[A system of indicators for identifying the specific healthcare needs of communities by large health departments]. / Un sistema di indicatori distrettuali come strumento di lettura di una realtà aziendale complessa.

Clinical governance of healthcare and community services by healthcare organizations requires the use of validated tools for identifying the specific healthcare needs of the local population. The population served by a local health organization may be large and although data regarding this population as a whole is useful for a preliminary evaluation, it may be too generic for an accurate estimation of the healthcare needs at the district level since different districts may face different challenges and have profoundly different realities. In this context, it can be strategically useful to use a system of indicators targeted at districts, the latter regarded as the basic unit of the health care system and characterized by a relatively constant structure and size.A set of district indicators has been developed and adopted by a local health authority in Rome (Italy) "ASL Roma B", as part of a collaborative project with the Public Health Agency of the Lazio region. In this paper, we present the main results of the first four years of implementation of the system (from 2007 to 2010).The data shows that even within a metropolitan health organization serving an apparently homogeneous population, health needs, provision of services and outcomes may vary greatly between different districts suggesting the adoption of diverse operational strategies.

[Defining a set of indicators for the evaluation of healthcare needs and of the performance of local health authorities]. / Costruzione di un set di indicatori per la valutazione dei bisogni sanitari e della performance dei distretti.

A set of indicators for assessing healthcare needs and evaluating healthcare services are needed. This paper presents a set of indicators for evaluating healthcare districts, defined by a local health authority in the city of Rome. The set of indicators was developed by selecting 11 areas of interest and assigning to each area indicators that would allow an evaluation of its main functional aspects. Overall, 99 indicators were chosen and listed under one of two sections: basic and specific indicators. Annual measurements of the indicators is performed and a study will be conducted during 2010 to evaluate the system of indicators.

Implementing a guideline for the treatment of type 2 diabetics: results of a cluster-randomized controlled trial (C-RCT).

BACKGROUND: In Italy many diabetics still lack adequate care in general practice. We assessed the effectiveness of different strategies for the implementation of an evidence-based guideline for the management of non-complicated type 2 diabetes among General Practitioners (GPs) of Lazio region. METHODS: Three-arm cluster-randomised controlled trial with GPs as units of randomisation (clusters). 252 GPs were randomised either to an active strategy (training module with administration of the guideline), or to a passive dissemination (administration of the guideline only), or to usual care (control). Data on prescriptions of tests and drugs were collected by existing information systems, whereas patients' data came from GPs' databases. Process outcomes were measured at the cluster level one year after the intervention. Primary outcomes concerned the measurement of glycosilated haemoglobin and the commissioning of micro- and macrovascular complications assessment tests. In order to assess the physicians' drug prescribing behaviour secondary outcomes were also calculated. RESULTS: GPs identified 6395 uncomplicated type 2 patients with a high prevalence of cardiovascular risk factors. Data on GPs baseline performance show low proportions of glycosilated haemoglobin assessments. Results of the C-RCT analysis indicate that the active implementation strategy was ineffective relating to all primary outcomes (respectively, OR 1.06 [95% IC: 0.76-1.46]; OR 1.07 [95% IC: 0.80-1.43]; OR 1.4 [95% IC:0.91-2.16]. Similarly, passive dissemination of the guideline showed no effect. CONCLUSION: In our region compliance of GPs with guidelines was not enhanced by a structured learning programme. Implementation through organizational measures appears to be essential to induce behavioural changes. TRIAL REGISTRATION: ISRCTN80116232.

Strategies for the introduction and implementation of a guideline for the treatment of type 2 diabetics by general practitioners (GPs) of the Lazio region of Italy (IMPLEMEG study): protocol for a cluster randomised controlled trial [ISRCTN80116232].

BACKGROUND: Despite broad agreement on the necessity to improve quality of diabetic care through implementation of clinical guidelines, in Italy many people with diabetes still lack adequate care in general practice. In addition there is little evidence to support the choice of implementation strategies, especially in the Lazio region (central Italy), where comparative studies among general practitioners (GPs) are uncommon. The primary objective of the study is to assess the effectiveness of different strategies for the implementation of an evidence-based guideline for the management of non-complicated type 2 diabetes mellitus (DM) among GPs of the Lazio region. METHODS/DESIGN: Three-arm cluster-randomised trial (C-RCT). 252 GPs were randomised either to arm 1 (comprising a training module and administration of the guideline), or to arm 2 (administration of guideline without training), or to arm 3 (control arm), continuing current practice. Arm 1 participants attended a two-day course with CME credits. Data collection will be performed using current information systems. Patients' health data was also collected to describe diabetic populations cared for by GP participants. Process outcomes will be measured at the patient level and at the cluster level one year after the intervention. We will assess GPs' adherence to guideline recommendations for diabetes management relative to: 1) pharmacological management of diabetes; 2) pharmacological management of cardiovascular risk factors (hypertension and dislypidaemia); 3) measurement of glycosilated haemoglobin as the principal indicator of glycaemic control; 4) micro- and macrovascular complications assessment tests. Outcomes will be expressed as proportions of patients cared for by GPs who will have prescriptions of drugs, requests for tests and for outpatient appointment visits. To estimate the efficiency of resource use associated with the intervention a cost-effectiveness analysis will be carried out. The design of the study is based on three Cochrane and one Health Technology Assessment systematic reviews of guideline dissemination and implementation strategies.