Paolo Parente

Economic impact of adult obesity on health systems: a systematic review

BACKGROUND Obesity represents an important public health issue. An assessment of its costs would be useful to provide recommendations for policy and decision-making strategies. The aims of our study were to carry out a systematic review to assess the economic burden of adult obesity in terms of direct and indirect costs and to perform a quality appraisal of the analysed studies. METHODS A literature search was carried out on PubMed, Scopus and Cochrane Library to retrieve cost-of-illness (COI) analyses focused on adult (aged 18 years or more) overweight or obese people and published up to 2013. COI analyses that considered direct and indirect costs were included. Each included manuscript was independently appraised by three groups of researchers on the basis of the British Medical Journal Drummonds checklist. RESULTS Approximately 2044 articles were initially retrieved, and 17 were included in the current review. The included studies showed a medium-high-quality level. The available studies seemed to be heterogeneous both in terms of methodology and results reporting. However, as many studies have been conducted from the payer perspective, just direct medical costs can be considered exhaustive. As only three studies included considered also indirect costs, there is no strong evidence to give a comprehensive picture of this phenomenon also from the societal perspective. CONCLUSION The review confirmed that obesity absorbs a huge amount of health-care resources. Further research is therefore needed to better understand the economic impact and to identify and promote public health strategies to tackle obesity.

Does clinical governance influence the appropriateness of hospital stay

BackgroundClinical Governance provides a framework for assessing and improving clinical quality through a single coherent program. Organizational appropriateness is aimed at achieving the best health outcomes and the most appropriate use of resources. The goal of the present study is to verify the likely relationship between Clinical Governance and appropriateness of hospital stay.MethodsA cross-sectional study was conducted in 2012 in an Italian Teaching Hospital. The OPTIGOV© (Optimizing Health Care Governance) methodology was used to quantify the level of implementation of Clinical Governance globally and in its main dimensions. Organizational appropriateness was measured retrospectively using the Italian version of the Appropriateness Evaluation Protocol to analyze a random sample of medical records for each clinical unit.Pearson-correlation and multiple linear regression were used to test the relationship between the percentage of inappropriate days of hospital stay and the Clinical Governance implementation levels.Results47 Units were assessed. The percentage of inappropriate days of hospital stay showed an inverse correlation with almost all the main Clinical Governance dimensions. Adjusted multiple regression analysis resulted in a significant association between the percentage of inappropriate days and the overall Clinical Governance score (β = −0.28; p < 0.001; R-squared = 0.8). EBM and Clinical Audit represented the Clinical Governance dimensions which had the strongest association with organizational appropriateness.ConclusionsThis study suggests that the evaluation of both Clinical Governance and organizational appropriateness through standardized and repeatable tools, such as OPTIGOV© and AEP, is a key strategy for healthcare quality. The relationship between the two underlines the central role of Clinical Governance, and especially of EBM and Clinical Audit, in determining a rational improvement of appropriateness levels.

Angio-Architectural Features of High-Grade Intracranial Dural Arteriovenous Fistulas: Correlation With Aggressive Clinical Presentation and Hemorrhagic Risk

BACKGROUND High-grade dural arteriovenous fistulas (dAVFs) can present shunts with very different angio-architectural characteristics. Specific hemodynamic factors may affect clinical history and determine very different clinical courses. OBJECTIVES To evaluate the relationship between some venous angio-architectural features in high-grade dAVFs and clinical presentation. Specific indicators of moderate or severe venous hypertension were analyzed, such as altered configurations of the dural sinuses (by a single or a dual thrombosis), or overload of cortical vessels (restrictions of outflow, pseudophlebitic cortical vessels, and venous aneurysms). METHODS The institutional series was retrospectively reviewed (49 cases), and the pattern of venous drainage was analyzed in relationship with clinical presentation (benign/aggressive/hemorrhage). RESULTS Thirty-five of 49 cases displayed cortical reflux (high-grade dAVFs). This subgroup displayed a benign presentation in 31.42% of cases, an aggressive in 31.42%, and hemorrhage in 37.14%. CONCLUSIONS Our data confirm that within high-grade dAVFs, 2 distinct subpopulations exist according to severity of clinical presentation. Some indicators we examined showed correlation with aggressive nonhemorrhagic manifestations (outflow restriction and pseudophlebitic cortical vessels), while other showed a correlation with hemorrhage (dual thrombosis and venous aneurysms). Current classifications appear insufficient to identify a wide range of conditions that ultimately determine the organization of the cortical venous drainage. Intermediate degrees of venous congestion correlate better with the clinical risk than the simple definition of cortical reflux. The angiographic aspects of venous drainage presented in this study may prove useful to assess dAVF hemodynamic characteristics and identify conditions at higher clinical risk.

Are undocumented migrants’ entitlements and barriers to healthcare a public health challenge for the European Union?

Undocumented migrants (UMs) are at higher risk for health problems because of their irregular status and the consequences of economic and social marginalization. Moreover, the emergent reality of undocumented migration in Europe calls for action in the field of management of UM’s health demands as their access to health services has become a sensitive political and social issue. In this light, this paper aims to address UMs’ entitlement and barriers to healthcare and related policies citing evidence from peer-reviewed and grey literature concerning people living in a country within the European Union without the legal right to be/remain in the destination country. A systematic review was performed using several databases and websites, and a total of 54 publications in English, with full text available, were taken into consideration.Between 2000 and 2015, Europe hosted the second largest number of international migrants (20 million, 1.3 million per year) after Asia. Even though there is limited evidence specifically focused on UMs’ health, it is possible to state that infectious diseases, chronic illnesses, mental disorders, maternal-child conditions, dental issues, acute illnesses and injuries are the most common pathologies. In most cases across Europe, UMs have access only to emergency care. Even in countries where they are fully entitled to healthcare, formal and informal barriers hinder them from being or feeling entitled to this right. Socio-cultural barriers, such as language and communication problems, lack of formal and informal social and healthcare networks and lack of knowledge about the healthcare system and about informal networks of healthcare professionals are all common impediments. From the healthcare providers’ perspective, there can be difficulties in providing appropriate care and in dealing with cultural and language barriers and false identification. Communication strategies play a central role in addressing the inequalities in access to healthcare services, and the definition and provision of specific training, focused on UMs’ health needs, would be desirable.Improving access to healthcare for UMs is an urgent priority since the lack of access is proven to have serious consequences for UMs’ health and wellbeing. Notwithstanding, few available examples of policies and best practices aimed at overcoming barriers in the delivery of healthcare to UMs are available.

Empathy and attitudes towards mental illness among Italian medical students

ABSTRACT There is a growing interest regarding the attitudes of medical students towards people with mental illness, since discrimination and stigma may affect healthcare workers and education should be aimed to improve empathy and attitudes at medical school level. A cross-sectional study was conducted at medical schools in Rome and Foggia (Italy). We recruited 339 medical students who completed an anonymous self-report questionnaire including sociodemographic data, the 40-item Community Attitudes toward the Mentally Ill scale (CAMI) and the 60-item Baron Cohen’s Empathy Quotient. The questionnaires were administered before and after the yearly academic course of psychiatry. This study shows a significant improvement in some CAMI items and total score after the yearly academic course of psychiatry among medical students, especially among those who had personal experience with mentally ill people (including the training in a psychiatric ward). Female students reported higher empathy quotient and CAMI scores. Students who preferred medical disciplines to surgical ones seemed to be less stigmatizing towards mental illness. Our results confirm evidence from the scientific literature about medical students’ attitudes towards mental illness and highlight that the improvements in the attitudes increased improving students’ psychiatric knowledge, both theoretical and practical.

Motivational aspects and level of satisfaction of Italian junior doctors with regard to knowledge and skills acquired attending specific general practice training courses. A national web survey

The demographic and epidemiological transitions resulted in a pressing need to reformulate the health workforce demand and to revise preand post-graduate training to prepare the medical profiles to meet the new health needs focused on chronic diseases. The Italian Junior Doctors Association and the Giotto Movement carried out a web survey to identify the motivational aspects and the level of satisfaction of Italian junior doctors regarding knowledge and skills acquired after attending the General Practitioners’ specific training (GP-ST). Three-hundred-forty-seven General Practitioners (GPs), 302 trainees and 45 newly qualified trainees answered a web questionnaire. Significant differences (p-value= 0.018) were documented between the two groups regarding the level of satisfaction on the GP-ST. The analysis by geographic macro-areas of the answers given by the 302 trainees showed a heterogeneous level of overall satisfaction (p-value= 0.005). In conclusion, the evidence provided by this cross-sectional study support the proposal to evolve theGP-ST regional courses into general practice and primary care specialization

Can Clinical Governance tools improve the appropriateness in hospital stay

Data on all somatic specialist hospital admissions in Finland, both public and private, in 1998-2010 were obtained from the Hospital Discharge Register. The register data were limited to patients aged 25-85 years. Patients’ disposable family income each year was individually linked to each admission from the Employment Statistics and adjusted for family size. Main disease categories were formed using DRG classification. Agestandardised admission costs and cost per bed day were calculated per 100 000 person years for men and women separately and deflated for 2010. Time trends were analysed using concentration index. Results Hospital admission costs reduced with increasing income. The differences between the extreme quintiles widened from 1998 to 2010. In 1998, men in the lowest income group had on average EUR 552 (12%) higher admission costs than men in the highest, while in 2010, the difference was EUR 1187 (24%). The corresponding figures for women were EUR 444 (12%) and EUR 814 (18%). A similar pattern was found in main DRG disease categories and number of bed days. A reverse pattern was found in costs per bed day. In 1998, the highest income group among men had EUR 104 (21%), and in 2010, EUR 222 (28%) higher costs per bed day than the lowest. The results were similar for women. The differences between income groups were prominent in disease categories involving surgery, while less evident in non-surgical disease categories such as diseases of the nervous and respiratory system. Discussion One of the main reasons for the differences in hospital costs between income groups is likely to be the observed differences in length of stay. The shorter length of stay among highincome earners may originate from their overall better health. The higher costs per bed day among high-income patients may originate from differential morbidity profiles or inequality in the use of more costly health care technology. Key messages An inverse stepwise gradient was found between income groups as reported by earlier research. However, according to our results this is likely to be due to longer length of stay. High-income groups were found to have higher costs per ded day, which may be due to use of more costly health care technology.