Observational pre-post study showed that a quality improvement project reduced paediatric antibiotic prescribing rates in primary care.

AIM: This study assessed the effectiveness of a quality improvement project that aimed to promote more considered antibiotic prescribing in paediatric primary care. METHOD: This was an observational pre-post study that used patient-level prescribing data from the Emilia-Romagna region of Italy to monitor indicators from 2005 to 2016. Multilevel interventions and activities were started in 2007 and these included developing guidelines and updates, disseminating evidence, audits and feedback, public information campaigns, engaging health managers and performance incentives. The primary outcomes were total antibiotic prescription rates for children aged 0-13 years and the rates for specific drugs. RESULTS: The intervention was associated with a significant reduction in the antibiotic prescribing rate, from 1307 per 1000 children in 2005 to 881 prescriptions in 2016 (p for trend <0.001), and a significant increase in the ratio of amoxicillin to amoxicillin-clavulanic acid, from 0.6 to 1.1 (p for trend = 0.001). Prescriptions of other second-choice antibiotics also declined significantly. In contrast, antibiotic prescribing rates remained high in the rest of Italy. CONCLUSION: The intervention was effective in promoting a more considered use of antibiotic in paediatric primary care in an Italian region. Further studies are needed to confirm its effectiveness in other settings.

Intensity of integrated cancer palliative care plans and end-of-life acute medical hospitalisation among cancer patient in Northern Italy.

A high hospital utilisation at the end of life (EOL) is an indicator of suboptimal quality of health care. We evaluated the impact of the intensity of different Integrated Cancer Palliative Care (ICPC) plans on EOL acute medical hospitalisation among cancer decedents. Decedents of cancer aged 18-84 years, who were residents in two Italian regions, were investigated through integrated administrative data. Outcomes considered were prolonged hospital stay for medical reasons, 2+ hospitalisations during the last month of life and hospital death. The ICPC plans instituted 90 to 31 days before death represented the main exposure of interest. Other variables considered were gender, age class at death, marital status, recent hospitalisation and primary cancer site. Among 6,698 patients included in ICPC plans, 44.3% presented at least one critical outcome indicator; among these, 76.5% died in hospital, 60.3% had a prolonged (12+ days) medical hospitalisation, 19.1% had 2+ hospitalisations at the EOL. These outcomes showed a strong dose-response effect with the intensity of the ICPC plans, which is already evident at levels of moderate intensity. A well-ICPC approach can be very effective-beginning at low levels of intensity of care-in reducing the percentage of patients spending many days or dying in hospital.

End-of-Life Place of Care, Health Care Settings, and Health Care Transitions Among Cancer Patients: Impact of an Integrated Cancer Palliative Care Plan.

CONTEXT: Frequent end-of-life health care setting transitions can lead to an increased risk of fragmented care and exposure to unnecessary treatments. OBJECTIVES: We assessed the relationship between the presence and the intensity of an Integrated Cancer Palliative Care (ICPC) plan and the occurrence of multiple transitions during the last month of life. METHODS: Decedents of cancer aged 18-85 years residents in two regions of Italy were investigated accessing their integrated administrative data (death certificates, hospital discharges, hospice, and home care records). The principal outcome was defined as having 3+ health care setting transitions during the last month of life. The ICPC plans instituted 90-31 days before death represented the main exposure of interest. RESULTS: Of the 17,604 patients, 6698 included in an ICPC, although spending in hospital a median number of only two days (interquartile range 1-2), experienced 1+ (59.8%), 2+ (21.1%), or 3+ (5.9%) health care transitions. Among the latter group, the most common trajectory of care is home-hospital-home-hospital (36.0%). The intensity of the ICPC plan showed a marked protective effect toward the event of 3+ health care setting transitions; the effect is already evident from an intensity of at least one home visit/week (odds ratio 0.73; 95% confidence interval 0.62-0.87). CONCLUSION: A well-integrated palliative care approach can be effective in further reducing the percentage of patients who spent many days in hospital and/or undergo frequent and inopportune changes of their care setting during their last month of life.

The implementation of a Community Health Centre-based primary care model in Italy. The experience of the Case della Salute in the Emilia-Romagna Region.

BACKGROUND: The Comunity Health Centre (CHC) primary care model is a team-based health care delivery model intended to provide comprehensive and continuous medical care to patients within a defined community. The CHC, Case della Salute in Italian, model was introduced in the Emilia-Romagna Region in 2010. METHODS: We present updated data on the implementation on the CHC Case della Salute primary care model in the Emilia-Romagna Region. RESULTS: There are 67 operating CHCs in Emilia-Romagna (update March 2015); 26 small (39%), 24 medium (36%) and 17 large (25%). Since 2011 the number of operating CHCs has increased by 60%, reaching 55% of the target planned CHCs (n. = 122). There is, on average, one running CHC per 66.524 inhabitants. 16% of total general practitioners (GPs) and 8.4% of total family paediatricians working in Emilia-Romagna have their practice in CHCs. CHCs offer primary and specialist integrated care, prevention services, health education and social care. DISCUSSION: Although preliminary results suggest CHCs have fostered primary care's quality and efficiency, more research is needed to assess their impact on improving clinical, social and economic outcomes.

[The primary healthcare centres]. / Le Case della salute.

The central attributes of primary care are: first contact (accessibility), longitudinality (person- focused preventive and curative care overtime), patient-oriented comprehensiveness and coordination (including navigation towards secondary and tertiary care). Besides taking care of the needs of the individuals, primary health care teams are also looking at the community, especially when addressing social determinants of health. The rationale for the benefits for primary care for health has been found in: 1) greater access to needed services; 2) better quality of care; 3) a greater focus on prevention; 4) early management of health problems; 5) organizing and delivering high quality care for chronic non-communicable diseases. This paper describes the role of primary healthcare centres in strengthening community primary services and in reducing health inequalities. Furthemore, the experiences of Regional Health Services from Tuscany and Emilia-Romagna are discussed, with a brief overview of the literature.

Group versus single handed primary care: a performance evaluation of the care delivered to chronic patients by Italian GPs.

OBJECTIVES: In family medicine contrasting evidence exists on the effectiveness of team practice compared with solo practice on chronic disease management. In Italy, several experiences of team practice have been introduced since the late 1990s but few studies detail their impact on the quality of care. The aim of this paper is to evaluate the impact of team practice in family medicine in six Italian regions using chronic disease management process indicators as a measure of outcome. METHODS: Cross-sectional studies were performed to assess impact on quality of care for diabetes, congestive heart failure and ischaemic heart disease. The impact of team vs. solo practice was approximated through performance comparison of general practitioners (GPs) adhering to a team with respect to GPs working in a solo practice. Among the 2082 practitioners working in the 6 regions those assisting 300+ patients were selected. Quality of care towards 164,267 patients having at least one of three chronic conditions was estimated for the year 2008 using administrative databases. Quality indicators (% of patients receiving appropriate care) were selected (4 for diabetes, 4 for congestive heart failure, 3 for ischaemic heart disease) and a total score was computed for each patient. For each disease the response variable associated to each physician was the average score of the patients on his/her list. A multilevel model was estimated assessing the impact of team vs. solo practice. RESULTS: No impact was found for diabetes and heart failure. For ischaemic heart disease a slightly significant impact was observed (0.040; 95% CI: 0.015, 0.065). CONCLUSIONS: No significant difference was found between team practice and solo practice on chronic disease management in six Italian regions.

MM2-thalamic Creutzfeldt-Jakob disease: neuropathological, biochemical and transmission studies identify a distinctive prion strain.

In Creutzfeldt-Jakob disease (CJD), molecular typing based on the size of the protease resistant core of the disease-associated prion protein (PrP(Sc) ) and the M/V polymorphism at codon 129 of the PRNP gene correlates with the clinico-pathologic subtypes. Approximately 95% of the sporadic 129MM CJD patients are characterized by cerebral deposition of type 1 PrP(Sc) and correspond to the classic clinical CJD phenotype. The rare 129MM CJD patients with type 2 PrP(Sc) are further subdivided in a cortical and a thalamic form also indicated as sporadic fatal insomnia. We observed two young patients with MM2-thalamic CJD. Main neuropathological features were diffuse, synaptic PrP immunoreactivity in the cerebral cortex and severe neuronal loss and gliosis in the thalamus and olivary nucleus. Western blot analysis showed the presence of type 2A PrP(Sc) . Challenge of transgenic mice expressing 129MM human PrP showed that MM2-thalamic sporadic CJD (sCJD) was able to transmit the disease, at variance with MM2-cortical sCJD. The affected mice showed deposition of type 2A PrP(Sc) , a scenario that is unprecedented in this mouse line. These data indicate that MM2-thalamic sCJD is caused by a prion strain distinct from the other sCJD subtypes including the MM2-cortical form.

[Preventive cardiology: comparisons of European and Italian projects with the Cardiac Units from Emilia Romagna region. A workshop of IACPR/GICR - Emilia Romagna]. / La Cardiologia Preventiva: prospettive nazionali ed europee a confronto con le Cardiologie dell'Emilia Romagna. Workshop IACPR/GICR - Emilia Romagna.

A workshop endorsed by the Italian Association of Cardiovascular Prevention and Rehabilitation--Emilia Romagna Section--held in Piacenza in May 2011, gave the opportunity to discuss the emerging role of Preventive Cardiology in the modern era. From the new documents recently published by the European and Italian Scientific Associations, the barriers in their implementation, and the contribution of the health care providers, physicians, nurses, both in primary and secondary prevention were discussed. The local initiatives of cardiac prevention in different areas were presented and compared. A new project of secondary prevention in the follow-up and management of patients with dilated cardiomyopathy and heart failure promoted by the Emilia Romagna Region Health Authority was presented.

Urinary excretion of 1-hydroxypyrene as a biomarker of exposure to polycyclic aromatic hydrocarbons from different sources.

1-Hydroxypyrene (1-OHP) urinary excretion has been studied in subjects exposed to polycyclic aromatic hydrocarbons (PAH) from different sources (urban air pollution, cigarette smoking, food contamination or occupational exposure). In Study A, statistically significant differences among subjects categorized according to daily cigarette consumption were observed: 1-OHP median excretion of heavy smokers (more than 20 cigarettes per day; 1-OHP=371 ng l(-1); n=6) was significantly increased over that of non-smokers (1-OHP=160 ng l(-1); n=79), light smokers (less than 10 cigarettes per day,1-OHP=157 ng l(-1); n=7) and also medium smokers (10-20 cigarettes per day, 1-OHP=154 ng l(-1); n=13) (p<0.04). In smokers, 1-OHP excretion (y, ng l(-1)) increased with the intensity of cigarette consumption and was associated with self-reported number of cigarettes smoked daily (x, n) (y=20+16.6x; r=0.58, n=22, p<0.01), urinary thiocyanate (x, µmoll(-1)) (y=55+2.6x; r=0.57, n=20, p<0.01) and cotinine (x, µg l(-1)) (y=89+0.23x; r=0.62, n=17, p<0.01). In Study B the influence of smoked food consumption on 1-OHP excretion was evaluated: 1-OHP excretion began to increase as soon as 3 h after a PAH-rich meal and peak values were reached between 6 and 9 h after lunch. Maximum excretion mean values were respectively 525 ng l(-1) for non-smokers (n=8) and 650 ng l(-1) for smokers (n= 4). 1-OHP concentrations in next-morning samples were back to pre-lunch levels both for non-smokers and smokers. In Study C non-smoker workers (n=28) occupationally exposed to PAH in a steel plant were investigated. At values of airborne pyrene ranging between 6 and 30 µg m(-3), excretion values of 1-OHP up to 80000 ng l(-1) were observed. The use of urinary 1-OHP as a screening test to discriminate between smokers and non-smokers in the presence of uncorrected dietary influence has been calculated according to a cut-off value of 461 ng l(-1) (reference group upper limit): the 1-OHP positive predictive value is 57%, its predictive negative value is 77%, sensitivity is 15% and specificity is 96%. In conclusion, 1-OHP appears to be a valuable biomarker of pyrene exposure. It will be nevertheless more accurate in assessing human PAH exposure from multiple sources if the influence of different kinetics for inhaled (particulate or gaseous) or ingested PAH are considered and if the role of oxidative polymorphism is adequately elucidated. The possibility of using 1-OHP to estimate the total burden of PAH from different sources or of screening groups with different PAH exposure appears to be a possible approach. However, the use of 1-OHP to evaluate the associated risk of cancer is still a premature target.