Relation between pre-existing quality management measures and prevention and containment of COVID-19 outbreaks in 159 nursing homes in Tuscany: a mixed methods study.

BACKGROUND: Nursing homes were often the focus of COVID-19 outbreaks. Many factors are known to influence the ability of a nursing home to prevent and contain a COVID-19 outbreak. The role of an organisation's quality management prior to the pandemic is not yet clear. In the Italian region of Tuscany nursing home performance indicators have been regularly collected since before the pandemic, providing the opportunity to better understand this relationship. OBJECTIVES: To test if there is a difference in the results achieved by nursing homes in Tuscany on 13 quality management indicators, when grouped by severity of COVID-19 outbreaks; and to better understand how these indicators may be related to the ability to control COVID-19 outbreaks, from the perspective of nursing homes. METHODS: We used a mixed methods sequential explanatory design. Based on regional and national databases, 159 nursing homes in Tuscany were divided into four groups by outbreak severity. We tested the significance of the differences between the groups with respect to 13 quality management indicators. The potential relation of these indicators to COVID-19 outbreaks was discussed with 29 managers and other nursing homes' staff through four group interviews. RESULTS: The quantitative analysis showed significant differences between the groups of nursing homes for 3 of the 13 indicators. From the perspective of nursing homes, the indicators might not be good at capturing important aspects of the ability to control COVID-19 outbreaks. For example, while staffing availability is seen as essential, the staff-to-bed ratio does not capture the turn-over of staff and temporary absences due to positive COVID-19 testing of staff. CONCLUSIONS: Though currently collected indicators are key for overall performance monitoring and improvement, further refinement of the set of quality management indicators is needed to clarify the relationship with nursing homes' ability to control COVID-19 outbreaks.

Astrocyte structural heterogeneity in the mouse hippocampus.

Astrocytes are integral components of brain circuits, where they sense, process, and respond to surrounding activity, maintaining homeostasis and regulating synaptic transmission, the sum of which results in behavior modulation. These interactions are possible due to their complex morphology, composed of a tree-like structure of processes to cover defined territories ramifying in a mesh-like system of fine leaflets unresolved by conventional optic microscopy. While recent reports devoted more attention to leaflets and their dynamic interactions with synapses, our knowledge about the tree-like "backbone" structure in physiological conditions is incomplete. Recent transcriptomic studies described astrocyte molecular diversity, suggesting structural heterogeneity in regions such as the hippocampus, which is crucial for cognitive and emotional behaviors. In this study, we carried out the structural analysis of astrocytes across the hippocampal subfields of Cornu Ammonis area 1 (CA1) and dentate gyrus in the dorsoventral axis. We found that astrocytes display heterogeneity across the hippocampal subfields, which is conserved along the dorsoventral axis. We further found that astrocytes appear to contribute in an exocytosis-dependent manner to a signaling loop that maintains the backbone structure. These findings reveal astrocyte heterogeneity in the hippocampus, which appears to follow layer-specific cues and depend on the neuro-glial environment.

Managing community engagement initiatives in health and social care: lessons learned from Italy and the United Kingdom.

BACKGROUND: Determining the different features and potential impacts of community initiatives aimed at health-related outcomes poses challenges for both researchers and policy makers. PURPOSE: This article explores the nature of heterogeneous "community engagement initiatives" (CEIs) considering both their social and organizational features in order to understand the managerial and policy implications to maximize their potential local health and social care-related impacts. METHODOLOGY: A threefold qualitative analysis was conducted: (a) Three frameworks were developed to classify and analyze different CEIs features, building upon the current literature debate; (b) primary data were collected from Italian CEIs; and (c) a comparative cross-case analysis of a total of 79 CEIs in Italy and the United Kingdom was implemented. FINDINGS: The results show two types of strategic policy and management implications: (a) CEI portfolios are very broad and differentiated; (b) different social networks have diversified social constructs, internal cultures, and organizational features; and (c) there is a consequent need to contextualize relational and steering approaches in order to maximize their potential community added value. CONCLUSION: CEIs are fundamental pillars of contemporary welfare systems because of both the changing demography and epidemiology and the disruptive impact of platform economy models. This challenging scenario and the related CEIs involve a complex social mechanism, which requires a new awareness and strengthened competences for public administrations' steering. PRACTICE IMPLICATIONS: It is crucial for policy makers and managers to become familiar with all the different CEIs available in order to choose which solution to implement, depending on their potential impacts related to local public health and social care priorities. They also need to select the related effective steering logic.

3D Reality-Based Survey and Retopology for Structural Analysis of Cultural Heritage.

Cultural heritage's structural changes and damages can influence the mechanical behaviour of artefacts and buildings. The use of finite element methods (FEM) for mechanical analysis is largely used in modelling stress behaviour. The workflow involves the use of CAD 3D models and the use of non-uniform rational B-spline (NURBS) surfaces. For cultural heritage objects, altered by the time elapsed since their creation, the representation created with the CAD model may introduce an extreme level of approximation, leading to wrong simulation results. The focus of this work is to present an alternative method intending to generate the most accurate 3D representation of a real artefact from highly accurate 3D reality-based models, simplifying the original models to make them suitable for finite element analysis (FEA) software. The approach proposed, and tested on three different case studies, was based on the intelligent use of retopology procedures to create a simplified model to be converted to a mathematical one made by NURBS surfaces, which is also suitable for being processed by volumetric meshes typically embedded in standard FEM packages. This allowed us to obtain FEA results that were closer to the actual mechanical behaviour of the analysed heritage asset.

Using co-creation to develop a cardiology online open course: an effective approach for implementing digital learning.

AIMS: we developed a massive online open course (MOOC) through co-creation between medical students and academic staff on heart semeiotics and evaluated its teaching efficiency and user satisfaction. METHODS: "The Heart, Its Signs and Symptoms" was a MOOC aimed to teach medical students to collect clinical history and perform physical examination of patients presenting with chest pain, dyspnea, palpitations, or syncope. It consisted of 4 interactive cases with preliminary, interim and final evaluation tests. A group of medical students, with the supervision of a multidisciplinary team of University professors residents, health management and informatics researchers developed the MOOC. RESULTS: Users (n = 701) registered to the online platform over 1 month. Students from 34 of the 40 Italian medical faculties participated. 96% of those who started the online course completed at least one of the 4 modules. Among users completing both the preliminary test and the final exam (n = 239, 34% of those registered to the online platform), the percentage of subjects passing the evaluation test raised s from 74% to 95% after the course. Younger age, attendance of Universities in Southern Italy, and a lower number of correct answers during the pre-test predicted a greater increase in the number of correct answers; Almost all participants who provided a feedback (n = 238) felt satisfied by the course. CONCLUSIONS: Partnership of medical students and academic staff was a key asset for the success of the initiative. The high rate of involvement and positive feedback from learners suggest a still unmet need for online learning resources.

What Counts in Nursing Homes' Quality and Efficiency? Results From Data Envelopment Analysis in Italy.

PURPOSE: Economic resource constrains in public spending budget in a country, such as Italy, with an ageing population with high incidence of chronic diseases calls for better strategies to improve measuring quality and efficiency in nursing homes (NHs). This paper analyses the efficiency of 40 NHs based in Tuscany considering not only structural characteristics but also quality of care, including residents, relatives and staff satisfaction. METHODOLOGY: We run a classic data envelopment analysis (DEA) on data gathered by the NHs' regional performance evaluation system. We include as inputs the number of total work hours as labour and the daily cost for services as economic resources. As outputs we include measures for quality of care (number of falls, urinary infections and antidepressants), satisfaction (residents, relatives and professionals) and quality of life (days of recreational activities). We run a multivariate regression to analyse the determinants of previously obtained efficiency scores considering factors such as: institutional (ownership), managerial (training) and clinical (patient's severity). FINDINGS: Results find 35% efficient NHs. Moreover, management and the managerial factor (staff trained in end-of-life support) are predictors of the efficiency score.Originality: Our study uses satisfaction (residents, relatives and professionals) measures as proxy for quality output in the DEA model and measures related to staff management (eg training) as predictors of the efficiency scores.

Trade union or trait d'union? Setting targets for general practitioners: A regional case study.

AIMS: The Italian general practitioners (GPs) are not directly employed by the National Health Service but work as independent contractors. Their activity and their salary are managed at the national, regional, and local level. This paper analyses the Tuscany Region case study to investigate if primary care's target-setting styles are associated with different GP perceptions, by comparing nine different local agreements to a survey on 102 GPs. We propose a classification of the different target-setting (ideal typical) styles, ranging from "financial governance" (FG), mainly based on financial targets, to "clinical governance" (CG), that mainly relies on clinical and quality targets. FINDINGS: Results show that GPs are more likely to have a more favourable attitude toward primary care managerial tools if they have certain characteristics, ie, quality measures. This suggest that target setting system might promote both the GPs' compliance to the targets set by the agreement and the involvement of the GPs in the LHA's governance processes too. CONCLUSIONS: The managerial tools could pave the way to overcome the classical "trade unionist" relationship between the regional and local authority and the GPs, working as a "trait d'union" between the two players.

General practitioners: Between integration and co-location. The case of primary care centers in Tuscany, Italy.

Healthcare systems have followed several strategies aimed at integrating primary care services and professionals. Medical homes in the USA and Canada, and primary care centres across Europe have collocated general practitioners and other health and social professionals in the same building in order to boost coordination among services and the continuity of care for patients. However, in the literature, the impact of co-location on primary care has led to controversial results. This article analyses the possible benefits of the co-location of services in primary care focusing on the Italian model of primary care centres (Case della Salute) in terms of general practitioners' perception. We used the results of a web survey of general practitioners in Tuscany to compare the experiences and satisfaction of those general practitioners involved and not involved in a primary care centre, performed a MONAVA and ANOVA analysis. Our case study highlights the positive impact of co-location on the integration of professionals, especially with nurses and social workers, and on organizational integration, in terms of frequency of meeting to discuss about quality of care. Conversely, no significant differences were found in terms of either clinical or system integration. Furthermore, the collaboration with specialists is still weak. Considering the general practitioners' perspective in terms of experience and satisfaction towards primary care, co-location strategies is a necessary step in order to facilitate the collaboration among professionals and to prevent unintended consequences in terms of an even possible isolation of primary care as an involuntary 'disintegration of the integration'.

Reported experience of patients with single or multiple chronic diseases: empirical evidence from Italy.

BACKGROUND: More and more countries have been implementing chronic care programs, such as the Chronic Care Model (CCM) to manage non-acute conditions of diseases in a more effective and less expensive way. Often, these programs aim to provide care for single conditions instead of the sum of diseases. This paper analyzes the satisfaction and better management of single and multiple chronic patients with the core elements of chronic care programs in Siena, Italy. In addition, the paper also considers whether the CCM introduced in Siena has any influence on satisfaction and better self-management. METHODS: Survey data from patients with single chronic (N = 500) and multiple chronic diseases (N = 454), assisted by the Local Health Authority in Siena (Tuscany, Italy), were considered for the analysis. Variables on education, monitoring system, proactivity, relational continuity, model of care (CCM versus no CCM) and patient demographics were used to detect which strategies are associated with a higher patient-reported ability to better self-manage the disease and overall patient satisfaction. Logistic and ordinary logistic models were executed on data related to patients with both single and multiple chronic diseases. RESULTS: The results showed that monitoring was the sole strategy associated with overall satisfaction and better self-management for both single and multiple chronic patients. Relational continuity also showed a significant positive association with better self-management perception for both patient groups, but had a positive association with patient satisfaction only for single chronic patients. Enrolment in the CCM was not associated with both overall satisfaction and better management for the two patient groups. CONCLUSIONS: Strategies that are significantly associated with satisfaction and perception of better disease self-management were the same for both single and multiple chronic patients. The delivery of care based on the Siena CCM does not seem to make a difference in the perception of better self-management and overall satisfaction for all the patients. Other concurrent strategies implemented by the regional government in Tuscany on primary care monitoring and health promotion could partially explain why CCM does not have a significant influence.

Hospitalization among migrants in Italy: Access to health care as an opportunity for integration and inclusion.

This paper analyzes migrant access to health care by comparing hospitalizations of native and immigrant population with respect the Tuscany Region (Italy). In the analyses, a critical gap both for legal and undocumented migrant population is highlighted. Indeed, we found some key differences between the migrant and native populations related to the use of specific hospital services in Tuscany and, indirectly, of community and primary care services. Moreover, especially for undocumented migrants, hospitals seem to be the only point of access to the health-care system for migrant populations. The results suggest that the Italian health-care system is unable to ensure an equitable access to health services. In this context, maternity care could be a key point of access to the welfare system that allows participation in the health system not only for mothers but also for all migrant family members.

Strategies and governance to reduce health inequalities: evidences from a cross-European survey.

BACKGROUND: The main objective of the paper is to identify the governance system related to policies to reduce health inequalities in the European regions. Considering the Action Spectrum of inequalities and the check list of health equity governance, we developed a survey in the framework of the AIR Project - Addressing Inequalities Intervention in Regions - was an European project funded by the Executive Agency of Health and Consumers. METHODS: A web-based qualitative questionnaire was developed that collected information about practiced strategies to reduce health inequalities. In total 28 questionnaires from 28 different regions, related to 13countries, were suitable for the analysis. RESULTS: Progress in health equity strategies at the national and regional levels has been made by countries such as France, Portugal, Poland, and Germany. On the other hand, Spain, Italy, and Belgium have a variable situation depending on the region. However, the results of the survey indicate that the governance system for health equity different in terms of commitment, resources and tools. CONCLUSIONS: The survey highlights a weakness of governance system for the majority of countries in terms of evaluation actions and of impact of interventions in reducing inequalities, and the difficulties in having a clear and integrated vision between the national and regional levels.

Consistency of priorities for quality improvement for nursing homes in Italy and Canada: A comparison of optimization models of resident satisfaction.

The paper seeks to identify aspects of care that may be easily modified to yield a desired level of improvement in residents' overall satisfaction with nursing homes, comparing data across Canada and Italy. Using a structured questionnaire, 681 and 1116 nursing home residents were surveyed in Ontario in 2009 and in Tuscany in 2012, respectively. Fourteen items were common to the surveys, including willingness to recommend (WTR), which was used as the dependent variable and measure of global satisfaction. The other analogous items were entered as covariates in ordinal logistic regression models predicting residents' WTR in each jurisdiction separately. Regression coefficients were then incorporated into a constrained nonlinear optimization problem selecting the most efficient combination of predictors necessary to increase WTR by as much as 15%. Staff-related aspects of care were selected first in the optimization models of each jurisdiction. In Ontario, to improve WTR the primary focus should be on staff relationships with residents, while in Tuscany it was the technical skill and knowledge of staff that was selected first by the optimization model. Different optimization solutions might mean that the strategies required to improve global satisfaction in one jurisdiction could be different than those for the other jurisdictions. The optimization model employed provides a novel solution for prioritizing areas of focus for quality improvement for nursing homes.

Is the co-location of GPs in primary care centres associated with a higher patient satisfaction? Evidence from a population survey in Italy.

BACKGROUND: Several countries have co-located General Practitioners (GPs) in Primary Care Centres (PCCs) with other health and social care professionals in order to improve integrated care. It is not clear whether the co-location of a multidisciplinary team actually facilitates a positive patient experience concerning GP care. The aim of this study was to verify whether the co-location of GPs in PCCs is associated positively with patient satisfaction with their GP when patients have experience of a multidisciplinary team. We also investigated whether patients who frequently use health services, due to their complex needs, benefitted the most from the co-location of a multidisciplinary team. METHODS: The study used data from a population survey carried out in Tuscany (central Italy) at the beginning of 2015 to evaluate the patients' experience and satisfaction with their GPs. Multilevel linear regression models were implemented to verify the relationship between patient satisfaction and co-location. This key explanatory variable was measured by considering both the list of GPs working in PCCs and the answers of surveyed patients who had experienced the co-location of their GP in a multidisciplinary team. We also explored the effect modification on patient satisfaction due to the use of hospitalisation, access to emergency departments and visits with specialists, by performing the multilevel modelling on two strata of patient data: frequent and non-frequent health service users. RESULTS: A sample of 2025 GP patients were included in the study, 757 of which were patients of GPs working in a PCC. Patient satisfaction with their GP was generally positive. Results showed that having a GP working within a PCC and the experience of the co-located multidisciplinary team were associated with a higher satisfaction (p < 0.01). For non-frequent users of health services on the other hand, the co-location of multidisciplinary team in PCCs was not significantly associated with patient satisfaction, whereas for frequent users, the strength of relationships identified in the overall model increased (p < 0.01). CONCLUSION: The co-location of GPs with other professionals and their joint working as experienced in PCCs seems to represent a greater benefit for patients, especially for those with complex needs who use primary care, hospitals, emergency care and specialized care frequently.

Interventions addressing health inequalities in European regions: the AIR project.

Disparities in health between social groups have been documented all over Europe. We summarize the methods and results of the Addressing Inequalities in Regions (AIR) project, which identified illustrative interventions and policies developed in European regions to reduce inequalities at the primary health care level. The first phase was a systematic review of the published literature. The second phase was a survey of European regions, collecting information on policies aiming at reducing health inequalities through primary health care and identifying regional, innovative and evaluated interventions. The third phase assessed interventions through methods defined by a formal consensus, and selected illustrative practices considered good practices for several of nine evaluation criteria. The review included 98 evaluations of interventions and 10 reviews; 80% of interventions were from North-America. Three main pathways to reduce health inequalities were identified: providing health promotion, improving financial access to care and modifying care provision. The first survey identified 90 interventions. Most national strategies included health inequalities issues. Education was the most frequently identified targeted determinant. Most interventions were health promotion general or targeted at specific health determinants, conditions or groups. The second survey assessed 46 interventions. Many involved the population in planning, implementation and evaluation. We also identified the multidisciplinary of interventions, and some who had an impact on empowerment of the targeted population. The AIR project documented that policies and actions can be implemented at the regional level through primary care providers. Policies and interventions are seldom evaluated.

Patient satisfaction, e-health and the evolution of the patient-general practitioner relationship: Evidence from an Italian survey.

BACKGROUND: Scientific and public interest in the use of the Internet for health-related purposes has grown considerably. Concerns regarding its impact on patient-doctor relationship and risks for patients have inflamed the debate. Literature provides scarce evidence in this field. This paper investigates whether a patient's decision to use the web also depends on previous experience and satisfaction with healthcare. METHOD: Statistical analyses were conducted using data from a survey of more than 1700 citizens in Tuscany (Italy). The Andersen behavioural model was adopted as framework for investigating two patient behaviours: Internet use for health-related purposes; discussion of online findings with the physician. Two separate multivariate logistic models were performed to verify whether satisfaction and experience with healthcare system and general practitioners were associated with the e-health behaviours. RESULTS: Age, education and dissatisfaction with the healthcare system are the main determinant factors of e-health use. The behaviour of sharing the e-health experience with general practitioners is more diffused among those patients who are more satisfied with physicians for the involvement in the decision-making process and suggestions on life-style. IMPLICATIONS: Whether patients choice to share information found online with the doctor depends on the ability of the doctor to engage patients in decision-making, e-health can produce a 'double-empowerment' process: experienced by the patient on the Internet, and legitimated by the doctor during encounters.

Criteria for implementing interventions to reduce health inequalities in primary care settings in European regions.

BACKGROUND: The current social and political context is generating socio-economic inequalities between and within countries, causing and widening health inequalities. The development and implementation of interventions in primary health care (PHC) settings seem unavoidable. Attempts have been made to draw up adequate criteria to guide and evaluate interventions but none for the specific case of PHC. This methodological article aims to contribute to this field by developing and testing a set of criteria for guiding and evaluating real-life interventions to reduce health inequalities in PHC settings in European regions. METHODS: A literature review, nominal group technique, survey and evaluation template were used to design and test a set of criteria. The questionnaire was answered by professionals in charge of 46 interventions carried out in 12 European countries, and collected detailed information about each intervention. Third-party experts scored the interventions using the set of evaluation criteria proposed. RESULTS: Nine criteria to guide and evaluate interventions were proposed: relevance, appropriateness, applicability, innovation, quality assurance, adequacy of resources, effectiveness in the process, effectiveness in results and mainstreaming. A working definition was drawn up for each one. These criteria were then used to evaluate the interventions identified. CONCLUSIONS: The set of criteria drawn up to guide the design, implementation and evaluation of interventions to reduce health inequalities in PHC will be a useful instrument to be applied to interventions under development for culturally, politically and socio-economically diverse PHC contexts throughout Europe.

The equity lens in the health care performance evaluation system.

The main objective of this paper is to describe how indicators of the equity of access to health care according to socioeconomic conditions may be included in a performance evaluation system (PES) in the regional context level and in the planning and strategic control system of healthcare organisations. In particular, the paper investigates how the PES adopted, in the experience of the Tuscany region in Italy, indicators of vertical equity over time. Studies that testify inequality of access to health services often remain just a research output and are not used as targets and measurements in planning and control systems. After a brief introduction to the concept of horizontal and vertical equity in health care systems and equity measures in PES, the paper describes the 'equity process' by which selected health indicators declined by socioeconomic conditions were shared and used in the evaluation of health care institutions and in the CEOs' rewarding system, and subsequently analyses the initial results. Results on the maternal and child path and the chronicity care path not only show improvements in addressing health care inequalities, but also verify whether the health system responds appropriately to different population groups.

Building China's municipal healthcare performance evaluation system: a Tuscan perspective.

Regional healthcare performance evaluation systems can help optimize healthcare resources on regional basis and improve the performance of healthcare services provided. The Tuscany region in Italy is a good example of an institution which meets these requirements. China has yet to build such a system based on international experience. In this paper, based on comparative studies between Tuscany and China, we propose that the managing institutions in China's experimental cities can select and commission a third-party agency to, respectively, evaluate the performance of their affiliated hospitals and community health service centers. Following some features of the Tuscan experience, the Chinese municipal healthcare performance evaluation system can be built by focusing on the selection of an appropriate performance evaluation agency, the design of an adequate performance evaluation mechanism and the formulation of a complete set of laws, rules and regulations. When a performance evaluation system at city level is formed, the provincial government can extend the successful experience to other cities.