Assessing the maturity of the healthcare system for integrated care: testing measurement properties of the SCIROCCO tool.

BACKGROUND: The Scaling Integrated Care in Context (SCIROCCO) tool has been developed to facilitate knowledge transfer and learning about the implementation and scaling-up of integrated care in European regions. To adequately test the functionality of the tool in assessing the maturity for integrated care within regions, this study evaluated its structural validity, internal consistency and convergent validity. METHODS: Exploratory factor analysis was used to investigate the structural validity of the 12-items of the SCIROCCO tool. Hereafter, the internal consistency was assessed by calculating Cronbach's and ordinal alpha. The convergent validity was explored by testing 23 pre-hypothesized relationships between items of the SCIROCCO tool and items of an instrument measuring a similar construct. RESULTS: Factor analysis revealed a one-factor structure. Cronbach's alpha of the overall instrument was 0.92, ordinal alpha was 0.94. Only 30.34% of the hypotheses for testing the convergent validity were met. CONCLUSION: The one-factor structure is considered relevant in representing the structural validity of the SCIROCCO tool. The scale of the SCIROCCO tool shows good internal consistency. The tool (DMIC Quickscan) used to assess the convergent validity might measure a different aspect of integrated care than the SCIROCCO tool. Further research is needed to continue investigating the validity and reliability of the tool.

The influential role of personal advice networks on general practitioners' performance: a social capital perspective.

BACKGROUND: In several health systems of advanced countries, reforms have changed primary care in the last two decades. The literature has assessed the effects of a variety of interventions and individual factors on the behavior of general practitioners (GPs). However, there has been a lack of investigation concerning the influence of the resources embedded in the GPs' personal advice networks (i.e., social capital) on GPs' capacity to meet defined objectives. The present study has two goals: (a) to assess the GPs' personal advice networks according to the social capital framework and (b) to test the influence of such relationships on GPs' capacity to accomplish organizational goals. METHODS: The data collection relied on administrative data provided by an Italian local health authority (LHA) and a survey administered to the GPs of the selected LHA. The GPs' personal advice networks were assessed through an ad-hoc instrument and interpreted as egocentric networks. Multivariate regression analyses assessed two different performance measures. RESULTS: Social capital may influence the GPs' capacity to meet targets, though the influence differs according to the objective considered. In particular, the higher the professional heterogeneity of a GP personal advice network, the lower her/his capacity is to meet targets of prescriptive appropriateness. CONCLUSIONS: Our findings might help to design more effective primary care reforms depending on the pursued goals. However, further research is needed.

ExplorinG frailty and mild cognitive impairmEnt in kidney tRansplantation to predict biomedicAl, psychosocial and health cost outcomeS (GERAS): protocol of a nationwide prospective cohort study.

AIM: To present the rationale, design and methodology of the GERAS project, which examines whether assessment of frailty and mild cognitive impairment could enhance risk prediction for biomedical, psychosocial outcomes and foster efficient resource allocation in kidney transplantation. BACKGROUND: For the burgeoning cohort of older patients considered for kidney transplantation, evidence gaps regarding frailty and mild cognitive impairment limit clinical decision-making and medical management. As known risk factors for 'hard' clinical outcomes in chronic illness, both require further study in transplantation. Integrating these and other bio-psychosocial factors into a comprehensive pre-transplant patient assessment will provide insights regarding economic implications and may improve risk prediction. DESIGN: A nation-wide multi-centre prospective cohort study nested in the Swiss Transplant Cohort Study. METHODS: Our nationally representative convenience sample includes 250 adult kidney transplant recipients. Data sources include the Swiss Transplant Cohort Study and primary data collected at time of transplantation, 6 months, 1 and 2 years post-transplant via established measures (the Montreal Cognitive Assessment, Psychosocial Questionnaire, Fried Frailty Instrument and a blood analysis), investigator-developed instruments and datasets compiled by hospitals' management control units, sickness funds, the Swiss Federal Statistical Office and the European Renal Association. Descriptive, competing risk survival and mixed effects analyses will be performed. Research Ethics Committee approval was obtained in January 2016. DISCUSSION: This pioneering project jointly examines frailty and mild cognitive impairment from bio-psychosocial and health economic perspectives. Results may significantly inform risk prediction, care tailoring and resource optimization to improve health outcomes in the ageing kidney transplant cohort.

The relationship between senior management team culture and clinical governance: Empirical investigation and managerial implications.

BACKGROUND: Health care organizations are pressured to improve the cost-effectiveness of service delivery. Clinical governance is an important trigger to improve care quality and safety and rank high in the reform agenda of health systems. The senior management team culture plays a major role in establishing clinical governance practices, because it strongly influences the values, attitudes, and behaviors of the members of an organization. PURPOSES: The aim of this study was to investigate the relationship between senior management team culture and clinical governance in the public health care organizations of three Italian regions. METHODOLOGY: The assessment of senior management culture was conducted using the Competing Values Framework and a corresponding instrument adapted for the Italian context. Clinical governance was assessed using an ad hoc instrument focused on the senior management team's perception and attitude toward clinical governance. FINDINGS: The survey achieved a 54% response rate. The results of four different models demonstrate that organizations characterized by different dominant cultures are associated with significant differences in attitudes toward clinical governance. In particular, on average, dominant cultures with a prevailing external focus are associated with a more positive attitude toward clinical governance. PRACTICE IMPLICATIONS: The selection and appointments of top managers should consider the style of leadership that is most apt to facilitate the growth of rational and developmental cultures. Furthermore, the training of top managers and leading doctors should reinforce leadership aptitude and approaches that are consistent with the desired organizational cultures.

Keep-or-drop multidimensional control systems in professional organisations: evidence on the use of the balanced scorecard in healthcare.

PURPOSE: During the 1990s, Italian healthcare organisations (HOs) underwent a process of corporatisation, and the most innovative HOs introduced the balanced scorecard (BSC) to address the need for broader accountability. Currently, there is a limited understanding of the dynamics and outcomes of such a process. Therefore, this study aims to explore whether the BSC is still considered an effective performance management tool and analyse the factors driving and hindering its evolution and endurance in public and non-profit HOs. DESIGN/METHODOLOGY/APPROACH: We conducted a retrospective longitudinal analysis of two pioneering cases in the adoption of the BSC: one in a public hospital and the other in a non-profit hospital. Data collection relied on accessing institutional documents and reports from the early 2000s to the present, as well as conducting semi-structured interviews with the internal sponsors of the BSC. FINDINGS: We found evidence of three main categories of factors that trigger or hinder the adoption and development of the BSC: (1) the role of the internal sponsor and professionals' commitment; (2) information technology and the controller's technological skills; and (3) the relationship between the management and professionalism logics during the implementation process. At the same time, there is no evidence to suggest that specific technical features of the BSC influence its endurance. ORIGINALITY/VALUE: The paper contributes to the debate on the key factors for implementing and sustaining multidimensional control systems in professional organisations. It emphasises the importance of knowledge-based assets and distinctive internal capabilities for the success of the business. The implications of the BSC legacy are discussed, along with future developments of multidimensional control tools aimed at supporting strategy execution.

Effects of the bio-psycho-social frailty dimensions on healthcare utilisation among elderly in Europe: A cross-country longitudinal analysis.

Frailty represents an emerging challenge and has major implications for clinical practice, public health, and the sustainability of health systems. It is a geriatric condition, related to but distinct from disability and multimorbidity and characterized by a diminished physiological reserve of multiple organs. Despite limited consensus and evidence, it has been argued that cognitive and social aspects influence the condition. Therefore, we aim to provide evidence on the importance of taking a broader approach in defining frailty, by investigating the role of its physical, social, and psychological subdomains to predict healthcare utilisation in elderly Europeans. The study is based on the Survey of Health, Ageing and Retirement in Europe (SHARE), and uses 185,169 total observations from 12 European countries included in wave 4, 5, 6, and 8. The analysis investigates the influence of the physical frailty index (a proxy of the Frailty Phenotype definition), psychological and social frailty indexes (built to proxy the Tilburg Frailty Index) on the likelihood of hospitalisation and the number of doctor visits. We addressed missing values due to item non-response with fully conditional specification multivariate imputation and exploited the longitudinal structure of the data to control for time-fixed unobserved characteristics. In addition, our two multivariate models included regressors to correct for demand side factors (health status, socio-economic status, and behavioral risk) as well as for country-specific characteristics. Physical and psychological frailty positively influence the likelihood of hospitalisation (OR = 1.90 and OR = 1.31, respectively) and the number of doctor visits (IRR = 1.30 and IRR = 1.07), while social frailty reduces the two types of health services utilisation (OR = 0.53 and IRR = 0.90). The three frailty dimensions are relevant risk stratification factors in elderly Europeans, and health policies should focus more on the psycho-social aspects of this condition, as a strategy to both contain expenditures and avoid potential healthcare inequalities.

Identification and economic burden of main adverse events of nerve injuries caused by regional anesthesia: a systematic review.

BACKGROUND AND OBJECTIVES: Anesthesiologists and hospitals are increasingly confronted with costs associated with the complications of Peripheral Nerve Blocks (PNB) procedures. The objective of our study was to identify the incidence of the main adverse events associated with regional anesthesia, particularly during anesthetic PNB, and to evaluate the associated healthcare and social costs. METHODS: According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we conducted a systematic search on EMBASE and PubMed with the following search strategy: ("regional anesthesia" OR "nerve block") AND ("complications" OR "nerve lesion" OR "nerve damage" OR "nerve injury"). Studies on patients undergoing a regional anesthesia procedure other than spinal or epidural were included. Targeted data of the selected studies were extracted and further analyzed. RESULTS: Literature search revealed 487 articles, 21 of which met the criteria to be included in our analysis. Ten of them were included in the qualitative and 11 articles in the quantitative synthesis. The analysis of costs included data from four studies and 2,034 claims over 51,242 cases. The median claim consisted in 39,524 dollars in the United States and 22,750 pounds in the United Kingdom. The analysis of incidence included data from seven studies involving 424,169 patients with an overall estimated incidence of 137/10,000. CONCLUSIONS: Despite limitations, we proposed a simple model of cost calculation. We found that, despite the relatively low incidence of adverse events following PNB, their associated costs were relevant and should be carefully considered by healthcare managers and decision makers.

Coevolution of patients and hospitals: how changing epidemiology and technological advances create challenges and drive organizational innovation.

Over the last 20 years, hospitals have revised their organizational structures in response to new environmental pressures. Today, demographic and epidemiologic trends and recent technological advances call for new strategies to cope with ultra-elderly frail patients characterized by chronic conditions, high-severity health problems, and complex social situations. The main areas of change surround new ways of managing emerging clusters of patients whose needs are not efficiently or effectively met within traditional hospital organizations. Following the practitioner and academic literature, we first identify the most relevant clusters of new kinds of patients who represent an increasingly larger share of the hospital population in developed countries. Second, we propose a framework that synthesizes the major organizational innovations adopted by successful organizations around the world. We conclude by substantiating the trends of and the reasoning behind the prospective pattern of hospital organizational development.

Performance management and goal ambiguity: managerial implications in a single payer system.

BACKGROUND: Goal ambiguity influences the effectiveness of performance management systems to drive organizations toward enhanced results. The literature analyzes the antecedents of goal ambiguity and shows the influence of goal ambiguity on the performance of U.S. federal agencies. However, no study has analyzed goal ambiguity in other countries or in health care systems. PURPOSE: This study has three aims: to test the validity of a measurement instrument for goal ambiguity, to investigate its main antecedents, and to explore the relationship between goal ambiguity and organizational performance in a large, public, Beveridge-type health care system. METHODOLOGY: A nationwide survey of general managers of the Italian national health system was performed. A factor analysis was used to validate the mono-dimensionality of an instrument that measured goal ambiguity. Structural equation modeling was used to test both the antecedents and the influence of goal ambiguity on organizational performance. RESULTS: Data from 135 health care organizations (53% response rate) were available for analysis. The results confirm the mono-dimensionality of the instrument, the existence of two environmental sources of ambiguity (political endorsement and governance commitment), and the negative relationship between goal ambiguity and organizational performance. PRACTICE IMPLICATIONS: Goal ambiguity matters because it may hamper organizational performance. Therefore, performance should be fostered by reducing goal ambiguity (e.g., goal-setting model, funding arrangements, and political support). Mutatis mutandis, our results may apply to public health care systems of other countries or other "public interest" sectors, such as social care and education.

Information integration in health care organizations: The case of a European health system.

BACKGROUND: Information system integration is an important dimension of a company's information system maturity and plays a relevant role in meeting information needs and accountability targets. However, no generalizable evidence exists about whether and how the main integrating technologies influence information system integration in health care organizations. PURPOSE: This study examined how integrating technologies are adopted in public health care organizations and chief information officers' (CIOs) perceptions about their influence on information system integration. METHODOLOGY: We used primary data on integrating technologies' adoption and CIOs' perception regarding information system integration in public health care organizations. Analysis of variance (ANOVA) and multinomial logistic regression were used to examine the relationship between CIOs' perception about information system integration and the adopted technologies. RESULTS: Data from 90 health care organizations were available for analyses. Integrating technologies are relatively diffused in public health care organizations, and CIOs seem to shape information system toward integrated architectures. There is a significant positive (although modest, .3) correlation between the number of integrating technologies adopted and the CIO's satisfaction with them. However, regression analysis suggests that organizations covering a broader spectrum of these technologies are less likely to have their CIO reporting main problems concerning integration in the administrative area of the information system compared with the clinical area and where the two areas overlap. PRACTICE IMPLICATIONS: Integrating technologies are associated with less perceived problems in the information system administrative area rather than in other areas. Because CIOs play the role of information resource allocators, by influencing information system toward integrated architecture, health care organization leaders should foster cooperation between CIOs and medical staff to enhance information system integration.

Picture, archiving and communication system in the Italian NHS: a primer on diffusion and evaluation analysis.

This contribution focuses on picture archiving and communication systems (PACS) in the Italian National Healthcare System (NHS). It finally aims to test the Chiefs Radiology Department's perceptions about PACS along the main evaluation dimensions emerging from the literature. First, a brief review of the main literature concerning PACS evaluation leads the authors to classify the different approaches undertaken and highlight the main variables of investigation. Second, the evidence emerging from a survey is presented and discussed in the light of the literature review. The survey aims to: (a) map out the degree of PACSs diffusion and their main features in the Italian NHS; (b) verify whether and how PACS impact the dimensions analyzed in many evaluation studies carried out to date; (c) test the relationship between some measured impacts and specific PACS features.

The Core Dimensions of Integrated Care: A Literature Review to Support the Development of a Comprehensive Framework for Implementing Integrated Care.

OBJECTIVE: As part of the EU-funded Project INTEGRATE, the research sought to develop an evidence-based understanding of the key dimensions and items of integrated care associated with successful implementation across varying country contexts and relevant to different chronic and/or long-term conditions. This paper identifies the core dimensions of integrated care based on a review of previous literature on the topic. METHODOLOGY: The research reviewed literature evidence from the peer-reviewed and grey literature. It focused on reviewing research articles that had specifically developed frameworks on integrated care and/or set out key elements for successful implementation. The search initially focused on three main scientific journals and was limited to the period from 2006 to 2016. Then, the research snowballed the references from the selected published studies and engaged leading experts in the field to supplement the identification of relevant literature. Two investigators independently reviewed the selected articles using a standard data collection tool to gather the key elements analyzed in each article. RESULTS: A total of 710 articles were screened by title and abstract. Finally, 18 scientific contributions were selected, including studies from grey literature and experts' suggestions. The analysis identified 175 items grouped in 12 categories. CONCLUSIONS: Most of the key factors reported in the literature derive from studies that developed their frameworks in specific contexts and/or for specific types of conditions. The identification and classification of the elements from this literature review provide a basis to develop a comprehensive framework enabling standardized descriptions and benchmarking of integrated care initiatives carried out in different contexts.

Barriers and Facilitators to Workforce Changes in Integrated Care.

INTRODUCTION: The aim of the study is to investigate the barriers and facilitators to the implementation of workforce changes implemented as part of integrated chronic care interventions. METHODS: We used a qualitative multimethod design that combined expert questionnaires, a systematic literature review, and secondary analysis of two case reports. Twenty-five experts, twenty-one studies and two case reports were included in the study. RESULTS: Most barriers related to problematic delivery structures, health professionals' skills and enthusiasm, IT, funding, culture and cooperation and communication. Most facilitators related to health professionals' motivation and enthusiasm, good delivery structures, communication and cooperation, IT, patients, leadership and senior management. Overall, similar categories of barriers and facilitators were found. DISCUSSION: We recommend that future research focusses on more complex designs including multiple data sources, as these are better able to capture the complexity of interventions such as integrated care. We recommend that health managers and policy-makers should invest in delivery structures and skills and motivation of health professionals to improve the implementation of workforce changes in integrated chronic care interventions. CONCLUSION: The added value of the present study lies in its provision of information on which factors might mitigate the success of an intervention, which helps to prevent premature conclusions of ineffectiveness for complex interventions.

Identification and economic burden of main adverse events of nerve injuries caused by regional anesthesia: a systematic review

Abstract Background and objectives: Anesthesiologists and hospitals are increasingly confronted with costs associated with the complications of Peripheral Nerve Blocks (PNB) procedures. The objective of our study was to identify the incidence of the main adverse events associated with regional anesthesia, particularly during anesthetic PNB, and to evaluate the associated healthcare and social costs. Methods: According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we conducted a systematic search on EMBASE and PubMed with the following search strategy: (‟regional anesthesia" OR ‟nerve block") AND (‟complications" OR ‟nerve lesion" OR ‟nerve damage" OR ‟nerve injury"). Studies on patients undergoing a regional anesthesia procedure other than spinal or epidural were included. Targeted data of the selected studies were extracted and further analyzed. Results: Literature search revealed 487 articles, 21 of which met the criteria to be included in our analysis. Ten of them were included in the qualitative and 11 articles in the quantitative synthesis. The analysis of costs included data from four studies and 2,034 claims over 51,242 cases. The median claim consisted in 39,524 dollars in the United States and 22,750 pounds in the United Kingdom. The analysis of incidence included data from seven studies involving 424,169 patients with an overall estimated incidence of 137/10,000. Conclusion: Despite limitations, we proposed a simple model of cost calculation. We found that, despite the relatively low incidence of adverse events following PNB, their associated costs were relevant and should be carefully considered by healthcare managers and decision makers.

The Development, Description and Appraisal of an Emergent Multimethod Research Design to Study Workforce Changes in Integrated Care Interventions.

INTRODUCTION: In this paper, we provide a detailed and explicit description of the processes and decisions underlying and shaping the emergent multimethod research design of our study on workforce changes in integrated chronic care. THEORY AND METHODS: The study was originally planned as mixed method research consisting of a preliminary literature review and quantitative check of these findings via a Delphi panel. However, when the findings of the literature review were not appropriate for quantitative confirmation, we chose to continue our qualitative exploration of the topic via qualitative questionnaires and secondary analysis of two best practice case reports. RESULTS: The resulting research design is schematically described as an emergent and interactive multimethod design with multiphase combination timing. In doing so, we provide other researchers with a set of theory- and experience-based options to develop their own multimethod research and provide an example for more detailed and structured reporting of emergent designs. CONCLUSION AND DISCUSSION: We argue that the terminology developed for the description of mixed methods designs should also be used for multimethod designs such as the one presented here.

Exploration of workforce changes in integrated chronic care: Findings from an interactive and emergent research design.

INTRODUCTION: Integrated care interventions introduced in response to the increased demand for long-term care entail profound changes to the health workforce. This exploratory study aims to provide an overview of the workforce changes implemented as part of integrated chronic care interventions. METHODS: An interactive and emergent research design was used consisting of a literature review, qualitative expert questionnaires and case reports. We defined integrated care as interventions targeting at least two of the six Chronic Care Model components. Workforce changes were defined as those changes experienced by clinical and non-clinical staff responsible for public and individual health intervention. RESULTS: Seven workforce changes were identified: (1) nurse involvement, (2) multidisciplinary staff, (3) multidisciplinary protocols/pathways, (4) provider training, (5) case manager/care coordinator, (6) team meetings, and (7) new positions. Most interventions included more than one of these workforce changes. CONCLUSION: The results of this study provide detailed insights into the current implementation of workforce changes in integrated care interventions and thereby pave the way for further investigations into the relative effectiveness of different workforce changes within the scope of complex interventions. Advancing knowledge in this area is essential for fostering health systems' capacity to cope with the challenges related to the current demographic and epidemiological trends.

Unraveling care integration: Assessing its dimensions and antecedents in the Italian Health System.

In recent decades, consensus has grown on the need to organize health systems around the concept of care integration to better confront the challenges associated with demographic trends and financial sustainability. However, care integration remains an imprecise umbrella term in both the academic and policy arenas. In addition, little substantive knowledge exists on the success factors for integration initiatives. We propose a composite measure of care integration and a conceptual framework suggesting its relationships with three types of antecedents: contextual, cultural, and organizational factors. Our framework was tested using data from the Italian National Health System (NHS). We administered an ad-hoc questionnaire to all Italian local health units (LHUs), with a 60.4% response rate, and used structural equation modeling to assess the relationships between the relevant latent constructs. The results validated our measure of care integration and supported the hypothesized relationships. In particular, integration was found to be fostered by results-oriented institutional settings, a professional culture conducive to inclusiveness and shared goals, and organizational arrangements promoting clear expectations among providers. Thus, integration improves care and mediates the effects of specific operating means on care enhancement.

A cost analysis of orthopedic foot surgery: can outpatient continuous regional analgesia provide the same standard of care for postoperative pain control at home without shifting costs?

BACKGROUND AND OBJECTIVES: Same-day surgery is common for foot surgery. Continuous regional anesthesia for outpatients has been shown effective but the economic impact on the perioperative process-related healthcare costs remains unclear. METHODS: One hundred twenty consecutive patients were included in this assessor-blinded, prospective cohort study and allocated according to inclusion criteria in the day-care or in the in-patient group. Standardized continuous popliteal sciatic nerve block was performed in both groups for 48 h using an elastomeric pump delivering ropivacaine 0.2 % at a rate of 5 ml/h with an additional 5 ml bolus every 60 min. Outpatients were discharged the day of surgery and followed with standardized telephone interviews. The total direct health costs of both groups were compared. Moreover, the difference in treatment costs and the difference in terms of quality of care and effectiveness between the groups were compared. RESULTS: Total management costs were significantly reduced in the day-care group. There was no difference between the groups regarding pain at rest and with motion, persistent pain after catheter removal and the incidence of PONV. Persistent motor block and catheter inflammation/infection were comparable in both groups. There was neither a difference in the number of unscheduled ambulatory visits nor in the number of readmissions. CONCLUSIONS: Day-care continuous regional analgesia leads to an overall positive impact on costs by decreasing the incidence of unplanned ambulatory visits and unscheduled readmissions, without compromising on the quality of analgesia, patients' satisfaction, and safety.

The patterns of health care utilization by elderly Europeans: frailty and its implications for health systems.

OBJECTIVE: To examine the patterns of health care utilization by the elderly and test the influence of functional decline. DATA SOURCE AND STUDY DESIGN: We used the three regular waves of the SHARE survey to estimate the influence of frailty on health care utilization in 10 European countries. We controlled for the main correlates of frailty and unobserved individual effects. RESULTS: The frail elderly increase their primary and hospital care utilization before the onset of disability. Multimorbidity moderates the effect of frailty on care utilization. CONCLUSIONS: The prevalence of frailty is high in most countries and is expected to increase. This renders frailty prevention and remediation efforts imperative for two complementary reasons: to promote healthier aging and to reduce the burden on health systems.

Does informal care impact utilization of healthcare services? Evidence from a longitudinal study of stroke patients.

Understanding the interplay between informal care and formal healthcare is important because it sheds light on the financial implications of such interactions and may result in different policies. On the basis of a major database on 532 Italian stroke patients enrolled in the period 2007-2008, we investigate whether the presence of a potential caregiver and the amount of informal care provided influences the use and the costs of healthcare services, and in particular rehabilitation, in the post-acute phase. Primary caregivers of stroke patients were interviewed at 3, 6 and 12 months after the acute event and use of healthcare and informal care were documented. The panel dataset included socio-demographic, clinical and economic data on patients and caregivers. A longitudinal log-linear model was applied to test the impact of informal care on total healthcare costs in the observation period. A double hurdle model was used to investigate the impact of informal care on rehabilitation costs. A total of 476 of stroke survivors in 44 hospitals were enrolled in the study and presence of informal caregiver was reported in approximately 50% of the sample (range 48.2-52.5% across the three periods). Healthcare costs at 12 months after the acute event are €5825 per patient, with rehabilitation costs amounting to €3985 (68.4%). Healthcare costs are significantly different between the patients with and without caregiver in all three periods. The presence of the caregiver is associated with 54.7% increase in direct healthcare costs (p < 0.01). Instead, the amount of informal care provided does not influence significantly direct healthcare costs. The presence of caregiver significantly increases the probability of access to rehabilitation services (ß = 0.648, p = 0.039) while, once the decision on access is made, it doesn't influence the amount of services used. Our results suggest that informal caregivers facilitate or even promote the access to healthcare services.