Outpatient therapeutic chronic opioid consumption in Italy: a one-year survey.

BACKGROUND: In Italy since the 38/2010 law concerning Palliative Care and pain therapy has been promulgated, the consumption of opioids started increasing. However, despite the availability of a large amount of data regarding opioid prescription, a database including all patients on chronic opioid therapy does not yet exist. METHODS: Retrospective analysis of analgesic opioid consumption was performed between January 2013 and December 2013 using the data of national refunded medications for outpatients, collected by Italian Ministry of Health. We considered patients on chronic opioid therapy those patients with at least three opioids prescriptions in three consecutive months and/or six opioid prescriptions in six even not consecutive months in the observation period. We considered cancer patients those with neoplasm exemption code in the scheduled prescription and/or patients with at least one ROOs prescription (rapid onset opioids, approved in Italy for Break Through cancer Pain-BTcP- only). We also calculated the patient's morphine daily mean dose (MED) converting all prescribed opioids in equivalent of morphine using specific conversion tables. RESULTS: This census revealed a total of 422,542 patients in chronic therapy with opioids, of those 369.961 with chronic non-cancer pain and 52,581 with chronic cancer pain. This represents about 4% of the estimated requirement in Italy for both groups based on previous surveys regarding the prevalence of chronic pain. CONCLUSIONS: Relatively to MED, We found that in Italy chronic cancer pain patients receive doses similar to patients with cancer pain in other Literature reports, whereas patients with chronic non-cancer pain received lower dosages.

The rights of the dying child and the duties of healthcare providers: the "Trieste Charter".

PURPOSE: The death of a child is a devastating and tragic event for all those involved. This charter aims to help healthcare workers and people assisting terminally ill children to recognize some important rights of the child, with some related suggestions. We consider it important to have a trace of this process, based on the skillfulness of long-lasting experts. METHODS: In September 2012, a group of professionals working with children affected by incurable illness in Italy launched a project to formulate the charter. Trieste is the city where the group of professionals first met to start the project. The first step was a detailed literature search on the topic, the second step was an extensive discussion among the professionals (writing committee) to prepare a first draft; later (third step) the draft was revised by 38 experts in different areas, including patient and family representatives, and lastly (fourth step) the final version of the charter was prepared. RESULTS: We developed a document containing 10 rights and corresponding duties that could be applied to any clinical situation or circumstances and used as a guide by professionals and families caring for children in the terminal stages of an illness. CONCLUSIONS: The Trieste Charter proposes fundamental rights for children who are approaching the end of their lives. The charter will have achieved its purpose when every person caring for a dying child is capable of staying near the child until the last moments of his or her life, prepared to accept his or her death, ensuring both respect and dignity.

Barriers to the development of pediatric palliative care in Italy.

INTRODUCTION: In recent years the emergence of new types of patient, clinical situations, technological frontiers and "health" objectives have changed considerably the needs of ill children, this also concerns pediatric palliative care (PPC). In Italy, despite the introduction of legislation (Law 38/2010) stipulating the right of children and families to access appropriate services for pain control and pediatric palliative care, the availability of these services is still limited. AIM: The aim of this study is to highlight, through a review of the existing data and published literature, the critical issues that obstacle the planning and development of PPC services in Italy. RESULTS: Four main areas identified were: socio-cultural setting; types of patients and nature of diseases requiring PPC; training for PPC providers; regulatory and political issues. CONCLUSIONS: This type of analysis can provide the rational for advancing proposals and developing supportive, corrective and implementation strategies.

Use of a checklist to improve pain control in hospitalized cancer patients: the 38Checkpain project.

AIM: Checklists may improve management of patients in different settings. However, no studies have been conducted to investigate the use of this tool to improve inpatient pain control. This study, conducted in Italy, aims to describe the experience, in terms of pain control, of the widespread introduction of a checklist for pain control in oncological patients, according to current Italian legislation. MATERIALS & METHODS: In total, 92 Italian centers were randomly assigned to the use of the 38Checkpain to monitor pain management or to continue their standard practice without the use of this tool. RESULTS: The 38Checkpain improved the control of pain compared with centers who did not use this tool. CONCLUSION: Overall, the findings of this study suggest that the application of the 38Checkpain may help improve control of pain of hospitalized oncological patients.

Narrative medicine to highlight values of Italian pain therapists in a changing healthcare system.

Until 2010 pain management in Italy was only partially covered and no structural and qualitative mapping had ever been realized. The VEDUTA project was designed to provide a tool to unite pain therapists in national cooperation. Quantitative questionnaires and narrative plots were sent to 350 Italian specialists; 184 therapists completed the first section and 87 also wrote their stories. Narratives were analyzed through transactional analysis and emotional intelligence. Overall, results show that a patient-centered approach is common in daily practice, but that bureaucracy is endangering quality of care. This cultural analysis, through both the application of quantitative assessment and narrative plots, provides a useful tool to improve those aspects of the system detrimental to the appropriate management of pain in Italy.

Hospitalization in children eligible for palliative care.

INTRODUCTION: Medical and technological progress allows newborns, children and teenagers suffering from life-limiting and life-threatening illness to survive, but not necessarily to recover. Data on the number of children eligible for pediatric palliative care [PPC] and their needs are useful for health care planning. The main aim of this study was to ascertain the prevalence and the course of children eligible for pediatric palliative care in Italy. METHODS: The data source considered was the hospital discharge records (HDR), containing information on the children's diagnosis, their personal and clinical details, hospital admissions, procedures and discharge. The list of diseases eligible for PPC was based on the ICD IX CM list, according to ACT criteria. All records of hospital admissions in Italy for the years 2001-2003 were processed. The first step was to identify hospital admissions involving individuals 0-17 years old with at least one of the selected life-limiting and life-threatening illnesses. The main features of these hospital admissions were described in terms of duration, frequency, and discharge arrangements, estimating the number of patients eligible for PPC and the number of deaths occurring in hospital. RESULTS: The total number of hospital admissions concerning patients aged 0-17 years amounted to 3,578,649. Our restrictive criteria identified 323,415 hospital admissions in 3 years relating to diseases eligible for pediatric palliative care, which involved approximately 12,000 children. The most common diseases fell respectively into the following sectors: perinatal, neurological, neoplastic and congenital diseases. The number of days spent in hospital for diseases eligible for PPC ranged from 556,075 days/year to 591,983, and concerned 35,000 children every year. CONCLUSIONS: Our data agree with other international surveys on the prevalence and typology of pediatric patients. The HDR could be useful for the estimation of the cases eligible for pediatric palliative care and for monitoring of deaths in hospital.

Pediatric palliative care.

The WHO defines pediatric palliative care as the active total care of the child's body, mind and spirit, which also involves giving support to the family. Its purpose is to improve the quality of life of young patients and their families, and in the vast majority of cases the home is the best place to provide such care, but for cultural, affective, educational and organizational reasons, pediatric patients rarely benefit from such an approach. In daily practice, it is clear that pediatric patients experience all the clinical, psychological, ethical and spiritual problems that severe, irreversible disease and death entail. The international literature indicates a prevalence of incurable disease annually affecting 10/10,000 young people from 0 to 19 years old, with an annual mortality rate of 1/10,000 young people from birth to 17 years old. The needs of this category of patients, recorded in investigations conducted in various parts of the world, reveal much the same picture despite geographical, cultural, organizational and social differences, particularly as concerns their wish to be treated at home and the demand for better communications between the professionals involved in their care and a greater availability of support services. Different patient care models have been tested in Italy and abroad, two of institutional type (with children staying in hospitals for treating acute disease or in pediatric hospices) and two based at home (the so-called home-based hospitalization and integrated home-based care programs). Professional expertise, training, research and organization provide the essential foundations for coping with a situation that is all too often underestimated and neglected.