Excess hospitalizations and in-hospital mortality associated with seasonal influenza in Italy: a 11-year retrospective study.

BACKGROUND: Influenza and flu-like syndromes are difficult to monitor because the symptoms are not specific, laboratory tests are not routinely performed, and diagnosis codes are often lacking or incompletely registered in medical records. This may result in an underestimation of hospital admissions, associated costs, and in-hospital mortality. Therefore, this study aimed to estimate the public health and economic burden of hospitalisations associated with influenza in Italy, at the national and regional levels. METHODS: This 11-year retrospective study included patients admitted to hospitals for influenza or diagnoses associated with influenza (including respiratory and cardiocirculatory conditions) from 2008/09 to 2018/19. Data on hospitalisations were extracted from the Italian Hospital Discharge Records. Information on weekly influenza-like syndrome incidence and weekly average temperature were used to estimate the burden of influenza in terms of hospital admissions in every Italian region and for different age groups by applying a negative binomial model. The model was also applied to estimate in-hospital mortality and the total costs of influenza and influenza-like hospital admissions. RESULTS: Over the study period, in addition to 3,970 average seasonal admissions coded as influenza, we estimated an average of 21,500 excess hospitalization associated with influenza per season, which corresponds to 36.4 cases per 100,000. Most of the excess hospitalisations concerned older individuals (> 65 years) and children (0-4 years) with 86 and 125 cases per 100,000, respectively. Large variations were observed across regions. Overall, the total estimated hospital burden associated with influenza (including respiratory and cardiocirculatory conditions) was approximately €123 m per year. While the in-hospital mortality for admissions with a primary diagnosis of influenza was very low (~ 150 cases per season), cases increased dramatically for primary diagnoses of influenza and pneumonia (about 9,500 cases per season). The average seasonal in-hospital deaths attributable to influenza were equal to 2,775 cases. CONCLUSIONS: Our findings suggest a remarkable underestimation of the burden of influenza, mostly in the older population but not neglectable in younger individuals. Our results may aid the management of current and future flu seasons and should be used for policy making (e.g., vaccine strategies) and operation management choices (e.g., planning and staffing beds during influenza peaks). Overall, the present study supports the need for increased testing for influenza in Italy to tackle the current underestimation of influenza burden.

Full cost of diagnostic pathology for lung carcinoma in Italy: results from four Pathology Units.

Objective: To calculate the full cost of diagnostic pathology tests for Non-Small Cell Lung Cancer (NSCLC) across four Italian Pathology Units. Methods: Pathology Units were located in private (2) and public (2) hospitals distributed across the Italian territory (North: 2; Centre: 1; South: 1). Pathologists provided via questionnaire data on tests on NSCLC samples along with the identification and quantification of the necessary healthcare resources (diagnostic technologies, laboratory instruments and personnel). Resources were valued according to hospital-specific unit, yearly and hourly costs (disposables; technologies; professional clusters). Results: The full cost per NSCLC tissue sample included histopathological immunophenotypic and required molecular analysis. Overall, it reached € 659.77 and it was mainly composed of direct costs (77.69%). The processing of a NSCLC tissue sample was labour intensive, as a relevant share of the full cost (44.98%) was actually due to personnel costs, with laboratory technicians, biologists and pathologist driving this finding (17.09%,12.43% and 10.81%, respectively). Conclusions: The results of this research can facilitate the negotiation of new dedicated tariffs for NSCLC sample processing with the national or local third party-payers.

Longitudinal associations between different measures of socioeconomic status and health behavior among adolescents. Data from a wealthy Italian region.

We investigate the association between socio-economic status and unhealthy behaviors among adolescents. By using different measures of socio-economic status, we capture both subjective aspects, as operationalized by perceived family affluence, and objective aspects, such as parents' educational levels and family affluence scale. We use data from a sample of 11,623 adolescents who participated in the Health Behavior in School-aged Children (HBSC) study in 2007, 2010, and 2014 in the Lombardy region of Italy. Results show that all of our measures of socio-economic status are correlated with unhealthy behaviors among adolescents. In particular, perceiving a family affluence below average is significantly correlated with a higher probability of reporting all of the unhealthy behaviors included in our analysis. Having at least one parent with university education significantly decreases the odds of being obese or overweight, having an unbalance diet, being physically inactive, and reporting sedentary behaviors. However, adolescents with at least one university educated parent are more likely to make use of cannabis. When controlling for all of our SES measures simultaneously, we find that family affluence scale is no longer significant in determining adolescents' behaviors. Our findings suggest that, when focusing on health inequalities among adolescents, self-perceptions and non-material dimensions of SES have more explanatory power than its material dimensions.

A scoping review of core outcome sets and their 'mapping' onto real-world data using prostate cancer as a case study.

BACKGROUND: A Core Outcomes Set (COS) is an agreed minimum set of outcomes that should be reported in all clinical studies related to a specific condition. Using prostate cancer as a case study, we identified, summarized, and critically appraised published COS development studies and assessed the degree of overlap between them and selected real-world data (RWD) sources. METHODS: We conducted a scoping review of the Core Outcome Measures in Effectiveness Trials (COMET) Initiative database to identify all COS studies developed for prostate cancer. Several characteristics (i.e., study type, methods for consensus, type of participants, outcomes included in COS and corresponding measurement instruments, timing, and sources) were extracted from the studies; outcomes were classified according to a predefined 38-item taxonomy. The study methodology was assessed based on the recent COS-STAndards for Development (COS-STAD) recommendations. A 'mapping' exercise was conducted between the COS identified and RWD routinely collected in selected European countries. RESULTS: Eleven COS development studies published between 1995 and 2017 were retrieved, of which 8 were classified as 'COS for clinical trials and clinical research', 2 as 'COS for practice' and 1 as 'COS patient reported outcomes'. Recommended outcomes were mainly categorized into 'mortality and survival' (17%), 'outcomes related to neoplasm' (18%), and 'renal and urinary outcomes' (13%) with no relevant differences among COS study types. The studies generally fulfilled the criteria for the COS-STAD 'scope specification' domain but not the 'stakeholders involved' and 'consensus process' domains. About 72% overlap existed between COS and linked administrative data sources, with important gaps. Linking with patient registries improved coverage (85%), but was sometimes limited to smaller follow-up patient groups. CONCLUSIONS: This scoping review identified few COS development studies in prostate cancer, some quite dated and with a growing level of methodological quality over time. This study revealed promising overlap between COS and RWD sources, though with important limitations; linking established, national patient registries to administrative data provide the best means to additionally capture patient-reported and some clinical outcomes over time. Thus, increasing the combination of different data sources and the interoperability of systems to follow larger patient groups in RWD is required.

Low socio-economic conditions and prematurity-related morbidities explain healthcare use and costs for 2-year-old very preterm children.

AIM: To estimate healthcare use and related costs for 2-year-old very preterm (VP) children after discharge from the neonatal unit. METHODS: As part of a European project, we recruited an area-based cohort including all VP infants born in three Italian regions (Lazio, Emilia-Romagna and Marche) in 2011-2012. At 2 years corrected age, parents completed a questionnaire on their child health and healthcare use (N = 732, response rate 75.6%). Cost values were assigned based on national reimbursement tariffs. We used multivariable analyses to identify factors associated with any rehospitalisation and overall healthcare costs. RESULTS: The most frequently consulted physicians were the paediatrician (85% of children), the ophthalmologist (36%) and the neurologist/neuropsychiatrist (26%); 38% of children were hospitalised at least once after the initial discharge, for a total of 513 admissions and over one million euros cost, corresponding to 75% of total healthcare costs. Low maternal education and parental occupation index, congenital anomalies and postnatal prematurity-related morbidities significantly increased the risk of rehospitalisation and total healthcare costs. CONCLUSION: Rehospitalisation and outpatient care are frequent in VP children, confirming a substantial health and economic burden. These findings should inform the allocation of resources to preventive and rehabilitation services for these children.

Five year trends (2008-2012) in cardiac implantable electrical device utilization in five European nations: a case study in cross-country comparisons using administrative databases.

Aims: Common methodologies for analysis of analogous data sets are needed for international comparisons of treatment and outcomes. This study tests using administrative hospital discharge (HD) databases in five European countries to investigate variation/trends in pacemaker (PM) and implantable cardioverter defibrillator (ICD) implant rates in terms of patient characteristics/management, device subtype, and initial implantation vs. replacement, and compares findings with existing literature and European Heart Rhythm Association (EHRA) reports. Methods and results: HD databases from 2008 to 2012 in Austria, England, Germany, Italy and Slovenia were interrogated to extract admissions (without patient identification) associated with PM and ICD implants and replacements, using direct cross-referencing of procedure codes and common methodology to compare aggregate data. 1 338 199 records revealed 212 952 PM and 62 567 ICD procedures/year on average for a 204.4 million combined population, a crude implant rate of about 104/100 000 inhabitants for PMs and 30.6 for ICDs. The first implant/replacement rate ratios were 81/24 (PMs) and 25/7 (ICDs). Rates have increased, with cardiac resynchronization therapy (CRT) subtypes for both devices rising dramatically. Significant between- and within-country variation persists in lengths of stay and rates (Germany highest, Slovenia lowest). Adjusting for age lessened differences for PM rates, scarcely affected ICDs. Male/female ratios remained stable at 56/44% (PMs) and 79/21% (ICDs). About 90% of patients were discharged to home; 85-100% were inpatient admissions. Conclusion: To aid in policymaking and track outcomes, HD administrative data provides a reliable, relatively cheap, methodology for tracking implant rates for PMs and ICDs across countries, as comparisons to EHRA data and the literature indicated.

The short-term economic burden of gestational diabetes mellitus in Italy.

BACKGROUND: The incidence of Gestational Diabetes Mellitus (GDM) is rising in all developed countries. This study aimed at assessing the short-term economic burden of GDM from the Italian healthcare system perspective. METHODS: A model was built over the last pregnancy trimester (i.e., from the 28th gestational week until childbirth included). The National Hospital Discharge Database (2014) was accessed to estimate delivery outcome probabilities and inpatient costs in GDM and normal pregnancies (i.e., euglycemia). International Classification of Disease-9th Revision-Clinical Modification (ICD9-CM) diagnostic codes and Diagnosis-Related Group (DRG) codes were used to identify GDM cases and different types of delivery (i.e., vaginal or cesarean) within the database. Neonatal outcomes probabilities were estimated from the literature and included macrosomia, hypoglycemia, hyperbilirubinemia, shoulder dystocia, respiratory distress, and brachial plexus injury. Additional data sources such as regional documents, official price and tariff lists, national statistics and expert opinion were used to populate the model. The average cost per case was calculated at national level to estimate the annual economic burden of GDM. One-way sensitivity analyses and Monte Carlo simulations were performed to quantify the uncertainty around base case results. RESULTS: The amount of pregnancies complicated by GDM in Italy was assessed at 54,783 in 2014 using a prevalence rate of 10.9%. The antenatal outpatient cost per case was estimated at €43.7 in normal pregnancies compared to €370.6 in GDM patients, which is equivalent to a weighted sum of insulin- (14%; €1034.6) and diet- (86%; €262.5) treated women's costs. Inpatient delivery costs were assessed at €1601.6 and €1150.3 for euglycemic women and their infants, and at €1835.0 and €1407.7 for GDM women and their infants, respectively. Thus, the overall cost per case difference between GDM and normal pregnancies was equal to €817.8 (+ 29.2%), resulting in an economic burden of about €44.8 million in 2014 at national level. Probabilistic sensitivity analysis yielded a cost per case difference ranging between €464.9 and €1164.8 in 80% of simulations. CONCLUSIONS: The economic burden of GDM in Italy is substantial even accounting for short-term medical costs only. Future research also addressing long-term consequences from a broader societal perspective is recommended.

Physicians' professional autonomy and their organizational identification with their hospital.

BACKGROUND: Managing medical professionals is challenging because professionals tend to adhere to a set of professional norms and enjoy autonomy from supervision. The aim of this paper is to study the interplay of physicians' professional identity, their organizational identity, and the role of professional autonomy in these processes of social identification. METHODS: We test hypotheses generated according to social identity theory using a survey of physicians working in public hospitals in Italy in 2013. RESULTS: Higher degrees of organizational and economic professional autonomy are correlated with higher organizational identification. Identification with the profession is positively correlated with identification with the organization. CONCLUSIONS: Although the generalizability of our results is limited, this study suggests that organizations should support the organizational and economic autonomy of their physicians to project an organizational identity that preserves the continuity of a doctor's self-concept and that is evaluated as positive by doctors. As a result, organizations will be able to foster organizational identification, which is potentially capable of inducing pro-social organizational behavior.

Investigating Regional Variation of Cardiac Implantable Electrical Device Implant Rates in European Healthcare Systems: What Drives Differences?

Despite established efficacy for cardiac implantable electrical devices (CIEDs), large differences in CIED implant rates have been documented across and within countries. The aim of this paper is to investigate the influence of socio-economic, epidemiological and supply side factors on CIED implant rates across 57 Regions in 5 EU countries and to assess the feasibility of using administrative data for this purpose. A total of 1 330 098 hospitalizations for CIED procedures extracted from hospital discharge databases in Austria, England, Germany, Italy and Slovenia from 2008 to 2012 was used in the analysis. Higher levels of tertiary education among the labour force and percent of aged population are positively associated with implant rates of CIED. Regional per capita GDP and number of implanting centres appear to have no significant effect. Institutional factors are shown to be important for the diffusion of CIED. Wide variation in CIED implant rates across and within five EU countries is undeniable. However, regional factors play a limited part in explaining these differences with few exceptions. Administrative databases are a valuable source of data for investigating the diffusion of medical technologies, while the choice of appropriate modelling strategy is crucial in identifying the drivers for variation across countries. © 2017 The Authors. Health Economics published by John Wiley & Sons, Ltd.

Health, Wellbeing and Social Sciences.

For social interventions aimed at improving nutrition behavior evidence from randomized trials is essential but cannot be the only approach of research activities. Interventions on dietary habits require considerations on food security, economic and environmental sustainability, and a broad meaning of wellbeing which includes, but also goes beyond, health effects. The model of research in nutrition requires a new consideration of observational studies, mainly through different analytical models. Nutrition and food studies need research programs where medical (nutrition and health), psychology (how we behave), economics (how resources are used and their impact on wellbeing) and sociology (how social determinant shape behavior) collaborate.

Near zerO fluoroscopic exPosure during catheter ablAtion of supRavenTricular arrhYthmias: the NO-PARTY multicentre randomized trial.

AIMS: Aim of this study was to compare a minimally fluoroscopic radiofrequency catheter ablation with conventional fluoroscopy-guided ablation for supraventricular tachycardias (SVTs) in terms of ionizing radiation exposure for patient and operator and to estimate patients' lifetime attributable risks associated with such exposure. METHODS AND RESULTS: We performed a prospective, multicentre, randomized controlled trial in six electrophysiology (EP) laboratories in Italy. A total of 262 patients undergoing EP studies for SVT were randomized to perform a minimally fluoroscopic approach (MFA) procedure with the EnSiteTMNavXTM navigation system or a conventional approach (ConvA) procedure. The MFA was associated with a significant reduction in patients' radiation dose (0 mSv, iqr 0-0.08 vs. 8.87 mSv, iqr 3.67-22.01; P < 0.00001), total fluoroscopy time (0 s, iqr 0-12 vs. 859 s, iqr 545-1346; P < 0.00001), and operator radiation dose (1.55 vs. 25.33 µS per procedure; P < 0.001). In the MFA group, X-ray was not used at all in 72% (96/134) of cases. The acute success and complication rates were not different between the two groups (P = ns). The reduction in patients' exposure shows a 96% reduction in the estimated risks of cancer incidence and mortality and an important reduction in estimated years of life lost and years of life affected. Based on economic considerations, the benefits of MFA for patients and professionals are likely to justify its additional costs. CONCLUSION: This is the first multicentre randomized trial showing that a MFA in the ablation of SVTs dramatically reduces patients' exposure, risks of cancer incidence and mortality, and years of life affected and lost, keeping safety and efficacy. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01132274.

The 2022 community-based integrated care reform in Italy: From desiderata to implementation.

The Italian National Recovery and Resilience Plan allocated € 7 Bn for community care. In May 2022, the Italian government issued a Decree to define the strategy for the development of community-based integrated care. The reform aims to create uniformly a network of services close to where patients live, thus overcoming geographical disparities between regions. The strategy is based on a strong role of the central government in community care, but still leaves autonomy to regions. Levelling availability of services across territories, setting uniform targets with a short period horizon and disregarding starting points may create important implementation problems. Financial constraints will also hamper the implementation of the reform. Ultimately the development of Italian community care will depend on the institutional and managerial capabilities of regions and local health authorities. Firstly, they should shape the actual implementation of community care services by defining organizational arrangements, priority targets and models of care delivery. Secondly, they should develop strategies to face the lack of financial resources and the shortage of healthcare workforce. This contribution informs international readers about a major policy in a European country and its implementation challenges. It offers insights into inter-government relations in NHS-type healthcare systems (Nordic countries and Spain), showcasing the complexity of policymaking involving multiple political actors and resulting indeterminacy of policies and their implementation.

Reducing the burden of travel and environmental impact through decentralization of cancer care.

Life expectancy, quality of life and satisfaction of oncologic patients highly depend on access to adequate specialized services, that consider their conditions in a holistic way. The present study aims to evaluate the introduction of oncology services in an outpatient setting in a mountain village in Northern Italy. The initiative is evaluated using the three pillars of sustainability (social, economic and environmental) as dimensions that are often overlooked by healthcare policy makers. Using micro data on 18,625 interventions, we estimate the number of kilometers saved by patients (reduction of "travel burden" as indicator of social sustainability), the additional travel costs for the NHS (indicator of economic sustainability) and the implied reduction of CO2 emissions (indicator of environmental sustainability). Over the period July 2016-2021, the decentralized health center delivered 2,292 interventions saving 218,566 km for a corresponding value of €131,140. The additional costs for the NHS was €26,152. The reduction of CO2 emissions was 32.37 Tons (€5,989). Overall, the socio-economic benefit of reducing travel of care for the patients residing in this remote valley was €110,976. This study adds original understanding of the benefits of decentralizing oncologic care and shows its operational feasibility conditions. Given the modest number of similar projects, it provides evidence to policy makers and, especially, managers who are faced with the challenge to implement the decentralization of specialized services.

The importance of values in shaping how health systems governance and management can support universal health coverage.

In this article, we use cultural theory to investigate the nature of health systems governance and management, showing that it may be helpful in identifying key aspects of the debate about how to promote universal health coverage. Cultural theory argues that "how" we govern and manage health services depends on what we think about the nature of government organizations and the legitimacy of their scope of action. The values that are implied by universal health coverage underlie choices about "how" health systems are governed and their organizations are managed. We draw two main conclusions. First, the translation of principles and goals into practice requires exceptional efforts to design adequate decision-making arrangements (the essence of governance) and management practices. Management and governance, or "how" policies are decided and conducted, are not secondary to the selection of the best policy solutions (the "what"). Second, governance and management solutions are not independent of the values that they are expected to serve. Instead, they should be designed to be consonant with these values. Cultural theory suggests-and experience supports-the idea that "group identity" is favorable for shaping different forms of social life and public administrations. This approach should thus be a starting point for those who strive to obtain universal health coverage.

Do policies affect management? Evidence from a survey of clinicians of the Italian National Health Service.

Since the early 1990s, New Public Management ideas have deeply influenced reforms and their implementation in the Italian NHS. We compare doctors' perceptions about management systems in two Italian regions which differ in the dominant values of the regional political environment. In total 220 doctors, orthopaedists and cardiologists, working in public hospitals in Lombardy and Emilia-Romagna, were surveyed. Doctors in Emilia-Romagna perceived their organization to be more managerially driven in comparison to their colleagues in Lombardy. Doctors from Lombardy perceived their professional freedom to be higher, regardless of their specialization. The divergence of professionals' perception between these two Italian regions, which operate within the same Beveridge model, shows that dominant values of regional politics may have tangible effects on hospital management.

Geographical variation in the use of private health insurance in a predominantly publicly-funded system.

We provide evidence of geographical variations in the use of private health insurance (PHI) in Italy. Our study offers an original contribution, using a 2016 dataset on the use of PHI amongst a population of more than 200,000 employees of a major company. The average claim per enrolee was €925, representing approximately 50% of public health expenditure per capita, primarily for dental care (27.2%), specialist outpatient services (26.3%) and inpatient care (25.2%). Residents in northern regions and metropolitan areas respectively claimed reimbursements for €164 and €483 more than those in southern regions and in non-metropolitan areas. Both supply and demand factors can explain these large geographical differences. The study suggests the urgency for policymakers to address the considerable disparities in the Italian healthcare system, revealing the overall social, cultural and economic conditions that shape the demand for healthcare.

The social and economic burden of stroke survivors in Italy: a prospective, incidence-based, multi-centre cost of illness study.

BACKGROUND: The aim of this study was to estimate the one-year societal costs due to a stroke event in Italy and to investigate variables associated with costs in different phases following hospital admission. METHODS: The patients were enrolled in 44 hospitals across the country and data on socio-demographic, clinical variables and resource consumption were prospectively surveyed for 411 stroke survivors at admission, discharge and 3, 6 and 12 months post the event. We adopted a micro-costing procedure to identify cost generating components and the attribution of appropriate unit costs for three cost categories: direct healthcare, direct non-healthcare (including informal care costs) and productivity losses. The relation between costs of stroke management and socio-demographic and clinical characteristics as well as disability levels was evaluated in a series of bivariate analyses using non parametric tests (Mann Whitney and Kruskal-Wallis). Multiple linear regression analyses were performed to determine predictors of costs incurred by stroke patients during the acute phase and follow-up of 1 year. RESULTS: On average, one-year healthcare and societal costs amounted to €11,747 and € 19,953 per stroke survivor, respectively. The major cost component of societal costs was informal care accounting for € 6,656 (33.4% of total), followed by the initial hospitalisation, (€ 5,573; 27.9% of total), rehabilitation during follow up (€ 4,112; 20.6 %), readmissions (€ 439) and specialist and general practioner visits (€ 326). Mean drug costs per patient over the follow-up period was about € 50 per month. Costs associated to the provision of paid and informal care followed different pattern and were persistent over time (ranging from € 639 to € 597 per month in the first and the second part of the year, respectively). Clinical variables (presence of diabetes mellitus and hemorrhagic stroke) were significant predictors of total healthcare costs while functional outcomes (Barthel Index and Modified Ranking Scale scores) were significantly associated with both healthcare and societal costs at one year. CONCLUSIONS: The significant role of informal care in stroke management and different distribution of costs over time suggest that appropriate planning should look at both incident and prevalent stroke cases to forecast health infrastructure needs and more importantly, to assure that stroke patients have adequate "social" support.

The impact of management on medical professionalism: a review.

In the last three decades, medical doctors have increasingly been exposed to management control measures. This phenomenon has been reflected in a number of studies in various disciplines, including sociology, organisation studies, management, and health service research. This article seeks to provide a comprehensive overview of the studies dealing with the impact of management on professional control. In particular, it seeks to bridge the diversity of assumptions, theoretical perspectives and conceptual underpinnings at play, by exploring synergies between them and opening up new horizons for research. The review shows how the relationship between clinicians and management has been analysed at an organisational level using two interconnected analytical frameworks focusing on the sociocultural and task-related dimensions of professionalism. In the final discussion, we argue that comparative, longitudinal and cross-sectional research is necessary, and there is a need to overcome the hegemony/resistance framework in current analyses of the impact of management on professionalism. Such an approach would contribute to the revision of macro theories of professionalism and stimulate emerging research by examining different perspectives towards management in medical specialisations. This approach might also stimulate a discussion of medical professionals' relationships with members of other professional groups, including nurses and healthcare managers.