Under-spending, over-spending or substitution among services? Spatial patterns of unexplained shares of health care expenditures.

Using individual-level administrative data, we investigate the spatial patterns of unexplained shares of health care expenditures (HCE) at the municipality level. The focus is on the elderly population in the Italian Region Friuli-Venezia Giulia observed over the period 2017-2019. The empirical analysis comprises two steps. First, random-effects two-part models are estimated to analyze the effect of age, morbidity, and death on the probability and amount of positive individual total HCE and its components. Second, the unexplained shares of HCE at the municipality level are examined to identify areas with under- or over-spending and substitution among services. Results confirm the existing findings on the determinants of HCE and reveal geographic patterns in the unexplained shares of expenditures. We identify clusters of municipalities with observed HCE higher than predicted for each type of service and clusters with substitution between home care and all other services. These findings are associated with the degree of urbanization of these areas and, consequently, with the ease of access to health care. This is crucial from a policy perspective, as it indicates specific policy targets for public health intervention.

Self-feeding dependence incidence and predictors among nursing home residents: Findings from a 5 year retrospective regional study.

The aim of this regionally-based, retrospective study was to describe the incidence of self-feeding dependence and predictors among elderly patients admitted from 2008 to 2013 to 105 Italian nursing homes. Data reported in a regional database collected at the time of nursing home admission and every 6 months up to the resident's death were accessed. The self-feeding degree of dependence was the dependent variable; at the individual and nursing home levels, explanatory variables were those collected at nursing home admission and every 6 months. The structural equation model and the ordinal polynomial logit regression analysis were performed. A total of 13 175 records of residents when admitted to the nursing home and their following 69 341 records, were included. At the time of nursing home admission, 6496 residents (49.3%) reported a certain degree of dependence in self-feeding and showed slight worsening in their dependence every 6 months. At the individual level, the increased functional dependence raised the proportional odds ratios of approximately 4.36 times of an increased dependence in self-feeding; the degree of cognitive impairment, the lack of social interactions, the occurrence of pressure sores, comorbidities, as well as the clinical instability and time all raised the risk of self-feeding dependence progression. At the nursing home level, an increased number of beds emerged as a factor also increasing the proportional odds of dependence in self-feeding. Factors affecting self-feeding dependence are multi-faceted at the individual and at the nursing home levels.

Opportunity to discuss ethical issues during clinical learning experience.

BACKGROUND: Undergraduate nursing students have been documented to experience ethical distress during their clinical training and felt poorly supported in discussing the ethical issues they encountered. RESEARCH AIMS: This study was aimed at exploring nursing students' perceived opportunity to discuss ethical issues that emerged during their clinical learning experience and associated factors. RESEARCH DESIGN: An Italian national cross-sectional study design was performed in 2015-2016. Participants were invited to answer a questionnaire composed of four sections regarding: (1) socio-demographic data, (2) previous clinical learning experiences, (3) current clinical learning experience quality and outcomes, and (4) the opportunity to discuss ethical issues with nurses in the last clinical learning experience (from 0 - 'never' to 3 - 'very much'). PARTICIPANTS AND RESEARCH CONTEXT: Participants were 9607 undergraduate nursing students who were attending 95 different three-year Italian baccalaureate nursing programmes, located at 27 universities in 15 Italian regions. ETHICAL CONSIDERATIONS: This study was conducted in accordance with the Human Subject Research Ethics Committee guidelines after the research protocol was approved by an ethics committee. FINDINGS: Overall, 4707 (49%) perceived to have discussed ethical issues 'much' or 'very much'; among the remaining, 3683 (38.3%) and 1217 (12.7%) students reported the perception of having discussed, respectively, 'enough' or 'never' ethical issues emerged in the clinical practice. At the multivariate logistic regression analysis explaining 38.1% of the overall variance, the factors promoting ethical discussion were mainly set at the clinical learning environment levels (i.e. increased learning opportunities, self-directed learning, safety and nursing care quality, quality of the tutorial strategies, competences learned and supervision by a clinical nurse). In contrast, being male was associated with a perception of less opportunity to discuss ethical issues. CONCLUSION: Nursing faculties should assess the clinical environment prerequisites of the settings as a context of student experience before deciding on their accreditation. Moreover, the nursing faculty and nurse managers should also enhance competence with regard to discussing ethical issues with students among clinical nurses by identifying factors that hinder this learning opportunity in daily practice.