Co-production in healthcare services: What we know, how we can evaluate it

Background In times of increasing population aging, higher incidence of chronic diseases and higher expectations regarding public service provision, healthcare services are under increasing strain to cut costs while keeping quality. In this context, debates on the importance of promoting systems of co-produced health between stakeholders have gained considerable traction both in the literature and in policy debates of the public sector (Dunston et al., 2009, Voorberg et al. 2015; European Commission 2010). Co-production occurs \u201cwhen public service organizations partner with external entities, including other public organizations, third sector, or service user, to jointly produce services that they previously produced on their own\u201d (Thomas, 2013, p. 788). In this perspective, co-production is not only a patient involvement tool, but mainly a managerial tool, where partner in the production process could influence the methods used to organise and manage the service delivery (Sorrentino et al., 2015; Brandsen and Honingh, 2015; Gilardi et al., 2016). Despite this widespread acceptance, minimal consensus exists on the mechanisms for evaluating the actual impacts of the co-production in healthcare sector. More specifically, little has been produced on how the results of these changing structures, practices and goals in healthcare management and provision can be monitored and evaluated (Hardyman et al., 2015; Gilardi et al., 2016; Palumbo, 2016). Objectives The study aims at filling this gap by developing a conceptual framework for assessing co-production in healthcare. Specifically, drawing on existing literature on co-production in healthcare, we develop an original analytical evaluation framework with respect to: i) the multidimensional perspectives to be taken into consideration; ii) the dimensions to be analysed; iii) the methods that allow implementing our framework in practice. Methodolody First of all, a quantitative bibliometric analysis, using Bibliometrix software (Aria and Cuccurullo, 2017), is carried out. The reference database chosen is WoS and the inclusion criterion is \u201cco-production AND heath* OR coproduction AND health*\u201d in topic. Moreover, the search is refined by language, i.e. English, and type of publication, i.e. journal academic article. No time limitation is selected. After deleting non-inherent papers, our final sample was made up of 213 papers. As second stage, a qualitative content analysis based on PRISMA protocol is developed, focusing on those papers targeting evaluation issues. Finally, a preliminary co-production evaluation model proposal is proposed and discussed. Main results The study shows an increasing attention on the co-production topic, as highlighted by an annual percentage growth rate of about 26% and the big increase in the last 5 years in number of publications. The countries with a highest number of publications and collaborations are UK (mainly England), Netherlands, Australia and USA. As expected, the most repeated keyword is co-production, however, it is interesting to underline the presence of \u201cmental health\u201d and \u201cpublic health\u201d, that can be assumed as the main topic of studies analyzed. Nonetheless, only few studies focus on the evaluation of outcomes. Among them, the content analysis has revealed a predominantly mono-dimensional and mono-stakeholder approach. Specifically, clinical, economic or psychological-social - mainly in terms of patient satisfaction \u2013 impacts (i.e. Lwembe et al., 2016; Harvey et al., 2017) are assessed. The analysis reveals that one of the main challenges of assessing co-production lies in its multi-dimensional nature; thus a multiple perspectives framework has to be adopted. To contribute filling this gap, we developed a preliminary multidimensional (i.e. performance indicators) and multi-stakeholder (i.e. different actors involved) evaluation model (Figure 1). Specifically, the framework takes into account the three main outcome domains \u2013 i) economic, ii) managerial/organisational and iii) clinical \u2013 and three main stakeholders involved \u2013 i) hospital, ii) healthcare professionals, iii) patients and their families. The economic and efficiency measures concerning direct and indirect cost for hospital and patients/family, should be integrated with clinical and managerial measures for each stakeholder: 1. Hospital: administrative efficiency, activating capacity, inclusiveness of decision making, stability/flexibility of rules, conflict resolution and collaboration climate, frequency of interaction. 2 Patient (and caregiver or family): objective (i.e. compliance) and subjective (i.e. quality of life, quality of care perception, patient satisfaction) indicators. 3. Healthcare professional and staff: objective (e.g. turnover rate, absences, injuries and work-related ill health) and subjective (e.g. burnout, satisfaction, healthcare professional engagement, occupational health, risk perception) indicators

In vivo metabolic imaging of Traumatic Brain Injury.

Complex alterations in cerebral energetic metabolism arise after traumatic brain injury (TBI). To date, methods allowing for metabolic evaluation are highly invasive, limiting our understanding of metabolic impairments associated with TBI pathogenesis. We investigated whether 13C MRSI of hyperpolarized (HP) [1-13C] pyruvate, a non-invasive metabolic imaging method, could detect metabolic changes in controlled cortical injury (CCI) mice (n = 57). Our results show that HP [1-13C] lactate-to-pyruvate ratios were increased in the injured cortex at acute (12/24 hours) and sub-acute (7 days) time points after injury, in line with decreased pyruvate dehydrogenase (PDH) activity, suggesting impairment of the oxidative phosphorylation pathway. We then used the colony-stimulating factor-1 receptor inhibitor PLX5622 to deplete brain resident microglia prior to and after CCI, in order to confirm that modulations of HP [1-13C] lactate-to-pyruvate ratios were linked to microglial activation. Despite CCI, the HP [1-13C] lactate-to-pyruvate ratio at the injury cortex of microglia-depleted animals at 7 days post-injury remained unchanged compared to contralateral hemisphere, and PDH activity was not affected. Altogether, our results demonstrate that HP [1-13C] pyruvate has great potential for in vivo non-invasive detection of cerebral metabolism post-TBI, providing a new tool to monitor the effect of therapies targeting microglia/macrophages activation after TBI

Migraine and cluster headache show impaired neurosteroids patterns

Background: Perturbation of neuronal excitability contributes to migraine. Neurosteroids modulate the activity of γ-aminobutyric acid A and N-methyl-d-aspartate receptors, and might be involved in the pathogenesis of migraine. Here, we measured plasma levels of four neurosteroids, i.e., allopregnanolone, epiallopregnanolone, dehydroepiandrosterone and deydroepiandrosterone sulfate, in patients affected by episodic migraine, chronic migraine, or cluster headache. Methods: Nineteen female patients affected by episodic migraine, 51 female patients affected by chronic migraine, and 18 male patients affected by cluster headache were recruited to the study. Sex- and age-matched healthy control subjects (31 females and 16 males) were also recruited. Patients were clinically characterized by using validated questionnaires. Plasma neurosteroid levels were measured by liquid chromatography-tandem mass spectrometry. Results: We found disease-specific changes in neurosteroid levels in our study groups. For example, allopregnanolone levels were significantly increased in episodic migraine and chronic migraine patients than in control subjects, whereas they were reduced in patients affected by cluster headache. Dehydroepiandrosterone and dehydroepiandrosterone sulfate levels were reduced in patients affected by chronic migraine, but did not change in patients affected by cluster headache. Conclusion: We have shown for the first time that large and disease-specific changes in circulating neurosteroid levels are associated with chronic headache disorders, raising the interesting possibility that fluctuations of neurosteroids at their site of action might shape the natural course of migraine and cluster headache. Whether the observed changes in neurosteroids are genetically determined or rather result from exposure to environmental or intrinsic stressors is unknown. This might also be matter for further investigation because stress is a known triggering factor for headache attacks in both migraineurs and cluster headache patients

Hyperpolarized 13 C magnetic resonance spectroscopy detects toxin-induced neuroinflammation in mice.

Lipopolysaccharide (LPS) is a commonly used agent for induction of neuroinflammation in preclinical studies. Upon injection, LPS causes activation of microglia and astrocytes, whose metabolism alters to favor glycolysis. Assessing in vivo neuroinflammation and its modulation following therapy remains challenging, and new noninvasive methods allowing for longitudinal monitoring would be highly valuable. Hyperpolarized (HP) 13 C magnetic resonance spectroscopy (MRS) is a promising technique for assessing in vivo metabolism. In addition to applications in oncology, the most commonly used probe of [1-13 C] pyruvate has shown potential in assessing neuroinflammation-linked metabolism in mouse models of multiple sclerosis and traumatic brain injury. Here, we aimed to investigate LPS-induced neuroinflammatory changes using HP [1-13 C] pyruvate and HP 13 C urea. 2D chemical shift imaging following simultaneous intravenous injection of HP [1-13 C] pyruvate and HP 13 C urea was performed at baseline (day 0) and at days 3 and 7 post-intracranial injection of LPS (n = 6) or saline (n = 5). Immunofluorescence (IF) analyses were performed for Iba1 (resting and activated microglia/macrophages), GFAP (resting and reactive astrocytes) and CD68 (activated microglia/macrophages). A significant increase in HP [1-13 C] lactate production was observed at days 3 and 7 following injection, in the injected (ipsilateral) side of the LPS-treated mouse brain, but not in either the contralateral side or saline-injected animals. HP 13 C lactate/pyruvate ratio, without and with normalization to urea, was also significantly increased in the ipsilateral LPS-injected brain at 7 days compared with baseline. IF analyses showed a significant increase in CD68 and GFAP staining at 3 days, followed by increased numbers of Iba1 and GFAP positive cells at 7 days post-LPS injection. In conclusion, we can detect LPS-induced changes in the mouse brain using HP 13 C MRS, in alignment with increased numbers of microglia/macrophages and astrocytes. This study demonstrates that HP 13 C spectroscopy has substantial potential for providing noninvasive information on neuroinflammation

New perspectives on an “old” technique: Lipari obsidian and Neolithic communities investigated by Fission Track Dating

“Lipari obsidian and Neolithic human communities in the Aeolian islands” is a project aimed at studying the connection between obsidian flows on the island of Lipari and Neolithic populations on the Aeolian archipelago, in Italy. As it is well known, obsidian is of particular interest to trace prehistorical trading patterns; indeed, Lipari obsidian has the widest distribution and has been found in southern France, Dalmazia, Sicily and mainland Italy. The project outputs will give a general vision of both archaeological and volcanological aspects through thestratigraphic and radiometric dating of eruptions which produced obsidian, in relationship with the first phases of the human settlements and row material exploitation. To reach this goal, we are considering both raw materials (geological samples) from different flows and artifacts from Neolithic settlements (archaeological samples) on the Aeolian islands, and performing fission track dating to get the age of obsidian sources and artefacts. Obtained results are expected to shed some new light on the raw material procurement and on the ability of the Neolithic populations to move from their locations, with particular attention to the consequences of environmental features on the first human settlements on the Aeolian islands

'First, do no harm': the role of negative emotions and moral disengagement in understanding the relationship between workplace aggression and misbehavior

Workplace aggression is a critical phenomenon particularly in the healthcare sector, where nurses are especially at risk of bullying and third-party aggression. While workplace aggression has been frequently examined in relation to health problems, less is known about the possible negative impact such aggression may have on the (un)ethical behavior of victims. Our research aims to fill this gap. Drawing on literature on counterproductive work behavior (CWB) and the social-cognitive literature on aggression we investigated in two independent studies (NStudy1 = 439; NStudy2 = 416), the role of negative emotions - in particular anger, fear, and sadness, - and of moral disengagement (MD) in the paths between workplace aggression, CWB and health symptoms. The focus on these relationships is rooted in two reasons. First, misbehavior at work is a pervasive phenomenon worldwide and second, little research has been conducted in the healthcare sector on this type of behavior despite the potential importance of the issue in this context. We empirically tested our hypotheses considering a specific form of workplace aggression in each study: workplace bullying or third-party aggression. Results from the two empirical studies confirm the hypotheses that being target of workplace aggression (bullying or third-party aggression) is not only associated with health symptoms but also with misbehavior. In addition, the results of structural equation modeling attest the importance of examining specific discrete negative emotions and MD for better understanding misbehavior at work. In particular, this research shows for the first time that anger, fear, and sadness, generally aggregated into a single dimension, are indeed differently associated with MD, misbehavior and health symptoms. Specifically, in line with the literature on discrete emotions, while sadness is only associated with health symptoms, anger and fear are related to both health and misbehavior

Cost of chronic and episodic migraine patients in continuous treatment for two years in a tertiary level headache Centre

Background: Migraine is one of the most common neurological diseases and an estimated 1.04 billion people worldwide have been diagnosed with migraine. Available data suggest that migraine is world widely associated with a high economic burden, but there is great variability in estimated costs that depends on the geographical, methodological and temporal differences between the studies. The purpose of this study was to quantify the annual direct cost of episodic migraine (EM) and chronic migraine (CM), both for the patient and for the National Health System (NHS), using data from subjects who attended an Italian tertiary headache centre. Furthermore, we evaluated comparatively the impact of gender and age on the economic burden of migraine. Methods: We conducted a retrospective and non-interventional observational analysis of the electronic medical records of subjects with EM and CM who consecutively attended the Regional Referral Headache Centre of Rome and undergoing continuous treatment in the 2 years prior to 31 January 2019. This approach was intended to prevent distorsions due to natural fluctuations in migraine status over time. The collected data included demographic characteristics, number of specialist visits, consumption of medications, diagnostic tests, accesses in the emergency department (ED) and days of hospitalization due to the pathology. Results: Our sample consisted of 548 patients (85.4% women and 14.6% men): 65.5% had CM and 34.5% had EM. The average annual expenditure per patient was 1482. 82.8% of the total cost (1227) was covered by the NHS. The main item of expenditure were medications that represented 86.8% (1286), followed by specialist visits (10.2%), hospitalizations for (1.9%), diagnostic tests for (1%) and ED visits for (0.1%). Costs were significantly higher for women than men (1517 vs. 1274, p = 0.013) and increased with age (p = 0.002). The annual direct cost of CM was 4.8-fold higher than that of EM (2037 vs. 427, p = 0.001). Conclusion: Our results provide a valuable estimate of the annual direct cost of CM and EM patients in the specific setting of a tertiary headache centre and confirm the high economic impact of migraine on both the NHS and patients

Healthcare Co-production and the Indirect Government Paradigm: addressing the managerial challenges

This qualitative study focuses on the relevant organizational challenges of co-production for the public healthcare system at the micro-level, that of the providers: the hospitals, trust, local health communities, etc. To build this complex picture the authors use a framework developed in the field of policy studies. An analysis and discussion of the scientific literature on the implications of the co-production options highlights the implementation gaps and the as-yet unsolved organizational puzzles and how they are managed in actual practice. The study considers co-production as an indirect tool of government and maps a research agenda of the knowledge gaps and open issues in extant literature

Healthcare services and the co-production challenge : insights for engaging unwilling patterns

The need to reconcile effectiveness with shrinking budgets is pushing contemporary health services to develop co-production practices. But the patient is often an unwilling client and patient engagement with both their therapy and the relative organizational system remains largely unexplored. The article analyzes an Italian hospital\u2019s co-production initiative and uses the results to reflect on what key factors impact the efficacy and the efficiency of healthcare co-production. The empirical evidence indicates that a) the socio-organizational conditions of both the patients and the relevant actors must be taken into account to achieve the truly meaningful engagement of the patient, as opposed to merely symbolic acceptance in co-production practices, as opposed to just their symbolic acceptance; b) no divide exists between organizational production and client co-production, rather, it is a relationship of interdependence that in turn raises critical issues; and c) to take a significant step forward in our understanding of co-production and its managerial challenges we must perforce combine the use of public management studies and health psychology studie