Including environmental and social sustainability in the planning process of healthcare services: A case study of cancer screening programs in an inner area in Italy.

Healthcare systems plan their activities to achieve efficiency and effectiveness, without addressing environmental and social sustainability. This paper describes a new approach adopted in Italy to plan and deliver health prevention services in an inner area of the Tuscany region (in Italy) to guarantee proximity of care and environmental and social sustainability. The project examines the design and delivery of cancer screening programmes using a mobile screening unit to maximise social benefits while minimising environmental waste. A cost analysis was developed to estimate the difference in CO2 equivalent emissions, travel costs, and productivity losses, comparing the current screening programmes against the introduction of a comprehensive full-service mobile screening unit. The results indicate that the new service model reduces direct non-medical costs incurred by the population and improves environmental sustainability. This alternative can reduce, annually, over 95,000 euros in terms of travel costs and productivity losses, as well as 35 tons of CO2-equivalent travel emissions for a population of 59,000 inhabitants in a mountainous area with around 6000 people involved in the screening programme. The study supports the need to adopt a new planning methodology that considers environmental, social, and financial sustainability jointly in the provision of public health services in rural areas.

Women's choices of hospital for breast cancer surgery in Italy: Quality and equity implications.

This paper employs mixed logit regression to investigate the effects of providers characteristics on women's choice of hospital for breast surgery. Patient level data are used to model choices in Tuscany region, Italy. In particular, we focus on the effects of travel time and hospital quality indicators including quality standard (volumes of breast surgery), measurement of process (waiting times) and quality of surgical procedures. Variation in preferences related to individual characteristics such as age, education and travel distance from the hospital are also considered. Findings show that, on average, women prefer closer hospital with longer waiting times and higher quality (high volumes of interventions). We found preference heterogeneity associated to education: travel distance affects choice especially among less educated women (regardless of age), while among younger women (<65 years), less educated ones prefer shorter waiting times. These results could be used to optimize the allocation of resources toward breast cancer units that meet quality and efficacy standards to increase the efficiency and responsiveness of breast cancer care.

Healthcare costs of diabetic foot disease in Italy: estimates for event and state costs.

OBJECTIVE: This study aimed to estimate healthcare costs of diabetic foot disease (DFD) in a large population-based cohort of people with type-2 diabetes (T2D) in the Tuscany region (Italy). DATA SOURCES/STUDY SETTING: Administrative healthcare data of Tuscany region, with 2018 as the base year. STUDY DESIGN: Retrospective study assessing a longitudinal cohort of patients with T2D. DATA COLLECTION/EXTRACTION METHODS: Using administrative healthcare data, DFD were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification codes. METHODS: We examined the annual healthcare costs of these clinical problems in patients with T2D between 2015 and 2018; moreover, we used a generalized linear model to estimate the total healthcare costs. PRINCIPAL FINDINGS: Between 2015 and 2018, patients with T2D experiencing DFD showed significantly higher average direct costs than patients with T2D without DFD (p < 0.0001). Among patients with T2D experiencing DFD, those who experienced complications either in 2015-2017 and in 2018 incurred the highest incremental costs (incremental cost of € 16,702) followed by those with complications in 2018 only (incremental cost of € 9,536) and from 2015 to 2017 (incremental cost of € 800). CONCLUSIONS: DFD significantly increase healthcare utilization and costs among patients with TD2. Healthcare costs of DFD among patients with T2D are associated with the timing and frequency of DFD. These findings should increase awareness among policymakers regarding resource reallocation toward preventive strategies among patients with T2D.

Exploring Cost-Effectiveness of the Comprehensive Geriatric Assessment in Geriatric Oncology: A Narrative Review.

The Comprehensive Geriatric Assessment (CGA) and the corresponding geriatric interventions are beneficial for community-dwelling older persons in terms of reduced mortality, disability, institutionalisation and healthcare utilisation. However, the value of CGA in the management of older cancer patients both in terms of clinical outcomes and in cost-effectiveness remains to be fully established, and CGA is still far from being routinely implemented in geriatric oncology. This narrative review aims to analyse the available evidence on the cost-effectiveness of CGA adopted in geriatric oncology, identify the relevant parameters used in the literature and provide recommendations for future research. The review was conducted using the PubMed and Cochrane databases, covering published studies without selection by the publication year. The extracted data were categorised according to the study design, participants and measures of cost-effectiveness, and the results are summarised to state the levels of evidence. The review conforms to the SANRA guidelines for quality assessment. Twenty-nine studies out of the thirty-seven assessed for eligibility met the inclusion criteria. Although there is a large heterogeneity, the overall evidence is consistent with the measurable benefits of CGA in terms of reducing the in-hospital length of stay and treatment toxicity, leaning toward a positive cost-effectiveness of the interventions and supporting CGA implementation in geriatric oncology clinical practice. More research employing full economic evaluations is needed to confirm this evidence and should focus on CGA implications both from patient-centred and healthcare system perspectives.

Research protocol for the validation of a new portable technology for real-time continuous monitoring of Early Warning Score (EWS) in hospital practice and for an early-stage multistakeholder assessment.

INTRODUCTION: The real-time continuous monitoring of vital parameters in patients affected by multiple chronic conditions and/or COVID-19 can lead to several benefits to the Italian National Healthcare System (IT-NHS). The UBiquitous Integrated CARE (UBICARE) technology is a novel health digital platform at the validation stage in hospital setting. UBICARE might support the urgent need for digitalisation and early intervention, as well as minimise the face-to-face delivery of care in both hospital and community-based care settings. This research protocol aims to design an early-stage assessment of the multidimensional impact induced by UBICARE within the IT-NHS alongside technology validation in a hospital ward. METHODS AND ANALYSIS: The targeted patients will be medium/high-risk hypertensive individuals as an illustrative first example of how UBICARE might bring benefits to susceptible patients. A mixed-method study will be applied to incorporate to the validation study a multistakeholder perspective, including perceived patient experiences and preferences, and facilitate technology adoption. First, semistructured interviews will be undertaken with a variety of stakeholders including clinicians, health managers and policy-makers to capture views on the likely technology utility, economic sustainability, impact of adoption in hospital practice and alternative adoption scenarios. Second, a monocentric, non-randomised and non-comparative clinical study, supplemented by the administration of standardised usability questionnaires to patients and health professionals, will validate the use of UBICARE in hospital practice. Finally, the results of the previous stages will be discussed in a multidisciplinary-facilitated workshop with IT-NHS relevant stakeholders to reconcile stakeholders' perspectives. Limitations include a non-random recruitment strategy in the clinical study, small sample size of the key stakeholders and potential stakeholder recruitment bias introduced by the research technique. ETHICS AND DISSEMINATION: The Ethics Committee for Clinical Experimentation of Tuscany Region approved the protocol. Participation in this study is voluntary. Study results will be disseminated through peer-reviewed publications and academic conferences.

A Performance Management System in Healthcare for All Seasons?

Health systems face challenges which are inherent to care demand and supply evolution (i.e., demographic change, new technologies) or are the results of unexpected occurrence originating outside the health system, such as economic shocks or epidemic outbreaks. Both challenges often require a paradigm shift in governance and organization, financing and resource allocation, accountability frameworks, as well as public health system responses. Based on key reviews and seminal papers of performance management, public health, sustainability and resilience, the article presents three emerging challenges for performance management systems in healthcare: i) the inclusion of the population approach; ii) the measurement and consideration of the multi-facets concepts of value; iii) the importance of resilience and sustainability. Performance management systems need to evolve to cope with this changing scenario. The article sheds light on uncovered areas by performance management, and it proposes a research agenda for scholars of both performance management and health service research.

Waiting time information in the Italian NHS: A citizen perspective.

Public involvement in the management and communication of waiting times is known to support initiatives to reduce waiting times, as well as increase fairness and promote transparency and accountability. In order to improve transparency and communication to citizens, Italy recently updated the National Regulatory Plan for Waiting Lists (2019-2021), which calls for the disclosure of waiting time information on healthcare provider webpages. This study analyses waiting time information for outpatient visits and digital services available on the institutional website pages of 144 public healthcare organisations in nine regions and two autonomous provinces of Italy. Web pages were analysed both in terms of the available information/services, using a grid, and in terms of the quality of the text using an advanced readability assessment tool (READ-IT). This information was complemented and validated by regional healthcare key informants during research-specific workshops. Waiting time information disclosure, digital services and text readability varied both within and between the regional healthcare systems and organisations. The types and characteristics of waiting time information and statistics vary considerably with a negative impact on their use for benchmarking and their readability and usability for booking purposes. Overall, communication weaknesses due to low harmonization and clarity of information can undermine efforts in effectively informing and involving the public through online waiting time data disclosure.

Explaining performance in health care: How and when top management competencies make the difference.

BACKGROUND: One of the most distinctive management competencies is related to the ability to structure the strategic vision, develop long-term plans, and communicate them efficiently to the employees in order to empower them to enact. These managerial competencies in complex organizations are strongly related to the capacity to engage professionals as a predictor of high-performing organizations. PURPOSE: The aim of this study was to investigate the relationship between top management competencies, information sharing, and organizational performance in public health care system and to look at the management role in assuring information sharing on organizational strategies to achieve professionals' engagement. METHODOLOGY/APPROACH: This relationship is empirically tested using the longitudinal data of public health care organizations from the Tuscany Region (Italy). The top management competencies and information sharing are evaluated by the heads of the departments. While information sharing refers to the organizational level (e.g., to convey the objectives), managerial competencies refer to the individual level (e.g., to manage conflict). A random effect regression model is estimated using average responses by the health organization. Data come from the multidimensional performance evaluation system (2008 to 2014 years). RESULTS: Findings show that managerial competencies are positively associated to organizational performance. Moreover, managerial competencies are strongly linked to the information sharing process developed into the organizations. In particular, managerial competencies play a significant role on whole performance, and results are mediated by the use of mature information sharing instruments such as benchmarking of performance results. CONCLUSION: Systematic information sharing process regarding performance results, goals, and organizational structure provided by top management seems an effective strategy to engage professionals. Control variables suggest that top management tenure and turnover do not have an effect, whereas bigger health care organizations seem to negatively influence this relation. PRACTICE IMPLICATIONS: Information sharing is the basis for clinicians' engagement and adds value to organizational performance.

Budget impact analysis of sFlt-1/PlGF ratio as prediction test in Italian women with suspected preeclampsia.

INTRODUCTION: Preeclampsia (PE) is a pregnancy disease which represents a leading cause of maternal and perinatal mortality and morbidity. Accurate prediction of PE risk could provide an increase in health benefits and better patient management. OBJECTIVE: To estimate the economic impact of introducing Elecsys sFlt-1/PlGF ratio test, in addition to standard practice, for the prediction of PE in women with suspected PE in the Italian National Health Service (INHS). METHODS: A decision tree model has been developed to simulate the progression of a cohort of pregnant women from the first presentation of clinical suspicion of PE in the second and third trimesters until delivery. The model provides an estimation of the financial impact of introducing sFlt-1/PlGF versus standard practice. Clinical inputs have been derived from PROGNOSIS study and from literature review, and validated by National Clinical Experts. Resources and unit costs have been obtained from Italian-specific sources. RESULTS: Healthcare costs associated with the management of a pregnant woman with clinical suspicion of PE equal €2384 when following standard practice versus €1714 using sFlt-1/PlGF ratio test. CONCLUSIONS: Introduction of sFlt-1/PlGF into hospital practice is cost-saving. Savings are generated primarily through improvement in diagnostic accuracy and reduction in unnecessary hospitalization for women before PE's onset.

The fiscal crisis in the health sector: Patterns of cutback management across Europe.

PURPOSE: The article investigates trends in health sector cutback management strategies occurred during the ongoing financial and fiscal crisis across Europe. SETTING: A European-wide survey to top public healthcare managers was conducted in ten different countries to understand their perception about public sector policy reactions to the financial and economic crisis; answers from 760 respondents from the healthcare sector (30.7% response rate) were analyzed. METHOD: A multinomial logistic regression was used to assess the characteristics of respondents, countries' institutional healthcare models and the trend in public health resources availability during the crisis associated to the decision to introduce unselective cuts, targeted cuts or efficiency savings measures. RESULTS: Differentiated responses to the fiscal crisis that buffeted public finances were reported both across and within countries. Organizational position of respondents is significant in explaining the perceived cutback management approach introduced, where decentralized positions detect a higher use of linear cuts compared to their colleagues working in central level organizations. Compared to Bismark-like systems Beveridge-like ones favour the introduction of targeted cuts. Postponing the implementation of new programmes and containing expenses through instruments like pay freezes are some of the most popular responses adopted, while outright staff layoffs or reduction of frontline services have been more selectively employed. CONCLUSION: To cope with the effects of the fiscal crisis healthcare systems are undergoing important changes, possibly also affecting the scope of universal coverage.

Italy: health system review.

Italy is the sixth largest country in Europe and has the second highest average life expectancy, reaching 79.4 years for men and 84.5 years for women in 2011. There are marked regional differences for both men and women in most health indicators, reflecting the economic and social imbalance between the north and south of the country. The main diseases affecting the population are circulatory diseases, malignant tumours and respiratory diseases. Italy's health care system is a regionally based national health service that provides universal coverage largely free of charge at the point of delivery. The main source of financing is national and regional taxes, supplemented by copayments for pharmaceuticals and outpatient care. In 2012, total health expenditure accounted for 9.2 percent of GDP (slightly below the EU average of 9.6 percent). Public sources made up 78.2 percent of total health care spending. While the central government provides a stewardship role, setting the fundamental principles and goals of the health system and determining the core benefit package of health services available to all citizens, the regions are responsible for organizing and delivering primary, secondary and tertiary health care services as well as preventive and health promotion services. Faced with the current economic constraints of having to contain or even reduce health expenditure, the largest challenge facing the health system is to achieve budgetary goals without reducing the provision of health services to patients. This is related to the other key challenge of ensuring equity across regions, where gaps in service provision and health system performance persist. Other issues include ensuring the quality of professionals managing facilities, promoting group practice and other integrated care organizational models in primary care, and ensuring that the concentration of organizational control by regions of health-care providers does not stifle innovation.

Critical review of economic evaluation studies of interventions promoting low-fat diets.

Various national and local policies encouraging healthy eating have recently been proposed. The present review aims to summarize and critically assess nutrition-economic evaluation studies of direct (e.g., diet counseling) and indirect (e.g., food labeling) interventions aimed at improving dietary habits. A systematic literature review was performed by searching 5 databases (PubMed, Ovid Medline, EconLit, Agricola, and Embase) using a combination of diet-related (fat, diet, intake, nutrition) and economics-related (cost-effectiveness, cost-benefit, cost-utility, health economics, economic evaluation) key words. The search yielded 36 studies that varied in target population, study design, economic evaluation method, and health/economic outcome. In general, all provide limited experimental evidence and adopt the framework of economic evaluations in healthcare. Certain important aspects were not well considered: 1) the non-health-related effects of nutrition interventions on well-being; 2) the private nature of food expenditures; 3) the distributional effects on food expenditures across socioeconomic groups; and 4) the general economic implications (e.g., agrofoods, import/export) of such interventions. Overall, the methodology for the economic evaluation of nutrition interventions requires substantial improvement.

Generating appropriate clinical data for value assessment of medical devices: what role does regulation play?

Assessing the value of health technologies, through health technology assessment is critically dependent on the existence of relevant and robust clinical data on the efficacy, safety and ideally, effectiveness of the technologies concerned. However, in the case of medical devices, such clinical data may not always be available, because of the different nature of the regulatory requirements in different jurisdictions. Therefore, we conducted a systematic review of the regulatory requirements in seven major jurisdictions in order to identify current challenges and to suggest possible improvements. There are differences in the requirements across jurisdictions and in the balance between pre-market and post-market controls. Several improvements are required in order to generate adequate clinical data for health technology assessment.

Cost-effectiveness of a programme of screening and brief interventions for alcohol in primary care in Italy.

BACKGROUND: As alcohol-related health problems continue to rise, the attention of policy-makers is increasingly turning to Screening and Brief Intervention (SBI) programmes. The effectiveness of such programmes in primary healthcare is well evidenced, but very few cost-effectiveness analyses have been conducted and none which specifically consider the Italian context. METHODS: The Sheffield Alcohol Policy Model has been used to model the cost-effectiveness of government pricing and public health policies in several countries including England. This study adapts the model using Italian data to evaluate a programme of screening and brief interventions in Italy. Results are reported as Incremental Cost-Effectiveness Ratios (ICERs) of SBI programmes versus a 'do-nothing' scenario. RESULTS: Model results show such programmes to be highly cost-effective, with estimated ICERs of €550/Quality Adjusted Life Year (QALY) gained for a programme of SBI at next GP registration and €590/QALY for SBI at next GP consultation. A range of sensitivity analyses suggest these results are robust under all but the most pessimistic assumptions. CONCLUSIONS: This study provides strong support for the promotion of a policy of screening and brief interventions throughout Italy, although policy makers should be aware of the resource implications of different implementation options.

Italy: health system review

Italy is the sixth largest country in Europe and has the second highest average life expectancy, reaching 79.4 years for men and 84.5 years for women in 2011. There are marked regional differences for both men and women in most health indicators, reflecting the economic and social imbalance between the north and south of the country. Italy’s health system is a regionally based national health service that provides universal coverage largely free of charge at the point of delivery. The main source of financing is national and regional taxes, supplemented by co-payments for pharmaceuticals and outpatient care. In 2012, total health expenditure accounted for 9.2% of GDP. Public sources made up 78.2% of total health care spending. While the central government provides a stewardship role, setting the fundamental principles and goals of the health system and determining the core benefit package available to all citizens, the regions are responsible for organizing and delivering primary, secondary and tertiary health services as well as preventive and health promotion services. Faced with the current economic constraints of having to contain or even reduce health expenditure, the largest challenge facing the health system is to achieve budgetary goals without reducing the provision of health services to patients. This is related to the other key challenge of ensuring equity across regions, where gaps in service provision and health system performance persist. Other issues include ensuring the quality of professionals managing facilities, promoting group practice and other integrated care organizational models in primary care, and ensuring that the concentration of organizational control by regions of health care providers does not stifle innovation.

The financial crisis in Italy: implications for the healthcare sector.

The global economic and financial crisis is having and impact on the Italian healthcare system which is undergoing a devolution process from the central government to regions and where about one third of the regional governments (mainly in the central and southern part of the country) are facing large financial deficits. The paper briefly describes the current macro scenario and the main responses taken to face the crisis and highlights the downside risks of introducing "linear" cuts in the allocation of resources. While justified by the risk of a national debt default, present fiscal policies might increase inequalities in access to care, deteriorate overall health indicators and population wellbeing, and sharpen existing difference in the quality of care between regions. Preliminary evidence shows that the crisis is affecting the quality of nutrition and the incidence of psychiatric disorders. During this difficult financial situation Italy is also facing the risk of a major reduction in investments for preventive medicine, Evidence Based Medicine infrastructures, health information systems and physical capital renewal. This cost-cutting strategy may have negative long term consequences Also, important achievement in terms of limiting waiting lists, improving continuity of care and patients' centeredness, and promoting integration between social and health care may be negatively affected by unprecedented resources' cuts. It is essential that in such a period of public funding constraints health authorities monitor incidence of diseases and access to care of the most vulnerable groups and specifically target interventions to those who may be disproportionally hit by the crisis.

The challenge and the future of health care turnaround plans: evidence from the Italian experience.

Over the last two decades, health policy and governance in Italy have undergone decentralisation at the regional level. The central government was expected to play a guiding role in defining minimum care standards and controlling health expenditures at the regional level in order to keep the entire Italian National Health System (INHS) on track. Although health performance trends have been consistent across regions, public health expenditures have been variable and contributed to a cumulative deficit of 38 billion Euros from 2001 to 2010. To address the deficit, the government called for a resolution introducing a partial bail-out plan and later institutionalised a process to facilitate a turnaround. The upturn started with the development of a formal regional turnaround plan that proposed strategic actions to address the structural determinants of costs. The effectiveness of this tool was widely questioned, and many critics suggested that it was focused more on methods to address short-term issues than on the long-term strategic reconfiguration that is required for regional health systems to ultimately address the structural causes of deficits.We propose an interpretative framework to understand the advantages and disadvantages of turnaround plans, and we apply the findings to the development of policy recommendations for the structure, methods, processes and contexts of the implementation of this tool.

Aphasia induced by gliomas growing in the ventrolateral frontal region: assessment with diffusion MR tractography, functional MR imaging and neuropsychology.

INTRODUCTION: Lesions in the ventrolateral region of the dominant frontal lobe have been historically associated with aphasia. Recent imaging results suggest that frontal language regions extend beyond classically defined Broca's area to include the ventral precentral gyrus (VPCG) and the arcuate fasciculus (AF). Frontal gliomas offer a unique opportunity to identify structures that are essential for speech production. The aim of this prospective study was to investigate the correlation between language deficits and lesion location in patients with gliomas. METHODS: Nineteen patients with glioma and 10 healthy subjects were evaluated with diffusion tensor imaging magnetic resonance (MR) tractography, functional MR (verb generation task) and the Aachener Aphasie Test. Patients were divided into two groups according to lesion location with respect to the ventral precentral sulcus: (i) anterior (n=8) with glioma growing in the inferior frontal gyrus (IFG) and underlying white matter; (ii) posterior (n=11) with glioma growing in the VPCG and underlying white matter. Virtual dissection of the AF, frontal intralobar tract, uncinate fasciculus (UF) and inferior frontal occipital fasciculus (IFOF) was performed with a deterministic approach. RESULTS: Seven posterior patients showed aphasia classified as conduction (4), Broca (1), transcortical motor (1) and an isolated deficit of semantic fluency; one anterior patient had transcortical mixed aphasia. All posterior patients had invasion of the VPCG, however only patients with aphasia had also lesion extension to the AF as demonstrated by tractography dissections. All patients with language deficits had high grade glioma. Groups did not differ regarding tumour volume. A functional pars opercularis was identified with functional MR imaging (fMRI) in 17 patients. CONCLUSIONS: Gliomas growing in the left VPCG are much more likely to cause speech deficits than gliomas infiltrating the IFG, including Broca's area. Lesion extension to the AF connecting frontal to parietal and temporal regions is an important mechanism for the appearance of aphasia.