Increasing public healthcare network performance by deî¸hospitalization:A patient pathway perspective

PurposeThe aim of this paper is to support public decision‐makers in a local healthcare agency (LHA) in evaluating the effects of different de‐hospitalization strategies and the potential for outsourcing clinical services.Design/methodology/approachThe approach adopted is based on the “patient pathway” perspective. Starting from the identification of specific care pathways, all the feasible care paths in a given LHA in Italy are investigated in order to evaluate the practicability of the de‐hospitalization of some phases with a particular focus on co‐ordination of hospitals and territorial services. A heuristic approach based on discrete‐event simulation modelling is proposed. The methodology and the simulation model have been validated with reference to field data derived from a full‐scale case study carried out within a LHA in southern Italy.FindingsThe results show where, in terms of care pathways, de‐hospitalization is practicable, valuable in terms of better resource utilization, and eligible for outsourcing. The outsourcing option appears to be more sustainable from a social point of view. It specifies that there would be no dismissal of employees, and that there would be recruitment of specialized workers such as nurses and doctors, employed under more flexible conditions. Savings in overheads would be achieved by means of patient de‐hospitalization.Originality/valueThe existing scientific literature, to the best of the authors' knowledge, deals with patient flow management at the hospital level. However, in the European countries, the public healthcare system is generally organized in terms of the territorially based allocation of service centres. Given the scarcity of public resources, the main difficulty seems to be a mismatch among actions needed to improve territorial and residential care for outsourcing, and the interventions needed to contain hospital costs.</jats:sec

[Optimizing the care management pathway of patients with ischemia and non-obstructive coronary arteries]

Ischemia with non-obstructive coronary arteries (INOCA) is defined by the coexistence of anginal symptoms and demonstrable ischemia, with no evidence of obstructive coronary arteries. The underlying mechanism of INOCA is coronary microvascular dysfunction with or without associated vasospasm. INOCA patients have recurrent symptoms, functional limitations, repeated access to the emergency department, impaired quality of life and a higher incidence of cardiovascular events than the general population. Although well described in chronic coronary syndrome guidelines, INOCA remains underdiagnosed in clinical practice because of insufficient awareness, lack of accurate diagnostic tools, and poorly standardized and consistent definitions to diagnose, both invasively and non-invasively, coronary microvascular dysfunction.To disseminate current scientific evidence on INOCA as a distinct clinical entity, during 2022 we conducted at 30 cardiology units all over the country a clinical practice improvement initiative, with the aim of developing uniform and shared management pathways for INOCA patients across different operational settings. The present document highlights the outcomes of this multidisciplinary initiative

Sex-Related Differences in Long-Term Outcomes After Early-Onset Myocardial Infarction

ImportanceThere is growing awareness of sex-related differences in cardiovascular risk profiles, but less is known about whether these extend to pre-menopausal females experiencing an early-onset myocardial infarction (MI), who may benefit from the protective effects of estrogen exposure. MethodsA nationwide study involving 125 Italian Coronary Care Units recruited 2,000 patients between 1998 and 2002 hospitalized for a type I myocardial infarction before the age of 45 years (male, n = 1,778 (88.9%). Patients were followed up for a median of 19.9 years (IQR 18.1-22.6). The primary composite endpoint was the occurrence of cardiovascular death, non-fatal myocardial re-infarction or non-fatal stroke, and the secondary endpoint of hospitalization for revascularisation by means of a percutaneous coronary intervention (PCI) or coronary artery bypass surgery (CABG). ResultsST-elevation MI was the most frequent presentation among both men and women (85.1 vs. 87.4%, p = ns), but the men had a greater baseline coronary atherosclerotic burden (median Duke Coronary Artery Disease Index: 48 vs. 23; median Syntax score 9 vs. 7; both p &lt; 0.001). The primary composite endpoint occurred less frequently among women (25.7% vs. 37.0%; adjusted hazard ratio: 0.69, 95% CI 0.52-0.91; p = 0.01) despite being less likely to receive treatment with most secondary prevention medications during follow up. ConclusionsThere are significant sex-related differences in baseline risk factors and outcomes among patients with early-onset MI: women present with a lower atherosclerotic disease burden and, although they are less frequently prescribed secondary prevention measures, experience better long-term outcomes