Search

Il divario tra ricerca e pratica si riferisce ai casi in cui la ricerca fatica a essere applicabile in contesti concreti, come quello sanitario, con un notevole impatto sull’organizzazione dell’assistenza, sull’erogazione dei servizi e sugli esiti di salute. Questo aspetto si somma, nei sistemi sanitari come quello italiano, a una forte variabilità nell’accesso ad assistenza di qualità e negli esiti di salute tra le Regioni e nello stesso territorio. Viene usata l’espressione “trasferimento della conoscenza”1 per spiegare il processo iterativo di sintesi e scambio dai risultati della ricerca sanitaria al miglioramento della qualità nella pratica clinica. Comprendere e applicare tutto ciò risulta essenziale per implementare con tempestività ed efficacia le evidenze scientifiche.

Editorial Value Based in Oncology

Objective: To analyze the research status of clinical governance (CG); the most productive authors, countries and organizations; connections among research themes. Methods: We used a ‘funnel model’, consisting of 3 layers describing various CG domains and settings. We retrieved bibliometric data from 1998 to 2021 from the Scopus database. Text mining, visual analysis, descriptive statistics and data visualization were performed. Citation bursts were detected. Results: The total number of studies was 2429. On a global scale, there is a swinging trend in publications, with four peaks detected (2000, 2009, 2013, 2021). Citation burst keywords include: “national health service”, “medical audit”, “psychological aspect”, “quality improvement” and “surveys and questionnaires”. UK is the most productive and cited country. The most active organizations were in the UK, Australia, USA, Italy and Iran. The most productive journals and authors were identified. The most frequent keywords identified were ‘health care quality’, ‘clinical governance’, ‘organization and management’ and ‘medical audit’. Research trends for each CG domain and setting type were reported. Conclusion: By using scientometric methodology, we created a thorough scientific picture on CG, including the mapping of pivotal concepts as a function of time.

Introduction: Critical pathways (CPs) are effective change management tools used to improve quality in healthcare nationally implemented in Italy in 2015. This study aims to map the country's state-of-the-art regarding the adoption of CPs and to verify the existence of factors that determine the success of their implementation and the relative entity of their impact, by analysing the management of Lung Cancer (LC) as a case-study. Methods: Our methodology followed the SQUIRE guidelines for quality improvement reporting (2015). Starting from the 2017 ranking table published by the National Outcome Program, we selected and included in our sample all Italian hospitals who, according to Ministerial Decree n. 70/2015, met national quality threshold for LC treatment. To investigate regional-level and hospital-level factors believed to be responsible for the successful implementation of a CP, a Google Modules questionnaire was constructed and sent to the selected facilities; subsequently, a web-based research was carried out for missing data. Associations between variables were tested in STATA by means of correlation tests and a linear regression model. Results: 41 hospitals matched our inclusion criteria. Of these, 68% defined an internal Lung Cancer Critical Pathway (LCCP). Our results confirmed the presence of critical success factors that favour the correct implementation of a LCCP. Conclusions: Notwithstanding the availability of CPs, their adoption in routine clinical practice still lacks consistency, suggesting the necessity to resort to digital solutions, to increment the level of regional commitment and workforce commitment and to reinforce quality standards monitoring.

Prendersi cura della persona che soffre implica, oggi, combinare le esigenze di efficacia e sostenibilità dell’assistenza con i principi di carità, gratuità e prossimità. Tale sfida passa per l’umanizzazione delle cure, i cui fondamenti sono: la centralità della persona e il perseguimento del “valore” della cura. Il tema del valore declina attenzione alle risorse ed efficacia delle cure secondo la prospettiva del paziente attraverso la lente della dignità della persona, dell’eticità delle scelte e della costante condivisione delle decisioni assistenziali., To take care of suffering people aims at combining effectiveness and sustainability with the principles of charity, gratuitousness and proximity. This challenge involves the humanization of care, whose foundations include each person’s centrality and the pursuit of value of care. The concept of ‘value’, in particular, by matching outcomes that matter to patients with resources, encompasses dignity, ethical nature of choices and ongoing sharing of care decisions.

Background: Rising incidence and prevalence of end-stage renal disease is a worldwide concern for sustainability of healthcare systems and societies. Living donor renal transplant [LDRT] provides highest health achievements and cost containment than any alternative form of renal replacement therapy. Nonetheless, about 25% of potential LDRTs are missed for causes directly related with inadequate timing in donor assessment. Our quality improvement (QI) project implement process control tools and strategy aiming at reducing total evaluation time for donor candidates and minimizing dialysis exposure for intended recipients, which are the two main determinants of clinical outcomes and costs. Methods: The study includes patients who underwent donor nephrectomy between January 1, 2017 and December 31, 2021. Six Sigma DMAIC approach was adopted to assess Base Case performance (Jan2017-Jun2019) and to design and implement our QI project. Study of current state analysis focused on distribution of time intervals within the assessment process, analysis of roles and impacts of involved healthcare providers and identification of targets of improvement. Improved Scenario (Jul2019-Dec2021) was assessed in terms of total lead time reduction, total pre-transplantation dialysis exposure and costs reduction, and increase in pre-emptive transplantations. The study was reported following SQUIRE 2.0 Guidelines for QI projects. Results: Study population includes 63 patients, 37 in Base Case and 26 in Improved Scenario. Total lead time reduced from a median of 293 to 166 days and this in turn reduced pre-transplantation dialysis exposure and costs by 45%. Rate of potential pre-emptive donors’ loss changes from 44% to 27%. Conclusions: Lean methodology is an effective tool to improve quality and efficiency of healthcare processes, in the interest of patients, healthcare professionals and payers.

Background: Owing to COVID-19, all stakeholders have recognized the advantages of telehealth and they were available for its permanent implementation, both from the normative and economic point of view. It is, therefore, necessary to understand what were the real benefits created in society through telehealth.Objective: Develop a method to identify a social impact of telemedicine in Italy, considering the reduction on the patient moves with a consequent travel cost, time (opportunity costs), and carbon emission savings.Methods: Since March 2020, we have conducted a quality improvement study in 17 centers, collecting sociodemographic variables. To assess the social impact, we transform the data into outcome measures. The protocol used "Telemedicina Subito" allows the rapid implementation of telemedicine, using operating manual, structured according Health Technology Assessment approach.Results: We collected data related to 2,091 televisits, analyzing three different perspectives. First, one patient with a televisit had a saving equal to the median of EUR 97.16 (interquartile range [IQR]: 64.29-159.69), USD 113.88; considering that the median cost for the visit in presence was EUR 105.91 (p-value <0.05) and after the use of telehealth had a median of EUR 0 (mean: EUR 14.70; p-value <0.05). Second, informal caregivers have a median savings of EUR 65.06 (IQR: 55.52-89.21), USD 76.26. Finally, for one single telemedicine visits we can contribute with a median carbon emission savings of similar to 13 kg (IQR: 6-24).Conclusions: The evaluation of the social impact on telemedicine facilitated the creation of an important framework for decision-makers.

Audit and Feedback (A&F) is an effective multidimensional strategy for improving the quality of care. The optimal methods for its implementation remain unclear. This study aimed to map the state of art of A&F strategies in the hospitals involved in a time-dependent emergency network. For these purposes, a structured questionnaire was defined and discussed within the research group. This consists of 29 questions in three sections: (1) characteristics of the structure, (2) internal feedback systems, and (3) external feedback systems. All structures involved in the network were invited to participate in the e-survey by indicating a Health Management representative and a clinical representative for the Cardiovascular (CaV) and/or for the Cerebrovascular area (CeV). Of 20 structures invited, a total of 13 (65%) responded to the survey, 11 for the CaV area and 8 for the CeV area. A total of 10 of 11 (91%) facilities for the CaV area and 8/11 (75%) for the CeV area reported that they perform A&F activities. All facilities perform at least one of the activities defined as “assimilating A&F procedures.” The most frequent is the presentation and discussion of clinical cases (82% CaV and 88% CeV) and the least is the identification of responsible for improvement actions (45% CaV and 38% CeV). In 4/10 (40%) facilities for the CaV area and 4/8 (50%) for the CEV area, corrective actions are suggested or planned when the feedback is returned. These results confirm the need to define, in a synergistic way with the relevant stakeholders, an effective and agreed A&F intervention to improve the level of implementation of A&F strategies.

This analysis of the Italian health system reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. Italy has a regionalized National Health Service (SSN) that provides universal coverage largely free of charge at the point of delivery, though certain services and goods require a co-payment. Life expectancy in Italy is historically among the highest in the EU. However, regional differences in health indicators are marked, as well as in per capita spending, distribution of health professionals and in the quality of health services. Overall, Italy's health spending per capita is lower than the EU average and is among the lowest in western European countries. Private spending has increased in recent years, although this trend was halted in 2020 during the coronavirus disease 2019 (COVID-19) pandemic. A key focus of health policies in recent decades was to promote a shift away from unnecessary inpatient care, with a considerable reduction of acute hospital beds and stagnating overall growth in health personnel. However, this was not counterbalanced by a sufficient strengthening of community services in order to cope with the ageing population's needs and related chronic conditions burden. This had important repercussions during the COVID-19 emergency, as the health system felt the impact of previous reductions in hospital beds and capacity and underinvestment in community-based care. Reorganizing hospital and community care will require a strong alignment between central and regional authorities. The COVID-19 crisis also highlighted several issues pre-dating the pandemic that need to be addressed to improve the sustainability and resilience of the SSN. The main outstanding challenges for the health system are linked to addressing historic underinvestment in the health workforce, modernizing outdated infrastructure and equipment, and enhancing information infrastructure. Italy's Nat

Provider payment mechanisms were adjusted in many countries in response to the COVID-19 pandemic in 2020. Our objective was to review adjustments for hospitals and healthcare professionals across 20 countries.We developed an analytical framework distinguishing between payment adjustments compensating income loss and those covering extra costs related to COVID-19. Information was extracted from the Covid-19 Health System Response Monitor (HSRM) and classified according to the framework. We found that income loss was not a problem in countries where professionals were paid by salary or capitation and hospitals received global budgets. In countries where payment was based on activity, income loss was compensated through budgets and higher fees. New FFS payments were introduced to incentivize remote services. Payments for COVID-19 related costs included new fees for out-and inpatient services but also new PD and DRG tariffs for hospitals. Budgets covered the costs of adjusting wards, creating new (ICU) beds, and hiring staff.We conclude that public payers assumed most of the COVID-19-related financial risk. In view of future pandemics policymakers should work to increase resilience of payment systems by: (1) having systems in place to rapidly adjust payment systems; (2) being aware of the economic incentives created by these adjustments such as cost-containment or increasing the number of patients or services, that can result in unintended consequences such as risk selection or overprovision of care; and (3) periodically evaluating the effects of payment adjustments on access and quality of care.(c) 2021 Published by Elsevier B.V.

Background and AimsIn oncology, there is increasing talk of personalized treatment and shared decision-making (SDM), especially when multiple treatment options are available with different outcomes depending on patient preference. The present study aimed to define the set of main dimensions and relative tools to assess the Value brought to patients from a Breast Cancer's Clinical pathway structured according to a dynamic SDM framework.MethodsStarting from our previous systematic review of the literature, a deep search of the main evidence-based and already validated questionnaires was carried out. In the second phase, to corroborate this grid, a Delphi survey was conducted to assess each questionnaire identified for each dimension, against the following seven value-based criteria: Clinical Benefit, Safety, Care Team Well Being, Patient Reported Outcomes Measures, Green Oncology, Impact on Health Budget, and Genomic Profile.ResultsThe resulting 7-dimension questionnaire is composed of 72 questions. Of these, some quantitatively and objectively assess the evolution of the patient's disease state, whereas others aim to ask patients about their active involvement in decisions affecting them and to investigate whether they were free to explore their preferences. Furthermore, to frame the analyzed phenomenon at the right time, for each questionnaire section, the specific, evidence-based timing of administration is indicated.ConclusionThe resulting questionnaire is validated in its entirety and it is composed of a set of questions and relative time point for data collections to assess the Value brought to patients undertaking a Breast Cancer's Clinical pathway, structured according to a dynamic SDM framework. It constitutes a quantitative instrument to integrate patient centeredness with a personalized perspective in the care management of women with breast cancer.

The use of organo-iodinated contrast media (CM) in diagnostics and intervention has increased in the last 10 years. It is necessary to distinguish between the different types of contrast agent, primarily with respect to osmolarity: with low osmolarity the safety profile for the patient is higher. The risk of acute renal injury caused by contrast agent (PC-AKI) is however determined also by risk factors related to the patient. Particularly in main centers, it is advisable to have a standardized program in order to stratify patients with respect to risk, to define prevention strategies and the roles of the specialists involved. The experience described in this work consists in the application of an organizational model relating to CT, with a feasibility study of applying an evidence-based check-list in the clinical routine, as a tool to support clinical decisions (Clinical Decision Support System, CDSS) in the oncology field. A pilot evaluation was carried out on 54 patients belonging to the case series treated in a Teaching Hospital, in a day service regime with a diagnosis of solid tumor. The results of this evaluation led the working group to believe that the CDSS thus structured determines the possibility of overestimating the clinical risk of PC-AKI, and consequently to redefine the evaluation form. Experience has shown that it is not generally easy to immediately identify an algorithm useful for standardizing the management of clinically complex situations, such as PC-AKI prevention. The conduction of pilot evaluations can be a valid instrument of harmonization between the solidity of the references deriving from evidence based medicine and the tangibility of real world data. It is advisable to broaden the application of the CDSS more in a larger number of cases, as well as conduct a pre-post analysis relating to the clinical impact in terms of incidence from PC-AKI.

This paper conducts a comparative review of the (curative) health systems' response taken by Cyprus, Greece, Israel, Italy, Malta, Portugal, and Spain during the first six months of the COVID-19 pandemic. Prior to the COVID-19 pandemic, these Mediterranean countries shared similarities in terms of health system resources, which were low compared to the EU/OECD average. We distill key policy insights regarding the governance tools adopted to manage the pandemic, the means to secure sufficient physical infrastructure and workforce capacity and some financing and coverage aspects. We performed a qualitative analysis of the evidence reported to the 'Health System Response Monitor' platform of the European Observatory by country experts. We found that governance in the early stages of the pandemic was undertaken centrally in all the Mediterranean countries, even in Italy and Spain where regional authorities usually have autonomy over health matters. Stretched public resources prompted countries to deploy "flexible" intensive care unit capacity and health workforce resources as agile solutions. The private sector was also utilized to expand resources and health workforce capacity, through special public-private partnerships. Countries ensured universal coverage for COVID-19-related services, even for groups not usually entitled to free publicly financed health care, such as undocumented migrants.

Introduction: The COVID-19 pandemic represented an unprecedented challenge for the healthcare world and the introduction of a new stronger and believable project plays a fundamental role for the quality of work and the provision of qualitative care. Aim: The survey provided by Italian Association for the Quality of Health and Social Care (ASIQUAS) aims to examines the impact of "Health" chapter included in the Recovery Plan, through the assessment of management quality of the COVID-19 pandemic. Methods: Starting from a literature review, in September 2021, a web-based survey has been conducted and administered by e-mail. It has been taken into account measures widely used by different healthcare structures in order to analyze the projects implemented in the face of pandemic and to evaluate the new real possibility to invest funds in new healthcare structures and projects. Results: The survey consists of 19 multiple choices and respondents were from different types of structures, including regional departments and regional health agencies (1.4%), universities, research centers and scientific hospitalization and treatment institutes (IRCCS) (11%), hospitals and university polyclinics (34.2%), Local Health Authorities (39.7%), socio-health organizations and Others (13.7%). The pandemic has highlighted many vulnerabilities at both hospitals and territorial level. The major weaknesses revealed by the survey are mainly due to the lack of support from new staff units and poor availability of specific training tools for COVID-19 procedures. The Recovery Plan is still unclear with a lot of concern about the implementation and many limits of diffusion. Conclusions: It becomes essential to guarantee a new effective and interoperative model of integration. Today we can start more aware for the implementation of a system closer to everyone's needs, making shortcomings the new strength and starting point.

This analysis of the Italian health system reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. Italy has a regionalized National Health Service (SSN) that provides universal coverage largely free of charge at the point of delivery, though certain services and goods require a co-payment. Life expectancy in Italy is historically among the highest in the EU. However, regional differences in health indicators are marked, as well as in per capita spending, distribution of health professionals and in the quality of health services. Overall, Italy's health spending per capita is lower than the EU average and is among the lowest in western European countries. Private spending has increased in recent years, although this trend was halted in 2020 during the coronavirus disease 2019 (COVID-19) pandemic. A key focus of health policies in recent decades was to promote a shift away from unnecessary inpatient care, with a considerable reduction of acute hospital beds and stagnating overall growth in health personnel. However, this was not counterbalanced by a sufficient strengthening of community services in order to cope with the ageing population's needs and related chronic conditions burden. This had important repercussions during the COVID-19 emergency, as the health system felt the impact of previous reductions in hospital beds and capacity and underinvestment in community-based care. Reorganizing hospital and community care will require a strong alignment between central and regional authorities. The COVID-19 crisis also highlighted several issues pre-dating the pandemic that need to be addressed to improve the sustainability and resilience of the SSN. The main outstanding challenges for the health system are linked to addressing historic underinvestment in the health workforce, modernizing outdated infrastructure and equipment, and enhancing information infrastructure. Italy's Nat

Background: High-income countries continuously reform their healthcare systems. Often, similar reforms are introduced concomitantly across countries. Although national policymakers would benefit from considering reform experiences abroad, exchange is limited. This paper provides an overview of health reform trends in 31 high-income countries in 2018 and 2019, i.e., before Covid-19.Methods: Information was collected from national experts from the Health Systems and Policy Monitor network. Experts were asked to report on the three "top" national health reforms 2018 and 2019. In 2019, they provided an update of 2018 reforms. Reforms were assigned to one of 11 clusters and identified as one of seven different reform types.Results: 81 reforms were reported in 28 countries in 2018. 44/81 went to four clusters: 'insurance coverage & resource generation', 'governance', 'healthcare purchasing & payment', and 'organisation of hospital care'. In 2019, 86 reforms in 30 countries were reported. 48/86 fell under 'organisation of primary & ambulatory care', 'governance', 'care coordination & specialised care', and 'organisation of hospital care'. Most 2018 reforms were reported ongoing in 2019; 27 implemented; seven abandoned. Health agency-led reforms were implemented most frequently, followed by central government-legislated reforms.Conclusions: Policymakers can leverage international experience of distinct reform approaches addressing similar challenges and similar approaches to address distinct problems. Such knowledge may help inspire or support future successful health reform processes. (c) 2021 Published by Elsevier B.V.

Provider payment mechanisms were adjusted in many countries in response to the COVID-19 pandemic in 2020. Our objective was to review adjustments for hospitals and healthcare professionals across 20 countries. We developed an analytical framework distinguishing between payment adjustments compensating income loss and those covering extra costs related to COVID-19. Information was extracted from the Covid-19 Health System Response Monitor (HSRM) and classified according to the framework. We found that income loss was not a problem in countries where professionals were paid by salary or capitation and hospitals received global budgets. In countries where payment was based on activity, income loss was compensated through budgets and higher fees. New FFS payments were introduced to incentivize remote services. Payments for COVID-19 related costs included new fees for out- and inpatient services but also new PD and DRG tariffs for hospitals. Budgets covered the costs of adjusting wards, creating new (ICU) beds, and hiring staff. We conclude that public payers assumed most of the COVID-19-related financial risk. In view of future pandemics policymakers should work to increase resilience of payment systems by: (1) having systems in place to rapidly adjust payment systems; (2) being aware of the economic incentives created by these adjustments such as cost-containment or increasing the number of patients or services, that can result in unintended consequences such as risk selection or overprovision of care; and (3) periodically evaluating the effects of payment adjustments on access and quality of care.

This paper conducts a comparative review of the (curative) health systems’ response taken by Cyprus, Greece, Israel, Italy, Malta, Portugal, and Spain during the first six months of the COVID-19 pandemic. Prior to the COVID-19 pandemic, these Mediterranean countries shared similarities in terms of health system resources, which were low compared to the EU/OECD average. We distill key policy insights regarding the governance tools adopted to manage the pandemic, the means to secure sufficient physical infrastructure and workforce capacity and some financing and coverage aspects. We performed a qualitative analysis of the evidence reported to the ‘Health System Response Monitor’ platform of the European Observatory by country experts. We found that governance in the early stages of the pandemic was undertaken centrally in all the Mediterranean countries, even in Italy and Spain where regional authorities usually have autonomy over health matters. Stretched public resources prompted countries to deploy “flexible” intensive care unit capacity and health workforce resources as agile solutions. The private sector was also utilized to expand resources and health workforce capacity, through special public-private partnerships. Countries ensured universal coverage for COVID-19-related services, even for groups not usually entitled to free publicly financed health care, such as undocumented migrants. We conclude that flexibility, speed and adaptive management in health policy responses were key to responding to immediate needs during the COVID-19 pandemic. Financial barriers to accessing care as well as potentially higher mortality rates were avoided in most of the countries during the first wave. Yet it is still early to assess to what extent countries were able to maintain essential services without undermining equitable access to high quality care.

OBJECTIVE: The study aims to define the set of Key Performance Indicators (KPIs) required to assess the Value delivered by managing patients with Clostridioides difficile infection through a Critical Pathway. We used the quadruple aim Value-Based approach, and we validated the set of KPIs with the Delphi method. MATERIALS AND METHODS: The study focuses on patients on board a Critical Pathway on Clostridioides difficile Infection and targeted towards a Fecal Microbiota Transplantation (FMT). FMT has been used to successfully treat recurrent Clostridium difficile infection. A two-round e-Delphi survey collecting data was conducted in 2019-2020 to validate the Value-Based evaluation tool. The Value-Based criteria taken into account are Clinical Outcomes, Experience of Care, Per-capita cost, Physician's burnout. RESULTS: The two rounds led to the validation of 50 items, and four primary clinical outcomes (Mortality rate, length of stay, readmission and complications related to the illness). CONCLUSIONS: The evaluation tool included is validated in its totality and can provide a comprehensive overview of the Value created by the Critical pathway for patients with Clostridioides difficile. We can extend the approach illustrated in this study can also to evaluate other Critical pathways.

Background: Suspending ordinary care activities during the COVID-19 pandemic made it necessary to find alternative routes to comply with care recommendations not only for acute health needs but also for patients requiring follow-up and multidisciplinary visits. We present the ‘Contactless’ model, a comprehensive operational tool including a plurality of services delivered remotely, structured according to a complexity gradient, aimed to cover diagnostic procedures and monitor disease progression in chronic pediatric patients. Methods: A multidisciplinary and multiprofessional project team was recruited, in collaboration with patients’ associations, to map a panel of available Evidence-Based solutions and address individual needs in full respect of the concept of personalized medicine. The solutions include a number of services from videoconsultations to more structure videotraining sessions. Results: A modular framework made up of four three Macro-levels of complexity - Contactless Basic, Intermediate and Advanced - was displayed as an incremental set of services and operational planning establishing each phase, from factors influencing eligibility to the delivery of the most accurate and complex levels of care. Conclusion: The multimodal, multidisciplinary ‘Contactless’ model allowed the inclusion of all Units of our Pediatric Department and families with children with disability or complex chronic conditions. The strengths of this project rely on its replicability outside of pediatrics and in the limited resources needed to practically impact patients, caregivers and professionals involved in the process of care. Its implementation in the future may contribute to reduce the duration of hospital admissions, money and parental absence from work.

Background: Patient registration with a primary care providers supports continuity in the patient-provider relationship. This paper develops a framework for analysing the characteristics of patient registration across countries; applies this framework to a selection of countries; and identifies challenges and ongoing reform efforts. Methods: 12 jurisdictions (Denmark, France, Germany, Ireland, Israel, Italy, Netherlands, Norway, Ontario [Canada], Sweden, Switzerland, United Kingdom) were selected for analysis. Information was collected by national researchers who reviewed relevant literature and policy documents to report on the establishment and evolution of patient registration, the requirements and benefits for patients, providers and payers, and its connection to primary care reforms. Results: Patient registration emerged as part of major macro-level health reforms linked to the introduction of universal health coverage. Recent reforms introduced registration with the aim of improving quality through better coordination and efficiency through reductions in unnecessary referrals. Patient registration is mandatory only in three countries. Several countries achieve high levels of registration by using strong incentives for patients and physicians (capitation payments). Conclusion: Patient registration means different things in different countries and policy-makers and researchers need to take into consideration: the history and characteristics of the registration system; the use of incentives for patients and providers; and the potential for more explicit use of patient-provider agreements as a policy to achieve more timely, appropriate, continuous and integrated care.

Breast Cancer (BC) is the leading cause of death due to cancer in women. Ensuring equitable, quality-assured and effective care has increased the complexity of BC management. This systematic review reports on the state-of-the art of available literature investigating the enactment of personalized treatment and patient-centered care models in BC clinical practice, building a framework for the delivery of personalized BC care within a Patient-Centered model. Databases were searched for articles (from the inception to December 2020) reporting on Patient-Centered or Personalized Medicine BC management models, assessing success factors or limits. Out of 1885 records, 25 studies were included in our analysis. The main success factors include clearly defined roles and responsibilities within a multi-professional collaboration, appropriate training programs and adequate communication strategies and adopting a universal genomic language to improve patients’ involvement in the decision-making process. Among detected barriers, delays in the use of genetic testing were linked to the lack of public reimbursement schemes and of clear indications in timing and appropriateness. Overall, both care approaches are complementary and necessary to effectively improve BC patient management. Our framework attempts to bridge the gap in assigning a central role played by shared decision-making, still scarcely investigated in literature.

Dear Editor, We read with a great interest the publication on “Acute stroke management pathway during Coronavirus-19 pandemic” [1] where Baracchini et al. shared their experience in the management of stroke patients in a COVID-19 Hospital. In particular, they underlined how pre-triage, a mobile CT unit for COVID-19 patients, and dedicated COVID-19 areas were effective measures to deal with the COVID-19 emergency. We would like to share our experience on the changes of integrated care pathway (ICP) focused on ischemic stroke patients.

OBJETCTIVE: The aim of this systematic review was to summarize the scientific literature concerning the use of the Precede-Proceed model (PPM) applied to educational programs and health screenings contextsV. STUDY DESIGN: Systematic review. METHODS: The search process was based on a selection of publications listed in Medline and Scopus. The keywords used were "Precede-Proceed" AND ("screening" OR "educational programs"). Studies included in the systematic review were subdivided into those applying the model in a screening context, and those applying it within educational programs. RESULTS: Twenty-seven studies were retrieved, mostly performed in the USA and, generally, the promoting center was the University. In the context of cancer screening, the PPM model was most of all applied to Mammography Screening (5 of 13 studies in cancer screening), and Cervical Cancer Screening (5 of 13). Another three studies within the cancer field investigated Menopause-Inducing Cancer Treatments, Oral cancer prevention, and cancer screening in general. In the remaining studies, the model was applied in various screening areas, particularly chronic and degenerative diseases. There were many different study designs, most of which cross-sectional (8), though several RTCs (8) and focus groups (5) were also found. For the cross-sectional studies the methodological quality varied between 3/10 and 9/10, whilst for the RCTs it ranged from 2/5 to 3/5. CONCLUSIONS: The PPM provides an excellent framework for health intervention programs especially in screening contexts, and could improve the understanding of the relationship between variables such as knowledge and screening. Given the complexity of a behavioral change process, certain important predisposing factors could be measured in future studies, and during health intervention planning.

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.

Aim: The aim of this study was to map a patient's journey along all stages of his daily care path in an Oncology outpatient department, to identify and eliminate "bottleneck" situations that interfere with the patient's flow of care. The main key performance indicators used in the study were: waiting times for each stage of the care process, time required for each activity, and resources used. Methods: The study was conducted from 17-30 January 2018 at the medical oncology clinic of a large university teaching and research hospital in Italy. We analyzed all the healthcare services provided during the monitoring period, dividing them into: first appointments, therapy, visits for adjustments of the therapeutic plan, visits for i.v. therapy, visits for oral therapy, follow-up visits, other visits (e.g. for positioning of peripherally inserted central catheter). Data collection was performed by administering two questionnaires: a Patient Journey (PJ) questionnaire to patients and a Medical Journey (MJ) questionnaire to clinicians. This project employed Lean principles in order to: view the process and specify value through the patient's point of view, identify waste in processes and eliminate any steps lacking any added value, reduce variation of and leveling workload to improve quality and ?ow of care, engage patients and staff to redesign the process. Results: The response rate in 1351 outpatients who were invited to participate was 63%; for doctors it was 81%. The mean waiting time for first visits and follow up visits performed in a single day was 50 minutes. An audit process was thus performed and a series of quality improvement measures were defined and shared with health professionals. Conclusions: The Lean methodology could provide a robust framework for improved understanding and management of complex system constraints in outpatient oncology clinics, and could result in improved access to treatment and reduced waiting times for patients.

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, p1⁄40.25) 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, po0.001). Results revealed no statistically significant decrease in readmission rates within 30 days (5.7 percent, p1⁄40.85) 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.

Objective: To report the experience developed in a Third Level Referral Center in performing a multifaceted intervention strategy to reduce Caesarian Sections (CS) rate. A comparison of our results with the performance of the best Italian hospitals for number of deliveries and CS has been performed. Methods: A monitoring system was set up, based on a prospective collection of all deliveries from 2013 to 2017, according to Robson’s classification. Data have also been collected retrospectively at a regional and national level to compare our results to other institutions. The multi-approach intervention consisted of evidence based tools: process management, training, multiprofessionalism, development of planning and control systems, continuous monitoring, audit and feedback. Results: The percentage of primary CS decreased from 26.71% in 2013 to 15.03% in 2017 (RR adjusted considering the regional average: 0.87 in 2013; 0.57 in 2017, p < .001). A raise of 19.76% in the annual volume of deliveries was registered. Such results have also been confirmed after comparing to the best performing Italian centers. From 2013 to 2016 the percentage of primary CS decreased from 27.02% to 18.04% (RR adjusted considering the regional average: 1.04 in 2013, p > .05; 0.74 in 2016, p < .001), while there was an increase in the annual volume of deliveries from 3,311 to 4,219. Conclusions: Our study confirms that multifaceted interventions can strengthen a continuous quality and safety improvement approach. This is of crucial relevance in the obstetric field and in the Italian country, where overall performance in CS needs to be improved.

Background: Clinical Diagnostic Care Pathways (CDCP) are management tools widespread throughout the world to improve the quality of patient care through a well-organized care continuum and to enhance the patient's "risk-adjusted" outcomes; indeed they could optimize the management of resources. They are particularly effective in the management of patients with chronic degenerative diseases, such as chronic kidney disease, with increasingly incidence and prevalence, with an estimated 11-13% of the population being affected. The aim of this study is to apply the Health Services Research methods to estimate the relationship between need, demand and supply in patients with stage 5 Chronic Kidney Disease (CKD) for, then to describe the definition of a CDCP dedicated to patients in Lazio Region, so to allow an appropriate patient management, to reduce the likely complications and the patients' migration to facilities outside the region. Methods: The study was conducted in 2017 in collaboration between the National Institute of Health, the University of Messina and the S. Giovanni Addolorata Hospital. Results: We analyzed the data for the CKD in Roma and in the San Giovanni Addolorata Hospital Trust and we found a drop out in the patients' attendance towards other regions and/or hospitals. So we defined a CDCP to be adopted at the San Giovanni Addolorata hospital. Conclusions: To define management and care tools to provide adequate, efficient and patient centered care is a nowadays "must", to ensure the sustainability of the Italian NHS, which today is comparable to a "ship that is heading towards a perfect storm".

Background: Clinical Diagnostic Care Pathways (CDCP) are management tools widespread throughout the world to improve the quality of patient care through a well-organized care continuum and to enhance the patient's "risk-adjusted" outcomes; indeed they could optimize the management of resources. They are particularly effective in the management of patients with chronic degenerative diseases, such as chronic kidney disease, with increasingly incidence and prevalence, with an estimated 11-13% of the population being affected. The aim of this study is to apply the Health Services Research methods to estimate the relationship between need, demand and supply in patients with stage 5 Chronic Kidney Disease (CKD) for, then to describe the definition of a CDCP dedicated to patients in Lazio Region, so to allow an appropriate patient management, to reduce the likely complications and the patients' migration to facilities outside the region. Methods: The study was conducted in 2017 in collaboration between the National Institute of Health, the University of Messina and the S. Giovanni Addolorata Hospital. Results: We analyzed the data for the CKD in Roma and in the San Giovanni Addolorata Hospital Trust and we found a drop out in the patients' attendance towards other regions and/or hospitals. So we defined a CDCP to be adopted at the San Giovanni Addolorata hospital. Conclusions: To define management and care tools to provide adequate, efficient and patient centered care is a nowadays "must", to ensure the sustainability of the Italian NHS, which today is comparable to a "ship that is heading towards a perfect storm".

La gestione per processi ed i percorsi clinico assistenziali (PCA) sono strumenti vincenti per il miglioramento della qualità all’interno di ogni organizzazione sanitaria, nel rispetto delle logiche della clinical governance. Come uno dei più grandi ospedali italiani, che ha fatto della centralità del paziente uno dei temi fondanti la sua mission, ha legato alla sua recente riorganizzazione l’attivazione di un modello di gestione dell’assistenza per percorsi dedicati a problemi di salute (dalla diagnosi al follow-up), che operano secondo le logiche della gestione per processi? Come questa esperienza ha collocato tale Struttura in un ruolo di riferimento a livello nazionale? Il manuale è concettualmente articolato in due sezioni. Dopo una breve introduzione sulla necessità oggi, nel contesto italiano e internazionale, di improntare l’assistenza su logiche sostenibili di centralità del paziente e di cure appropriate e basate sulle prove di efficacia, il manuale propone: - uno strumento operativo e flessibile in grado di supportare il management e gli operatori delle aziende sanitarie pubbliche e private operanti nell’ambito del Servizio Sanitario Nazionale italiano in tutte le fasi dell’implementazione dei PCA dalla loro introduzione in azienda, all’implementazione, al monitoraggio fino alla revisione e dell’approccio metodologico alla base dello strumento stesso. Tale strumento si basa su un modello rigoroso definito al termine di un Progetto di Dottorato dedicato, che ne ha permesso la concettualizzazione. Partendo da questo framework, viene definito un approccio metodologico articolato in sei fasi: selezione del problema di salute; costruzione del gruppo di lavoro multidisciplinare; analisi del percorso effettivo e del percorso di riferimento; descrizione del percorso obiettivo; implementazione del PCA; monitoraggio e audit. Particolare attenzione è stata dedicata alle modalità che supportano il change management e il miglioramento della qualità dell’assis

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.

Introduction: Integrated Care Pathways (ICPs) are a method for the mutual decision-making and organization of care for a well-defined group of patients during a well-defined period. The aim of a care pathway is to enhance the quality of care by improving patient outcomes, promoting patient safety, increasing patient satisfaction, and optimizing the use of resources. To describe this concept, different names are used, e.g. care pathways and integrated care pathways. Modern information technologies (IT) can support ICPs by enabling patient empowerment, better management, and the monitoring of care provided by multidisciplinary teams. This study analyses ICPs across Europe, identifying commonalities and success factors to establish good practices for IT-supported ICPs in diabetes care. Methods: A mixed-method approach was applied, combining desk research on 24 projects from the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA) with follow-up interviews of project participants, and a non-systematic literature review. We applied a Delphi technique to select process and outcome indicators, derived from different literature sources which were compiled and applied for the identification of successful good practices. Results: Desk research identified sixteen projects featuring IT-supported ICPs, mostly derived from the EIP on AHA, as good practices based on our criteria. Follow-up interviews were then conducted with representatives from 9 of the 16 projects to gather information not publicly available and understand how these projects were meeting the identified criteria. In parallel, the non-systematic literature review of 434 PubMed search results revealed a total of eight relevant projects. On the basis of the selected EIP on AHA project data and non-systematic literature review, no commonalities with regard to defined process or outcome indicators could be identified through our approach. Conversely, the research produced a heterogeneous picture i

Increased participation in cancer screening programs is undoubtedly a primary objective in Public Health. The Green and Kreuter model, structured in an Access program, was presented to the Regional Coordinators for cancer screening during specific training events. This survey was carried out to verify their appreciation of the model and whether those who participated in the project intended to use the program

This brief note presents a few examples of successful health collaboration to improve healthcare in Arab countries. Considerable growth has been noticed in the past years in the health sector of the Middle East and North Africa region countries due to the need to address health service capacity gaps and improve the quality of health infrastructure. The rising population coupled with the aging demographic is expected to drive healthcare demand in the Arab region, augmenting its demand. In order to meet this demand, a lot of progress within the public sector has been made and several initiatives have taken place to create awareness of the most common diseases affecting the region. Among the steps undertaken in order to face the shortage of experience of medical personnel and the rising cost of the delivery of health services, the most noticeable ones relate to major investments within the realm of healthcare provision. However, country-specific drivers of disease burden should inform financial and research investments, prevention efforts, health policies, and health system improvement initiatives for all countries along the development continuum. Moreover, health gains will need to be sustained by supporting interventions on income, education, and fertility as drivers of health improvement.

Risk management is a key tool in Clinical Governance. Our project aimed to define, share, apply and measure the impact of tools and methodologies for the continuous improvement of quality of care, especially in relation to the multi-disciplinary and integrated management of the hyperglycemic patient in hospital settings. A training project, coordinated by a scientific board of experts in diabetes and health management and an Expert Meeting with representatives of all the participating centers was launched in 2014. The project involved eight hospitals through the organization of meetings with five managers and 25 speakers, including diabetologists, internists, pharmacists and nurses. The analysis showed a wide variability in the adoption of tools and processes towards a comprehensive and coordinated management of hyperglycemic patients.

The aim of this study was to assess the long-term physical and psychological disabilities and their economic impact in severe trauma survivors.

BACKGROUND: Gender differences are evident in many common health conditions, especially respiratory diseases such as asthma and chronic obstructive pulmonary disease (COPD). The aim of this review was to identify published studies describing gender differences in asthma and COPD, in particular regarding pathophysiology, diagnosis and treatment, with a focus on Italian data. METHODS: a literature review was performed from April to November 2015, using the PubMed scientific database and the following ??eywords: "gender differences" and "asthma" for the asthma review and "gender differences" and "COPD" for the COPD review. RESULTS: Gender differences in asthma are related to age groups. In the female population, asthma is generally more severe and disabling, and presents higher mortality rates with respect to same-age males. COPD prevalence is growing and is underestimated in women, because it tends to be diagnosed with difficulty and at a delayed stage. The same findings were observed when restricting the review to Italian data. CONCLUSION: Clinicians should collaborate to develop a more gender-oriented approach towards diagnosis and treatment of asthma and COPD. In Italy, this would also facilitate measures to improve compliance, particularly among women.

OBIECTIVE: Emergency Departments (EDs) worldwide face the challenges of crowding, waiting times, and cost containment. This review aims to provide a synthesis of the current literature focused on how Lean Thinking Principles and tools can be applied in an ED to address overcrowding and hospital admissions. MATERIALS AND METHODS: Primary studies showing Lean interventions and implementation in ED visits, not requiring additional resources measuring specific outcomes (i.e. length of stay, patient volume, patient satisfaction, waiting times for the first visit, waiting times for diagnostic results, left without being seen) were selected. PubMed, Scopus, CINAHL, EconLit, NHS Economic Evaluation Database, Business Sources Complete, and Health Technology Assessment were used to conduct searches. Full-text articles of all potentially relevant publications were reviewed for eligibility. Discrepancies were resolved through discussion by all reviewers. Quality assessment and critical appraisal of selected studies were also evaluated by applying the Quality Improvement Minimum Quality Criteria Set. RESULTS: Nine before-and-after studies met these eligibility criteria. Management of patient flow was the main intervention. Almost all studies showed EDs performance improvement: increased patient volume, decreased length of stay and number of patients left without being seen, reduced costs, and increased patient satisfaction. Only one case reported worse results after Lean intervention implementation. CONCLUSIONS: Though Lean Principals have been used in healthcare for many years conclusion of their effects could still not be drawn. Surely, human-centered approach, top management support, work standardization, resources allocation and adaptation to the local context seem to be crucial for success. Furthermore, higher quality studies are needed: specific research design, appropriate statistical tests and outcome measures are needed. Before large-scale implementation, further studie

OBJECTIVE: Antibiotic prophylaxis (AP) is useful to prevent antimicrobial overuse, misuse and abuse, as well against the occurrence of surgical site infections (SSIs). This study aimed to describe the implementation of a quality improvement intervention on AP for elective surgery, as informal interviews showed a lower than expected compliance with internal recommendations, and to evaluate intervention's effect in terms of main drug consumption. DESIGN: A quality improvement intervention on all elective cases within 14 main surgical departments was performed. SQUIRE 2.0 guidelines were used in designing and reporting. SETTING: The intervention was implemented in an Italian Teaching Hospital 2 years after the adoption of internal evidence-based AP recommendations. PARTICIPANTS: Professionals involved in elective surgery. INTERVENTIONS: The intervention was structured into two phases: a survey was conducted during two non-consecutive weeks period (April-May 2013) to assess the adherence to the international guidelines in AP; survey's results were presented and discussed with all the surgical teams (December 2013-April 2014). MAIN OUTCOME MEASURES: Impact on cefazolin consumption (in defined daily doses per 100 procedures). RESULTS: Data of AP for 653 surgical procedures in terms of type, timing, duration, excess and defect were analyzed. An optimal AP rate resulted in 48.1% cases. Reduction in cefazolin use (-21.5%) and cost (-22.9%) was registered. CONCLUSIONS: Though results cannot be generalized to all hospital populations, the implemented intervention is likely to improve AP consequently improving quality of care and reducing costs. Further studies are needed to evaluate specific outcomes such as rate of SSIs and antibiotic resistance.

BACKGROUND: Clinical governance (CG) is an approach to quality improvement in healthcare aimed at achieving a patient-centered health care system. The main objective of this study was to highlight human centered healthcare latent factors underlying the results of a CG assessment performed in the teaching hospital "A. Gemelli" of Rome, Italy. MATERIALS AND METHODS: CG implementation levels were assessed through OPTIGOV© (OPTimizing healthcare GOVernance), a CG scorecard methodology. In order to identify the variables generating latent factors that can influence the governance of the Hospital, the multiple correspondence analysis (MCA) was applied. RESULTS: The application of OPTIGOV© showed a good CG implementation level in the Gemelli Hospital. By applying MCA, the variables aggregated so as to define 3 latent factors (F1: assessment for people oriented improvement strategy; F2: assessment for people targeted management; F3: tracking for timely accountable people) explaining as a whole 82.68% of the total variance and respectively 48.09% (F1), 24.95% (F2) and 9.64% (F3). CONCLUSIONS: The heuristic interpretation of the three latent factors could bring back to the concept of humanization in healthcare. This study shows that in the teaching hospital "A. Gemelli" humanization in healthcare is the driver of health care quality improvement.

Accountability and Public Reporting: in Performance to Improve Quality towards Promoting patient engagement and participation for effective healthcare reform

In Italia, la variabilità nella pratica clinica è comune e rappresenta una delle maggiori preoccupazioni per pazienti, professionisti e decisori. Attraverso la selezione di tre aree cliniche (gravidanza e parto, trattamento con Angioplastica Coronarica Transluminale Percutanea - PTCA nei pazienti con infarto miocardico acuto e gestione del diabete), gli autori sottolineano come vi sia, in ciascuna delle tre aree, una ingiustificata variabilità, che non può essere spiegata solo dalla frequenza/gravità della malattia o da altri fattori relativi al paziente. Al fine di descrivere la variabilità tra le Regioni italiane, gli autori hanno scelto sia indicatori di processo (esempio volumi) sia di risultato (esempio mortalità, complicanze). L’incidenza di tagli cesarei è particolarmente elevata in Italia rispetto agli altri Paesi europei. Più che altrove, le pressioni legate alla cosiddetta medicina difensiva, la pianificazione del parto per ragioni di convenienza sia dei medici che dei pazienti e, più in generale, i cambiamenti nel rapporto medico-paziente sono probabilmente responsabili dell’induzione di pratiche inappropriate. Inoltre, importanti variazioni si osservano a livello intraregionale, in particolare per quanto riguarda il tipo di ospedale (privato, pubblico e universitario). Anche l’esecuzione tempestiva della PTCA è caratterizzata da una variabilità interregionale che ancora una volta non può essere spiegata solo da fattori clinici. In particolare, si osserva un’estrema variabilità tra strutture appartenenti alla stessa Regione nella percentuale di PTCA eseguite entro 48 ore. Per quanto riguarda il diabete, sono state osservate differenze rilevanti nel consumo di farmaci, nel controllo metabolico dei pazienti e nei ricoveri per complicanze a breve e a lungo termine, che sono considerate un proxy della gestione dei pazienti a livello territoriale. Tale gestione genera disuguaglianze nel campo della salute, con effetti rilevanti sulla sostenibilità finanziaria

Introduzione. La variabilità nella pratica clinica rappresenta uno dei temi più attuali e complessi in Sanità Pubblica. Tale variabilità si osserva anche nella gestione del diabete, patologia cronica ampiamente diffusa e gravata, se non correttamente gestita, da molteplici complicanze. In Italia, la prevalenza del diabete è del 5,5% e la sua frequenza è in continuo aumento. L’assistenza ai pazienti, dato l’oneroso impatto sociale, economico e sanitario della malattia, rappresenta, oggi, uno degli elementi essenziali su cui si deve focalizzare l’organizzazione dei sistemi sanitari. Metodi. Attraverso una revisione della letteratura, abbiamo approfondito la tematica della variabilità nelle cure in Italia, prendendo in considerazione la gestione terapeutica del diabete e l’accesso all’ospedale per le complicanze ad esso associate. Risultati. Dalla consultazione dei dati del Programma Nazionale Esiti 2014 si evince che il tasso di ospedalizzazione per complicanze a breve e a lungo termine del diabete presenta un’importante eterogeneità inter ed intra-regionale. Variabilità esiste anche nella gestione terapeutica della patologia che, come emerge dal Rapporto OsMed 2013, presenta differenze significative sia in termini di consumi che di spesa lorda pro capite. É possibile identificare, in generale, un gradiente crescente Nord-Sud che, se da un lato può essere ricondotto alla prevalenza della malattia, dall’altro può mascherare carenze nel controllo della malattia a livello territoriale. Conclusioni. L’analisi dei dati rivela una variabilità ingiustificata, in termini sia di consumo di risorse che di stato di salute degli assistiti, che sta ad indicare che, ad oggi, non esiste uniformità assistenziale nel nostro Paese. Il “governo della variabilità” rappresenta, quindi, una necessità strategica funzionale al miglioramento, uniforme ed equo su tutto il territorio nazionale, del controllo della malattia diabetica e richiede una responsabilizzazione locale e r

Introduzione: La Clinical Governance (CG) è un approccio teso al miglioramento della qualità in sanità nelle more della patient-centeredness. Obiettivo di questo studio è stato analizzare i risultati dellavalutazione della CG nel Policlinico Gemelli per identificare leve strategiche atte al miglioramento dell’assistenza erogata, valutandone il grado di “umanizzazione”. Materiali e metodi: La CG nel Policlinico Gemelli è stata valutata nel 2012 con la metodologia OPTIGOV. Al fine di individuare le variabili generatrici di fattori latenti in grado di influenzare la governance dell’ospedale è stata applicata l’analisi delle corrispondenze multiple (MCA). Risultati: L’applicazione di OPTIGOV ha evidenziato un buon livello d’implementazione della CG. La MCA tramite l’aggregazione delle variabili ha definito 3 fattori latenti: F1=48,09%; F2= 24,95%; F3=9,64%, che spiegano l’82,68 % della varianza totale. In relazione alla loro interpretazione euristica sono stati definiti: F1: “VALUTAZIONE PER STRATEGIE DI MIGLIORAMENTO ORIENTATE ALLA PERSONA” à con focus su professionisti sanitari e pazienti, per individuare strategie di miglioramento continuo tramite la produzione di evidenze e feedback sulle performance. F2: “VALUTAZIONE PER UNA GESTIONE FINALIZZATA ALLA PERSONA” à con focus su sanitari e pazienti, per migliorare la qualità dell’assistenza attraverso l’empowerment dei lavoratori, tramite la valutazione delle performance tesa alla programmazione. F3: “TRACCIABILITÀ PER UN’ACCOUNTABILITY PUNTUALE DEI PROFESSIONISTI” à con focus sulla qualità dell’assistenza, per migliorare la comunicazione e la cooperazione tra i professionisti sanitari, la relazione medico-paziente, la sicurezza di operatori e pazienti. Conclusioni L’interpretazione euristica dei risultati riconduce al concetto di umanizzazione dell’assistenza sanitaria. Dallo studio emerge come all’interno del Policlinico A. Gemelli l’umanizzazione delle cure continua ad essere il driver del miglioramento d

Issue/problem Decision-making in hospitals is evolving from being opinionbased to being evidence-based. Whilst clinical guidelines provide evidence-based recommendations, evidence-based practice needs to address the local structure, systems and time-frames. Clinical pathways are document-based tools that provide a link between the best available evidence and clinical practice. Problem During a meeting with the professional from all ‘A. Gemelli’ teaching hospital units involved in the care of stomach cancer patients as well as primary care representatives, the Clinical Governance Unit presented the project of developing a clinical pathway for the care of stomach cancer patients. Professionals were divided in three groups: a first group analyzed the specific epidemiological context of stomach cancer patients attending the hospital, a second group designed on the basis of evidence and current practice the pathway flowchart in a diagram that shows on vertical axis stages of care and on orizonal axis the places of care and a third group selected quality indicators useful for future audits. After joint debates, the complete clinical pathway was reviewed by the whole group of involved professionals. Results A report including the pathway flowchart of activities articulated in clinical episodes and 28 indicators covering 5 quality dimensions was approved. Multidisciplinary team meetings as well as joint surgeon/medical oncologist examinations were introduced in hospital practice. Case management and cooperation between hospital and primary care were enhanced. The use of hospital resource and the timing between the different care stages as well as patients’ satisfaction resulted improved. Preliminary results show also improvements in clinical outcome measured. Lessons Clinical pathways are an effective instrument to decrease undesired practice variability and improve clinician performance. The early involvement of all professionals in the development of clinical pathways is

La Clinical Governance (CG) è un approccio teso al miglioramento della qualità in sanità nelle more della patient-centeredness. Obiettivo di questo studio è stato analizzare i risultati dellavalutazione della CG nel Policlinico Gemelli per identificare leve strategiche atte al miglioramento dell’assistenza erogata, valutandone il grado di “umanizzazione”. Materiali e metodi: La CG nel Policlinico Gemelli è stata valutata nel 2012 con la metodologia OPTIGOV. Al fine di individuare le variabili generatrici di fattori latenti in grado di influenzare la governance dell’ospedale è stata applicata l’analisi delle corrispondenze multiple (MCA). Risultati: L’applicazione di OPTIGOV ha evidenziato un buon livello d’implementazione della CG. La MCA tramite l’aggregazione delle variabili ha definito 3 fattori latenti: F1=48,09%; F2= 24,95%; F3=9,64%, che spiegano l’82,68 % della varianza totale. In relazione alla loro interpretazione euristica sono stati definiti: F1: “VALUTAZIONE PER STRATEGIE DI MIGLIORAMENTO ORIENTATE ALLA PERSONA” à con focus su professionisti sanitari e pazienti, per individuare strategie di miglioramento continuo tramite la produzione di evidenze e feedback sulle performance. F2: “VALUTAZIONE PER UNA GESTIONE FINALIZZATA ALLA PERSONA” à con focus su sanitari e pazienti, per migliorare la qualità dell’assistenza attraverso l’empowerment dei lavoratori, tramite la valutazione delle performance tesa alla programmazione. F3: “TRACCIABILITÀ PER UN’ACCOUNTABILITY PUNTUALE DEI PROFESSIONISTI” à con focus sulla qualità dell’assistenza, per migliorare la comunicazione e la cooperazione tra i professionisti sanitari, la relazione medico-paziente, la sicurezza di operatori e pazienti. Conclusioni L’interpretazione euristica dei risultati riconduce al concetto di umanizzazione dell’assistenza sanitaria. Dallo studio emerge come all’interno del Policlinico A. Gemelli l’umanizzazione delle cure continua ad essere il driver del miglioramento della qualità

The need to integrate clinical and public health training of medical students is increasingly important. Future physicians need to be able to deal with new, complex and growing public health challenges. MATERIALS AND METHODS: A literature search was performed through Pubmed to identify the conceptual reference framework. Meetings were carried out to identify the most appropriate modalities and priorities required for drafting the project, to identify the skills to be acquired by students, to decide on teaching formats and methods to assess student learning, to draw up the teaching schedule, to define the statistical methods to be used to assess student satisfaction, and to perform the statistical analysis of results. Training in hospital hygiene and environmental safety was carried out through presentation of a relevant case. After being divided into groups the students attended the three units (Environmental Microbiology, Environmental Xenobiotics, Genetic Epidemiology and Molecular Biology) of the Hygiene Section of a Public Health Institute. Training in Organization and Health Programming involved presentation of a set of indicators for the definition of objectives and assessment of health systems or services. RESULTS: The literature search led to the identification of the relevant literature. With regard to student satisfaction, 96% of those who replied to the questionnaire gave an overall positive review of the training course (at least 3 on a scale from 1 to 5). CONCLUSIONS: the overall high level of student satisfaction suggests that the proposed model may be exportable. Further developments will be the assessment of trends regarding functioning of the organizational model and perceived teaching quality.

BACKGROUND: There isn't a validated questionnaire in Italian language to evaluate the quality perceived by the patient in Digestive Endoscopy. OBJECTIVE: validation of the translation of a questionnaire from English to Italian language to measure the level of patient satisfaction. MATERIALS AND METHODS: we conducted a prospective study on validation in Italian of a short questionnaire adapted for Endoscopy by the American Society of Gastrointestinal Endoscopy, the GHAA-9m. It's been tested with the technique of the questionnaire / interview on 80 outpatients who underwent in the month of September 2014 to endoscopic examinations of the gastrointestinal tract. The patients were divided into 2 groups of 40 patients: group 1 was administered before the questionnaire and subsequently the interview was conducted, on the contrary on the group 2 was administered before the interview and subsequently the questionnaire. The results of the two groups were compared using the inter-rater agreement. It was also evaluated the internal consistency of the questions. RESULTS: The results show that the instrument is experienced as simple and quick to use for patients. Data analysis allowed us to conclude that the Italian translation is valid and consistent. In the phase of the interview there were some aspects that suggest, in a development of this tool, some changes that could increase the accuracy and informational content. CONCLUSIONS: The Italian version of the questionnaire GHAA-9m has good validity, reliability, and shows property valuation comparable to those of the American version and can therefore be used in daily practice Digestive Endoscopy

In Italy, major initiatives to address chronic diseases are relatively recent but relevant strategies are receiving increasingly greater attention by policy-makers and health care providers. However, as a consequence of the increasing autonomy of regions, there is considerable diversity with regard to the extent and quality of such strategies across the country, or even across local health authorities within regions, with many initiatives tending to be located in the north of the country. In addition, as in other countries, there is considerable fragmentation between social (municipalities) and health care services (local health agencies). Recent initiatives have aimed to overcome these challenges through implementing centrally planned and target-driven coordination. Examples include diabetes, for which there is a framework for initiatives of regional and local authorities, which are responsible for adapting the guidelines to their own specific organizational and epidemiological features and to achieving the targets agreed upon. This framework for diabetes was confirmed by the 2010 national plan for prevention, covering the period 2010–2012 and identifying diabetes management as a priority for regional and local authorities and which has been adopted by all regions. Furthermore, a small number of regions and local health agencies have cautiously introduced a number of experimental initiatives on chronic diseases that are not (yet) considered by national projects, mainly involving specific formation of GPs – often promoted by scientific organizations or pharmaceutical companies. Accordingly, attempts to implement disease management can be expected to spread slowly.