Using patient-reported measures to drive change in healthcare: the experience of the digital, continuous and systematic PREMs observatory in Italy

BACKGROUND: The use of Patient Reported Experience Measures (PREMs) has great potential in healthcare service improvement, but a limited use. This paper presents an empirical case of PREMs innovation in Italy, to foster patient data use up to the ward level, by keeping strengths and addressing weaknesses of previous PREMs survey experiences. The paper reports key lessons learned in this ongoing experience of action research, directly involving practitioners. METHODS: The aim of this paper is to present the results of an ongoing action research, encompassing the innovation of PREMs collection, reporting and use, currently adopted by 21 hospitals of two Italian regions. The continuous and systematic PREMs collection has been implemented between 2017 and 2019 and includes: a continuous web-based administration, using web-services; an augmented and positive questionnaire matching standard closed-ended questions with narrative sections; the inclusion and benchmarking of patient data within a shared performance evaluation system; public disclosure of aggregated anonymized data; a multi-level and real-time web-platform for reporting PREMs to professionals. The action research was carried out with practitioners in a real-life and complex context. The authors used multiple data sources and methods: observations, feedback of practitioners, collected during several workshops and meetings, and analysis of preliminary data on the survey implementation. RESULTS: A continuous and systematic PREMs observatory was developed and adopted in two Italian regions. PREMs participation and response rates tend to increase over time, reaching stable percentages after the first months. Narrative feedback provide a 'positive narration' of episodes and behaviours that made the difference to patients and can inform quality improvement actions. Real-time reporting of quantitative and qualitative data is enabling a gratifying process of service improvement and people management at all the hospitals' levels. CONCLUSIONS: The PREMs presented in this paper has been recognized by healthcare professionals and managers as a strategic and positive tool for improving an actual use of PREMs at system and ward levels, by measuring and highlighting positive deviances, such as compassionate behaviours

Relationships between technical efficiency and the quality and costs of health care in Italy†

Objectives This paper reports the measurement of technical efficiency of Tuscan Local Health Authorities and its relationship with quality and appropriateness of care. Design First, a bias-corrected measure of technical efficiency was developed using the bootstrap technique applied to data envelopment analysis. Then, correlation analysis was used to investigate the relationships among technical efficiency, quality and appropriateness of care. Setting and Participants These analyses have been applied to the Local Health Authorities of Tuscany Region (Italy), which provide not only hospital inpatient services, but also prevention and primary care. All top managers of Tuscan Local Health Authorities were involved in selection of the inputs and outputs for calculating technical efficiency. Main Outcome Measures The main measures used in this study are volume, quality and appropriateness indicators monitored by the multidimensional performance evaluation system developed in the Tuscany Region. Results On average, Tuscan Local Health Authorities experienced 14(%) of bias-corrected inefficiency in 2007. Correlation analyses showed a significant negative correlation between per capita costs and overall performance. No correlation was found in 2007 between technical efficiency and overall performance or between technical efficiency and per capita costs. Conclusions Technical efficiency cannot be considered as an extensive measure of healthcare performance, but evidence shows that Tuscan Local Health Authorities have room for improvement in productivity levels. Indeed, correlation findings suggest that, to pursue financial sustainability, Local Health Authorities mainly have to improve their performance in terms of quality and appropriateness

Healthcare resources and expenditure in financial crisis: scenarios and managerial strategies

What are the implications of financial crisis on healthcare expenditure? This paper explores different approaches applied across European countries focusing on the role that managerial tools may have in coping with this challenge. Method: The paper reports the results of recent studies on responses to financial crisis from European countries and which are the techniques they had applied to reallocate resources. Results: Although resources scarcity, some governments did not reduce the healthcare expenditure because they believe in its focal role on the economic development and on maintaining social cohesion and protection of vulnerable people. Other countries decided a strong reduction of costs which often has affected services delivered. In both cases authors suggest to avoid across-the-board cuts in favor of approach involving priority setting. Conclusion: The public sector has assumed new responsibilities following the global crisis and the rising demand for social services. Some countries shifted the healthcare costs from the public purse to private households undermining the survival of the health system and the universal coverage. A way to avoid this risk is based on the ability to share discussion about where to cut and where to reallocate resources

Obesity and fracture risk.

Obesity and osteoporosis are two common diseases with an increasing prevalence and a high impact on morbidity and mortality. Obese women have always been considered protected against osteoporosis and osteoporotic fractures. However, several recent studies have challenged the widespread belief that obesity is protective against fracture and have suggested that obesity is a risk factor for certain fractures. Fat and bone are linked by many pathways, which ultimately serve the function of providing a skeleton appropriate to the mass of adipose tissue it is carrying. Leptin, adiponectin, adipocytic estrogens and insulin/amylin are involved in this connection. However, excessive body fat, and particularly abdominal fat, produces inflammatory cytokines which may stimulate bone resorption and reduce bone strength. This review aimed to examine the literature data on the relationships of BMI and fat mass with factures in adult and elderly subjects. Even though the more recent studies have shown conflicting results, there is growing evidence that obesity, and particularly severe obesity, may be related to an increased risk of fracture at different skeletal sites which is partially independent from BMD. Moreover, the relationship between obesity and fracture appears to be markedly influenced by ethnicity, gender and fat distribution. Even though the incidence and the pathogenesis of fracture in obese individuals has not yet been clearly defined, the growing evidence that obesity may be related to an increased risk of fracture has important public health implications and emphasizes the need to develop effective strategies to reduce fracture risk in obese subject

Do Patient Preferences Change in a Pandemic? Exploring Italian Patient Reported Experience DATA during the COVID-19 Crisis (PNS245)

Objectives Patient experience is an important metric of hospital performance, both in its own right and due to its association with good processes and a range of positive outcomes. Little is known about the impact of crisis situations on patient experience, such as in the COVID-19 pandemic, where extraordinary measures were necessary to maintain healthcare provision. Methods We performed multilevel and multivariate regression to evaluate the differences in hospitalisation experience before and during the COVID-19 outbreak in Tuscany and Veneto, regions differently affected by the pandemic. Experience was measured by continuously collected online Patient-Reported Experience Measures (PREMs), with 8,712 questionnaires collected from January-April 2020. Results Almost all PREM scores increased in the COVID-19 period compared to the two months preceding. Multilevel analysis showed very low, nonsignificant variation in overall satisfaction and Willingness-to-Recommend (WOM) between hospitals in the same region, controlling for health status, sex, age, and first incidence of COVID-19 in the region. Multivariate regression models, including demographic factors only, found increased WOM in the worse affected region. By including relevant PREM items, we found the items most predictive of WOM changed during pandemic situations, with a greater effect and significance for items associated with emotional support and communication (e.g. having fears and anxieties addressed by clinicians [0.25, p=0.07; 0.46 p=0.03]) alongside reduced effect sizes and higher p-values for items most affected by pandemic control processes (e.g. ward silence [0.47, p=0.04; 0.14, p=0.45], communication with relatives [0.3, p=0.02; 0.005, p=0.98). Conclusions Hospitals in Tuscany and Veneto were able to provide a positive patient experience in the COVID-19 pandemic, despite operating challenges. Patient expectations of their hospitalisation may have changed through awareness of the wider health crisis. The different factors most predictive of WOM during the pandemic may be explained by patient recognition and understanding of the great efforts and professionalism of healthcare professionals

Divergent effects of obesity on fragility fractures

Obesity was commonly thought to be advantageous for maintaining healthy bones due to the higher bone mineral density observed in overweight individuals. However, several recent studies have challenged the widespread belief that obesity is protective against fracture and have suggested that obesity is a risk factor for certain fractures. The effect of obesity on fracture risk is site-dependent, the risk being increased for some fractures (humerus, ankle, upper arm) and decreased for others (hip, pelvis, wrist). Moreover, the relationship between obesity and fracture may also vary by sex, age, and ethnicity. Risk factors for fracture in obese individuals appear to be similar to those in nonobese populations, although patterns of falling are particularly important in the obese. Research is needed to determine if and how visceral fat and metabolic complications of obesity (type 2 diabetes mellitus, insulin resistance, chronic inflammation, etc) are causally associated with bone status and fragility fracture risk. Vitamin D deficiency and hypogonadism may also influence fracture risk in obese individuals. Fracture algorithms such as FRAX® might be expected to underestimate fracture probability. Studies specifically designed to evaluate the antifracture efficacy of different drugs in obese patients are not available; however, literature data may suggest that in obese patients higher doses of the bisphosphonates might be required in order to maintain efficacy against nonvertebral fractures. Therefore, the search for better methods for the identification of fragility fracture risk in the growing population of adult and elderly subjects with obesity might be considered a clinical priority which could improve the prevention of fracture in obese individual