AHRQ prevention quality indicators to assess the quality of primary care of local providers: a pilot study from Italy.

BACKGROUND: Outside the USA, Agency for Healthcare Research and Quality (AHRQ) prevention quality indicators (PQIs) have been used to compare the quality of primary care services only at a national or regional level. However, in several national health systems, primary care is not directly managed by the regions but is in charge of smaller territorial entities. We evaluated whether PQIs might be used to compare the performance of local providers such as Italian local health authorities (LHAs) and health districts. METHODS: We analysed the hospital discharge abstracts of 44 LHAs (and 11 health districts) of five Italian regions (including ≈18 million residents) in 2008-10. Age-standardized PQI rates were computed following AHRQ specifications. Potential predictors were investigated using multilevel modelling. RESULTS: We analysed 11 470 722 hospitalizations. The overall rates of preventable hospitalizations (composite PQI 90) were 1012, 889 and 988 (×100 000 inhabitants) in 2008, 2009 and 2010, respectively. Composite PQIs were able to differentiate LHAs and health districts and showed small variation in the performance ranking over years. CONCLUSION: Although further research is required, our findings support the use of composite PQIs to evaluate the performance of relatively small primary health care providers (50 000-60 000 enrollees) in countries with universal health care coverage. Achieving high precision may be crucial for a structured quality assessment system to align hospitalization rate indicators with measures of other contexts of care (cost, clinical management, satisfaction/experience) that are typically computed at a local level.

A nationwide prospective study on prescribing pattern of antidepressant drugs in Italian primary care.

PURPOSE: Our purpose was to explore antidepressant drug (AD) prescribing patterns in Italian primary care. METHODS: Overall, 276 Italian general practitioners (GPs) participated in this prospective study, recruiting patients >18 years who started AD therapy during the enrolment period (January 2007 to June 2008). During visits at baseline and 3, 6, and 12 months, data about patients' characteristics and AD treatments were collected by the GPs. Discontinuation rate among new users of AD classes [i.e., selective serotonin reuptake inhibitors (SSRI); tricyclics (TCAs); other ADs) were compared. Logistic regression analyses were performed to identify predictors of AD discontinuation. RESULTS: SSRIs were the most frequently prescribed ADs (N = 1,037; 75.3 %), especially paroxetine and escitalopram. SSRIs were more likely to be prescribed because of depressive disorders (80 %), and by GPs (51.1 %) rather than psychiatrists (31.8 %). Overall, 27.5 % (N = 378) of AD users discontinued therapy during the first year, mostly in the first 3 months (N = 242; 17.6 %), whereas 185 (13.4 %) were lost to follow-up. SSRI users showed the highest discontinuation rate (29 %). In patients with depressive disorders, younger age, psychiatrist-based diagnosis, and treatment started by GPs were independent predictors of SSRI discontinuation. CONCLUSIONS: In Italy, ADs-especially SSRIs-are widely prescribed by GPs because of depressive/anxiety disorders. Active monitoring of AD users in general practice might reduce the AD discontinuation rate.

Homecare for patients with heart failure in Italy.

UNLABELLED: BACKGROUND; Heart failure (HF) represents an important health issue in western countries, especially for the elderly, frail population. A number of HF patients must usually be assisted at home. No information is available about the usual care of HF patients in Italy. The aim of this study was to describe the characteristics of HF patients receiving homecare in the Italian general practice. METHODS: A questionnaire was sent to 320 general practitioners (GPs) involved in the Health Search project. Among these, 148 (46.2%) answered and 376 home-ridden HF patients (60.3% women, median age 85 years) were identified. RESULTS: 257 (57%) patients were in NYHA class III or IV. Multiple relevant concomitant diseases occurred in 326 (86.7%) subjects. Only 140 (37.2%) patients were able to take their pills without any help; caregivers, mainly family members, were required 24 hours a day in 78.7% of cases. The length of homecare was > 1 year in 84.5% of cases. CONCLUSIONS: According to our data, thousands of HF patients are usually assisted at home for long periods in Italy. This is a very old group of subjects with heavy co-morbidity and a high need for continuous, prolonged assistance. Studies specifically aimed at the care of HF patients are needed.

Effects of an automated electronic reminder in changing the antiplatelet drug-prescribing behavior among Italian general practitioners in diabetic patients: an intervention trial.

OBJECTIVE: To evaluate whether an electronic reminder integrated into a routine computer system increases the use of antiplatelet drugs for diabetic patients among Italian general practitioners (GPs). RESEARCH DESIGN AND METHODS: A randomized controlled trial was carried out among 300 GPs and their patients selected from the Health Search Database. Among these, 150 GPs (intervention group) received instructions to activate an electronic reminder plus a letter summarizing the beneficial effects of antiplatelet drugs in diabetic patients with at least one additional cardiovascular risk factor ("high risk"), whereas the other 150 GPs (control group) received only the letter. The electronic reminder, integrated into a standard software system for the management of the daily clinical practice, was displayed when every participating GP opened the medical record of diabetic patients aged > or =30 years. Only high-risk diabetic patients were included in the analysis. Patients were considered under antiplatelet treatment if they received two or more prescriptions at baseline and during the follow-up. RESULTS: We selected 15,343 high-risk diabetic patients, 7,313 belonging to GPs of the control group and 8,030 belonging to GPs of the intervention group. Overall, 1,672 patients (22.9%) of the control group and 1,886 (23.5%) patients of the intervention group received antiplatelet drugs at baseline (P = N.S.). At the end of the follow-up, the number of treated patients was significantly increased in the intervention group (odds ratio 1.99, 95% CI 1.79-2.22) versus the control group. The effect of the electronic reminder was more relevant among those patients with one or more cardiovascular risk factors but without previous cardiovascular diseases (CVDs), compared with those with CVDs. CONCLUSIONS: These findings provide evidence for the effect of an electronic reminder in affecting the prescriptive behavior of GPs.

Secondary prevention of stroke in Italy: a cross-sectional survey in family practice.

BACKGROUND: Hypertension control and antiplatelet or oral anticoagulant drugs are the basis for secondary prevention of cerebrovascular events. Family physicians (FPs) are usually involved in both aspects of prevention, but no research has been carried out in Italy to evaluate the behavior of FPs in this field of prevention. METHODS: Data concerning 318 Italian FPs and 465,061 patients were extracted from the Health Search Database. Patients with coded diagnoses of stroke and transient ischemic attack (TIA) were selected. Demographic records and information regarding presence of concurrent disease and medical records were also obtained. Logistic regression analyses were carried out to assess whether conditions exist that make appropriate control of blood pressure (BP) and prescription of antiplatelet or anticoagulant drugs more likely. RESULTS: We selected 2555 patients with diagnosis of stroke and 2755 with TIA. Among all of the subjects, 32.6% had no BP recorded. Among the remaining subjects, 58.7% reported uncontrolled BP. Isolated systolic hypertension has been shown in 68.8% of patients with uncontrolled BP. Antiplatelet and anticoagulant drugs were prescribed in 72% of these cases. Factors that made the prescription significantly more unlikely were diagnosis of TIA (odds ratio [OR], 0.47; 95% confidence interval [CI], 0.41 to 0.54), total invalidity (OR, 0.66; 95% CI 0.56 to 0.78), and time from event of 5 years or more (OR, 0.81; 95% CI, 0.70 to 0.94). CONCLUSIONS: Italian FPs could improve secondary prevention of cerebrovascular accidents. The primary target of intervention should be the control of systolic BP, and the group of patients with unacceptably high BP should be given priority. All of these patients should have been prescribed antiplatelet drugs or anticoagulant agents, except in cases of extremely short life expectancy or substantial contraindications.

Prescribing pattern of antipsychotic drugs in the Italian general population 2000-2005: a focus on elderly with dementia.

The objective of this study was to evaluate the antipsychotic drug prescribing pattern in the Italian general population, elderly, and especially elderly with dementia, in relation to the safety warnings issued by international regulatory agencies about the risk of cerebrovascular adverse events and mortality in 2004 and 2005. A cohort study was conducted using the electronic medical records of the Italian general practice database 'Health Search/Thales'. On the basis of prescription data, 1-year and monthly prevalence estimates were calculated for atypical and typical antipsychotic use in general population, elderly, and elderly demented outpatients. One-year prevalence of individual medication use in elderly demented patients was calculated as well. The prevalence of use of atypical agents in demented patients progressively increased from 2000 [0.2 (0.05-0.7) per 10 000] until the beginning of 2004 [9.7 (8.1-11.6) per 10 000], after which a slight decrease started, whereas the prevalence of use of typical antipsychotics decreased from 2001 [15.7 (13.5-18.2) per 10 000] until 2004 [10.7 (9.0-12.7) per 10 000], then slightly increased in December 2005 [12.1 (10.4-14.2) per 10 000]. Monthly trends in general population and elderly were quite similar and differed significantly from the trend in elderly with dementia: stable use of atypicals from 2002 to 2005 and strong reduction of typicals from 2001 to the end of 2004. The recent safety warnings led to an increasing trend in the use of typical agents and decreasing trend in the use of atypical agents in elderly demented outpatients in Italy. Similar trends were not observed in general population and elderly as a whole.

[CardiReset: general medicine and monitoring of cardiovascular risk factors in a whole region]. / CardioRESET: medicina generale e monitoraggio dei fattori di rischio cardiovascolare in un'intera regione.

BACKGROUND: The CardioRESET project was carried out in 2005 to evaluate the feasibility of a cardiovascular risk factor survey by general practitioners in Friuli Venezia Giulia, a north-eastern Italian region. METHODS: We randomized 2701 subjects (1336 males and 1365 females), aged 35-74 years, from the general population. The family doctors surveyed the randomized population sample using the standardized methods of the Osservatorio Epidemiologico Cardiovascolare, a reference national survey. RESULTS: The participation rate was 85.4% and all variables were recorded at least in 60% of subjects. Mean values of risk factors, prevalence of hypertension, dyslipidemia, diabetes and data on their control, smoking habits were comparable with data from the Osservatorio Epidemiologico Cardiovascolare; only the mean value of low-density lipoprotein cholesterolemia was higher in our region. CONCLUSIONS: This experience points out that in a small region it is possible to engage general practitioners to achieve a standardized surveillance of cardiovascular risk factors at a low cost.

Mental disorders associated with benzodiazepine use among older primary care attenders--a regional survey.

BACKGROUND: Benzodiazepines (BDZs) are among the most commonly prescribed drugs in the elderly and their use is often too prolonged according to current international guidelines. METHODS: We investigated the pattern of use of BDZs among 65- to 84-year-old attenders at 40 Italian primary care practices who answered positively in a questionnaire on the use of anxiolytic/hypnotic drugs and successfully completed the PRIME-MD questionnaire. The survey lasted 6 months, from February to July 2001. RESULTS: Of the 1,156 subjects who completed the PRIME-MD, 748 subjects were positive for at least one psychiatric diagnosis. A depressive disorder was present in 36.5% of all PRIME-MD completers and in about one-third of cases represented by major depression, whereas anxiety disorders, somatoform disorders and alcohol abuse accounted for 18.2%, 8.1% and 1.7% of all PRIME-MD completers, respectively. Most patients were first prescribed BDZs by their General Practitioners (GPs) for each diagnostic group. However, patients with pure anxiety started BDZ treatment during hospitalisation more often (19.7%) than patients with depressive disorders (13.7 %). Moreover, patients with comorbid anxiety and depressive disorders (CADD) were most likely to receive their first BDZ prescription from a psychiatrist (15.7 %). Sleep disturbances were present in at least 50% of cases (and up to 86 %) in each diagnostic group. About 75% of prescriptions concerned anxiolytic BDZ or medium/long-acting BDZ. Most patients with anxiety, CADD and depression used night-time BDZ (65.2%, 56.9 % and 60.5%, respectively). The prevalence of chronic use of BDZs was equally high in all categories of psychiatric disorder (about 90 % for each), showing that the vast majority of patients, irrespective of the diagnosis, had been using BDZs for years. CONCLUSIONS: BDZs are widely prescribed for elderly people by their GPs, often for a considerable length of time. The evidence that many BDZ consumers suffer from a depressive or an anxiety disorder, or both, could be a starting point for encouraging a rational prescription in accordance with international guidelines.

Prevalence estimates for chronic diseases in Italy: exploring the differences between self-report and primary care databases.

BACKGROUND: The aim of this study was to describe population and primary care morbidity and to examine how the differences vary across the diseases and are influenced by patients' demographic characteristics. METHODS: A comparison of the prevalence of four chronic conditions for 432747 patients from the Health Search Database (HSD) and 119799 individuals from a Health Interview Survey was carried out. A linear regression was performed to study the associations between age and difference in morbidity. RESULTS: Similar prevalence was found for diabetes and hypertension, whereas for chronic obstructive pulmonary disease (COPD) and gastroduodenal ulcer lower HSD prevalence was reported. Among females, age was always associated with morbidity difference. Among males, significant associations were found only for COPD (R2 = 0.81; p = 0.001) and gastroduodenal ulcer (R2 = 0.93; p < 0.001). CONCLUSIONS: The difference between population and primary care morbidity is affected by disease under investigation and patients' demographic characteristics. Therefore, in choosing the more cost-effective approach to collect data such evidence should be taken into account, and results should be interpreted with great caution.