Piloting a PREMs and PROMs longitudinal survey on the integration of healthcare services for patients living with hepatitis C in Tuscany region: study protocol.

INTRODUCTION: Patient-reported measures are an invaluable resource for health systems to improve the quality of healthcare services. Patients with hepatitis C virus (HCV) are an under-represented group within the stream of literature on collecting and using the experiences and outcomes reported by patients to improve healthcare performance. This protocol outlines the methodology to implement a longitudinal survey in Tuscany, Italy, to systematically gather patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs) for patients with HCV, with a focus on the integration of primary and hospital care. METHODS AND ANALYSIS: We designed and developed a longitudinal survey to collect HCV PREMs and PROMs. The survey, which lasts 1 year, consists of three questionnaires, starting with the first visit with a specialist/treatment initiation, with follow-ups at 6 and 12 months. It was implemented in six hospitals in Tuscany, Italy, of which three are University Hospitals. The survey was offered to all patients treated for HCV at these healthcare centres, deliberately not applying a specific criterion for patient selection, through both paper based and electronic modes of completion. The data from the three structured questionnaires will be analysed quantitatively. ETHICS AND DISSEMINATION: The Ethics Committee for Clinical Experimentation of Area Vasta Nord Ovest approved the protocol (CEAVNO-CODE 18829). Participation in this study is voluntary. Study results will be disseminated through peer-reviewed publications and academic conferences.

Nursing and midwifery simulation training with a newly developed low-cost high-fidelity placenta simulator: a collaboration between Italy and Ethiopia.

BACKGROUND: Simulation training provides safe environment for skill acquisition and retention. This study addresses a critical challenge in Africa - umbilical cord and placenta management after childbirth - aiming to bridge theoretical learning with practical experiences through simulation. We realized a new low-cost high-fidelity simulator of placenta and umbilical cord. We conducted a needs-based training course for nursing and midwifery students at St. Luke Hospital of Wolisso, Ethiopia, to validate our new simulator and compare its acceptability and teaching effectiveness with other two simulators (conventional low-fidelity model and human placenta). METHODS: We surveyed St. Luke Hospital medical experts to obtain their feedback on the new simulator's face, content, and usability. We carried out a simulation training course for 67 students who received theoretical lectures and simulation courses being divided into three groups according to the simulator used. We assessed the simulators' user acceptability using the Technology Acceptance Model (TAM) and compared the final objective evaluations by tutors between groups. RESULTS: Experts confirmed the new simulator's fidelity, material quality, and usability. Students training on the new simulator demonstrated higher objective scores and perceived it as more useful and user-friendly compared to human placenta, while there was no difference between conventional simulator and human placenta in the TAM items. CONCLUSION: We validated a new high-fidelity simulator developed by the Sant'Anna School of Advanced Studies in Pisa, Italy, using the TAM scale and robust statistical methods, thanks to a successful collaboration with St. Luke's Hospital in a simulation training course where students achieved higher objective scores and perceived the simulator as more useful and easier to use than a real human placenta, suggesting significant educational benefits and potential for future research.

Evaluating hepatitis C cascade of care surveillance system in Tuscany, Italy, through a population retrospective data-linkage study, 2015-2021.

This comprehensive retrospective data-linkage study aimed at evaluating the impact of Direct-Acting Antivirals (DAAs) on Hepatitis C Virus (HCV) testing, treatment trends, and access to care in Tuscany over six years following their introduction. Utilizing administrative healthcare records, our work reveals a substantial increase in HCV tests in 2017, attributed to the decision to provide universal access to treatment. However, despite efforts to eradicate chronic HCV through a government-led plan, the target of treating 6,221 patients annually was not met, and services contracted after 2018, exacerbated by the COVID-19 pandemic. Key findings indicate a higher prevalence of HCV screening among females in the 33-53 age group, influenced by pregnancy-related recommendations, while diagnostic tests and treatment uptake were more common among males. Problematic substance users constituted a significant proportion of those tested and treated, emphasizing their priority in HCV screening. Our paper underscores the need for decentralized HCV models and alternative testing strategies, such as point-of-care assays, especially in populations accessing harm reduction services, communities, and prisons. The study acknowledges limitations in relying solely on administrative records, advocating for improved data access and timely linkages to accurately monitor HCV care cascades and inform regional plans. Despite challenges, the paper demonstrates the value of administrative record linkages in understanding the access to care pathway for hard-to-reach populations. The findings emphasize the importance of the national HCV elimination strategy and the need for enhanced data collection to assess progress accurately, providing insights for future regional and national interventions.

Pregnancy vaccination predictive factors and uptake profiles among Italian women: A cross-sectional survey study on a large population.

OBJECTIVES: To assess influenza and Tdap (tetanus, diphtheria, pertussis) vaccine coverage during pregnancy, explore key socioeconomic and maternity pathway-related predictors of vaccination, and detect specific patterns of vaccination uptake. METHODS: The authors cross-sectionally analyzed self-reported data obtained from the systematic survey on the maternity pathways of Tuscany. They selected all pregnant women that completed from March 2019 to June 2022 the third-trimester questionnaire (n = 25 160), which included two dichotomous items on influenza and Tdap vaccination, as well as socioeconomic and pathway-related questions. Multilevel logistic models were performed to assess vaccination predictors and cluster analysis to identify vaccination patterns. RESULTS: Vaccination coverage was higher for pertussis (56.5%) than for influenza (18.9%). The main predictors of vaccination were high socioeconomic status, attending private gynecologists, and receiving vaccine information. Three clusters were identified: cluster 1 included women receiving both Tdap and influenza vaccines; cluster 2 included women receiving no vaccinations; and cluster 3 included women receiving only the pertussis vaccine. Although women from cluster 3 were of middle to low education status, vaccine information was the main adherence determinant also in this group. CONCLUSIONS: Health workers and policymakers should focus on groups of pregnant women less prone to vaccination to promote vaccination information and encourage wider uptake and coverage.

Value of Including the Children's Experience for Improving Their Rights During Hospitalization: Protocol for the VoiCEs Project.

BACKGROUND: Users' feedback is a key asset for organizations that want to improve their services. Studying how organizations are enabling their users to participate in evaluation activities is particularly important, especially when there are vulnerable or disadvantaged people, and the services to be evaluated can be life-changing. This is the case in the coassessment by pediatric patients experiencing hospital stay. The international literature reports a few attempts and several challenges in systematically collecting and using the pediatric patient experience with respect to hospitalization, to undertake quality improvement actions. OBJECTIVE: This paper describes the research protocol of a European project intended to develop and implement a systematic pediatric patient-reported experience measures (PREMs) observatory that will be shared by 4 European children's hospitals in Finland, Italy, Latvia, and the Netherlands. METHODS: The VoiCEs (Value of including the Children's Experience for improving their rightS during hospitalization) project uses a participatory action research approach, based on a mixture of qualitative and quantitative methods. It consists of 6 different phases, including a literature review, an analysis of the previous experiences of pediatric PREMs reported by project partners, a Delphi process, a cycle of focus groups or in-depth interviews with children and their caregivers, a series of workshops with interactive working groups, and a cross-sectional observational survey. The project guarantees the direct participation of children and adolescents in the development and implementation phases of the project. RESULTS: The expected results are (1) a deeper knowledge of published methodologies and tools on collecting and reporting pediatric patients' voice; (2) lessons learnt from the analysis of previous experiences of pediatric PREMs; a consensus reached through a participatory process (3) among experts, (4) pediatric patients and caregivers about a standard set of measures for the evaluation of hospitalization by patients; (5) the implementation of a European observatory on pediatric PREMs; and (6) the collection and comparative reporting of the pediatric patients' voice. In addition, the project is aimed at studying and proposing innovative methodologies and tools for capturing the pediatric patients' feedback directly, avoiding the intermediation of parents/guardians. CONCLUSIONS: Over the last decade, the collection and use of PREMs have gained importance as a research field. Children and adolescents' perspectives have also been increasingly taken into consideration. However, to date, there are limited experiences regarding the continuous and systematic collection and use of pediatric PREMs data for implementing timely improvement actions. In this perspective, the VoiCEs project provides room for innovation, by contributing to the creation of an international, continuous, and systematic pediatric PREMs observatory that can be joined by other children's hospitals or hospitals with pediatric patients, and foresees the return of usable and actionable data in benchmarking. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/42804.

Effectiveness of measures to preserve labour and childbirth companionship at the times of COVID-19 outbreak.

INTRODUCTION: Although childbirth services were accessible after COVID-19 outbreak, the measures taken by the Italian Government for contagion containment required some restrictions on the presence of trusted persons for mothers, forcing them to isolation during hospitalization. To preserve companionship, the Regional Health Authority of Tuscany issued a resolution providing partners with the possibility to be present during labour and childbirth for non-asymptomatic women. OBJECTIVES: In this study, we: 1) analyse the impact of pandemic on companionship in terms of significant reduction of the possibility for women to be accompanied by a trusted person during labour and childbirth; and 2) ascertain if the regional resolution issued was effective in containing the reduction of companionship. METHODS: We performed an interrupted time series analysis to measure the variation of the possibility for women to be accompanied by a trusted person during labour and childbirth, in response to formalization of lock-down due to COVID-19 outbreak and the introduction of the regional resolution aimed at contrasting negative effects on companionship. RESULTS AND CONCLUSIONS: The ITS analysis showed that there was a significant decrease in the women-reported experience of companionship in the month of the formalization of lock-down, namely March 2020, followed by a slight increase in the upcoming months. A trend reversal was observed after May 2020, when the regional resolution was fully operational.

The uses of Patient Reported Experience Measures in health systems: A systematic narrative review.

BACKGROUND: Many governments have programmes collecting and reporting patient experience data, captured through Patient Reported Experience Measures (PREMs). Our study aims to capture and describe all the ways in which PREM data are used within healthcare systems, and explore the impacts of using PREMs at one level (e.g. national health system strategy) on other levels (e.g. providers). METHODS: We conducted a narrative review, underpinned by a systematic search of the literature. RESULTS: 1,711 unique entries were identified through the search process. After abstract screening, 142 articles were reviewed in full, resulting in 28 for final inclusion. A majority of papers describe uses of PREMs at the micro level, focussed on improving quality of front-line care. Meso-level uses were in quality-based financing or for performance improvement. Few macro-level uses were identified. We found limited evidence of the impact of meso­ and macro- efforts to stimulate action to improve patient experience at the micro-level. CONCLUSIONS: PREM data are used as performance information at all levels in health systems. The use of PREM data at macro- and meso­ levels may have an effect in stimulating action at the micro-level, but there is a lack of systematic evidence, or evaluation of these micro-level actions. Longitudinal studies would help better understand how to improve patient experience, and interfaces between PREM scores and the wider associated positive outcomes.

Influence of the COVID-19 pandemic on self-reported urinary incontinence during pregnancy and postpartum: A prospective study.

OBJECTIVE: To explore how the COVID-19 pandemic influenced self-reported occurrence and severity of pregnancy-related urinary incontinence (UI) in the maternity pathways of Tuscany, Italy. METHODS: In this prospective pre-post cohort study, we selected a pre-pandemic (n = 1018) and a post-pandemic (n = 3911) cohorts of women that completed, from the first trimester until 3 months postpartum, three surveys including validated patient-reported outcome measures for UI. Data were obtained from systematic surveys on the maternity pathways of Tuscany from March 2019 to June 2021. We performed panel regression models to explore how UI risk differed between COVID-19 groups. RESULTS: UI occurred less frequently and less severely in post-pandemic patients-especially stress/mixed UI in women never performing pelvic floor muscle training (PFMT)-whereas no difference emerged in women performing during-pregnancy PFMT. During COVID-19, obese women had higher risk of UI, whereas women undergoing operative delivery had lower risk. The post-pandemic group reported more severe UI symptoms at the third trimester, but less severe UI postpartum in women suffering from UI during pregnancy. CONCLUSIONS: During the COVID-19 pandemic, women reported fewer UI symptoms because they might have lacked chances to identify UI symptoms as a result of pandemic-related sedentarism and inactivity. The risk in women performing during-pregnancy PFMT was not increased, but just six of 26 health districts organized remote PFMT sessions, thus revealing limited resilience to the pandemic in Tuscany.

Evaluating Healthcare Performance in Low- and Middle-Income Countries: A Pilot Study on Selected Settings in Ethiopia, Tanzania, and Uganda.

The literature reports some experiences regarding the design of integrated healthcare Performance Evaluation Systems (PES) applied in Low- and Middle-income Countries (LMIC). This study describes the design of an integrated and bottom-up PES aimed at evaluating healthcare services delivery in rural settings. The analysis involved four hospitals and their relative health districts in Ethiopia, Tanzania, and Uganda. The evaluation process was undertaken for those indicators that could be evaluated using the same reference standard. The evaluation scores were determined through the international standards identified in the literature or through benchmarking assessment. Both administrative and health data were extracted from the hospitals' registers and District Health Information Systems (DHIS) from 2017 to 2020. We defined 128 indicators: 88 were calculated at the hospital level and 40 at the health district level. The evaluation process was undertaken for 48 indicators. The evaluated indicators are represented using effective graphical tools. In settings characterised by multiple healthcare providers, this framework may contribute to achieving good governance through performance evaluation, benchmarking, and accountability. It may promote evidence-based decision-making in the planning and allocation of resources, thus ultimately fostering quality improvement processes and practices, both at the hospital and health district level.

Promoting healthy eating habits among youth according to their preferences: Indications from a discrete choice experiment in Tuscany.

INTRODUCTION: The incidence of overweight among youth in Western Countries requires the implementation of initiatives to promote healthy lifestyles. Although under particular conditions obesity is not preventable, drawing attention on factors affecting teenagers' preferences can ameliorate the efficacy of public interventions designed for health promotion. METHODS: This study aims at eliciting teenagers' food preferences through a discrete choice experiment, conducted in Tuscany using a webAPP survey, with the participation of more than 4,700 teenagers. Respondents expressed their preferences for breakfast food based on three attributes: food quality, packaging and claim. The survey also collected information on respondents' socio-demographic characteristics, social influence and media use for food information. RESULTS: Teenagers' preferences for healthy foods seem positively related with their own level of food literacy. The tendency of respondents to read labels and nutritional facts is positively associated with preferences for healthier foods. Peers' influence is not significant, while family influence has a positive impact on teenagers' healthy choices. Internet usage is associated with unhealthy choices with a healthy aspect. CONCLUSION: The results can be useful in defining effective actions for the promotion of healthy behaviors among teenagers, either in communication and awareness campaigns or in education and activation initiatives, with respect to the reading and interpretation of nutritional facts and labels, the role of family and friends, and the use of media.

Learning from Excellence to Improve Healthcare Services: The Experience of the Maternal and Child Care Pathway.

The ability to deal with adversity and the resilience of people and groups are shown to depend positively on the tendency to nurture positivity. Therefore, the aim of this study is to evaluate whether Learning from Excellence (LfE) can be an effective method to manage systematic health systems, when transparent disclosure and benchmarking of data are adopted in performance evaluation. This study consists of a quantitative and a qualitative phase. In the former, maternal care is investigated at the regional level, starting from performance data and indicators of the maternity pathway referred to 98 healthcare providers in 10 Italian regions, that share the same evaluation system. The second phase investigates qualitatively the organizational determinants and the experience of professionals involved in the pathway, through the organization of on-site workshops. We identified the seven best practices among the 42 units of analysis. Communication, trust and shared goals among health professionals involved in the pathway emerged as core themes from the qualitative analysis. This study confirms that LfE under the conditions of benchmarking assessment and transparent disclosure of data can be implemented systematically in management practice, in order to boost health personnel's resilience and, in general, the organizational climate in the working environment.

Benchmarking experience to improve paediatric healthcare: listening to the voices of families from two European Children's University Hospitals.

BACKGROUND: Patient Reported Experience Measures (PREMs) are recognized as an important indicator of high quality care and person-centeredness. PREMs are increasingly adopted for paediatric care, but there is little published evidence on how to administer, collect, and report paediatric PREMs at scale. METHODS: This paper describes the development of a PREMs questionnaire and administration system for the Meyer Children's University Hospital in Florence (Meyer) and the Children's Clinical University Hospital in Riga (CCUH). The system continuously recruits participants into the electronic administration model, with surveys completed by caregivers or adolescents at their convenience, post-discharge. We analyse 1661 responses from Meyer and 6585 from CCUH, collected from 1st December 2018 to 21st January 2020. Quantitative and qualitative experience analyses are included, using Pearson chi-square tests, Fisher's exact tests and narrative evidence from free text responses. RESULTS: The large populations reached in both countries suggest the continuous, digital collection of paediatric PREMs described is feasible for collecting paediatric PREMs at scale. Overall response rates were 59% in Meyer and 45% in CCUH. There was very low variation in mean scores between the hospitals, with greater clustering of Likert scores around the mean in CCUH and a wider spread in Meyer for a number of items. The significant majority of responses represent the carers' point of view or the perspective of children and adolescents expressed through proxy reporting by carers. CONCLUSIONS: Very similar reported scores may reflect broadly shared preferences among children, adolescents and carers in the two countries, and the ability of both hospitals in this study to meet their expectations. The model has several interesting features: inclusion of a narrative element; electronic administration and completion after discharge from hospital, with high completion rates and easy data management; access for staff and researchers through an online platform, with real time analysis and visualization; dual implementation in two sites in different settings, with comparison and shared learning. These bring new opportunities for the utilization of PREMs for more person-centered and better quality care, although further research is needed in order to access direct reporting by children and adolescents.

Physical Activity in the Daily Life of Adolescents: Factors Affecting Healthy Choices from a Discrete Choice Experiment.

Physical activity improves peoples' well-being and can help in preventing weight gain, obesity, and related non-communicable diseases. Promoting healthy behaviors in the daily travels and transport choices of adolescents is very important in early establishing healthy habits that imply routine physical activity. For designing and developing effective strategies, it is relevant to study adolescents' preferences for physical activity and what factors in the social and environmental contexts affect their preferences. The paper investigates these aspects by means of a discrete choice experiment, using data from more than 4300 16-17 year-old adolescents in Italy. The results show that adolescents generally prefer walking for long time alone. However, females prefer cycling, while adolescents from lower educated families prefer motorized means of transport. Environmental factors affect the adolescents' preferences: living nearby a green area is associated with more active and healthier choices in their short daily travels. Conversely, adolescents living closer to an industrial or high traffic area prefer to use motorized vehicles. Such findings have been discussed and policy implications presented, in order to support policymakers in designing cross-sectoral policies to promote healthy choices related to physical activity in adolescence.

Measuring the quality of care in small countries: the empirical analysis of 30-day mortality following acute myocardial infarction and ischaemic stroke in Latvia.

The evaluation of quality of care is a complex task that, over the last decades, has been performed using the Donabedian model as its main conceptual framework. Small countries are an ideal setting in which to make innovative, empirical evaluations of the quality of care. In this research, we discussed the challenges and opportunities of assessing hospital performance in Latvia, a small country in the Baltic region of Northern Europe. The study outcomes were 30-day acute myocardial infarction mortality and 30-day ischaemic stroke mortality. We described how indicator specifications, risk-adjustment, data reliability assessment and graphical representations were tailored to the geographic and institutional context of Latvia. By looking at the impact of structural characteristics on hospital performance, we found that cath labs and large caseloads were significantly associated with lower mortality. This approach allows decision-makers at different governance levels to design and implement actions aimed at improving the quality of care. At the health system level, it may help policy-makers adopt proper strategies to tackle poor outcomes; at the hospital level, it may help managers intervene on structural determinants of performance. Because small countries face some relevant issues that have implications for health care, these analyses might be relevant also for larger countries to improve the design of their health-care services.

Health system performance assessment in small countries: The case study of Latvia.

Managing the complexity that characterizes health systems requires sophisticated performance assessment information to support the decision-making processes of healthcare stakeholders at various levels. Accordingly, in the past few decades, many countries have designed and implemented health system performance assessment (HSPA) programmes. Literature and practice agree on the key features that performance measurement in health should have, namely, multidimensionality, evidence-based data collection, systematic benchmarking of results, shared design, transparent disclosure, and timeliness. Nevertheless, the specific characteristics of different countries may pose challenges in the implementation of such programmes. In the case of small countries, many of these challenges are common and related to their inherent characteristics, eg, small populations, small volumes of activity for certain treatments, and lack of benchmarks. Through the development of the case study of Latvia, this paper aims at discussing the challenges and opportunities for assessing health system performance in a small country. As a result, for each of the performance measurement features identified by the literature, the authors discuss the issues emerging when adopting them in Latvia and set out the potential solutions that have been designed during the development of the case study.