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Structural asymmetries of brain regions associated with lateralised functions have been extensively studied. However, there are fewer morphometric analyses of asymmetries of the gyri and sulci of the entire cortex. The current study assessed cortical asymmetries in a sample of healthy adults (N = 175) from an admixed population from South America. Grey matter volume and surface area of 66 gyri and sulci were quantified on T1 magnetic resonance images. The departure from zero of the differences between left and right hemispheres (L-R), a measure of directional asymmetry (DA), the variance of L-R, and an index of fluctuating asymmetry (FA) were evaluated for each region. Significant departures from perfect symmetry were found for most cortical gyri and sulci. Regions showed leftward asymmetry at the population level in the frontal lobe and superior lateral parts of the parietal lobe. Rightward asymmetry was found in the inferior parietal, occipital, frontopolar, and orbital regions, and the cingulate (anterior, middle, and posterior-ventral). Despite this general pattern, several sulci showed the opposite DA compared to the neighbouring gyri, which remarks the need to consider the neurobiological differences in gyral and sulcal development in the study of structural asymmetries. The results also confirm the absence of DA in most parts of the inferior frontal gyrus and the precentral region. This study contributes with data on populations underrepresented in the databases used in neurosciences. Among its findings, there is agreement with previous results obtained in populations of different ancestry and some discrepancies in the middle frontal and medial parietal regions. A significant DA not reported previously was found for the volume of long and short insular gyri and the central sulcus of the insula, frontomarginal, transverse frontopolar, paracentral, and middle and posterior parts of the cingulate gyrus and sulcus, gyrus rectus, occipital pole, and olfactory sulcus, as well as for the volume and area of the transverse collateral sulcus and suborbital sulcus. Also, several parcels displayed significant variability in the left-right differences, which can be partially attributable to developmental instability, a source of FA. Moreover, a few gyri and sulci displayed ideal FA with non-significant departures from perfect symmetry, such as subcentral and posterior cingulate gyri and sulci, inferior frontal and fusiform gyri, and the calcarine, transverse collateral, precentral, and orbital sulci. Overall, these results show that asymmetries are ubiquitous in the cerebral cortex.
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Corteza Cerebral , Sustancia Gris , Adulto , Humanos , Sustancia Gris/diagnóstico por imagen , Corteza Cerebral/diagnóstico por imagen , Lóbulo Frontal , Giro del Cíngulo , Imagen por Resonancia Magnética/métodos , América del SurRESUMEN
In Italy, despite strong community-based mental health services, needs assessment is unsatisfactory. Using the Mental Health Clustering Tool (MHCT) we adopted a multidimensional and non-diagnosis dependent approach to assign mental health services users with similar needs to groups corresponding to resources required for effective care. We tested the MHCT in nine Departments of Mental Health in four Italian regions. After a brief training, 318 professionals assessed 12,938 cases with a diagnosis of schizophrenia, depression, bipolar disorder and personality disorder through the MHCT. 53% of cases were 40-59 years, half were females, 51% had a diagnosis of schizophrenia, 48% of cases were clinically severe. Clusters included different levels of clinical severity and diagnostic groups. The largest cluster was 11 (ongoing recurrent psychosis), with 18.9% of the sample, followed by cluster 3 (non-psychotic disorders of moderate severity). The MHCT could capture a variety of problems of people with mental disorders beyond the traditional psychiatric assessment, therefore depicting service population from a different standpoint. Following a brief training, MHCT assessment proved to be feasible. The automatic allocation of cases made the attribution to clusters easy and acceptable by professionals. To what extent clustering provide a sound base for care planning will be the matter of further research.
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Servicios de Salud Mental , Trastornos Psicóticos , Esquizofrenia , Femenino , Humanos , Masculino , Proyectos Piloto , Salud MentalRESUMEN
BACKGROUND: The assessment of the quality of care pathways delivered to people with severe mental disorders in a community-based system remains uncommon, especially using healthcare utilization databases. The aim of the study was to evaluate the quality of care provided to people with bipolar disorders taken-in-care by mental health services of four Italian areas (Lombardy, Emilia-Romagna, Lazio, province of Palermo). METHODS: Thirty-six quality indicators were implemented to assess quality of mental health care for patients with bipolar disorders, according to three dimensions (accessibility and appropriateness, continuity, and safety). Data were retrieved from healthcare utilization (HCU) databases, which contain data on mental health treatments, hospital admissions, outpatient interventions, laboratory tests and drug prescriptions. RESULTS: 29,242 prevalent and 752 incident cases taken-in-care by regional mental health services with a diagnosis of bipolar disorder in 2015 were identified. Age-standardized treated prevalence rate was 16.2 (per 10,000 adult residents) and treated incidence rate 1.3. In the year of evaluation, 97% of prevalent cases had ≥ 1 outpatient/day-care contacts and 88% had ≥ 1 psychiatric visits. The median of outpatient/day-care contacts was 9.3 interventions per-year. Psychoeducation was provided to 3.5% of patients and psychotherapy to 11.5%, with low intensity. 63% prevalent cases were treated with antipsychotics, 71.5% with mood stabilizers, 46.6% with antidepressants. Appropriate laboratory tests were conducted in less than one-third of prevalent patients with a prescription of antipsychotics; three quarters of those with a prescription of lithium. Lower proportions were observed for incident patients. In prevalent patients, the Standardized Mortality Ratio was 1.35 (95% CI: 1.26-1.44): 1.18 (1.07-1.29) in females, 1.60 (1.45-1.77) in males. Heterogeneity across areas was considerable in both cohorts. CONCLUSIONS: We found a meaningful treatment gap in bipolar disorders in Italian mental health services, suggesting that the fact they are entirely community-based does not assure sufficient coverage by itself. Continuity of contacts was sufficient, but intensity of care was low, suggesting the risk of suboptimal treatment and low effectiveness. Care pathways were monitored and evaluated using administrative healthcare databases, adding evidence that such data may contribute to assess the quality of clinical pathways in mental health.
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Antipsicóticos , Trastorno Bipolar , Servicios de Salud Mental , Adulto , Femenino , Masculino , Humanos , Salud Mental , Trastorno Bipolar/terapia , LitioRESUMEN
BACKGROUND: The beginning of the Covid-19 pandemic has forced many hospital departments worldwide to implement telehealth strategies for the first time. Telehealth represents the opportunity to increase value for all stakeholders, including patients and healthcare staff, but its success constitutes a challenge for all of them and particularly patients play a crucial role for their needed adherence. This study focuses on the experience of the Rheumatology Unit of Niguarda Hospital in Milan (Italy), where telehealth projects have been implemented for more than a decade with structured design and organized processes. The case study is paradigmatic because patients have experimented personalized mixes of telehealth channels, including e-mails and phone calls, Patient Reported Outcomes questionnaires, and home delivery of drugs. Given all these peculiarities, we decided to deepen patients' perspective through three main aspects related to the adoption of telehealth: (i) the benefits perceived, (ii) the willingness to enrol in future projects, (iii) the preference on the service-mix between remote contacts and in-person visits. Most importantly, we investigated differences in the three areas among all patients based on the mix of telehealth channels experienced. METHODS: We conducted a survey from November 2021 to January 2022, enrolling consecutively patients attending the Rheumatology Unit of Niguarda Hospital in Milan (Italy). Our survey comprised an introductory set of questions related to personal, social, clinical and ICT skills information, followed by the central part on telehealth. All the answers were analysed with descriptive statistics and regression models. RESULTS: A complete response was given by 400 patients: 283 (71%) were female, 237 (59%) were 40-64 years old, 213 (53%) of them declared to work, and the disease most represented was Rheumatoid Arthritis (144 patients, 36%). Descriptive statistics and regression results revealed that (i) non-users imagined wide-ranging benefits compared to users; (ii) other things being equal, having had a more intense experience of telehealth increased the odds of accepting to participate to future projects by 3.1 times (95% C.I. 1.04-9.25), compared to non-users; (iii) the more telehealth was experienced, the higher the willingness to substitute in-person with online contacts. CONCLUSIONS: Our study contributes to enlighten the crucial role played by the telehealth experience in determining patients' preferences.
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COVID-19 , Reumatología , Telemedicina , Humanos , Femenino , Adulto , Persona de Mediana Edad , Masculino , Pandemias , COVID-19/epidemiología , Encuestas y CuestionariosRESUMEN
BACKGROUND: Mental health (MH) care often exhibits uneven quality and poor coordination of physical and MH needs, especially for patients with severe mental disorders. This study tests a Population Health Management (PHM) approach to identify patients with severe mental disorders using administrative health databases in Italy and evaluate, manage and monitor care pathways and costs. A second objective explores the feasibility of changing the payment system from fee-for-service to a value-based system (e.g., increased care integration, bundled payments) to introduce performance measures and guide improvement in outcomes. METHODS: Since diagnosis alone may poorly predict condition severity and needs, we conducted a retrospective observational study on a 9,019-patient cohort assessed in 2018 (30.5% of 29,570 patients with SMDs from three Italian regions) using the Mental Health Clustering Tool (MHCT), developed in the United Kingdom, to stratify patients according to severity and needs, providing a basis for payment for episode of care. Patients were linked (blinded) with retrospective (2014-2017) physical and MH databases to map resource use, care pathways, and assess costs globally and by cluster. Two regions (3,525 patients) provided data for generalized linear model regression to explore determinants of cost variation among clusters and regions. RESULTS: Substantial heterogeneity was observed in care organization, resource use and costs across and within 3 Italian regions and 20 clusters. Annual mean costs per patient across regions was 3,925, ranging from 3,101 to 6,501 in the three regions. Some 70% of total costs were for MH services and medications, 37% incurred in dedicated mental health facilities, 33% for MH services and medications noted in physical healthcare databases, and 30% for other conditions. Regression analysis showed comorbidities, resident psychiatric services, and consumption noted in physical health databases have considerable impact on total costs. CONCLUSIONS: The current MH care system in Italy lacks evidence of coordination of physical and mental health and matching services to patient needs, with high variation between regions. Using available assessment tools and administrative data, implementation of an episodic approach to funding MH could account for differences in disease phase and physical health for patients with SMDs and introduce performance measurement to improve outcomes and provide oversight.
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Trastornos Mentales , Gestión de la Salud Poblacional , Humanos , Macrodatos , Estudios Retrospectivos , Trastornos Mentales/diagnóstico , Trastornos Mentales/terapia , Salud MentalRESUMEN
BACKGROUND: The success of antiretroviral therapies has made human immunodeficiency virus (HIV) a chronic disease, changing the care scenario dramatically. This study aimed to measure adherence to diabetes mellitus standards of care provided for people living with HIV (PLWH). Diabetes represents a paradigmatic case for tackling chronic care management in this target group. METHODS: This retrospective observational study was performed on administrative health data retrieved from 2014 to 2016, with a validated algorithm to identify patients with HIV using: (i) hospital discharge records (ICD9-CM codes); (ii) drug dispensing records (with ATC codes); and (iii) disease-specific exemptions from co-payments for healthcare services. HIV-related treatments, comorbidities and health service utilization were measured, as was adherence to clinical guidelines-recommended standards of care for diabetes. RESULTS: A population of 738 cases were identified in two Local Health Authorities in Italy, representing a prevalence of 0.14% of the general population, in line with the expected prevalence. Thirty-one cases of HIV patients diagnosed with diabetes were identified, a prevalence ratio of 4.2% compared to the 8% in the overall population. Adherence to diabetes standards of care tested within the same population was low, with the exception of those tests commonly administered for standard HIV follow-up care. CONCLUSIONS: The use of administrative data, combined with a Population Health Management approach represents a powerful tool for evaluating system capacity to manage HIV comorbidities. Study findings prove that it is time to design new care models for PLWH, affected by one or more chronic conditions, both to prevent their onset and to manage their comorbidities.
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Diabetes Mellitus , Infecciones por VIH , Gestión de la Salud Poblacional , Humanos , Infecciones por VIH/tratamiento farmacológico , Infecciones por VIH/epidemiología , Comorbilidad , Diabetes Mellitus/epidemiología , Diabetes Mellitus/terapia , Prevalencia , Enfermedad CrónicaRESUMEN
PURPOSE: To measure indicators of timeliness and continuity of treatments on patients with schizophrenic disorder in 'real-life' practice, and to validate them through their relationship with relapse occurrences. METHODS: The target population was from four Italian regions overall covering 22 million beneficiaries of the NHS (37% of the entire Italian population). The cohort included 12,054 patients newly taken into care for schizophrenic disorder between January 2015 and June 2016. The self-controlled case series (SCCS) design was used to estimate the incidence rate ratio of relapse occurrences according to mental healthcare coverage. RESULTS: Poor timeliness (82% and 33% of cohort members had not yet started treatment with psychosocial interventions and antipsychotic drug therapy within the first year after they were taken into care) and continuity (27% and 23% of patients were persistent with psychosocial interventions, and antipsychotic drug therapy within the first 2 years after starting the specific treatment) were observed. According to SCCS design, 4794 relapses occurred during 9430 PY (with incidence rate of 50.8 every 100 PY). Compared with periods not covered by mental healthcare, those covered by psychosocial intervention alone, antipsychotic drugs alone and by psychosocial intervention and antipsychotic drugs together were, respectively, associated with relapse rate reductions of 28% (95% CI 4-46%), 24% (17-30%) and 44% (32-53%). CONCLUSION: Healthcare administrative data may contribute to monitor and to assess the effectiveness of a mental health system. Persistent use of both psychosocial intervention and antipsychotic drugs reduces risk of severe relapse.
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Antipsicóticos , Esquizofrenia , Antipsicóticos/uso terapéutico , Estudios de Cohortes , Humanos , Salud Mental , Proyectos de Investigación , Esquizofrenia/tratamiento farmacológico , Esquizofrenia/epidemiologíaRESUMEN
Introduction: It is essential to have sensitive, economical and quick cognitive screening tools for early detection of Mild Cognitive Impairment (MCI). The objective of the present study was to assess a new way of interpreting widely used screening tests, generating a new score: the CSIS (Combined Screening Interpretation Score). The CSIS considers the performance in various routine screening tests (MMSE, Clock drawing test, Short form of the Boston naming test, Phonological and Semantic fluency tests and the Frontal Assessment Battery) by summing up their gross scores in one general score. Methods: We calculated the CSIS of 90 Hispanic older adults without dementia (40 controls and 50 patients with a diagnosis of MCI). The differences of the CSIS between the groups, and the discriminative capacity of the CSIS and each separate test were analyzed. Results: Significant differences in the CSIS were observed between the groups, as a higher discriminative capacity of the CSIS compared to the other screening tests. A score of 86 points in the CSIS discriminates the groups with 84% sensitivity and 90% specificity. Conclusion: It is concluded that the CSIS is a useful, simple and brief tool to assess the cognitive performance of subjects with MCI.
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Envejecimiento , Disfunción Cognitiva , Anciano , Disfunción Cognitiva/diagnóstico , Humanos , Tamizaje Masivo , Pruebas NeuropsicológicasRESUMEN
Cocaine related disorders are currently among the most devastating mental diseases, as they impoverish all spheres of life resulting in tremendous economic, social and moral costs. Despite multiple efforts to tackle cocaine dependence, pharmacological as well as cognitive therapies have had limited success. In this review, we discuss the use of recent neuromodulation techniques, such as conventional repetitive transcranial magnetic stimulation (rTMS), deep brain stimulation (DBS) and the use of H coils for deep rTMS for the treatment of cocaine dependence. Moreover, we discuss attempts to identify optimal brain targets underpinning cocaine craving and withdrawal for neurodisruption treatment, as well as some weaknesses in the literature, such as the absence of biomarkers for individual risk classification and the inadequacy of treatment outcome measures, which may delay progress in the field. Finally, we present some genetic markers candidates and objective outcome measures which could be applied in combination with TMS treatment of cocaine dependence. We anticipate future research in this area combining genetic and physiological markers, neurodisruption, and clinical behavioral measures.
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OBJECTIVE: Temporal lobe epilepsy can disturb eloquent areas, affecting language. We applied a visually-mediated task to measure lateralization of language recognition in drug-resistant temporal lobe epilepsy. METHOD: Patients with left (n = 26), right (n = 28) temporal lobe epilepsy and controls (n = 30) were administered the translingual lexical decision task. We performed repeated measures analyses of variance, with the visual half-field as an intrasubject factor and the group as an intersubject factor. RESULTS: A main effect of visual half-field was found, showing the right visual field (left hemisphere) advantage for both accuracy and response time. A main effect of the group was found in accuracy, showing that both epilepsy groups performed less accurately than controls, and left temporal lobe epilepsy performed less accurately than right temporal lobe epilepsy. Also, the group-by-visual half-field interaction was significant. Post hoc t tests indicated the controls and right temporal lobe epilepsy performed better in the right visual field than in the left visual field, whereas no visual half-field effect was found in left temporal lobe epilepsy. For response times, the interaction was also significant. Post hoc t tests showed a significant right visual-field advantage for controls (two-tailed) and for the right temporal lobe epilepsy (one-tailed). Right visual-field advantage was absent in left temporal lobe epilepsy. CONCLUSIONS: The translingual lexical decision task can efficiently distinguish between left and right temporal lobe epilepsy. Compared to right temporal lobe epilepsy and controls, language lateralization is diminished in left temporal lobe epilepsy. The potential use of the translingual lexical decision task as an effective noninvasive presurgical language lateralization screening tool is highlighted. (PsycInfo Database Record (c) 2024 APA, all rights reserved).
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INTRODUCTION: Current hospital-based care pathways are generally single-disease centred. As a result, coexisting morbidities are often suboptimally evaluated and managed, a deficiency becoming increasingly apparent among older patients who exhibit heterogeneity in health status, functional abilities, frailty, and other geriatric impairments. To address this issue, our study aims to assess a newly developed patient-centred care pathway for older patients with multimorbidity and cancer. The new care pathway was based on currently available evidence and co-designed by end-users including health care professionals, patients, and informal caregivers. Within this care pathway, all healthcare professionals involved in the care of older patients with multimorbidity and cancer will form a Health Professional Consortium (HPC). The role of the HPC will be to centralise oncologic and non-oncologic treatment recommendations in accordance with the patient's priorities. Moreover, an Advanced Practice Nurse will act as case-manager by being the primary point of contact for the patient, thus improving coordination between specialists, and by organising and leading the consortium. Patient monitoring and the HPC collaboration will be facilitated by digital communication tools designed specifically for this purpose, with the added benefit of being customisable for each patient. MATERIALS AND METHODS: The GERONTE study is a prospective international, multicentric study consisting of two stepped-wedge trials performed at 16 clinical sites across three European countries. Each trial will include 720 patients aged 70 years and over with a new or progressive cancer (breast, lung, colorectal, prostate) and at least one moderate or severe multimorbidity. The patients in the intervention group will receive the new care pathway whereas patients in the control group will receive usual oncologic care. DISCUSSION: GERONTE will evaluate whether this kind of holistic, patient-oriented healthcare management can improve quality of life (primary outcome) and other valuable endpoints in older patients with multimorbidity and cancer. An ancillary study will assess in depth the socio-economic impact of the intervention and deliver concrete implementation guidelines for the GERONTE intervention care pathway. TRIAL REGISTRATION: FRONE: NCT05720910 TWOBE: NCT05423808.
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Multimorbilidad , Neoplasias , Atención Dirigida al Paciente , Humanos , Neoplasias/complicaciones , Neoplasias/terapia , Anciano , Tecnología de la Información , Vías Clínicas , Salud Holística , Anciano de 80 o más Años , Masculino , FemeninoRESUMEN
BACKGROUND: The frontal aslant tract (FAT) is a bilateral tract located within each frontal lobe. It connects the supplementary motor area in the superior frontal gyrus with the pars opercularis in the inferior frontal gyrus. There is a new and broader conceptualization of this tract called the extended FAT (eFAT). The eFAT tract role is believed to be related to several brain functions, including verbal fluency as one of its main domains. METHODS: Tractographies were performed by using DSI Studio software on a template of 1065 healthy human brains. The tract was observed in a three-dimensional plane. The Laterality Index was calculated based on the length, volume, and diameter of fibers. A t test was performed to verify the statistical significance of global asymmetry. The results were compared with cadaveric dissections performed according to the Klingler technique. An illustrative case enlightens the neurosurgical application of this anatomic knowledge. RESULTS: The eFAT communicates the superior frontal gyrus with the Broca area (within the left hemisphere) or its contralateral homotopic area within the nondominant hemisphere. We measured the commisural fibers, traced cingulate, striatal, and insular connections and showed the existence of new frontal projections as part of the main structure. The tract did not show a significant asymmetry between the hemispheres. CONCLUSIONS: The tract was successfully reconstructed, focusing on its morphology and anatomic characteristics.
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Corteza Motora , Sustancia Blanca , Humanos , Vías Nerviosas/anatomía & histología , Mapeo Encefálico/métodos , Lóbulo Frontal/diagnóstico por imagen , Lóbulo Frontal/cirugía , Lóbulo Frontal/anatomía & histología , Corteza Prefrontal/diagnóstico por imagen , Corteza Prefrontal/cirugía , LenguajeRESUMEN
Ensuring adequate quality of care to patients with severe mental disorders remains a challenge. The implementation of clinical indicators aimed at assessing the quality of health care pathways delivered is crucial for the improvement of mental health services (MHS). This study aims to evaluate the quality of care delivered to patients who are taken-into-care with depressive disorders by MHS. Thirty-four clinical indicators concerning accessibility, appropriateness, continuity, and safety were estimated using health care utilization databases from four Italian regions (Lombardy, Emilia-Romagna, Lazio, Sicily). A total of 78,924 prevalent patients treated for depressive disorders in 2015 were identified, of whom 15,234 were newly engaged by MHS. During the year of follow-up, access to psychotherapeutic interventions was low, while the intensity was adequate; 5.1% of prevalent patients received at least one hospitalization in a psychiatric ward (GHPW), and 3.3% in the cohort of newly engaged in services. Five-out-of-10 patients had contact with community services within 14 days after GHPW discharge, but less than half of patients were persistent to antidepressant drug therapy. Furthermore, prevalent patients showed an excess of mortality compared to the general population (SMR = 1.35; IC 95%: 1.26-1.44). In conclusion, the quality of health care is not delivered in accordance with evidence-based mental health standards. Evaluation of health interventions are fundamental strategies for improving the quality and equity of health care.
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BACKGROUND: Italy can be viewed as a laboratory to assess the quality of mental healthcare delivered in a community-oriented system, especially for severe mental disorders, such as personality disorders. Although initiatives based on clinical indicators for assessing the quality of mental healthcare have been developed by transnational-organisations, there is still no widespread practice of measuring the quality of care pathways delivered to patients with severe mental disorders in a community-oriented system, especially using administrative healthcare databases. The aim of the study is to evaluate the quality of care delivered to patients with personality disorders taken-in-care by mental health services of four Italian regions (Lombardy, Emilia-Romagna, Lazio, Sicily). METHODS: A set of thirty-three clinical indicators, concerning accessibility, appropriateness, continuity, and safety of care, was implemented using regional healthcare utilization databases, containing data on mental health treatments and diagnosis, hospital admissions, outpatient interventions and exams and drug prescriptions. RESULTS: 31,688 prevalent patients with personality disorders treated in 2015 were identified, of whom 2,331 newly taken-in-care. One-in-10 patients received a standardized assessment, the treatment discontinuity affected half of the cases. 12.7% of prevalent patients received at least one hospitalization, 10.6% in the newly taken-in-care cohort. 6-out-of-10 patients had contact with community-services within 14 days from hospital discharge. Access to psychotherapy and psychoeducational treatments was low and delivered with a low intensity. The median of psychosocial interventions per person-year was 19.1 and 9.4, respectively, in prevalent and newly taken-in-care cases. Nearly 50% of patients received pharmacological treatments. CONCLUSIONS: Healthcare utilization databases were used to systematically evaluate and assess service delivery across regional mental health systems; suggesting that in Italy the public mental health services provide to individuals with personality disorders suboptimal treatment paths.
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This policy paper aims to compare what policies are developed in Italy for the management of chronic patients in order to improve population health, quality of care and patient experience and reduce per-capita cost. The paper also aims to identify the key trends and evolutionary trajectories across the Country. METHODOLOGY: The analysis focuses on 10 Italian Regions and the time span of observation is 7 years (from 2014 to 2020). Data collection and analysis adopts mixed methods in order to have a more in-depth picture of the contextual factors, mechanisms and outcomes. It includes a desk research of the literature and documentary analysis; semi-structured interviews; a theory driven evaluation of 12 programmes identified at the regional level; and a Consensus Conference to discuss and validate the results with an Expert Panel Group. CONCLUSIONS: The paper firstly describes the main policies developed in Italy in the last seven years; secondly, it discusses six main trends and clusters them into three strategies: demand management strategies; strategies to improve the management of comorbid and frail patients; and strategies to improve the coordination between levels of care and the patient journey; thirdly, it discusses eight trends and evolutionary trajectories which are now emerging.
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Therapeutic innovation is expected to change if not disrupt present care models for several chronic diseases in the coming years, as suggested by recent clinical trials. New drugs that anticipate and possibly delay the full expression of a disease will likely face some common challenges, such as the need of designing and implementing large scale interventions; the necessary engagement of multiple specialties for both diagnosis and treatment; the shift from specialist to non-specialist interventions and secondary prevention. Building on the case of HCV and other innovation in hepatology, we discuss common challenges caused by disruptive change that other chronic conditions faced in the past. The recent history of hepatology shows interesting examples of disruptive innovations that completely reverted traditional treatment approaches. As we learned from the slow early diffusion of antiviral drugs, without a clear information and a prompt design of the appropriate delivery modalities, the effectiveness of new treatments is undermined and care risk to be postponed for long time. This implies the definition of (i) new service models diversified by care phases and patients' target; (ii) horizontal integration: to go beyond the professional boundaries to build solid alliances; (iii) vertical integration between primary and secondary care.
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Objectives: To measure the gap between contact and effective coverage of mental healthcare (MHC). Materials and methods: 45,761 newly referred cases of depression, schizophrenia, bipolar disorder, and personality disorder from four Italian regions were included. A variant of the self-controlled case series method was adopted to estimate the incidence rate ratio (IRR) for the relationship between exposure (i.e., use of different types of MHC such as pharmacotherapy, generic contact with the outpatient services, psychosocial intervention, and psychotherapy) and relapse (emergency hospital admissions for mental illness). Results: 11,500 relapses occurred. Relapse risk was reduced during periods covered by (i) psychotherapy for patients with depression (IRR 0.67; 95% CI: 0.49 to 0.91) and bipolar disorder (0.64; 0.29 to 0.99); (ii) psychosocial interventions for those with depression (0.74; 0.56 to 0.98), schizophrenia (0.83; 0.68 to 0.99), and bipolar disorder (0.55; 0.36 to 0.84), (iii) pharmacotherapy for patients with schizophrenia (0.58; 0.49 to 0.69), and bipolar disorder (0.59; 0.44 to 0.78). Coverage with generic care, in absence of psychosocial/psychotherapeutic interventions, did not affect risk of relapse. Conclusion: This study ascertained the gap between contact and effective coverage of MHC and showed that administrative data can usefully contribute to assess the effectiveness of a mental health system.
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Efficiency in healthcare is crucial since available resources are scarce, and the cost of inefficient allocation is measured in prior outcomes. This is particularly relevant for cancer. The aim of this paper is to gain a comprehensive overview of the areas and dimensions to improve efficiency, and establish the indicators, different methods, perspectives, and areas of evaluation, to provide recommendations for how to improve efficiency and measure gains in cancer care. METHODS: We conducted a two-phase design. First, a comprehensive scoping literature review was conducted, searching four databases. Studies published between 2000 and 2021 were included if they described experiences and cases of efficiency in cancer care or methods to evaluate efficiency. The results of the literature review were then discussed during two rounds of online consultation with a panel of 15 external experts invited to provide insight and comments to deliberate policy recommendations. RESULTS: 46 papers met the inclusion criteria. Based on the papers retrieved we identified six areas for achieving efficiency gains throughout the entire care pathway and, for each area of efficiency, we categorized the methods and outcomes used to measure efficiency gain. CONCLUSION: This is the first attempt to systemize a scattered body of literature on how to improve efficiency in cancer care and identify key areas of improvement. POLICY SUMMARY: There are many opportunities to improve efficiency in cancer care. We defined seven policy recommendations on how to improve efficiency in cancer care throughout the care pathway and how to improve the measurement of efficiency gains.
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Atención a la Salud , Neoplasias , Neoplasias/terapiaRESUMEN
AIMS: To evaluate the quality of mental health care delivered to patients with schizophrenia and related disorders taken-in-care by mental health services in four Italian regions (Lombardy, Emilia-Romagna, Lazio, Sicily). METHODS: Thirty-one clinical indicators concerning accessibility, appropriateness, continuity and safety were defined and estimated using healthcare utilisation (HCU) databases, containing data on mental health treatments, hospital admissions, outpatient interventions, lab tests and drug prescriptions. RESULTS: A total of 70 586 prevalent patients with schizophrenia and related disorders treated in 2015 were identified, of whom 1752 were newly taken-in-care by the facilities of regional mental health services. For most patients community care was accessible and moderately intensive. However, care pathways were not implemented based on a structured assessment and only half of the patients received psychosocial treatments. One patient out of ten had access to psychological interventions and psychoeducation. Activities specifically addressed to families involved a third of prevalent patients and less than half of new patients. One patient out of six was admitted to a community residential facility, and one out of ten to a General Hospital Psychiatric Ward (GHPW); higher values were identified in new cases. In general hospitals, few patients had a length of stay (LoS) of more than 30 days, while one-fifth of the admissions were followed by readmission within 30 days of discharge. For two-thirds of patients, continuity of community care was met, and six times out of ten a discharge from a GHPW was followed by an outpatient contact within 2 weeks. For cases newly taken-in-care, the continuity of community care was uncommon, while the readiness of outpatient contacts after discharge was slightly more frequent. Most of the patients received antipsychotic medication, but their adherence to long-term treatment was low. Antipsychotic polytherapy was frequent and the control of metabolic side effects was poor. The variability between regions was high and consistent in all the quality domains. CONCLUSIONS: The Italian mental health system could be improved by increasing the accessibility to psychosocial interventions, improving the quality of care for newly taken-in-care patients, focusing on somatic health and mortality, and reducing regional variability. Clinical indicators demonstrate the strengths and weaknesses of the mental health system in these regions, and, as HCU databases, they could be useful tools in the routine assessment of mental healthcare quality at regional and national levels.
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Trastornos Mentales , Servicios de Salud Mental , Esquizofrenia , Humanos , Italia/epidemiología , Trastornos Mentales/epidemiología , Trastornos Mentales/terapia , Salud Mental , Aceptación de la Atención de Salud , Esquizofrenia/epidemiología , Esquizofrenia/terapiaRESUMEN
Introduction: The perisylvian region is the cortical core of language and speech. Several accessory sulci have been described in this area, whose presence could modify the results of the automatic quantification of gray matter by popularly used software. This study aimed to assess the expression of accessory sulci in the frontoparietal operculum (FPO) and to evaluate their influence on the gray matter volume estimated by an automatic parcellation of cortical gyri and sulci. Methods: Brain MRI scans of 100 healthy adult volunteers were visually analyzed. The existence of the triangular and diagonal sulci, and the number of accessory sulci in the frontoparietal operculum, were assessed on T1 images. Also, the gray matter volume of gyri and sulci was quantified by an automatized parcellation method. Interhemispheric differences in accessory sulci were evaluated with Chi-square and Wilcoxon paired tests. The effects of the hemisphere, sex, age, total intracranial volume, and accessory sulci on morphometric variables were assessed by linear models. Results: These sulci were found in more than half of the subjects, mostly in the left hemisphere, and showed a significant effect on the gray matter content of the FPO. In particular, the volume of the inferior frontal sulcus, pars opercularis of the inferior frontal gyrus, horizontal ramus of the lateral sulcus, angular gyrus, and postcentral gyrus showed a significant influence on the presence of accessory sulci. Discussion: The prevalence of tertiary sulci in the FPO is high, although their meaning is not yet known. Therefore, they should be considered to reduce the risk of misclassifications of normal variation.