Francesco Taroni

The Evolution of Health-Policy Making in Italy

An analysis of the dynamics of health care policy in Italy suggests that in recent years the pace of change in the health care system has accelerated. Although the basic features of universalism, comprehensiveness, and funding from general taxation have remained remarkably constant, the capacity to innovate policy tools and their settings and to take account of domestic and international experience seems to have increased. The political will and capacity to combat entrenched interests may also have increased, although implementation is still weak. The imperative to contain public expenditure has heavily conditioned health policy and will continue to do so. This has occurred mainly at the national level, but as the principal locus of health-policy making progressively shifts to the regions, so too will the constraining effect of this imperative move downward. If the decentralization process continues, problems could arise due to interregional differences in capacities to formulate and implement appropriate policies and to tackle special interest groups.

Gallstone recurrence after successful oral bile acid treatment

Recurrence is a major problem in the medical treatment of gallstones but its extent is still uncertain. The aim of this study was to determine the magnitude of this event and to assess the effectiveness of a postdissolution treatment in preventing it. We evaluated the long-term recurrence rate after 96 confirmed dissolutions observed in 86 subjects (71 women, 15 men) over a 12-yr follow-up period. A low-dose postdissolution treatment (ursodeoxycholic acid, 300 mg/day) was administered to 36 subjects, whereas in the remaining 60 cases no postdissolution treatment was given. By actuarial life-table analysis, the cumulative proportion of gallstone recurrence was 12.5% at the first year, rising to 61% at the 11th year. Postdissolution treatment was effective in reducing the frequency of gallstone recurrence (p = 0.0067), but this was mainly related to its effect on younger subjects (less than or equal to 50 yr old). In older subjects the recurrence rate was unaffected by treatment. The probability of gallstone recurrence was significantly higher in subjects with multiple stones before dissolution treatment than in those who had had solitary stones (p = 0.0091). No other factor predictive of gallstone recurrence could be identified.

Using pharmacy data to identify those with chronic conditions in Emilia Romagna, Italy.

Background and objectives: Automated pharmacy data have been used to develop a measure of chronic disease status in the general population. The objectives of this project were to refine and apply a model of chronic disease identification using Italian automated pharmacy data; to describe how this model may identify patterns of morbidity in Emilia Romagna, a large Italian region; and to compare estimated prevalence rates using pharmacy data with those available from a 2000 Emilia Romagna disease surveillance study. Methods: Using the Chronic Disease Score, a list of chronic conditions related to the consumption of drugs under the Italian pharmaceutical dispensing system was created. Clinical review identified medication classes within the Italian National Therapeutic Formulary that were linked to the management of each chronic condition. Algorithms were then tested on pharmaceutical claims data from Emilia Romagna for 2001 to verify the applicability of the classification scheme. Results: Thirty-one chronic condition drug groups (CCDGs) were identified. Applying the model to the pharmacy data, approximately 1.5 million individuals (37.1%) of the population were identified as having one or more of the 31 CCDGs. The 31 CCDGs accounted for 77% (E556 million) of 2001 pharmaceutical expenditures. Cardiovascular diseases, rheumatological conditions, chronic respiratory illness, gastrointestinal diseases and psychiatric diseases were the most frequent chronic conditions. External validation comparing rates of the diseases found through using pharmacy data with those of a 2000 Emilia Romagna disease surveillance study showed similar prevalence of illness. Conclusions: Using Italian automated pharmacy data, a measure of population-based chronic disease status was developed. Applying the model to pharmaceutical claims from Emilia Romagna 2001, a large proportion of the population was identified as having chronic conditions. Pharmacy data may be a valuable alternative to survey data to assess the extent to which large populations are affected by chronic conditions.

Effect of hospital ownership status and payment structure on the adoption and use of drug-eluting stents for percutaneous coronary interventions

Background: The impact of the use of drug-eluting stents in percutaneous coronary intervention (PCI) on cardiac care is still uncertain. We examined the influence of systemic factors, such as hospital ownership status, organizational characteristics and payment structure, on the use of drug-eluting stents in PCI and the effect on cardiac surgery volume. Methods: We conducted a cross-sectional analysis of drug-eluting stent use in 12 993 patients undergoing PCI with stenting (drug-eluting or bare-metal) and time-series regression analyses of the monthly number of cardiac surgery and PCI procedures performed using data collected from 1998 to 2004 at 13 public and private hospitals in the Emilia-Romagna region of Italy. Results: Public hospitals used drug-eluting stents more selectively than private hospitals, targeting the new device to patients at high risk of adverse events. The time-series regression analyses showed that the number of PCI procedures performed per year increased during this period, both in public (slope coefficient 36.4, 95% confidence interval [CI] 30.2 to 43.1) and private centres (slope coefficient 6.4, 95% CI 3.1 to 9.2 ). Concurrently, there was a reduction in the number of isolated coronary artery bypass graft (CABG) surgeries, although the degree of change was higher in public than in private hospitals (coefficient –16.1 v. –6.2 respectively ). The number of CABG procedures associated with valve surgery decreased in public hospitals (coefficient –5.0, 95% CI –6.1 to –3.8) but increased in private hospitals (coefficient 4.1, 95% CI 2.0 to 6.1). Interpretation: Public and private hospitals behaved differently in adopting drug-eluting stents and in using PCI with drug-eluting stents as a substitute for surgical revascularization.

Increasing appropriateness of hospital admissions in the Emilia-Romagna region of Italy

Objectives: The Emilia-Romagna region of Italy has reduced the number of available hospital beds and introduced financial incentives to curb hospital use. The goal of this study was to assess the impact of these policies on changes over time in the number of acute hospital admissions classified in diagnosis related groups (DRGs) that could be treated safely and effectively in alternative, less costly settings. Methods: The assessment of the appropriate site of care was based on analysis of hospital discharge data for all hospitals for the selected diagnosis related groups in the Emilia-Romagna region for 2001 to 2005. The necessity for acute hospital admission was based on the severity of a patients principal diagnosis, co-morbid diseases and, for surgical admissions, procedure performed. Results: From 2001 to 2005, potentially inappropriate medical admissions of more than one day decreased from 20,076 to 11,580, a 42% decrease. Inappropriate admissions decreased in both public and private hospitals but there remained a higher rate of inappropriate admissions to private hospitals. Potentially inappropriate medical admissions accounted for 128,319 bed-days in 2001 and 68,968 bed-days in 2005, a reduction of 59,351 bed-days. Potentially inappropriate surgical admissions decreased from 7383 in 2001 to 4349 in 2005, a 41% decrease. Bed-days consumed by inappropriate surgical admissions decreased from 23,181 in 2001 to 13,660 in 2005. Conclusions: The Emilia-Romagna region has succeeded in reducing the use of acute hospital beds for patients in selected diagnosis related groups. However, there are still substantial numbers of admissions that could potentially be treated in less costly settings.

Natural history of gallstone disease: the Sirmione study

In the past many textbooks have indicated that the onset of symptoms and biliary complications are the rule for patients with gallstones, and therefore cholecystectomy has been widely performed all over the world also in subjects with asymptomatic disease.

Mass Media Interventions

Mass public health campaigns aim at channeling the power of the media toward the public good, ensuring adequate exposure of the target audience. Public health practitioners should learn how to harness the power of the different media and to successfully compete in a contested environment. The quality of news reporting in medicine is largely determined by medical journals, research, and health-care institutions as well as by individual scientists competing for visibility, funding, and profits. Audiences, however, are more active than usually assumed and mass campaigns should be appropriately used as legitimate spaces for debate of social issues at the science–policy interface.

Outcomes Management: The Italian Case-Mix Project

In spite of the current emphasis on quality assurance (QA) in health and its spread in most European countries, evidence of its effectiveness in changing physician practice and promoting quality health care is still scanty [1]. After an extensive review of the few validated models of QA, the Institute of Medicine has suggested that currently available methods of QA are of “questionable value” in improving average provider behavior [2]. This is why outcomes management has become one of the buzzwords in the health services research and administration field. The notion of outcomes management goes beyond Donabedian’s classic tripod of structure, process and outcome, in that it interrelates concerns about quality with cost effectiveness of alternative care profiles and focuses on better managerial control over the end results of medical care. By doing so, outcomes management draws upon four still developing techniques [3]. The pillars of outcomes management are: 1. Massive pooling of clinical and outcome data; 2. Measurement of patient functional well-being; 3. Effective dissemination of data to the relevant decision-makers; 4. Development of standards and clinical guidelines.

Risk adjustment in a non-market-based system: the case of Emilia-Romagna, Italy

Risk adjustment is a useful tool for setting budgets in non-market-based healthcare systems. This paper develops a prospective risk adjuster for 4 million residents of Regione Emilia-Romagna, Italy. The risk adjuster predicts hospital and pharmacy costs based on clinical information collected in the prior year in 114 Disease Staging Groups based upon hospital data and 31 Chronic Condition Drug Groups based upon pharmacy data. For the prospective risk adjuster, model R-squareds of 7.8% for hospital costs and 25.3% for pharmacy costs is reported. The risk adjuster is evaluated on individual and group predictive accuracy and ways to use the adjuster as a budgeting tool during negotiations between local health unit and district managers are discussed.

Healthcare Reform and Disease Management in Italy: Promoting the Effectiveness and Appropriateness of Health Service Use

The 1999 reform of the Italian healthcare system has softened the effects of the 1992 shift to market mechanisms and competition within healthcare by promoting cooperation and partnerships among providers and Local Health Units (LHUs). In addition, it has facilitated the completion of transfering organizational and financial responsibility to the regional governments.Such health policy developments require both the introduction of administrative tools, which stimulates integration, and the design of a coherent policy for quality of care. A 3-fold integration between healthcare and social services has been promoted to tackle the introduction of administrative tools: institutional integration between municipalities and LHUs, managerial integration at the district level for the provision of primary care and non-hospital care, and professional integration between healthcare professionals. A similar approach has characterized the policy for quality of care: an essential benefit package is to be identified as a guarantee to all citizens, practice guidelines will be developed and implemented and an accreditation process is underway.Implementation issues aside, effective introduction of the suggested tools requires careful planning and organization of the system and, above all, coordinated interventions at the 3 levels of healthcare provision (i.e. the macro, intermediary and micro levels).