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Background Digital health interventions are effective for hypertension self-management, but a comparison of the effectiveness and implementation of the different modes of interventions is not currently available. This study aimed to compare the effectiveness of SMS, smartphone application, and website interventions on improving blood pressure in adults with hypertension, and to report on their reach, uptake, and feasibility. Methods In this systematic review and meta-analysis we searched CINAHL Complete, Cochrane Central Register of Controlled Trials, Ovid Embase, Ovid MEDLINE, and APA PsycInfo on May 25, 2022, for randomised controlled trials (RCTs) published in English from Jan 1, 2009, that examined the effectiveness of digital health interventions on reducing blood pressure in adults with hypertension. Screening was carried out using Covidence, and data were extracted following Cochrane's guidelines. The primary endpoint was change in the mean of systolic blood pressure. Risk of bias was assessed with Cochrane Risk of Bias 2. Data on systolic and diastolic blood pressure reduction were synthesised in a meta-analysis, and data on reach, uptake and feasibility were summarised narratively. Grading of Recommendations, Assessment, Development, and Evaluation criteria were used to evaluate the level of evidence. The study was registered with PROSPERO CRD42021247845. Findings Of the 3235 records identified, 29 RCTs from 13 regions (n=7592 participants) were included in the systematic review, and 28 of these RCTs (n=7092 participants) were included in the meta-analysis. 11 studies used SMS as the primary mode of delivery of the digital health intervention, 13 used smartphone applications, and five used websites. Overall, digital health intervention group participants had a –3·62 mm Hg (95% CI –5·22 to –2·02) greater reduction in systolic blood pressure, and a –2·45 mm Hg (–3·83 to –1·07) greater reduction in diastolic blood pressure, compared with control group participants. No statistically significant differences between the three different modes of delivery were observed for both the systolic (p=0·73) and the diastolic blood pressure (p=0·80) outcomes. Smartphone application interventions had a statistically significant reduction in diastolic blood pressure (–2·45 mm Hg [–4·15 to –0·74]); however, there were no statistically significant reductions for SMS interventions (–1·80 mm Hg [–4·60 to 1·00]) or website interventions (–3·43 mm Hg [–7·24 to 0·38]). Due to the considerable heterogeneity between included studies and the high risk of bias in some, the level of evidence was assigned a low overall score. Interventions were more effective among people with greater severity of hypertension at baseline. SMS interventions reported higher reach and smartphone application studies reported higher uptake, but differences were not statistically significant. Interpretation SMS, smartphone application, and website interventions were associated with statistically and clinically significant systolic and diastolic blood pressure reductions, compared with usual care, regardless of the mode of delivery of the intervention. This conclusion is tempered by the considerable heterogeneity of included studies and the high risk of bias in most. Future studies need to describe in detail the mediators and moderators of the effectiveness and implementation of these interventions, to both further improve their effectiveness as well as increase their reach, uptake, and feasibility.

In healthcare, the introduction of quality standards and indicators to assess performance triggered the development of multidimensional Performance Management Systems (PMSs). The concept of performance in healthcare has recently evolved and broadened its scope. One of the current challenges of PMSs is measuring and integrating the patient perspective into traditional measures. In the regional healthcare system of Tuscany (Italy), a PMS has been implemented and used since 2005. The PMS counts on the systematic involvement of clinicians and managers. Furthermore, the PMS also includes patients' perspective. Moreover, Tuscany has recently implemented the first regional permanent Patient-Reported Outcome and Experience Measures (PROMs and PREMs) Observatory in Italy. This paper presents the results of an action research aimed at analysing the integration of patient-reported outcome and experience indicators into a consolidated PMS. The study describes the process of identifying and discussing of patient-reported indicators with practitioners and categorising findings into three domains: design of patient-reported indicators, integration process into the PMS, and goal of adoption of the patient-related indicators. The paper also describes facilitators, challenges, and lessons learnt with respect to organisational, methodological, cultural, and responsibility-linked factors. The study discusses the ability to agree on how to transform patient data, especially PROMs, into effective performance indicators. The integration of patient-reported indicators into the PMS poses two main challenges: one in terms of sustainability of the performance system itself, and another regarding the attribution of the responsibility for patient outcomes between care settings and providers. This paper provides initial insights on how the integration of patient-reported indicators can make PMSs more inclusive and focussed on the patient-centred perspective.

Background Equity and quality in healthcare are key goals embraced by universal healthcare systems; however, inequalities in access and unwarranted variations in quality of care are well documented in the Italian healthcare system. To reduce unwarranted variation and improve equal utilization of services at hospital level, national quality standards have been applied for selected clinical procedures including oncological surgery for which there is evidence of a positive relationship between volumes and clinical outcomes. However, high dispersion of surgical interventions across hospitals still exists highlighting the need to understand the determinants behind women’s choice for hospital for breast surgery. Methods We apply mixed logit regression to investigate the determinants, both at patient and provider level, associated with women’s choice of hospital for breast surgery. Patient level non-emergency hospital data are used to model breast cancer surgical choices in Tuscany region, Italy. We considered hospitalizations occurring during 2016. We focused on the effects of travel time and hospital performance for breast cancer treatments (elective surgery) in different patient groups. Hospital quality indicators include structural variables (volumes), measurement of process (timeliness) and quality of surgical procedures as recommended by clinical guidelines (proportion of breast-conservative surgery and execution of the sentinel lymph node biopsy). Results Results reveal that women prefer hospitals nearby, delivering high volumes of interventions with an appropriate surgical approach. Differences in women choice depend on education and age. Highly educated patients travelled further to seek surgical intervention for breast cancer and were likely to select high performing hospitals. Moreover, older women preferred quicker response compared to younger women when awaiting surgical interventions. Conclusions Differences in patient choice highlight equity concerns in access to elective breast cancer surgery. These results could be used to optimize the allocation of resources toward breast cancer units that meet quality and efficacy standards to increase the efficiency and responsiveness of breast cancer care.

Italy is the sixth largest country in Europe and has the second highest average life expectancy, reaching 79.4 years for men and 84.5 years for women in 2011. There are marked regional differences for both men and women in most health indicators, reflecting the economic and social imbalance between the north and south of the country. The main diseases affecting the population are circulatory diseases, malignant tumours and respiratory diseases. Italy's health care system is a regionally based national health service that provides universal coverage largely free of charge at the point of delivery. The main source of financing is national and regional taxes, supplemented by copayments for pharmaceuticals and outpatient care. In 2012, total health expenditure accounted for 9.2 percent of GDP (slightly below the EU average of 9.6 percent). Public sources made up 78.2 percent of total health care spending. While the central government provides a stewardship role, setting the fundamental principles and goals of the health system and determining the core benefit package of health services available to all citizens, the regions are responsible for organizing and delivering primary, secondary and tertiary health care services as well as preventive and health promotion services. Faced with the current economic constraints of having to contain or even reduce health expenditure, the largest challenge facing the health system is to achieve budgetary goals without reducing the provision of health services to patients. This is related to the other key challenge of ensuring equity across regions, where gaps in service provision and health system performance persist. Other issues include ensuring the quality of professionals managing facilities, promoting group practice and other integrated care organizational models in primary care, and ensuring that the concentration of organizational control by regions of health-care providers does not stifle innovation.