Scelte gestionali per sostenere e migliorare i programmi di screening oncologico.

Improving screening programmes in terms of increasing screening participation and providing appropriate follow-up is a major challenge requiring great planning. This contribution discusses the effect of a major intra-organizational intervention on three population-based oncological screening programs (i.e., breast, cervical, and colorectal cancers) active in a large Italian Screening Centre. A review of the literature data on the key elements for high-quality healthcare was conducted. The PRECEDE-PROCEED model was retrospectively used as a theoretical frame for the improvement strategies adopted in the Centre. Classification of interventions to increase participation was performed according by target: individual, population, health workers, tests, and health service management. To assess the impact of the reorganization on the three screening programmes, the 'participation rate in the first-level screening tests' indicator was considered; the years 2018, 2019, and 2022 were analyzed.The main factors driven by the change were optimization of resources (human and financial), a stronger leadership, a higher collaboration level, stakeholders' engagement, positive work culture, and continuous staff learning. Reminders to non-responders (mobile phone text-message and letter), delivery of publicity by media, offering the self-sampling method for HPV testing, and increasing accessibility were implemented.A significant increase in screening participation was observed for all screening programmes when comparing the participation rates in 2022 to those in 2018 and 2019. In particular, focusing on 2019 (the last standard activity year before the COVID-19 emergency), an increase in participation rate of 3% for breast, 8.5% for cervical, and 4.6% for colorectal cancer screening was observed. This increase can plausibly be an effect of the improvement strategies implemented in the Centre.Performance measurements and internal and external feedback are regularly conducted to ensure ongoing improvement.

Prolonged outbreak of New Delhi metallo-beta-lactamase-producing carbapenem-resistant Enterobacterales (NDM-CRE), Tuscany, Italy, 2018 to 2019.

In Tuscany, Italy, New Delhi metallo-beta-lactamase-producing carbapenem-resistant Enterobacterales (NDM-CRE) have increased since November 2018. Between November 2018 and October 2019, 1,645 samples were NDM-CRE-positive: 1,270 (77.2%) cases of intestinal carriage, 129 (7.8%) bloodstream infections and 246 (14.9%) infections/colonisations at other sites. Klebsiella pneumoniae were prevalent (1,495; 90.9%), with ST147/NDM-1 the dominant clone. Delayed outbreak identification and response resulted in sustained NDM-CRE transmission in the North-West area of Tuscany, but successfully contained spread within the region.

Opposite trends in hospitalization and mortality after implementation of a chronic care model-based regional program for the management of patients with heart failure in primary care.

BACKGROUND: The chronic care model (CCM) is an established framework for the management of patients with chronic illness at the individual and population level. Its application has been previously shown to improve clinical outcome in several conditions, but the prognostic impact of CCM-based programs for the management of patients with chronic heart failure (HF) in primary care is still to be elucidated. METHODS: We assessed the prognostic impact of a primary-care, CCM-based project applied in Tuscany, Italy, in 1761 patients with chronic HF enrolled in a retrospective matched cohort study. The project was based on predefined working teams including general practitioners and nurses, proactively scheduled regular follow-up visitations for each patient, counseling for therapy adherence and lifestyle modifications, appropriate diagnostic and therapeutic pathways according to international guidelines, and a key supporting role of the nurses, who were responsible for the practical coordination of the follow-up. A matched group of 3522 HF subjects assisted by general practitioners not involved in the project was considered as control group. The endpoints of this study were HF hospitalization and all-cause mortality. RESULTS: Over a 4-year follow-up period, HF hospitalization rate was higher in the CCM group than the controls (12.1 vs 10.3 events/100 patient-years; incidence rate ratio 1.15[1.05-1.27], p = 0.0030). Mortality was lower in the CCM group than the controls (10.8 vs 12.6 events/100 patient-years; incidence rate ratio 0.82[0.75-0.91], p < 0.0001). In multivariable analysis, the CCM status was associated with a 34% higher risk of HF hospitalization and 18% lower risk of death (p < 0.0001 for both). The effect on HF hospitalization was mostly driven by a 50% higher rate of planned HF hospitalization. CONCLUSIONS: Implementation of a CCM-based program for the management of HF patients in primary care led to reduced mortality and increased HF hospitalization. These findings support the hypothesis that the beneficial effects of CCM on survival might be extended to patients with chronic HF followed in primary care, but also support the need for further strategies aimed at improving the management of these patients in terms of hospitalizations.

The Positive Effect of an Online Appointment Portal on a Breast Cancer Screening Program.

BACKGROUND: The adoption of web-based appointment methods by health care systems is increasing. OBJECTIVES: This study primarily aimed to evaluate in the setting of an organized breast cancer screening program the actual usage of an online appointment portal by the target population, i.e., how the online tool was used (type and timing of the actions performed) and by whom (users' characteristics); the effect of coronavirus disease 2019 (COVID-19) on its usage was also investigated. The effect of adopting this tool on the attendance to breast cancer screening was contextually investigated. METHODS: Electronic data records of 75,903 women (45-74 years old, residing in the territory of Bologna Local Health Authority) were retrospectively reviewed. RESULTS: In total, 12.4% of women logged into the online portal at least once. Most of them (79.9%) rescheduled, 15.7% viewed, and 4.4% cancelled their own appointment. In addition, 40.6% of all rescheduling actions were performed by the online portal; the remaining was performed by the toll-free number/dedicated email address. The highest peak (13.8%) of web accesses was registered at 10 a.m. Monday to Friday, when the toll-free number service is available. Percentages of portal usage were higher: (1) among the younger women, of Italian nationality, and for the first time invited to mammographic screening (p < 0.0001), and (2) in the pandemic period versus the prepandemic period (12.5 vs. 8.6%, respectively; p < 0.001). Finally, when compared to not using, the online portal usage led to an overall reduction in the no-show rate of almost 20% (p < 0.0001). CONCLUSION: The action mainly performed by using the online appointment portal was the appointment rescheduling. The usage of this tool had a positive effect on the no-show rate and it can be speculated that has led to a reduction of the request load to be handled by the center's screening staff. Finally, this study confirmed that the COVID-19 pandemic boosted the use of digital technologies.

Applying the healthcare failure mode and effects analysis approach to improve the quality of an organised colorectal cancer screening programme.

OBJECTIVE: The first level of a colorectal cancer (CRC) screening process was systematically analysed using the Healthcare Failure Mode and Effects Analysis (HFMEA) approach by a multidisciplinary team aiming to improve the programme quality. SETTING: The study was conducted at the Local Health Authority of Bologna, Northern Italy. METHODS: Seven brainstorming sessions were conducted and all the activities performed were recorded on a FMEA worksheet consisting of individual records reporting the specific phases of the analysed process along with associated activities, possible failure modes, their causes and effects, the obtained risk priority numbers (RPNs) and the control measures to plan. RESULTS: Twenty-three failure modes, 14 effects and 12 possible causes were identified. Nine failure modes were prioritised according to the RPN obtained; most resulted in possible false-negative faecal immunochemical test (FIT) results (66.7%), followed by sample loss (22.2%) and not reaching the entire target population (11.1%). This leads to 66.7% of corrective/preventive actions being applied to the phase of returning the stool sample by the citizen. For this phase reorganisation, the local pharmacies were involved not only as FIT kit delivery points but also as specimen collection and sending points to the laboratory. These organisational changes allowed the introduction of complete traceability of kits and specimens flow, as well as temperature control. A re-evaluation of the prioritised failure modes 6 months after launching the implemented screening process showed that HFMEA application decreased the risk of potential errors by 75.9%. CONCLUSION: HFMEA application in CRC screening programme is a useful tool to reduce potential errors.

Association between satisfaction and stress with aspects of job and practice management among primary care physicians.

BACKGROUND: Reforms introduced in the last decade in Italian general practice, have contributed to the changing role of primary care physicians (PCPs) within the Italian National Health Service, with potential difficulties adapting that may lead to job stress and dissatisfaction. The present study aims to compare job satisfaction and stress levels of PCPs working in primary healthcare teams (PHCTs) with those for practitioners operating in single ambulatory offices, and to assess potential associations with aspects of job and practice management. METHOD: A postal survey was conducted between January and March 2005 among PCPs working in Tuscany. Data were collected by using a structured questionnaire containing questions concerning personal, professional, job and practice characteristics. The Warr-Cook-Wall scale and the Cooper test were used to assess job satisfaction and stress, respectively. RESULTS: From 3043 PCPs, a response rate of 45.2% was achieved. Significant differences were found between PHCT physicians and solo practitioners in several aspects of their job. Physicians working in PHCTs appeared more satisfied in some aspects of their practice such as organisation, whereas they were less satisfied about workload and interaction with other healthcare providers. Multivariate modelling showed relevant aspects of dissatisfaction and stress, particularly the difficulties of collaboration with other healthcare providers, and access to specialised services. CONCLUSION: Reform strategies aimed at improving the quality of care among PCPs needs to take into account the contextual determinants of physician satisfaction and stress, and should highlight programmes that might be pursued to improve the integration of PCPs within the Italian National Health System.

Chronic Care Model for the Management of Patients with Heart Failure in Primary Care.

We recently investigated the prognostic impact of a Chronic Care Model (CCM)-based healthcare program applied in primary care in Tuscany Region mainly run by multidisciplinary teams composed of general practitioners (GPs) and nurses. The project included proactively planned follow-up visits for each patient, individualized counselling to optimize lifestyle modifications and adherence to appropriate diagnostic and therapeutic pathways. 1761 patients with Chronic heart failure (CHF) directly enrolled by the GPs were matched with 3522 CHF controls not involved in the project. Over a 4-year follow-up in the CCM group a higher CHF hospitalization rate was found (12.1 vs 10.3 events/100 patient-years; incidence rate ratio [IRR] 1.15, p=0.0030), whereas mortality was lower (10.8 vs 12.6 events/100 patient-years; IRR 0.82, p<0.0001). The CCM status was independently associated with a 34% increase in the risk of CHF hospitalization and a 18% reduction in the risk of death (p<0.0001 for both). The CCM status was associated with a 50% increase in the rate of planned Heart failure (HF) hospitalizations whereas the rate of 1-month CHF readmissions showed no differences. Such a divergent trend could be explained by the direct involvement of GPs in the CCM program, leading them to a better awareness of patients' clinical status, and then to a more frequent use of clinical pathways and facilities, including hospitalization. It is reasonable to argue that not all hospitalizations must necessarily be considered as a poor outcome, as they often provide additional opportunities to improve therapies, optimize patient education, or define follow-up strategies. The evidence of a divergent trend between mortality and hospitalization in our population might support the clinical importance of a multidisciplinary approach for the management of patients with HF.

The impact of different rehabilitation strategies after major events in the elderly: the case of stroke and hip fracture in the Tuscany region.

BACKGROUND: On a regional level, our aims were to describe rehabilitation patterns for elderly patients with stroke and hip fracture and to investigate mortality risk during the 6-month post acute period. METHODS: Data sources included administrative data relative to patients aged 65+ resident in Tuscany admitted in hospital for stroke or hip fracture between 2001 and 2003, traced up to 3 years before and 6 months following index admission. The study design involves computerized linkage of administrative data, and an exploratory analysis of the association between rehabilitation patterns and 6-month mortality, adjusting for clinical, demographic, and acute-related care characteristics using multivariate Cox regression. RESULTS: Rehabilitation patterns vary greatly across Tuscany with considerable cost implications. Six month mortality risk for stroke patients is significantly lower among residents of Local Health Authorities where patients are more frequently rehabilitated, specifically in extra-hospital settings. CONCLUSION: Our study, targeting two crucial conditions for elderly patients, found a high variability of rehabilitation patterns across a region, albeit coherent between the two pathologies, associated with remarkable differences in average expenditure. Differences in hazard rates for 6-month mortality after stroke at population level were also found. These results need to be confirmed and further investigated through a more robust information framework.

[Femur fractures among elderly in Lazio and Tuscany regions from 1999 to 2003]. / Le fratture di femore tra gli anziani del Lazio e della Toscana: analisi del fenomeno nel periodo 1999-2003.

OBJECTIVES: to compare the assistance delivered to elderly persons (age 65 +) hospitalized in 1999-2003 after femur fracture between two Italian regions (Lazio and Tuscany). Indicators derived from current databases have been used. MAIN OUTCOMES: 1) age-standardized proportion of patients treated surgically; 2) age-standardized proportion of patients with surgery within 2 days from admission among all the patients with surgery; 3) age-standardized proportion of deaths within 30 days from admission. METHODS: incident cases and patients undergoing surgery were retrieved from abstract discharge records, while deaths were traced through record linkage with mortality registers. RESULTS: in the period covered by the study, 32019 incident cases occurred in Lazio region and 30406 in Tuscany. The analysis shows better results for Tuscany for each indicator. In 2003, the age-standardized proportions of patients treated surgically were 83.0% in Lazio and 86.2% in Tuscany. The age-standardized proportion of patients undergoing surgery within 2 days from admission were respectively 14.7%, and 29.8%. The age-standardized proportions of deaths occurring within 30 days from admission were 5.0% and 2.8%. Lazio shows higher proportions of deaths both for patients with and without surgery. CONCLUSIONS: the use of the same procedure based on purely administrative data (available at national level) provides confidence on the reliability of the comparison between the two regions. Similar low-budget studies may easily be extended to other geographical areas.

Screening for gestational diabetes in Tuscany, Italy. A population study.

AIMS: According to current Italian guidelines, only women at higher risk of gestational diabetes (GDM) are eligible for receiving a glucose tolerance test (OGTT) during pregnancy. This study evaluates the compliance to national guidelines, additionally proposing an algorithm able to identify women with GDM. METHODS: The study included 23,270 pregnant women aged >15yr, resident in Tuscany, a region in central Italy, delivering in year 2015, identified by certificates of care at delivery. Eligibility to screening was evaluated by fulfillment to regional guidelines recommending a 2-h-75g-OGTT only in presence of risk factors. Additionally, a validated algorithm is proposed to diagnose GDM from regional administrative databases. RESULTS: Glucose tolerance was tested in 79.2% of women. Eligibility criteria were fulfilled in 55.6% of OGTT performers and in 40.2% of those who didn't perform any OGTT. Performers' rate increased with age, body weight, higher education degree and in those followed by a well defined clinical setting. Housewives and students had a lower chance of receiving an OGTT. Algorithm identified GDM in 11% of women, ranging from 14% among eligible and 7% among non-eligible ones. CONCLUSION: Selective screening for GDM is not being currently applied in Tuscany. Despite the percentage of eligible women by national guidelines was 55%, the rate of those who performed the screening was about 80%, with a 40% of low risk women continuing to be screened. Moreover, GDM rate, calculated by algorithm, was relatively large (7%) among non-eligible women, suggesting the need of universal glucose screening to adequately capture all GDM cases.

[Prevalence of dementia in Tuscany: results from four population-based epidemiological studies]. / La prevalenza della demenza in Toscana: i risultati di quattro studi epidemiologici di popolazione.

OBJECTIVE: to provide information on epidemiology of dementia in Tuscany needed to plan for dedicated health and social services. DESIGN: analysis of pooled baseline data from 4 population-based longitudinal studies. SETTING: 4 municipalities in Tuscany. PARTICIPANTS: 4,056 elderly subjects enrolled in 4 longitudinal studies. MAIN OUTCOME MEASURES: age- and sex-specific dementia prevalence rates and estimated number of demented people, by degree of cognitive impairment and BADL disability in the elderly population of Tuscany. RESULTS: out of the evaluated subjects, 293 are demented. Prevalence of dementia increases from about 1 % in the 65-69 age group to about 28 % in the 90+ age group both among women and men. About 43% of the demented study subjects suffer from severe mental deterioration (MMSE < 14) and56% are disabled in at least one Basic Activity of Daily Living (BADL). We estimate that about 19 thousand demented elderly men and 40 thousand demented elderly women are currently living in Tuscany of whom 26 thousand severely mentally impaired and 34 thousand disabled in at least one BADL. The resulting overall dementia prevalence standardised on the Italian 65+ population is 5,3% for men and 7,7% for women. CONCLUSIONS: these estimates could be used as a basis for the evaluation and the planning of social and health care services dedicated to demented people.

The Tuscany experimental registry for Alzheimer's disease and other dementias: how many demented people does it capture?

BACKGROUND AND AIMS: A Regional Registry for Alzheimer's Disease and Other Dementias is being tested in Tuscany (Italy) to provide a basis for epidemiological studies. Current results are presented and critically evaluated. METHODS: The Registry extracts data on cases of dementia from Hospital Discharge Records, Outpatient Service Records, Regional Mortality Registry and Disease-Specific Co-payment Exemption Records, based on ICD-9 codes of dementias, and from Prescription Records based on registered anti-dementia drug codes. A list of cases of dementia prevalent at the end of 2005 was produced by cross-checking captured cases with the Regional Mortality Registry. RESULTS: The Registry captured 47,889 cases, of which 27,796 were still alive at the end of 2005. Captured cases represent slightly less than half of all the cases of dementia estimated to be present in Tuscany among older residents (65+) according to recent prevalence studies. Conversely, of 87 subjects 65 years of age or older selected from the Registry and directly evaluated, 80 (92%) were truly cognitively impaired subjects. CONCLUSIONS: The Registry has low sensitivity, probably because not all demented individuals are diagnosed as such in current practice and/or use health services. Conversely, the Registry has high specificity, and the produced lists of prevalent dementia cases are the key to estimating health and quality-of-care indicators for the demented population, and may constitute a basis for epidemiological studies.

Screening of older community-dwelling people at risk for death and hospitalization: the Assistenza Socio-Sanitaria in Italia project.

OBJECTIVES: To develop and validate mortality and hospitalization prognostic tools based upon information readily available to primary care physicians (PCPs). DESIGN: Population-based cohort study. Baseline predictors were patient demographics, a seven-item questionnaire on functional status and general health, use of five or more drugs, and previous hospitalization. SETTING: Community-based study. PARTICIPANTS: Prognostic indexes were developed in 2,470 subjects and validated in 2,926 subjects, all community-dwelling, aged 65 and older, and randomly sampled from the rosters of 98 PCPs in Florence, Italy. MEASUREMENTS: Fifteen-month mortality and hospitalization. RESULTS: Two scores were derived from logistic regression models and used to stratify participants into four groups. With Model 1, based upon the seven-item questionnaire, mortality rate ranged from 0.8% in the lowest-risk group (0-1 point) to 9.4% in the highest risk group (> or = 3 points), and hospitalization rate ranged from 12.4% to 29.3%; area under the receiver operating characteristic curves (AUC) was 0.75 and 0.60, respectively. With Model 2, considering also drug use and previous hospitalization, mortality and hospitalization rates ranged from 0.3% to 8.2% and from 8.1% to 29.7%, for the lowest-risk to the highest-risk group; the AUC increased significantly only for hospitalization (0.67). CONCLUSION: Prediction of death and hospitalization in older community-dwelling people can be easily obtained with two indexes using information promptly available to PCPs. These tools might be useful for guiding clinical care and targeting interventions to reduce the need for hospital care in older persons.