Paola Colais

The EASY-NET network program (NET-2016-02364191)—effectiveness of audit and feedback (A&F) strategies to improve health practice and equity in various clinical and organizational settings), piloted a novel and more structured A&F strategy. This study compared the effectiveness of the novel strategy against the sole periodic dissemination of indicators in enhancing the appropriateness and timeliness of emergency health interventions for patients diagnosed with acute myocardial infarction (AMI) and ischemic stroke in the Lazio Region. The efficacy of the intervention was assessed through a prospective quasi-experimental design employing a pre- and post-intervention (2021–2022) comparison with a control group. Participating hospitals in the Lazio Region, where professional teams voluntarily engaged in the intervention, constituted the exposed group, while the control group exclusively engaged in routine reporting activities. Effectiveness analysis was conducted at the patient level, utilizing regional health information systems to compute process and outcome indicators. The effectiveness of the intervention was evaluated using difference-in-difference models, comparing pre- and post-intervention periods between exposed and control groups. Estimates were calculated in terms of the difference in percentage points (PP) between absolute risks. Sixteen facilities for the AMI pathway and thirteen for the stroke pathway participated in the intervention. The intervention yielded a reduction in the proportion of 30-day readmissions following hospitalization for ischemic stroke by 0.54 pp in the exposed patients demonstrating a significant difference of −3.80 pp (95% CI: −6.57; −1.03; 5453 patients, 63.7% cases) in the exposed group compared to controls. However, no statistically significant differences attributable to the implemented A&F intervention were observed in other indicators considered. These results represent the first evidence in Italy of the impact of A&F interventions in an emergency setting, utilizing aggregated data from hospitals involved in the Lazio Region’s emergency network.

The EASY-NET network program (NET-2016-02364191 - Effectiveness of Audit and Feedback (A&F) strategies to improve health practice and equity in various clinical and organizational set-tings), piloted a new and more structured A&F strategy. This study compared the effectiveness of the new strategy versus the periodic publication of indicators alone in improving the appropri-ateness and timeliness of emergency health interventions in patients with Acute Miocardial In-farction (AMI) and ischemic stroke in the Lazio Region. Efficacy was evaluated according to a prospective quasi-experimental design of pre-post (2021-2022) intervention type with control group. The exposed are hospitals in the Lazio Region where professional teams voluntarily par-ticipated in the intervention. The control group is involved only in the usual reporting activities. Effectiveness analysis was conducted at the patient level. Regional health information systems were used to calculate process and outcome indicators. The effectiveness of the intervention was assessed with Difference In Difference models, comparing pre-post intervention periods between exposures and controls. Estimates were calculated in terms of the difference in percentage points (pp) between absolute risks. Sixteen facilities for the IMA pathway and 13 for the stroke pathway joined the intervention. The intervention reduced the proportion of 30-days readmissions after a hospitalization for ischemic stroke by 0.54 pp in the exposed patients with a significant difference of -3.80 pp (IC95% -6.57; -1.03; 5453 patients, 63.7% cases) in the exposed compared to controls. There were no statistically significant differences attributable to the implemented A&F interven-tion in the other indicators considered. The results show, for the first time in Italy, the impact of A&F interventions in an emergency setting using aggregated data from hospitals involved in the Lazio Region emergency network.

Within the EASY-NET network program (NET-2016-02364191), Work Package 1 Lazio evaluates the effectiveness of a structured audit and feedback (A&F) intervention compared with the web-based regional periodic publication of indicators in improving the appropriateness and timeliness of emergency healthcare for acute myocardial infarction (AMI). This work describes the A&F methodology and presents the results of the first feedback delivered. The intervention involves sending periodic reports via e-mail to participating hospitals. The feedback reports include a set of volume and quality (process and outcome) indicators, calculated by facility through the health information system of the Lazio Region and compared with regional mean, target values and values calculated for hospitals with similar volumes of activity. Health managers and clinicians of each participating hospital represent the “feedback recipients”. They are invited to organize clinical and organizational audit meetings to identify possible critical issues in the care pathway and define, where necessary, improvement actions. A total of 16 facilities are involved. Twelve facilities present high volumes in all volume indicators, while three facilities present low volumes for each indicator. Concerning the quality indicators, four facilities do not present critical indicators or had average results, three facilities do not present critical indicators but show average results in at least one of the indicators and six facilities present a critical value for at least one of the indicators. The first report highlighted some critical issues in some facilities on several indicators. During the audit meetings, each facility analyzes these issues, defining appropriate improvement actions. The outcome of these actions will be monitored through subsequent reporting to support the continuous care quality improvement process.

Audit and Feedback (A&F) is an effective multidimensional strategy for improving the quality of care. The optimal methods for its implementation remain unclear. This study aimed to map the state of art of A&F strategies in the hospitals involved in a time-dependent emergency network. For these purposes, a structured questionnaire was defined and discussed within the research group. This consists of 29 questions in three sections: (1) characteristics of the structure, (2) internal feedback systems, and (3) external feedback systems. All structures involved in the network were invited to participate in the e-survey by indicating a Health Management representative and a clinical representative for the Cardiovascular (CaV) and/or for the Cerebrovascular area (CeV). Of 20 structures invited, a total of 13 (65%) responded to the survey, 11 for the CaV area and 8 for the CeV area. A total of 10 of 11 (91%) facilities for the CaV area and 8/11 (75%) for the CeV area reported that they perform A&F activities. All facilities perform at least one of the activities defined as “assimilating A&F procedures.” The most frequent is the presentation and discussion of clinical cases (82% CaV and 88% CeV) and the least is the identification of responsible for improvement actions (45% CaV and 38% CeV). In 4/10 (40%) facilities for the CaV area and 4/8 (50%) for the CEV area, corrective actions are suggested or planned when the feedback is returned. These results confirm the need to define, in a synergistic way with the relevant stakeholders, an effective and agreed A&F intervention to improve the level of implementation of A&F strategies.

In Italy the National Outcomes Evaluation Programme, (P.N.E.) is the most comprehensive comparative evaluation of healthcare outcomes at the national level. The aim of this report is to describe the P.N.E. and some of the most relevant results achieved. The P.N.E. analysed 184 indicators on quality of care in 2015–2020 period. The data sources are the Italian Health Information Systems. The indicators reported were: proportion of surgery within 2 days after hip fracture in the elderly (HF), 30-day mortality after hospital admission for acute myocardial infarction (AMI), proportion of reoperations within 90 days of breast-conserving surgery and proportion of primary caesarean deliveries. Risk adjustment methods were used to take into account patients’ characteristics. From 2010 to 2020 the proportion of interventions within 2 days after HF increased from 31.3% to 64.6%, the AMI 30-day mortality decreased from 10.4% to 8.3%, the proportion of reinterventions within 90 days of breast-conserving surgery decreased from 12.0% to 5.9% and the proportion of primary caesarean deliveries decreased from 28.4% to 22.7%. Results by area of residence showed heterogeneity of healthcare quality. We observed a general improvement in different clinical areas not always associated with a reduction of heterogeneity among areas of residence.

This study compares surgery volumes for fractures of the neck of the femur (FNF) and hip replacements during the COVID-19 pandemic compared with previous years. Historical (2018–2019) and pandemic (2020–2021) surgery rates for FNF and hip replacement in Lazio, adjusted for age and gender, were calculated per period and compared with a Poisson regression model. For hip replacement surgery, a comparison of different types of hospitals was also made. Before COVID-19’s spread, no difference was found in the volume of surgery of both interventions. From the lockdown to the end of 2021, a decrease in surgery volumes for FNF with stabilization between summer 2020 and summer 2021, as well as an additional decline beginning at the start of Omicron’s spread, were found. Hip replacement surgeries showed a greater decline during the lockdown period and increased during summer 2020 and during the Delta wave period. The increment in hip replacements, mainly observed in 2021, is due to private and religious hospitals. These results highlight that the pandemic emergency, caused by SARS-CoV-2, has had an important indirect effect on the population’s health assistance in the field of orthopedics.

Patients who leave Emergency Department before physician’s visit (LWBS) or during treatment (LDT) represent a useful indicator of the emergency care's quality. The profile of patients LWBS was described: they are generally males, young, with lower urgency triage allocation and longer waiting time. They have a greater risk of ED re-admission compared to discharged patients, but effect on hospitalization and mortality are more controversial. The aims of this study are to identify determinants and adverse short term outcomes for LWBS and LDT patients. This is a retrospective cohort study that include all ED visits of LWBS, LDT and discharged patients in 2015 in the Lazio region, Central Italy. Determinants of LWBS or LDT were selected from gender, age, citizenship, residence area, triage category, chronic comorbidities, number of uncompleted ED visit in the previous year, mode of arrival in ED, time-band, day of the week, waiting time and ED crowding, using a multi-level logistic regression. A multivariate logistic regression was used to test if LWBS or LDT have a greater risk of short term adverse outcome compared to discharged patients. The cohort consists in 835,440 visits in ED, 86.8% subjects visited and discharged, 8.9% subjects are LWBS patients and 4.3% LDT. LWBS and LDT patients are mainly young, males, with a less severe triage, with long waiting times in ED. Moreover, ED crowding and leaving ED before physician’s visit in the previous year are risk factors of self-discharging. LWBS and LDT patients have a higher risk of readmission (LWBS: OR = 4.63, 95%CI 4.5–4.7; OR = 2.89, 95%CI 2.8–2.9; LDT: OR = 3.12, 95%CI 3–3.2; OR = 2.25, 95%CI2.2–2.3 for readmissions within 2 and 7 days respectively) and hospitalization (LWBS: OR = 3.65, 95%CI 3.4–3.9; OR = 2.25, 95%CI 2.1–2.4; LDT: OR = 3.96, 95%CI 3.6–4.3; OR = 2.62, 95%CI 2.4–2.8 for hospitalization within 2 and 7 days respectively). Furthermore, we find a mortality excess of risk for LWBS patients compared to the reference group (OR = 2.56, 95%CI1.6–4.2; OR = 1.7, 95%CI 1.3–2.2 within 2 and 7 days respectively). Determinants of LWBS confirmed what already known, but LDT patients should be further investigated. There could be adverse health effects for people with LWBS and LDT behaviour. This could be an issue that the Regional Health System should deal with.

The rates of caesarean section (CS) are increasing globally. CS rates are one of the most frequently used indicators of health care quality. Vaginal Birth After Caesarean (VBAC) could be considered a reasonable and safe option for most women with a previous CS. Despite this fact, in some European countries, many women who had a previous CS will have a routine CS subsequently and VBAC rates are extremely variable across countries. VBAC use is inversely related to caesarean use. The objective of the present study was to analyze VBAC rates with respect to caesarean rates and the variations among areas of residence, hospitals and hospital ownership types in Italy. This study was based on information from the Hospital Information System (HIS). We collected data from all deliveries in Italy from January 1, 2010 to December 31, 2014 and we considered only deliveries with a previous caesarean section. Applying multivariate logistic regression analysis, the adjusted proportions of VBAC for each Local Health Units (LHU), each hospital and by hospital ownership types were calculated. Cross-classified logistic multilevel models were performed to analyze within geographic, hospitals and hospital ownership types variations. We studied a total of 77,850 deliveries with a previous caesarean section in Italy between January 1, 2010 and December 31, 2014. The proportion of VBAC in Italy slightly increased in the last few years, from 5.8% in 2010 to 7.5% in 2014. Proportions of VBAC ranged from 0.29 to 50.05% in Italian LHUs. The LHUs with lower proportions of VBAC deliveries were characterized by higher values for primary caesarean deliveries. Private hospitals showed the lowest mean of crude VBAC proportions but the highest variation among hospitals, ranging from 0 to 47.1%. Hospital rates of caesarean section for women with at least one previous caesarean section vary widely, and only some of the variation can be explained by case-mix and hospital-level factors, suggesting that additional factors influence practices. Identifying disparities in VBAC may have important implications for health services planning and targeted efforts to reduce overall rates of caesarean deliveries.

Inequalities in health among groups of various socio-economic status (as measured by education, occupation, and income) constitute one of the main challenges for public health. Since 2006, the Lazio Regional Outcome Evaluation Program (P.Re.Val.E.), presents a set of indicators of hospital performance based on quality standards driven by strong clinical recommendations, and measures the variation in the access to effective health care for different population groups and providers in the Lazio Region. One of the aims of the program was to compare population subgroups in order to promote equity in service provision. Since June 2013, a new management strategy has been put in place that assigned specific goals based on performance assessment to the chief executive officers of the hospitals. To evaluate whether, in recent years, there has been a reduction in the differential access to effective health care, among individuals with different educational levels. We enrolled all patients discharged from both public and private hospitals of the Lazio region between 2012 and 2015, living in Lazio region. We analysed the proportion of patients with ST-elevation myocardial infarction (STEMI) treated with percutaneous coronary intervention within 90 minutes (primary PCI), the proportion of patients with hip fracture (HF) who underwent surgery within 2 days, and the proportion of women with primary C-section. We applied multivariate logistic regression models to assess the effect of educational level on health outcomes, adjusting for demographic characteristics and comorbidities that could affect the outcomes. For each year of the study period, we compared adjusted proportions of outcomes for the highest and the lowest level of education by using percentage differences. In the Lazio region, 44.6% of STEMI patients (N = 3,299) were treated with primary PCI, 54.4% of patients with hip fractures (N = 6,602) underwent surgery within 2 days, and 27.7% of women without a previous C-section (N = 34,718) delivered via C-section, in 2015. The corresponding proportions in 2012 were 27.8%, 31.3% and 31.5%, respectively. By comparing the adjusted proportions in patients with the highest education level (a university degree or higher) to those with the lowest level education level (None/Primary school), a decrease in the percentage difference was observed during the study period. In STEMI and delivery cohorts, the improvement of outcomes involved the least and the most educated patients, respectively, and the difference between the two educational levels was close to zero in 2015, whereas for hip patients, the improvement was more evident among the less educated patients. In the Lazio region, we observed a reduction in the differential access to effective heath care by educational level, in different clinical areas. Different factors might explain these results. On top of the public disclosure of outcome data, the management strategy applied in mid-2013 might have driven the overall improvement of the health system for the considered conditions, helping to achieve a fairer access to health.

Background: Relapse is frequently considered an outcome measure of disease activity in relapsing-remitting multiple sclerosis (MS). The objectives of this study were to identify relapse episodes in patients with MS in the Lazio region using health administrative databases and to evaluate the validity of the algorithm using patients enrolled at MS treatment centers. Methods: MS cases were identified in the period between January 1, 2006 and December 31, 2009 using data from regional Health Information Systems (HIS). An algorithm based on HIS was used to identify relapse episodes, and patients recruited at MS centers were used to validate the algorithm. Positive and negative predictive values (PPV, NPV) and the Cohen's kappa coefficient were calculated. Results: The overall MS population identified through HIS consisted of 6,094 patients, of whom 67.1% were female and the mean age was 41.5. Among the MS patients identified by the algorithm, 2,242 attended the centers and 3,852 did not. The PPV was 58.9%, the NPV was 76.3%, and the kappa was 0.36. Conclusions: The proposed algorithm based on health administrative databases does not seem to be able to reliably detect relapses; however, it may be a helpful tool to detect healthcare utilization, and therefore to identify the worsening condition of a patient's health.