Penicillin Allergy Testing and Delabeling for Patients Who Are Prescribed Penicillin: A Systematic Review for a World Health Organization Guideline.

Secondary prevention with penicillin aims to prevent further episodes of acute rheumatic fever and subsequent development of rheumatic heart disease (RHD). Penicillin allergy, self-reported by 10% of the population, can affect secondary prevention programs. We aimed to assess the role for (i) routine penicillin allergy testing and the (ii) safety of penicillin allergy delabeling approaches in this context. We searched MEDLINE, Embase, CENTRAL, ClinicalTrials.gov, WHO ICTRP, ISRCTN, and CPCI-S to identify the relevant reports. We found 2419 records, but no studies addressed our initial question. Following advice from the WHO-Guideline committee and experts, we identified 6 manuscripts on allergy testing focusing on other populations showing that the prevalence of allergy confirmed by testing was low and the incidence of life-threatening reactions to BPG was very low (< 1-3/1000 individuals treated). A subsequent search addressed penicillin allergy delabeling. This found 516 records, and 5 studies addressing the safety of direct oral drug challenge vs. skin testing followed by drug administration in patients with suspected penicillin allergy. Immediate allergic reactions of minor severity were observed for a minority of patients and occurred less frequently in the direct drug challenge group: 2.3% vs. 11.5%; RR = 0.25, 95%CI 0.15-0.45, P < 0.00001, I2 = 0%. No anaphylaxis or deaths were observed. Severe allergic reactions to penicillin are extremely rare and can be recognized and dealt by trained healthcare workers. Confirmation of penicillin allergy diagnosis or delabeling using direct oral drug challenge or penicillin skin testing seems to be safe and is associated with a low rate of adverse reactions.

Handheld echocardiography for the screening and diagnosis of rheumatic heart disease: a systematic review to inform WHO guidelines.

BACKGROUND: Early detection and diagnosis of acute rheumatic fever and rheumatic heart disease are key to preventing progression, and echocardiography has an important diagnostic role. Standard echocardiography might not be feasible in high-prevalence regions due to its high cost, complexity, and time requirement. Handheld echocardiography might be an easy-to-use, low-cost alternative, but its performance in screening for and diagnosing acute rheumatic fever and rheumatic heart disease needs further investigation. METHODS: In this systematic review and meta-analysis, we searched Embase, MEDLINE, LILACS, and Conference Proceedings Citation Index-Science up to Feb 9, 2024, for studies on the screening and diagnosis of acute rheumatic fever and rheumatic heart disease using handheld echocardiography (index test) or standard echocardiography or auscultation (reference tests) in high-prevalence areas. We included all studies with useable data in which the diagnostic performance of the index test was assessed against a reference test. Data on test accuracy in diagnosing rheumatic heart disease, acute rheumatic fever, or carditis with acute rheumatic fever (primary outcomes) were extracted from published articles or calculated, with authors contacted as necessary. Quality of evidence was appraised using GRADE and QUADAS-2 criteria. We summarised diagnostic accuracy statistics (including sensitivity and specificity) and estimated 95% CIs using a bivariate random-effects model (or univariate random-effects models for analyses including three or fewer studies). Area under the curve (AUC) was calculated from summary receiver operating characteristic curves. Heterogeneity was assessed by visual inspection of plots. This study was registered with PROSPERO (CRD42022344081). FINDINGS: Out of 4868 records we identified 11 studies, and two additional reports, comprising 15 578 unique participants. Pooled data showed that handheld echocardiography had high sensitivity (0·87 [95% CI 0·76-0·93]), specificity (0·98 [0·71-1·00]), and overall high accuracy (AUC 0·94 [0·84-1·00]) for diagnosing rheumatic heart disease when compared with standard echocardiography (two studies; moderate certainty of evidence), with better performance for diagnosing definite compared with borderline rheumatic heart disease. High sensitivity (0·79 [0·73-0·84]), specificity (0·85 [0·80-0·89]), and overall accuracy (AUC 0·90 [0·85-0·94]) for screening rheumatic heart disease was observed when pooling data of handheld echocardiography versus standard echocardiography (seven studies; high certainty of evidence). Most studies had a low risk of bias overall. Some heterogeneity was observed for sensitivity and specificity across studies, possibly driven by differences in the prevalence and severity of rheumatic heart disease, and level of training or expertise of non-expert operators. INTERPRETATION: Handheld echocardiography has a high accuracy and diagnostic performance when compared with standard echocardiography for diagnosing and screening of rheumatic heart disease in high-prevalence areas. FUNDING: World Health Organization. TRANSLATIONS: For the Chinese, French, Italian, Persian, Portuguese, Spanish and Urdu translations of the abstract see Supplementary Materials section.

Health economic evaluations of interventions for supporting adult carers in the UK: a systematic review from the NICE Guideline.

BACKGROUND: Policy making increasingly needs cost-effectiveness evidence to inform resource allocation. The objective of this review is to identify and to investigate evidence evaluating the cost-effectiveness of interventions aimed to support adult carers, drawing on the National Institute for Health and Care guideline on Supporting Adult Carers. METHODS: The protocol of the review was aimed to identify the economic studies published from 2003 onwards on all types of interventions for supporting adult carers. The applicability to the review and methodological quality of included economic evaluations were assessed using pre-established checklists specified in the National Institute for Health and Care (NICE) manual for developing guidelines. RESULTS: Our search yielded 10 economic evaluations. The main types of strategies evaluated were psychological and emotional support, training, and education support interventions. We found that the interventions more likely to be cost-effective were usually tailored to the specific carers' circumstances and delivered face-to-face and were multi-component in nature, including elements of psycho-education, training, psychological and practical support. The narrative synthesis of results indicated a wide variation in cost-effectiveness findings and methodological quality. CONCLUSIONS: This article indicates that systematic reviews of economic evaluations can be considered as an appropriate means to support decision makers in allocating health and social care resources. Given the high economic and social impact of unpaid caring, and based on the research gaps identified, we recommend that future economics research should be targeted on interventions for identifying carers; and programs for providing carers with support and advice to help them to enter, remain in or return to paid work.

Diagnosis and management of pancreatic cancer in adults: A summary of guidelines from the UK National Institute for Health and Care Excellence.

To enable standardisation of care of pancreatic cancer patients and facilitate improvement in outcome, the United Kingdom's National Institute for Health and Care Excellence (NICE) developed a clinical guideline for the diagnosis and management of pancreatic cancer in adults. Systematic literature searches, systematic review and meta-analyses were undertaken. Recommendations were drafted on the basis of the group's interpretation of the best available evidence of clinical and cost effectiveness. There was patient involvement and public consultation. Recommendations were made on: diagnosis; staging; monitoring of inherited high risk; psychological support; pain; nutrition management; and the specific management of people with resectable-, borderline-resectable- and unresectable-pancreatic cancer. The guideline committee also made recommendations for future research into neoadjuvant therapy, cachexia interventions, minimally invasive pancreatectomy, pain management and psychological support needs. These NICE guidelines aim to promote best current practice and support and stimulate research and innovation in pancreatic cancer.

Contribution of physician assistants/associates to secondary care: a systematic review.

OBJECTIVE: To appraise and synthesise research on the impact of physician assistants/associates (PA) in secondary care, specifically acute internal medicine, care of the elderly, emergency medicine, trauma and orthopaedics, and mental health. DESIGN: Systematic review. SETTING: Electronic databases (Medline, Embase, ASSIA, CINAHL, SCOPUS, PsycINFO, Social Policy and Practice, EconLit and Cochrane), reference lists and related articles. INCLUDED ARTICLES: Peer-reviewed articles of any study design, published in English, 1995-2017. INTERVENTIONS: Blinded parallel processes were used to screen abstracts and full text, data extractions and quality assessments against published guidelines. A narrative synthesis was undertaken. OUTCOME MEASURES: Impact on: patients' experiences and outcomes, service organisation, working practices, other professional groups and costs. RESULTS: 5472 references were identified and 161 read in full; 16 were included-emergency medicine (7), trauma and orthopaedics (6), acute internal medicine (2), mental health (1) and care of the elderly (0). All studies were observational, with variable methodological quality. In emergency medicine and in trauma and orthopaedics, when PAs are added to teams, reduced waiting and process times, lower charges, equivalent readmission rate and good acceptability to staff and patients are reported. Analgesia prescribing, operative complications and mortality outcomes were variable. In internal medicine outcomes of care provided by PAs and doctors were equivalent. CONCLUSIONS: PAs have been deployed to increase the capacity of a team, enabling gains in waiting time, throughput, continuity and medical cover. When PAs were compared with medical staff, reassuringly there was little or no negative effect on health outcomes or cost. The difficulty of attributing cause and effect in complex systems where work is organised in teams is highlighted. Further rigorous evaluation is required to address the complexity of the PA role, reporting on more than one setting, and including comparison between PAs and roles for which they are substituting. PROSPERO REGISTRATION NUMBER: CRD42016032895.

The determinants and consequences of adult nursing staff turnover: a systematic review of systematic reviews.

BACKGROUND: Nurses leaving their jobs and the profession are an issue of international concern, with supply-demand gaps for nurses reported to be widening. There is a large body of existing literature, much of which is already in review form. In order to advance the usefulness of the literature for nurse and human resource managers, we undertook an overview (review of systematic reviews). The aim of the overview was to identify high quality evidence of the determinants and consequences of turnover in adult nursing. METHODS: Reviews were identified which were published between 1990 and January 2015 in English using electronic databases (the Cochrane Database of Systematic Reviews, MEDLINE, EMBASE, Applied Social Sciences Index and Abstracts, CINAHL plus and SCOPUS) and forward searching. All stages of the review were conducted in parallel by two reviewers. Reviews were quality appraised using the Assessment of Multiple Systematic Reviews and their findings narratively synthesised. RESULTS: Nine reviews were included. We found that the current evidence is incomplete and has a number of important limitations. However, a body of moderate quality review evidence does exist giving a picture of multiple determinants of turnover in adult nursing, with - at the individual level - nurse stress and dissatisfaction being important factors and -at the organisational level - managerial style and supervisory support factors holding most weight. The consequences of turnover are only described in economic terms, but are considered significant. CONCLUSIONS: In making a quality assessment of the review as well as considering the quality of the included primary studies and specificity in the outcomes they measure, the overview found that the evidence is not as definitive as previously presented from individual reviews. Further research is required, of rigorous research design, whether quantitative or qualitative, particularly against the outcome of actual turnover as opposed to intention to leave. TRIAL REGISTRATION: PROSPERO Registration 17 March 2015: CRD42015017613 .

Interprofessional collaboration to improve professional practice and healthcare outcomes.

BACKGROUND: Poor interprofessional collaboration (IPC) can adversely affect the delivery of health services and patient care. Interventions that address IPC problems have the potential to improve professional practice and healthcare outcomes. OBJECTIVES: To assess the impact of practice-based interventions designed to improve interprofessional collaboration (IPC) amongst health and social care professionals, compared to usual care or to an alternative intervention, on at least one of the following primary outcomes: patient health outcomes, clinical process or efficiency outcomes or secondary outcomes (collaborative behaviour). SEARCH METHODS: We searched CENTRAL (2015, issue 11), MEDLINE, CINAHL, ClinicalTrials.gov and WHO International Clinical Trials Registry Platform to November 2015. We handsearched relevant interprofessional journals to November 2015, and reviewed the reference lists of the included studies. SELECTION CRITERIA: We included randomised trials of practice-based IPC interventions involving health and social care professionals compared to usual care or to an alternative intervention. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed the eligibility of each potentially relevant study. We extracted data from the included studies and assessed the risk of bias of each study. We were unable to perform a meta-analysis of study outcomes, given the small number of included studies and their heterogeneity in clinical settings, interventions and outcomes. Consequently, we summarised the study data and presented the results in a narrative format to report study methods, outcomes, impact and certainty of the evidence. MAIN RESULTS: We included nine studies in total (6540 participants); six cluster-randomised trials and three individual randomised trials (1 study randomised clinicians, 1 randomised patients, and 1 randomised clinicians and patients). All studies were conducted in high-income countries (Australia, Belgium, Sweden, UK and USA) across primary, secondary, tertiary and community care settings and had a follow-up of up to 12 months. Eight studies compared an IPC intervention with usual care and evaluated the effects of different practice-based IPC interventions: externally facilitated interprofessional activities (e.g. team action planning; 4 studies), interprofessional rounds (2 studies), interprofessional meetings (1 study), and interprofessional checklists (1 study). One study compared one type of interprofessional meeting with another type of interprofessional meeting. We assessed four studies to be at high risk of attrition bias and an equal number of studies to be at high risk of detection bias.For studies comparing an IPC intervention with usual care, functional status in stroke patients may be slightly improved by externally facilitated interprofessional activities (1 study, 464 participants, low-certainty evidence). We are uncertain whether patient-assessed quality of care (1 study, 1185 participants), continuity of care (1 study, 464 participants) or collaborative working (4 studies, 1936 participants) are improved by externally facilitated interprofessional activities, as we graded the evidence as very low-certainty for these outcomes. Healthcare professionals' adherence to recommended practices may be slightly improved with externally facilitated interprofessional activities or interprofessional meetings (3 studies, 2576 participants, low certainty evidence). The use of healthcare resources may be slightly improved by externally facilitated interprofessional activities, interprofessional checklists and rounds (4 studies, 1679 participants, low-certainty evidence). None of the included studies reported on patient mortality, morbidity or complication rates.Compared to multidisciplinary audio conferencing, multidisciplinary video conferencing may reduce the average length of treatment and may reduce the number of multidisciplinary conferences needed per patient and the patient length of stay. There was little or no difference between these interventions in the number of communications between health professionals (1 study, 100 participants; low-certainty evidence). AUTHORS' CONCLUSIONS: Given that the certainty of evidence from the included studies was judged to be low to very low, there is not sufficient evidence to draw clear conclusions on the effects of IPC interventions. Neverthess, due to the difficulties health professionals encounter when collaborating in clinical practice, it is encouraging that research on the number of interventions to improve IPC has increased since this review was last updated. While this field is developing, further rigorous, mixed-method studies are required. Future studies should focus on longer acclimatisation periods before evaluating newly implemented IPC interventions, and use longer follow-up to generate a more informed understanding of the effects of IPC on clinical practice.

Hospital efficiency: how to spend less maintaining quality?

INTRODUCTION: The recent global economic crisis is pushing governments worldwide to obtain a more explicit and urgent rationing of resources. The purpose of this study is to provide, through Data Envelopment Analysis (DEA), a methodological framework useful for investigating technical efficiency of hospital care. METHODS: To validate such framework, we compared 50 Italian public hospital trusts (AOs) to identify relative efficient using inputs and outputs from national databases. We also evaluated if, and how, efficiency is affected by various exogenous factors. RESULTS: On average, Italian AOs had an efficiency score of 77% (SD 0.12). Tobit regression model identified a positive association between efficiency and a lower case-mix index, being in the north of Italy, in a region with fiscal autonomy, with a higher public and a lower private expenditure on health as percentage of GDP. CONCLUSIONS: DEA may provide useful and especially objective information regarding the technical efficiency of hospital care and support hospital management and policy makers' decisions.

Interventions to Reduce Adult Nursing Turnover: A Systematic Review of Systematic Reviews.

BACKGROUND: Nurse turnover is an issue of concern in health care systems internationally. Understanding which interventions are effective to reduce turnover rates is important to managers and health care organisations. Despite a plethora of reviews of such interventions, strength of evidence is hard to determine. OBJECTIVE: We aimed to review literature on interventions to reduce turnover in nurses working in the adult health care services in developed economies. METHOD: We conducted an overview (systematic review of systematic reviews) using the Cochrane Database of Systematic Reviews, MEDLINE, EMBASE, Applied Social Sciences Index and Abstracts, CINAHL plus and SCOPUS and forward searching. We included reviews published between 1990 and January 2015 in English. We carried out parallel blinded selection, extraction of data and assessment of bias, using the Assessment of Multiple Systematic Reviews. We carried out a narrative synthesis. RESULTS: Despite the large body of published reviews, only seven reviews met the inclusion criteria. These provide moderate quality review evidence, albeit from poorly controlled primary studies. They provide evidence of effect of a small number of interventions which decrease turnover or increase retention of nurses, these being preceptorship of new graduates and leadership for group cohesion. CONCLUSION: We highlight that a large body of reviews does not equate with a large body of high quality evidence. Agreement as to the measures and terminology to be used together with well-designed, funded primary research to provide robust evidence for nurse and human resource managers to base their nurse retention strategies on is urgently required.

Using a meta-ethnographic approach to explore the nature of facilitation and teaching approaches employed in interprofessional education.

BACKGROUND: Interprofessional facilitators and teachers are regarded as central to the effective delivery of interprofessional education (IPE). As the IPE literature continues to expand, most studies have focused on reporting learner outcomes, with little attention paid to IPE facilitation. However, a number of studies have recently emerged reporting on this phenomenon. AIM: To present a synthesis of qualitative evidence on the facilitation of IPE, using a meta-ethnographic approach. METHODS: Electronic databases and journals were searched for the past 10 years. Of the 2164 abstracts initially found, 94 full papers were reviewed and subsequently 12 papers were included. Teams of two reviewers independently completed each step in the review process. The quality of these papers was assessed using a modified critical appraisal checklist. RESULTS: Seven key concepts embedded in the included studies were synthesized into three main factors which provided an insight into the nature of IPE facilitation. Specifically, the synthesis found that IPE facilitation is influenced by "contextual characteristics"; "facilitator experiences"; and the "use of different facilitation strategies". CONCLUSIONS: IPE facilitation is a complex activity affected by contextual, experiential and pedagogical factors. Further research is needed to explore the effects of these factors on the delivery of IPE.

Interprofessional education in the care of people diagnosed with dementia and their carers: a systematic review.

OBJECTIVES: This systematic review is linked to the multifaceted social, economic and personal challenges of dementia and the international recognition of the value of interprofessional education (IPE) and its influence on health and social care outcomes. This review therefore aimed to identify, describe and evaluate the impact of IPE interventions on health and social care practitioners (prequalification and postqualification) understanding of dementia, the quality of care for people with dementia and support for their carers. METHODS: Following PRISMA guidelines, 9 databases were searched (MEDLINE, EMBASE, The Cochrane Library, PsycINFO, CINAHL Plus, Applied Social Sciences Index and Abstracts, Healthcare Management Information Consortium, ERIC and British Education Index). Narrative analysis of the findings was undertaken. DESIGN: Systematic review. RESULTS: 6 studies meeting the inclusion criteria were identified. The majority of studies were conducted in North America. Participants in 4 studies were health and social care practitioners caring for people with dementia, whereas the remaining studies focused on training graduate or undergraduate students. Diverse IPE activities with varying content, delivery mode and duration were reported. Although some studies reported more positive attitudes to interprofessional working as a result of the interventions, none reported benefits to patients or carers. The quality of the included studies varied. Overall, the evidence for the reported outcomes was considered weak. CONCLUSIONS: This review identified 6 studies describing IPE interventions intended to improve collaborative knowledge, skills, interprofessional practice and organisational awareness of dementia and dementia care. The small number of studies, their varied nature, scope and settings combined with poor quality of evidence limits our understanding of the effectiveness of IPE on the care and support of people with dementia and their carers. Further research is required to develop the evidence base and provide robust studies to inform IPE development. TRIAL REGISTRATION NUMBER: CRD42014015075.

Psychosocial interventions for people with young onset dementia and their carers: a systematic review.

BACKGROUND: Dementia in younger people, known as young (YOD) or early onset dementia (EOD), can pose significant challenges. YOD is often diagnosed in those in paid employment who have relatively young children, leading to different challenges to those for older people. It is therefore very important to provide support tailored to their specific needs. This systematic review aimed to synthesize the literature investigating the impact of psychosocial interventions for people with YOD and their family carers. METHOD: Eight electronic databases were searched and three key journals were also hand searched. Narrative synthesis of the selected articles was undertaken. RESULTS: Of the 498 records identified, 495 were ineligible after application of the exclusion criteria. The final sample included three studies, all of which were employment-based. Two were qualitative and one used mixed methods. Study quality was mixed. People with YOD and their carers reported benefits from participating in work-based interventions designed for those with YOD, including improved self-esteem and sense of purpose. Social contact was highlighted. Despite cognitive decline, maintenance in well-being was also reported. Carers described benefits for people with YOD, which extended outside the intervention, e.g. enhanced sleep and mood. The impact of the interventions on carers was not assessed. CONCLUSIONS: This review suggests work-based interventions providing supported, meaningful work outside the home can be beneficial. However, the dearth of studies, the lack of focus on family carers and their mixed quality demonstrate the need for better quality, mixed methods research with larger sample sizes.

General practice based psychosocial interventions for supporting carers of people with dementia or stroke: a systematic review.

BACKGROUND: Particularly with ageing populations, dementia and stroke and their resultant disability are worldwide concerns. Much of the support for people with these conditions comes from unpaid carers or caregivers. The carers' role is often challenging and carers themselves may need support. General practice is often the first point of contact for people with these conditions and their carers, making it potentially an important source of support. This systematic review therefore synthesised the available evidence for the impact of supportive interventions for carers provided in general practice. METHODS: PRISMA guidelines were adopted and the following databases were searched: MEDLINE; EMBASE; the Cochrane Library; PsycINFO; CINAHL Plus; Applied Social Sciences Index and Abstracts and Healthcare Management Information Consortium. RESULTS: Two thousand four hundred eighty nine results were identified. Four studies, involving 447 carers, fitted the inclusion criteria. Three of these came from the United States of America. None investigated supportive interventions for carers of people with stroke. Primarily by the provision of information and educational materials, the interventions focussed on improving carer mental health, dementia knowledge, caregiving competence and reducing burden, difficulties and frustrations. Overall the evidence suggests that these interventions may improve carer well-being and emotional health but the impact on physical health and social variables was less clear. However, the diversity of the carer outcomes and the measures used means that the findings must be viewed with caution. CONCLUSIONS: Unpaid carers pay an essential role in caring for people with stroke and dementia and the dearth of literature investigating the impact of supportive interventions for these carers of is surprising. The available evidence suggests that it may be possible to offer support for these carers in general practice but future research should consider focussing on the same outcome measures in order to allow comparisons across interventions.

Genetic testing and economic evaluations: a systematic review of the literature.

OBJECTIVES: To identify those studies in which economic analysis of predictive genetic and pharmacogenetic testing programs have been carried out. Since the Italian National Prevention Plan 2014-2018 foresees the implementation of genetic testing for inherited breast cancer, special attention was given to the cost-effectiveness of BRCA1/2 testing programs. METHODS: A systematic review of primary economic evaluations (EEs) of predictive genetic and pharmacogenetic testing programs and an overview of previously published systematic reviews of economic evaluations (ERs) was performed. RESULTS: Overall 128 EEs and 11 ERs were identified. The methodological quality of both EEs and ERs was good on average. Both predictive genetic and pharmacogenetic testing programs were mainly concerned with oncological diseases. Seventeen percent of genetic testing programs are cost-saving, while a further 44% of cost/QALY ratios fall under the commonly used threshold of €37,000 per QALY. For BRCA1/2 testing, only cascade genetic screening programs, targeted to close relatives of carriers, show clear evidence of cost-effectiveness. CONCLUSION: Despite some limitations, EEs and ERs are powerful tools that provide indications to policy-makers on which genetic testing programs might be introduced into health care systems and public health practice.

Interprofessional education in the care of people diagnosed with dementia: protocol for a systematic review.

INTRODUCTION: Interprofessional education (IPE) offers a possible way to improve interprofessional collaboration and patient care. Current research addressing the effectiveness of IPE in dementia care is limited. A protocol is described for a systematic review to investigate the evidence for the influence of IPE on collaborative knowledge and skills; interprofessional practice and the delivery of dementia care. METHODS AND ANALYSIS: We will search the following electronic databases: PubMed, EMBASE, The Cochrane Library, PsycINFO CINAHL, Applied Social Sciences Index and Abstracts (ASSIA), ERIC British Education Index (BEI) and the Healthcare Management Information Consortium (HMIC). Additional studies will be identified by manually searching relevant journals and the reference list of selected studies. The selection of the studies, data collection and quality appraisal will be performed independently by two reviewers. Data will be initially analysed through a narrative synthesis method. If a subset of data we analyse appears comparable, we will investigate the possibility of pooling such data via formal meta-analysis analytical techniques. ETHICS AND DISSEMINATION: Ethics approval will not be required as this is a protocol for a systematic review. This systematic review aims to establish the effectiveness of IPE programmes on collaborative professional practice and the delivery of care for people with dementia. The findings of this systematic review may also identify specific gaps in the evidence informing a future agenda for research, policy and practice. It will be published in a peer-reviewed journal. TRIAL REGISTRATION NUMBER: PROSPERO CRD42014015075.

Primary care efficiency measurement using data envelopment analysis: a systematic review.

There is a gap between the demand and supply of efficiency analyses within primary care (PC), despite the threatening financial sustainability of health care systems. This paper provides a systematic literature review on PC efficiency analysis using Data Envelopment Analysis (DEA). We reviewed 39 DEA applications in PC, to understand how methodological frameworks impact results and influence the information provided to decision makers. Studies were combined using qualitative narrative synthesis. This paper reports data for each efficiency analysis on the: 1) evaluation context; 2) model specifications; 3) application of methods to test the robustness of findings; 4) presentation of results. Even though a consistent number of analyses aim to support policymakers and practice managers in improving the efficiency of their PC organizations, the results indicate that DEA--at least when applied to PC--is a methodology still in progress; it needs to be further advanced to meet the complexity that characterizes the production of PC outcomes. Future studies are needed to fill some gaps in this particular domain of research, such as on the standardization of methodologies and the improvement of outcome research in PC. Most importantly, further studies should include extensive uncertainty analyses and be based on good evidence-based rationales. We suggest a number of considerations to academics and researchers to foster the utility of efficiency measurement for the decision making purposes in PC.

Wait watchers: the application of a waiting list active management program in ambulatory care.

OBJECTIVE: This study describes and evaluates the application of a waiting list management program in ambulatory care. DESIGN: Waiting list active management survey (telephone call and further contact); before and after controlled trial. SETTING: Local Health Trust in Veneto Region (North-East of Italy) in 2008-09. PARTICIPANTS: Five hundred and one people on a 554 waiting list for C Class ambulatory care diagnostic and/or clinical investigations (electrocardiography plus cardiology ambulatory consultation, eye ambulatory consultation, carotid vessels Eco-color-Doppler, legs Eco-color-Doppler or colonoscopy, respectively). INTERVENTION: Active list management program consisting of a telephonic interview on 21 items to evaluate socioeconomic features, self-perceived health status, social support, referral physician, accessibility and patients' satisfaction. A controlled before-and-after study was performed to evaluate anonymously the overall impact on patients' self-perceived quality of care. MAIN OUTCOME MEASURES: The rate of patients with deteriorating healthcare conditions; rate of dropout; interviewed degree of satisfaction about the initiative; overall impact on citizens' perceived quality of care. RESULTS: 95.4% patients evaluated the initiative as useful. After the intervention, patients more likely to have been targeted with the program showed a statistically significant increase in self-reported quality of care. CONCLUSIONS: Positive impact of the program on some dimensions of ambulatory care quality (health status, satisfaction, willingness to remain in the queue), thus confirming the outstanding value of 'not to leave people alone' and 'not to leave them feeling themselves alone' in healthcare delivery.

How to achieve optimal organization of primary care service delivery at system level: lessons from Europe.

OBJECTIVE: To measure the relative efficiency of primary care (PC) in turning their structures into services delivery and turning their services delivery into quality outcomes. DESIGN: Cross-sectional study based on the dataset of the Primary Healthcare Activity Monitor for Europe project. Two Data Envelopment ANALYSIS: models were run to compare the relative technical efficiency. A sensitivity analysis of the resulting efficiency scores was performed. SETTING: PC systems in 22 European countries in 2009/2010. MAIN OUTCOME MEASURES: Model 1 included data on PC governance, workforce development and economic conditions as inputs and access, coordination, continuity and comprehensiveness of care as outputs. Model 2 included the previous process dimensions as inputs and quality indicators as outputs. RESULTS: There is relatively reasonable efficiency in all countries at delivering as many as possible PC processes at a given level of PC structure. It is particularly important to invest in economic conditions to achieve an efficient structure-process balance. Only five countries have fully efficient PC systems in turning their services delivery into high quality outcomes, using a similar combination of access, continuity and comprehensiveness, although they differ on the adoption of coordination of services. There is a large variation in efficiency levels obtained by countries with inefficient PC in turning their services delivery into quality outcomes. CONCLUSIONS: Maximizing the individual functions of PC without taking into account the coherence within the health-care system is not sufficient from a policymaker's point of view when aiming to achieve efficiency.

Interventions to evaluate fitness to drive among people with chronic conditions: Systematic review of literature.

When an health condition has been identified, the question of whether to continue driving depends not on a medical diagnosis, but on the functional consequences of the illness. The complex nature of physical and mental impairments and their relationship with safe driving make the availability of evidence based tools necessary for health professionals. The review aims at identifying and summarizing scientific findings concerning the relationship between neuropsychological and clinical screening tests and fitness to drive among people with chronic conditions. Studies were searched for driving ability evaluation by road test or simulator, clinical/neuropsychological examinations of participants with chronic diseases or permanent disablement impairing driving performance, primary outcomes as fatal/non-fatal traffic injuries and secondary outcomes as fitness to drive assessment. Twenty-seven studies fulfilled the inclusion criteria. Some studies included more than one clinical condition. The illness investigated were Alzheimer Disease (n=6), Parkinson Disease (n=8), Cardiovascular Accident (n=4), Traumatic Brain Injuries (n=3), Sleep Apnea Syndrome (n=2), Narcolepsy (n=1), Multiple Sclerosis (n=1) and Hepatic Encephalopathy (n=1), comorbidities (n=3). No studies match inclusion criteria about Myasthenia Gravis, Diabetes Mellitus, Renal Diseases, Hearing Disorders and Sight Diseases. No studies referred to primary outcomes. The selected studies provided opposite evidences. It would be reasonable to argue that some clinical and neuropsychological tests are effective in predicting fitness to drive even if contrasting results support that driving performance decreases as a function of clinical and neuropsychological decline in some chronic diseases. Nevertheless we found no evidence that clinical and neuropsychological screening tests would lead to a reduction in motor vehicle crashes involving chronic disabled drivers. It seems necessary to develop tests with proven validity for identifying high-risk drivers so that physicians can provide guidance to their patients in chronic conditions, and also to medical advisory boards working with licensing offices.

The measurement of relative efficiency of general practice and the implications for policy makers.

PURPOSE: This study aimed to compare technical efficiency of general practice (GP) delivered by the twenty Regions of Italy's decentralized healthcare system and to determine if it was affected by contextual factors. METHODS: First, we calculated the Regional efficiency scores by means of Data Envelopment Analysis. Then we carried out a regression analysis to investigate the influence of contextual factors on the efficiency in the provision of GP services. RESULTS: Six Northern Regions were identified as efficient using the best combinations of general practitioners to deliver a given level of GP outcomes. Compared with peer benchmarks, inefficient Regions used more (on-call and regular) general practitioners with important underproductions of outputs (e.g. avoidable hospitalizations). The regression analysis showed a negative relationship between efficiency and the Regional total health care expenditures as percentage of its Gross Domestic Product. DISCUSSION: Improving efficiency of GP services delivery is likely to result in reduced health expenditures. Since there is a general tendency in Europe to decentralize governmental systems of countries and Italy can be seen as an extreme example of this trend, we consider our findings of high relevance for international comparative studies on performance of primary care systems.