Reducing clinical variations with clinical pathways: do pathways work?

OBJECTIVE: To test clinical pathways in a variety of Italian health care organizations in 2000-2002 to measure performance in decreasing process and outcome variations. DESIGN: Creation of indicators, specific for each clinical pathway, to measure variations in the care processes and outcomes. Pre- and post-analysis model to evaluate the possible effect of the clinical pathways on each indicator. SETTING: We tested the clinical pathways in six sites, each with different clinical pathways. RESULTS: Reductions in health care macro-variation phenomena (length of stay, patient pathways, etc.) and in performance micro-variation (variations in diagnostic and therapeutic prescriptions, protocol implementation, etc.) were shown in sites where pathways were implemented successfully. A significant improvement in outcome for patients who were treated according to the clinical pathway for heart failure was also demonstrated. CONCLUSIONS: The overall purpose of clinical pathways is to improve outcome by providing a mechanism to coordinate care and to reduce fragmentation, and ultimately cost. Our results demonstrated that it is possible to achieve this goal. Although controversial elements still exist, we think that clinical pathways can have a positive impact on quality in health care

5.11 'Raffaello Project': Application of the 'Disease and Care Management' Approach in Cardiovascular Disease Prevention

n/

Influenza vaccine effectiveness for the elderly: a cohort study involving General Practitioners from Abruzzo, Italy

Introduction. In all Italian regions influenza vaccine is routinely administered to the elderly population. However, vaccination impact has been rarely evaluated because of the high costs of conventional cohort investigations. A promising low-cost alter- native approach uses administrative discharge data to derive vaccine effectiveness indicators (hospitalizations and/or deaths) and involves General Practitioners (GPs) to document the exposure. We conducted a cohort analysis using such approach to assess influenza vaccine effectiveness and to investigate the feasibility and validity of that methodology for routine vaccine evaluation. Methods. During October 2006, all GPs from two Local Health Units (LHUs) were requested to indicate immunization status of all their patients in a specific form containing patient?s demo- graphic records. Immunization status information were also collected from Prevention Departments. Main outcomes were hospitalizations for influenza and/or pneumonia. Analyses were based upon random-effect logistic regression. Results. Of a total of 414 GPs assisting 103,162 elderly, 116 GPs (28%) provided data on 32,457 individuals (31.5%). The sample was representative and had an overall 66.2% vaccina- tion rate. During the first semester 2007, the hospitalization rate was low in the sample, with only 7 elderly patients admitted for influenza and 135 for pneumonia. At either bivariate or multi- variate analysis, vaccination did not significantly reduce the risk of in-hospital death, influenza or pneumonia admission. Discussion. The study had minimal costs, recruited a large and representative sample size, and had no evidence of a substantial selection bias. Administrative and GP?s data may be successively pooled to provide routine assessment of vaccination effectiveness

Can miRNAs be useful biomarkers in improving prognostic stratification in endometrial cancer patients? An update review

Endometrial cancer (EC) is the most common gynecological cancer, with annual incidence rates in Western countries ranging between 15 and 25 per 100 000 women. About 15% to 20% of patients with EC have high-risk disease and follow an aggressive clinical course. Unfortunately, the assessment of histologic parameters is poorly reproducible and conventional clinicopathological and molecular features do not reliably predict either the patient's response to the available treatments or the definition of personalized therapeutic approaches. In this context, the identification of novel diagnostic and prognostic biomarkers, which can be integrated in the current classification schemes, represents an unmet clinical need and an important challenge. miRNAs are key players in cancer by regulating the expression of specific target genes. Their role in EC, in association with clinical and prognostic tumor biomarkers, has been investigated but, so far, with little consensus among the studies. The present review aims to describe the recent advances in miRNAs research in EC taking into consideration the current classification schemes and to highlight the most promising miRNAs. Finally, a perspective point of view sheds light on the challenges ahead in the landscape of EC

Influenza vaccine uptake among community-dwelling Italian elderly: results from a large cross-sectional study

<p>Abstract</p> <p>Background</p> <p>Flu vaccination significantly reduces the risk of serious complications like hospitalization and death among community-dwelling older people, therefore vaccination programmes targeting this population group represent a common policy in developed Countries. Among the determinants of vaccine uptake in older age, a growing literature suggests that social relations can play a major role.</p> <p>Methods</p> <p>Drawing on the socio-behavioral model of Andersen-Newman - which distinguishes predictors of health care use in predisposing characteristics, enabling resources and need factors - we analyzed through multilevel regressions the determinants of influenza immunization in a sample of 25,183 elderly reached by a nationally representative Italian survey.</p> <p>Results</p> <p>Being over 85-year old (OR = 1.99; 95% CI 1.77 - 2.21) and suffering from a severe chronic disease (OR = 2.06; 95% CI 1.90 - 2.24) are the strongest determinants of vaccine uptake. Being unmarried (OR = 0.81; 95% CI 0.74 - 0.87) and living in larger households (OR = 0.83; 95% CI 0.74 - 0.87) are risk factors for lower immunization rates. Conversely, relying on neighbors' support (OR = 1.09; 95% CI 1.02 - 1.16) or on privately paid home help (OR = 1.19; 95% CI 1.08 - 1.30) is associated with a higher likelihood of vaccine uptake.</p> <p>Conclusions</p> <p>Even after adjusting for socio-demographic characteristics and need factors, social support, measured as the availability of assistance from partners, neighbors and home helpers, significantly increases the odds of influenza vaccine use among older Italians.</p

A cluster randomized controlled trial of a clinical pathway for hospital treatment of heart failure: study design and population

<p>Abstract</p> <p>Background</p> <p>The hospital treatment of heart failure frequently does not follow published guidelines, potentially contributing to the high morbidity, mortality and economic cost of this disorder. Consequently the development of clinical pathways has the potential to reduce the current variability in care, enhance guideline adherence, and improve outcomes for patients. Despite enthusiasm and diffusion, the widespread acceptance of clinical pathways remain questionable because very little prospective controlled data demonstrated their effectiveness. The Experimental Prospective Study on the Effectiveness and Efficiency of the Implementation of Clinical Pathways was designed in order to conduct a rigorous evaluation of clinical pathways in hospital treatment of acute heart failure. The primary objective of the trial was to evaluate the effectiveness of the implementation of clinical pathways for hospital treatment of heart failure in Italian hospitals.</p> <p>Methods/design</p> <p>Two-arm, cluster-randomized trial. 14 community hospitals were randomized either to arm 1 (clinical pathway: appropriate use of practice guidelines and supplies of drugs and ancillary services, new organization and procedures, patient education, etc.) or to arm 2 (no intervention, usual care). 424 patients sample (212 in each group), 80% of power at the 5% significance level (two-sided). The primary outcome measure is in-hospital mortality. We will also analyze the impact of the clinical pathways comparing the length and the appropriateness of the stay, the rate of unscheduled readmissions, the customers' satisfaction and the costs treating the patients with the pathways and with the current practice along all the observation period. The quality of the care will be assessed by monitoring the use of diagnostic and therapeutic procedures during hospital stay and by measuring key quality indicators at discharge.</p> <p>Discussion</p> <p>This paper examines the design of the evaluation of a complex intervention. Since clinical pathways are made up of various interconnecting parts we have chosen the cluster-randomized controlled trial because is widely accepted as the most reliable method of determining effectiveness when measuring cost-effectiveness in real practice.</p> <p>Trial Registration</p> <p>ClinicalTrials.gov ID [NCT00519038]</p

An integrated assessment of the Good Environmental Status of Mediterranean Marine Protected Areas

Este artículo contiene 11 páginas, 2 figuras, 2 tablas.Local, regional and global targets have been set to halt marine biodiversity loss. Europe has set its own policy targets to achieve Good Environmental Status (GES) of marine ecosystems by implementing the Marine Strategy Framework Directive (MSFD) across member states. We combined an extensive dataset across five Mediterranean ecoregions including 26 Marine Protected Areas (MPAs), their reference unprotected areas, and a no-trawl case study. Our aim was to assess if MPAs reach GES, if their effects are local or can be detected at ecoregion level or up to a Mediterranean scale, and which are the ecosystem components driving GES achievement. This was undertaken by using the analytical tool NEAT (Nested Environmental status Assessment Tool), which allows an integrated assessment of the status of marine systems. We adopted an ecosystem approach by integrating data from several ecosystem components: the seagrass Posidonia oceanica, macroalgae, sea urchins and fish. Thresholds to define the GES were set by dedicated workshops and literature review. In the Western Mediterranean, most MPAs are in good/high status, with P. oceanica and fish driving this result within MPAs. However, GES is achieved only at a local level, and the Mediterranean Sea, as a whole, results in a moderate environmental status. Macroalgal forests are overall in bad condition, confirming their status at risk. The results are significantly affected by the assumption that discrete observations over small spatial scales are representative of the total extension investigated. This calls for large-scale, dedicated assessments to realistically detect environmental status changes under different conditions. Understanding MPAs effectiveness in reaching GES is crucial to assess their role as sentinel observatories of marine systems. MPAs and trawling bans can locally contribute to the attainment of GES and to the fulfillment of the MSFD objectives. Building confidence in setting thresholds between GES and non-GES, investing in long-term monitoring, increasing the spatial extent of sampling areas, rethinking and broadening the scope of complementary tools of protection (e.g., Natura 2000 Sites), are indicated as solutions to ameliorate the status of the basin.This article was undertaken within the COST Action 15121 MarCons (http://www.marcons-cost.eu, European Cooperation in Science and Technology), the Interreg MED AMAre Plus (Ref: 8022) and the project PO FEAMP 2014-2020 Innovazione, sviluppo e sostenibilita ` nel settore della pesca e dell’acquacoltura per la Regione Campania (ISSPA 2.51). M.C.U., A.B. have been funded by the project MEDREGION (European Commission DG ENV/MSFD, 2018 call, Grant Agreement 110661/ 2018/794286/SUB/ENV.C2). Aegean Sea data were retrieved from the project PROTOMEDEA (www.protomedea.eu), funded by DG for Marine Affairs and Fisheries of the EC, under Grant Agreement SI2.721917. JB acknowledges support from the Spanish Ministry of Science and Innovation (Juan de la Cierva fellowship FJC 2018-035566-I).With the institutional support of the ‘Severo Ochoa Centre of Excellence’ accreditation (CEX2019-000928-S).Peer reviewe