Risk and protective factors for pregnancy-related urinary incontinence until 1 year postpartum: A cohort study using patient-reported outcome measures in Italy.

OBJECTIVE: To investigate the epidemiology of pregnancy-related urinary incontinence (UI) and the related risk factors, focusing also on women's characteristics related to maternity pathway utilization. METHODS: In this prospective cohort study, we used patient-reported data obtained from the systematic survey on the maternity pathway that all pregnant women in Tuscany, Italy, can join. We selected 8410 women who completed-between March 2019 and November 2022-all five follow-up questionnaires from the first trimester until 12 months postpartum, each including a UI-specific patient-reported outcome measure. We performed panel regression models to explore the related risk factors. RESULTS: Prevalence of UI was 4.4% at the first trimester, 23.7% at the third trimester, and 15.6%, 12.6%, and 12.4% at 3, 6, and 12 months postpartum. UI occurrence and severity were higher in older, overweight/obese, and unemployed women. High-risk pregnancy and discomfort during pregnancy were risk factors. Receiving a cesarean section reduced the risk, while spontaneous tears, episiotomy, and high birth weight increased it. Women who experienced delays in pregnancy examinations because of long waiting times and women who had planned pregnancy had a higher risk, while performing during-pregnancy pelvic-floor-muscle training was protective. CONCLUSION: Besides confirming the classic risk and protective factors for UI, we also found novel determinants related to the proper maternity pathway utilization.

Value of Including the Children's Experience for Improving Their Rights During Hospitalization: Protocol for the VoiCEs Project.

BACKGROUND: Users' feedback is a key asset for organizations that want to improve their services. Studying how organizations are enabling their users to participate in evaluation activities is particularly important, especially when there are vulnerable or disadvantaged people, and the services to be evaluated can be life-changing. This is the case in the coassessment by pediatric patients experiencing hospital stay. The international literature reports a few attempts and several challenges in systematically collecting and using the pediatric patient experience with respect to hospitalization, to undertake quality improvement actions. OBJECTIVE: This paper describes the research protocol of a European project intended to develop and implement a systematic pediatric patient-reported experience measures (PREMs) observatory that will be shared by 4 European children's hospitals in Finland, Italy, Latvia, and the Netherlands. METHODS: The VoiCEs (Value of including the Children's Experience for improving their rightS during hospitalization) project uses a participatory action research approach, based on a mixture of qualitative and quantitative methods. It consists of 6 different phases, including a literature review, an analysis of the previous experiences of pediatric PREMs reported by project partners, a Delphi process, a cycle of focus groups or in-depth interviews with children and their caregivers, a series of workshops with interactive working groups, and a cross-sectional observational survey. The project guarantees the direct participation of children and adolescents in the development and implementation phases of the project. RESULTS: The expected results are (1) a deeper knowledge of published methodologies and tools on collecting and reporting pediatric patients' voice; (2) lessons learnt from the analysis of previous experiences of pediatric PREMs; a consensus reached through a participatory process (3) among experts, (4) pediatric patients and caregivers about a standard set of measures for the evaluation of hospitalization by patients; (5) the implementation of a European observatory on pediatric PREMs; and (6) the collection and comparative reporting of the pediatric patients' voice. In addition, the project is aimed at studying and proposing innovative methodologies and tools for capturing the pediatric patients' feedback directly, avoiding the intermediation of parents/guardians. CONCLUSIONS: Over the last decade, the collection and use of PREMs have gained importance as a research field. Children and adolescents' perspectives have also been increasingly taken into consideration. However, to date, there are limited experiences regarding the continuous and systematic collection and use of pediatric PREMs data for implementing timely improvement actions. In this perspective, the VoiCEs project provides room for innovation, by contributing to the creation of an international, continuous, and systematic pediatric PREMs observatory that can be joined by other children's hospitals or hospitals with pediatric patients, and foresees the return of usable and actionable data in benchmarking. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/42804.

Pregnancy vaccination predictive factors and uptake profiles among Italian women: A cross-sectional survey study on a large population.

OBJECTIVES: To assess influenza and Tdap (tetanus, diphtheria, pertussis) vaccine coverage during pregnancy, explore key socioeconomic and maternity pathway-related predictors of vaccination, and detect specific patterns of vaccination uptake. METHODS: The authors cross-sectionally analyzed self-reported data obtained from the systematic survey on the maternity pathways of Tuscany. They selected all pregnant women that completed from March 2019 to June 2022 the third-trimester questionnaire (n = 25 160), which included two dichotomous items on influenza and Tdap vaccination, as well as socioeconomic and pathway-related questions. Multilevel logistic models were performed to assess vaccination predictors and cluster analysis to identify vaccination patterns. RESULTS: Vaccination coverage was higher for pertussis (56.5%) than for influenza (18.9%). The main predictors of vaccination were high socioeconomic status, attending private gynecologists, and receiving vaccine information. Three clusters were identified: cluster 1 included women receiving both Tdap and influenza vaccines; cluster 2 included women receiving no vaccinations; and cluster 3 included women receiving only the pertussis vaccine. Although women from cluster 3 were of middle to low education status, vaccine information was the main adherence determinant also in this group. CONCLUSIONS: Health workers and policymakers should focus on groups of pregnant women less prone to vaccination to promote vaccination information and encourage wider uptake and coverage.

Effectiveness of measures to preserve labour and childbirth companionship at the times of COVID-19 outbreak.

INTRODUCTION: Although childbirth services were accessible after COVID-19 outbreak, the measures taken by the Italian Government for contagion containment required some restrictions on the presence of trusted persons for mothers, forcing them to isolation during hospitalization. To preserve companionship, the Regional Health Authority of Tuscany issued a resolution providing partners with the possibility to be present during labour and childbirth for non-asymptomatic women. OBJECTIVES: In this study, we: 1) analyse the impact of pandemic on companionship in terms of significant reduction of the possibility for women to be accompanied by a trusted person during labour and childbirth; and 2) ascertain if the regional resolution issued was effective in containing the reduction of companionship. METHODS: We performed an interrupted time series analysis to measure the variation of the possibility for women to be accompanied by a trusted person during labour and childbirth, in response to formalization of lock-down due to COVID-19 outbreak and the introduction of the regional resolution aimed at contrasting negative effects on companionship. RESULTS AND CONCLUSIONS: The ITS analysis showed that there was a significant decrease in the women-reported experience of companionship in the month of the formalization of lock-down, namely March 2020, followed by a slight increase in the upcoming months. A trend reversal was observed after May 2020, when the regional resolution was fully operational.

Managing community engagement initiatives in health and social care: lessons learned from Italy and the United Kingdom.

BACKGROUND: Determining the different features and potential impacts of community initiatives aimed at health-related outcomes poses challenges for both researchers and policy makers. PURPOSE: This article explores the nature of heterogeneous "community engagement initiatives" (CEIs) considering both their social and organizational features in order to understand the managerial and policy implications to maximize their potential local health and social care-related impacts. METHODOLOGY: A threefold qualitative analysis was conducted: (a) Three frameworks were developed to classify and analyze different CEIs features, building upon the current literature debate; (b) primary data were collected from Italian CEIs; and (c) a comparative cross-case analysis of a total of 79 CEIs in Italy and the United Kingdom was implemented. FINDINGS: The results show two types of strategic policy and management implications: (a) CEI portfolios are very broad and differentiated; (b) different social networks have diversified social constructs, internal cultures, and organizational features; and (c) there is a consequent need to contextualize relational and steering approaches in order to maximize their potential community added value. CONCLUSION: CEIs are fundamental pillars of contemporary welfare systems because of both the changing demography and epidemiology and the disruptive impact of platform economy models. This challenging scenario and the related CEIs involve a complex social mechanism, which requires a new awareness and strengthened competences for public administrations' steering. PRACTICE IMPLICATIONS: It is crucial for policy makers and managers to become familiar with all the different CEIs available in order to choose which solution to implement, depending on their potential impacts related to local public health and social care priorities. They also need to select the related effective steering logic.

Influence of the COVID-19 pandemic on self-reported urinary incontinence during pregnancy and postpartum: A prospective study.

OBJECTIVE: To explore how the COVID-19 pandemic influenced self-reported occurrence and severity of pregnancy-related urinary incontinence (UI) in the maternity pathways of Tuscany, Italy. METHODS: In this prospective pre-post cohort study, we selected a pre-pandemic (n = 1018) and a post-pandemic (n = 3911) cohorts of women that completed, from the first trimester until 3 months postpartum, three surveys including validated patient-reported outcome measures for UI. Data were obtained from systematic surveys on the maternity pathways of Tuscany from March 2019 to June 2021. We performed panel regression models to explore how UI risk differed between COVID-19 groups. RESULTS: UI occurred less frequently and less severely in post-pandemic patients-especially stress/mixed UI in women never performing pelvic floor muscle training (PFMT)-whereas no difference emerged in women performing during-pregnancy PFMT. During COVID-19, obese women had higher risk of UI, whereas women undergoing operative delivery had lower risk. The post-pandemic group reported more severe UI symptoms at the third trimester, but less severe UI postpartum in women suffering from UI during pregnancy. CONCLUSIONS: During the COVID-19 pandemic, women reported fewer UI symptoms because they might have lacked chances to identify UI symptoms as a result of pandemic-related sedentarism and inactivity. The risk in women performing during-pregnancy PFMT was not increased, but just six of 26 health districts organized remote PFMT sessions, thus revealing limited resilience to the pandemic in Tuscany.

Implementing midwifery units in a European country: Situational analysis of an Italian case study.

INTRODUCTION: Strong evidence recommends midwifery-led care for women with uncomplicated pregnancies. International research is now focusing on how to implement midwifery models of care in countries where they are not well established. In Europe, many countries like Italy are promoting midwifery-led care in national guidelines but often struggle to apply this change in practice. METHODS: This study collected data on professional, organisational and service users' levels to conduct a situational analysis of an Italian service which is approaching the implementation of a midwifery unit. Participatory Action Research was used together with the support of the Consolidated Framework for Implementation Research to conduct data collection and analysis. RESULTS: Forty-eight participants amongst professionals (midwives, obstetricians and neonatologists) and at organisational level (midwifery leaders and medical directors) were recruited; secondary data on service users' views was analysed via regional online surveys. Barriers and facilitators to the implementation were identified to assess the readiness of the local context. CONCLUSIONS: This study is the first to include professionals, managers and service users in a European context such as Italy. Facilitators to the implementation of the alongside midwifery unit were found in national guidelines, allocated funding, collaborative engagement and medical support. Hierarchical structures, a prevalent medical model and lack of trust and awareness of the evidence of safety of midwifery-led models were main barriers.

Higher readability of institutional websites drives the correct fruition of the abortion pathway: A cross-sectional study.

BACKGROUND: In Italy, abortion services are public: therefore, health Institutions should provide clear and easily readable web-based information. We aimed to 1) assess variation in abortion services utilisation; 2) analyse the readability of institutional websites informing on induced abortion; 3) explore whether easier-to-read institutional websites influenced the correct fruition of abortion services. METHODS: We identified from the 2021 administrative databases of Tuscany all women having an abortion, and-among them-women having an abortion with the certification provided by family counselling centres, following the pathway established by law. We assessed variation in total and certified abortion rates by computing the Systematic Component of Variation. We analysed the readability of the Tuscan health authorities' websites using the readability assessment tool READ-IT. We explored how institutional website readability influenced the odds of having certified abortions by running multilevel logistic models, considering health authorities as the highest-level variables. RESULTS: We observed high variation in the correct utilization of the abortion pathway in terms of certified abortion rates. The READ-IT scores showed that the most readable text was from the Florence Teaching Hospital website. Multilevel models revealed that higher READ-IT scores, corresponding to more difficult texts, resulted in lower odds of certified abortions. CONCLUSIONS: Large variation in the proper fruition of abortion pathways occurs in Tuscany, and such variation may depend on readability of institutional websites informing on induced abortion. Therefore, health Institutions should monitor and improve the readability of their websites to ensure proper and more equitable access to abortion.

A Comparison of Census and Cohort Sampling Models for the Longitudinal Collection of User-Reported Data in the Maternity Care Pathway: Mixed Methods Study.

BACKGROUND: Typical measures of maternity performance remain focused on the technical elements of birth, especially pathological elements, with insufficient measurement of nontechnical measures and those collected pre- and postpartum. New technologies allow for patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs) to be collected from large samples at multiple time points, which can be considered alongside existing administrative sources; however, such models are not widely implemented or evaluated. Since 2018, a longitudinal, personalized, and integrated user-reported data collection process for the maternal care pathway has been used in Tuscany, Italy. This model has been through two methodological iterations. OBJECTIVE: The aim of this study was to compare and contrast two sampling models of longitudinal user-reported data for the maternity care pathway, exploring factors influencing participation, cost, and suitability of the models for different stakeholders. METHODS: Data were collected by two modes: (1) "cohort" recruitment at the birth hospital of a predetermined sample size and (2) continuous, ongoing "census" recruitment of women at the first midwife appointment. Surveys were used to collect experiential and outcome data related to existing services. Women were included who passed 12 months after initial enrollment, meaning that they either received the surveys issued after that interval or dropped out in the intervening period. Data were collected from women in Tuscany, Italy, between September 2018 and July 2020. The total sample included 7784 individuals with 38,656 observations. The two models of longitudinal collection of user-reported data were analyzed using descriptive statistics, survival analysis, cost comparison, and a qualitative review. RESULTS: Cohort sampling provided lower initial participation than census sampling, although very high subsequent response rates (87%) were obtained 1 year after enrollment. Census sampling had higher initial participation, but greater dropout (up to 45% at 1 year). Both models showed high response rates for online surveys. There were nonproportional dropout hazards over time. There were higher rates of dropout for women with foreign nationality (hazard ratio [HR] 1.88, P<.001), and lower rates of dropout for those who had a higher level of education (HR 0.77 and 0.61 for women completing high school and college, respectively; P<.001), were employed (HR 0.87, P=.01), in a relationship (HR 0.84, P=.04), and with previous pregnancies (HR 0.86, P=.002). The census model was initially more expensive, albeit with lower repeat costs and could become cheaper if repeated more than six times. CONCLUSIONS: The digital collection of user-reported data enables high response rates to targeted surveys in the maternity care pathway. The point at which pregnant women or mothers are recruited is relevant for response rates and sample bias. The census model of continuous enrollment and real-time data availability offers a wider set of potential benefits, but at an initially higher cost and with the requirement for more substantial data translation and managerial capacity to make use of such data.

Patient-reported outcome measures for pregnancy-related urinary and fecal incontinence: A prospective cohort study in a large Italian population.

OBJECTIVE: To investigate prevalence and risk factors of pregnancy-related urinary/fecal incontinence (UI/FI) in a large Italian population. METHODS: This is a prospective cohort study analyzing patient-reported outcome (PRO) measures obtained from the systematic longitudinal survey on the maternity pathway of Tuscany from March 2019 to April 2021. Four questionnaires were completed by 6023 women from the beginning of pregnancy until 6 months postpartum, each including two PRO measures-Wexner scale for FI and ICIQ-SF for UI-, and questions investigating sociodemographic/clinical factors. After assessing UI/FI prevalence at each time-point, we run panel regressions to explore the related risk factors. RESULTS: Women reporting UI and FI were, respectively, 24.3% and 6.2% in the third trimester, and 12.6% and 4.2% 6 months postpartum. UI occurrence and severity were higher in highly educated, aged >30, and overweight/obese women. Spontaneous tears or episiotomy were risk factors for postpartum UI, while receiving cesarean-section and performing pelvic-floor-muscle-training during pregnancy were protective, mainly in specific groups. Finally, higher FI prevalence and severity emerged in overweight, aged >40, highly educated, non-Italian women and in those undergoing tears. CONCLUSION: We employed PRO measures to investigate the epidemiology of pregnancy-related UI/FI and detect the main risk groups. Pelvic-floor-muscle-training may be recommended in women with peculiar sociodemographic/clinical features.

What are the strategies for implementing primary care models in maternity? A systematic review on midwifery units.

BACKGROUND: Midwifery Units (MUs) are associated with optimal perinatal outcomes, improved service users' and professionals' satisfaction as well as being the most cost-effective option. However, they still do not represent the mainstream option of maternity care in many countries. Understanding effective strategies to integrate this model of care into maternity services could support and inform the MU implementation process that many countries and regions still need to approach. METHODS: A systematic search and screening of qualitative and quantitative research about implementation of new MUs was conducted (Prospero protocol reference: CRD42019141443) using PRISMA guidelines. Included articles were appraised using the CASP checklist. A meta-synthesis approach to analysis was used. No exclusion criteria for time or context were applied to ensure inclusion of different implementation attempts even under different historical and social circumstances. A sensitivity analysis was conducted to reflect the major contribution of higher quality studies. RESULTS: From 1037 initial citations, twelve studies were identified for inclusion in this review after a screening process. The synthesis highlighted two broad categories: implementation readiness and strategies used. The first included aspects related to cultural, organisational and professional levels of the local context whilst the latter synthesised the main actions and key points identified in the included studies when implementing MUs. A logic model was created to synthesise and visually present the findings. CONCLUSIONS: The studies selected were from a range of settings and time periods and used varying strategies. Nonetheless, consistencies were found across different implementation processes. These findings can be used in the systematic scaling up of MUs and can help in addressing barriers at system, service and individual levels. All three levels need to be addressed when implementing this model of care.

Evaluating Healthcare Performance in Low- and Middle-Income Countries: A Pilot Study on Selected Settings in Ethiopia, Tanzania, and Uganda.

The literature reports some experiences regarding the design of integrated healthcare Performance Evaluation Systems (PES) applied in Low- and Middle-income Countries (LMIC). This study describes the design of an integrated and bottom-up PES aimed at evaluating healthcare services delivery in rural settings. The analysis involved four hospitals and their relative health districts in Ethiopia, Tanzania, and Uganda. The evaluation process was undertaken for those indicators that could be evaluated using the same reference standard. The evaluation scores were determined through the international standards identified in the literature or through benchmarking assessment. Both administrative and health data were extracted from the hospitals' registers and District Health Information Systems (DHIS) from 2017 to 2020. We defined 128 indicators: 88 were calculated at the hospital level and 40 at the health district level. The evaluation process was undertaken for 48 indicators. The evaluated indicators are represented using effective graphical tools. In settings characterised by multiple healthcare providers, this framework may contribute to achieving good governance through performance evaluation, benchmarking, and accountability. It may promote evidence-based decision-making in the planning and allocation of resources, thus ultimately fostering quality improvement processes and practices, both at the hospital and health district level.

Nurses and the acceptance of innovations in technology-intensive contexts: the need for tailored management strategies.

BACKGROUND: Several technological innovations have been introduced in healthcare over the years, and their implementation proved crucial in addressing challenges of modern health. Healthcare workers have frequently been called upon to become familiar with technological innovations that pervade every aspect of their profession, changing their working schedule, habits, and daily actions. PURPOSE: An in-depth analysis of the paths towards the acceptance and use of technology may facilitate the crafting and adoption of specific personnel policies taking into consideration definite levers, which appear to be different in relation to the age of nurses. APPROACH: The strength of this study is the application of UTAUT model to analyse the acceptance of innovations by nurses in technology-intensive healthcare contexts. Multidimensional Item Response Theory is applied to identify the main dimensions characterizing the UTAUT model. Paths are tested through two stage regression models and validated using a SEM covariance analysis. RESULTS: The age is a moderator for the social influence: social influence, or peer opinion, matters more for young nurse. CONCLUSION: The use of MIRT to identify the most important items for each construct of UTAUT model and an in-depth path analysis helps to identify which factors should be considered a leverage to foster nurses' acceptance and intention to use new technologies (o technology-intensive devices). PRACTICAL IMPLICATIONS: Young nurses may benefit from the structuring of shifts with the most passionate colleagues (thus exploiting the social influence), the participation in ad hoc training courses (thus exploiting the facilitating conditions), while other nurses could benefit from policies that rely on the stressing of the perception of their expectations or the downsizing of their expectancy of the effort in using new technologies.

Caesarean sections in teaching hospitals: systematic review and meta-analysis of hospitals in 22 countries.

OBJECTIVE: The aim of this study is to determine the odds of caesarean section in all births in teaching hospitals as compared with non-teaching hospitals. SETTING: Over 3600 teaching and non-teaching hospitals in 22 countries. We searched CINAHL, The Cochrane Library, PubMed, sciELO, Scopus and Web of Science from the beginning of records until May 2020. PARTICIPANTS: Women at birth. Over 18.5 million births. INTERVENTION: Caesarean section. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome measures are the adjusted OR of caesarean section in a variety of teaching hospital comparisons. The secondary outcome is the crude OR of caesarean section in a variety of teaching hospital comparisons. RESULTS: In adjusted analyses, we found that university hospitals have lower odds than non-teaching hospitals (OR=0.66, 95% CI 0.56 to 0.78) and other teaching hospitals (OR=0.46, 95% CI 0.24 to 0.89), and no significant difference with unspecified teaching status hospitals (OR=0.92, 95% CI 0.80 to 1.05, τ2=0.009). Other teaching hospitals had higher odds than non-teaching hospitals (OR=1.23, 95% CI 1.12 to 1.35). Comparison between unspecified teaching hospitals and non-teaching hospitals (OR=0.91, 95% CI 0.50 to 1.65, τ2=1.007) and unspecified hospitals (OR=0.95, 95% CI 0.76 to 1.20), τ2<0.001) showed no significant difference. While the main analysis in larger sized groups of analysed studies reveals no effect between hospitals, subgroup analyses show that teaching hospitals carry out fewer caesarean sections in several countries, for several study populations and population characteristics. CONCLUSIONS: With smaller sample of participants and studies, in clearly defined hospitals categories under comparison, we see that university hospitals have lower odds for caesarean. With larger sample size and number of studies, as well as less clearly defined categories of hospitals, we see no significant difference in the likelihood of caesarean sections between teaching and non-teaching hospitals. Nevertheless, even in groups with no significant effect, teaching hospitals have a lower or higher likelihood of caesarean sections in several analysed subgroups. Therefore, we recommend a more precise examination of forces sustaining these trends. PROSPERO REGISTRATION NUMBER: CRD42020158437.

Mobile Health Intervention in the Maternal Care Pathway: Protocol for the Impact Evaluation of hAPPyMamma.

BACKGROUND: Mobile health (mHealth) has great potential to both improve the quality and efficiency of care and increase health literacy and empowerment of patient users. There are several studies related to the introduction of mHealth tools for supporting pregnancy and the postnatal period, with promising but not yet rigorously evaluated impacts. This article presents the protocol for evaluating an mHealth intervention (hAPPyMamma) applied in the maternal and child care pathway of a high-income country (in a pilot area of Tuscany Region, Italy). OBJECTIVE: The protocol describes hAPPyMamma and the methods for evaluating its impact, including the points of view of women and practitioners. The research hypothesis is that the use of hAPPyMamma will facilitate a more appropriate use of available services, a better care experience for women, and an improvement in the maternal competencies of the women using the app compared to the control group. The protocol also includes analysis of the organizational impact of the introduction of hAPPyMamma in the maternal pathway. METHODS: A pre-post quasiexperimental design with a control group is used to undertake difference-in-differences analysis for assessing the impact of the mHealth intervention from the mothers' points of view. The outcome measures are improvement of maternal health literacy and empowerment as well as experience in the maternal care pathway of the control and intervention groups of sampled mothers. The organizational impact is evaluated through a quantitative and qualitative survey addressing professionals and managers of the maternal care pathway involved in the intervention. RESULTS: Following study recruitment, 177 women were enrolled in the control group and 150 in the intervention group, with a participation rate of 97%-98%. The response rate was higher in the control group than in the intervention group (96% vs 67%), though the intervention group had less respondent loss at the postintervention survey (10% compared to 33% of the control group). Data collection from the women was completed in April 2018, while that from professionals and managers is underway. CONCLUSIONS: The study helps consolidate evidence of the utility of mHealth interventions for maternal and child care in developed countries. This paper presents a protocol for analyzing the potential role of hAPPyMamma as an effective mHealth tool for improving the maternal care pathway at individual and organizational levels and consequently helps to understand whether and how to scale up this intervention, with local, national, and international scopes of application. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/19073.

Trade union or trait d'union? Setting targets for general practitioners: A regional case study.

AIMS: The Italian general practitioners (GPs) are not directly employed by the National Health Service but work as independent contractors. Their activity and their salary are managed at the national, regional, and local level. This paper analyses the Tuscany Region case study to investigate if primary care's target-setting styles are associated with different GP perceptions, by comparing nine different local agreements to a survey on 102 GPs. We propose a classification of the different target-setting (ideal typical) styles, ranging from "financial governance" (FG), mainly based on financial targets, to "clinical governance" (CG), that mainly relies on clinical and quality targets. FINDINGS: Results show that GPs are more likely to have a more favourable attitude toward primary care managerial tools if they have certain characteristics, ie, quality measures. This suggest that target setting system might promote both the GPs' compliance to the targets set by the agreement and the involvement of the GPs in the LHA's governance processes too. CONCLUSIONS: The managerial tools could pave the way to overcome the classical "trade unionist" relationship between the regional and local authority and the GPs, working as a "trait d'union" between the two players.

General practitioners: Between integration and co-location. The case of primary care centers in Tuscany, Italy.

Healthcare systems have followed several strategies aimed at integrating primary care services and professionals. Medical homes in the USA and Canada, and primary care centres across Europe have collocated general practitioners and other health and social professionals in the same building in order to boost coordination among services and the continuity of care for patients. However, in the literature, the impact of co-location on primary care has led to controversial results. This article analyses the possible benefits of the co-location of services in primary care focusing on the Italian model of primary care centres (Case della Salute) in terms of general practitioners' perception. We used the results of a web survey of general practitioners in Tuscany to compare the experiences and satisfaction of those general practitioners involved and not involved in a primary care centre, performed a MONAVA and ANOVA analysis. Our case study highlights the positive impact of co-location on the integration of professionals, especially with nurses and social workers, and on organizational integration, in terms of frequency of meeting to discuss about quality of care. Conversely, no significant differences were found in terms of either clinical or system integration. Furthermore, the collaboration with specialists is still weak. Considering the general practitioners' perspective in terms of experience and satisfaction towards primary care, co-location strategies is a necessary step in order to facilitate the collaboration among professionals and to prevent unintended consequences in terms of an even possible isolation of primary care as an involuntary 'disintegration of the integration'.

Is the co-location of GPs in primary care centres associated with a higher patient satisfaction? Evidence from a population survey in Italy.

BACKGROUND: Several countries have co-located General Practitioners (GPs) in Primary Care Centres (PCCs) with other health and social care professionals in order to improve integrated care. It is not clear whether the co-location of a multidisciplinary team actually facilitates a positive patient experience concerning GP care. The aim of this study was to verify whether the co-location of GPs in PCCs is associated positively with patient satisfaction with their GP when patients have experience of a multidisciplinary team. We also investigated whether patients who frequently use health services, due to their complex needs, benefitted the most from the co-location of a multidisciplinary team. METHODS: The study used data from a population survey carried out in Tuscany (central Italy) at the beginning of 2015 to evaluate the patients' experience and satisfaction with their GPs. Multilevel linear regression models were implemented to verify the relationship between patient satisfaction and co-location. This key explanatory variable was measured by considering both the list of GPs working in PCCs and the answers of surveyed patients who had experienced the co-location of their GP in a multidisciplinary team. We also explored the effect modification on patient satisfaction due to the use of hospitalisation, access to emergency departments and visits with specialists, by performing the multilevel modelling on two strata of patient data: frequent and non-frequent health service users. RESULTS: A sample of 2025 GP patients were included in the study, 757 of which were patients of GPs working in a PCC. Patient satisfaction with their GP was generally positive. Results showed that having a GP working within a PCC and the experience of the co-located multidisciplinary team were associated with a higher satisfaction (p < 0.01). For non-frequent users of health services on the other hand, the co-location of multidisciplinary team in PCCs was not significantly associated with patient satisfaction, whereas for frequent users, the strength of relationships identified in the overall model increased (p < 0.01). CONCLUSION: The co-location of GPs with other professionals and their joint working as experienced in PCCs seems to represent a greater benefit for patients, especially for those with complex needs who use primary care, hospitals, emergency care and specialized care frequently.

Rethinking Healthcare Performance Evaluation Systems towards the People-Centredness Approach: Their Pathways, their Experience, their Evaluation.

Patient experience should be the starting point to achieve a high quality of care. Coherently, healthcare performance evaluation systems, driving the change in line with the main strategic goals, should be designed considering the patient perspective. Instead, they are traditionally defined according to the healthcare service provider's point of view. Consequently, they reproduce a "silo-vision" characterized by a clear separation of responsibilities limited to a specific setting of care or to a single organization. This commentary discusses the importance of using patient-reported measures together with indicators based on administrative data to evaluate cross-setting healthcare services within a multidimensional healthcare performance evaluation system. The experience of the Tuscany regional healthcare Performance Measurement System (PMS), implemented more than 10 years ago and in continuous evolution, represents an innovative example of how to measure the quality of the whole care pathway including patient experience. This new approach is based on a systematic, systemic and standardized collection of patient-reported experience measures in several healthcare pathways and evaluating them using a coherent graphical representation. Targets, incentives and other managerial tools are fixed, overcoming organizational boundaries and integrating the patient point of view with the goal of moving the healthcare system towards a patient-centredness approach to care.

The effect of contraceptive counselling in the pre and post-natal period on contraceptive use at three months after delivery among Italian and immigrant women.

INTRODUCTION: Contraceptive counselling in the pre and post-natal period may be important for the use of postpartum contraception and prevention of induced abortion. This paper evaluates the use of postpartum contraceptives and the factors associated with it in a sample of Italian and immigrant women. MATERIALS AND METHODS: Data are drawn from two population-based follow-up surveys conducted to evaluate the quality of maternal care in 25 Italian Local Health Units in 2008/9 and 2010/1. Descriptive analyses and logistic regression models for complex survey data were used. RESULTS: The use of effective contraceptives in the postpartum period is similar between Italians and immigrants (65%). Fifty-nine percent of Italians and 63% of immigrants received contraceptive counselling by natal care services. Women who received counselling are more likely to use effective contraceptives (Italians OR = 2.55 95% CI 2.06 - 3.14; immigrants OR = 4.01 95% CI 2.40 - 6.70). CONCLUSIONS: This study supports the notion that health professionals should take every opportunity during pregnancy, childbirth and puerperium to provide information and counselling to improve knowledge and awareness of contraception.