Characteristics of the health districts in Italy and their implication in primary health care policies: an analysis of socio-demographic trends.

Introduction: The Health District (HD) is a critical component of Italy's National Health Service, responsible for ensuring Primary Health Care (PHC) services in response to community health needs. The Italian government established a national strategic reform program, the National Recovery and Resilience Plan (PNRR), starting in 2022, with a series of health interventions to reorganize the PHC setting, the main reform being the Ministerial Decree 77/2022 (DM77). Our study aimed to provide a description of socio-demographic data and to assess the correlation between HDs, in order to suggest health intervention priorities in PHC reforms. Materials and methods: We conducted our analysis using a cross-sectional record linkage of data from multiple sources to compare organizational and socio-demographic variables. A dataset was created with each of the 21 Italian Regions' HDs data of population, land area, mean age, ageing index, old-age dependency ratio, birth rate and death rate. The Inland Areas Project data was integrated for a socio-economic perspective. Results: Our study identified comparable groups of HDs, considering demographical, socio-economic and geographical aspects. The study provides a baseline understanding of the Italian situation prior to the implementation of DM77. It also highlights that inhabitants number cannot be the only variable to take into account for the definition of Italian HDs organisation and PHC reform, providing intercorrelated variables that take into account geographic location, demographic data, and socio-economic aspects. Conclusion: By acknowledging the interplay of demographic, socio-economic, and geographic factors, policymakers can tailor interventions to address diverse community needs, ensuring a more effective and equitable PHC system.

Distance learning in primary health care: an Italian experience among medical residents to integrate public health and primary health care.

Investing in Primary Health Care (PHC) is crucial for the future of Public Health (PH), although recent studies highlighted the lack of training in PHC within Italian Residency Schools. This article intends to show the experience and impact of a training course focused on standardizing the knowledge of medical residents in Hygiene and preventive medicine regarding PHC. The strength of the intervention was to demonstrate the feasibility of a unique and homogeneous educational path throughout the national territory. From the results of the evaluation questionnaires, a strong approval of the training experience emerged, with a significant improvement in the perceived knowledge of the subject.

Community-based participatory research to engage disadvantaged communities: Levels of engagement reached and how to increase it. A systematic review.

Community-based participatory research (CBPR) is one of the most used community engagement frameworks to promote health changes in vulnerable populations. The more a community is engaged, the more a program can impact the social determinants of health. The present study aims to measure the level of engagement reached in randomized controlled trials (RCTs) using CBPR in disadvantaged populations, and to find out the CBPR components that better correlate with a higher level of engagement. A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Embase, Web of Science, MEDLINE, Cochrane and Scopus databases were queried. Engagement level was assessed using the revised version of IAP2 spectrum, ranging from "inform" to "shared leadership" . Fifty-one RCTs were included, belonging to 36 engagement programs. Fourteen CBPR reached the highest level of engagement. According to the multivariate logistic regression, a pre-existing community intervention was associated with a higher engagement level (OR = 10.08; p<0.05). The variable "institutional funding" was perfectly correlated with a higher level of engagement. No correlation was found with income status or type of preventive programs. A history of collaboration seems to influence the effectiveness in involving communities burdened with social inequities, so starting new partnerships remains a public health priority to invest on. A strong potentiality of CBPR was described in engaging disadvantaged communities, addressing social determinants of health. The key findings described above should be taken into account when planning a community engagement intervention, to build up an effective collaborative field between researchers and population.

Cyclin-Dependent Kinase 4/6 Inhibitors and Dermatologic Adverse Events: Results from the EADV Task Force "Dermatology for Cancer Patients" International Study.

BACKGROUND: The introduction of cyclin-dependent kinase inhibitors (CDK4/6i) was a great advance in therapeutics for patients with estrogen receptor+/human epidermal growth factor receptor (HER2) locally advanced and metastatic breast cancer. Despite the increasing use of these agents, their adverse drug-related events have not yet been fully characterized. We describe the spectrum of cutaneous adverse reactions occurring in advanced breast cancer patients treated with cyclin-dependent kinase inhibitors, analyzing types, severity, time to onset, and possible treatment outcomes. METHODS: We performed a multicentric retrospective study including patients with advanced breast cancer who developed cutaneous lesions during treatment with CDK4/6i in the period from June 2020 to June 2021. Patients > 18 years were recruited at eleven onco-dermatology units located in Albania (1), Argentina (1), France (1), Greece (3), Italy (3), and Spain (2). We evaluated patients' epidemiological and clinical characteristics, types of cutaneous adverse events, their time to onset, and treatment outcomes. The severity of the skin reactions was assessed using the Common Terminology Criteria for Adverse Events (CTCAE) version 5.0 score. RESULTS: Seventy-nine patients (median age: 62.3 years; range 39-83 years) were included in the study, and, collectively, we recorded a total of 165 cutaneous adverse events during follow-up visits. The most frequent cutaneous reactions were pruritus (49/79 patients), alopecia (25/79), and eczematous lesions (24/79). Cutaneous toxicities were usually mild in severity (>65%) and occurred after a median of 6.5 months. Only four patients (5%) required treatment discontinuation due to the severity of the skin lesions. The majority of the skin reactions were managed with topical treatments. CONCLUSIONS: To the best of our knowledge, we present the largest case series of cutaneous adverse events developing in advanced breast cancer patients treated with CDK4/6i. We showed that cutaneous toxicities are usually mild in severity, and manageable with standard supportive care; however, in selected cases, they can lead to treatment discontinuation with possible implications for patients' clinical outcomes.

Networks as a way to hospital and primary/community care integration: findings from a narrative review of the main international models.

Background Healthcare systems are complex systems. Achieving financial, social, and environmental sustainability of these systems requires a high degree of integration and coordination at all levels, especially between acute-care settings and primary/community care services. Some authors have, therefore, suggest redirecting integrated healthcare research towards the network theory and network concepts as a useful lens. Objective The current paper proposes to investigate the existence, the institutional level of formalization and the degree of development of hospital/primary-community care Networks currently present in the main types of healthcare systems worldwide by studying an appropriate selection of representative countries for each system typology. Materials and Methods A narrative review of the scientific and gray literature following the methodology by Green et al. was, therefore, conducted to describe hospital and primary/community care networks and their integration/coordination in the main international models. To select these models, one country with the current highest life expectancy at birth for each of the B öhm's five healthcare system categories was chosen. The grade of integration of the Networks retrieved for each State was therefore qualitatively appraised (high, medium or low degree), following Valentijn's framework. Results The networks retrieved show: in Norway, Australia and Japan both at the government/ national and at the regional/lower level/other a high degree of systemic, organizational, normative and functional integration; in Switzerland both at the government/national and at the regional/lower level/other a medium degree of systemic, organizational, normative and functional integration; in the USA at the governmental/institution level a low degree of systemic, organizational and normative integration, with a medium degree of functional integration and at the regional/lower level/other integration a low degree of systemic and normative integration with medium degree of organization integration and high degree of functional integration. Discussion The high levels and degree of hospital/primary - community care integration of Norway, Australia and Japan are in line with what could be expected from the universalistic healthcare system in place. The medium levels of integration of Switzerland are also in line with what the Social health insurance system and, especially, the cantonal system. The low levels of integration of the USA are in line with the privatistic healthcare systems. However, a medium degree was found for functional integration probably due to its unparalleled technological advancement. Conclusions The study shows how the levels of hospital/primary-community care integration are connected to the specific healthcare system in place in each country. COVID-19 showed how complex systems like healthcare systems had to reconfigure themselves to reach high levels of integration in small time to be able to save lives and contain the spread of the virus. These results will prove useful for policymakers, healthcare and public health professionals in the task of establishing effective Networks to achieve high levels of integration in their institutions.

Nudging Interventions on Alcohol and Tobacco Consumption in Adults: A Scoping Review of the Literature.

Background: The World Health Organization identified alcohol and tobacco consumption as the risk factors with a greater attributable burden and number of deaths related to non-communicable diseases. A promising technique aimed to modify behavioral risk factors by redesigning the elements influencing the choice of people is nudging. Methodology: A scoping review of the literature was performed to map the literature evidence investigating the use of nudging for tobacco and alcohol consumption prevention and/or control in adults. Results: A total of 20 studies were included. The identified nudging categories were increasing salience of information or incentives (IS), default choices (DF), and providing feedback (PF). Almost three-quarters of the studies implementing IS and half of those implementing PF reported a success. Three-quarters of the studies using IS in conjunction with other interventions reported a success whereas more than half of the those with IS alone reported a success. The PF strategy performed better in multi-component interventions targeting alcohol consumption. Only one DF mono-component study addressing alcohol consumption reported a success. Conclusions: To achieve a higher impact, nudging should be integrated into comprehensive prevention policy frameworks, with dedicated education sessions for health professionals. In conclusion, nudge strategies for tobacco and alcohol consumption prevention in adults show promising results. Further research is needed to investigate the use of nudge strategies in socio-economically diverse groups and in young populations.

Lower Gastrointestinal Bleeding in the Emergency Department: High- Volume vs. Low-Volume Peg Bowel Preparation for Colonoscopy: A Randomized Trial.

BACKGROUND: Lower Gastrointestinal Bleeding (LGIB) is a common cause of admission to the Emergency Department (ED). Early colonoscopy is the exam of choice for evaluating LGIB, and an adequate colon cleansing is essential. High-volume solution 4L-PEG is largely used, but it has some limitations. Low-volume solution 2L-PEG may improve patient's tolerability and compliance, reducing the time of administration and speeding up the exam. PATIENTS AND METHODS: We conducted a randomized 1:1, prospective observational monocentric study in 228 patients (144M/84F) with LGIB. 121 (69M/52F) received the High-Volume, while 107 (75M/32F) received Low-Volume. They completed a "satisfaction questionnaire" (taste and smell, mood, time of taking, general experience). We collected the results of the Boston Bowel Preparation Scale (BBPS) and the final diagnosis. The study was retrospectively registered on clinicaltrial.gov with protocol number NCT0536 2227. RESULTS: A mean value of BBPS 6,3 was achieved by both groups (p=0.57). Regarding smell, taste, mood and time of taking (1 to 5), we do not find any statistically differences. The overall satisfaction between the two preparations was 2.90 for low-volume compared to 3.17 for Highvolume (p=0.06). No side effects were reported. The proportion of patients without an evident source of bleeding was higher in High volume preparations compared to Low-volume (39% vs. 30%, respectively). CONCLUSION: Low volume bowel preparation showed the same efficacy and tolerability with better satisfaction compared with high volume. Low-volume could represent an effective and more desirable preparation for patients in the ED.

Impact of the Covid-19 pandemic on palliative care provision by a hospital-based unit: results from an observational study.

Background Palliative care is a key approach in improving the quality of life of patients and their families facing the end-of-life care process. It is widely regarded as a public-health concern, especially considering the rapidly increasing end-of-life care needs worldwide. Its provision has been highly challenged by the COVID-19 pandemic emergency. Objective This study aims to analyse whether and to what extent the provision of Palliative Care to non-COVID patients provided by a hospital-based unit has changed during the COVID-19 pandemic. Material and methods A retrospective observational study was performed. All non-COVID patients admitted from October 1, 2019 to September 30, 2020 and evaluated by the hospital-based Palliative Care team were considered. Three time periods were considered: pre-lockdown, lockdown and post-lockdown. A trend analysis and multiple linear and logistic regressions to study and quantify the statistical significance of the associations were performed. Results A statistically significant positive linear trend of the number of hospitalized patients in need of Palliative Care was found over the study period. Compared to pre-lockdown, the rest of the study period presented more female and elderly patients, the length of stay and the number of patients discharged to a Hospice setting were significantly reduced. The waiting time did not change in lockdown but decreased in post-lockdown and the mortality rate was not significantly different. Also, the average number of Palliative Care consultations per patient significantly increased in the lockdown and post-lockdown. Discussion First, the significant admissions drop between the start of the pandemic and the following study period is in line with recent literature. The consequent rebound registered may be attributed to the high pressure from outside requiring admission and care. Second, the significantly older age of patients found during the lockdown than before the lockdown could be attributed to a "selection effect" of young patients, more able to delay hospitalization than the elderly, also in line with recent literature. Third, the shorter waiting time for Palliative Care activation the post-lockdown compared to the pre-lockdown period could be due to both increased hospital efficiency and to the greater pressure to discharge patients during the post-lockdown period. Also, the significant reduction in the lockdown and post-lockdown of the length of stay after Palliative Care activation could be explained considering both the greater receptivity of healthcare services outside the hospital, such as Hospices, and the greater pressure on hospital wards to discharge. Fourth, the unchanged in-hospital mortality rate remained over the entire period could be an indication of the high quality of care provided by this hospital setting to fragile patients, which is to be noted especially considering the average mortality rate registered during pandemic context in healthcare facilities. Conclusions The study aimed to quantify the impact of the COVID-19 on the provision of Palliative Care by a hospital-based team. We believe it might represent an innovative contribution and we hope similar research will be produced in order build the evidence for future challenges in this field.

Queueing Theory and COVID-19 Prevention: Model Proposal to Maximize Safety and Performance of Vaccination Sites.

Introduction: COVID-19 (Coronavirus Disease 19) has rapidly spread all around the world. Vaccination represents one of the most promising counter-pandemic measures. There is still little specific evidence in literature on how to safely and effectively program access and flow through specific healthcare settings to avoid overcrowding in order to prevent SARS-CoV-2 transmission. Literature regarding appointment scheduling in healthcare is vast. Unpunctuality however, especially when targeting healthcare workers during working hours, is always possible. Therefore, when determining how many subjects to book, using a linear method assuming perfect adhesion to scheduled time could lead to organizational problems. Methods: This study proposes a "Queuing theory" based approach. A COVID-19 vaccination site targeting healthcare workers based in a teaching hospital in Rome was studied to determine real-life arrival rate variability. Three simulations using Queueing theory were performed. Results: Queueing theory application reduced subjects queueing over maximum safety requirements by 112 in a real-life based vaccination setting, by 483 in a double-sized setting and by 750 in a mass vaccination model compared with a linear approach. In the 3 settings, respectively, the percentage of station's time utilization was 98.6, 99.4 and 99.8%, while the average waiting time was 27.2, 33.84, and 33.84 min. Conclusions: Queueing theory has already been applied in healthcare. This study, in line with recent literature developments, proposes the adoption of a Queueing theory base approach to vaccination sites modeling, during the COVID-19 pandemic, as this tool enables to quantify ahead of time the outcome of organizational choices on both safety and performance of vaccination sites.

Multiple-access versus telemedicine home-based sleep apnea testing for obstructive sleep apnea (OSA) diagnosis: a cost-minimization study.

PURPOSE: The aim of the present study was to compare two clinical pathways: the multiple-access outpatient pathway versus the telemedicine pathway. METHODS: The multiple-access outpatient pathway and the telemedicine pathway were both performed with WatchPAT and implemented in a real-life healthcare scenario, adopting a cost-minimization approach. A cost-minimization analysis was undertaken to assess the economic impact of the two alternatives. The cost analyses were performed in euros for the year 2021 adopting the patient, the hospital, and the societal perspectives. Given the chosen perspectives, direct medical costs, direct nonmedical costs, and indirect costs were considered. In addition, a univariate sensitivity analysis was conducted. RESULTS: From a hospital perspective, the telemedicine approach was estimated to cost €49 more than the multiple-access alternative. Considering the patient perspective, the telemedicine approach was estimated to cost €167 less than the multiple-access pathway. Considering the societal perspective, the telemedicine approach is estimated to cost €119 less than the multiple-access pathway. CONCLUSION: The adoption of telemedicine home sleep apnea testing could improve the efficiency of the healthcare processes if considering the direct and indirect costs incurred by patients and not only by healthcare providers.

COVID-19 Seroprevalence among Healthcare Workers of a Large COVID-19 Hospital in Rome Reveals Strengths and Limits of Two Different Serological Tests.

Healthcare workers are at the forefront against COVID-19, worldwide. Since Fondazione Policlinico Universitario A. Gemelli (FPG) IRCCS was enlisted as a COVID-19 hospital, the healthcare workers deployed to COVID-19 wards were separated from those with limited/no exposure, whereas the administrative staff were designated to work from home. Between 4 June and 3 July 2020, an investigation was conducted to evaluate the seroprevalence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) immunoglobulin (IgG) antibodies among the employees of the FPG using point-of-care (POC) and venous blood tests. Sensitivity, specificity, and predictive values were determined with reverse-transcription polymerase chain reaction on nasal/oropharyngeal swabs as the diagnostic gold standard. The participants enrolled amounted to 4777. Seroprevalence was 3.66% using the POC test and 1.19% using the venous blood test, with a significant difference (p < 0.05). The POC test sensitivity and specificity were, respectively, 63.64% (95% confidence interval (CI): 62.20% to 65.04%) and 96.64% (95% CI: 96.05% to 97.13%), while those of the venous blood test were, respectively, 78.79% (95% CI: 77.58% to 79.94%) and 99.36% (95% CI: 99.07% to 99.55%). Among the low-risk populations, the POC test's predictive values were 58.33% (positive) and 98.23% (negative), whereas those of the venous blood test were 92.86% (positive) and 98.53% (negative). According to our study, these serological tests cannot be a valid alternative to diagnose COVID-19 infection in progress.

Is COVID-19 a Real Incentive for Flu Vaccination? Let the Numbers Speak for Themselves.

Seasonal flu vaccination is one of the most important strategies for preventing influenza. The attitude towards flu vaccination in light of the COVID-19 pandemic has so far been studied in the literature mostly with the help of surveys and questionnaires. Whether a person chooses to be vaccinated or not during the COVID-19 pandemic, however, speaks louder than any declaration of intention. In our teaching hospital, we registered a statistically significant increase in flu vaccination coverage across all professional categories between the 2019/2020 and the 2020/2021 campaign (24.19% vs. 54.56%, p < 0.0001). A linear regression model, based on data from four previous campaigns, predicted for the 2020/2021 campaign a total flu vaccination coverage of 30.35%. A coverage of 54.46% was, instead, observed, with a statistically significant difference from the predicted value (p < 0.0001). The COVID-19 pandemic can, therefore, be considered as an incentive that significantly and dramatically increased adherence to flu vaccination among our healthcare workers.

COVID-19 and digital competencies among young physicians: are we (really) ready for the new era? A national survey of the Italian Young Medical Doctors Association.

BACKGROUND: Digital health (DH) is nowadays fundamental for physicians. Despite the improvement of information and communications technology (ICT), Italian medical doctors' (MDs) education system seems inadequate in this area. Moreover, due to the COVID-19 pandemic, societies are waking up to their limitations. The aim of this paper is to analyze the Italian status quo in DH. METHODS: The Italian Young Medical Doctors Association (Segretariato Italiano Giovani Medici - SIGM) proposed a web-based survey to assess DH awareness and previous knowledge among young doctors. Investigated areas were: big data, -omics technology and predictive models, artificial intelligence (AI), internet of things, telemedicine, social media, blockchain and clinical-data storage. RESULTS: A total of 362 participants answered to the survey. Only 13% had experience in big data during clinical or research activities, 13% in -omics technology and predictive models, 13% in AI, 6% had experience in internet of things, 22% experienced at least one telemedicine tool and 23% of the participants declared that during their clinical activities data collection was paper-driven. CONCLUSIONS: Three categories of MDs, high-tech, low-tech and no-tech, can be identified from the survey-based investigation. Our survey's results indicate an urgent need for integration of pre- and post-graduation training in digital health to provide adequate medical education.

Enhancement of Vaccination Attitude and Flu Vaccination Coverage among Pregnant Women Attending Birthing Preparation Course.

Most vaccinations are recommended within the 15th month of life, in order to reduce risks and to protect children from the initial stages of their lives. A vaccination training session was carried out during the birthing preparation course, aimed at increasing the attitude toward vaccination in maternal-child age. A questionnaire on vaccination awareness was administered before and after the training session and on-site flu vaccination was offered to women and their companions. The percentage of participants who consider the preparatory course a useful tool to obtain information about vaccines increases significantly from 30.34% at pre-intervention to 64.56% at post-intervention (p < 0.001). There is a significant increase in the mean number of vaccinations that the participants want their children to get. The number of participants believing that there is no relationship between vaccination and autism rose from 41.05 to 72.97% (p < 0.001). In total, 48 out of 119 (40.34%) pregnant women participating in the course and 39 companions were vaccinated for influenza. Vaccination knowledge and attitude significantly increased after a training session dedicated to vaccination as a part of the pregnant pre-birth course, whose aim can be therefore extended to the management of the health of the child, well beyond the period of pregnancy, according to the life-course approach to health.

A Six-Year Point Prevalence Survey of Healthcare-Associated Infections in an Italian Teaching Acute Care Hospital.

Healthcare-associated infections (HAI) represent one of the most common cause of infection and an important burden of disease. The aim of this study was to analyze the results of a six-year HAI point prevalence survey carried out yearly in a teaching acute care hospital from 2013 to 2018, following the European Center for Disease Prevention and Control (ECDC) guidelines. Surgical site infections, urinary tract infections, bloodstream infections, pneumonia, meningitis, and Clostridium difficile infections were considered as risk factors. A total of 328 patients with HAI were detected during the 6-year survey, with an average point prevalence of 5.24% (95% CI: 4.70-5.83%). Respiratory tract infections were the most common, followed by surgical site infections, urinary tract infections, primary bloodstream infections, Clostridium difficile infections, and central nervous system infections. A regression model showed length of stay at the moment of HAI detection, urinary catheter, central venous catheter, and antibiotic therapy to be the most important predictors of HAI prevalence, yielding a significant adjusted coefficient of determination (adjusted R2) of 0.2780. This will provide future infection control programs with specific HAI to focus on in order to introduce a proper prophylaxis and to limit exposure whenever possible.

Strategies to Increase Flu Vaccination Coverage among Healthcare Workers: A 4 Years Study in a Large Italian Teaching Hospital.

Flu vaccination is recommended among healthcare workers (HCWs). The low vaccination coverage registered in our hospital among HCWs called for new engaging approaches to improve flu vaccination coverage. The aim of this study was to evaluate the efficacy of different strategies implemented during the last four years (2015-2019). A quasi-experimental study was conducted, involving almost 4000 HCWs each year. Starting from the 2015-2016 campaign, new evidence-based strategies were progressively implemented. At the end of each campaign, an evaluation of the vaccination coverage rate reached was performed. Moreover, during the last three campaigns, differences in coverage among job category, wards involved or not in on-site vaccination (OSV) intervention, age classes and gender were analyzed. An increasing flu vaccination coverage rate was registered, from 6% in 2015-2016 to almost 22% at the end of 2018-2019. The overall number of vaccinated HCWs increased, especially at younger ages. OSV strategy always leads to better results, and physicians always show a higher vaccination coverage than nurses and other HCWs. The implemented strategies were effective in achieving higher flu vaccination coverage among HCWs in our hospital and therefore can be considered valuable examples of good prevention practices in hospital settings.

A management model for Hospital Hygiene Unit: evidence-based proactive surveillance of potential environmental sources of infection in order to prevent patient's risk.

INTRODUCTION: The aim of this study is to describe a proactive surveillance system of food, water and environmental surfaces, in order to avoid Healthcare-Associated Infections (HAIs) from hospital environment. METHODS: It is a retrospective descriptive study. The surveillance system consists of two integrated phases: pre-analytic and post-analytic. The activities are distinguished in ordinary control activities, performed after scheduled and shared surveys, and compliance activities, performed when it is necessary to establish the adequacy of the destination use, for example opening a new ward. RESULTS: A total of 1,470 Samples were collected and 539 Reports were generated across the five-year study period. Water for human consumption procedure: a statistically significant trend was found only in the total number of Samples collected (p < 0.001). Legionella spp. infection water risk procedure: all Samples and Reports, with the exception of Compliance Report Samples, showed a statistically significant trend (p < 0.001). Pseudomonas aeruginosa water risk procedure: only Ordinary Reports and Compliance Report Samples trend were statistically significant (p = 0.002 and p = 0.028 respectively). Effectiveness of surface sanitization procedure: no trend was statistically significant (p < 0.05). Hospital catering and food surfaces procedure: Samples and Reports yearly number was constant, no trend analysis was performed. HAIs prevalence was never over 5% in the hospital under study. CONCLUSIONS: This surveillance system of water, food and environmental surfaces represents an innovative way of approaching hospital safety for patients and personnel because it overcomes the limitations due to a classic approach limited to a laboratory analytic phase only, according to the best available scientific evidence.