On the importance of primary and community healthcare in relation to global health and environmental threats: lessons from the COVID-19 crisis.

In the course of the COVID-19 pandemic, it has become clear that primary healthcare systems play a critical role in clinical care, such as patient screening, triage, physical and psychological support and also in promoting good community advice and awareness in coordination with secondary healthcare and preventive care. Because of the role of social and environmental factors in COVID-19 transmission and burden of disease, it is essential to ensure that there is adequate coordination of population-based health services and public health interventions. The COVID-19 pandemic has shown the primary and community healthcare (P&CHC) system's weaknesses worldwide. In many instances, P&CHC played only a minor role, the emphasis being on hospital and intensive care beds. This was compounded by political failures, in supporting local community resilience. Placing community building, social cohesion and resilience at the forefront of dealing with the COVID-19 crisis can help align solutions that provide a vision of 'planetary health'. This can be achieved by involving local well-being and participation in the face of any pervasive health and environmental crisis, including other epidemics and large-scale ecological crises. This paper proposes that P&CHC should take on two critical roles: first, to support local problem-solving efforts and to serve as a partner in innovative approaches to safeguarding community well-being; and second, to understand the local environment and health risks in the context of the global health perspective. We see this as an opportunity of immediate value and broad consequence beyond the control of the COVID-19 pandemic.

[Diagnostic imaging procedures and prescribing appropriateness: are administrative data a proper instrument? An experience from Piedmont Region (Northern Italy)]. / Diagnostica per immagini e appropriatezza prescrittiva: i dati amministrativi possono essere uno strumento informativo adeguato? Un'esperienza nella Regione Piemonte.

OBJECTIVES: to assess at population level if healthcare administrative data can be suitable to identify variability and determinants of the prescribing rates for some diagnostic imaging procedures at high-risk of inappropriateness. DESIGN: population-based observational study. SETTING AND PARTICIPANTS: Piedmont Region (Northern Italy) adult population (>20 years) in year 2013. The subjects included were 3,566,147, referring to 3,016 general practitioners (GPs), in 12 Local Health Authorities (LHAs). MAIN OUTCOME MEASURES: prescription rates of 4 diagnostic imaging procedures at high-risk of inappropriateness (vertebral and joint magnetic resonance - MR, vertebral computed tomography - CT, and bone densitometry). The following factors have been investigated: sociodemographic and clinical data of the subjects, prescribing GPs' characteristics, and organizational environment of the LHA for whom the GP is working. For each procedure, prescription rate determinants have been estimated by a logistic regression modelling of the probability of receiving at least one prescription during the year. Hierarchical data structure has been managed. The Intraclass Correlation Coefficient (ICC) and the Median Odds Ratio (MOR) were used as measures of variability due to GPs and LHAs. RESULTS: the degree of variability among LHAs and, within each LHA, among GPs was moderate (ICC for LHA: 0.009 and 0.004; ICC for GP: 0.015 and 0.014, respectively, for vertebral and joint MR). Prescribing probability was mainly explained by the demographic and clinical characteristics of the subjects. Most of the GPs' characteristics did not show any relevant association. Results suggest also a potential role of the private technology availability in the LHA where the GP is working. CONCLUSIONS: administrative healthcare data did not describe a relevant degree of variability in prescribing diagnostic imaging procedures in Piedmont Region, except for some GPs and LHAs with a different rate from the regional average. To explain differences in prescribing rates of some GPs or LHAs and to assess their appropriateness, outpatient databases should be enriched with clinical data (mainly, diagnosis or clinical suspicion) or different tools, such as clinical audit, should be used.

[A survey carried out among Italian physicians regarding non-required clinical examinations, treatments and procedures in the current clinical practice: results and considerations.] / Esami diagnostici, trattamenti e procedure non necessari: risultati e considerazioni da un'indagine sui medici italiani.

A survey addressed to all Italian physicians regarding how they behave when a patient asks them to prescribe non-required clinical examinations, treatments and procedures has been carried out for the first time. The survey - realized during the last months of the year 2015 thanks to the collaboration between Slow Medicine and the National Federation of Associations of Doctors, Surgeons and Dentists - is based on a questionnaire given to the America physicians by the ABIM Foundation in 2014. The Italian survey results cannot be compared with the American ones because different approaches were used. 4,263 physicians started to fill in the questionnaire and 3,688 completed it. The results suggest that the physicians that answered the questions are highly aware of the over-usage of diagnostic tests and treatments, and among the main reasons they cite the need of safety and then the fear of legal consequences. Most of the physicians who answered the questions believe to be responsible for giving patients accurate information in order to avoid non-required practices, and that the physician is the right person with the most suitable role to face the problem. Among the most important and useful tools to reduce the prescription of non-required examinations and treatments, physicians indicate the possibility to have much more time available to discuss the different options with their patients, to arrange the evidence-based information material for the patients, and to explain the reform on the physician's responsibility (recently approved as law). Therefore, it stands out the opportunity to apply provisions aimed at providing the patients with more accurate information and at improving the relationship between the physician and the patient by ensuring on the one hand more availability of dedicated time and on the other hand the training of the physicians on scientific topics as well as on topics concerning communication and shared decisions. The communication can be strengthened by evidence-based information tools for patients and citizens to be used during the visits with the physician as well as in case of an institutional communication about the over-usage of clinical examinations and treatments.

[Are medical students influenced by the promotion of the pharmaceutical industry?]. / Gli studenti di medicina sono influenzati dalla promozione dell'industria farmaceutica?

The pharmaceutical and medical devices industry provides one of the main sources of scientific information for physicians. The impact of this kind of information on physicians' prescribing behavior has been extensively studied. Available evidence consistently shows that prescription habits are affected by industry-driven scientific research data. This questionable influence has an impact also on medical students, residents, and doctors in training. Recent studies have shown that a frequent contact with industry representatives is inversely related to the knowledge of the foundations of evidence-based medicine and directly related to a higher use of brand-name prescription drugs. Several American universities decided to prohibit any relationships between students and industry representatives. It would be desirable that such policies be adopted by other institutions. In addition, the practical guide published by the World Health Organization "Understanding and Responding to Pharmaceutical Promotion" should be better known and used.

Primary surgery in rural areas of southern Sudan.

BACKGROUND: We report through a retrospective analysis our experience of providing surgical care and on-the-job training through mobile surgical missions in southern Sudan during the post conflict period between 2005 and 2009. METHODS: Three surgical teams conducted 23 missions in 5 primary health care centers sited in remote areas of southern Sudan. King's analytical framework for surgical care in developing countries is adopted to evaluate the appropriateness of services rendered. Exact logistic regression was performed to investigate differences in mortality depending on the level of training of the operators and anesthetists. RESULTS: A total of 1,543 patients were operated on during a 5 year period, of which 9 (0.58%) died. The majority of operations were elective surgery cases (which may help contextualize the exceptionally low mortality rate). Several adaptations to surgical techniques adopted and preoperative and postoperative care were required. There were no statistically significant differences in mortality between operations performed by expatriate specialists and local midlevel providers with lower level training. CONCLUSIONS: This experience in southern Sudan demonstrates that surgical services can be established utilizing simple facilities and equipment and employing local personnel selected and trained on-the-job by teams composed of a consultant surgeon, anesthetist, and scrub nurse. Delegation of tasks relating to anesthesia and surgery to midlevel health providers is an appropriate approach in developing countries facing shortage and maldistribution of more qualified health workers.

Rural surgery in southern Sudan.

INTRODUCTION: This article reports a retrospective analysis of a 6-year experience of providing surgical care in remote areas of southern Sudan under extremely adverse conditions. METHODS: Teams of expatriate consultants (surgeon, anesthetist, scrub nurse) carried out 28 "surgical missions" with the aims of treating surgical cases previously selected and of training local personnel in basic surgery on the job. RESULTS: A total of 1642 patients (71% males, 30% under the age of 16) have undergone an operation. Altogether, 1264 elective procedures (77%) and 378 emergency procedures (23%) were performed. Hernia surgery comprised the main workload, followed by proctologic and gynecologic operations. Most operations were performed under spinal anesthesia. Other cases required ketamine, and a small number of patients had local anesthesia. There were 14 fatal complications, most of them related to the delay in obtaining medical attention. Based on the training results, the Sudanese personnel of two of the five health centers involved in the program are already fully autonomous. Two doctors and two nurses are proficient in essential surgery; two not qualified nurses are proficient in "primary" anesthesia; and others are proficient in scrubbing and surgical nursing. CONCLUSIONS: This report demonstrates that it is feasible to establish surgical services in rural areas of developing countries by utilizing simple facilities, providing them with basic equipment, and employing local personnel selected and trained on the job by teams composed of a consultant surgeon, anesthetist, and scrub nurse. This seems to be the only realistic possibility for providing surgical care to the rural populations of the least developed countries.