[Health expenditure for prevention in Italy (2006-2013): descriptive analysis, regional trends and international comparisons]

We systematically assess and critically appraise Italian national and regional-level data on health expenditure for prevention in the pe- riod 2006-2013, expanding on international figures available from the Organisation for Economic Cooperation and Development (OECD) reports. At the national health system level, as emerges from the health expenditure monitoring system of the Italian Na- tional Agency for Regional Health Services (Agenas), in Italy pub- lic health expenditure for prevention in Italy accounts for about 4.2% of total public health expenditure (4.9 billion euros in 2013); these figures being constant over the study period. Expenditure for preventive services targeting individuals (i.e., immunization and screening) has increased over time (+8.7%), while public hy- giene and veterinary expenditure has decreased (-5.7 and -3.8%, respectively). International comparisons, which consider different parameters, report Italy to spend 2.9% of total health expenditure on prevention, which is in line with the OECD Countries average. In Italy expenditure for prevention is still below the 5% national target, with a lot of heterogeneity by region. In the context of a health system that still provides universal health coverage, increased resources should be devoted to plan and implement preventive pro- grammes of proven efficacy and cost effectiveness

La valutazione degli indicatori di processo e outcome per confermare la validità della proposta operativa

Unlike other chronic diseases, little attention in scientific literature on obesity has been dedicated to the issue of outcome and, above all, process indicators. This is undoubtedly due to the fact that it was only in relatively recent times that besity was categorized as a chronic disease, which is associated with an increase in the morbidity and mortality in the general population, and one of the main causes of disability and spending on healthcare. On the other hand, the relatively poor efficacy of the treatments available compared to that achieved for other chronic illnesses and the relatively recent advent of more effective therapies, such as bariatric or weight loss surgery and multidisciplinary rehabilitation, make the field of obesity therapy one that is still largely experimental and lacking in well-defined guidelines. When dealing with this topic, the issue of process and outcome indicators has been considered according to the different levels within the healthcare setting in which the management of the obese patient takes place

[Development of a conceptual model for interpretation of monitoring indicators of childhood obesity prevention from the Italian National Prevention Plan] Sviluppo di un modello concettuale di riferimento per l\u2019interpretazione degli indicatori di prevenzione dell\u2019obesit\ue0 infantile e nell'adolescenza nel Piano nazionale della prevenzione

INTRODUZIONE: il Piano nazionale della prevenzione (PNP) 2014-2018 ha indicato alle Regioni obiettivi e strategie per la prevenzione dell\u2019obesit\ue0 e si \ue8 dotato di un sistema di valutazione d\u2019impatto. OBIETTIVI: sviluppare un modello per l\u2019interpretazione delle variazioni negli indicatori relativi all\u2019obesit\ue0 infantile e nell\u2019adolescenza. METODI: da una revisione sistematica, DPSEEA (\uabforze trainanti\ubb, \uabpressioni\ubb, \uabstato\ubb, \uabesposizione\ubb, \uabeffetto\ubb, \uabazioni\ubb) \ue8 risultata la cornice concettuale pi\uf9 completa e applicabile. Un gruppo di esperti ha identificato determinanti e nessi causali e possano agire gli interventi proposti dal PNP come su questi. Il modello finale \ue8 stato ottenuto attraverso un processo iterativo che ha coinvolto un comitato consultivo di decisori e rappresentanti di societ\ue0 scientifiche. RISULTATI: \uabforze trainanti\ubb identificate sono legate a profitto dell\u2019industria alimentare, all\u2019alimentazione scolastica, al contesto domestico. Tra le \uabPressioni\ubb rientrano abitudini familiari, offerta delle mense scolastiche e fattori socioculturali, contesto di vita, organizzazione dell\u2019attivit\ue0 fisica (AF) scolastica ed extra-scolastica. Nello \uabstato\ubb sono inclusi: frequente consumo di cibo confezionato, alta quantit\ue0 di cibo ipercalorico disponibile, mancanza del pasto in famiglia, consumo di bevande gasate e zuccherate, interruzione precoce dell\u2019allattamento al seno, scarsa fruibilit\ue0 di spazi esterni, frequente uso del trasporto privato e scarsa offerta di AF nelle scuole. \uabEsposizione\ubb sono le opportunit\ue0 di AF e apporto calorico, che agiscono su \uabeffetto\ubb (prevalenza di obesit\ue0). CONCLUSIONI: il modello interpretativo colloca le \uabazioni\ubb e i meccanismi che dovrebbero modificare AF e apporto calorico, in una sequenza causale, rendendo esplicito il costrutto degli indicatori di monitoraggio e d\u2019impatto.BACKGROUND: the Italian National Prevention Plan (PNP) posed the standard to be achieved by Regions for the prevention of obesity in childhood and adolescence. The PNP also set up a monitoring system to assess the impact of implemented policies. OBJECTIVES: to develop a conceptual model to facilitate interpretation of variation in outcome indicators. METHODS: after a systematic review, the DPSEEA (\uabDriving forces\ubb, \uabPressures\ubb, \uabState\ubb, \uabExposure\ubb, \uabEffect\ubb, \uabActions!) was identified as the more appropriate framework to assess the results of preventive policies. Factors for each component of the framework were identified and indicators that allow measuring the changing of each of these factors were defined. RESULTS: the included \uabdriving forces\ubb were related to the profit-led food industry, to the nutrition environment at school, and to household-level factors. Among the \uabpressures\ubb, parenting behaviours, food provided by school canteens, sociocultural factors, social context, physical activity (PA), opportunities at school or after-school were included. In the State, the high consumption of processed food, the large quantities of high-calorie food easy available, the consumption of carbonated and sugar-sweetened beverages, the reduced social function of mealtimes in families, the early cessation of breastfeeding, the reduction of outdoors activity, active transportation, and PA at school for children were identified. The \uabexposure\ubb factors were the reduced opportunities of doing PA and the over-consumption of calories that influence the \uabeffect\ubb, described as the prevalence of children and adolescents affected by obesity. CONCLUSIONS: through the DPSEEA, a conceptual model was set up; it allows to place in the causal chain the \uabactions\ubb and the mechanisms through which these actions should impact on the \uabexposure\ubb (PA and over-consumption of calories), making the rationale of process and impact indicators explicit

Monitoring the care process of disable elderly, reports for doing public governance: do they work?

Background There has been an increasing interest and necessity to measure Long term care - LTC services for dependent elderly. The LUNA study conducted by the National Agency for regional healthcare services aimed to contribute to the development and implementation of a governance tool to monitor and improve LTC services. Methods A set of indicators for evaluating care delivered to disabled elderly in local areas of five Italian regions – Lombardy, Veneto, Tuscany, Apulia, Emilia Romagna was defined and a report was developed as governance tool. All records relative to residents in Brescia Local Health Unit (LHU), Vicenza LHU, Tuscany, Taranto LHU, Bologna LHU aged 65years, assisted at least one day between Jan, 1 2012 and June, 30 2013 were extracted from national home and residential care databases. These records were linked with hospital discharges and emergency room access databases. The outcome measures were ratios, arithmetic means, incidence rates, Odds Ratio (CI 95%) adjusted for the main confounders. Independent audit and coordinated focus groups were performed across the LHU involved to test the utility of the report as governance tool. Results 33 indicators on access, multidimensional evaluation, tempestivity, continuity, efficacy were calculated. An example of appropriateness regards the Emergency Access rate with white or green code of elderly in home care. The rates were 28% person-years at Brescia, 80% person-years at Empoli, 38% at Bologna, 37% at Vicenza and 19% person-years at Taranto. 8 focus groups were performed involving 87 professionals and stakeholders of LTC services. Qualitative concerns reveal that despite the high validity of the set of indicators developed, less technicality and a deeper bottom up approach in the set of indicators design and selection would have been recommended from the health care professionals and governors involved in the implementation of the report as governance tool. The report was appreciated as tool for integration. Conclusions Regional differences either in process of care either in the usefulness of the tool were found. Further analyses are needed to improve this innovative quality instrument in order to be easily implemented to do public governance of LTC services and focus also on equity aspects. Key message reports to do public governance of LTC service are neede

Circulating biomarkers in pulmonary arterial hypertension : an update

Pulmonary arterial hypertension (PAH) is a rare subtype of group 1 pulmonary hypertension (PH) diseases, characterized by high pulmonary artery pressure leading to right ventricular dysfunction and potential life-threatening consequences. PAH involves complex mechanisms: vasoconstriction, vascular remodeling, endothelial dysfunction, inflammation, oxidative stress, fibrosis, RV remodeling, cellular hypoxia, metabolic imbalance, and thrombosis. These mechanisms are mediated by several pathways, involving molecules like nitric oxide and prostacyclin. PAH diagnosis requires clinical evaluation and right heart catheterization, confirming a value of mPAP ≥ 20 mmHg at rest and often elevated pulmonary vascular resistance (PVR). Even if an early and accurate diagnosis is crucial, PAH still lacks effective biomarkers to assist in its diagnosis and prognosis. Biomarkers could contribute to arousing clinical suspicion and serve for prognosis prediction, risk stratification, and dynamic monitoring in patients with PAH. The aim of the present review is to report the main novelties on new possible biomarkers for the diagnosis, prognosis, and treatment monitoring of PAH

Monitoraggio dell\u2019impatto dei progetti regionali censiti e valutati in termini di miglioramento dell\u2019assistenza fornita sul territorio \u201cAssistenza H24 e riduzione degli accessi impropri al Pronto Soccorso\u201d. Quali determinanti organizzativi e professionali di rilievo?

Monitoring the impact of regional projects selected and evaluated on the basis of improvement of primary healthcare provision \u201cAround the clock healthcare services and reduction of inappropriate access to Accident and Emergency Departments\u201d. Which are the major organizational and professional determinants? The Italian Health Ministry and Agenas monitor the impact of selected regional projects on primary healthcare services directed at non-urgent patients healthcare aiming to reduce inappropriate access to Accident & Emergency Departments (A&E). The goal of the project is to identify and evaluate the main organizational and professional determinants of around the clock healthcare services (ACHS) provision and drivers of reducing inappropriate attendances to A&E Departments. Inclusion criteria were chosen. A checklist was designed to identify professional and organizational deter- minants of projects. 93% of the projects involve out-of-hours Medical Services and 71% involve GPs; 93% deliver healthcare services 5/7 days; 29% provide ACHS and none provide care for less than 12 hours. The study suggests the analysis and monitoring methodology to evaluate results achieved by each project. A relevant role played by GPs group practice was shown. Further studies are needed to evaluate the impact of these organizational models