[Specialists, generalists and the importance of people.] / Gli specialisti, i generalisti e l'importanza delle persone.

The health systems of developed countries are now made by specialists and specialties and the resulting fragmentation of competences makes it increasingly difficult to consider the patient/person as a whole. An orchestra director is needed, a generalist, however generalists are a few and are generally confined to primary care. Perhaps hospital generalists should be introduced and a new training model for the generalist should be devised.

[The integration between clinical care and population health is a priority for the health system.] / L'integrazione tra clinica e sanità di popolazione è una priorità per il sistema sanitario.

Between the end of the 19th and the beginning of the 20th century the growth of scientific knowledge made it possible a wider understanding of disease mechanisms and promoted multiple government actions in several countries to improve urban hygiene, to ameliorate living conditions, and to enrich daily nutrition in order to better population health. However, during a few following decades, research progress and industrial development induced radical changes in medicine as new diagnostic tools and effective treatment capabilities became available to be administered to single patients for specific ailments. The individualized nature of these novel interventions rapidly took their control away from the public sphere into the domain of multiple bilateral relationships between patient and physician. A space was then created in which the contention between public health and clinical medicine took finally shape and the split between public health professionals - not always medical doctors - and physicians, became increasingly blatant: on one side those who cared for collective welfare on the other those who cared for individual patients. Here we still stand even if it is really difficult and poorly effective to imagine a divided health since each single patient and each health professional must constantly confront the constraints of public health policies, while public health measures are always kept at bay by individual compliance and their efficacy need to be constantly verified at an individual level. On the contrary a full integration between clinical medicine and population health is an actual priority of health planning, health policies implementation and health research as well as of practicing clinicians. Differences in issues, methods and approach cannot obviously be denied but these differences just represent the warp and weft threads of the same fabric, of a medicine which does not exist without their weaving and which grows with their development. A clinical population medicine is needed which enables professionals to operate within and outside the boundaries of their specialties to build a project of common health. A clinical population medicine in which persons and communities could found a way to socialize their health problems and to require individual as well as collective answers to their risks, their diseases and their worries. In such a way a different sense and a different meaning of its responsibility could possibly be restituted to a health system which needs to reestablish stronger ties with its constituency, a health system whose crisis depends on bureaucratization and inadequate resources as much as on its lack of sound and long-ranging perspectives.

[The tale of illness and illness as a tale.] / Il racconto della malattia e la malattia come racconto.

The practice of medicine is something different from the knowledge of disease mechanisms and cannot be performed without the relationship with the patient. Nothing new: in 1927 - when medicine already seemed to be receiving an extraordinary boost from technology - Francis Peabody emphasised the importance of considering the patient «at the centre of his home, his work, his relationships and friends, his joys and sorrows, his hopes and fears¼. In the same years, Virginia Woolf came to similar conclusions but reversed the point of observation. To talk about illness, Peabody and Woolf focus on the person: both emphasise her/his historical nature and social dimension. The former, however, talks about the person to tell about the illness, the latter talks about the illness to tell about the person. An imaginary conversation that is still useful today in order to reflect on medicine's inability to tune in to the individuality of patients, to pay attention to the affective and cultural dimensions of illness and treatment, to meet a patient dazed by the fragmentation of responses and by the over-specialism whose logic he or she does not understand, to effectively prevent errors and, above all, to admit them when they occur. The development of these capacities can be helped by the coherent and rigorous construction of an ability to narrate, an essential competence to realise in care those objectives of humanisation and richness of relationships that so often appear aleatory and unattainable.

[To understand and to act the complexity of the health system.] / Comprendere e agire la complessità del sistema sanitario.

Complexity can be rigorously defined to become a major instrument for interpreting organizations, including health care systems. Complexity analysis tools can effectively describe the adaptive capacity, the intrinsic interdependency, and the autonomous transformation drive of health systems. Therefore, a study of health care organizations as complex adaptive systems (Cas) provide useful keys to understand their functioning and to manage effectively their ongoing changes.

[Effectiveness and efficiency: has the time come?] / Efficacia ed efficienza: è arrivata l'ora?

The different attitude of health professionals and health system administrators towards efficiency and effectiveness reveals an inner health systems tension between the logic of producing and that of caring. This tension entails the risk of dire consequences for universalist health protection systems, as it pushes towards a dissociation in which care relationships are privatized, to safeguard them from the constraints of efficiency, while forms of access inequality are generated. However, efficiency in the production of health does not mean cuts but quality of care and quality in operational choices. It asks clinicians for evidence-based medicine and administrators for a balance sheet valuing health results and not just health services. A health system to effectively serve its scope, must administers effective treatments and only to those people and in those conditions who benefit from it.

GRADE EVIDENCE TO DECISION (EtD) FRAMEWORK FOR COVERAGE DECISIONS.

OBJECTIVES: Coverage decisions are decisions by third party payers about whether and how much to pay for technologies or services, and under what conditions. Given their complexity, a systematic and transparent approach is needed. The DECIDE (Developing and Evaluating Communication Strategies to Support Informed Decisions and Practice Based on Evidence) Project, a GRADE (Grading of Recommendations Assessment, Development and Evaluation) Working Group initiative funded by the European Union, has developed GRADE Evidence to Decision (EtD) framework for different types of decisions, including coverage ones. METHODS: We used an iterative approach, including brainstorming to generate ideas, consultation with stakeholders, user testing, and pilot testing of the framework. RESULTS: The general structure of the EtD includes formulation of the question, an assessment using twelve criteria, and conclusions. Criteria that are relevant for coverage decisions are similar to those for clinical recommendations from a population perspective. Important differences between the two include the decision-making processes, accountability, and the nature of the judgments that need to be made for some criteria. Although cost-effectiveness is a key consideration when making coverage decisions, it may not be the determining factor. Strength of recommendation is not directly linked to the type of coverage decisions, but when there are important uncertainties, it may be possible to cover an intervention for a subgroup, in the context of research, with price negotiation, or with restrictions. CONCLUSIONS: The EtD provides a systematic and transparent approach for making coverage decisions. It helps ensure consideration of key criteria that determine whether a technology or service should be covered and that judgments are informed by the best available evidence.

[DECIDE: developing and evaluating communication strategies to support informed decisions and practice based on evidence]. / DECIDE: uno strumento per rendere trasparenti i criteri utilizzati per le decisioni in sanità

Healthcare systems are offered with a wide range of technologies and services, but they have to cope with decreasing resources and the uncertainty about what is effective and more appropriate. Making decisions about health care interventions is complex. Decisions should be informed by the best available evidence, being comprehensive to take into account all the relevant aspects (e.g. efficacy, safety, equity, costs), and taken within a limited time period. DECIDE is a project funded by the European Community that, using the GRADE methodology, aims at implementing strategies to enhance dissemination and communication of scientific evidence to support on-time evidence-based decision making in clinical practice and healthcare policies. Communication strategies are developed in order to address different target audiences, trying to meet their information needs. One key target are policy makers and managers who are responsible for coverage decision making.

Toward a new payment system for inpatient rehabilitation. Part II: Reimbursing providers.

BACKGROUND: The major fault with existing reimbursement systems lies in their failure to discriminate for the effectiveness of stay, both when paying per day and when paying per episode of treatment. OBJECTIVES: We sought to define an average length of effective stay and recovery trends by impairment category, to design a prospective payment system that takes into account costs and expected recovery trends, and to compare the calculated reimbursement with the predicted costs estimated in a previous study (Saitto C, Marino C, Fusco D, et al. A new prospective payment system for inpatient rehabilitation. Part I: predicting resource consumption. Med Care. 2005;43:844-855). RESEARCH DESIGN: We considered all rehabilitation admissions from 5 Italian inpatient facilities during a 12-month period for which total cost of care had already been estimated and daily cost predicted through regression model. We ascertained recovery trends by impairment category through repeated MDS-PAC schedules and factorial analysis of functional status. We defined effective stay and daily resource consumption by impairment category and used these parameters to calculate reimbursement for the admission. We compared our reimbursement with predicted cost through regression analysis and evaluated the goodness of fit through residual analysis. RESULTS: We calculated reimbursement for 2079 admissions. The r(2) values for the reimbursement to cost correlation ranged from 0.54 in the whole population to 0.56 for "multiple trauma" to 0.85 for "other medical disorders." The best fit was found in the central quintiles of the cost and severity distributions. CONCLUSION: For each impairment category, we determined the number of days of effective hospital stay and the trends of functional gain. We demonstrated, at least within the Italian health care system, the feasibility of a reimbursement system that matches costs with functional recovery. By linking reimbursement to effective stay adjusted for trends of functional gain, we suggest it is possible to avoid both needless cuts and extensions of hospital admissions.

Toward a new payment system for inpatient rehabilitation. Part I: Predicting resource consumption.

BACKGROUND: The measures of clinical status used to predict costs must pay the most attention possible to medical conditions and clinical complexity. Length of stay (LOS), which has been used as a proxy for resource consumption, is not a direct measure of costs. Classification and regression trees, which are used in defining iso-resource groups, can be affected by overfitting and are based on a priori choices of the splitting attributes. Finally, current approaches are mainly concerned in estimating average group costs and do not attempt to estimate individual case costs. OBJECTIVES: We sought to define comprehensive measures of clinical status and detailed measures of resource consumption. We also sought to predict individual inpatient rehabilitation costs through multiple regression models. RESEARCH DESIGN: A prospective analysis was conducted of all rehabilitation cases admitted to 5 Italian inpatient facilities during a period of 12 months. All admissions underwent repeated Minimum Data Set-Post Acute Care (MDS-PAC) schedules to collect information on clinical status and treatment provided. We used factorial analysis to yield continuous variables representing clinical characteristics, and we priced treatments to obtain cost of stay. We used linear regression models to predict cost of stay and validated the model-based cost predictions by data-splitting. RESULTS: We collected 9720 MDS-PAC schedules from 2702 hospital admissions. The multivariate regression models fitted costs reasonably well with r(2) values of at least 0.34. On cross-validation, the ability of the regression models to predict cost was confirmed. CONCLUSION: We were able to estimate actual rehabilitation costs and define reliable regression models to predict costs from individual patient characteristics. Our approach identifies the contribution of any single patient characteristic to rehabilitation cost and tests the assumptions of the analysis.

[Functional recovery in post-acute rehabilitation: patient characteristics and treatment effect]. / Il recupero funzionale nella riabilitazione post acuzie: caratteristiche dei pazienti ed effetto dei trattamenti.

OBJECTIVE: Most studies on the effectiveness of rehabilitation consider only particular rehabilitation treatments for particular conditions, and do not give a global vision of the issue. This study evaluated the effectiveness of various types of post acute rehabilitative care in patients with different diagnoses by investigating the association between treatments and functional gain by type of impairment and severity on admission. DESIGN, SETTING AND PARTICIPANTS: Information on the characteristics of patients and the rehabilitative treatments was collected using an Italian version of the Minimum Data Set-Post Acute Care. The questionnaire was created and validated by the Centers for Medicare and Medicaid Services, it is divided in various section and was filled in at regular intervals throughout the hospital stay. Patients included in the study were 1918. MAIN OUTCOME MEASURES: We used factor analysis to summarize each section in a single continuous variable. The observed functional gain was calculated as the difference between functional status at the beginning and at the end of the admission. A multiple linear regression analysis was performed to evaluate the association between rehabilitation treatments and functional gain, adjusting for patient characteristics and severity at admission. The effectiveness of the treatments were obtained by calculating the difference between the overall functional gain of the hospital stay and the predicted functional gain of the stay in the absence of rehabilitation treatments. RESULTS AND CONCLUSION: The effectiveness of treatments differs across diagnostic class and it is associated directly with severity of functional status at admission. In most cases, the positive effect of treatments combines with the spontaneous functional gain; in other cases the positive effect of treatments opposes the spontaneous deterioration of patient functional status.

Differences in access to coronary care unit among patients with acute myocardial infarction in Rome: old, ill, and poor people hold the burden of inefficiency.

BACKGROUND: Direct admission to Coronary Care Unit (CCU) on hospital arrival can be considered as a good proxy for adequate management in patients with acute myocardial infarction (AMI), as it has been associated with better prognosis. We analyzed a cohort of patients with AMI hospitalized in Rome (Italy) in 1997-2000 to assess the proportion directly admitted to CCU and to investigate the effect of patient characteristics such as gender, age, illness severity on admission, and socio-economic status (SES) on CCU admission practices. METHODS: Using discharge data, we analyzed a cohort of 9127 AMI patients. Illness severity on admission was determined using the Deyo's adaptation of the Charlson's comorbidity index, and each patient was assigned to one to four SES groups (level I referring to the highest SES) defined by a socioeconomic index, derived by the characteristics of the census tract of residence. The effect of gender, age, illness severity and SES, on risk of non-admission to CCU was investigated using a logistic regression model (OR, CI 95%). RESULTS: Only 53.9% of patients were directly admitted to CCU, and access to optimal care was more frequently offered to younger patients (OR = 0.35; 95%CI = 0.25-0.48 when comparing 85+ to >=50 years), those with less severe illness (OR = 0.48; 95%CI = 0.37-0.61 when comparing Charlson index 3+ to 0) and the socially advantaged (OR = 0.81; 95%CI = 0.66-0.99 when comparing low to high SES). CONCLUSION: In Rome, Italy, standard optimal coronary care is underprovided. It seems to be granted preferentially to the better off, even after controversial clinical criteria, such as age and severity of illness, are taken into account.

Diabetes management by hospital-affiliated diabetes centres in Lazio, Italy.

BACKGROUND: In Italy, diabetes centres are considered to provide adequate care but little is known about their performance. METHODS: Inpatient and outpatient administrative databases were used to select and study a cohort of 2,568 diabetic patients. Adherence to guidelines and effect of patient characteristics and diabetes centre on treatment was assessed. Mortality rate was calculated. RESULTS: Patients averaged 9.3 outpatient visits per year. Each patient received a mean of 21.8 ambulatory services per year but only 2.21 Haemoglobin A1C tests, and only 0.56 procedures suggested by the guidelines. Diabetes management depended mainly on the care centre. A mortality rate of 6.9 per hundred person-years was observed. CONCLUSIONS: Hospital-affiliated centres do not ensure adequate diabetes management.

A follow-up analysis of transient ischemic attack patients suggests unsatisfactory disease management and possible underutilization of carotid endarterectomy in Lazio, Italy.

We evaluated the disease management of transient ischemic attack in patients admitted to Lazio hospitals from July 1997 to June 1998. We assessed the effects of patient characteristics including chronic comorbidities on the use of diagnostic procedures, endarterectomy, and on the risk of adverse cerebrovascular outcome or death. There were 2,608 patients in the study who were followed up over a 18- to 30-month period. Carotid surgery was performed on 1.15% of the subjects, total mortality was 34.7 per 1,000 person-years and adverse cerebrovascular outcome was observed in 38.1 per 1,000 person-years. Chronic comorbidities did affect the mortality rate and the rate of adverse outcome, but not the rate of endarterectomies. Carotid surgery was infrequently performed in study subjects. It seems that this potentially stroke-preventive treatment was not offered to suitable candidates in many instances.

Outcome of patients with cardiac diseases admitted to coronary care units: a report from Lazio, Italy.

BACKGROUND: Coronary care units (CCUs) currently treat a variety of diseases, but little is known about the effectiveness of CCUs on heart conditions other than acute myocardial infarction. OBJECTIVES: The objectives of this study were to evaluate the association between direct admission to CCUs and the risk of inhospital death in patients with heart disease, to investigate factors affecting direct admission to a CCU, and to assess the effect of CCU admission on the use of invasive procedures in patients with arrhythmias. RESEARCH DESIGN: We conducted a retrospective analysis of discharge-abstract data from Lazio, Italy, hospitals. We used logistic regression, propensity score, and instrumental variable analysis to compare inhospital risk of death between patients admitted to CCUs and to ordinary wards in 13 different groups of heart disease. We used linear regression to study the association between the rate of CCU admission and the relative risk of death. RESULTS: The study included 181,049 heart disease admissions, of which 8620 were admitted to CCUs (4.8%). Risk of death was significantly lower in patients admitted directly to CCUs for "acute myocardial infarction" (odds ratio [OR], 0.57), "acute ischemic heart disease" (OR, 0.55), and "other arrhythmias" (OR, 0.56). Mortality ORs were inversely related to the rate of CCU admission. CCU patients with arrhythmias received more invasive procedures (OR, 2.70) than non-CCU patients. CONCLUSION: Direct admission to a CCU is associated with a decrease in mortality for patients with "acute myocardial infarction," "acute heart ischemia," and "other arrhythmias." Patients most likely to benefit from CCU care are preferentially admitted to CCUs. CCUs make larger use of invasive procedures than ordinary wards.

[Supply of outpatient care in the Lazio region: geographic distribution and characteristics of outpatient clinics]. / Il sistema dell'offerta di prestazioni di assistenza specialistica ambulatoriale nella regione Lazio.

Outpatient care accounts every year for a large share of the National Health Fund spending, however characteristics of supply have not been thoroughly investigated. Objective of the study is the description of the outpatient care system of Lazio region and of the main characteristics of outpatient clinics, through indicators obtained using data from the Outpatient Care Information System (SIAS) for 1999. Outpatient clinics were classified into three categories: ASL managed clinics, private clinics and hospital trusts. Absolute and relative density of supply (respectively DAO and DRO) were used as indicators of clinics distribution in the regional area. Number of specialties, average procedure weight and volume of procedures performed were used as indicators of complexity. Absolute density of supply (DAO = n. of dispatch points/population) is generally high, and a large and statistically significant variability is observed (p < 0.001). The relative density (i.e. the correlation coefficient between DAO and population density) is positive overall (r = 0.43), but it is higher within the private sector (r = 0.62) independently from provider category. Statistically significant differences were observed among categories of providers in terms of average number of specialties (ASL managed: 9.9; private clinics: 1.7; hospital trusts: 16.1), average weight (ASL managed: 1.1; private clinics: 0.9; hospital trusts: 1.3) and average volume of procedures supplied (ASL managed: 35.000; private clinics: 59.000; hospital trusts: 282.000). The administrative SIAS database was a useful tool to define indicators aimed at describing characteristics of the outpatient care system, although these results must be confirmed with a higher and more homogeneous level of coverage.