Access to Healthcare as a New Commons: Telemedicine as a Strategy for Providing Value-Based Healthcare Services in Rural Areas

Commons is a general term that refers to a resource shared by a group of people. Over the years, scholars have identified two generations of commons. The first generation of commons was about sharing of physical things; the second one is about intangible commons pool resources such as science and culture. These generally can be recognized as "rights" (Hess 2008). Among the various New Commons sectors there is medical and health. In the perspective of guaranteeing the right of Health, the ―Access to Healthcare‖ could be considered as a New Commons provided by worldwide National Healthcare Systems (NHS), However, healthcare sector is characterized by plenty of stakeholders with myriad, often, conflicting goals. The value-based approach (Porte, 2010) attempts to introduce a new universal language in healthcare management around the value for the patient that reconcile all stakeholders‘ interests. The goal of this approach is to improve the outcome and increase the number of treatments. This aim is very difficult to be enriched for rural residents; when patients live in remote areas, providing them with valuable medical care can be considered a hard challenge for the NHS, which has to be addressed also by the employment of new healthcare strategies and technologies. Defined as "a new healthcare delivery process provided when patient and professional are not physically in the same place" (Italian Ministry of Health, 2014), telemedicine could be seen as an answer to this challenge. Accordingly, this study aims at discovering if telemedicine employment can be effectively considered as a successful strategy to improve healthcare in location far from specialized hospital, enhancing the New Commons ―Access to care‖. A statistical-based narrative review of the literature was conducted in the field of telemedicine, with the aim to understand which experiences of telemedicine applications have got successful results as support of healthcare delivering in rural locations. With regards to rural and remote areas, several Authors recognized telemedicine-based strategies as a method to facilitate the access to healthcare in different medical disciplines. In particular, many studies highlight that telemedicine improves patient care by increasing the capacity of the rural clinician to manage patient locally, minimizing time away to support networks and reducing unnecessary transfers. Telemedicine could also be considered a cost-effective method whose outcomes remain similar (if not better) in quality to ―staffed‖ services, whose infrastructural costs could be easily paid-back

La Telemedicina tra innovazione e sostenibilità: modello operativo generale e tassonomia delle risorse coinvolte

Il progressivo innalzamento dell’età media delle popolazioni nei Paesi Occidentale ha contribuito all’incremento esponenziale del tasso d’incidenza delle mattie croniche e all’aumento di poli-patologie e nuove sindromi, con importanti ripercussioni sulle esigenze socio-sanitarie diffuse. Tale circostanza sta fortemente mettendo a rischio la sostenibilità economico-finanziaria dei Sistemi Sanitari Nazionali, costringendoli a fronteggiare una nuova sfida legata all’erogazione di servizi sanitari qualitativamente adeguati e a costi contenuti. In tale contesto, le tecnologie digitali possono rappresentare un elemento estremamente rilevante per vincere tale sfida. Tra queste, in particolare, la Telemedicina si configura come un’innovazione tecnologica clinicamente efficacie, capace di incrementare l’equità d’accesso ai servizi assistenziali, con simultanea riduzione delle risorse necessarie alla loro erogazione. Un’innovazione, dunque, pienamente coerente con le logiche del Value-Based Healthcare. Nonostante le sue elevate potenzialità, la diffusione della Telemedicina stenta ancora a diffondersi nei processi correnti delle organizzazioni sanitarie; ciò sembra essere prevalentemente imputabile all’esigenze di cambiamento delle strutture produttive ed organizzative, nonché di conoscenze, tecnologie e processi operativi, che le aziende devono affrontare per introdurre tale innovazione. Tuttavia, la conoscenza e l’analisi delle le risorse richieste per l’ammodernamento dei processi assistenziali, sembra essere un prerequisito vincolante a tale percorso di cambiamento. A partire da ciò, il presente lavoro ha l’obiettivo di delineare le caratteristiche generali di un modello di erogazione di assistenza sanitaria in Telemedicina, e di classificare, per tipologia, le risorse necessarie alla sua implementazione. Tale disamina può contribuire, dunque, alla definizione di una prima base di conoscenza utile alle decisioni d’investimento in sanità digitale, con il fine di agevolare la valutazione di convenienza economica e di recuperabilità di tale tipologia d’investimento

The diet of Weddell seals (Leptonychotes weddellii) in Terra Nova Bay using stable isotope analysis

Stable isotope analyses were used to investigate the diet of Weddell seals in Terra Nova Bay (Ross Sea) and the potential variation of their foraging behaviour with age, sex and body mass. For this purpose, skin samples were collected from adult breeding seals and pups, together with muscle samples of their potential prey. Our results showed variation in foraging behavior between age classes, with pups reporting lower δ13C values than adults, while no significant differences in δ15N were recorded. In addition, contrary to expectations, a mixing model analysis showed that adult seals foraged mainly on shallow benthic prey, such as Trematomus spp. (34.1%) and Dissostichus mawsoni (21.1%), rather than on pelagic fish, such as Pleuragramma antarcticum (9.8%). Overall, with this paper we provide novel diet information on a seal colony not previously sampled, adding new insight into the feeding ecology of a top Antarctic predator

L’accordo per la definizione della “vertenza fasce” degli anni 2010-2016: dal blocco delle relazioni sindacali al rilancio della progettazione dell’innovazione organizzativa nella Azienda Sanitaria di Matera

Riassunto: L’obiettivo del presente lavoro è di ripercorrere il percorso strategico-amministrativo che ha portato alla risoluzione della annosa problematica della “vertenza fasce” 2010-2016 nell’Azienda Sanitaria di Matera (ASM), conseguente all’ispezione MEF-RGS del 2018, con la quale veniva contestato un irregolare trasferimento permanente di risorse dal Fondo “Produttività” al Fondo “Posizione”. Inquadrato nell’ambito teorico del Management Strategico e della Public Service Motivation, il lavoro intende evidenziare: i) i passaggi necessari al raggiungimento dell’accordo (poi approvato dal MEFRGS nel 2020) con le organizzazioni sindacali; ii) come tale accordo abbia contribuito a sbloccare la paralisi dei processi produttivi, gestionali e d’innovazione organizzativa della ASM; iii) gli attuali risultati operativi dell’ASM dopo la positiva risoluzione della vertenzaThis work aims to retrace the strategic-managerial path that led to the resolution of the 2010-2016 “dispute on roles” in the Matera Health Authority (ASM). This controversy was consequent to the 2018 inspection from the Italian Ministry of Economy and Finance (MEF-RGS), which notified an irregular transfer of financial resources from the “Productivity” Fund to the “Position” one. Based on the theoretical background of Strategic Management and Public Service Motivation, the work highlights: i) the steps required to reach an agreement (MEF-RGS approved in 2020) with trade Unions; ii) how this agreement contributed to unjamming the paralysis of ASM management, operational and organizational innovation processes; iii) the current ASM results and outcomes, after the positive resolution of the dispute

Economic impact of remote monitoring on ordinary follow-up of implantable cardioverter defibrillators as compared with conventional in-hospital visits: a single-center prospective and randomized study

Few data are available on actual follow-up costs of remote monitoring (RM) of implantable defibrillators (ICD). Our study aimed at assessing current direct costs of 1-year ICD follow-up based on RM compared with conventional quarterly in-hospital follow-ups. Methods and results Patients (N=233) with indications for ICD were consecutively recruited and randomized at implant to be followed up for 1 year with standard quarterly inhospital visits or by RM with one in-hospital visit at 12 months, unless additional in-hospital visits were required due to specific patient conditions or RM alarms. Costs were calculated distinguishing between provider and patient costs, excluding RM device and service cost. The frequency of scheduled in-hospital visits was lower in the RM group than in the control arm. Follow-up required 47 min per patient/year in the RM arm versus 86 min in the control arm (p=0.03) for involved physicians, generating cost estimates for the provider of USD 45 and USD 83 per patient/- year, respectively. Costs for nurses were comparable. Overall, the costs associated with RM and standard follow-up were USD 103±27 and 154±21 per patient/year, respectively (p=0.01). RM was cost-saving for the patients: USD 97±121 per patient/year in the RM group versus 287± 160 per patient/year (p=0.0001). Conclusion The time spent by the hospital staff was significantly reduced in the RM group. If the costs for the device and service are not charged to patients or the provider, patients could save about USD 190 per patient/year while the hospital could save USD 51 per patient/year

Meningococci of serogroup X clonal complex 181 in refugee camps, Italy

Four cases of infection with serogroup X meningococci (MenX) (1 in 2015 and 3 in 2016) occurred in migrants living in refugee camps or reception centers in Italy. All MenX isolates were identified as clonal complex 181. Our report suggests that serogroup X represents an emerging health threat for persons arriving from African countries

Genome-based study of a spatio-temporal cluster of invasive meningococcal disease due to Neisseria meningitidis serogroup C, clonal complex 11

Summary Objectives To describe a spatio-temporal cluster of invasive meningococcal disease (IMD) due to serogroup C meningococci, occurred in a restricted area of Tuscany between January and October 2015, and the results of whole genome sequencing (WGS). Methods Surveillance activities and public health measures were implemented in the Region. Bacterial isolates from IMD cases were characterized by the National Reference Laboratory of the Istituto Superiore di Sanita (ISS), and WGS was performed on available strains. The kSNP software was used to identify core genome SNPs. Results Overall, 28 IMD cases due to meningococcus C were identified up to 31st October, 2015. Of them, 26 were due to meningococcus C:P1.5-1,10-8: F3-6:ST-11 (cc11) and 2 to C:P1.5-1,10-8: F3-6:ST-2780 (cc11). WGS of 13 meningococci isolated during the outbreak occurred in Tuscany in 2015 showed higher similarity when compared with those of 47 C: P1.5-1,10-8: F3-6:ST-11 (cc11) invasive strains from sporadic cases previously detected in Italy. Conclusions A highly aggressive meningococcal C strain was involved in the cluster of severe IMD occurred in Tuscany, a Region with high vaccine coverage among children. Whether this was due to low herd immunity related to the short duration of vaccine protection needs further investigation

Genome-based study of a spatio-temporal cluster of invasive meningococcal disease due to Neisseria meningitidis serogroup C, clonal complex 11

SummaryObjectivesTo describe a spatio-temporal cluster of invasive meningococcal disease (IMD) due to serogroup C meningococci, occurred in a restricted area of Tuscany between January and October 2015, and the results of whole genome sequencing (WGS).MethodsSurveillance activities and public health measures were implemented in the Region. Bacterial isolates from IMD cases were characterized by the National Reference Laboratory of the Istituto Superiore di Sanità (ISS), and WGS was performed on available strains. The kSNP software was used to identify core genome SNPs.ResultsOverall, 28 IMD cases due to meningococcus C were identified up to 31st October, 2015. Of them, 26 were due to meningococcus C:P1.5-1,10-8: F3-6:ST-11 (cc11) and 2 to C:P1.5-1,10-8: F3-6:ST-2780 (cc11). WGS of 13 meningococci isolated during the outbreak occurred in Tuscany in 2015 showed higher similarity when compared with those of 47 C: P1.5-1,10-8: F3-6:ST-11 (cc11) invasive strains from sporadic cases previously detected in Italy.ConclusionsA highly aggressive meningococcal C strain was involved in the cluster of severe IMD occurred in Tuscany, a Region with high vaccine coverage among children. Whether this was due to low herd immunity related to the short duration of vaccine protection needs further investigation