Effectiveness of clinical pathway in subjects with heart failure: A real-world study from Italian health claims

Background: Several process-of-care indicators have been developed and implemented to improve the quality of heart failure (HF) patients care. The aim of this study is to assess the relationship between a set of recommendations for HF care with measurable clinical outcomes, also in terms of outcomes that could be avoided. Methods: A retrospective cohort study was carried out on subjects with at least one hospitalization with a primary diagnosis of HF in 2007. Data were retrieved from healthcare utilization databases of Lombardy region (Italy). Exposure to selected recommendations (periodic control of echocardiogram and use of blockers of the renin-angiotensin system and beta-blockers) was recorded. All cause mortality and hospitalization with primary diagnosis of HF were considered as outcomes. Multivariable Cox models and Poisson model were fitted to estimate the exposure-outcome association. Results: Among 8207 cases of HF, those who adhered to none, one or all recommendations during the first year after diagnosis were 11%, 60% and 30%, respectively. Compared to patients who adhered to no recommendation, a significant mortality risk reduction of 24% (95% CI 17-31%) and 44% (36 52%) were observed for those who adhered to one and all recommendations, respectively. A significant reduction in the rate of re-hospitalizations in subjects adhered to at least one recommendation was also observed. A decreased trend in Population Attributable Fraction for death cases according to follow-up time was observed. Conclusion: A strict control of patients with HF through regular clinical examinations must be considered as fundamental for the reduction of mortality and re-hospitalizations

Confronto tra Inquiry-based Science Education ed insegnamento tradizionale delle Scienze in alcune scuole superiori italiane

This study aims to evaluate if inquiry-based science education (IBSE) at the high school level allows the achievement of better learning objectives with respect to conventional science education (CSE). The findings would help to understand if, how, and why IBSE can be used as a successful teaching approach. The study included four high schools with different specialties, eight experienced science teachers and approximately 350 students, attending sixteen classes. Two biochemistry topics were taught by the same teacher in two classes. A two stage quasi experimental, crossover design was adopted. The primary outcome compared the difference in the average pre-teaching and post-teaching test-scores, using a 3-multilevel analysis. On average, the outcome in terms of scores significantly improved by 4% with IBSE with respect to the CSE approach, demonstrating differences among the school specialties. In conclusion, our study indicates that IBSE is significantly more effective in enhancing skills.Questo studio mira a valutare se l’approccio “Inquiry-based science education” (IBSE) consenta il raggiungimento di obiettivi di apprendimento, a livello di scuola superiore, in modo più efficacerispetto all’educazione scientifica convenzionale (CSE). I risultati possono aiutare a capire se, come e perché IBSE può essere utilizzato come approccio didattico di successo. Lo studio ha inclusoquattro scuole superiori con diversi indirizzi, otto insegnanti di scienze con esperienza e circa 350 studenti, suddivisi in sedici classi. Due tematiche di biochimica sono state insegnate dallo stesso docente in due classi parallele. È stato adottato un disegno quasi sperimentale, crossover, a due fasi. Obiettivo primario è stato confrontare la differenza nei punteggi medi nei test prima e dopo le attività, utilizzando un’analisi gerarchica a 3 livelli. In media, il risultato in termini di punteggi è migliorato significativamente del 4% con IBSE rispetto all’approccio CSE, dimostrando differenze tra gli indirizzi scolastici. In conclusione, il nostro studio indica che IBSE è significativamente più efficace nel migliorare le competenze

Ex-vivo recruitment and x-ray assessment of donor lungs in a challenging retrieval from a donor supported by lvad using the portable normothermic perfusion system: A case report

Lung transplantation (LTx) is limited by the shortage of suitable donors. To overcome this problem, many programs have begun to use donors with extended criteria (marginal donors). However, brain-dead patients with implanted mechanical circulatory support system have rarely been considered as potential lung donors. This case demonstrates the feasibility of lung transplantations from organ donors supported by a mechanical circulatory support system despite the possible difficulties of lung retrieval. CASE PRESENTATION: Our case presents a successful procurement and bilateral lung transplantation from a donor supported by a left ventricular assist device (LVAD) who experienced an intraoperatively haemodynamic complication. The use of portable normothermic perfusion device let us to reduce ischemic injury and assess these marginal donor lungs helping us to determine the clinical suitability for transplantation. Given our extensive experience with the device instrumentation and management, the EVLP process was uneventful with excellent post-transplant course. CONCLUSIONS: This case report demonstrates the feasibility of lung transplantations from organ donors supported by a mechanical circulatory support system using the portable normothermic perfusion platform to assess and preserve these donor lungs

Adherence With Antihypertensive Drug Therapy and the Risk of Heart Failure in Clinical Practice

Randomized clinical trials have shown that antihypertensive treatment reduces the risk of heart failure (HF). Limited evidence exists, however, on whether and to what extent this benefit is translated into real-life practice. A nested case–control study was carried out by including the cohort of 76 017 patients from Lombardy (Italy), aged 40 to 80 years, who were newly treated with antihypertensive drugs during 2005. Cases were the 622 patients who experienced hospitalization for HF from initial prescription until 2012. Up to 5 controls were randomly selected for each case. Logistic regression was used to model the HF risk associated with adherence to antihypertensive drugs, which was measured by the proportion of days covered by treatment (PDC). Data were adjusted for several covariates. Sensitivity analyses were performed to account for possible sources of systematic uncertainty. Compared with patients with very low adherence (PDC, ≤25%), low, intermediate, and high adherences were associated with progressively lower risk of HF, reduction in the high-adherence group (>75%) being 34% (95% confidence interval, 17%–48%). Similar effects were observed in younger (40–70 years) and older (71–80 years) patients and between patients treated with angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and diuretics. There was no evidence that adherence with calcium-channel blockers reduced the HF risk. Antihypertensive treatment lowers the HF risk in real-life practice, but adherence to treatment is necessary for a substantial benefit to take place. This is the case with a variety of antihypertensive drugs

Real-world assessment of healthcare provided by the National Health Service: The network of regional Beaver research platforms

Real-world evidence can provide answers on healthcare utilization and appropriateness, post-marketing drugs safety and comparative effectiveness, and cost-effectiveness profiles of healthcare pathways. Healthcare utilization databases, possibly integrated with drug and disease registries, electronic medical records, survey and cohort data (i.e. real-world data), allow to trace healthcare ‘footprints’ left from beneficiaries of National Health Service. Beaver is a research platform available on demand to Italian regions which we developed for computing indicators of healthcare utilization and clinical outcomes, as well as for generating evidence on effectiveness and cost-effectiveness profile. Two distinct solutions may be adopted. One, the so-called Beaver Light front-end allows to automatically compute health indicators of adherence to official guidelines. Two, the so-called Beaver Full front-end involves an eight-step procedure entirely driven by the study protocol. In order to fulfil the directives recently issued by the European Parliament and Council and the Italian Authority for the protection of individual data, the platform resides in each region’s infrastructure, so limiting the free movement of electronic health data. Indeed, regional authorities should be responsible for data safety and for allowing data accessibility. The use of standardized and validated algorithms enables to obtain regional estimates that, being obtained by employing regional platforms containing data extracted with standardized procedure, may be compared and possibly summarized by using common meta-analytic techniques. In conclusion, the Beaver regional platform is a promising tool which may contribute to stimulate healthcare research in Italy

Surgical and neurologic outcomes after robotic thymectomy in 100 consecutive patients with myasthenia gravis

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Psychiatric rehabilitation patterns in Italy: Results from the Italian Society of Psychosocial Rehabilitation (SIRP) survey

IntroductionPsychiatric rehabilitation can be considered a bidirectional technique, designed to allow patients to achieve their personal target, focusing on the individuals' strengths and challenges related to these targets and also on the community organizations in which they will live them out. Unfortunately, psychiatric rehabilitation is too often not considered a first line treatment. Moreover, rehabilitation has been confused with a generic and rough practice, consisting of extemporary actions and aimless entertainments designed to fill "the time passing". MethodsThe aim of this study was to increase the knowledge and awareness about the state of the art of different systems of management and funding of psychosocial rehabilitation in the Italian "real-world" rehabilitative settings, using a specifically developed questionnaire. ResultsThe data obtained are positive for some aspects of the rehabilitation interventions, in particular for the use of validated tools for the evaluation and revision of projects and for the trend to work on a team, even though the scarcity of evidence-based rehabilitation interventions applied in Italian psychiatric services is less encouraging. ConclusionThis survey presents, at least partially, the "real-world" of rehabilitation in Italy so that we can lay the foundations for the definition of an updated, validated and shared network of what is implemented in the context of psychiatric rehabilitation

Acquired tracheoesophageal fistula repair, due to prolonged mechanical ventilation, in patient with double incomplete aortic arch

We report a case of the repair of an acquired benign tracheoesophageal fistula (TEF) after prolonged mechanical invasive ventilation. Patient had an unknown double incomplete aortic arch determining a vascular ring above trachea and esophagus. External tracheobronchial compression, caused by the vascular ring, increasing the internal tracheoesophageal walls pressure determined by endotracheal and nasogastric tubes favored an early TEF development. The fistula was repaired through an unusual left thoracotomy and vascular ring dissection. TEFs are a heterogeneous group of diseases affecting critically ill patients. Operative closure is necessary to avoid further complications related to this condition. Pre-operative study is mandatory to plan an adequate surgical approach

Flexible Approaches Based on Multistate Models and Microsimulation to Perform Real-World Cost-Effectiveness Analyses: An Application to Proprotein Convertase Subtilisin-Kexin Type 9 Inhibitors

Objectives: This study aims to show the application of flexible statistical methods in real-world cost-effectiveness analyses applied in the cardiovascular field, focusing specifically on the use of proprotein convertase subtilisin-kexin type 9 inhibitors for hyperlipidemia. Methods: The proposed method allowed us to use an electronic health database to emulate a target trial for cost-effectiveness analysis using multistate modeling and microsimulation. We formally established the study design and provided precise definitions of the causal measures of interest while also outlining the assumptions necessary for accurately estimating these measures using the available data. Additionally, we thoroughly considered goodness-of-fit assessments and sensitivity analyses of the decision model, which are crucial to capture the complexity of individuals' healthcare pathway and to enhance the validity of this type of health economic models. Results: In the disease model, the Markov assumption was found to be inadequate, and a "time-reset" timescale was implemented together with the use of a time-dependent variable to incorporate past hospitalization history. Furthermore, the microsimulation decision model demonstrated a satisfying goodness of fit, as evidenced by the consistent results obtained in the short-term horizon compared with a nonmodel-based approach. Notably, proprotein convertase subtilisin-kexin type 9 inhibitors revealed their favorable cost-effectiveness only in the long-term follow-up, with a minimum willingness to pay of 39 000 Euro/life years gained. Conclusions: The approach demonstrated its significant utility in several ways. Unlike nonmodel-based or alternative model-based methods, it enabled to (1) investigate long-term cost-effectiveness comprehensively, (2) use an appropriate disease model that aligns with the specific problem under study, and (3) conduct subgroup-specific cost-effectiveness analyses to gain more targeted insights