Guideline Adherence as an Indicator of PET Scan Overuse in an Italian Teaching Hospital: An Observational Study.

BACKGROUND: Evidence of inappropriate overuse and underuse of medical procedures has been documented in modern healthcare systems around the world. Excessive use of health services can contribute to a rapid increase in healthcare costs and harm the patient physically and psychologically; conversely, underuse can lead to the inability to provide effective treatments when clinically indicated. OBJECTIVE: The study's aim is twofold: a) to measure the appropriateness of PET prescription in a cohort of patients, offering empirical evidence of overuse of health care services; b) to evaluate how the overuse of PET could affect public health expenditure and, consequently, the system's financial sustainability. METHODS: In this observational study, we have analyzed prospectively and retrospectively health patient records who underwent 18F-FDG PET/TC scan at the Nuclear Medicine Department of the University Hospital Mater Domini in Catanzaro (Italy) from 29/09/2022 to 10/02/2023. Patients' diagnostic questions have been defined as appropriate, not completely appropriate and completely inappropriate according to the 18F-FDG PET/CT recommendations defined by the "Conditions of Supply and Indications of Prescriptive Appropriateness of Italian NHS (National Health Systems)" published in the Official Gazette no. 15 of 20 January 2016 (Decree 9 December 2015) and by the AIMN (Italian Association of Nuclear Medicine) guidelines. RESULTS: We gathered data from 500 oncological patients (242 males and 258 females). The results show that 423/500 of patients' prescriptions were appropriate, while 77/500 of patients' prescriptions were completely inappropriate (63/77) or not completely appropriate (14/77). CONCLUSION: Analysis showed a not complete adherence to national guidelines and no shared decision-making approach.

[Choosing a tailored prosthetic valve in cardiac surgery: what is the current role of mechanical prostheses?] / Il ruolo delle protesi valvolari meccaniche oggi. Dalla letteratura alla situazione italiana.

The choice of the mechanical/biological heart valve prosthesis is a topic currently debated in the light of the transcatheter prosthetic models and the results obtained/expected with the new biological valve models. Consequently, it seems that increasingly younger patients would be indicated for an implantation of a biological prosthesis. This is also in order to improve the quality of life of patients who want to avoid oral anticoagulant therapy. On the other hand, the guidelines for the treatment of heart valve disease assign a central role to the use of mechanical valve prostheses, particularly for certain patient subsets and age groups. This means that mechanical prostheses are still widely used worldwide, especially in non-European or North American regions. The cardiac surgery community therefore seems to be very interested in biological prostheses and transcatheter implants and scarcely interested in mechanical prostheses, including possible strategies for self-management of anticoagulant therapy. Recently, the Italian Society of Cardiac Surgery promoted a survey among its members to stimulate interest in the cardiac surgery community. This review article aims to summarize the most current results recorded with the use of mechanical prostheses and possible strategies, especially for the management of oral anticoagulant therapy, which can improve the patient's quality of life.

The 2022 primary care reform in Italy: Improving continuity and reducing regional disparities?

Several member countries of the Organisation for Economic Co-operation and Development are reforming their primary care systems to improve continuity and co-ordination of care. In May 2022, the Italian health minister issued a new Decree on 'defining models and standards for the development of primary care in the national health service', which addresses some of the major challenges outlined by the National Recovery and Resilience Plan. The reform will target many aspects of the Italian national health system by transforming primary care into community care, while aiming to overcome geographical disparities and achieve greater effectiveness of services. The reform seeks to establish a new organisational model of the primary care network. There exists the potential to guarantee the same quality of care nationwide, thereby reducing geographical differences in the provision of services and improving healthcare services overall. Nevertheless, in a decentralised health system such as Italy's, reform implementation could actually proliferate rather than reduce regional disparities. This study explains the main points of the Decree, shows how the primary care models of the Italian regions may evolve in relation to the specified criteria, and examines the Decree's capacity to bridge regional discrepancies.

Exploring the effectiveness of a P4P scheme from the perspective of Italian general practitioners: A replication study.

A major problem of the primary healthcare system is the deficiency in performance quality. From the second half of the 20th century, many countries introduced pay for performance reimbursement schemes to encourage practitioner behaviour to align with specific objectives of decision-makers and to incentivise the provision of targeted services. The study of Krauth et al. (2016) provides key evidence from a European country, determining whether German general practitioners would participate in a pay for performance programme and under what conditions. Our research replicates this survey, adjusting it to the Italian context. We assessed the attitudes of Italian general practitioners towards the current remuneration scheme and analysed how such views varied among respondents. Results showed that the current remuneration scheme for Italian general practitioners does not seem to be proportional to the efforts given for the provision of care and does not provide appropriate incentives to supply high-quality healthcare. Most of respondents supported the introduction of a pay for performance remuneration system, although perceived potential obstacles. We conclude that for a successful implementation of a quality-based compensation scheme, GPs should be involved. Such participation would help better identify perceived obstacles and overcome them.

The role of European health system characteristics in affecting Covid 19 lethality during the early days of the pandemic.

This article examines the main factors affecting COVID-19 lethality across 16 European Countries with a focus on the role of health system characteristics during the first phase of the diffusion of the virus. Specifically, we investigate the leading causes of lethality at 10, 20, 30, 40 days in the first hit of the pandemic. Using a random forest regression (ML), with lethality as outcome variable, we show that the percentage of people older than 65 years (with two or more chronic diseases) is the main predictor variable of lethality by COVID-19, followed by the number of hospital intensive care unit beds, investments in healthcare spending compared to GDP, number of nurses and doctors. Moreover, the variable of general practitioners has little but significant predicting quality. These findings contribute to provide evidence for the prediction of lethality caused by COVID-19 in Europe and open the discussion on health policy and management of health care and ICU beds during a severe epidemic.

Italian responses to the COVID-19 emergency: Overthrowing 30 years of health reforms?

This paper discusses the measures adopted by the Italian government to face the COVID-19 emergency after the first wave in March/April 2020. This study places these measures in light of the massive reform process based on the "managerialism" of healthcare, which started in the 1990s. These reforms, which were inspired by the ideas of 'New Public Management', introduced managerialism, regionalization and quasi-markets to the Italian National Health System. As a result, dramatic changes have been made in public healthcare, and the responsibility for healthcare was decentralized to regions, introducing a multi-level governance structure. The COVID-19 emergency has drawn the results of this approach into question. With the enactment of new decrees, the central government directly intervened in the management of the health system by introducing specific measures aiming to increase the number of hospital beds and personnel, which w previously downsized. We describe the main content of the new measures adopted to face the COVID-19 emergency and discuss how key points of the managerialization process in Italy are being questioned as a result of these measures. The COVID-19 emergency will likely redesign the trajectory of health reforms in Italy and other countries in Europe.

Effect of financial incentives on breast, cervical and colorectal cancer screening delivery rates: Results from a systematic literature review.

Preventive care, such as screening, is important for reducing the risk of cancer, a leading cause of death worldwide. Indeed, some type of cancers are detected through screening programs, which in most countries run for colorectal, breast, and cervical cancers. In this context, general practitioners play a key role in increasing the participation rate in cancer screening programs. To improve cancer screening delivery rates, performance incentives have increasingly been implemented in primary care by healthcare payers and organizations in different countries. The effects of these tools are still not clear. We conducted a systematic literature review in order to answer the following research question: What is the evidence in the literature for the effects of financial incentives on the delivery rates of breast, cervical and colorectal cancer screening in general practice? We performed a literature search in Web of Science, PubMed, Cochrane Library and Google Scholar, according to the PRISMA guidelines. 18 studies were selected, classified and discussed according to the health preventive services investigated. Most of studies showed partial or no effects of financial incentives on breast and cervical cancer screening delivery rates. Few positive or partial effects were found regarding colorectal cancer screening. Ongoing monitoring of incentive programs is critical to determining the effectiveness of financial incentives and their effects on the improvement of cancer screening delivery rates.

Personalized medicine in colorectal cancer diagnosis and treatment: a systematic review of health economic evaluations.

BACKGROUND: Due to its epidemiological relevance, several studies have been performed to assess the cost-effectiveness of diagnostic tests and treatments in colorectal cancer (CRC) patients. OBJECTIVE: We reviewed economic evaluations on diagnosis of inherited CRC-syndromes and genetic tests for the detection of mutations associated with response to therapeutics. METHODS: A systematic literature review was performed by searching the main literature databases for relevant papers on the field, published in the last 5 years. RESULTS: 20 studies were included in the final analysis: 14 investigating the cost-effectiveness of hereditary-CRC screening; 5 evaluating the cost-effectiveness of KRAS mutation assessment before treatment; and 1 study analysing the cost-effectiveness of genetic tests for early-stage CRC patients prognosis. Overall, we found that: (a) screening strategies among CRC patients were more effective than no screening; (b) all the evaluated interventions were cost-saving for certain willingness-to-pay (WTP) threshold; and (c) all new CRC patients diagnosed at age 70 or below should be screened. Regarding patients treatment, we found that KRAS testing is economically sustainable only if anticipated in patients with non-metastatic CRC (mCRC), while becoming unsustainable, due to an incremental cost-effectiveness ratio (ICER) beyond the levels of WTP-threshold, in all others evaluated scenarios. CONCLUSIONS: The poor evidence in the field, combined to the number of assumptions done to perform the models, lead us to a high level of uncertainty on the cost-effectiveness of genetic evaluations in CRC, suggesting that major research is required in order to assess the best combination among detection tests, type of genetic test screening and targeted-therapy.

Efficiency and optimal size of hospitals: Results of a systematic search.

BACKGROUND: National Health Systems managers have been subject in recent years to considerable pressure to increase concentration and allow mergers. This pressure has been justified by a belief that larger hospitals lead to lower average costs and better clinical outcomes through the exploitation of economies of scale. In this context, the opportunity to measure scale efficiency is crucial to address the question of optimal productive size and to manage a fair allocation of resources. METHODS AND FINDINGS: This paper analyses the stance of existing research on scale efficiency and optimal size of the hospital sector. We performed a systematic search of 45 past years (1969-2014) of research published in peer-reviewed scientific journals recorded by the Social Sciences Citation Index concerning this topic. We classified articles by the journal's category, research topic, hospital setting, method and primary data analysis technique. Results showed that most of the studies were focussed on the analysis of technical and scale efficiency or on input / output ratio using Data Envelopment Analysis. We also find increasing interest concerning the effect of possible changes in hospital size on quality of care. CONCLUSIONS: Studies analysed in this review showed that economies of scale are present for merging hospitals. Results supported the current policy of expanding larger hospitals and restructuring/closing smaller hospitals. In terms of beds, studies reported consistent evidence of economies of scale for hospitals with 200-300 beds. Diseconomies of scale can be expected to occur below 200 beds and above 600 beds.