[Effect of hospital policies on patient mobility: Siennese experience]. / Programmazione ospedaliera e flussi di pazienti: esperienza senese.

The Italian National Health Service (S.S.N.), adopted in 1978 (Law n 833) and based on Beveridge's model, emphasises the citizens freedom to choose and the equal opportunity in accessing health care structures. Local Health Authorities--L.H.A. (U.S.L.--Unità Sanitarie Locali) become owners of almost all the structures in their territories and directly responsible for the satisfaction of all residents health needs. The former hospitals' network, based on independent first, second and third level public hospitals, in potential competition, was dismantled. Hospitals' financing, the main economic role of the S.S.N., was based on the documented running expenses: therefore the hospital interest to attract patients diminished and expenses increased in a uncontrolled way. In 1992, the Italian Government, (re)introduced (Law n 502) the quasi-market administered competition between Italian hospitals, making the major ones independent (Aziende Ospedaliere--A.O.) from the L.H.A. Hospital income from then is based on DRGs; the L.H.A. (and hospitals) leadership is now entrusted to managers and not politicians. We describe now how these changes were experienced by our hospital (A.O. Senese), placed in Southern Tuscany, Italy. We elaborated hospitalisation data regarding residents in the province of Siena (252,000 inhabitants) and activity data regarding its main hospital (A.O. Senese, 1200 beds, 47,000 admissions/year). Using the Gandy's Nomogram, we show the variation of patients mobility from 1988 to 1999. Our survey demonstrates that the Italian hospital system answers well enough to the legislative regulations: following the Law 833/1978 our hospital diminished its ability to attract patients from other areas; at the same time migrations of hospitals patients from Siena increased. Following the Law 502/1992, the power of attraction of our hospital is increased. Nevertheless the flow of escape continued to increase. It appears that to discourage the attraction power means to promote the loss of perceived quality and that it is difficult to correct such effects.

Prediction of mortality for congestive heart failure patients: results from different wards of an Italian teaching hospital.

Congestive heart failure (CHF) constitutes an important public health problem in Italy, evidenced by the high number of hospital admissions each year. Significant inter-hospital as well as interward differences in mortality rates for CHF patients that have been described may, in part, be explained by the differences in the severity of the illness of admitted patients. The goal of this study was to predict 30-day severity-adjusted mortality risk in patients with CHF admitted to wards of a teaching hospital in Siena, Italy, in 1997. A 30-day mortality was determined by linking hospital discharge files with the Tuscany Mortality Registry database. The 3M all patient refined diagnosis related group (APR-DRG) software was used as a risk assessment method. The relationships between death and the following variables were studied by univariate analyses: APR-severity risk, APR-mortality risk, age, sex, length of stay and, discharge ward. Multivariate analysis was also performed to verify the associations between death and those parameters found to be significant by univariate analysis. Unadjusted mortality proportions ranged from 4.3 to 44.0%. Logistic regression analysis demonstrated that APR-mortality risk, length of stay, and discharge ward were significantly and independently associated with 30-day mortality risk in patients with CHF. In summary, 30-day mortality risk varied significantly according to the ward of discharge in an Italian teaching hospital, even after adjustment for severity of illness.

Antitetanus immunity in a sample of adult population from the Siena area (Italy).

1045 subjects (427 males and 618 females) from the Siena area, aged 20-85, were screened for tetanus antitoxin by the means of a passive haemogglutination assay. 32% of subjects was found protected against tetanus (antitoxin titre greater than or equal to 0.1 I.U./ml), 34.7% resulted partially protected (titre greater than or equal to 0.01 - less than 0.1 I.U./ml), and 33.3% was found unprotected (titre less than 0.01 I.U./ml). The protection rate was higher among males (44.9%) than among females (23%) and showed a definite age-related decrease. Within each age group, the protection rate was higher among males. The lowest protection rate (3.2%) was observed among females aged 70 or more. Analysis of the protection rate according to the individuals' occupation showed the highest value (44.9%) among workmen and the lowest (12.1%) among housewives. The anamnestic criterion was found exceedingly unreliable to assess the individual's immune status. Results, which are consistent with present tetanus italian epidemiology, are discussed for their implications relating to a possible improvement of current antitenus immunization policy.