Telemedicine to Improve Access to Specialist Care in Fetal Heart Rate Monitoring: Analysis of 17 Years of TOCOMAT Network Clinical Activity.

BACKGROUND: The objective of this article is to provide an overview of the clinical experience of our telemedicine network (TOCOMAT) for fetal well-being assessment through computerized Cardiotocography (cCTG), analyzing cultural, socioeconomic, and environmental conditions of pregnant women and its economic sustainability over time. MATERIALS AND METHODS: We used the central data store, including all cCTG records collected in Campania region (Italy) during 17 years of activity. The Operations Center acquires the traces recorded in the Remote Units and simultaneously performs a complex fetal heart rate analysis. An Internet or phone conference calling is available to discuss the information transmitted. Finally, the report is send back to the Remote Units. RESULTS: The number of cCTG traces performed was constantly increasing, despite the progressive reduction in the number of peripheral units involved. Pregnant women in Remote Unit group were younger and overweight and showed a higher incidence of diabetes and fetal defects than Operations Center ones. Moreover, a high rate of African migrant women and low socioeconomic and cultural standards were found in Remote Unit group. The cost analysis showed an economic advantage both in the reduction of inappropriate admissions and in the improvement of admission indicators (hospital stay days) for pregnant women. DISCUSSION: The global economic recession has had a significant impact on the Italian regional healthcare system and socioeconomic deprivation. CONCLUSIONS: Telemedicine could avoid unnecessary referral to Level III centers (Hospital) in Campania region, where the average population density is very high, allowing equal access to ultra-specialist assessment irrespective of the geographical location of the pregnant woman with medium to high risk, as well as rationalizing the costs for maternal and fetal care.

Positioning matrix of economic efficiency and complexity: a case study in a university hospital.

At the end of 2010, the Federico II University Hospital in Naples, Italy, initiated a series of discussions aimed at designing and applying a positioning matrix to its departments. This analysis was developed to create a tool able to extract meaningful information both to increase knowledge about individual departments and to inform the choices of general management during strategic planning. The name given to this tool was the positioning matrix of economic efficiency and complexity. In the matrix, the x-axis measures the ratio between revenues and costs, whereas the y-axis measures the index of complexity, thus showing "profitability" while bearing in mind the complexity of activities. By using the positioning matrix, it was possible to conduct a critical analysis of the characteristics of the Federico II University Hospital and to extract useful information for general management to use during strategic planning at the end of 2010 when defining medium-term objectives.

Exit, voice, and loyalty in the Italian public health service: macroeconomic and corporate implications.

The paper analyses how customers of public health organizations can express their dissatisfaction for the services offered to them. The main aim is to evaluate the effects that possible dissatisfaction of Italian public health service customers can have on public health organizations. We adopted the methodological scheme developed by Hirschman with exit, voice, and loyalty, considering the macroeconomic and corporate implications that it causes for Italian public health organizations. The study investigated the effects developed by exit of the patients on the system of financing of local health authorities considering both the corporate level of analysis and the macroeconomic level. As a result, local health authority management is encouraged to pay greater attention to the exit phenomena through the adoption of tools that promote loyalty, such as the promotion of voice, even if exit is not promoting, at a macroeconomic level, considerable attention to this phenomenon.

Governance of innovation and appropriateness of hospitalization for high-risk pregnancy: the TOCOMAT system.

BACKGROUND: Over the last 30 years, a great increase in the application of technologies in public health, with an undisputed impact on both the effectiveness of performance and the investment and management costs, has occurred. This evidence has induced the development of assessment tools to clarify the relationships among resources, outputs, and outcomes of technological innovations. This analysis was developed in order to examine the use of a telematic system for reporting remotely transmitted cardiotocographic traces, specifically (1) its impact on the health organization and on the appropriateness of the care setting used and (2) the efficiency of its adoption in a regional network. MATERIALS AND METHODS: We adopted a case-control study on patients' medical records during the first 4 months of 2009, 2010, and 2011 and a cost analysis of resources used for the creation of a computerized telecardiotocography network connecting eight peripheral areas to the operations center. RESULTS: The case-control study showed a reduction in the average hospital stay days for high-risk patients (1.32) and for low-risk patient (1.7) with a total of cost savings of €89,628 for high-risk patients and €170,170 for low-risk patients. The cost savings of the regional network was €20,769.04. CONCLUSIONS: The adoption of a remote transmission system of cardiotocography provided a managerial and economic advantage in the reduction of inappropriate admissions for prepartum symptoms and an improvement in the admission indicators (hospital stay days).

A cost study of prenatal telemedicine.

We calculated the cost of using a telemedicine system for the cardiotocographic (CTG) recording of fetal heart rate. In a one-year study in the Campania region of Italy, 162 patients were monitored. The total cost of the telemedicine system was euro;344796. A control group was retrospectively drawn from all deliveries at the university hospital in Naples during the year 2000. Patients were retrospectively assigned to a category of high or low risk, and the hospital costs of the high-risk patients were compared. In the intervention group, 11 of the 87 high-risk patients (13%) were admitted to hospital prematurely, and stayed on average 12 days. In the control group, 203 of the 813 women in the high-risk group (25%) were admitted to hospital prematurely, and stayed on average 20 days. If the women in the control group had been monitored, there would have been a notional saving, through avoided bed days, amounting to 358280, which was similar to the cost of the telemedicine system. The study suggests that the use of telemedicine in CTG monitoring improves the quality of prenatal care.

Redesigning service delivery for hypertensive patients: a methodological guideline to improve the management of chronic diseases.

Best care is not necessarily the most expensive, but the most appropriate, and prevention is the most powerful tool to promote health. A novel approach might envision the reduction of hospital admittance (thus meeting a requirement from long term condition patients: they would rather not being hospitalized!) and the enforcement of peripheral (both on the territory and at home) assistance. In this direction, experiences of reshaping new service deliveries towards an integrated disease management, namely clinical pathways, can be observed in Europe and in different parts of the world. Aim of this paper is to provide a methodological guideline to support the management in planning clinical pathways, also outlining the main barriers limiting the process. In particular, we present the results of planning a clinical pathway at the Centre for Hypertension of the Federico II University Hospital (Naples, Italy). The case study showed that the introduction of a similar service impacts on the organisation of the structure. An analysis of organizational processes "as are" and the re-design of processes "to be" are necessary to integrate the clinical pathway into the actual activities.

The balanced scorecard as a strategic management tool: its application in the regional public health system in Campania.

Health, as a primary and advanced need, can only be guaranteed through the appropriate management of dedicated resources. As in any situation where funds are limited, it is vital to have logical frameworks and tools to set up structures capable of making a complex system like the health service work. Only through an appropriate and competent activity of governance can such structures be identified, organized, and rendered operational. This can be achieved by using ad hoc tools such as the Balanced Scorecard. Its application in the case of the Regional Government of Campania indicates that it is a valid tool in all circumstances except in situations of crisis.