Search

Background The success of antiretroviral therapies has made human immunodeficiency virus (HIV) a chronic disease, changing the care scenario dramatically. This study aimed to measure adherence to diabetes mellitus standards of care provided for people living with HIV (PLWH). Diabetes represents a paradigmatic case for tackling chronic care management in this target group. Methods This retrospective observational study was performed on administrative health data retrieved from 2014 to 2016, with a validated algorithm to identify patients with HIV using: (i) hospital discharge records (ICD9-CM codes); (ii) drug dispensing records (with ATC codes); and (iii) disease-specific exemptions from co-payments for healthcare services. HIV-related treatments, comorbidities and health service utilization were measured, as was adherence to clinical guidelines-recommended standards of care for diabetes. Results A population of 738 cases were identified in two Local Health Authorities in Italy, representing a prevalence of 0.14% of the general population, in line with the expected prevalence. Thirty-one cases of HIV patients diagnosed with diabetes were identified, a prevalence ratio of 4.2% compared to the 8% in the overall population. Adherence to diabetes standards of care tested within the same population was low, with the exception of those tests commonly administered for standard HIV follow-up care. Conclusions The use of administrative data, combined with a Population Health Management approach represents a powerful tool for evaluating system capacity to manage HIV comorbidities. Study findings prove that it is time to design new care models for PLWH, affected by one or more chronic conditions, both to prevent their onset and to manage their comorbidities.

Introduction Appropriateness is an essential element of quality of care. Several methods and tools have been developed to measure the appropriateness of care, however, none of these could be used to systematically support providers in keeping the appropriateness under control. Our study aimed to develop a framework to evaluate the appropriateness of care that took into account four dimensions of appropriateness: clinical dimension, equity, service delivery model, outcome. Methods We employed mixed-method approaches. These included a retrospective analysis of administrative data collected from Kinetika Sardinia (Italy) and a qualitative analysis of stakeholders’ experiences and perspectives aimed at supporting data collection, identification of improvement actions and definition of performance indicators. We used arthrodesis as a paradigmatic example of potentially inappropriate elective surgery. Results We collected data from 2,584 patients that underwent arthrodesis between January 1, 2010 and April 30, 2015. Based on the analysis and the exchanges with professionals, we identified 11 improvement actions. Monitoring and evaluation actions were finally conducted for 171 patients that underwent spinal fusion during the first semester of 2016 in order to assess if the improvement actions identified were put into practice and acquired desirable outcomes. Conclusions Our work provides a definition of appropriateness that goes beyond the clinical perspective and includes other perspectives (equity, service delivery and outcome); develops a framework and an approach that can be a valid help to systematically assess the appropriateness of elective surgery, adopt improvement actions, and monitor their impact; discusses what are the competencies necessary for measuring the appropriateness.

I cambiamenti demografici ed epidemiologici in atto pongono seri interrogativi sulla tenuta dei principi posti a fondamento del Servizio Sanitario Nazionale (SSN) italiano e il prossimo decennio rappresenta un momentum critico per la tenuta del suo formato istituzionale. Le politiche di rimborsabilita possono rappresentare un rilevante strumento di policy per orientare i comportamenti di erogatori e pazienti. Oggi questo aspetto non sembra essere adeguatamente presidiato e il sistema di remunerazione adottato appare non piu coerente al contesto, miope e per lo piu orientato al breve periodo. Il contributo discute le prospettive di sviluppo delle politiche di rimborsabilita per il SSN in un’ottica di Value-Based Health Care (VBHC) ed enfatizza l’esistenza di gap da colmare e di punti di attenzione da non sottovalutare in fase applicativa. Propone altresi uno sviluppo teorico al modello fondante la logica VBHC. Allo stesso tempo, mostra come il sistema abbia gia in dote informazioni e, in parte, know-how adeguati per una graduale diffusione e implementazione di tecniche di misurazione e modelli di finanziamento che possano stimolare logiche di rimborsabilita centrate sul valore.

Il contributo rappresenta il documento di posizionamento sulle politiche e sui modelli di gestione delle patologie croniche, risultato della Consensus Conference che ha visto la partecipazione dei delegati di 14 istituzioni portatrici di interesse diretto sul tema, svolta nei mesi di ottobre e novembre 2018. Dopo un’analisi delle politiche sulla cronicita di 10 regioni italiane, il paper focalizza l’attenzione sui modelli di gestione rivolti a una delle popolazioni croniche intorno alle quali gli interventi regionali si sono concentrati: lo scompenso cardiaco. Lo scopo del presente paper e quello di: 1) accertare lo stato dell’arte delle politiche italiane sulla gestione delle patologie croniche tramite la mappatura di piani, programmi e progetti regionali; 2) identificare i trend principali che caratterizzano le politiche di gestione sulle patologie croniche e sullo scompenso cardiaco, tramite un’analisi comparata delle fonti legislative mappate; 3) individuare le caratteristiche dei progetti regionali relativi alla gestione delle cronicita e, ove presenti, dello scompenso cardiaco, grazie all’analisi dei progetti regionali maggiormente rappresentativi delle scelte regionali. Emerge come le politiche di gestione della cronicita si stiano muovendo lungo delle traiettorie che includono strategie di governo della domanda, gestione delle polipatologie e organizzazione della fruizione dei servizi. Il paper si conclude approfondendo 8 statement che rappresentano il punto di vista dell’expert panel group che ha preso parte alla Consensus Conference sui temi oggetto del lavoro.

We assessed the outcome of dysphagia rehabilitation in all the 139 patients with post-stroke dysphagia admitted to our Neurorehabilitation Unit during 2 years (2017 and 2018), divided into two groups: old (aged 65-84 years) and oldest-old (aged 85 or above). We studied which factors predicted dysphagia improvement in the two groups. The potential association of improvement with type of discharge was also evaluated. On admission, 'old' patients had more frequently aphasia (P = 0.02) and less frequently dysarthria (P = 0.03); 'oldest old' had more severe pressure ulcers (P = 0.008), higher levels of c reacting protein (P = 0.01) and more heart problems (P = 0.004). None of these factors was associated with the outcome of dysphagia. We found no difference between the two groups in the severity of dysphagia, as measured with Dysphagia Outcome and Severity Scale on admission and discharge, but due to minor differences, the degree of improvement was higher in the 'old' group (P = 0.02). The number of patients discharged with improved swallowing was also comparable. Cognitive impairment had a negative predicting role in the 'old' group (odds ratio 0.270, 95% confidence interval 0.101-0.725, P = 0.007). Norton Scale score predicted dysphagia improvement in the 'oldest old' group (odds ratio 1.611, 95% confidence interval 1.102-2.355, P = 0.007). Dysphagia improvement was associated with discharge home in general (P = 0.011) and in the 'old' group (P = 0.04). Our data, though preliminary, could give a contribution to implement patient-specific rehabilitation strategies; these could increase swallowing improvement in post-stroke dysphagia.

Ensuring adequate quality of care to patients with severe mental disorders remains a challenge. The implementation of clinical indicators aimed at assessing the quality of health care pathways delivered is crucial for the improvement of mental health services (MHS). This study aims to evaluate the quality of care delivered to patients who are taken-into-care with depressive disorders by MHS. Thirty-four clinical indicators concerning accessibility, appropriateness, continuity, and safety were estimated using health care utilization databases from four Italian regions (Lombardy, Emilia-Romagna, Lazio, Sicily). A total of 78,924 prevalent patients treated for depressive disorders in 2015 were identified, of whom 15,234 were newly engaged by MHS. During the year of follow-up, access to psychotherapeutic interventions was low, while the intensity was adequate; 5.1% of prevalent patients received at least one hospitalization in a psychiatric ward (GHPW), and 3.3% in the cohort of newly engaged in services. Five-out-of-10 patients had contact with community services within 14 days after GHPW discharge, but less than half of patients were persistent to antidepressant drug therapy. Furthermore, prevalent patients showed an excess of mortality compared to the general population (SMR = 1.35; IC 95%: 1.26–1.44). In conclusion, the quality of health care is not delivered in accordance with evidence-based mental health standards. Evaluation of health interventions are fundamental strategies for improving the quality and equity of health care.

This policy paper aims to compare what policies are developed in Italy for the management of chronic patients in order to improve population health, quality of care and patient experience and reduce per-capita cost. The paper also aims to identify the key trends and evolutionary trajectories across the Country. Methodology: The analysis focuses on 10 Italian Regions and the time span of observation is 7 years (from 2014 to 2020). Data collection and analysis adopts mixed methods in order to have a more in-depth picture of the contextual factors, mechanisms and outcomes. It includes a desk research of the literature and documentary analysis; semi-structured interviews; a theory driven evaluation of 12 programmes identified at the regional level; and a Consensus Conference to discuss and validate the results with an Expert Panel Group. Conclusions: The paper firstly describes the main policies developed in Italy in the last seven years; secondly, it discusses six main trends and clusters them into three strategies: demand management strategies; strategies to improve the management of comorbid and frail patients; and strategies to improve the coordination between levels of care and the patient journey; thirdly, it discusses eight trends and evolutionary trajectories which are now emerging.

Aims To evaluate the quality of mental health care delivered to patients with schizophrenia and related disorders taken-in-care by mental health services in four Italian regions (Lombardy, Emilia-Romagna, Lazio, Sicily). Methods Thirty-one clinical indicators concerning accessibility, appropriateness, continuity and safety were defined and estimated using healthcare utilisation (HCU) databases, containing data on mental health treatments, hospital admissions, outpatient interventions, lab tests and drug prescriptions. Results A total of 70 586 prevalent patients with schizophrenia and related disorders treated in 2015 were identified, of whom 1752 were newly taken-in-care by the facilities of regional mental health services. For most patients community care was accessible and moderately intensive. However, care pathways were not implemented based on a structured assessment and only half of the patients received psychosocial treatments. One patient out of ten had access to psychological interventions and psychoeducation. Activities specifically addressed to families involved a third of prevalent patients and less than half of new patients. One patient out of six was admitted to a community residential facility, and one out of ten to a General Hospital Psychiatric Ward (GHPW); higher values were identified in new cases. In general hospitals, few patients had a length of stay (LoS) of more than 30 days, while one-fifth of the admissions were followed by readmission within 30 days of discharge. For two-thirds of patients, continuity of community care was met, and six times out of ten a discharge from a GHPW was followed by an outpatient contact within 2 weeks. For cases newly taken-in-care, the continuity of community care was uncommon, while the readiness of outpatient contacts after discharge was slightly more frequent. Most of the patients received antipsychotic medication, but their adherence to long-term treatment was low. Antipsychotic polytherapy was frequent and the control of metabolic side effects was poor. The variability between regions was high and consistent in all the quality domains. Conclusions The Italian mental health system could be improved by increasing the accessibility to psychosocial interventions, improving the quality of care for newly taken-in-care patients, focusing on somatic health and mortality, and reducing regional variability. Clinical indicators demonstrate the strengths and weaknesses of the mental health system in these regions, and, as HCU databases, they could be useful tools in the routine assessment of mental healthcare quality at regional and national levels.

Efficiency in healthcare is crucial since available resources are scarce, and the cost of inefficient allocation is measured in prior outcomes. This is particularly relevant for cancer. The aim of this paper is to gain a comprehensive overview of the areas and dimensions to improve efficiency, and establish the indicators, different methods, perspectives, and areas of evaluation, to provide recommendations for how to improve efficiency and measure gains in cancer care. Methods: We conducted a two-phase design. First, a comprehensive scoping literature review was conducted, searching four databases. Studies published between 2000 and 2021 were included if they described experiences and cases of efficiency in cancer care or methods to evaluate efficiency. The results of the literature review were then discussed during two rounds of online consultation with a panel of 15 external experts invited to provide insight and comments to deliberate policy recommendations. Results: 46 papers met the inclusion criteria. Based on the papers retrieved we identified six areas for achieving efficiency gains throughout the entire care pathway and, for each area of efficiency, we categorized the methods and outcomes used to measure efficiency gain. Conclusion: This is the first attempt to systemize a scattered body of literature on how to improve efficiency in cancer care and identify key areas of improvement. Policy summary: There are many opportunities to improve efficiency in cancer care. We defined seven policy recommendations on how to improve efficiency in cancer care throughout the care pathway and how to improve the measurement of efficiency gains.

GERONTE is funded by the European Union’s Horizon 2020 research and innovation programme under grant agreement No. 945218. A poster presentation that identifies GERONTE'sco-design method. GERONTE's novel co-design method combines existing empirical research method, Participatory Rapid Appraisal and Focus Groups, in a structured way thatenables meaningful engagementwithend-users across the design and implementation process. Serial FG provide in-depth understanding of end-users’ needs across both stakeholders and FG iterations. PRA enables rapid analysis, sense checking, and feedback of findings. The combination of these methods, in a structured and sequenced way, provides a practical way to design, refine, and implement the care pathway and technology in the healthcare setting. The method continues to undergo testing by GERONTE Partners, but existing results indicate it is a practical, robust, time-efficient way to co-design technology-supported and complex interventions. The key steps in GERONTE's co-design method are overview of the three (3) design cycles aim and their outcomes First design cycle AIM: Identify participants needs and wants (forthe intervention) and include these in the early design stage Data collection:Focus Group or individual interview with end-userusing semi-structed format. Focus groups can be mixed-participant or single-type participant depending on the aim (such as to identify need or to reach a consensus on the priorities) If possible, use practical supports such as audio-recording and auto-transcription to expediate analysis. Compliance with ethical approval, consent, anonymisation, data minimisation, and confidentiality are critical area to address. Data analysis: Rapid analysis of the FG transcript. Create a short report outlining the findings (what were end-users' needs and wants). Participant feedback:to ensure robustness of data: Send the report to the participants (end users) and seek their feedback. Amend the report based on feedback. Output: Send the report to the design team. Design team to develop a design prototype based on end-users needs and wants. Second design cycle AIM: Gain end-users' feedback on the design prototype Data collection:Focus Group or individual interview with end-userusing semi-structed formatplus simulation or scenario-basedtesting of the prototype's functionality and user-experience Focus groups can be mixed-participant or single-type participant depending on the aim If possible, use practical supports such as audio-recording and auto-transcription to expediate analysis. Data analysis: Rapid analysis of the FG transcript. Create a short report outlining end-users views on the design functionality and user-experience Participant feedback (sense-checking):Send the report to the participants (end users) and seek their feedback. Amend the report based on feedback. Output: Send the report to the design team. Design team to refine the design based on feedback. Third design cycle AIM: Gain end-users' feedback on refineddesign Data collection:Focus Group or individual interview to checkfunctionality and user-experience Focus groups can be mixed-participant or single-type. If possible, use practical supports such as audio-recording. Data analysis: Rapid analysis of the FG transcript. Create a short report outlining end-users views. Participant feedbackto ensure robustness of data: Send the report to the participants (end users) and seek their feedback. Amend the report based on feedback. Output: Send the report to the design team. Design team to refine if needed. Complete additional cycles to further refine if needed or progress to next stage (such as implementation planning). &nbsp

BACKGROUND Dysphagia prevalence increases with age and a significant contribution is given by stroke survivors; its treatment is mainly based on rehabilitation, but outcome cannot be easily predicted. OBJECTIVE The aim of this study is to detect possible predictors of the outcome of dysphagia in patients beginning rehabilitation after a major Central Nervous System injury. METHODS Dysphagia severity was measured in 95 consecutive patients (71 with ischemic or hemorrhagic stroke) upon admission to our neurorehabilitation unit and at discharge, during the year 2017. The initial evaluation included also demographic data, functional and geriatric multidimensional assessment, laboratory test results and comorbidities. Their possible predictive value on the degree of recovery of the swallowing process at discharge has been analyzed. RESULTS Poor functional conditions and the presence of cognitive impairment on admission appear to be associated with a worse outcome of dysphagia at discharge. A significant correlation exists between scores at functional scales at the beginning of rehabilitation and dysphagia score at discharge. Patients with cognitive impairment at the beginning (n = 60) showed a significantly lower degree of recovery of dysphagia at discharge. CONCLUSION Other factors, beside the degree of dysphagia itself, are important to predict its outcome. Their knowledge not only allows an initial prognostic assessment; it can also be useful to decide which aspects should receive greater attention when treating patients with dysphagia.

Purpose To measure indicators of timeliness and continuity of treatments on patients with schizophrenic disorder in ‘real-life’ practice, and to validate them through their relationship with relapse occurrences. Methods The target population was from four Italian regions overall covering 22 million beneficiaries of the NHS (37% of the entire Italian population). The cohort included 12,054 patients newly taken into care for schizophrenic disorder between January 2015 and June 2016. The self-controlled case series (SCCS) design was used to estimate the incidence rate ratio of relapse occurrences according to mental healthcare coverage. Results Poor timeliness (82% and 33% of cohort members had not yet started treatment with psychosocial interventions and antipsychotic drug therapy within the first year after they were taken into care) and continuity (27% and 23% of patients were persistent with psychosocial interventions, and antipsychotic drug therapy within the first 2 years after starting the specific treatment) were observed. According to SCCS design, 4794 relapses occurred during 9430 PY (with incidence rate of 50.8 every 100 PY). Compared with periods not covered by mental healthcare, those covered by psychosocial intervention alone, antipsychotic drugs alone and by psychosocial intervention and antipsychotic drugs together were, respectively, associated with relapse rate reductions of 28% (95% CI 4–46%), 24% (17–30%) and 44% (32–53%). Conclusion Healthcare administrative data may contribute to monitor and to assess the effectiveness of a mental health system. Persistent use of both psychosocial intervention and antipsychotic drugs reduces risk of severe relapse.

PurposeTransitional care (TC) models emerged to ensure healthcare coordination and continuity, as at-risk patients transfer between different settings or different levels of care within the same setting. TC models have been developed in many countries as well as within different healthcare service delivery models and organizations. This paper aims to focus on a TC model developed in Italy called Operating Centre for Transition (OCT), in order to (1) explore its distinctive features by establishing a framework of analysis, (2) apply the framework to study two OCTs and (3) provide recommendations on how to use the framework to evaluate and develop new OCTs in the future.Design/methodology/approachThe authors adopted a grounded theory method to develop and validate the framework of analysis. The authors employed several qualitative methods following four iterative and recursive steps: (1) desk analysis of relevant documents, (2) in-depth interviews to key informants, (3) three meetings of an expert working group and (4) application of the framework to two case studies.FindingsThe framework of analysis identifies three core dimensions that are always present in any OCT: the service model, the functions and the organizational features. Moreover, for every dimension several variables that capture and understand OCTs’ nature, role and development level are identified.Originality/valueThe results of the study highlight the key elements of the OCT model in Italy and show that the proposed framework can be useful both to analyse existing OCTs and to support health managers and policy makers to create new OCTs or develop those already active.

A CADEL (Cable-Driven Elbow assisting device) is presented with experimental results of a lab campaign for a performance evaluation. The device is characterized by a wearable cable-driven parallel architecture with motion sensors for elbow motion assistance. An experimental layout is designed for testing with healthy human users in operation modes with and without load. Results of lab tests with a first prototype are discussed to characterize the feasibility and performance of the proposed design and its operation giving outcomes also with indications of required future improvements.

Il contributo e il position paper sulla presa in carico delle malattie rare e ultrarare, frutto della consensus conference a cui ha preso parte un expert panel group, composto dai principali portatori d’interesse istituzionali di rilevanza nazionale. I risultati sono proposti su tre livelli: il metodo della consesus conference e lo scenario nazionale sulle malattie rare; la presentazione di dieci priorita per migliorare la gestione delle malattie rare in una logica multilivello (europea, nazionale, regionale e aziendale); la proposizione di soluzioni per la continuita assistenziale in linea con le scelte sulla gestione delle cronicita.

BACKGROUND We evaluated the role of [18F]FDG PET/CT in tumor response assessment and prognosis of primary extranodal lymphoma (PEL) patients. METHODS We examined retrospectively, 56 PEL patients: 31 with aggressive diffuse large B cell lymphoma (DLBCL) and 25 with indolent lymphoma (20 mucosa-associated lymphoid tissue lymphoma and five follicular lymphoma). All patients had undergone [18F]FDG PET/CT at diagnosis (PET-I) and 50 of them also after therapy (PET-II). Moreover, 52 patients were subjected to a mean follow-up period of 76 months. RESULTS PET-I was positive in 50 (89%) patients (mean SUVmax 10.3±6.7). In the assessment of tumor response, according to Lugano classification, 45 patients showed complete metabolic response (CMR), four patients had partial metabolic response (PMR) and one had progressive metabolic disease (PMD). Based on 66% ΔSUVmax cut-off, among CMR patients, 41 showed a ΔSUVmax>66% whereas among non-responders, four patients showed a ΔSUVmax

What role did primary care and general practice play in the different phases of Covid-19 epidemic? What can we learn from the emergency to innovate the health system and the role of primary care in our country? The article addresses these questions by presenting the happenings that directly involved primary care and general practitioners (especially on topics concerning USCA, personal safety and protection, and new care models) and by making some considerations on the immediate future The role of general practice is discussed from a double perspective, where the epidemic situation coexists with the ordinary care management, especially of chronic patients The management of the pandemic forces us to reflect on i) the coordination of territorial actors, ii) the management of territorial services network operations, iii) the consequences of challenging the traditional care model, and iv) the hypothesis of a new mix of person-centred services and community centred-services Copyright © FrancoAngeli

Cancer care involves a growing number of specialists and health professionals as intervention areas expand to encompass psychosocial support, genetics and frailty aspects (among other areas) and consensus decisions are needed at all stages of care. As the care pathway becomes more complex, the potential for miscommunication, poor coordination between providers, and fragmentation of services increases. In this context, multidisciplinary teams (MDTs) has been identified as key enablers in the provision of high-quality treatment and care for cancer patients, as a way to improve optimal decision-making in the diagnosis, treatment and support of cancer patients and as a practical necessity for optimal coordination among health professionals and clear communication with patients. The use of MDTs in cancer care is endorsed internationally. Several European cancer plans stress the importance of multidisciplinary care, setting specific guidance for its implementation, however, this prioritization coexists with significant differences in performance, implementation and organisation of cancer care and access across countries as well as in policy measures taken to promote this approach. These include, among the others, MDT discussion and evaluation held with or without the patient, multidisciplinary clinics staffed by a mix of different health professionals or MDTs that hold regular meetings to discuss patient care plans prospectively. Based on this heterogeneity, we analysed the MDTs model and approached for head and neck cancer patients within three hospital hubs (Trieste, Udine and Pordenone) in Friuli Venezia Giulia Region in the North-Est of Italy. The analysis aimed to address three research questions: 1) what are the models and configurations of MDTs?; 2) which MDT models and configurations lead to optimal patient outcomes?; 3) What are the requirements for an effective MDT, which types and structural configurations of MDT function best and in what circumstances? For the assessment of complex behaviours and activities in MDTs we exploited a mixed method analysis based on observation of MDT meetings and interviews and focus group with professionals involved in the MDT. We also distributed a survey to MDT coordinator to analyse the professional and coordination model, the clinical decision making and clinical governance. For the survey we used an adapted version of the Multidisciplinary treatment planning questionnaire (MTP) of the National Cancer Institute Division of Cancer Control & Population Sciences. The analysis underlined three MDT models: one based on a professional evaluation without patient named the complexity model; one in which patients are seen sequentially by physicians from each discipline, and a third model in which patients are seen concurrently by physicians from each discipline. Data from interviews and focus group demonstrated several elements in common and several wide variations among the three configurations. Based on the findings we defined the key elements for operating an effective MDT organized within four domains: the team, infrastructure for meetings, meetings organizations and logistics, clinical decision making.

The paper presents a new rehabilitation device for elbow motion as based on a cable-driven parallel manipulator. The kinematic design is presented as characterized with a numerical evaluation of motion performance and an experimental validation. A CAD design is simulated as the basis for a prototype construction. Tests with a built prototype are discussed to show its feasibility and operation characteristics.

The paper provides an in-depht explorative analysis of the challenges and requirements to make Integrated Practice Units IPU Porter, 2013 work, relying on evidence from a research on Breast Cancer Integrated Care Pathways ICPs. The latter involved 4 provinces in Italy and the unit of analysis has been the breast cancer ICP, where “integrated” means yet the services’ integration, from preventative screening to end of life care, yet integration between the province Local Health Authority LHA and the public hospital where autonomous from the LHA, by setting up inter-organisational multiprofessional groups for designing a common ICP. Provinces have a middle size with on average 400k to 500k inhabitants. In all provinces, Breat Units BU according to EUSOMA are in place and, in two provinces, two BUs coexist. Indeed, in some cases there are private accredited hospitals with recognised BU. It is largely recognised that BU today represents the paradigmatic example of IPU. The study, based on quantative and qualitative analyses of ICPs, according to the PHM, provides key lessons over the efficacious roles of IPUs to deliver ICPs. The predominant understanding tackles out that the IPU model can not work efficaciously outside Accountable Care Organisations, featured by an integrated commissioning function over all services required by the ICP across different providers either public or private and by the capacity to steer and nudge patients’ choices. This understanding holds a crucial role for the Italian NHS, wherein LHAs are gaining increasing value as Health Population organisations, enlarging the population served and value chain of services provided. In this line, the study provides four lessons. Firstly, IPU as BUs actually does not include all services required as for screening or radiology services: the professional responsibilities and services are fragmented and the BU is not always able to manage effects as drop-out or patients shopping around. The solution of inter-organisational tumor boards are not largely spread-out. Secondly, this fragmentation largely belongs to the context setting, yet from the geography or the urbanisation level of LHA, which can influence the IPU’s efficacy; yet form the local path-dependency in setting-up agreements of integration/collaboration among providers and/or the LHA’s commissioning capacity and power. Third, whereas patient choice is a value and would be recognised, in most cases what can be observed is that most of the women shop around for accelerating some diagnostics more than seeking for centres of excellence, and in any case the latter usually are the most literate persons who maintain a contact with local services. Finally, the IPU model has enhanced the competition with the private providers, but given the mission of the IPU, new competitive patterns are emerging: namely a competition for the market but within targeted-services, and not the overall ICP. Private IPU would not be able to provide full IPC in a quasi –market as the Italian NHS. Indeed, the requirement for public providers to set up IPU/BU hinders any collaborative-competitive pattern unless it will not be promoted directly by the LHA, as commissioner, according to the ACO model.

Background: Rare diseases are a group of more than 6000 disorders that on the whole may affect 30 million European Union citizens. Most rare diseases are of genetic origin, are often chronic and life-threatening. Patients living with rare diseases typically receive care from many providers and move frequently within health care settings, so high-quality transitional care is especially important for them, as well as for their family caregivers. Poor communications, incomplete transfer of information, inadequate education of health professionals, limited access to expertise services, and the absence of a single point person to ensure continuity of care all contribute to gaps in care during transitions. The research project focuses on four rare Lysosomal storage disease - LSDs (Pompe disease, Anderson-Fabry disease, Gaucher disease and Mucopolysaccharidosis type 1) featured by the availability of treatments that allow for a good quality of life for patients and aims to gather information on the real patient journey and on the health and social services used in order to analyse and identify the key conditions for improving the care management of rare and ultra-rare diseases (RD). Methods: We conducted a national survey, distributed to patients and caregivers from the 1st of June 2016 to the 7th of August 2016. Data were gathered through questionnaires disseminated online (through the patient associations’ websites, Facebook pages and other online networks) or administered directly to patients through the patients’ associations, to maintain the privacy and anonymity. The questionnaire consisted of 70 questions related to history and pattern of referrals to specialist, time to diagnosis, core medical tests, disciplines and specialists, time and type of treatment. The questionnaire was developed based on 16 in-depth interviews to patients sampled to cover the 4 LSDs, different ages and residence at the national level and further tested through the support of patients’ associations. Data were analysed by descriptive and analytical statistics. Results: Of the survey participants, 177 patients provided evaluable data. The sample covered the national territory, was mainly composed of adult patients (average 40 age), who were diagnosed with rare LSDs 13 years ago. According to the survey patients living with rare LSD diseases visited an average of 2.4 centres before receiving an accurate diagnosis and the mean length of time from symptom onset to accurate diagnosis was around 7.3 years, however, there was a significant relationship between mean length of time for diagnosis and age (P >0.001), the mean length of time was reduced to 1.5 years for young patients (under 20 age), while was around 12 years for the older ones (over 65 age), indicating therefore the clear improvement in the diagnostic phase and in the access to reference centres. The analysis revealed the variability in tackling rarity and complexity, the wide number and specialization of professionals involved and the difficulty to provide integrated care pathways (ICPs) due to the lack of scalability and standardisation of care processes. Conclusion: The combination of rarity, complexity and lack of effective treatment creates huge obstacles to the provision of holistic care and in many cases significant medical, psychological and social needs remain unmet. Rare and ultra-rare disease challenge the most traditional care management models, indeed, people with a RD often need follow up care and support from different categories of health professionals, often from several different medical specialities, as well as by social workers and other social and local service providers which requires a level of coordination not easy to organise in most health care systems.

The shift from volume-based systems to value-based care has driven public and private payers to redesign reimbursement models that stress accountability for care quality and healthcare costs. As the dominant fee-for-service model for reimbursement encourages fragmented care, with little incentive for resource stewardship, coordination or communication across multiple providers, alternative payment models like episode-based, bundled payments have come to the forefront of the international discussion on combating rising healthcare costs. Bundled payment is a single payment for all services related to a specific treatment or condition, possibly spanning multiple providers in multiple settings. Although not a new policy initiative, bundled payments have resurfaced in the current era of health care reform with its advocates arguing that it can curtail health care costs while simultaneously improving quality. Despite the copious discussion on health care payment reform in recent years, there has been little focus on mental health and, with few exceptions, the application of bundled reimbursement models has lagged in mental health compared with other specialties. Based on these findings we aim to provide a realist review of bundled payment initiatives across the world aimed at discerning what works for whom, in what circumstances, in what respects and how. We therefore aim to discuss what are the main characteristics of bundled payment initiatives worldwide; what are their potential advantages and disadvantages for mental health; what are the opportunities, threats and levers of improvement across different system configurations; and what implications these initiatives might have in a national health system such as Italy. In order to do this, we employed a realist approach to evaluation. The first step was to make explicit the programme theory or theories, the underlying assumptions about how an intervention is meant to work and what impacts it is expected to have. We then defined the scope of the review concept mining and framework formulation; searched for and scrutinized the evidence; extracted and synthetized the evidence; and developed the narrative, including hypotheses. We found few examples and theories of bundled payment in mental health, although some notable examples and theories have been described and also a number of programs underway in mental health that will hopefully prove out just how sustainable this pay-for-value approach will be for providers. Bundled payments for mental health, have the potential to substantially improve care coordination among hospital and community services, to encourage integration of physical and mental health providers, could compel systems and payers to focus on well-described critical time windows for mental health patients, such as transition of care from inpatient to outpatient settings or vice versa and generate savings for mental health. Our review enabled the decision-makers to reach a deeper understanding of the intervention and how it can be made to work most effectively and provided the key elements to design the first bundled payment for severe mental health patient in Italy.

The coordination of care across the health care continuum represents the most critical organisational knot to meet the actual implementation, management, and outcome evaluation of a patient’s care plan. In fact, poor coordination of services, fragmentation of treatments, lack of discharge planning and ineffective handoff of information between care providers can lead to poor transitions and, in turn, can cause overlaps with treatment plans, duplicative testing, discrepancies in medications, missed physician follow-up, patient dissatisfaction and, consequently, burgeoning of health care costs. Transitional Care TC models are gaining increasing value and a wide spread out, at the international level, to improve the quality and efficiency of health services’ delivery and have been piloted and tested in different Countries as well as within different healthcare service delivery models and organisations. TC models have a long-lasting presence in the literature if we consider discharge management and planning services, however, analysis of the emergence of new TC models, especially exploiting the health service management perspective and the interest to generalise models of care to support health managers and policy makers are very limited. In this line, there is a widespread recognition across experts that more research is needed on services organisations. In this broad scenario, we aim to provide a comparative analysis of TC patterns across Europe by cross-tabulating independent and dependent variables featuring the institutional and organisational context of development. We therefore aim to explore what are the main characteristics of the health service delivery model; what are the opportunities, threats and levers of improvement across different organisational configurations; and to what extent organizational arrangements of TC models may impact their capacity to influence the health service delivery model, the strategic planning and indeed the capacity to meet patients’ needs. We employed mixed methods in order to exploit a multiple case-study analysis. These included a literature review of theoretical frameworks and TC experiences developed at an international level and an in-depth analysis of several TC experiences analysing local documents and interviewing key managers of the services. Whereas the new models of TC retain the original objectives of discharge management and planning services, their role and organisation is changing dramatically within the renewed model of delivery designed by managed care models and the search for integration across the overall care system from community to acute to end of life care. Of interest, in most cases, either due to the complexity of the new TC models, which require not only discharge management but the overall management of patient and of transitions across care settings, or due to the fragmentation of services, TC services have been externalised to new agencies or services outside the delivery system i.e. the service centre. The latter organisational choice allows TC models to serve the organisations as well as the patients and families. On the contrary, where TC models have been established within healthcare organisation, they are located as a strategy service unit belonging to the strategic board of managers, but these patterns serve only the organisation and not the patients.

Introduction : Service delivery has traditionally developed in ways that have tended to fragment care. In the last decades, however, the growing numbers of people with complex needs (i.e. chronic conditions and multiple care needs) have required the development of delivery systems that bring together a range of professionals and skills from both the cure and care sectors to meet those needs. In other words, on the one hand people needs are changing and growing challenging the financial sustainability of health care systems while on the other delivery services are still linked to traditional organizational models and resources – people, time, facilities and knowledge— are scarce. In this contest Integrated care (IC) arrangements have emerged in a variety of ways and have become a priority in the policy agenda at National and Regional level throughout Europe. In response to concerns that the needs of the aging population for well-integrated care are increasing, our research aims to evaluate the impact of IC programs in terms of improvements in the quality of life, patient satisfaction, staff satisfaction and change in work processes. According to the literature evidence stating that the effectiveness of attempts to provide better integrated care is highly dependent on the context in which the intervention takes place and cannot be seen separated from this, the question guiding our research shifts from “what is the effectiveness of the particular integrated model (compared with non-integrated)?” to “what is the effectiveness of integrated model designed for a specific context?.” Theory and methods : We employed a theory-driven approach for the evaluation of IC programs in the Apulia Region (Italy). It requires surfacing the assumptions on which the program is based in considerable detail: what activities are being conducted, what effect each particular activity will have, what the program does next, what the expected response is, what happens next, what are the expected outcomes. Then the evaluation follows each step in the sequence in order to assess whether the expected mini-steps are actually experienced or not. According to this approach the evaluation aims to answer the following questions: what are the aims of IC? Why IC arrangements have emerged? What approaches work well and in what contexts? What is the role of different actors? What are the facilitating factors? What are the key components of good practical examples found? How to align objectives? What resources are required to make integration succeed and how can these be efficiently distributed and used? We adopted a multi-method approach triangulating data from different sources in order to gain an in-depth picture of the contexts, mechanisms and driving factors of IC. These include qualitative data collection, interviews and questionnaires with decision makers, staff, and patient/service users and non-participant observation of meetings. The evaluation presented is part of a broader three year PhD research project on the evaluation of IC. Results : The evaluation involved a number of activities leading to an exercise of judgement and an important part of the logic of the evaluation was to develop a set of hypotheses based on the ‘theory of change’. These evaluations aimed not only to understand the contribution made by a programme or activity to achieving outcomes, but also to interrogate evidence and communicate findings to support both learning and accountability. In the first paragraph we discuss the program theory underlying IC program based on the literature, on national and regional regulations and on interviews with decision-makers, we identify the main people and organisations involved and their roles, and we assess the financial flows. We then present some of the findings of the evaluation derived from staff questionnaires and patient questionnaires related to various domains (i.e. communication, care planning, frequency of certain critical events, job changes, satisfaction etc.). We finally discuss the results in order to derive some lessons from the experiences analysed and to process mapping the patient journey. Conclusion and discussion : The evaluation of IC arrangements is complicate and this is due to the complexity of the intervention itself, the fact that the evaluation may require detailed data collection across the health care system, the necessity (at least in some arrangements) to take into account other sectors than the health sector as well, the inclusion of a substantial percentage of patients with co-morbidity, and the situation that integrated care programmes may cover multiple patient groups.

Mucormycosis is an increasingly recognized invasive fungal infection (IFI) in patients with acute myeloid leukemia (AML) and after allogeneic (allo) stem cell transplantation (HSCT); it is mainly due to the severe and prolonged neutropenia related to high-dose chemotherapy. In such patients, the lung is the most frequently involved site in mucormycosis. Since rapidly progressive dissemination may occur after pulmonary mucormycosis in hematologic malignancies, early diagnosis and prompt initiation of an effective antifungal therapy is mandatory for a successful outcome. We report the case of a young AML patient who developed, early after the onset of neutropenia in the first induction phase of chemotherapy, a rapidly progressive pulmonary IFI, successfully treated with liposomal Amphotericin-B (LAmB) and then with a limited open toracothomy biopsy, clearly establishing diagnosis of mucormycosis and removing lung infiltrate. Secondary prophylaxis with LamB, applied during both consolidation therapy and myeloablative sibling allogeneic HSCT, was effective to prevent IFI recurrence despite the development of grade I acute graft-versus-host disease (GVHD) and limited chronic GVHD requiring immunosuppressive treatment. Our case report further provide evidence that the combined surgical and LAmB therapy is an effective and safe choice for the management of pulmonary mucormycosis in hematological immunocompromised patients.