Eco-productivity analysis of the municipal solid waste service in the Apulia region from 2010 to 2017

This paper presents a dynamic efficiency study of the solid waste management in the municipalities of the Apulia region (Southern Italy). The study employs the non-parametric Global Malmquist Index to measure the change in productivity of the municipal solid waste service from 2010 to 2017. Three different DEA-based models are implemented to measure productivity. The first model computes the service productivity solely from the economic perspective, while the second and third models compute the service productivity from both the economic and environmental perspectives. Adopting two distinct perspectives provides a more comprehensive insight into the performance of the waste management service considering the productivity and the eco-productivity of service provision. The results from the productivity analysis show that, between 2010 and 2017, the municipal solid waste sector was still facing a transitional period characterized by low cost-efficiency and productivity growth measurements. Vice versa, the efficiency and productivity indicators improve when the analysis is performed accounting for the environmental impact. Indeed, both the eco-efficiency and eco-productivity measures increase from 2010 to 2017. Findings demonstrate the critical importance to include environmental indicators in the efficiency and productivity analysis

"Delirium Day": A nationwide point prevalence study of delirium in older hospitalized patients using an easy standardized diagnostic tool

Background: To date, delirium prevalence in adult acute hospital populations has been estimated generally from pooled findings of single-center studies and/or among specific patient populations. Furthermore, the number of participants in these studies has not exceeded a few hundred. To overcome these limitations, we have determined, in a multicenter study, the prevalence of delirium over a single day among a large population of patients admitted to acute and rehabilitation hospital wards in Italy. Methods: This is a point prevalence study (called "Delirium Day") including 1867 older patients (aged 65 years or more) across 108 acute and 12 rehabilitation wards in Italian hospitals. Delirium was assessed on the same day in all patients using the 4AT, a validated and briefly administered tool which does not require training. We also collected data regarding motoric subtypes of delirium, functional and nutritional status, dementia, comorbidity, medications, feeding tubes, peripheral venous and urinary catheters, and physical restraints. Results: The mean sample age was 82.0 \ub1 7.5 years (58 % female). Overall, 429 patients (22.9 %) had delirium. Hypoactive was the commonest subtype (132/344 patients, 38.5 %), followed by mixed, hyperactive, and nonmotoric delirium. The prevalence was highest in Neurology (28.5 %) and Geriatrics (24.7 %), lowest in Rehabilitation (14.0 %), and intermediate in Orthopedic (20.6 %) and Internal Medicine wards (21.4 %). In a multivariable logistic regression, age (odds ratio [OR] 1.03, 95 % confidence interval [CI] 1.01-1.05), Activities of Daily Living dependence (OR 1.19, 95 % CI 1.12-1.27), dementia (OR 3.25, 95 % CI 2.41-4.38), malnutrition (OR 2.01, 95 % CI 1.29-3.14), and use of antipsychotics (OR 2.03, 95 % CI 1.45-2.82), feeding tubes (OR 2.51, 95 % CI 1.11-5.66), peripheral venous catheters (OR 1.41, 95 % CI 1.06-1.87), urinary catheters (OR 1.73, 95 % CI 1.30-2.29), and physical restraints (OR 1.84, 95 % CI 1.40-2.40) were associated with delirium. Admission to Neurology wards was also associated with delirium (OR 2.00, 95 % CI 1.29-3.14), while admission to other settings was not. Conclusions: Delirium occurred in more than one out of five patients in acute and rehabilitation hospital wards. Prevalence was highest in Neurology and lowest in Rehabilitation divisions. The "Delirium Day" project might become a useful method to assess delirium across hospital settings and a benchmarking platform for future surveys

The association of indwelling urinary catheter with delirium in hospitalized patients and nursing home residents: an explorative analysis from the "Delirium Day 2015"

Backround: Use of indwelling urinary catheter (IUC) in older adults has negative consequences, including delirium. Aim: This analysis, from the "Delirium Day 2015", a nationwide multicenter prevalence study, aim to evaluate the association of IUC with delirium in hospitalized and Nursing Homes (NHs) patients. Methods: Patients underwent a comprehensive geriatric assessment, including the presence of IUC; inclusion criteria were age > 65 years, being Italian speaker and providing informed consent; exclusion criteria were coma, aphasia, end-of-life status. Delirium was assessed using the 4AT test (score ≥ 4: possible delirium; scores 1-3: possible cognitive impairment). Results: Among 1867 hospitalized patients (mean age 82.0 ± 7.5 years, 58% female), 539 (28.9%) had IUC, 429 (22.9%) delirium and 675 (36.1%) cognitive impairment. IUC was significantly associated with cognitive impairment (OR 1.60, 95% CI 1.19-2.16) and delirium (2.45, 95% CI 1.73-3.47), this latter being significant also in the subset of patients without dementia (OR 2.28, 95% CI 1.52-3.43). Inattention and impaired alertness were also independently associated with IUC. Among 1454 NHs residents (mean age 84.4 ± 7.4 years, 70.% female), 63 (4.3%) had IUC, 535 (36.8%) a 4AT score ≥ 4, and 653 (44.9%) a 4AT score 1-3. The multivariate logistic regression analysis did not show a significant association between 4AT test or its specific items with IUC, neither in the subset of patients without dementia. Discussion: We confirmed a significant association between IUC and delirium in hospitalized patients but not in NHs residents. Conclusion: Environmental and clinical factors of acute setting might contribute to IUC-associated delirium occurrence

"Delirium Day": A nationwide point prevalence study of delirium in older hospitalized patients using an easy standardized diagnostic tool

Background: To date, delirium prevalence in adult acute hospital populations has been estimated generally from pooled findings of single-center studies and/or among specific patient populations. Furthermore, the number of participants in these studies has not exceeded a few hundred. To overcome these limitations, we have determined, in a multicenter study, the prevalence of delirium over a single day among a large population of patients admitted to acute and rehabilitation hospital wards in Italy. Methods: This is a point prevalence study (called "Delirium Day") including 1867 older patients (aged 65 years or more) across 108 acute and 12 rehabilitation wards in Italian hospitals. Delirium was assessed on the same day in all patients using the 4AT, a validated and briefly administered tool which does not require training. We also collected data regarding motoric subtypes of delirium, functional and nutritional status, dementia, comorbidity, medications, feeding tubes, peripheral venous and urinary catheters, and physical restraints. Results: The mean sample age was 82.0 ± 7.5 years (58 % female). Overall, 429 patients (22.9 %) had delirium. Hypoactive was the commonest subtype (132/344 patients, 38.5 %), followed by mixed, hyperactive, and nonmotoric delirium. The prevalence was highest in Neurology (28.5 %) and Geriatrics (24.7 %), lowest in Rehabilitation (14.0 %), and intermediate in Orthopedic (20.6 %) and Internal Medicine wards (21.4 %). In a multivariable logistic regression, age (odds ratio [OR] 1.03, 95 % confidence interval [CI] 1.01-1.05), Activities of Daily Living dependence (OR 1.19, 95 % CI 1.12-1.27), dementia (OR 3.25, 95 % CI 2.41-4.38), malnutrition (OR 2.01, 95 % CI 1.29-3.14), and use of antipsychotics (OR 2.03, 95 % CI 1.45-2.82), feeding tubes (OR 2.51, 95 % CI 1.11-5.66), peripheral venous catheters (OR 1.41, 95 % CI 1.06-1.87), urinary catheters (OR 1.73, 95 % CI 1.30-2.29), and physical restraints (OR 1.84, 95 % CI 1.40-2.40) were associated with delirium. Admission to Neurology wards was also associated with delirium (OR 2.00, 95 % CI 1.29-3.14), while admission to other settings was not. Conclusions: Delirium occurred in more than one out of five patients in acute and rehabilitation hospital wards. Prevalence was highest in Neurology and lowest in Rehabilitation divisions. The "Delirium Day" project might become a useful method to assess delirium across hospital settings and a benchmarking platform for future surveys

Effectiveness-efficiency nexus in municipal solid waste management: A non-parametric evidence-based study

The scope of this work is to present a comprehensive approach to analyze the effectiveness-efficiency nexus in the evaluation of the performance of municipal solid waste (MSW) management. The rate of separate MSW collection is used to measure service effectiveness. A multiple set of non-parametric indicators is employed to obtain measurements of technical, scale and congestion efficiencies of waste service provision. This approach was implemented to conduct an empirical study to evaluate the performance of MSW management in 258 municipalities in the Apulia region (Southern Italy) from 2010 to 2017. The study was organized in two phases. In the first phase, measures for the three efficiency indicators were calculated applying Data Envelopment Analysis (DEA) with an output-oriented model specification. In the second phase, Panel Tobit analysis with random parameters was employed to examine the effectiveness-efficiency one way nexus, considering both municipalities’ heterogeneities and context-specific variables. The efficiency analysis shows that several municipalities are still far from achieving acceptable performance scores. Between 2010 and 2017 the average rate of separate MSW collection increased only from 16.6% to 39.6%, while the average loss of technical efficiency ranged from 27% to 39%. On average, such inefficiency was due to an important extent to the low pure technical efficiency that ranged from about 69% to 81%, and to a lesser extent to scale and congestion inefficiencies. Indeed, scale efficiency was between 85.4% and 92.6%, whereas congestion efficiency was higher than 99%. The study also highlights that there is no trade-off between effectiveness and efficiency. For the largest part of the municipalities, high levels of effectiveness and efficiency can be achieved at the same time. For about 83% of the municipalities the decrease of the sorted waste collection rate is associated to a decrease of the pure technical efficiency. A drop of the output congestion efficiency due to a relatively high collection of the unsorted fraction of waste reduces the rate of the sorted waste collection for most of municipalities (77.3%). Results also indicate that for many municipalities (about 87%) improving the MSW service effectiveness necessarily requires reducing the average quantity of waste generated by people

Productivity Analysis of Municipal Solid Waste Collection in Italy using SBM DEA Malmquist Index

This paper presents a productivity analysis of municipal solid waste collection in Italian provinces from 2010 to 2019. Particularly, the total factor productivity was measured by computing the non-parametric Global Malmquist Productivity Index implementing Slack Based Measure Data Envelopment Analysis (SBM-DEA). Findings show that the productivity of the sorted waste collection service slightly grew from 2010 to 2019. Such growth was due to an increase of the technical efficiency and an improvement of the service technology. However, in some years the efficiency changes and productivity increase were affected by the rise of the per capita production of waste

Performance evaluation of social service provision in Italian major municipalities using Network Data Envelopment Analysis

This paper employs Network Data Envelopment Analysis (NDEA) to measure the municipality performance. The NDEA approach allows to have a more comprehensive evaluation of the municipality performance if compared to traditional DEA. The proposed NDEA model aims at shedding new light on the efficiency-effectiveness relationship in the provision of social services by municipalities. Municipal efficiency and effectiveness are combined to generate a single performance measure which can be considered as a proxy measure of the value for money of municipality services. A sample including 103 major Italian municipalities is used as a case to implement the proposed model. Findings indicate that there is no trade-off between the efficiency and effectiveness components of the overall municipal performance score, but rather they appear to be preconditions of each other. Therefore, higher level of performance can be achieved without conflicting one against the other. Furthermore, only 6 municipalities achieve the highest performance level, suggesting that there is still room for improving the performance of a great number of municipalities