Sara Barsanti

Criteria for implementing interventions to reduce health inequalities in primary care settings in European regions

BACKGROUND The current social and political context is generating socio-economic inequalities between and within countries, causing and widening health inequalities. The development and implementation of interventions in primary health care (PHC) settings seem unavoidable. Attempts have been made to draw up adequate criteria to guide and evaluate interventions but none for the specific case of PHC. This methodological article aims to contribute to this field by developing and testing a set of criteria for guiding and evaluating real-life interventions to reduce health inequalities in PHC settings in European regions. METHODS A literature review, nominal group technique, survey and evaluation template were used to design and test a set of criteria. The questionnaire was answered by professionals in charge of 46 interventions carried out in 12 European countries, and collected detailed information about each intervention. Third-party experts scored the interventions using the set of evaluation criteria proposed. RESULTS Nine criteria to guide and evaluate interventions were proposed: relevance, appropriateness, applicability, innovation, quality assurance, adequacy of resources, effectiveness in the process, effectiveness in results and mainstreaming. A working definition was drawn up for each one. These criteria were then used to evaluate the interventions identified. CONCLUSIONS The set of criteria drawn up to guide the design, implementation and evaluation of interventions to reduce health inequalities in PHC will be a useful instrument to be applied to interventions under development for culturally, politically and socio-economically diverse PHC contexts throughout Europe.

Building China's municipal healthcare performance evaluation system: a Tuscan perspective†

Regional healthcare performance evaluation systems can help optimize healthcare resources on regional basis and improve the performance of healthcare services provided. The Tuscany region in Italy is a good example of an institution which meets these requirements. China has yet to build such a system based on international experience. In this paper, based on comparative studies between Tuscany and China, we propose that the managing institutions in Chinas experimental cities can select and commission a third-party agency to, respectively, evaluate the performance of their affiliated hospitals and community health service centers. Following some features of the Tuscan experience, the Chinese municipal healthcare performance evaluation system can be built by focusing on the selection of an appropriate performance evaluation agency, the design of an adequate performance evaluation mechanism and the formulation of a complete set of laws, rules and regulations. When a performance evaluation system at city level is formed, the provincial government can extend the successful experience to other cities.

Interventions addressing health inequalities in European regions: the AIR project.

Disparities in health between social groups have been documented all over Europe. We summarize the methods and results of the Addressing Inequalities in Regions (AIR) project, which identified illustrative interventions and policies developed in European regions to reduce inequalities at the primary health care level. The first phase was a systematic review of the published literature. The second phase was a survey of European regions, collecting information on policies aiming at reducing health inequalities through primary health care and identifying regional, innovative and evaluated interventions. The third phase assessed interventions through methods defined by a formal consensus, and selected illustrative practices considered good practices for several of nine evaluation criteria. The review included 98 evaluations of interventions and 10 reviews; 80% of interventions were from North-America. Three main pathways to reduce health inequalities were identified: providing health promotion, improving financial access to care and modifying care provision. The first survey identified 90 interventions. Most national strategies included health inequalities issues. Education was the most frequently identified targeted determinant. Most interventions were health promotion general or targeted at specific health determinants, conditions or groups. The second survey assessed 46 interventions. Many involved the population in planning, implementation and evaluation. We also identified the multidisciplinary of interventions, and some who had an impact on empowerment of the targeted population. The AIR project documented that policies and actions can be implemented at the regional level through primary care providers. Policies and interventions are seldom evaluated.

Esperienze di integrazione nell’assistenza primaria basate sulla co-location dei servizi: quali prospettive per il modello della Casa della Salute?

L’integrazione nell’assistenza primaria rappresenta una sfida strategica per far fronte alla maggior complessita dei bisogni di presa in carico della popolazione. L’articolo analizza i modelli organizzativi dei servizi di assistenza primaria a partire dalla loro collocazione in sedi uniche che sono stati implementati sia nel contesto europeo che nazionale, osservando come vengono declinate le varie dimensioni dell’integrazione. A livello italiano viene analizzato il modello delle Case della Salute e il caso studio della Regione Toscana ne permette di identificare, attraverso l’analisi cluster, tre diverse articolazioni organizzative. Il confronto tra le esperienze europee, regionali e locali mette in evidenza luci, ombre e possibili sviluppi del modello di integrazione dell’assistenza primaria proposto dalle Case della Salute.

Strategies and governance to reduce health inequalities: evidences from a cross-European survey

BackgroundThe main objective of the paper is to identify the governance system related to policies to reduce health inequalities in the European regions. Considering the Action Spectrum of inequalities and the check list of health equity governance, we developed a survey in the framework of the AIR Project - Addressing Inequalities Intervention in Regions - was an European project funded by the Executive Agency of Health and Consumers.MethodsA web-based qualitative questionnaire was developed that collected information about practiced strategies to reduce health inequalities. In total 28 questionnaires from 28 different regions, related to 13countries, were suitable for the analysis.ResultsProgress in health equity strategies at the national and regional levels has been made by countries such as France, Portugal, Poland, and Germany. On the other hand, Spain, Italy, and Belgium have a variable situation depending on the region. However, the results of the survey indicate that the governance system for health equity different in terms of commitment, resources and tools.ConclusionsThe survey highlights a weakness of governance system for the majority of countries in terms of evaluation actions and of impact of interventions in reducing inequalities, and the difficulties in having a clear and integrated vision between the national and regional levels.

Is the co-location of GPs in primary care centres associated with a higher patient satisfaction? Evidence from a population survey in Italy

BackgroundSeveral countries have co-located General Practitioners (GPs) in Primary Care Centres (PCCs) with other health and social care professionals in order to improve integrated care. It is not clear whether the co-location of a multidisciplinary team actually facilitates a positive patient experience concerning GP care. The aim of this study was to verify whether the co-location of GPs in PCCs is associated positively with patient satisfaction with their GP when patients have experience of a multidisciplinary team. We also investigated whether patients who frequently use health services, due to their complex needs, benefitted the most from the co-location of a multidisciplinary team.MethodsThe study used data from a population survey carried out in Tuscany (central Italy) at the beginning of 2015 to evaluate the patients’ experience and satisfaction with their GPs. Multilevel linear regression models were implemented to verify the relationship between patient satisfaction and co-location. This key explanatory variable was measured by considering both the list of GPs working in PCCs and the answers of surveyed patients who had experienced the co-location of their GP in a multidisciplinary team. We also explored the effect modification on patient satisfaction due to the use of hospitalisation, access to emergency departments and visits with specialists, by performing the multilevel modelling on two strata of patient data: frequent and non-frequent health service users.ResultsA sample of 2025 GP patients were included in the study, 757 of which were patients of GPs working in a PCC. Patient satisfaction with their GP was generally positive. Results showed that having a GP working within a PCC and the experience of the co-located multidisciplinary team were associated with a higher satisfaction (p < 0.01). For non-frequent users of health services on the other hand, the co-location of multidisciplinary team in PCCs was not significantly associated with patient satisfaction, whereas for frequent users, the strength of relationships identified in the overall model increased (p < 0.01).ConclusionThe co-location of GPs with other professionals and their joint working as experienced in PCCs seems to represent a greater benefit for patients, especially for those with complex needs who use primary care, hospitals, emergency care and specialized care frequently.

Innovatori, indecisi, bisognosi o autonomi. I medici di medicina generale tra integrazione e accountability

L’assistenza primaria in Italia sta subendo una radicale riforma con l’introduzione delle Aggregazioni Funzionali Territoriali (AFT), ovvero gruppi obbligatori di medici di medicina generale che si associano per rispondere insieme sia ai bisogni della popolazione assistita, sia per implementare le logiche del governo clinico. La Toscana gia a partire del 2014 e stata una delle prime Regioni a formalizzare le AFT negli Accordi Regionali e Aziendali e a nominare i coordinatori di AFT, ovvero medici di medicina generale che hanno il compito di guidare l’AFT nella programmazione e revisione di obiettivi di governo. A partire da un questionario rivolto ai coordinatori di AFT toscani, gli autori hanno analizzato la percezione dei coordinatori rispetto all’innovazione rappresentata dalla AFT, sia in termini di fiducia verso la logica di integrazione monoprofessionale (fiducia verso l’organizzazione), sia in termini di difficolta percepita rispetto all’assolvimento del proprio incarico (fiducia verso il ruolo). Sulla base di tali criteri, gli autori hanno delineato, per il contesto della Toscana, 4 differenti gruppi di coordinatori con percezioni simili verso l’innovazione manageriale e organizzativa della medicina generale.

General practitioners: Between integration and co-location. The case of primary care centers in Tuscany, Italy

Healthcare systems have followed several strategies aimed at integrating primary care services and professionals. Medical homes in the USA and Canada, and primary care centres across Europe have collocated general practitioners and other health and social professionals in the same building in order to boost coordination among services and the continuity of care for patients. However, in the literature, the impact of co-location on primary care has led to controversial results. This article analyses the possible benefits of the co-location of services in primary care focusing on the Italian model of primary care centres (Case della Salute) in terms of general practitioners’ perception. We used the results of a web survey of general practitioners in Tuscany to compare the experiences and satisfaction of those general practitioners involved and not involved in a primary care centre, performed a MONAVA and ANOVA analysis. Our case study highlights the positive impact of co-location on the integration of professionals, especially with nurses and social workers, and on organizational integration, in terms of frequency of meeting to discuss about quality of care. Conversely, no significant differences were found in terms of either clinical or system integration. Furthermore, the collaboration with specialists is still weak. Considering the general practitioners’ perspective in terms of experience and satisfaction towards primary care, co-location strategies is a necessary step in order to facilitate the collaboration among professionals and to prevent unintended consequences in terms of an even possible isolation of primary care as an involuntary ‘disintegration of the integration’.

The benefits of co-location in primary care practices: the perspectives of general practitioners and patients in 34 countries

BackgroundThere is no clear evidence as to whether the co-location of primary care professionals in the same facility positively influences their way of working and the quality of healthcare as perceived by patients. The aim of this study was to identify the relationships between general practitioner (GP) co-location with other GPs and/or other professionals and the GP outcomes and patients’ experiences.MethodsWe wanted to test whether GP co-location is related to a broader range of services provided, the use of clinical governance tools and inter-professional collaboration, and whether the patients of co-located GPs perceive a better quality of care in terms of accessibility, comprehensiveness and continuity of care with their GPs. The source of data was the QUALICOPC study (Quality and Costs of Primary Care in Europe), which involved surveys of GPs and their patients in 34 countries, mostly in Europe. In order to study the relationships between GP co-location and both GPs’ outcomes and patients’ experience, multilevel linear regression analysis was carried out.ResultsThe GP questionnaire was filled in by 7183 GPs and the patient experience questionnaire by 61,931 patients. Being co-located with at least one other professional is the most common situation of the GPs involved in the study. Compared with single-handed GP practices, GP co-location are positively associated with the GP outcomes. Considering the patients’ perspective, comprehensiveness of care has the strongest negative relationship of GP co-location of all the dimensions of patient experiences analysed.ConclusionsThe paper highlights that GP mono- and multi-disciplinary co-location is related to positive outcomes at a GP level, such as a broader provision of technical procedures, increased collaboration among different providers and wider coordination with secondary care. However, GP co-location, particularly in a multidisciplinary setting, is related to less positive patient experiences, especially in countries with health systems characterised by a weak primary care structure.

Come valutare la ricerca nelle Aziende Ospedaliero-Universitarie? Metodi e proposte operative

La ricerca rappresenta una delle tre attivita che contraddistinguono la triplice mission delle Aziende Ospedaliero- Universitarie. Questo articolo analizza metodi e proposte di indicatori bibliometrici di monitoraggio della ricerca che possono essere parte dei sistemi di valutazione multidimensionali della performance. Dopo un’introduzione sui sistemi di accountability per le attivita di ricerca e sul dibattito intorno alla validita degli indicatori bibliometrici, l’articolo presenta alcune esperienze di misurazione della qualita della ricerca in sanita a livello internazionale e nazionale, in termini di valutazione delle istituzioni nel loro complesso e dei singoli ricercatori. L’ultima parte si focalizza sull’esperienza toscana di valutazione della performance delle Aziende Ospedaliero- Universitarie e presenta il set di indicatori bibliometrici elaborati, basati sulla metrica del l’Impact Factor, evidenziandone luci e ombre, possibili ambiti di applicazione e miglioramenti.