Link Workers in Social Prescribing for Young People Work: A Case Study From Sheffield Futures.

Introduction: Social Prescribing has an established recognition regarding the benefits provided to the health-related social needs of adults, but little is known about how the intervention addresses young people's needs. There is optimism regarding the central role of two core mechanisms that allows social prescribing to be effective, such as the empathetic role of Link Workers and the connection with community resources.This paper aims to describe the role played by Link Workers working a Social Prescribing intervention targeting young people. Description: This paper adopts a case study methodology to describe the role of Link Workers addressing young people's needs and implementing Social Prescribing scheme in Sheffield (UK). Data were collected through semi-structured interviews with four of the seven link workers of one organisation based in Sheffield. Data were analysed through an inductive approach for emerging themes. Discussion: We provided a description of the profiles and background of Link Workers and described the three models of referral pathways into the intervention. The paper also shows how Link Workers identify young people's needs and how they connect with the community. Conclusion: Based on the insights and the internationally accepted definition of Social Prescribing, we provide a visual representation of the Social Prescribing model and discuss challenges. The paper highlights lessons learned and future directions regarding the role of Link Workers from the case study.

Studying the Experience of Care Through Latent Class Analysis: An Application to Italian Neonatal Intensive Care Units.

Though many data on the experience of care of patients and caregivers are collected, they are rarely used to improve the quality of health care delivery. One of the main causes is the widespread struggle in interpreting and enhancing these data, requiring the introduction of new techniques to extract intelligible, meaningful, and actionable information. This research explores the potentiality of the latent class analysis (LCA) statistical model in studying experience data. A cross-sectional survey was administered to 482 parents of infants hospitalized in several Italian neonatal intensive care units. Through a 3-step LCA, four subgroups of parents with specific experience profiles, sociodemographic characteristics, and levels of satisfaction were identified. These were composed of parents who reported (1) a positive experience (36%), (2) problematic communication with unit staff (30%), (3) limited access to the unit and poor participation in their baby's care (26%), and (4) a negative experience (8%). Through its explorative segmentation, LCA can provide valuable information to design quality improvement interventions tailored to the specific needs and concerns of each subgroup.

Place4Carers: a multi-method participatory study to co-design, piloting, and transferring a novel psycho-social service for engaging family caregivers in remote rural settings.

BACKGROUND: Family caregivers are key actors in the ageing society. They are mediators between practitioners and patients and usually provide also essential daily services for the elders. However, till now, few services have been deployed to help caregivers in their care tasks as in improving their mental health which can experience sever burden due to caregiving duties. The purpose of the study is to implement a community-based participatory research project to co-design an innovative organizational model of social services for family caregivers of elderly health consumers living in remote rural areas in Italy. METHODS: This is a community-based participatory research project in the remote area of Vallecamonica involving four main phases. These included a quantitative analysis of caregiver needs, a scoping review on existing services for caregivers, co-design workshops with local stakeholders and caregivers to create a novel service the piloting and a first implementation of the service and the assessment of project transferability to other contexts. RESULTS: As the hours dedicated to elder care increases, both objective and developmental caregiver's burden significantly increases. Conversely, higher levels of engagement were associated with lower physical and emotional burden, and caregiver engagement was positively correlated with their perceived self-efficacy in managing disruptive patient behaviours. Based on these preliminary results, four co-design workshops with caregivers were conducted and led to the definition of the SOS caregivers service, built on four pillars structured upon the previous need analysis: a citizens' management board, training courses, peer-to-peer meetings, and project and service information. We found that co-design is an effective means of creating new services for family caregivers, whose experiential knowledge proved to be a key resource for the project team in delivering and managing services. Less positively, the transferability analysis indicated that local municipalities remain reluctant to acknowledge caregivers' pivotal role. CONCLUSIONS: A dedicated support service for caregivers can ameliorate caregiving conditions and engagement levels. The service has resulted a successful co-productive initiative for a psycho-social intervention for family caregivers. For the future, we suggest that family caregiver should be considered an active partner in the process of designing novel psycho-social services and not just as recipients to enhance a better aging-in-place process.

What does the patient have to say? Valuing the patient experience to improve the patient journey.

BACKGROUND: Patient-reported data-satisfaction, preferences, outcomes and experience-are increasingly studied to provide excellent patient-centred care. In particular, healthcare professionals need to understand whether and how patient experience data can more pertinently inform the design of service delivery from a patient-centred perspective when compared with other indicators. This study aims to explore whether timely patient-reported data could capture relevant issues to improve the hospital patient journey. METHODS: Between January and February 2019, a longitudinal survey was conducted in the orthopaedics department of a 250-bed Italian university hospital with patients admitted for surgery; the aim was to analyse the patient journey from the first outpatient visit to discharge. The same patients completed a paper-and-pencil questionnaire, which was created to collect timely preference, experience and main outcomes data, and the hospital patient satisfaction questionnaire. The first was completed at the time of admission to the hospital and at the end of hospitalisation, and the second questionnaire was completed at the end of hospitalisation. RESULTS: A total of 254 patients completed the three questionnaires. The results show the specific value of patient-reported data. Greater or less negative satisfaction may not reveal pathology-related needs, but patient experience data can detect important areas of improvement along the hospital journey. As clinical conditions and the context of care change rapidly within a single hospital stay for surgery, collecting data at two different moments of the patient journey enables researchers to capture areas of potential improvement in the patient journey that are linked to the context, clinical conditions and emotions experienced by the patient. CONCLUSION: By contributing to the literature on how patient-reported data could be collected and used in hospital quality improvement, this study opens the debate about the use of real-time focused data. Further studies should explore how to use patient-reported data effectively (including what the patient reports are working well) and how to improve hospital processes by profiling patients' needs and defining the appropriate methodologies to capture the experiences of vulnerable patients. These topics may offer new frontiers of research to achieve a patient-centred healthcare system.

How to prevent and avoid barriers in co-production with family carers living in rural and remote area: an Italian case study.

BACKGROUND: Co-production has been widely recognised as a potential means to reduce the dissatisfaction of citizens, the inefficacy of service providers, and conflicts in relations between the former and the latter. However, the benefits of co-production has begun to be questioned: co-production has often been taken for granted, and its effects may not be effective. To understand and prevent unsuccessful citizen and provider collaboration, the recent literature has begun to focus on the causes of co-destruction. This paper investigates how the barriers that may arise during the co-production of a new social service with family carers can be identified and interpreted. METHODS: To investigate this topic, we undertook a single case study - a longitudinal project (Place4Carers (Graffigna et al., BMJ Open 10:e037570, 2020)) intended to co-produce a new social care service with and for the family carers of elderly patients living in rural and remote areas. We organised collaborative co-assessment workshops and semi-structured interviews to collect the views of family carers and service providers on the co-production process. A reflexive approach was used in the analysis for collecting the opinions of the research team that participated in the co-production process. RESULTS: The analysis revealed four main co-production barriers: lack of trust, lack of effectiveness of engagement, participants' inability (or impossibility) to change and the lack of a cohesive partnership among partners. Despite these findings, the project increases carers' satisfaction, competence and trust in service providers by demonstrating the positive effects of co-production. CONCLUSIONS: Our article confirms that co-creation and co-destruction processes may coexist. The role of researchers and service providers is to prevent or remedy co-destruction effects. To this end, we suggest that in co-production projects, more time should be spent co-assessing the project before, during and after the co-production process. This approach would facilitate the adoption of adjustment actions such as creating mutual trust through conviviality among participants and fostering collaborative research between academia and organisations that are not used to working together.

Facilitating co-production in public services: Empirical evidence from a co-design experience with family caregivers living in a remote and rural area.

The involvement of vulnerable actors in co-production activities is a debated topic in the current public service literature. While vulnerable actors should have the same opportunities to be involved as other actors, they may not have the needed competences, skills and attitudes to contribute to this process.This paper is part of a broader project on family caregivers' engagement in remote and rural areas. In particular, it investigates how to facilitate co-production by looking at four co-design workshops with family caregivers, representatives of a local home care agency and researchers. The transcripts of the workshops were coded using NVivo, and the data were analysed based on the existing theory about co-production.Two main findings were identified from the analysis. First, the adoption of co-production by vulnerable actors may occur in conjunction with other forms of engagement. Second, the interactions among facilitators and providers play a crucial role in encouraging the adoption of co-production. We identified at least two strategies that may help facilitators and providers achieve that goal. However, there is a need for an in-depth understanding of how facilitators and providers should interact to enhance implementation of co-production.

Challenges and potential improvements in hospital patient flow: the contribution of frontline, top and middle management professionals.

PURPOSE: This study aims to describe and understand the contributions of frontline, middle and top management healthcare professionals in detecting areas of potential improvement in hospital patient flow and proposing solutions. DESIGN/METHODOLOGY/APPROACH: This is a qualitative interview study. Semistructured interviews were conducted with 22 professionals in the orthopedic department of a 250-bed academic teaching hospital. Data were analyzed through a thematic framework analytical approach by using an a priori framework. The Consolidated Criteria for Reporting Qualitative (COREQ) checklist for qualitative studies was followed. FINDINGS: When dealing with a hospital-wide process, the involvement of all professionals, including nonhealth professionals, can reveal priority areas for improvement and for services integration. The improvements identified by the professionals largely focus on covering major gaps detected in the technical and administrative quality. RESEARCH LIMITATIONS/IMPLICATIONS: This study focused on the professional viewpoint and the connections between services and further studies should explore the role of patient involvement. The study design could limit the generalizability of findings. PRACTICAL IMPLICATIONS: Improving high-quality, efficient hospital patient flow cannot be accomplished without learning the perspective of the healthcare professionals on the process of service delivery. ORIGINALITY/VALUE: Few qualitative studies explore professionals' perspectives on patient needs in hospital flow management. This study provides insights into what produces value for the patient within a complex process by analyzing the contribution of professionals from their particular role in the organization.

Place4Carers: a mixed-method study protocol for engaging family caregivers in meaningful actions for successful ageing in place.

INTRODUCTION: Engaging family caregivers could be a critical asset to make the 'ageing-in-place' imperative a reality. This is particularly evident in rural and remote areas, where caregivers can fill the gaps that exist due to the fragmentation of the welfare system. However, there is little knowledge about the expectations that family caregivers have from healthcare services in rural and remote areas.Place4Carers (P4C) project aims to co-produce an innovative organisational model of social and healthcare services for family caregivers of older citizens living in Vallecamonica (Italy). The project is expected to facilitate ageing-in-place for older citizens, thus helping caregivers in their daily care activities. METHODS AND ANALYSIS: P4C is a community-based participatory research project featuring five work packages (WPs). WP1 consists of a survey of unmet needs of caregivers and older people receiving services in Vallecamonica. WP2 consists of a scoping literature review to map services that provide interventions of support to caregivers living in remote areas and promote engagement. WP3 organises co-creation workshops with caregivers to co-design, co-manage, and co-assess ideas and proposals for shaping caregiver-oriented services and organisational models. WP3 enriches the results of WP1 (survey) and WP2 (scoping literature review), and aims to co-create new ideas for intervention support with and for caregivers in relation to the objectives, features and characteristics of a new service able to address the caregivers' needs and expectations. WP4 tests the service ideas co-created in WP3 through piloting an intervention based on ideas co-created with caregivers. Finally, WP5 assesses the transferability of the intervention to other similar contexts. ETHICS AND DISSEMINATION: The study has been approved by the Ethics Committees of the Department of Psychology of Università Cattolica del Sacro Cuore and Politecnico of Milan. Results will be disseminated through peer-reviewed journals, scientific meetings and meetings with the general population.

Electronic Medical Records implementation in hospital: An empirical investigation of individual and organizational determinants.

The implementation of hospital-wide Electronic Medical Records (EMRs) is still an unsolved quest for many hospital managers. EMRs have long been considered a key factor for improving healthcare quality and safety, reducing adverse events for patients, decreasing costs, optimizing processes, improving clinical research and obtaining best clinical performances. However, hospitals continue to experience resistance from professionals to accepting EMRs. This study combines institutional and individual factors to explain which determinants can trigger or inhibit the EMRs implementation in hospitals, and which variables managers can exploit to guide professionals' behaviours. Data have been collected through a survey administered to physicians and nurses in an Italian University Hospital in Rome. A total of 114 high-quality responses had been received. Results show that both, physicians and nurses, expect many benefits from the use of EMRs. In particular, it is believed that the EMRs will have a positive impact on quality, efficiency and effectiveness of care; handover communication between healthcare workers; teaching, tutoring and research activities; greater control of your own business. Moreover, data show an interplay between individual and institutional determinants: normative factors directly affect perceived usefulness (C = 0.30 **), perceived ease of use (C = 0.26 **) and intention to use EMRs (C = 0.33 **), regulative factors affect the intention to use EMRs (C = -0.21 **), and perceived usefulness directly affect the intention to use EMRs (C = 0.33 **). The analysis carried out shows that the key determinants of the intention to use EMRs are the normative ones (peer influence) and the individual ones (perceived usefulness), and that perceived usefulness works also as a mediator between normative factors and intention to use EMRs. Therefore, Management can leverage on power users to motivate, generate and manage change.

Exploring the hospital patient journey: What does the patient experience?

PURPOSE: To understand how different methodologies of qualitative research are able to capture patient experience of the hospital journey. METHODS: A qualitative study of orthopaedic patients admitted for hip and knee replacement surgery in a 250-bed university hospital was performed. Eight patients were shadowed from the time they entered the hospital to the time of transfer to rehabilitation. Four patients and sixteen professionals, including orthopaedists, head nurses, nurses and administrative staff, were interviewed. RESULTS: Through analysis of the data collected four main themes emerged: the information gap; the covering patient-professionals relationship; the effectiveness of family closeness; and the micro-integration of hospital services. The three different standpoints (patient shadowing, health professionals' interviews and patients' interviews) allowed different issues to be captured in the various phases of the journey. CONCLUSIONS: Hospitals can significantly improve the quality of the service provided by exploring and understanding the individual patient journey. When dealing with a key cross-functional business process, the time-space dynamics of the activities performed have to be considered. Further research in the academic field can explore practical, methodological and ethical challenges more deeply in capturing the whole patient journey experience by using multiple methods and integrated tools.

Diuretic Resistance in Cardio-Nephrology: Role of Pharmacokinetics, Hypochloremia, and Kidney Remodeling.

BACKGROUND: Diuretic resistance is among the most challenging problems that the cardio-nephrologist must address in daily clinical practice, with a considerable burden on hospital admissions and health care costs. Indeed, loop diuretics are the first-line therapy to overcome fluid overload in heart failure patients. The pathophysiological mechanisms of fluid and sodium retention are complex and depend on several neuro-hormonal signals mainly acting on sodium reabsorption along the renal tubule. Consequently, doses and administration modalities of diuretics must be carefully tailored to patients in order to overcome under- or overtreatment. The frequent and tricky development of diuretic resistance depends in part on post-diuretic sodium retention, reduced tubular secretion of the drug, and reduced sodium/chloride sensing. Sodium and chloride depletions have been recently shown to be major factors mediating these processes. Aquaretics and high-saline infusions have been recently suggested in cases of hyponatremic conditions. This review discusses the limitations and strengths of these approaches. SUMMARY: Long-term diuretic use may lead to diuretic resistance in cardio-renal syndromes. To overcome this complication intravenous administration of loop diuretics and a combination of different diuretic classes have been proposed. In the presence of hyponatremia, high-saline solutions in addition to loop diuretics might be beneficial, whereas aquaretics require caution to avoid overcorrection. Key Messages: Diuretic resistance is a central theme for cardio-renal syndromes. Hyponatremia and hypochloremia may be part of the mechanisms for diuretic resistance. Aquaretics and high-saline solutions have been proposed as possible new therapeutic solutions.

WhatsApp in hospital? An empirical investigation of individual and organizational determinants to use.

The increasing use of messaging applications such as WhatsApp for both social and personal purposes has determined an increase in the widespread use of these technologies, even in healthcare. A growing number of healthcare professionals have adopted WhatsApp in their daily work in order to share information with peers and patients. Past research has highlighted the advantages and disadvantages of WhatsApp usage in healthcare settings; in particular two positions appear to coexist in the scientific debate: those that expose and underline all of the positive aspects of the phenomenon, and those which also highlight the negative aspects, linked in particular to the clinical risks for patients, data security and privacy protection. The main objective of this study was to assess if and how individual and organizational determinants can trigger or inhibit the use of WhatsApp in a hospital setting, and which variables managers can exploit to guide professionals' behaviors. Data were collected through a survey administered to physicians and nurses in an Italian University Hospital in Rome; a total of 191 high-quality responses were received. The results show that WhatsApp is widely used in the Hospital, and that its use is mainly due to the perception of numerous advantages and benefits reported in clinical practice. Moreover, an interplay exists between organizational and individual factors in determining the use of WhatsApp between healthcare professionals and with patients. In particular, individual factors play a key role as determinants of the use of WhatsApp; healthcare professionals use this technology mainly based on its perceived usefulness. Instead, organizational factors play a secondary role; they do not have a direct influence on the use of WhatsApp, but always act through individual factors. This study is the first to analyses the influence of individual and organizational determinants of WhatsApp usage in the hospital setting, and provides hospital managers with important information in order to manage this phenomenon and implement adequate strategies to exploit its potential increase.

TECHNOLOGY ASSESSMENT IN HOSPITALS: LESSONS LEARNED FROM AN EMPIRICAL EXPERIMENT.

OBJECTIVES: Hospital Based Health Technology Assessment (HBHTA) practices, to inform decision making at the hospital level, emerged as urgent priority for policy makers, hospital managers, and professionals. The present study crystallized the results achieved by the testing of an original framework for HBHTA, developed within Lombardy Region: the IMPlementation of A Quick hospital-based HTA (IMPAQHTA). The study tested: (i) the HBHTA framework efficiency, (ii) feasibility, (iii) the tool utility and completeness, considering dimensions and sub-dimensions. METHODS: The IMPAQHTA framework deployed the Regional HTA program, activated in 2008 in Lombardy, at the hospital level. The relevance and feasibility of the framework were tested over a 3-year period through a large-scale empirical experiment, involving seventy-four healthcare professionals organized in different HBHTA teams for assessing thirty-two different technologies within twenty-two different hospitals. Semi-structured interviews and self-reported questionnaires were used to collect data regarding the relevance and feasibility of the IMPAQHTA framework. RESULTS: The proposed HBHTA framework proved to be suitable for application at the hospital level, in the Italian context, permitting a quick assessment (11 working days) and providing hospital decision makers with relevant and quantitative information. Performances in terms of feasibility, utility, completeness, and easiness proved to be satisfactory. CONCLUSIONS: The IMPAQHTA was considered to be a complete and feasible HBHTA framework, as well as being replicable to different technologies within any hospital settings, thus demonstrating the capability of a hospital to develop a complete HTA, if supported by adequate and well defined tools and quantitative metrics.

Trends in heart failure hospitalizations, patient characteristics, in-hospital and 1-year mortality: A population study, from 2000 to 2012 in Lombardy.

BACKGROUND: This study was undertaken to evaluate trends in heat failure hospitalizations (HFHs) and 1-year mortality of HFH in Lombardy, the largest Italian region, from 2000 to 2012. METHODS: Hospital discharge forms with HF-related ICD-9 CM codes collected from 2000 to 2012 by the regional healthcare service (n=699797 in 370538 adult patients), were analyzed with respect to in-hospital and 1-year mortality; Group (G) 1 included most acute HF episodes with primary cardiac diagnosis (70%); G2 included cardiomyopathies without acute HF codes (17%); and G3 included non-cardiac conditions with HF as secondary diagnosis (13%). Patients experiencing their first HFH since 2005 were analyzed as incident cases (n=216782). RESULTS: Annual HFHs number (mean 53830) and in-hospital mortality (9.4%) did not change over the years, the latter being associated with increasing age (p<0.0001) and diagnosis Group (G1 9.1%, G2 5.6%, G3 15.9%, p<0.0001). Incidence of new cases decreased over the years (3.62 [CI 3.58-3.67] in 2005 to 3.13 [CI 3.09-3.17] in 2012, per 1000 adult inhabitants/year, p<0.0001), with an increasing proportion of patients aged ≥85y (22.3% to 31.4%, p<0.0001). Mortality lowered over time in <75y incident cases, both in-hospital (5.15% to 4.36%, p<0.0001) and at 1-year (14.8% to 12.9%, p=0.0006). CONCLUSIONS: The overall burden and mortality of HFH appear stable for more than a decade. However, from 2005 to 2012, there was a reduction of new, incident cases, with increasing age at first hospitalization. Meanwhile, both in-hospital and 1-year mortality decreased in patients aged <75y, possibly due to improved prevention and treatment.

Stratified cost-utility analysis of C-Leg versus mechanical knees: Findings from an Italian sample of transfemoral amputees.

BACKGROUND: The fitting rate of the C-Leg electronic knee (Otto-Bock, D) has increased steadily over the last 15 years. Current cost-utility studies, however, have not considered the patients' characteristics. OBJECTIVES: To complete a cost-utility analysis involving C-Leg and mechanical knee users; "age at the time of enrollment," "age at the time of first prosthesis," and "experience with the current type of prosthesis" are assumed as non-nested stratification parameters. STUDY DESIGN: Cohort retrospective. METHODS: In all, 70 C-Leg and 57 mechanical knee users were selected. For each stratification criteria, we evaluated the cost-utility of C-Leg versus mechanical knees by computing the incremental cost-utility ratio, that is, the ratio of the "difference in cost" and the "difference in utility" of the two technologies. Cost consisted of acquisition, maintenance, transportation, and lodging expenses. Utility was measured in terms of quality-adjusted life years, computed on the basis of participants' answers to the EQ-5D questionnaire. RESULTS: Patients over 40 years at the time of first prosthesis were the only group featuring an incremental cost-utility ratio (88,779 €/quality-adjusted life year) above the National Institute for Health and Care Excellence practical cost-utility threshold (54,120 €/quality-adjusted live year): C-Leg users experience a significant improvement of "mobility," but limited outcomes on "usual activities," "self-care," "depression/anxiety," and reduction of "pain/discomfort." CONCLUSION: The stratified cost-utility results have relevant clinical implications and provide useful information for practitioners in tailoring interventions. Clinical relevance A cost-utility analysis that considered patients characteristics provided insights on the "affordability" of C-Leg compared to mechanical knees. In particular, results suggest that C-Leg has a significant impact on "mobility" for first-time prosthetic users over 40 years, but implementation of specific low-cost physical/psychosocial interventions is required to retun within cost-utility thresholds.

Integrated care in action: opening the "black box" of implementation.

The aim of this contribution is to explain how healthcare professionals implement policies for integrated care. More specifically, we aim to understand how these policies are received, interpreted and executed by primary care professionals. By opening the "black box" of policy implementation, we also explain how and why the process of implementation of the same policy diverges in practice. The research is framed according to both the neo-institutional and the change management perspectives. The empirical investigation is conducted through a documental analysis and a multiple-embedded case study. The results show that three forces affect and explain differences in the implementation processes: the unstable level of internal communication among the professionals involved, the limited use of power to resist to change and the poor learning process on the part of both the professionals and policy makers. The pressure of external institutions does not play a role in shaping the process. Through our study, we further knowledge about how healthcare professionals implement policies for integrated care, and we believe this is interesting, according to emerging evidence that variations in the effectiveness of policy outcomes may be explained by choices and potential distortions made during the initial stages of the policy implementation process. Copyright © 2015 John Wiley & Sons, Ltd. StartCopTextCopyright © 2015 John Wiley & Sons, Ltd.

MicroRNAs in Renal Diseases: A Potential Novel Therapeutic Target.

BACKGROUND: MicroRNAs (miRNAs) are a family of short noncoding RNAs that play important roles in posttranscriptional gene regulation. miRNAs inhibit target gene expression by blocking protein translation or by inducing mRNA degradation and therefore have the potential to modulate physiological and pathological processes. SUMMARY: In the kidney, miRNAs play a role in the organogenesis and in the pathogenesis of several diseases, including renal carcinoma, diabetic nephropathy, cystogenesis, and glomerulopathies. Indeed, podocytes, but also the parietal cells of the Bowman capsule are severely affected by miRNA deregulation. In addition, several miRNAs have been found involved in the development of renal fibrosis. These experimental lines of evidence found a counterpart also in patients affected by diabetic and Ig-A nephropathies, opening the possibility of their use as biomarkers. Finally, the possibility to direct target-specific miRNA to prevent the development of renal fibrosis is encouraging potential novel therapies based on miRNA mimicking or antagonism. This review reports the main studies that investigate the role of miRNAs in the kidneys, in particular highlighting the experimental models used, their potential role as biomarkers and, finally, the most recent data on the miRNA-based therapy. KEY MESSAGES: miRNAs are crucial regulators of cell function. They are easy to detect and represent potentially good targets for novel therapies.

Methodological issues on the use of administrative data in healthcare research: the case of heart failure hospitalizations in Lombardy region, 2000 to 2012.

BACKGROUND: Administrative data are increasingly used in healthcare research. However, in order to avoid biases, their use requires careful study planning. This paper describes the methodological principles and criteria used in a study on epidemiology, outcomes and process of care of patients hospitalized for heart failure (HF) in the largest Italian Region, from 2000 to 2012. METHODS: Data were extracted from the administrative data warehouse of the healthcare system of Lombardy, Italy. Hospital discharge forms with HF-related diagnosis codes were the basis for identifying HF hospitalizations as clinical events, or episodes. In patients experiencing at least one HF event, hospitalizations for any cause, outpatient services utilization, and drug prescriptions were also analyzed. RESULTS: Seven hundred one thousand, seven hundred one heart failure events involving 371,766 patients were recorded from 2000 to 2012. Once all the healthcare services provided to these patients after the first HF event had been joined together, the study database totalled about 91 million records. Principles, criteria and tips utilized in order to minimize errors and characterize some relevant subgroups are described. CONCLUSIONS: The methodology of this study could represent the basis for future research and could be applied in similar studies concerning epidemiology, trend analysis, and healthcare resources utilization.

Home-Based Telemanagement in Advanced COPD: Who Uses it Most? Real-Life Study in Lombardy.

Current evidence indicates that the benefits of tele-health may not be uniform across all patients. Therefore, to understand what specific variables influence use of home-based telemanagement in COPD, we conducted this retrospective study. A 6-month home-based telemanagement program (HTP) was offered to 1,074 COPD patients over a 4-year period. Multivarible linear regression analysis was used to identify predictors of HTP use/week (phone calls and specialist consultations) among all variables: clinical (body mass index, co-morbidities, HTP prescription not following an exacerbation, long-term oxygen therapy use, COPD severity, hospital readmissions, exacerbations and death), socio-demographic (sex, age, place of abode), smoking history, arterial blood gases (ABG), and specialist/general practitioner (GP) urgent need. Logistic regression was conducted to predict relapses/hospitalizations risk as well as the disease impact (COPD Assessment Test, CAT) at the end of the program. Presence of relapses (p < 0.001), ABGs (p < 0.001) and GP request (p < 0.001) were significantly associated with higher HTP-use. Smoking history (OR 1.542 [IC 95% 1.069-2.217], p = 0.020), specialist (OR 2.895 [2.144-3.910], p < 0.001) and GP consultations (OR 6.575 [4.521-9.561], p < 0.001) were the only independent risk factors for relapse. No predictor of hospitalization was found. High final CAT score was inversely related to oxygen therapy use (p = 0.001) and HTP prescription (p < 0.001), and positively related to presence of co-morbidities (p = 0.001) and baseline CAT (p < 0.001). This HTP in Lombardy shows that relapsers, people requiring several ABGs and urgent GP visits are the patient subgroup most likely to consume telemanagement services (scheduled and unscheduled). We propose a patient 'identikit' to improve prioritization for HTP prescriptions.

Empowering patients through eHealth: a case report of a pan-European project.

BACKGROUND: This paper crystallises the experience developed by the pan-European PALANTE Consortium in dealing with the generation of relevant evidence from heterogeneous eHealth services for patient empowerment in nine European Regions. The European Commission (EC) recently funded a number of pan-European eHealth projects aimed at empowering European patients/citizens thus transforming the traditional patient/citizen role in the management of their health (e.g., PALANTE, SUSTAIN, CARRE, HeartCycle, Empower). However, the heterogeneity of the healthcare systems, of the implemented services and of the target patients, the use of ad-hoc definitions of the salient concepts and the development of small-size experiences have prevented the dissemination of "global" results and the development of cumulative knowledge. The main challenge has been the generation of large-scale evidence from heterogeneous small-size experiences. DISCUSSION: Three lessons have been collectively learnt during the development of the PALANTE project, which involves 9 sites that have implemented different eHealth services for empowering different typologies of patients. These lessons have been refined progressively through project meetings, reviews with the EC Project Officer and Reviewers. The paper illustrates the ten steps followed to develop the three lessons. The first lesson learnt is about how EC-funded projects should develop cumulative knowledge by avoiding self-crafted measures of outcome and by adopting literature-grounded definitions and scales. The second lesson learnt is about how EC-funded projects should identify ambitious, cross-pilot policy and research questions that allow pooling of data from across heterogeneous experiences even if a multi-centre study design was not agreed before. The third lesson learnt is about how EC-funded projects should open their collections of data and make them freely-accessible to the scientific community shortly after the conclusion of the project in order to guarantee the replicability of results and conclusions. SUMMARY: The three lessons might provide original elements for fuelling the ongoing debate about the capability of the EC to develop evidence-based policies by pooling evidence from heterogeneous, local experiences.