Development of a prescriptive appropriateness project in RSAs affiliated with Local health authority of Vercelli: repercussions on the correct use of the drug and on the economic sustainability of the SSN.

Law 405/2001, DGR of 30 July 2012, n. 45-4248 and the DGR of 2 August 2013, n. 85-6287 provide that ASLs guarantee the direct distribution of drugs from the Company's Therapeutic Handbook (PTA) necessary for the treatment of patients in residential and semi-residential care. In this context, some critical issues have emerged such as: long dispensing times with repercussions of "extemporaneous" prescriptions in the area by GPs and consequent disbursements under contract (CONV) and distribution on behalf (DPC), poorly controlled stocks of medicines within the structures, lack of appropriateness of therapies, significant increase in costs. The final objective is to describe the process of supplying and managing medicines for guests hospitalized in facilities for the elderly and disabled (here in after RSA) and identify strategies to optimize appropriateness pathways. METHODS In 2022, there were 46 RSAs present in ASL VC, of which 31 were enrolled in the project and for which a retrospective descriptive study was conducted. Each RSA sends an Excel and a PDF (stamped and signed by the GP) of the drug request to the SC Farmaceutica Territoriale (SFT). The request indicates: date of completion, GP, tax code/patient name, surname, drug, quantity, dosage, AIFA note, any notes. The SFT checks the requests for quantity (packages requested/indicated dosage) and quality (prescriptive appropriateness) and forwards them to the Hospital Pharmacy for processing. RESULTS From 2019 to 2022, enrollment grew from 18 to 31 RSAs and guests from 1,387 to 1,678 with an average age of 83.84 (± 11.64); at the same time, there was a reduction in the average number of drugs given to patients from 62.5 to 47.3 and in prescriptions per patient from 32.8 to 31.7. Over the years the percentage of checks carried out by the SFT has increased from 2% to 5%. The most frequent inappropriatenesses were: lack of known AIFA (22.5%), missing PT (12.3%), drugs outside PTA (11.2%), expired PT (9.3%), absence of diagnosis (6.5%). The gross per capita affiliated pharmaceutical expenditure of €163.83 in 2019 fell to €136.97 in 2022 (-19%). The DPC increased from €27.83 to €38.80 in relation to the expansion of the drugs included in the PHT. DISCUSSION The project guarantees, through prescriptive appropriateness paths, a more controlled and punctual supply of the drug with a consequent reduction in the expenditure paid by the NHS. It also highlights the importance of the figure of the pharmacist, as a drug specialist, for the correct management and organization of procedures aimed at obtaining favorable results such as the deprescribing of drugs. CONCLUSION The project will continue with the enlistment of other RSAs and the proposal to include the pharmacist in the Supervisory Commission which inspects the structures to evaluate the management of the drug on site to guarantee the protection of patient health.

Profile, Healthcare Resource Consumption and Related Costs in ANCA-Associated Vasculitis Patients: A Real-World Analysis in Italy.

INTRODUCTION: Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAV) are rare autoimmune diseases triggering inflammation of small vessels. This real-world analysis was focused on the most common AAV forms, granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA), to describe patients' demographic and clinical characteristics, therapeutic management, disease progression, and the related economic burden. METHODS: A retrospective analysis was conducted on administrative databases of a representative sample of Italian healthcare entities, covering approximately 12 million residents. Between January 2010 and December 2020, adult GPA patients were identified by payment waiver code or hospitalization discharge diagnosis, and MPA patients by payment waiver code with or without hospitalization discharge diagnosis. Clinical outcomes were evaluated through AAV-related hospitalizations, renal failure onset, and mortality. Economic analysis included healthcare resource utilization deriving from drugs, hospitalizations, and outpatient specialist services. The related mean direct costs year/patient were also calculated in patients stratified by presence/absence of glucocorticoid therapy and type of inclusion criterion (hospitalization/payment waiver code). RESULTS: Overall, 859 AAV patients were divided into GPA (n = 713; 83%) and MPA (n = 146; 17%) cohorts. Outcome indicators highlighted a clinically worse phenotype associated with GPA compared to MPA. Cost analysis during follow-up showed tendentially increased expenditures in glucocorticoid-treated patients versus untreated (overall AAV: €8728 vs. €7911; GPA: €9292 vs. €9143; MPA: €5967 vs. €2390), mainly driven by drugs (AAV: €2404 vs. €874; GPA: €2510 vs. €878; MPA: €1881 vs. €854) and hospitalizations. CONCLUSION: Among AAV forms, GPA resulted in a worse clinical picture, higher mortality, and increased costs. This is the first real-world pharmaco-economic analysis on AAV patients stratified by glucocorticoid use on disease management expenditures. In both GPA and MPA patients, glucocorticoid treatment resulted in higher healthcare costs, mostly attributable to medications, and then hospitalizations, confirming the clinical complexity and economic burden for management of patients with autoimmune diseases under chronic immunosuppression.

Real-World Analysis of Outcomes and Economic Burden in Patients with Chronic Kidney Disease with and without Secondary Hyperparathyroidism among a Sample of the Italian Population.

This real-world analysis evaluated the clinical and economic burden of non-dialysis-dependent CKD patients with and without secondary hyperparathyroidism (sHPT) in Italy. An observational retrospective study was conducted using administrative databases containing a pool of healthcare entities covering 2.45 million health-assisted individuals. Adult patients with hospitalization discharge diagnoses for CKD stages 3, 4, and 5 were included from 1 January 2012 to 31 March 2015 and stratified using the presence/absence of sHPT. Of the 5710 patients, 3119 were CKD-only (62%) and 1915 were CKD + sHPT (38%). The groups were balanced using Propensity Score Matching (PSM). Kaplan-Meier curves revealed that progression to dialysis and cumulative mortality had a higher incidence in the CKD + sHPT versus CKD-only group in CKD stage 3 patients and the overall population. The total direct healthcare costs/patient at one-year follow-up were significantly higher in CKD + sHPT versus CKD-only patients (EUR 8593 vs. EUR 5671, p < 0.001), mostly burdened by expenses for drugs (EUR 2250 vs. EUR 1537, p < 0.001), hospitalizations (EUR 4628 vs. EUR 3479, p < 0.001), and outpatient services (EUR 1715 vs. EUR 654, p < 0.001). These findings suggest that sHPT, even at an early CKD stage, results in faster progression to dialysis, increased mortality, and higher healthcare expenditures, thus indicating that timely intervention can ameliorate the management of CKD patients affected by sHPT.

[Perceived quality of care in a nursing home in Piedmont (Italy)]. / La qualità dell'assistenza in una casa di cura piemontese: l'opinione dei degenti.

A cross-sectional study was conducted in the years 2003, 2005 and 2006, to assess client satisfaction in a nursing home in Piedmont (Italy). A structured questionnaire was used to evaluate three dimensions of care: interpersonal relationships, clinical care received and room comfort. Six-hundred eighty-four patients participated in the study. Of these, 33.6% were surgical patients, 33.6% were rehabilitation patients and 32.8% were medical patients. Overall, quality of care was reported as being "excellent" by 85% of patients in 2003, 85.3% of patients in 2005 and 66.1% in 2006. The study has made it possible to give a general description of client satisfaction regarding quality of services provided in a nursing home, and to identify the major critical areas. These should be analyzed in more detail, in order to identify which factors are most relevant to the patient and to implement corrective actions.

[Do critical pathways improve outcomes of patients with cardiac failure?]. / I percorsi assistenziali migliorano gli outcome dei pazienti affetti da scompenso cardiaco?

UNLABELLED: Cardiac failure represents an important public health problem and despite recent clinical, diagnostic and therapeutic advances, the incidence and prevalence of this syndrome show a steady increase. In view of this, the authors conducted a meta-analysis to evaluate the effect of critical pathways in the management of patients with cardiac failure when compared with standard care. The impact of critical pathways on the following outcomes were evaluated: hospital mortality, mortality at six months, mean length of hospital stay, direct costs, readmission rates at one, three and six months. METHODS: The following databases were consulted: Medline, Embase, CINAHL, Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews. The research was limited to articles published between January 1975 and June 2010. Methodological quality of studies was evaluated by the Jadad method (for RCTs, cRCT, CCT) and the New Castle Ottawa Scale for case-control and cohort studies. Data analysis was performed by using the statistical methods described in the Cochrane Collaboration guidelines. Meta-analyses were performed using RevMan software version 5. RESULTS: Eleven studies were included in the meta-analysis (5,460 patients). A lower mortality (hospital mortality and mortality at 6 months) was observed in the critical pathways group compared to the group treated with standard care. A positive impact of critical pathways was also observed in length of stay, direct costs, readmission after one, three and six months. CONCLUSIONS: Critical pathways can improve the quality of care provided to patients with cardiac failure. Further studies are needed to evaluate which mechanisms within the care pathways can truly improve the quality of care.

Key interventions and outcomes in joint arthroplasty clinical pathways: a systematic review.

UNLABELLED: SUMMARY RATIONALE, AIMS AND OBJECTIVES: Clinical pathways are globally used to improve quality and efficiency of care. Total joint arthroplasty patients are one of the primary target groups for clinical pathway development. Despite the worldwide use of clinical pathways, it is unclear which key interventions multidisciplinary teams select as pathway components, which outcomes they measures and what the effect of this complex intervention is. This literature study is aimed at three research questions: (1) What are the key interventions used in joint arthroplasty clinical pathways? (2) Which outcome measures are used? (3) What are the effects of a joint arthroplasty clinical pathway? METHOD: Systematic literature review using a multiple reviewer approach. Five electronic databases were searched comprehensively. Reference lists were screened. Experts were consulted. After application of inclusion and exclusion criteria and critical appraisal, 34 of the 4055 publications were included. RESULTS: Joint arthroplasty clinical pathways address pre-admission education, pre-admission exercises, pre-admission assessment and testing, admission and surgical procedure, postoperative rehabilitation, minimal manipulation, symptoms management, thrombosis prophylaxis, discharge management, primary caregiver involvement, home-based physiotherapy and continuous follow-up. An overview of target dimensions and corresponding indicators is provided. Clinical pathways for joint arthroplasty could improve process and financial outcomes. The effects on clinical outcome are mixed. Evidence on team and service outcome is lacking. CONCLUSIONS: A set of key interventions and outcome measures is available to support joint arthroplasty clinical pathways. Team and service outcomes should be further addressed in practice and research. Meta-analysis on the outcome indicators should be performed. Future studies should more rigorously comply with existing reporting standards.

Care pathways in obstetrics: the effectiveness in reducing the incidence of episiotomy in childbirth.

AIM: To develop a care pathway for childbirth. BACKGROUND: Care pathways are emerging as an effective tool to improve clinical and organizational performance. METHODS: A pre- and postimplementation analysis model was used to evaluate the effect of introducing a care pathway for childbirth. Key outcome indicators and costs were reviewed to compare the traditional care processes with those of the care pathway. The study involved 380 women. RESULTS: There was a significant reduction in episiotomy rate (from 14.90% to 8.6%, P = 0.02) in patients being cared for using a care pathway approach; however, there were no differences in caesarean section and in perineal wound rates. The average costs per patient on the care pathway were euro 1278.42 ( pound 873.64) compared with euro 1,146.87 ( pound 783.74) preimplementation. The study also demon- strated an increase in patient satisfaction for women cared for using the care pathway approach. CONCLUSIONS: The care pathway proved to be a valid methodological approach to childbirth, allowing healthcare workers to efficiently share the care of the women, guaranteeing safe and effective care.