importance of evidence-based guidelines for effective prevention, management and treatment. Diabetes self-management education (SME) produces positive effects on patient behaviours and health status. We analyzed the literature to identify (i) the level of integration between usual care and SME programs and (ii) any possible differences across them in terms of outcomes. Searches were made on three databases - PubMed, Scopus and Web of Science - to identify relevant publications on diabetes SME to 2015, which also describe the provider of usual care. In total, 49 studies met the inclusion criteria. We identified three levels of integration (high, medium and low) between usual care and SME programs based on the level of involvement of usual care professionals within the SME programs. In most cases, the primary care physician was responsible for the diabetes patients. Patient health behaviors and/or outcomes improve in most of the studies, independently from the level of integration. However, findings suggest that when patients/participants could perceive that usual care provider is highly involved in SME delivery, educational programs produced results that appear to be more positive.

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

Aim: This study reports the research methods and baseline data of a project aimed at assessing the effect of an intervention based on the 7 Steps of the Baby Friendly Community Initiative (BFCI) on the rate of exclusive breastfeeding at 6 months in Italy. Subjects and Methods: In this controlled, nonrandomized study, nine Local Health Authorities were assigned to an early and nine to a late intervention group. Data on breastfeeding in infants followed up from birth to 12 months were gathered at baseline and in two subsequent rounds, after the 7 Steps were implemented in the early and late intervention groups, respectively. Step-down logistic regression analysis, corrected for the cluster effect, was used to compare breastfeeding rates between groups. Results: At baseline, there were no significant differences in breastfeeding rates at birth (n = 1,781) and at 3 (n = 1,854), 6 (n = 1,601), and 12 (n = 1,510; loss to follow-up, 15.2%) months between groups. At birth, 96% of mothers initiated breastfeeding, 72% exclusively (recall from birth). At 3 months, 77% of infants were breastfed, 54% exclusively with 24-hour and 46% with 7-day recall. At 6 months, the rate of any breastfeeding was 62%, with 10% and 7% exclusive breastfeeding with 24-hour and 7-day recall, respectively. At 12 months, 31% of the children continued to breastfeed. Conclusions: The project is ongoing and will allow estimation of the effect of the BFCI.

Background Health systems are expected to be responsive, that is to provide services that are user-oriented and respectful of people. Several surveys have tried to measure all or some of the dimensions of the responsiveness (e.g. autonomy, choice, clarity of communication, confidentiality, dignity, prompt attention, quality of basic amenities, and access to family and community support), however there is little evidence regarding the level of responsiveness of primary care (PC) systems. Methods This work analyses the capacity of primary care systems to be responsive. Data collected from 32 PC systems were used to investigate whether a relationship exists between the responsiveness of PC systems and the PC doctor remuneration systems and domestic health expenditure. Results There appears to be a higher responsiveness of PC when doctors are paid via capitation than when they only receive a fee for services or a mixed payment method. In addition, countries that spend more on health services are associated with higher levels of dignity and autonomy. Conclusion Quality, as measured from the patient's perspective, does not necessarily overlap with PC performance based on structure and process indicators. The results could also stimulate a new debate on the role of economic resources and PC workforce payment mechanisms in the achievement of quality goals, in this case related to the capacity of PC systems to be responsive.

Objective To assess the effectiveness of the Baby Friendly Community Initiative (BFCI) on exclusive breast feeding at 6 months. Design Controlled, non-randomised trial. Setting 18 Local Health Authorities in 9 regions of Italy. Participants 5094 mother/infant dyads in 3 cohorts were followed up to 12 months after birth in 3 rounds of data collection: at baseline, after implementation of the intervention in the early intervention group and after implementation in the late intervention group. 689 (14%) dyads did not complete the study. Intervention Implementation of the 7 steps of the BFCI. Main outcome measures The rate of exclusive breast feeding at 6 months was the primary outcome; breast feeding at discharge, 3 and 12 months was also measured. Results The crude rates of exclusive breast feeding at discharge, 3 and 6 months, and of any breast feeding at 6 and 12 months increased at each round of data collection after baseline in the early and late intervention groups. At the end of the project, 10% of infants were exclusively breast fed at 6 months and 38% were continuing to breast feed at 12 months. However, the comparison by adjusted rates and logistic regression failed to show statistically significant differences between groups and rounds of data collection in the intention-to-treat analysis, as well as when compliance with the intervention and training coverage was taken into account. Conclusions The study failed to demonstrate an effect of the BFCI on the rates of breast feeding. This may be due, among other factors, to the time needed to observe an effect on breast feeding following this complex intervention.

In linea con le nuove strategie di intervento dei sistemi sanitari pubblici, orientate verso un approccio proattivo in grado di fornire servizi differenziati in base ai bisogni, lo studio propone un tentativo di segmentazione dell'utenza dei servizi distrettuali. Nella prima parte vengono presentate le motivazioni alla base della ricerca, la review della letteratura internazionale ed il contesto oggetto di analisi. Da un'indagine su 3461 utilizzatori, vengono successivamente individuati - tramite l'analisi fattoriale e l'analisi cluster - 4 segmenti: i "modesti", i "coscienti e sostenuti" gli "esperti" e gli "evoluti". Le caratteristiche dei segmenti vengono infine commentate, con l'esposizione delle possibili implicazioni gestionali.

Background The evolution in the surgical and diagnostic procedures, the attention to women’s preferences, the case mix, and differences in professional practices may lead to a variability in the quality of breast cancer clinical pathway. To catch and manage this variability it is important to use valid measures. The aim of this paper is to examine the concurrent validity of the breast-conserving surgery (BCS) indicator and to provide evidence to guide the quality improvement process. Methods The BCS indicator was calculated using hospital discharge records (HDRs) and was validated against surgical registry (SR) data in a random sample of 336 women undergoing breast cancer surgery in 2012 in two Tuscan teaching hospitals. The concurrent validity of BCS was examined by cross-tabulating patients using the ICD-9 CM codes for breast surgery obtained from the two data sources. Results The analysis, carried out involving breast cancer professionals, highlighted that the large majority of interventions coded as “mastectomies” in HDRs are in fact reconstructing procedures, including nipple-sparing, skin-sparing and skin-reducing mastectomies in SR. These results led us to refine the old algorithm, that calculates the proportion of breast-conserving surgery over the total number of breast interventions, and reclassify breast cancer surgical procedures into three categories: conservative, reconstructive and traditional mastectomy. Based on this new classification algorithm, the percentages of (I) reconstructive interventions were 16% at Florence TH and 38.3% at Pisa TH; (II) breast-conserving interventions were respectively 72.8 and 52.1%; and (III) mastectomies 11.2 and 9.6%. After adjusting for age in a logistic regression model, the percentages of reconstructive interventions at Florence and Pisa were respectively 22 and 34% and those of breast-conserving interventions 63 and 53%. Conclusions Our results indicate that breast cancer care indicators should be refined by distinguishing reconstructive procedures (nipple/skin-sparing surgery with implant or breast tissue expander insertion) from traditional mastectomy. The involvement of breast care professionals in the choice of indicators proved to be crucial to capture the up-to-date breast cancer surgical practice and inform the quality improvement process.

To investigate patients' perceptions of improvement potential in primary care in 34 countries.We did a cross-sectional survey of 69 201 patients who had just visited general practitioners at primary-care facilities. Patients rated five features of person-focused primary care - accessibility/availability, continuity, comprehensiveness, patient involvement and doctor-patient communication. One tenth of the patients ranked the importance of each feature on a scale of one to four, and nine tenths of patients scored their experiences of care received. We calculated the potential for improvement by multiplying the proportion of negative patient experiences with the mean importance score in each country. Scores were divided into low, medium and high improvement potential. Pair-wise correlations were made between improvement scores and three dimensions of the structure of primary care - governance, economic conditions and workforce development.In 26 countries, one or more features of primary care had medium or high improvement potentials. Comprehensiveness of care had medium to high improvement potential in 23 of 34 countries. In all countries, doctor-patient communication had low improvement potential. An overall stronger structure of primary care was correlated with a lower potential for improvement of continuity and comprehensiveness of care. In countries with stronger primary care governance patients perceived less potential to improve the continuity of care. Countries with better economic conditions for primary care had less potential for improvement of all features of person-focused care.In countries with a stronger primary care structure, patients perceived that primary care had less potential for improvement.Examiner la perception des patients quant au potentiel d'amélioration des soins de santé primaires dans 34 pays.Nous avons mené une enquête transversale sur 69 201 patients qui venaient juste de consulter des médecins généralistes dans des établissements de soins de santé primaires. Les patients ont évalué cinq caractéristiques des soins de santé primaires axés sur la personne: accessibilité/disponibilité, continuité, exhaustivité, implication du patient et communication entre le médecin et le patient. Un dixième des patients ont classé l'importance de chaque caractéristique sur une échelle allant d'un à quatre, et neuf dixièmes ont noté leur expérience des soins reçus. Nous avons calculé le potentiel d'amélioration en multipliant la proportion d'expériences négatives des patients avec le score moyen d'importance danschaque pays. Les scores ont été répartis en potentiels d'amélioration faible, moyen et élevé. Nous avons effectué des corrélations par paire entre les scores d'amélioration et les trois dimensions de la structure des soins de santé primaires: gouvernance, conditions économiques et constitution de la main-d'œuvre.Dans 26 pays, une ou plusieurs caractéristiques des soins de santé primaires présentaient des potentiels d'amélioration moyen ou élevé. L'exhaustivité des soins avait un potentiel d'amélioration moyen à élevé dans 23 des 34 pays. Dans tous les pays, la communication entre le médecin et le patient présentait un potentiel d'amélioration faible. Une structure globale plus forte des soins de santé primaires était corrélée avec un potentiel plus faible d'amélioration pour la continuité et l'exhaustivité des soins. Dans les pays avec une gouvernance plus forte des soins de santé primaires, les patients percevaient un moindre potentiel pour améliorer la continuité des soins. Les pays présentant de meilleures conditions économiques pour les soins de santé primaires avaient un moindre potentiel pour l'amélioration de toutes les caractéristiques des soins de santé axés sur la personne.Dans les pays avec une structure plus forte des soins de santé primaires, les patients perçoivent un moindre potentiel d'amélioration pour les soins de santé primaires.Investigar las percepciones de los pacientes acerca de la mejora en la atención primaria en 34 países.Se realizó una encuesta transversal de 69 201 pacientes que acababan de visitar médicos generales en centros de atención primaria. Los pacientes evaluaron cinco características de la atención primaria centrada en la persona: accesibilidad y disponibilidad, continuidad, exhaustividad, implicación del paciente, así como comunicación entre médico y paciente. Una décima parte de los pacientes clasificó la importancia de cada característica en una escala de uno a cuatro y nueve de cada diez pacientes evaluaron sus experiencias de la atención recibida. Se calculó el potencial de mejora multiplicando la proporción de experiencias negativas de pacientes con la puntuación media de la importancia en cada país. Las puntuaciones se dividieron en potencial de mejora bajo, medio y alto. Se realizaron correlaciones por pares entre las puntuaciones de mejora y las tres dimensiones de la estructura de atención primaria, a saber, gestión, condiciones económicas y desarrollo laboral.En 26 países, una o más características de la atención primaria tenían potenciales de mejora medios o altos. El carácter integral de la atención tenía un potencial de mejora entre medio y alto en 23 de 34 países. En todos los países, la comunicación entre médico y paciente tenía un potencial de mejora bajo. Una estructura global más fuerte de la atención primaria se correlacionó con un menor potencial de mejora en la continuidad y exhaustividad de la atención. En los países con una política de dirección de la atención primaria más sólida, los pacientes percibieron un potencial menor de mejora de la continuidad de la atención. Los países con mejores condiciones económicas para la atención primaria presentaron un potencial menor para la mejora de todas las características de la atención centradas en la persona.En países con una estructura de atención primaria más sólida, los pacientes perciben un menor potencial de mejora de la atención primaria.تحري تصورات المرضى حول احتمالات التحسين في مجال الرعاية الأولية في 34 بلداً.أجرينا مسحاً متعدد القطاعات على 69201 مريضاً قاموا للتو بزيارة الممارسين العموميين في مرافق الرعاية الأولية. وقام المرضى بتقييم خمس سمات للرعاية الأولية الشخصية - التوافر/الإتاحة والاستمرارية والشمولية وإشراك المرضى والتواصل بين الأطباء والمرضى. وقام عُشر المرضى بترتيب أهمية كل سمة من السمات باستخدام مقياس من واحد إلى أربعة وسجل تسعة أعشار المرضى خبراتهم بشأن تلقي الرعاية. وقمنا بحساب احتمالات التحسين بضرب نسبة الخبرات السلبية للمرضى بمتوسط درجة الأهمية في كل بلد. وتم تقسيم الدرجات إلى احتمالات تحسين منخفضة ومتوسطة ومرتفعة. وتم إيجاد الارتباطات الثنائية بين درجات التحسين والأبعاد الثلاثة لهيكل الرعاية الأولية وهي - تصريف الشؤون والظروف الاقتصادية وتنمية القوى العاملة.حظيت واحدة أو أكثر من سمات الرعاية الأولية في 26 بلداً باحتمالات تحسين متوسطة أو مرتفعة. وحظيت شمولية الرعاية باحتمالات تحسين من متوسطة إلى مرتفعة في 23 بلداً من أصل 34 بلداً. وفي جميع البلدان، حظي التواصل بين الأطباء والمرضى باحتمالات تحسين منخفضة. وارتبط ازدياد هيكل الرعاية الأولية الأقوى بشكل عام بانخفاض احتمالات التحسين في الاستمرارية وشمولية الرعاية. وكان تصور المرضى في البلدان التي تتميز بتصريف شؤون أقوى فيما يتعلق بالرعاية الأولية هو انخفاض احتمالات التحسين في استمرارية الرعاية. وانخفضت احتمالات التحسين في جميع سمات الرعاية الشخصية لدى البلدان ذات الظروف الاقتصادية الأفضل للرعاية الأولية.في البلدان ذات هيكل الرعاية الأولية الأقوى، تتسم الرعاية الأولية باحتمالات تحسين أقل وفق تصورات المرضى.调查34个国家病人对初级保健改善可能性的看法。.我们对最近前往初级保健设施的全科医生就医的69201名患者进行横断面调查。病人以个人为中心的初级保健的五个特性评级：可达性/可用性、连续性、综合性、病人参与和医患沟通。十分之一的患者按每个特性从一到四的重要性等级排名，十分之九的患者按所接受护理的体验评分。我们这样计算改善的可能性：负面病人体验比例乘以每个国家重要性平均值。改善可能性分数分为低、中、高等。在改善分数和初级保健结构的三个维度（治理、经济条件和人力发展）之间进行两两相关分析。.在26个国家，初级保健的一个或多个特性有中或高的改善可能性。在34个国家中有23个国家的护理综合性有中到高等的改善可能性。在所有国家中，医患沟通改善可能性较低。初级保健整体更强的结构与较低的护理连续性和综合性改善可能性相关。在初级保健治理更强的国家，患者认为不太可能改善医疗服务的连续性。初级护理经济条件更好的国家提高所有特性个人为中心护理的可能性更低。.在初级保健结构更强的国家，病人能意识到的初级保健改善可能性更低。.Исследовать восприятие пациентами потенциала улучшения первичной медицинской помощи в 34 странах.Было проведено перекрестное исследование 69 201 пациента, которые посещали только терапевтов в учреждениях первичной медицинской помощи. Пациенты дали оценку пяти характеристикам целенаправленной первичной медицинской помощи: доступность/наличие, непрерывность, комплексность, участие пациента и коммуникация между врачом и пациентом. Одна десятая пациентов расположила по важности каждую характеристику на шкале от одного до четырех, а девять десятых пациентов оценили свой опыт получения медицинской помощи. Потенциал улучшения рассчитывался путем умножения части пациентов с отрицательным опытом на средний балл важности в каждой стране. Баллы делились на низкий, средний и высокий потенциал улучшения. Попарные корреляции выводились между баллами улучшения и тремя характеристиками структуры первичной медицинской помощи: руководством, экономическим положением и подготовкой трудовых ресурсов.В 26 странах одна или более характеристик первичной медицинской помощи обладали средним или высоким потенциалом улучшения. Комплексность медицинской помощи обладала потенциалом улучшения от среднего до высокого в 23 из 34 стран. Во всех странах коммуникация между врачом и пациентом имела низкий потенциал улучшения. В целом сильная структура первичной медицинской помощи была связана с низким потенциалом улучшения непрерывности и комплексности медицинской помощи. В странах с эффективным руководством первичной медицинской помощью пациенты усматривали меньший потенциал для улучшения непрерывности медицинской помощи. Страны с лучшим экономическим положением в первичной медицинской помощи обладали меньшим потенциалом улучшения всех характеристик целенаправленной помощи пациенту.В странах с эффективной структурой первичной медицинской помощи пациенты усматривали меньший потенциал улучшения в данной области.

Healthcare providers often look for feedback from patient surveys. Does health-professional awareness of patient survey results improve communication between patients and providers? To test this hypothesis, we analyzed the data of two surveys on organizational-climate and patient experience in Italy. The two surveys were conducted in 26 hospitals in the Tuscany region and involved 8942 employees and 5341 patients, respectively. Statistical analysis showed that the patient experience index significantly improved by 0.35 points (scale: 0-100) when the professionals’ knowledge of the patient survey results increased by 1%. These findings suggest that the control systems should focus more on the dissemination phase of patient survey results among health professionals in order to improve the quality of services.

Continuity of care is one of the cornerstones of primary care. Initially, the concept of continuity largely corresponded to one care provider and continuity between doctor and patient, but today, healthcare processes and organisations have grown and become more complex. A survey of patients with complex care needs found that in all of 11 countries studied care was often poorly coordinated. Multidimensional models of continuity have to be developed.To study existing evidence concerning significance of continuity in primary care with special consideration given to the preferences of citizens and to patients with complex care needs.Contemporary literature was studied from the aspects of primary care, patients' point of view, multimorbidity and organisational models. Examples from country systems were collected. The topic and drafts were presented and discussed at two EFPC conference workshops.Evidence shows that both patients and caregivers identify and value continuity in the form of regular sources of care, and that provider continuity is related to lower total healthcare costs on a macro level. Continuity is a considerable component of quality in primary care. Methods to measure and compare between primary care centres, organisations and countries to stimulate improvements in continuity is lacking. The complexity of operationalising continuity in the context of multidisciplinary team-based primary care today and in the future remains a challenge.Continuity is, and will be, an important component of quality in primary care, especially from the perspective of citizens and growing multimorbidity. Methods to develop continuity should be promoted.

The Quality and Costs of Primary Care in Europe (QUALICOPC) study aims to analyse and compare how primary health care systems in 35 countries perform in terms of quality, costs and equity. This article answers the question 'How can the organisation and delivery of primary health care and its outcomes be measured through surveys of general practitioners (GPs) and patients?' It will also deal with the process of pooling questions and the subsequent development and application of exclusion criteria to arrive at a set of appropriate questions for a broad international comparative study.The development of the questionnaires consisted of four phases: a search for existing validated questionnaires, the classification and selection of relevant questions, shortening of the questionnaires in three consensus rounds and the pilot survey. Consensus was reached on the basis of exclusion criteria (e.g. the applicability for international comparison). Based on the pilot survey, comprehensibility increased and the number of questions was further restricted, as the questionnaires were too long.Four questionnaires were developed: one for GPs, one for patients about their experiences with their GP, another for patients about what they consider important, and a practice questionnaire. The GP questionnaire mainly focused on the structural aspects (e.g. economic conditions) and care processes (e.g. comprehensiveness of services of primary care). The patient experiences questionnaire focused on the care processes and outcomes (e.g. how do patients experience access to care?). The questionnaire about what patients consider important was complementary to the experiences questionnaire, as it enabled weighing the answers from the latter. Finally, the practice questionnaire included questions on practice characteristics.The QUALICOPC researchers have developed four questionnaires to characterise the organisation and delivery of primary health care and to compare and analyse the outcomes. Data collected with these instruments will allow us not only to show in detail the variation in process and outcomes of primary health care, but also to explain the differences from features of the (primary) health care system.

Over the last several years, interest in benchmarking health services' quality--particularly patient satisfaction (PS)--across organizations has increased. Comparing patient experiences of care across hospitals requires risk adjustment to control for important differences in patient case-mix and provider characteristics. This study investigates the individual-level and organizational-level determinants of PS with public hospitals by applying hierarchical models. The analysis focuses on the effect of hospital characteristics, such as self-discharges, on overall evaluations and on across hospital variation in scores. Sociodemographics, admission mode, place of residence, hospitalization ward and continuity of care were statistically significant predictors of inpatient satisfaction. Interestingly, it was observed that hospitals with a higher percentage of Patients Leaving Against Medical Advice (PLAMA) received lower scores. The latter result suggests that the percentage of PLAMA may provide a useful measure of a hospital's inability to meet patient needs and a proxy indicator of PS with hospital care.

In the last years the interest for patient experience with health care services largely increased. Several surveys have been conducted in order to observe if health care systems answer to the overall patient needs. In 2000 World Health Organization challenged modern health care providers to ensure responsiveness to patients, i.e. to deliver also non-health assistance (respect for dignity, confidentiality, prompt attention, quality of amenities, access to social support networks, choice of provider, etc.). Poor evidence is available in Italy about connections between perceived quality and the capability of the healthcare system to respond to patients’ needs. This work aims at investigating patient experience with General Practitioner (GP) assistance and at measuring the impact of personal and organizational characteristics on overall satisfaction and on willingness to recommend. In 2009 a sample survey was conducted in four regions of Italy (Tuscany, Piedmont, Umbria, and Liguria). About 15.000 citizens answered to a large questionnaire related to Primary Care services, including a section dedicated to General Practitioner (GP) assistance. A logistic regression analysis was applied to analyze which are the predictors of overall satisfaction with GP, focusing mainly on variables related to patient’s expectations, continuity of care and organizational aspects (e.g. scheduled access, waiting time, health case history, etc.) and if there are differences across the four Italian Regions. Econometric analysis has been carried out through both ordered logistic regression and generalised ordered logit models. The inhabitants of the four Italian Regions refer a nice experience with GP assistance: more than 85% of them judged excellent or good the overall service. Generally, in some regions patient expectations affect more the willingness to recommend GP to friends or family members than the overall judgement on service. Besides, the findings provide convincing evidence that GP is a nodal point in the continuity of care process .

Background La letteratura internazionale evidenzia che la relazione tra medico e paziente influisce sulla valutazione complessiva dei servizi sanitari. Obiettivi Il paper si concentra sull’assistenza offerta dai medici di famiglia (MMG) e si propone di analizzare come la comunicazione tra medico e paziente influenza la soddisfazione complessiva a seconda del profilo socio-demografico dell’utente. Metodologia Nel 2009 è stata condotta un’indagine campionaria sui servizi di medicina territoriale. Oltre 15.500 cittadini assistiti in Liguria, Piemonte, Toscana ed Umbria hanno risposto ad un questionario somministrato telefonicamente. Sui dati sono state condotte analisi descrittive e applicati modelli di regressione semplice. Risultati e conclusioni: La soddisfazione complessiva per il servizio offerto dai medici di famiglia è elevata: in media oltre l’85% dei cittadini esprime una valutazione positiva. È risultato inoltre che alcuni elementi della comunicazione medico-paziente condizionano positivamente tali giudizi, con differenze significative per età, sesso, titolo di studio e stato di salute percepito dei rispondenti. La responsiveness dei medici di famiglia deve perciò tenere sempre più conto anche delle differenti e crescenti aspettative dei pazienti.

The paper describes the performance measurement system of the maternity pathway used in Tuscany by health care professionals, general managers and regional policy-makers. This system uses 19 indicators grouped in six dimensions: population's state of health; compliance with regional guidelines; efficiency and financial performance; clinical and health assessment; patient satisfaction; and employees' satisfaction. The results are represented on a spider diagram that summarizes the results on the different dimensions. The Tuscan performance measurement system of the maternity pathway has been used to identify best practice within, and their adoption throughout, the Tuscan public health care system.

Introduzione Negli ultimi anni le organizzazioni sanitarie - sia a livello internazionale che nazionale e regionale – hanno adottato sistemi multidimensionali per la valutazione della performance dei servizi sanitari. Accanto ad indicatori clinici ed economici, viene considerata la patient satisfaction per offrire una nuova prospettiva di analisi agli stakeholders del sistema (policemakers, management e operatori sanitari). Con queste premesse, numerose indagini sono state condotte per conoscere e analizzare le determinanti della soddisfazione rispetto all’esperienza vissuta dagli utenti con i servizi e per comprendere quali azioni intraprendere per migliorarla. Occorre però chiedersi quanto siano validi e affidabili gli strumenti utilizzati per indagare l’esperienza degli utenti, poiché spesso è stata riservata una scarsa attenzione agli aspetti di validity e reliability, che risultano invece essenziali per dare credibilità ai risultati raccolti. Obiettivo Questo studio descrive lo sviluppo e il processo di validazione di un questionario sulla soddisfazione degli utenti dei servizi di medicina territoriale (medici di medicina generale – MMG, pediatria di libera scelta – PLS, specialistica e diagnostica ambulatoriale) applicabile nel contesto italiano. Metodo Il questionario oggetto di studio è stato costruito dopo aver ricercato nella bibliografia esistente le principali dimensioni misurate dai questionari sull’assistenza territoriale, adattando al contesto italiano gli items utilizzati nelle esperienze internazionali. Nel gennaio 2009 il questionario è stato somministrato nel corso di un’indagine (condotta con metodologia Computer Aided Telephone Interviews) rivolta ad un campione casuale di cittadini liguri che negli ultimi 12 mesi avevano avuto accesso ai servizi di medicina generale, pediatria di libera scelta, specialistica e diagnostica ambulatoriale presso le strutture delle aziende sanitarie liguri. Attraverso l’analisi fattoriale, il coefficiente di correlazione e l’alfa di Crombach si è voluto esaminare la relazione esistente tra gli items introdotti nel questionario e la loro affidabilità come misure di patient satisfaction con i servizi territoriali. Risultati L’analisi psicometrica condotta sulle dimensioni ha riportato evidenze positive sulla validità e affidabilità dello strumento. In particolare, l’analisi fattoriale ha confermato la sussistenza delle dimensioni in cui il questionario è stato strutturato producendo 4 fattori (loading>0.40) che corrispondono alle dimensioni: MMG (fattore1), specialistica ambulatoriale (fattore2), PLS (fattore3), diagnostica ambulatoriale (fattore4). Il coefficiente di intercorrelazione tra i singoli fattori (