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Current approach to identify BRCA 1/2 carriers in the general population is ineffective as most of the carriers remain undiagnosed. Radiomics is an emerging tool for large scale quantitative analysis of features from standard diagnostic imaging and has been applied also to identify gene mutational status. The objective of this study was to evaluate the clinical and economic impact of integrating a radiogenomics model with clinical and family history data in identifying BRCA mutation carriers in the general population. This cost‐effective analysis compares three different approaches to women selection for BRCA testing: established clinical criteria/family history (model 1); established clinical criteria/family history and the currently available radiogenomic model (49% sensitivity and 87% specificity) based on ultrasound images (model 2); same approach used in model 2 but simulating an improvement of the performances of the radiogenomic model (80% sensitivity and 95% specificity) (model 3). All models were trained with literature data. Direct costs were calculated according to the rates currently used in Italy. The analysis was performed simulating different scenarios on the generation of 18‐year‐old girls in Italy (274,000 people). The main outcome was to identify the most effective model comparing the number of years of BRCA‐cancer healthy life expectancy (HLYs). An incremental cost‐effectiveness ratio (ICER) was also derived to determine the cost in order to increase BRCA carriers‐healthy life span by 1 year. Compared to model 1, model 2 increases the detection rate of BRCA carriers by 41.8%, reduces the rate of BRCA‐related cancers by 23.7%, generating over a 62‐year observation period a cost increase by 2.51 €/Year/Person. Moreover, model 3 further increases BRCA carriers detection (+ 68.3%) and decrease in BRCA‐related cancers (− 38.4%) is observed compared to model 1. Model 3 increases costs by 0.7 €/Year/Person. After one generation, the estimated ICER in the

Background and Aim: Performance assessment of the Stroke Pathway is a key element in healthcare quality. The aim of this study has been to carry out a retrospective assessment of the Stroke Pathway in a first level Stroke Unit in Italy, analyzing the temporal trend of the Stroke Pathway performance and the impact of the COVID-19 pandemic. Methods: A retrospective observational study was carried out analyzing data from 1/01/2010 to 31/12/2020. The following parameters were considered: volume and characteristics of patients with ischemic stroke undergoing intravenous thrombolysis, baseline modified Rankin Scale (mRS) and National Institutes of Health Stroke Scale (NIHSS) scores, Onset-to-Door (OTD), Door-To-Imaging (DTI) and Door-To-Needle (DTN) Times, mRS score 3 months after the ischemic event onset (3 m-mRS) and NIHSS score 24 h after the ischemic event onset (24 h-NIHSS). The study also compared the pre-COVID-19 pandemic period (March-December 2019) with the one immediately following it (March-December 2020). Results: 418 patients were included. Over time, treatment was extended to older patients (mean age from 66.3 to 75.51 years; p = 0.006) and with a higher level of baseline disability (baseline mRS score from 0.22 to 1.22; p = 0.000). A statistically significant reduction over the years was found for DTN, going from 90 min to 61 min (p = 0.000) with also an increase in the number of thrombolysis performed within the “golden hour” – more than 50% in 2019 and more of 60% in 2020. Comparing pre- and during COVID-19 pandemic periods, the number of patients remained almost unchanged, but with a significantly higher baseline disability (mRS = 1.18 vs. 0.72, p = 0.048). The pre-hospital process indicator OTD increased from 88.13 to 118.48 min, although without a statistically significant difference (p = 0.197). Despite the difficulties for hospitals due to pandemic, the hospital process indicators DTI and DTN remained substantially unchanged, as well as the clinical

La continuità assistenziale è definita come un insieme di azioni volte a garantire il passaggio tra differenti livelli di cura. L’incremento dell’età della popolazione e della prevalenza delle malattie croniche necessitano di strategie e programmi che permettano ai pazienti di affrontare con sicurezza le difficoltà dell’ospedalizzazione, dell’assistenza post-acuzie e del passaggio tra i due livelli. La transizione assistenziale in un sistema di cure frammentato può compromettere lo stato di salute dei pazienti. Lo scopo di questo studio è quello di analizzare i modelli di continuità di cura e gli approcci internazionali al continuum assistenziale identificando i loro pilastri principali. Per la ricerca è stata eseguita una revisione narrativa della letteratura scientifica, all’interno del database Pubmed, tramite i termini a testo libero: chronic disease, continuum of care, primary care, secondary care, care models. Sono state incluse nello studio soltanto le revisioni sistematiche in lingua italiana e inglese incentrate sull’applicazione di modelli di continuum assistenziale, con particolare riferimento agli ambiti della cronicità, comorbidità, disabilità o fragilità. La ricerca iniziale ha identificato 129 studi. Dopo la lettura del titolo e dell’abstract sono stati selezionati 33 articoli; dopo quella del full-text sono state scelte 22 pubblicazioni. Dalla revisione sono emersi 9 modelli di continuità assistenziale, tra i quali il maggiormente descritto è il ‘’modello assistenziale integrato’’, che mira ad un migliore coordinamento tra assistenza primaria e secondaria. Lo studio ha evidenziato dei pilastri comuni ai modelli analizzati: coinvolgimento e responsabilizzazione del paziente (86% degli studi), multidisciplinarietà (73% degli studi), coordinamento assistenziale (50% degli studi), case management (50% degli studi), integrazione di assistenza sanitaria e sociale, centralità del paziente, digital health, rapporto e comunicazione medico-pazi

Colorectal cancer (RC) is the third most common cancer, with an increasing incidence in recent years. Digital health solutions supporting multidisciplinary tumor boards (MTBs) could improve positive outcomes for RC patients. This paper describes the implementation process of a digital solution within the RC-MTB and its impact analysis in the context of the Fondazione Policlinico 'A. Gemelli' in Italy. Adopting a two-phase methodological approach, the first phase qualitatively describes each phase of the implementation of the IT platform, while the second phase quantitatively describes the analysis of the impact of the IT platform. Descriptive and inferential analyses were performed for all variables, with a p-value < 0.05 being considered statistically significant. The implementation of the platform allowed more healthcare professionals to attend meetings and resulted in a decrease in patients sent to the RC-MTB for re-staging and further diagnostic investigations and an increase in patients sent to the RC-MTB for treatment strategies. The results could be attributed to the facilitated access to the platform remotely for specialists, partly compensating for the restrictions imposed by the COVID-19 pandemic, as well as to the integration of the platform into the hospital's IT system. Furthermore, the early involvement of healthcare professionals in the process of customizing the platform to the specific needs of the RC-MTB may have facilitated its use and contributed to the encouraging quantitative results

Background: Food environments have been recognised as highly influential on population diets. Government policies have great potential to create healthy food environments to promote healthy diets. This study aimed to evaluate food environment policy implementation in European countries and identify priority actions for governments to create healthy food environments. Methods: The Healthy Food Environment Policy Index (Food-EPI) was used to evaluate the level of food environment policy and infrastructure support implementation in Estonia, Finland, Germany, Ireland, Italy, the Netherlands, Norway, Poland, Portugal, Slovenia, and Spain in 2019-2021. Evidence of implementation of food environment policies was compiled in each country and validated by government officials. National experts evaluated the implementation of policies and identified priority recommendations. Findings: Finland had the highest proportion (32%, n = 7/22) of policies shaping food environments with a "high" level of implementation. Slovenia and Poland had the highest proportion of policies rated at very low implementation (42%, n = 10/24 and 36%, n = 9/25 respectively). Policies regarding food provision, promotion, retail, funding, monitoring, and health in all policies were identified as the most important gaps across the European countries. Experts recommended immediate action on setting standards for nutrients of concern in processed foods, improvement of school food environments, fruit and vegetable subsidies, unhealthy food and beverage taxation, and restrictions on unhealthy food marketing to children. Interpretation: Immediate implementation of policies and infrastructure support that prioritize action towards healthy food environments is urgently required to tackle the burden of obesity and diet-related non-communicable diseases in Europe

Background: Robotic surgery for malignant uterine cancer raises issue of economic sustainability for providers. The objective of this study was to assess the value of surgical admissions for malignant uterine cancer in a University Hospital through an analysis of their costs and outcomes by comparing three different surgical approaches (laparotomy, laparoscopic, and robotic surgery). Methods: Hospitalizations between 1 January 2019 and 31 October 2021 for malignant uterine cancer surgery were selected and stratified. For each surgical approach, mean values (with 95% confidence intervals, CI) were calculated for cost items. Moreover, 30-day readmission frequency was calculated for the three approaches compared to each other. ANOVA and Student's t-test and relative risk (RR) were used for statistical analysis. A break-even analysis was carried out by evaluating the volume of robotic and non-robotic surgical admissions. Results: A total of 1,336 hospitalizations were included in the study, 366 with robotic, 591 with laparoscopic, and 379 with laparotomy surgery. Robotic surgery, compared to laparoscopic and laparotomy ones, showed a statistically significant difference (p < 0.001) in the economic margin, which was largely negative (-1069.18 €; 95%CI:-1240.44--897.92 €) mainly due to devices cost, and a lower percentage of 30-day readmissions (1.4%; 95%CI: 0.2-2.6%), with a statistically significant difference only vs. laparotomy (p = 0.029). Laparoscopic compared to laparotomy surgery showed a significantly (p < 0,001) more profitable economic margin (1692.21 €; 95%CI: 1531.75 €-1852.66 €) without a significant difference for 30-day readmissions. Break-even analysis showed that, on average, for each malignant uterine cancer elective surgery performed laparoscopically, 1.58 elective robotic surgeries are sustainable for the hospital (95% CI: 1.23-2.06). Conclusion: Break-even analysis could be a useful tool to support hospital management in planning and governance

Background Gli ospedali, negli ultimi decenni a livello internazionale, hanno subito importanti cambiamenti, con pertanto la necessità di una maggiore integrazione tra ospedali e servizi territoriali. Le principali reti istituzionali sviluppate in Italia sono, come definito a livello istituzionale, 4 principali tipologie: la Rete emergenza-urgenza, le Reti tempo-dipendenti, le Reti oncologiche e le Reti con strutture territoriali. Vi è la necessità di valutare la condizione attuale e analizzarla in relazione a possibili sviluppi futuri. Lo scopo dello studio era raccogliere spunti sia dalla conoscenza basata sull'evidenza scientifica che sull'esperienza personale acquisita da esperti del settore in merito allo stato dell’arte e ai possibili sviluppi futuri delle reti ospedaliere. Materiale e metodi È stata scelta una metodologia di ricerca qualitativa. Sono stati organizzati quattro minifocus group tra partecipanti di comprovata esperienza in materia. Le discussioni sono state guidate mediante quattro domande a risposta aperta corrispondenti alle quattro aree di interesse. La directed content analysis è stata scelta come metodologia per l'analisi dei dati e la rendicontazione finale dei risultati. Risultati Sono state esplorate quattro categorie principali: “reti ospedaliere e complessità”, “complessità delle reti ospedaliere e necessità di integrazione”, “leve per la governance delle reti ospedaliere” e “la sfida COVID-19 e gli sviluppi futuri delle reti ospedaliere”. In particolare, i partecipanti hanno riscontrato come è importante comprendere i sistemi sanitari quali sistemi complessi e, quindi, studiare le proprietà di tali sistemi. In questo modo è possibile ottenere un'assistenza sanitaria basata sul valore in contesti complessi. È inoltre necessario tenere presente che la complessità rappresenta una sfida per il coordinamento/integrazione nelle reti ospedaliere. Mintzberg ha identificato meccanismi specifici per raggiungerlo. Tra questi, l'adatt, Background Hospitals have undergone important that changes that have led, in recent decades at the international level, to the need for greater integration between hospitals and local healthcare services. The main institutional networks that have been developed in Italy are, as commended by the institutional levels, of 4 main types: the Emergency-Urgency Network, the Time-Dependent Networks, the Oncological Networks, and the Networks with primary care settings. It was important to assess the state of the art and analyze it in relation to possible future developments. Objective The aim of the study was to collect insights from both evidence-based knowledge and personal experience gained by experts in the field regarding the current condition and possible future developments of hospital networks. Material and methods A qualitative research methodology was chosen. Four mini-focus group meetings were organized among participants with proven expertise on the subject. Discussions were guided by four open-ended questions corresponding to the four areas of interest. Directed content analysis was chosen as the methodology for data analysis and final reporting of results. Results Four main categories were explored: “hospital networks and complexity”, “hospital networks complexity and the need for integration”, “levers for hospital networks governance” and “the COVID-19 challenge and future developments for hospital networks”. In particular, the participants found that it is important to understand healthcare systems as complex systems and, therefore, to study the properties of complex systems. In this way it is possible to achieve value-based healthcare in complex contexts. It is also necessary to keep in mind that complexity represents a challenge for coordination/ integration in hospital networks. Mintzberg identified specific mechanisms to achieve it. Of them, mutual adaptation is the key to self-organization. Valentijn showed the organizational levels on which coordinatio

Background. Immediate breast reconstruction is recommended for eligible patients undergoing mastectomy, raising the issue of economic sustainability of both mastectomy and breast reconstruction performed within the same hospitalization, as opposed to two surgical procedures in two different hospitalizations. Study design. A retrospective analysis was conducted to compare economic sustainability of mastectomies with or without immediate breast reconstruction. Methods. Economic data on hospitalizations for mastectomy in a Teaching Hospital between 1 January 2019 and 31 March 2021 were analyzed to assess their sustainability. Results. 338 admissions were selected (63.9% with immediate breast reconstruction (CI 99%: 57.2% to 70.6%). Compared to mastectomy alone, mastectomy with immediate breast reconstruction had higher cost of € 2,245 (p < 0.001), with operating rooms and devices as main cost drivers. Current reimbursements rates (which are the same for mastectomy alone and for mastectomy with immediate breast reconstruction) led to an average loss of € 1,719 for each mastectomy with immediate breast reconstruction. Conclusion. Current DRGs reimbursement rates for hospital admissions for breast cancer surgery do not guarantee immediate breast reconstruction’s economic sustainability. DRGs system should be revised, or other solutions as bundled payment should be implemented in the light of the costs of innovation in healthcare, considering mastectomy and breast reconstruction steps in a path of linked actions aimed at improving patients’ health.

La sostenibilità rappresenta per i sistemi sanitari di tutto il mondo una delle maggiori sfide. Questo tema, già centrale nell’esercizio della tutela della salute in un’epoca di crescenti pressioni economiche, aumentoincontrollato della domanda di salute, legato ai trend demografici ed epidemiologici, aspettative crescenti da parte dei pazienti e innovazione tecnologica, è divenuto ancora più dominante a seguito della grave emergenza sanitaria su scala globale determinata dalla pandemia da SARS-Cov-2. Il perseguimento di obiettivi di efficacia assistenziale e, nel contempo, di appropriatezza clinica ed organizzativa ed efficienza nell’allocazione e nell’utilizzo delle risorse richiede quale priorità strategica la diffusione del linguaggio, delle logiche e degli strumenti della Programmazione e dell’Organizzazione sanitaria.

La sostenibilità rappresenta per i sistemi sanitari di tutto il mondo una delle maggiori sfide. Questo tema, già centrale nell’esercizio della tutela della salute in un’epoca di crescenti pressioni economiche, aumentoincontrollato della domanda di salute, legato ai trend demografici ed epidemiologici, aspettative crescenti da parte dei pazienti e innovazione tecnologica, è divenuto ancora più dominante a seguito della grave emergenza sanitaria su scala globale determinata dalla pandemia da SARS-Cov-2. Il perseguimento di obiettivi di efficacia assistenziale e, nel contempo, di appropriatezza clinica ed organizzativa ed efficienza nell’allocazione e nell’utilizzo delle risorse richiede quale priorità strategica la diffusione del linguaggio, delle logiche e degli strumenti della Programmazione e dell’Organizzazione sanitaria.

INTRODUZIONE Un blocco operatorio è una realtà complessa in cui si avvicendano diverse figure professionali. Perseguire obiettivi di efficacia ed efficienza risulta di primaria importanza ma allo stesso tempo di difficile attuazione. In tale contesto, sprechi di risorse e tempo sono un frequente rischio e possono impattare negativamente sulla qualità dell’assistenza procurando ritardi, cancellazioni e riprogrammazioni delle procedure. L’obiettivo dello studio è stato operare una valutazione complessiva del blocco operatorio di un presidio ospedaliero dell’Italia nord-orientale, per evidenziare i punti di debolezza e promuovere una strategia di miglioramento. MATERIALI E METODI La valutazione è stata condotta in tre fasi: iniziale process mapping del contesto lavorativo, analisi qualiquantitativa della documentazione sanitaria e valutazione finale delle criticità mediante Root Cause Analysis (RCA). Al fine di promuovere strategie di cambiamento, si è impostato un progetto di miglioramento basato sul modello del Plan Do Check Act (PDCA). RISULTATI Afferiscono al blocco operatorio sei unità operative: Chirurgia Generale, Ginecologia e Ostetricia, Oculistica, Ortopedia e Traumatologia, Urologia ed Endourologia. Al termine della valutazione sono state individuate e rappresentate mediante diagramma di Ishikawa le cause profonde dell’inefficienza, suddivise in quattro macro aree (1) organizzazione/struttura: non ottimale distribuzione delle sedute operatorie con una percentuale di occupazione delle sale del 98% il mattino e solo del 13% il pomeriggio; incompleta acquisizione del software PACS; (2) personale: eterogeneità delle competenze tecnico-informatiche; riduzione per ragioni di contenimento dei costi e per aumento delle inidoneità psicofisiche; (3) tecnologie: assenza di un’interfaccia tra i software e investimenti tecnologici insufficienti rispetto alle esigenze del contesto; (4) metodi: insufficienza di procedure e percorsi interni; scarsa offerta formativa azienda

Nel presente capitolo si parte dai bisogni di salute e risorse in sanità per tracciare una definizione e una descrizione delle funzioni necessarie per il management sanitario in maniera completa e approfondita, oltre che corredata da numerosi fonti bibliografiche e figure illustrative.

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: 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. METHOD: 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. RESULTS: Both approaches are flexible, patient-centred and include the evaluation of quality. Both provide financial and administrative support for the access. CONCLUSION: 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.

INTRODUZIONE: Le Partnership Pubblico-Privato (PPPs) sono una forma di cooperazione contrattuale tra un’ente pubblico e il settore privato. Obiettivo di questo studio è stato esplorare i modelli internazionali di PPP applicati in sanità pubblica e il loro impatto. MATERIALI E METODI: È stata condotta una revisione sistematica della letteratura dal 1990 al 2015 tramite Pubmed e Scopus. Gli studi emersi sono stati analizzati in base a titolo, abstract e full-text. Criteri di inclusione sono stati la descrizione di un’esperienza applicativa di PPP e il setting sanitario. È stata effettuata una valutazione di qualità degli studi e sono stati analizzati gli impatti quantitativo, qualitativo e finanziario delle diverse forme di PPP. RISULTATI: Sono stati selezionati 26 su 165 studi emersi, prevalentemente europei (35%). Sono stati classificati come di buona qualità 12 articoli. Il modello più descritto è quello dell’Accommodation only (38%, p=0,02). Dieci articoli (37%) descrivono un impatto quantitativo positivo (incremento ricoveri e prestazioni erogate, riduzione tempi di attesa); tuttavia, 5 (19%) dichiarano una evidente mancanza di risultati. Dieci articoli mostrano che le PPPs contribuiscono a una migliore qualità dell’assistenza (aumento soddisfazione del paziente e sviluppo di assistenza integrata); solo 2 articoli prendono in esame gli outcome clinici (riduzione infezioni e mortalità). In termini finanziari, 10 articoli descrivono una perdita di ricavi, 3 riportano un aumento di efficienza, mentre 5 riportano informazioni eterogenee/ insufficienti. CONCLUSIONI: Le PPPs sono una forma sempre più diffusa di contratto adottato in ambito sanitario, ma la valutazione dei loro vantaggi è ancora incerta a causa di dati insufficienti/eterogenei. La ricerca futura dovrebbe concentrarsi sulle PPPs da una prospettiva di governance affinchè ogni modello di PPP possa essere meglio adattato alle specifiche di contesto, al fine di promuovere l’efficienza e l’efficacia dei siste

INTRODUZIONE: Gli aspetti organizzativi influenzano il comportamento dei professionisti sanitari e dei manager ed aiutano a superare le barriere nell’implementazione di nuove tecnologie in sanità. Tuttavia, il dominio organizzativo è spesso sottorappresentato o assente nei report di Health Technology Assessment (HTA). Questo studio ha esplorato l’assessment organizzativo in HTA per la costruzione di un nuovo framework per esperienze applicative alla luce del confronto con il CoreModel 3.0 di EUnetHTA. MATERIALI E METODI: Sono stati estratti report HTA completi in letteratura e sui siti dei membri dell’International Network of Agencies for HTA, e si è analizzato al loro interno l’aspetto organizzativo. I risultati sono stati confrontati con un modello a 5 domini e 15 sottodomini del CoreModel. Un’analisi delle corrispondenze multiple ha permesso di valutare la potenza del CoreModel ed identificare nuovi domini comuni per guidare l’impatto organizzativo nei report di HTA. RISULTATI: L’analisi organizzativa nei report è risultata eterogenea, con tale aspetto meno rappresentato degli altri. I domini e sottodomini organizzativi del CoreModel non sono risultati omogeneamente espressi nell’analisi organizzativa (rappresentatività dal 19 al 62%). Attraverso una regressione statistica è stato sviluppato un nuovo framework, basato su nuovi indicatori compositi. CONCLUSIONI: Questo studio ha analizzato la rilevanza dell’analisi organizzativa nella letteratura scientifica e le sfide nel promuovere un approccio globale a tale questione. Sulla base della ricerca attuale, abbiamo proposto una nuova metodologia per analizzare gli aspetti più rilevanti dell’analisi organizzativa secondo nuovi domini, con un approccio più omogeneo e decontestualizzato, al fine di incoraggiare i professionisti sanitari a sviluppare l’analisi organizzativa e soddisfare le esigenze della futura ricerca in HTA.

Introduction. The recent global economic crisis is pushing governments worldwide to obtain a more explicit and urgent rationing of resources. The purpose of this study is to provide, through Data Envelopment Analysis (DEA), a methodological framework useful for investigating technical efficiency of hospital care. Methods. To validate such framework, we compared 50 Italian public hospital trusts (AOs) to identify relative efficient using inputs and outputs from national databases. We also evaluated if, and how, efficiency is affected by various exogenous factors. Results. On average, Italian AOs had an efficiency score of 77% (SD 0.12). Tobit regression model identified a positive association between efficiency and a lower case-mix index, being in the north of Italy, in a region with fiscal autonomy, with a higher public and a lower private expenditure on health as percentage of GDP. Conclusions. DEA may provide useful and especially objective information regarding the technical efficiency of hospital care and support hospital management and policy makers’ decisions.

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.