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BackgroundBreast cancer is the most common malignancy in women, with a complex clinical path that involves several professionals. A multidisciplinary approach is therefore essential and there is a growing emphasis on its application to breast cancer care. However, the effectiveness of breast cancer multidisciplinary care and the processes that contribute to its effectiveness have not yet been firmly determined. This study aims to evaluate the impact of MTBs on breast cancer care outcomes.MethodsA systematic literature review was carried out through Scopus, Web of Science and Pubmed databases. The search was restricted to articles assessing the impact of MTB implementation on breast cancer care, written in English and Italian language, published between 1995 and 2021.The quality of the included articles was assessed using the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies and the Quality Assessment Tool for Before-After (Pre-Post) Studies With No Control Group from National Heart, Lung and Blood Institute Study Quality Assessment Tools. To combine not homogeneous results, when appropriate, meta-analysis was performed.ResultsFourteen studies, published between 2006 and 2021, were included in the review. From the quality assessment, seven studies were found to be of FAIR and seven of GOOD quality. The most analysed outcomes were: diagnosis, therapy and survival. Four out of four studies showed that with the implementation of the MTB there was a change in diagnosis, and seven out of seven studies reported changes in the treatment plan after MTB implementation. In terms of survival, results were not unanimous. A pooled analysis of three studies reporting results on the outcome “mortality” showed, in the fixed-effects model (p=0.43), a statistically significant 14% reduction of mortality relative risk for patients enrolled versus not enrolled in MTBs (pooled HR = 0.86; 95%CI: 0.81- 0.97). ConclusionsThis study shows that the implementation of the MTBs is a valuable approach to deliver appropriate and effective care to patients affected by breast cancer and to improve their outcomes. Further studies are needed to enrich the evidences available to date concerning especially the outcomes less investigated, but important to improve clinical care and care processes.

Background Tumor Boards (TBs) are Multidisciplinary Team (MDT) meetings in which different specialists work together closely sharing clinical decisions in cancer care. The composition is variable, depending on the type of tumor discussed. As an organizational tool, MDTs are thought to optimize patient outcomes and to improve care performance. The aim of the study was to perform an umbrella review summarizing the available evidence on the impact of TBs on healthcare outcomes and processes. Methods Pubmed and Web of Science databases were investigated along with a search through citations. The only study design included was systematic review. Only reviews published after 1997 concerning TBs and performed in hospital settings were considered. Two researchers synthetized the studies and assessed their quality through the AMSTAR2 tool. Results Five systematic reviews published between 2008 and 2017 were retrieved. One review was focused on gastrointestinal cancers and included 16 studies; another one was centered on lung cancer and included 16 studies; the remaining three studies considered a wide range of tumors and included 27, 37 and 51 studies each. The main characteristics about format and members and the definition of TBs were collected. The decisions taken during TBs led to changes in diagnosis (probability to receive a more accurate assessment and staging), treatment (usually more appropriate) and survival (not unanimous improvement shown). Other outcomes less highlighted were quality of life, satisfaction and waiting times. Conclusions The study showed that the multidisciplinary approach is the best way to deliver the complex care needed by cancer patients; however, it is a challenge that requires organizational and cultural changes and must be led by competent health managers who can improve teamwork within their organizations. Further studies are needed to reinforce existing literature concerning health outcomes. Evidence on the impact of TBs on clinical practices is still lacking for many aspects of cancer care. Further studies should aim to evaluate the impact on survival rates, quality of life and patient satisfaction. Regular studies should be carried out and new process indicators should be defined to assess the impact and the performance of TBs more consistently.

This work aims to identify policies implemented for healthy food environments in Italy within The Healthy Food Environment Policy Index (Food-EPI) project.Food-EPI tool, which includes two components, thirteen domains and fifty good practice indicators, was adapted for the Italian context. Evidence for implementation was gathered and summarized for all fifty indicators from data sources such as governmental websites, non-government organizations publications and websites and via direct contact with Government officials.The highest level of evidence was found within five domains: food composition (2/2 indicators), labelling (3/4), promotion (4/5), provision (4/5) and leadership (5/5). The domains with less identified evidence were food prices (1/4), food in retail (0/4), trade and investment (0/2) and platforms and interaction (1/4).The evidence summarization and the upcoming stakeholders' meeting to rate the level of implementation for each indicator in Italy have the potential to improve Government commitment to shape healthier food environments.

Background Government actions play a critical role in shaping healthy food environments, which can improve population's diet and decrease the burden of disease. This study aims to determine and compare the level of policy implementation for healthy food environments in Italy with reference to international benchmarks and make prioritized recommendations based on the identified implementation gaps. Methods The Healthy Food Environment Policy Index (Food-EPI) tool from the International Network for Food and Obesity/NCDs Research, Monitoring and Action Support (INFORMAS) was adapted for the Italian context. This tool includes two components, thirteen domains and fifty good practice indicators, which were verified with experts from National Health Institute (NHI). Evidence for implementation was gathered and summarized for all fifty indicators from data sources such as governmental websites, non-government organizations publications and websites and via direct contact with government officials. After collecting all evidence, experts from the NHI verified the completeness and accuracy of it. The evidence document will be presented to stakeholders, aiming to seek consensus on the priority actions to be implemented by the Italian Government to improve food environments. Results The evidence for policy implementation concerning Italy varied among domains and indicators. We found the highest level of evidence within three domains: Food Composition (2/2 indicators), Food Labelling (3/4 indicators) and Food Promotion (4/5 indicators). The domains with less identified evidence were Food Prices (1/4 indicators), Food Retail (0/4 indicators), Food Trade and Investment (0/2 indicators) and Platforms and Interaction (1/4 indicators). Conclusions The evidence summarization and the upcoming stakeholders' meeting to rate the level of implementation for each indicator in Italy, have the potential to improve government commitment to shape healthier food environments. Key messages Food environment policies, implemented by the government, play a key role in the health of the population, decreasing the burden of disease. Several food environment policies have been implemented and supported by the Italian government but there are still some priority actions to be taken towards healthier food environments.

Breast cancer is the most common malignancy in women, with a complex clinical path that involves several professionals and that requires a multidisciplinary approach. However, the effectiveness of breast cancer multidisciplinary care and the processes that contribute to its effectiveness have not yet been firmly determined. This study aims to evaluate the impact of multidisciplinary tumor boards on breast cancer care outcomes. A systematic literature review was carried out through Scopus, Web of Science and Pubmed databases. The search was restricted to articles assessing the impact of MTB implementation on breast cancer care. Fourteen studies were included in the review. The most analyzed outcomes were diagnosis, therapy and survival. Four out of four studies showed that, with implementation of an MTB, there was a change in diagnosis, and all reported changes in the treatment plan after MTB implementation. A pooled analysis of three studies reporting results on the outcome “mortality” showed a statistically significant 14% reduction in mortality relative risk for patients enrolled versus not enrolled in an MTB. This study shows that MTB implementation is a valuable approach to deliver appropriate and effective care to patients affected by breast cancer and to improve their outcomes.

Italy was the first country in the western world to be affected by the COVID-19 pandemic, arguably among the worst-affected ones, counting 12 million cases and 150 thousand deaths two years since the first case. Facing new challenges, Italy has enacted different strategies and policies to limit the spread of the SARS-CoV-2 virus and treat those affected by COVID-19. This narrative review provided an overview of factors, measures, and actions that shaped Italy’s first two years of the COVID-19 pandemic by investigating epidemiological data and using a mixed-method approach. This narrative review aimed to summarize the most relevant aspects and measures and analyze available data to provide policymakers and healthcare providers with the instruments to learn from this pandemic and improve their preparedness for future pandemic events. The first two years of the pandemic differ in that, during the first year, significant necessary changes to the way health systems were organized were implemented, increasing healthcare spending and adopting social and physical distancing measures that were stricter than the ones adopted in the second year. However, as the pandemic progressed, increased knowledge of the virus and related variants, as well as the introduction of highly effective vaccines, which were not equally available to the whole population, resulted in a stratification of COVID-19 infections and deaths based on factors such as age, vaccination status, and individual susceptibility to the virus.

Background Organizational aspects in Health Technology Assessment (HTA) reports play a significant role in managing policies and strategies to implement new health technologies. The organizational domain, however, is often under-represented in HTA reports. This study explored how organizational assessment is carried out in HTA reports and designed a new perspective through an empirical approach after the comparison with EUnetHTA's Core Model 3.0. Methods Full HTA reports were extracted from the websites of members of International Network of Agencies for HTA and the aspects relating to the organizational assessment were analysed. HTA reports were classified into 4 typologies of technologies (device, diagnosis/screening, intervention and organizational procedures) and organizational aspects described were explored through a framework of 5 domains and 15 subdomains from Core Model. Specific Multiple Correspondence Analyses were carried out to identify technology-related domains for organizational assessment in reports. Results The analysis showed that domains and subdomains of Core Model were not covered homogeneously by the organizational assessments in the HTA reports. Through Multiple Correspondence Analyses, four new technology-related dimensions were identified and named according to the Core Model’s subdomains in the four new clusters. Conclusions This study analyzed the significance of organizational assessments in current literature and the challenges of improving this domain in HTA reports. Through an empirical analysis, we proposed a new methodology to cover the most relevant aspects of organizational appraisal according to new domains to promote support to the assessment of organizational issues in reports and fulfil the needs of future HTA research.

Community-based mental healthcare (CBMH) aims at supplying psychiatric patients with rehabilitative care outside the hospital. The aim of this study was to compare the organization of CBMH in a cross-border region of Germany and the Netherlands.Semi-structured interviews gave insight into characteristics of CBMH approaches applied in the German region of Aachen (IHP) and the Dutch Province of Limburg (FACT). We applied a Delphi technique to select a performance indicator (PI) set for CBMH, which served as a conceptual model to allow comparison.Both approaches are flexible, patient-centred and include the evaluation of quality. Both provide financial and administrative support for the access.CBMH approaches appear to be equally valid from several perspectives even if they revealed, at the same time, important differences related to scope, integration with non-CBMH care resources and geographic coverage. Secondarily, the study provides a contribution to the development of a PI set to compare and evaluate CBMH approaches.Zusammenfassung HINTERGRUND: Gemeindebasierende psychiatrische Versorgung (GPV) zielt darauf ab, Patienten außerhalb des Krankenhauses mit Rehabilitationsmaßnahmen zu versorgen. Ziel dieser Studie war es, die Organisation von GPV-Ansätzen im Grenzgebiet Aachen zur Provinz Limburg zu vergleichen.Interviews gaben Einblicke in die Merkmale der beiden GPV Ansätze. Wir verwendeten Delphi-Verfahren, um ein Leistungsindikatorenset auszuwählen, das als Konzeptmodell diente. Wir verglichen 1) Stärkefallmanagement mit seinem individuellen Hilfeplan in der deutschen Region mit 2) funktioneller konsequenter Gemeinschaftsbehandlung mit seinem intensiven Fallmanagement in der niederländischen Region.Beide Ansätze sind flexibel, patientenorientiert und beinhalten die Bewertung von Qualität. Beide Ansätze bieten finanzielle und administrative Unterstützung für den Versorgungszugang.GPV-Ansätze scheinen aus vielerlei Hinsicht gleichermaßen gültig zu sein, auch wenn sie gleichzeitig wichtige Unterschiede in Bezug auf Umfang, Integration mit Nicht-GPV-Betreuungsressourcen und der geografischen Abdeckung aufzeigen. Sekundär liefert die Studie einen Beitrag zur Entwicklung eines Leistungsindikatorensets, um GPV-Ansätze zu bewerten und zu vergleichen.

Background To keep a high quality of assistance it is important for hospitals to invest in health technologies (HTs) that have the potential of improving health outcomes. Even though guidance exists on how HTs should be introduced, used and dismissed, there is a surprising gap in literature concerning the awareness of hospitals in the actual utilization of HTs. Methods We performed a systematic literature review of qualitative and quantitative studies aimed at investigating hospital contextual factors that influence the actual utilization of HTs. PubMed, Scopus, Web of Science, Econlit and Ovid Medline electronic databases were searched to retrieve articles published in English and Italian from January 2000 to January 2019. The quality of the included articles was assessed using the Critical Appraisal Skills Programme checklist for qualitative studies, Newcastle-Ottawa Scale for the cross-sectional studies and the Mixed Methods Appraisal Tool for mixed method studies. Results We included 33 articles, which were of moderate to high methodological quality. The included articles mostly addressed the contextual factors that impact the implementation of information and communication technologies (ICTs). Overall, for all HTs, the hospital contextual factors were part of four categories: hospital infrastructure, human resource management, financial resources and leadership styles. Conclusion Our systematic review reported that the contextual factors influencing the HTs utilization at hospital level are mainly explored for ICTs. Several factors should be considered when planning the implementation of a new HTs at hospital level. A potential publication bias might be present in our work, since we included articles published only in English and Italian Language, from January 2000 to January 2019. There remains a gap in the literature on the facilitators and barriers influencing the implementation and concrete utilization of medical and surgical HTs, suggesting the need for further studies for a better understanding.

Healthcare organisations are social systems in which human resources are the most important factor. Leadership plays a key role, affecting outcomes for professionals, patients and work environment. The aim of this research was to identify and analyse the knowledge present to date concerning the correlation between leadership styles and nurses’ job satisfaction. A systematic review was carried out on PubMed, CINAHL and Embase using the following inclusion criteria: impact of different leadership styles on nurses’ job satisfaction; secondary care; nursing setting; full-text available; English or Italian language. From 11,813 initial titles, 12 studies were selected. Of these, 88% showed a significant correlation between leadership style and nurses’ job satisfaction. Transformational style had the highest number of positive correlations followed by authentic, resonant and servant styles. Passive-avoidant and laissez-faire styles, instead, showed a negative correlation with job satisfaction in all cases. Only the transactional style showed both positive and negative correlation. In this challenging environment, leaders need to promote technical and professional competencies, but also act to improve staff satisfaction and morale. It is necessary to identify and fill the gaps in leadership knowledge as a future objective to positively affect health professionals’ job satisfaction and therefore healthcare quality indicators.

Background Patients’ increasing needs and expectations require an overall assessment of hospital performance. Several international agencies have defined performance indicators sets but there exists no unanimous classification. The Impact HTA Horizon2020 Project wants to address this aspect, developing a toolkit of key indicators to measure hospital performance. The aim of this review is to identify and classify the dimensions of hospital performance indicators in order to develop a common language and identify a shared evidence-based way to frame and address performance assessment. Methods Following the PRISMA statement, PubMed, Cochrane Library and Web of Science databases were queried to perform an umbrella review. Reviews focusing on hospital settings, published January 2000–June 2019 were considered. The quality of the studies selected was assessed using the AMSTAR2 tool. Results Six reviews ranging 2002–2014 were included. The following dimensions were described in at least half of the studies: 6 studies classified efficiency (55 indicators analyzed); 5 studies classified effectiveness (13 indicators), patient centeredness (10 indicators) and safety (8 indicators); 3 studies responsive governance (2 indicators), staff orientation (10 indicators) and timeliness (4 indicators). Three reviews did not specify the indicators related to the dimensions listed, and one article gave a complete definition of the meaning of each dimension and of the related indicators. Conclusions The research shows emphasis of the importance of patient centeredness, effectiveness, efficiency, and safety dimensions. Especially, greater attention is given to the dimensions of effectiveness and efficiency. Assessing the overall quality of clinical pathways is key in guaranteeing a truly effective and efficient system but, to date, there still exists a lack of awareness and proactivity in terms of measuring performance of nodes within networks. The effort of classifying and systematizing performance measurement techniques across hospitals is essential at the organizational, regional/national and possibly international levels to deliver top quality care to patients.

Multimorbidity requires that many physicians shift the focus of the care they provide towards the management of multiple chronic conditions such as heart diseases, diabetes, chronic obstructive pulmonary disease and mental illness. The aim of this systematic review is to summarize the scientific evidence on the effects of Multidisciplinary Teams (MDT) on chronic patients' management in hospital settings, evaluating outcomes, costs and workload. Medline, Scopus and Ovid were queried for relevant articles using the Population-Intervention-Context-Outcome (PICO) model. Selected articles were assessed for quality and risk of bias using the National Institutes of Health Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Data were analyzed using descriptive statistics, and comparison among comorbid patients with at least one mental illness versus those without was performed using Chi-square test (p Out of 7332 records, 7 studies met the inclusion criteria and 85 indicators were identified: 52% improved significantly, 46% did not show any variation and 2% (nausea and delirium) worsened. In particular, in-hospital mortality was significantly reduced in 65% of the studies describing such indicator. The presence of a mental illness showed a statistically significant increase of length of stay (p MDT meetings represent a fundamental step in a complex path care. They are useful to discuss clinical cases to define their diagnosis and to formulate shared treatment plans in order to deliver personalized treatment options and appropriate follow-up. These findings should stimulate decision makers to invest in the development of MDT and further research should be conducted to evaluate team efficacy. Key messages Successful management of chronic diseases can be enhanced by Multidisciplinary Teams. Caregivers can be involved in this relational process to ensure a better path care.

Background Healthcare organizations are social systems in which human resources are generally the most important factor for the provision of care. In these contexts, leadership plays a key role in providing effective and efficient care and results in positive outcomes for professionals, patients and work environment. The aim of this review was to identify and analyze the knowledge present to date in literature concerning the correlation between leadership styles and nurses' job satisfaction. Methods A systematic review of the literature was carried out on Medline and CINAHL databases between June and October 2019 by using a specific search algorithm. The following inclusion criteria were set: focus on the impact of different leadership styles on nurses' job satisfaction; secondary care; nursing setting; full-text available; English or Italian language. Results 6681 titles, 410 abstracts and 57 full texts were analyzed. The 12 selected studies considered 7 leadership styles: Transformational, Transactional, Passive-Avoidant, Laissez-Faire, Resonant, Authentic and Servant. Four studies (33%) considered only 1 style, 3 studies (25%) 2 styles, 4 studies (33%) 3 styles and only one study (9%) considered 4 styles. Transformational and Transactional styles were the most represented (75% and 67% respectively). Most of the studies conducted (88%) showed a significant correlation, both positive and negative, between the adopted Leadership style and the nurses' job satisfaction. Conclusions In a complex and constantly evolving context, healthcare organizations need to guarantee not only technical and professional competence, but also satisfaction as a motivational lever for health workers. It is therefore necessary to identify and fill the gaps in leadership abilities as a present and future objective in order to positively affect health professionals' job satisfaction and therefore healthcare quality indicators. Key messages Job satisfaction plays a key role in healthcare and nursing as a motivational lever for health workers. Leadership styles directly impact on nurses' job satisfaction which in turn affects healthcare quality and patient outcomes.

Background Clinical risk is the probability that a patient is the victim of an adverse event attributable to medical care, albeit unintentionally; clinical risk management is therefore a key area for the quality of healthcare, especially in care-intensive settings; even more for pediatric patients. The objective of this review is to assess the impact of the application of tools and methodologies for clinical risk management in pediatric care-intensive settings. Methods Pubmed and Web of Science were queried to carry out a systematic review, using the PICO methodology to formulate the research strategy and query (June 2019). Application experiences of clinical risk management that had quantitative and qualitative impacts in pediatric intensive care units were included. Results A total of 1178 papers were reviewed and 22 articles were included, most of them from the US (8). Out of the 22 experiences described, 11 were related to reactive management tools, 7 to proactive tools; 4 experiences reported the use of both reactive and proactive tools; 11 articles made explicit a reduction in adverse events following the intervention in the study (29.8%-78.8%, p Conclusions The application of clinical risk management tools made changes in pediatric intensive care units; the integrated use of different methodologies, both proactive and passive, for the management of clinical risk is highlighted in many studies. Key messages Methodologies for clinical risk management can have significant impacts on organizational processes and outcomes of pediatric intensive care units, improving safety of patient and operators. The simultaneous use of several clinical risk management tools, both proactive and reactive, is increasingly widespread.

A Multidisciplinary Tumor Board (MTB) is a group of professionals from different clinical areas that meets to examine oncological patients to face multiple aspects of the pathology. MTBs represent an effective way for clinical decision making and management of complex diseases like cancer that needs an integrated approach. They have the potential to implement patient's care optimizing both evaluation and treatment. The aim of this study was to evaluate the clinical and organizational impact and benefits of MTBs on breast cancer cases. The databases investigated to carry out the research were Pubmed and Web of Science. Only Italian and English articles focused on breast cancer patients evaluated through MTB approach were included. No time restriction was adopted. Articles about other types of cancer were not included; systematic reviews and non-peer reviewed papers such as editorial and commentaries were excluded from the study. The research found 5163 publications; duplicated records were omitted. 5086 articles were excluded through the analysis of title and abstract; after full text reading 52 studies were excluded. Only 25 publications fulfilled the inclusion and exclusion criteria. Two articles considered the impact of MTB on overall survival; 1 publication studied the effect of diagnostic changes; 7 articles examined the impact of MTBs on cancer treatment; 2 studies analysed the effects on clinical performance. Other publications examined secondary outcomes and indicators. MTB has been described to have a positive impact on breast cancer. It improves overall survival (substantial results for over 65), diagnostic accuracy (up to 65%) and treatment scheme making it more adherent to guidelines (28%-93,1%). Furthermore, MTB makes patient's management more functional and avoids inappropriate interventions. Further studies are needed to deepen on some topics such as the economic aspects and the importance of the participation of general practitioners to MTBs. Key messages MTB could improve patient’s care and clinical management of cancer. It is necessary to study if greater accuracy in patient’s management could have economic impact as it avoids inappropriate procedures.

The WHO declared the novel coronavirus disease a pandemic, with severe consequences for health and global economic activity and Italy is one of the hardest hit countries. This study aims to assess the socio-economic burden of COVID-19 pandemic in Italy through the estimation of Disability-Adjusted Life Years (DALYs) and productivity loss. The observational study was based on data from official governmental sources collected since the inception of epidemic until 28 April 2020. DALYs for a disease combines the years of life lost due to premature mortality in the population and the years lost due to disability of the disease. In addition to DALYs, temporary productivity loss due to absenteeism from work and permanent productivity loss due to premature mortality were estimated using the Human Capital Approach. The total DALYs amount to 2.01 per 1000 persons. The total permanent productivity loss was around EUR 300 million while the temporary productivity loss was around EUR 100 million. This evaluation does not consider other economic aspects related to lockdown, quarantine of contacts, healthcare direct costs etc. The burden of disease methodology is functional metric for steering choices of health policy and allowing the government to be accountable for the utilization of resources.

Background The current economic context calls for rationalizing health resources that can be pursued through disinvestment from low value health technologies to invest in the best performing ones, ensuring high healthcare quality. Oncology is a field where, because of high costs of health technologies and rapid innovation, disinvestment is crucial. Methods On this basis, the research team investigated through a survey, based on a questionnaire, opinions and views of representatives of European countries about disinvestment, in terms of fields of application, potential advocates and barriers, specifically focusing on cancer care. Results A total of 17 questionnaires were filled in (response rate: 32.1%). The survey showed disinvestment is applied in several countries as a tool for containing health care expenditures and identifying obsolete technologies/ineffective interventions. Clinicians' resistance to change and industries' opposition are recognized as the most important barriers to the implementation of disinvestment policies. Potential targets of disinvestment in cancer are seen in diagnostic and therapeutic areas. Conclusion Despite the agreement on fields of waste and of disinvestment policies, operational methods to put disinvestment in place are lacking. Since they should rely on an inclusive assessment of the technology, Health Technology Assessment may represent a good approach.

Background In an era of a growing economic pressure for all health systems, the interest for “disinvestment” in healthcare increased. In this context, evidence based approaches such as Health Technology Assessment (HTA) are needed both to invest and to disinvest in health technologies. In order to investigate the extent of application of HTA in this field, methodological projects/frameworks, case studies, dissemination initiatives on disinvestment released by HTA agencies and organizations located in Europe were searched. Methods In July 2015, the websites of HTA agencies and organizations belonging to the European network for HTA (EUnetHTA) and the International Network of Agencies for HTA (INAHTA) were accessed and searched through the use of the term “disinvestment”. Retrieved deliverables were considered eligible if they reported methodological projects/frameworks, case studies and dissemination initiatives focused on disinvestment in healthcare. Results 62 HTA agencies/organizations were accessed and eight methodological projects/frameworks, one case study and one dissemination initiative were found starting from 2007. With respect to methodological projects/frameworks, two were delivered in Austria, one in Italy, two in Spain and three in U.K. As for the case study and the dissemination initiative, both came from U.K. The majority of deliverables were aimed at making an overview of existing disinvestment approaches and at identifying challenges in their introduction. Conclusions Today, in a healthcare context characterized by resource scarcity and increasing service demand, “disinvestment” from low-value services and reinvestment in high-value ones is a key strategy that may be supported by HTA. The lack of evaluation of technologies in use, in particular at the end of their lifecycle, may be due to the scant availability of frameworks and guidelines for identification and assessment of obsolete technologies that was shown by our work. Although several projects were carried out in different countries, most remain constrained to the field of research. Disinvestment is a relatively new concept in HTA that could pose challenges also from a methodological point of view. To tackle these challenges, it is necessary to construct experiences at international level with the aim to develop new methodological approaches to produce and grow evidence on disinvestment policies and practices. Electronic supplementary material The online version of this article (10.1186/s12913-018-2941-0) contains supplementary material, which is available to authorized users.

Background Public reporting (PR) of healthcare (HC) provider's quality was proposed as a public health instrument for providing transparency and accountability in HC. Our aim was to assess the impact of PR on five main domains: quality improvement; patient choice, service utilization and market share; provider's perspective; patient experience; and unintended consequences. Methods PubMed, Scopus, ISI WOS, and EconLit databases were searched to identify studies investigating relationships between PR and five main domains, published up to April 1, 2016. Results Sixty-two papers published between 1988 and 2015 were included. Nineteen studies investigated quality improvement, 19 studies explored the unintended consequences of PR, 10 explored the effects on market share, 10 on patients' choice, 7 evaluated the provider's perspective, 4 economic outcome, 4 service utilization, 2 purchasers' use of PR and 2 studies explored patient experiences. The effect of PR was diverse throughout the studies-mostly positive on: patient experience (100%), quality improvement (63%), patient choice, service utilization and market share (46%); mixed on provider's perspective and economic outcome (27%) and mainly negative on unintended consequences (68%). Conclusions Our research covering different outcomes and settings reported that PR is associated with changes in HC provider's behavior and can influence market share. Unintended consequences are a concern of PR and should be taken into account when allocating HC resources. The experiences collected in this paper could give a snapshot about the impact of PR on a HC user's perception of the providers' quality of care, helping them to make empowered choices.

Patients’ increasing needs and expectations demand for an overall assessment of hospital performances. Several Agencies described sets of performance indicators and there is not a unanimous classification. The ImpactHTA Horizon2020 Project wants to address this aspect, developing a toolkit of key indicators to measure hospital organizational performance. The aim of this review is to identify the dimensions of quality in which hospital performance indicators are grouped, and to assess if there has been an evolution over time of the above-mentioned dimensions. Following the PRISMA statement, PubMed, Ovid and Web of Science databases were queried to perform an umbrella review. Articles focusing on secondary care settings, published January 2000-May 2018 were considered. The study design included was systematic review. 3680 records were screened and 6 systematic reviews ranging 2002-2014 were included. The following dimensions were described in at least 50% of the studies: 6 studies classified efficiency (53 indicators analyzed); 5 studies classified effectiveness (12 indicators), patient centeredness (10 indicators) and safety (8 indicators); 3 studies responsive governance (2 indicators), staff orientation (8 indicators) and timeliness (4 indicators). 3 reviews did not specify the indicators related to the dimensions listed, 1 gave a complete definition of the meaning of each dimension and related indicators. The research shows steady awareness of the importance of patient centeredness, effectiveness, efficiency, and safety dimensions; apparently, there is still not much attention to sustainability, appropriateness and accessibility in terms of indicators measuring, although those dimensions are described in one of the latest review. Another review described a new dimension, resources and capacity, which focuses on the availability of new technologies, underlining the growing importance of the adoption of digitalization in healthcare. Key messages Main dimensions of performance indicators: efficiency, effectiveness, patient centeredness, safety. More emphasis to sustainability and appropriateness to align with today’s healthcare challenges.

Background Healthcare systems are facing great challenges due to increased share of aging population, growing health needs and economic restraints. To keep a high quality of assistance it is important to invest in health technologies (HTs) that have the potential of improving health outcomes. Even though a lot of guidance does exist on how HTs should be introduced, used and dismissed, there is a surprising gap in literature concerning the awareness of hospitals in the actual utilization of HTs, namely utilization in daily practice after formal adoption. Methods We performed a systematic literature review of qualitative and quantitative studies aimed at investigating hospital contextual factors that influence the actual utilization of HTs at hospital level. PubMed, Scopus, Web of Science, Econlit and Ovid were searched to retrieve studies published in English from 1st January 2010 to 31st May 2018. Results A total of 33 studies were included mostly addressing information and communication technologies (ICTs). Findings suggest that contextual factors that impact on actual utilization of HTs at hospital level are ascribable to four main families: financial factors, leadership styles, human resource management and hospital infrastructure. It emerges also that involving professionals at all levels and planning people’s work and competencies are major determinants of HTs actual utilization. Conclusions The evidence suggests that several contextual factors play a major role in HTs actual utilization at hospital level even though data are mostly referred to ICTs being the other HTs unexplored. Indeed, findings from this study suggest that numerous items should be evaluated when considering to use a new HTs at hospital level. Nevertheless, evidence regarding actual utilization of medical and surgical HTs is still lacking and future research is needed. Key messages Financial factors, leadership styles, human resource management, hospital infrastructure are relevant determinants of actual utilization of new HTs at hospital level. The evidence on contextual factors that influence actual utilization of HTs is mostly referred to ICTs and further research is indeed deserved.

The aim of this study was to review experiences of use of the Lean methodology in the hospital setting and assess the impact of the interventions in terms of time of processes, productivity, effects on staff and patientd satisfaction.PubMed, Scopus and CINAHL databases were searched to identify studies evaluating the lean methodology. Two reviewers screened the citations identified and extracted data according to the PRISMA methodology.In total, 635 citations were identified, of which 27 were included in the present review. Most studies showed a positive outcome related to the implementation of the Lean methodology and tools.

Purpose A clinical pathway for patients with acute ischemic stroke was implemented in 2014 by one Italian teaching hospital multidisciplinary team. The purpose of this paper is to determine whether this clinical pathway had a positive effect on patient management by comparing performance data. Design/methodology/approach Volume, process and outcome indicators were analyzed in a pre-post retrospective observational study. Patients’ (admitted in 2013 and 2015) medical records with International Classification of Diseases, ICD-9 code 433.x (precerebral artery occlusion and stenosis), 434.x (cerebral artery occlusion) and 435.x (transient cerebral ischemia) and registered correctly according to hospital guidelines were included. Findings An increase context-sensitive in-patient numbers with more severe cerebrovascular events and an increase in patient transfers from the Stroke to Neurology Unit within three days (70 percent, p=0.25) were noted. Clinical pathway implementation led to an increase in patient flow from the Emergency Department to dedicated specialized wards such as the Stroke and Neurology Unit (23.7 percent, pp=0.85) and no statistically significant differences in 30-day mortality. Research limitations/implications The pre-post retrospective observational study design was considered suitable to evaluate likely changes in patient flow after clinical pathway implementation, even though this design comes with limitations, describing only associations between exposure and outcome. Originality/value Clinical pathway implementation showed an overall positive effect on patient management and service efficiency owing to the standardized application in time-dependent protocols and multidisciplinary/integrated care implementation, which improved all phases in acute ischemic stroke care.