Ferruccio Pelone

Can primary care professionals' adherence to Evidence Based Medicine tools improve quality of care in Type 2 diabetes mellitus? A systematic review

BACKGROUND Our aim is to review the effectiveness of EBM tools available to primary care professionals to improve the quality of Type 2 diabetes disease management. METHODS A systematic review of RCT was performed according to the Cochrane methods. RESULTS Starting from an overall number of 1737 references found, a total of 13 studies met all the inclusion criteria. CONCLUSIONS The adherence to EBM instruments is likely to improve process of care, rather than patient outcomes. In addition, our review outlines that feedback reports and use of ICT devices are likely to be effective in diabetes disease management.

Primary Care Efficiency Measurement Using Data Envelopment Analysis: A Systematic Review

There is a gap between the demand and supply of efficiency analyses within primary care (PC), despite the threatening financial sustainability of health care systems. This paper provides a systematic literature review on PC efficiency analysis using Data Envelopment Analysis (DEA). We reviewed 39 DEA applications in PC, to understand how methodological frameworks impact results and influence the information provided to decision makers. Studies were combined using qualitative narrative synthesis. This paper reports data for each efficiency analysis on the: 1) evaluation context; 2) model specifications; 3) application of methods to test the robustness of findings; 4) presentation of results. Even though a consistent number of analyses aim to support policymakers and practice managers in improving the efficiency of their PC organizations, the results indicate that DEA –at least when applied to PC- is a methodology still in progress; it needs to be further advanced to meet the complexity that characterizes the production of PC outcomes. Future studies are needed to fill some gaps in this particular domain of research, such as on the standardization of methodologies and the improvement of outcome research in PC. Most importantly, further studies should include extensive uncertainty analyses and be based on good evidence-based rationales. We suggest a number of considerations to academics and researchers to foster the utility of efficiency measurement for the decision making purposes in PC.

How to achieve optimal organization of primary care service delivery at system level: lessons from Europe

OBJECTIVE To measure the relative efficiency of primary care (PC) in turning their structures into services delivery and turning their services delivery into quality outcomes. DESIGN Cross-sectional study based on the dataset of the Primary Healthcare Activity Monitor for Europe project. Two Data Envelopment ANALYSIS models were run to compare the relative technical efficiency. A sensitivity analysis of the resulting efficiency scores was performed. SETTING PC systems in 22 European countries in 2009/2010. MAIN OUTCOME MEASURES Model 1 included data on PC governance, workforce development and economic conditions as inputs and access, coordination, continuity and comprehensiveness of care as outputs. Model 2 included the previous process dimensions as inputs and quality indicators as outputs. RESULTS There is relatively reasonable efficiency in all countries at delivering as many as possible PC processes at a given level of PC structure. It is particularly important to invest in economic conditions to achieve an efficient structure-process balance. Only five countries have fully efficient PC systems in turning their services delivery into high quality outcomes, using a similar combination of access, continuity and comprehensiveness, although they differ on the adoption of coordination of services. There is a large variation in efficiency levels obtained by countries with inefficient PC in turning their services delivery into quality outcomes. CONCLUSIONS Maximizing the individual functions of PC without taking into account the coherence within the health-care system is not sufficient from a policymakers point of view when aiming to achieve efficiency.

Interventions to evaluate fitness to drive among people with chronic conditions: Systematic review of literature

When an health condition has been identified, the question of whether to continue driving depends not on a medical diagnosis, but on the functional consequences of the illness. The complex nature of physical and mental impairments and their relationship with safe driving make the availability of evidence based tools necessary for health professionals. The review aims at identifying and summarizing scientific findings concerning the relationship between neuropsychological and clinical screening tests and fitness to drive among people with chronic conditions. Studies were searched for driving ability evaluation by road test or simulator, clinical/neuropsychological examinations of participants with chronic diseases or permanent disablement impairing driving performance, primary outcomes as fatal/non-fatal traffic injuries and secondary outcomes as fitness to drive assessment. Twenty-seven studies fulfilled the inclusion criteria. Some studies included more than one clinical condition. The illness investigated were Alzheimer Disease (n=6), Parkinson Disease (n=8), Cardiovascular Accident (n=4), Traumatic Brain Injuries (n=3), Sleep Apnea Syndrome (n=2), Narcolepsy (n=1), Multiple Sclerosis (n=1) and Hepatic Encephalopathy (n=1), comorbidities (n=3). No studies match inclusion criteria about Myasthenia Gravis, Diabetes Mellitus, Renal Diseases, Hearing Disorders and Sight Diseases. No studies referred to primary outcomes. The selected studies provided opposite evidences. It would be reasonable to argue that some clinical and neuropsychological tests are effective in predicting fitness to drive even if contrasting results support that driving performance decreases as a function of clinical and neuropsychological decline in some chronic diseases. Nevertheless we found no evidence that clinical and neuropsychological screening tests would lead to a reduction in motor vehicle crashes involving chronic disabled drivers. It seems necessary to develop tests with proven validity for identifying high-risk drivers so that physicians can provide guidance to their patients in chronic conditions, and also to medical advisory boards working with licensing offices.

The measurement of relative efficiency of general practice and the implications for policy makers

PURPOSE This study aimed to compare technical efficiency of general practice (GP) delivered by the twenty Regions of Italys decentralized healthcare system and to determine if it was affected by contextual factors. METHODS First, we calculated the Regional efficiency scores by means of Data Envelopment Analysis. Then we carried out a regression analysis to investigate the influence of contextual factors on the efficiency in the provision of GP services. RESULTS Six Northern Regions were identified as efficient using the best combinations of general practitioners to deliver a given level of GP outcomes. Compared with peer benchmarks, inefficient Regions used more (on-call and regular) general practitioners with important underproductions of outputs (e.g. avoidable hospitalizations). The regression analysis showed a negative relationship between efficiency and the Regional total health care expenditures as percentage of its Gross Domestic Product. DISCUSSION Improving efficiency of GP services delivery is likely to result in reduced health expenditures. Since there is a general tendency in Europe to decentralize governmental systems of countries and Italy can be seen as an extreme example of this trend, we consider our findings of high relevance for international comparative studies on performance of primary care systems.

Long-Term Care Quality Assurance Policies in the European Union

This report analyses the quality assurance policies for long-term care (LTC) in the following countries: Austria, Estonia, Finland, France, Germany, Hungary, Italy, Latvia, Poland, Slovakia, Slovenia, Spain, Sweden, the Netherlands, and the United Kingdom.The authors first discuss quality assurance in LTC by analysing: the dimensions of quality, the policy frameworks for quality in LTC, the different levels of development of LTC quality policies at the international, national, organisational, and individual levels. Second, they describe the methodology for collecting and analysing data on quality policies in the selected countries, and report and discuss the results. Policy recommendations are proposed at the end.

Is there a relationship between health care models and their performance assessment? The results of an extensive review

Background : Health system performance is a multi-dimensional concept related to the achievement of several objectives such as effectiveness, efficiency and equity. The aim of this study is to investigate the relationship between models of health care systems (Beveridge, Bismarck and voluntary health insurance) and performance frameworks available in the scientific literature. Methods : An extensive literature search in several electronic databases was carried out. According to a preliminary classification of performance domains and dimensions, we analysed, among the selected articles, the relationship between domains/dimensions and the three main models of health care systems.Results: 12.6% of the children were obese and 26.3% overweight, with the percentage of obesity nearly double in those who do not practice organized sports activities at least once a week, in those who don’t have breakfast in the morning and in those who don’t spend their free time in movement games. From a multiple logistic regression it results that the risk of being obese is twice and three times higher for the children living respectively in medium and small towns than for the ones living in large towns. Results : From 540 references found, 17 papers were considered relevant for the purposes of this research. A total of 39 frameworks were identified: 41% referred to the “Beveridge model, 10% to the “Bismarck model”, and 23% to the “Voluntary health insurance” model and 26% to “Umbrella organizations” (e.g. OECD). Domains of effectiveness and responsiveness were covered by all of the frameworks while fewer covered equity and efficiency. The most frequent dimensions in all the models were effectiveness and technical efficiency, but relevant differences exist among the healthcare system models about dimensions of performance considered. Conclusions : Although the need of evaluate health care systems performance is recognized, there is not agreement on what concepts and dimensions of performance should be measured. Our study underlines an interesting link between the domains/dimensions of performance assessment and models of health care systems.

Smoking Prevention Through Mass Media Campaigns

The goal of this chapter is to describe the role of health communication in preventing smoking habits providing the reader with useful insight toward the theoretical and empirical underpinning of mass media campaigns. At the end of this chapter you will be able to address the tobacco prevention mass media campaigns core issues (e.g., theoretical framework and basic knowledge) and summarizing both the up-to-date scientific evidence and institutional reports.