The challenge of clinical reasoning in chronic multimorbidity: time and interactions in the Health Issues Network model.

The increasing prevalence of multimorbidity requires new theoretical models and educational approaches to develop physicians' ability to manage multimorbidity patients. The Health Issues Network (HIN) is an educational approach based on a graphical depiction of the evolutions over time of the concurrent health issues of a patient and of their interactions. From a theoretical point of view, the HIN approach is rooted in Prigogine's vision of the "becoming" of the events and in the concept of knowledge organization, intended as the process of storing and structuring of information in a learner's mind. The HIN approach allows to design clinical exercises to foster learners' ability to detect evolutionary paths and interactions among health issues. Recent findings of neuroscience support the expectation that interpreting, completing, and creating diagrams depicting complex clinical cases improves the "sense of time", as a fundamental competence in the management of multimorbidity. The application of the HIN approach is expected to decrease the risk of errors in the management of multimorbidity patients. The approach is still under validation, both for undergraduate students and for the continuous professional development of physicians.

Using Unified Modeling Language to Analyze Business Processes in the Delivery of Child Health Services.

Business Process Management (BPM) has been increasingly used in recent years in the healthcare domain to analyze, optimize, harmonize and compare clinical and healthcare processes. The main aim of this methodology is to model the interactions between medical and organizational activities needed to deliver health services, measure their complexity, variability and deviations to improve the quality of care and its efficiency. Among the different tools, languages and notations developed in the decades, UML (Unified Modeling Language) represents a widely adopted technique to model, analyze and compare business processes in healthcare. We adopted its diagrams in the MOCHA project to compare the different ways of organizing, coordinating and delivering child care across 30 EU/EEA countries both from an organization and control-flow perspectives. This paper provides an overview of the main components used to represent the business process using UML diagrams, also highlighting how we customized them to capture the specificity of the healthcare domain taking into account that processes are reconstructed on the basis of country experts' responses to questionnaires. The benefits of the application of this methodology are demonstrated by providing examples of comparing different aspects of child care.

Comparative analysis of pre-Covid19 child immunization rates across 30 European countries and identification of underlying positive societal and system influences.

This study provides a macro-level societal and health system focused analysis of child vaccination rates in 30 European countries, exploring the effect of context on coverage. The importance of demography and health system attributes on health care delivery are recognized in other fields, but generally overlooked in vaccination. The analysis is based on correlating systematic data built up by the Models of Child Health Appraised (MOCHA) Project with data from international sources, so as to exploit a one-off opportunity to set the analysis within an overall integrated study of primary care services for children, and the learning opportunities of the 'natural European laboratory'. The descriptive analysis shows an overall persistent variation of coverage across vaccines with no specific vaccination having a low rate in all the EU and EEA countries. However, contrasting with this, variation between total uptake per vaccine across Europe suggests that the challenge of low rates is related to country contexts of either policy, delivery, or public perceptions. Econometric analysis aiming to explore whether some population, policy and/or health system characteristics may influence vaccination uptake provides important results-GDP per capita and the level of the population's higher education engagement are positively linked with higher vaccination coverage, whereas mandatory vaccination policy is related to lower uptake rates. The health system characteristics that have a significant positive effect are a cohesive management structure; a high nurse/doctor ratio; and use of practical care delivery reinforcements such as the home-based record and the presence of child components of e-health strategies.

The Impact of Hospital Accessibility on Interregional Patient Mobility in Italy.

Patient mobility represents a proxy measure to assess the quality and availability of hospital services, especially in decentralized health systems. Different studies have been focused on the interregional mobility in Italy to capture factors influencing this phenomenon. Among them, hospital capacity is generally captured through the number of beds per population. However, this indicator does not consider the distance to hospitals and the accessibility of extra-regional beds, in particular for patients living at the regional borders. The aim of this paper is to analyse the effect of extra-regional spatial accessibility component on patient mobility among the Italian regions. This can help to capture the level of equity in the provision of services across the country providing a snapshot of the distribution of beds over the territory. Moreover, this study contributes to gain a deeper understanding of the allocation of health resources providing input for policy makers on the basis of the principles of service accessibility.

Beyond the FAIRness of COVID-19 Data: What about Quality?

Different datasets have been deployed at national level to share data on COVID-19 already at the beginning of the epidemic spread in early 2020. They distribute daily updated information aggregated at local, gender and age levels. To facilitate the reuse of such data, FAIR principles should be applied to optimally find, access, understand and exchange them, to define intra- and inter-country analyses for different purposes, such as statistical. However, another aspect to be considered when analyzing these datasets is data quality. In this paper we link these two perspectives to analyze to what extent datasets published by national institutions to monitor diffusion of COVID-19 are reusable for scientific purposes, such as tracing the spread of the virus.

Open Data Resources on COVID-19 in Six European Countries: Issues and Opportunities.

Since the beginning of the COVID-19 pandemic in March 2020, national and international authorities started to develop and update datasets to provide data to researchers, journalists and health care providers as well as public opinion. These data became one of the most important sources of information, which are updated daily and analysed by scientists in order to investigate and predict the spread of this epidemic. Despite this positive reaction from both national and international authorities in providing aggregated information on the diffusion of COVID-19, different challenges have been underlined in previously published studies. Different papers have discussed strengths and weaknesses of these types of datasets by focusing on different quality perspectives, which include the statistical methods adopted to analyse them; the lack of standards and models in the adoption of data for their management and distribution; and the analysis of different data quality characteristics. These studies have analysed datasets at the general level or by focusing the attention on specific indicators such as the number of cases or deaths. This paper further investigates issues and opportunities in the diffusion of these datasets under two main perspectives. At the general level, it analyses how data are organized and distributed to scientific and non-scientific communities. Moreover, it further explores the indicators adopted to describe the spread of the COVID-19 epidemic while also highlighting the level of detail used to describe them in terms of gender, age ranges and territorial units. The paper focuses on six European countries: Belgium, France, Germany, Italy, Spain and UK.

When Covid-19 first struck: Analysis of the influence of structural characteristics of countries - technocracy is strengthened by open democracy.

CONTEXT: The Covid-19 pandemic hit the developed world differentially due to accidental factors, and countries had to respond rapidly within existing resources, structures, and processes to manage totally new health challenges. This study aimed to identify which pre-existing structural factors facilitated better outcomes despite different starting points, as understanding of the relative impact of structural aspects should facilitate achieving optimal forward progress. METHODS: Desk study, based on selecting and collecting a range of measures for 48 representative characteristics of 42 countries' demography, society, health system, and policy-making profiles, matched to three pandemic time points. Different analytic approaches were employed including correlation, multiple regression, and cluster analysis in order to seek triangulation. FINDINGS: Population structure (except country size), and volume and nature of health resources, had only minor links to Covid impact. Depth of social inequality, poverty, population age structure, and strength of preventive health measures unexpectedly had no moderating effect. Strongest measured influences were population current enrolment in tertiary education, and country leaders' strength of seeking scientific evidence. The representativeness, and by interpretation the empathy, of government leadership also had positive effects. CONCLUSION: Strength of therapeutic health system, and indeed of preventive health services, surprisingly had little correlation with impact of the pandemic in the first nine months measured in death- or case-rates. However, specific political system features, including proportional representation electoral systems, and absence of a strong single party majority, were consistent features of the most successful national responses, as was being of a small or moderate population size, and with tertiary education facilitated. It can be interpreted that the way a country was lead, and whether leadership sought evidence and shared the reasoning behind resultant policies, had notable effects. This has significant implications within health system development and in promoting the population's health.

Quality of child healthcare in European countries: common measures across international databases and national agencies.

BACKGROUND: The evaluation of child healthcare is not yet widely explored, especially from a cross-country comparison perspective. The routine adoption of measures by national assessment agencies is under-investigated. Though the guiding principles developed at international level call for a child-centric multi-dimensional evaluation of child care, its feasibility is hampered by the availability of robust and harmonized data. METHODS: To explore the data availability, international databases (IDBs) were scrutinized and measures dealing with child health-related issues were collated. In parallel, an ad hoc questionnaire was administrated to 30 Country Agents (CAs) to gather measures routinely adopted at local level. To facilitate the comparison of measures, a three-level conceptual map was developed. RESULTS: The IDBs yielded at 207 measures that pertained mainly to non-health determinants of health, whereas the 352 measures obtained from CAs focused on process and outcome. A set of 33 common measures that related to immunization, morbidity and mortality were identified. CONCLUSIONS: A limited set of measures used both in IDBs and at national level identify common areas of concerns that certainly capture crucial issues with child prevention and health outcomes. However, they are far from satisfying a child-centric multi-dimensional approach to the evaluation of child well-being and well-becoming. There is room for improvement at both international and national levels. IDBs should include and harmonize measures that concern the provision of child-centric services and encompass physical, social and mental development. At the national level, efforts towards the inclusion of measures that concern non-health determinants of health should be pursued.

Spatial Inequity in Access to Intensive Care Unit Beds at Regional Level in Italy.

The high demand of hospitalization in the intensive care units (ICUs) during the first wave of the COVID-19 outbreak brought out the critical issues of the limited capacity of the regional systems to deal with high patient inflows in a short period of time. In this view, a rapid and efficient reallocation of resources is one of the main challenges to be addressed by regional systems to prevent overload and saturation. Aim of this study is to assess the spatial accessibility of ICU beds in the 20 Italian regions to capture the equity distribution of critical care services across the country. This analysis may contribute to gain a deeper understanding of the allocation of health resources. It can provide input for policy makers in view of a possible reorganization of the national system in terms of both its preparedness for emergency period and routine capability.

The efficiency in the ordinary hospital bed management: A comparative analysis in four European countries before the COVID-19 outbreak.

During COVID-19 emergency the majority of health structures in Europe saturated or nearly saturated their availabilities already in the first weeks of the epidemic period especially in some regions of Italy and Spain. The aim of this study is to analyse the efficiency in the management of hospital beds before the COVID-19 outbreak at regional level in France, Germany, Italy and Spain. This analysis can indicate a reference point for future analysis on resource management in emergency periods and help hospital managers, emergency planners as well as policy makers to put in place a rapid and effective response to an emergency situation. The results of this study clearly underline that France and Germany could rely on the robust structural components of the hospital system, compared to Italy and Spain. Presumably, this might have had an impact on the efficacy in the management of the COVID-19 diffusion. In particular, the high availability of beds in the majority of the France regions paired with the low occupancy rate and high turnover interval led these regions to have a high number of available beds. Consider also that this country generally manages complex cases. A similar structural component is present in the German regions where the number of available beds is significantly higher than in the other countries. The impact of the COVID-19 was completely different in Italy and Spain that had to deal with a relevant large number of patients relying on a reduced number of both hospital beds and professionals. A further critical factor compared to France and Germany concerns the dissimilar distribution of cases across regions. Even if in these countries the hospital beds were efficiently managed, the concentration of hospitalized patients and the scarcity of beds have put pressure on the hospital systems.

A system of concepts to support the integration of Health and social care and assistive domotics services: the Health@Home project.

The main objective of this work is to define a common shared conceptual model that describes the health care environment using the ContSys standard, harmonizing it with the social care and assistive domotics concepts. The development of this model supports the integration of services, the interoperability among systems and the continuity of care across domains.Starting from the identification and extraction of the portion of the ContSys model suitable for the healthcare part, the article provides the methodology adopted to extend it with social and home automation concepts and to integrate them in a unique framework that supports the continuity of care.The integrated model defined in this paper has been adopted in the design phase of an interoperable open platform, called Health@Home, that organizes the provision of a set of health, social and home automation integrated services provided at home.Our model is a starting point to analyze the various determinants of wellbeing able to guarantee a high-level individual's quality of life. At the moment the Health@Home system is at the implementation phase.

Variability in the assessment of children's primary healthcare in 30 European countries.

BACKGROUND: The high variability in the types and number of measures adopted to evaluate childcare across European countries makes it necessary to investigate country practices to identify trends in setting national priorities in the assessment of child well-being. OBJECTIVE: This paper intends to investigate country practices under the lens of variability to explore possible trends in setting national priority in the evaluation of childcare. In particular, it analyses variability considering to what extent this depends on the tendency of adopting a broad vision (i.e. selecting measures for a larger variety of aspects) or whether this is influenced by the choice of adopting an in-depth approach (i.e. using more measures to analyse a specific aspect). METHODS: An ad hoc questionnaire was administered to a national expert in each country and yielded 352 measures. To analyse variability, the breadth in the number of aspects considered was explored using a convergence index, while the depth in the distribution of measures in each aspect was investigated by computing a coefficient of variation. Countries were grouped by adopting a hierarchical clustering approach. RESULTS: There is a high variability across countries in the selection of measures that cover different aspects of childcare. Preferences in the distribution of measures are significant even at the domain level and in countries that use a limited number of measures and become more evident at the category and sub-category levels. The statistical analysis clusters countries in four main groups and two outliers. The in-depth distribution of measures focused on a specific aspect shows a homogeneous pattern, with the identification of two main groups of countries. CONCLUSIONS: A limited set of measures are shared across countries hampering a robust comparison of paediatric models. The selection of measures shows that the evaluation is closely related to national priorities as resulting from the number and types of measures adopted. Moreover, a range of a reasonable number of measures can be hypothesized to address the quality of childcare under a multi-dimensional perspective.

Analysis of the Different Approaches Adopted in the Italian Regions to Care for Patients Affected by COVID-19.

As the Italian health system is regionally based, COVID-19 emergency actions are based on a general lockdown imposed by national authority and then management at local level by 21 regional authorities. Therefore, the pandemic response plan developed by each region led to different approaches. The aim of this paper is to analyze whether differences in patient management may have influenced the local course of the epidemic. The analysis on the 21 Italian regions considers the strategies adopted in terms of hospitalization, treatment in the ICU and at home. Moreover, an in-depth analysis was carried out on: Lombardia, which adopted a hospitalization approach; Veneto, which tended to confine patients at home; and Emilia Romagna, which adopted a mixed hospitalization-home based approach. The majority of regions implemented a home-based approach, while the hospital approach was followed in three regions (Lombardia, Piemonte, and Lazio), mainly limited to the first period of the outbreak. All regions in the later phases tended to reduce hospitalization, preferring to confine patients at home. This comparison, highlighting the different phases of the pandemic, outlined that the adoption of home-based practices contributed to limiting infection rates among patients and health professionals as well as decreasing the number of deaths.

The efficiency in the ordinary hospital bed management in Italy: An in-depth analysis of intensive care unit in the areas affected by COVID-19 before the outbreak.

Since the end of February 2020 a severe diffusion of COVID-19 has affected Italy and in particular its northern regions, resulting in a high demand of hospitalizations in particular in the intensive care units (ICUs). Hospitals are suffering the high degree of patients to be treated for respiratory diseases and the majority of the health structures, especially in the north of Italy, are or are at risk of saturation. Therefore, the question whether and to what extent the reduction of hospital beds occurred in the past years has biased the management of the emergency has come to the front in the public debate. In our opinion, to start a robust analysis it is necessary to consider the Italian health system capacity prior to the emergency. Therefore, the aim of this study is to analyse the availability of hospital beds across the country as well as to determine their management in terms of complexity and performance of cases treated at regional level. The results of this study underlines that, despite the reduction of beds for the majority of the hospital wards, ICUs availabilities did not change between 2010 and 2017. Moreover, this study confirms that the majority of the Italian regions have a routinely efficient management of their facilities allowing hospitals to treat patients without the risk of having an overabundance of patients and a scarcity of beds. In fact, this analysis shows that, in normal situations, the management of hospital and ICU beds has no critical levels.

Extending Contsys Standard with Social Care Concepts: A Methodology Proposed by the UNINFO Working Group in Italy.

The increasing demand for territorial services requires the improvement of the coordination and cooperation among stakeholders in planning and delivery of integrated health and social services. In this scenario, to improve the communication among stakeholders there is a need of a formal conceptual model that facilitates the interoperability between organizations and professionals. This paper presents the methodology adopted by a UNINFO working group established in Italy to extend the ContSys standard with social care concepts to integrate health and social care contexts in a continuity of care perspective. An example of this extension is also provided considering the definition of patient's care plans.

Understanding Petri Nets in Health Sciences Education: The Health Issue Network Perspective.

Scarce literature exists as to the use of Petri Nets (PN) to model the dynamic evolution of health issues in a deterministic way. Starting from the HIN (Health Issue Network) approach, the paper aims at describing the suitability of PN in supporting the Case-Based Learning method for improving an educational simulation environment in which students can manage realistic clinical data related to the evolution of a patient's health state over time.

Ten simple rules for innovative dissemination of research.

How we communicate research is changing because of new (especially digital) possibilities. This article sets out 10 easy steps researchers can take to disseminate their work in novel and engaging ways, and hence increase the impact of their research on science and society.

Developing a Surgical Site Infection Surveillance System Based on Hospital Unstructured Clinical Notes and Text Mining.

Background: Electronic surveillance using clinical and administrative data from multiple sources has been reported as a tool for surveillance of surgical site infections (SSIs), but experiences are limited. In this study, we aimed to assess the accuracy of a text-searching algorithm to detect SSIs in children based on the application of regular expressions of unstructured clinical notes collected through different information systems. Methods: We developed an information system data warehouse that integrates data provided by electronic health and administrative records for patients who underwent surgical procedures in index weeks when active SSIs surveillances was conducted. To capture whether the patient developed an SSI, we developed a customized application to analyze clinical notes and code descriptions applying a pattern-matching algorithm based on regular expressions. We described the SSI cases detected by the active surveillance and the text-searching algorithm. To assess the accuracy in identifying the SSIs through the two methods, we adopted a reference standard that calculated the total number of SSIs as those detected by active surveillance plus those derived by the text-searching algorithm that was missed by active surveillance. Results: Compared with the total number of SSIs used as a reference standard, both methods had a specificity of 100%, a positive predictive value of 100%, and a negative predictive value >99.5%. Sensitivity was 70% for the text-mining algorithm and 60% for the active surveillance. Accuracy was >99% with both methods. The kappa value was 0.46. Conclusions: Compared with conventional surveillance of SSIs, a text-searching algorithm is a valid tool for case finding that has the potential to reduce drastically the workload of conventional surveillance, which involved direct contact with all families.

Application of Process Metrics to Compare Children's Asthma Diagnostic Pathways in 30 EU/EEA Countries.

The paper presents the results of the application of the business process approach to analyse and compare healthcare pathways performed in 30 EU/EEA countries focusing on children's asthma care. The adoption of process metrics allows the identification of different levels of fragmentation across countries resulting from the interactions among primary and secondary healthcare professionals as well as from parents' involvement in the process.

Modelling collaboration of primary and secondary care for children with complex care needs: long-term ventilation as an example.

Children dependent on long-term ventilation need the planning, provision and monitoring of complex services generally provided at home by professionals belonging to different care settings. The collaboration among professionals improves the efficiency and the continuity of care especially when treating children with complex care needs. In this paper, the Unified Modelling Language (UML) has been adopted to detect the variety of the patterns of collaboration as well as to represent and compare the different processes of care across the 30 EU/EEA countries of the MOCHA project.Conclusion: Half of the analysed countries have a multidisciplinary team with different degrees of team composition, influencing organisational features such as the development of the personalised plan as well as the provision of preventive and curative services. This approach provides indications on the efficiency in performing and organising the delivery of care in terms of family involvement, interactions among professionals and availability of ICT. What is known: • Children with CCNs require a coordination of efforts before and after discharge in a continuum of care delivery dependent on the level of integrated care solutions adopted at country level. What is new: •The adoption of a business process method contributes to perform a cross-country analysis highlighting the variability of team composition and its influence on the delivery of care. • This approach provides indications on the efficiency in performing and organising the delivery of care in terms of family involvement, interactions among professionals and availability of ICT.