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Background: the aim of the study was to assess the safety, efficacy and cost-effectiveness of negative Pressure wound therapy (nPT) for people with chronic and acute wounds.Methods: the scope and the final draft of the report have been submitted to the stakeholders (producers, payers and patients). safety issues were addressed through a systematic review of the meta-literature. efficacy was addressed through a systematic review and meta-analysis of randomized controlled trials (rcTs) comparing nPT and other standard therapies in patients with chronic or acute lesions. cost-consequence was analyzed through a systematic review of the existing studies.Results: we retrieved 19 studies, 13 of which were included in the meta-analysis. Many studies had biases that may have resulted in a better performance for nPT. nPT showed: a slightly shorter healing time (-10.4 days, p=0.001), with no heterogeneity, apart from one small study with very positive results, and 40% more patients healed (p=0.002, no heterogeneity).We identified 15 original research papers on nPT costs and cost per outcome. The costs-per-patient- treated varied from +29% to -60%, with several studies reporting savings for nPT.Conclusions: despite serious methodological flaws, the body of evidence available was sufficient to prove some clinical benefit of nPT in severe chronic and acute wound treatment. There is a need for independent and contextualized cost analyses....

Background: Hospitalization may often be prevented by timely and effective outpatient care either by preventing the onset of an illness, controlling an acute illness or managing a chronic disease with an appropriate follow-up. The objective of the study is to examine the variability of hospital admissions within Italian regions for Ambulatory Care Sensitive Conditions (ACSCs), and their relationship with primary care supply.Methods: Hospital discharge data aggregated at a regional level collected in 2005 were analysed by type of ACS conditions. Main outcome measures were regional hospital admission rates for ACSCs. Negative binomial models were used to analyse the association with individual risk factors (age and gender) and regional risk factors (propensity to hospitalisation and prevalence of specific conditions).Non-parametric correlation indexes between standardised hospital admission rates and quantitative measures of primary care services were calculated.Results: ACSC admissions accounted for 6.6% of total admissions, 35.7% were classified as acute conditions and 64.3% as chronic conditions. Admission rates for ACSCs varied widely across Italian regions with different patterns for chronic and acute conditions. Southern regions showed significantly higher rates for chronic conditions and North-eastern regions for acute conditions. We found a significant negative association between the provision of ambulatory specialist services and standardised hospitalization rates(SHR) for ACS chronic conditions (r=-0.50; p=0.02) and an inverse correlation among SHR for ACS acute conditions and the rate of GPs per 1,000 residents, although the latter was not statistically significant.Conclusions: In Italy, about 480,000 inpatient hospital admissions in 2005 were attributable to ACSCs. Evenadjusting for potential confounders, differences in hospital admissions for ACSCs among Italian regions were found. Such differences can be appropriately used to assess the effectiveness and/or appropriateness of the primary care provided within different regions.

Background Emergency Clinical Pathways (ECP) for stroke have never been tested in randomized controlled trials (RCTs). Objective To evaluate the effectiveness of an ECP for stroke patients in Latium (Italy) emergency system. Methods cluster-RCT designed to compare stroke patient referrals by Emergency Medical Service (EMS) and Emergency Room (ER) health professionals trained in the ECP, with those of non-trained EMS and ER controls. Primary outcome measure was the proportion of eligible (aged ≤ 80 and symptom onset ≤ 6 hours) stroke patients referred to a stroke unit (SU). Intention to treat (ITT) and per-protocol (PP) analyses were performed, and risk ratios (RR) adjusted by age, gender and area, were calculated. Results 2656 patients in the intervention arm and 2239 in the control arm required assistance; 78.3% of the former and 80.6% of the latter were admitted to hospitals, and respectively 74.8% and 78.3% were confirmed strokes. Of the eligible confirmed strokes, 106/434 (24.4%) in the intervention arm and 43/328 (13.1%) in the control arm were referred to the SU in the ITT analysis (RR = 2.01; 95% CI: 0.79–4.00), and respectively 105/243 (43.2%) and 43/311 (13.8%) in the PP analysis (RR = 3.21; 95%CI: 1.62–4.98). Of patients suitable for i.v. thrombolysis, 15/175 (8.6%) in the intervention arm and 2/115 (1.7%) in the control arm received thrombolysis (p = 0.02) in the ITT analysis, and respectively 15/99 (15.1%) and 2/107 (1.9%)(p = 0.001) in the PP analysis. Conclusion Our data suggest potenti efficiency and feasibility of an ECP. The integration of EMS and ERs with SU networks for organised acute stroke care is feasible and may ameliorate the quality of care for stroke patients. Trial registration Current Controlled Trials (ISRCTN41456865).

The aim of the study is to measure and to describe organizational appropriateness of a Paediatric Temporary Observation Ward in the Emergency Department. We selected hospital discharges related to 43 DRGs at high risk of inappropriateness (DPCM 29/11/2001); we studied the relationship between appropriateness and patient's or discharge characteristics. We also investigated the inappropriateness to find tools for improving ward's efficiency. Assessment of selected paediatric clinical records was performed using PRUO protocol and showed that 41.5% of hospital discharges are completely appropriated and only 13.8% are completely not appropriated and, consequently, could be provided in a different organizational setting. Inappropriateness in our study is lower than the expected one; this finding shows that the ward under investigation is able to provide health assistance with good level of appropriateness. The used tool to evaluate appropriateness is a modified PRUO version, specific for pediatric hospital stays. Pediatric PRUO protocol is easy to be applied even if reasonable and shared evaluation criteria do not seem able to recognise some peculiar characteristics of Pediatric Temporary Observation Ward in the Emergency Department.

The aim of the present work is to describe the characteristics of digestive endoscopy centers and the physicians that work there, with particular attention to their attitudes and practices in colorectal cancer screening. A questionnaire was sent to all 80 digestive endoscopy centers in the Lazio region, identified by the annual census of Italian Society of Digestive Endoscopy (Società Italiana di Endoscopia Digestiva, SIED). Seventy-one centers (89%), returned the questionnaire. Screening activity on average represents 14% of the centers' colonoscopy workload. Colonoscopy was considered to be a "very effective" screening test by 96% of physicians, the faecal occult blood test "very effective" by 20%, and flexosigmoidoscopy "very effective" by 11%. Ninety-seven percent (97%) of physicians reported recommending any test for screening: 80% colonoscopy, 61% faecal occult blood test, 14% double contrast barium enema and 11% flexosigmoidoscopy. Despite the fact that almost all physicians reported recommending screening, the centres are only marginally involved in screening practice. Endoscopy centers' physicians tend to have an aggressive strategy for colorectal cancer prevention and exclusive trust in colonoscopy; an attitude more consistent with a clinical-diagnostic approach than with real mass screening of a healthy population.

Aim of the study is to describe the characteristics of road, home and work-related traumas among adult immigrants born in non-industrialised Countries, and to compare the consequent probability of hospitalisation with Italian adults in Lazio Region, year 2000. Source of data is the Emergency-based Surveillance System, which collects all the emergency ward visits in Lazio region. Accident incidence has been estimated using alternatively the residence permits and the roman resident population born in non-industrialised Countries. The 7.7% of all the emergency visits of immigrants are trauma-related. Road traffic accident visits are more appropriate and urgent. Immigrants have a higher risk of hospitalisation both for road and home accidents compared to the Italians (OR = 1.59 and OR = 1.37 respectively). Immigrants use emergency wards for severe and urgent trauma-related accidents, they have higher probability of hospitalisation compared to the Italians. Our analysis highlights the necessity to improve tools to study immigrant health.

The use of hospital discharge abstracts in estimating the outcome of hospital care represents an ongoing interest in public health. However standardized methodologies are still not available. We carried out a retrospective study to estimate the association between demographic and clinical characteristics and in-hospital mortality after stroke by using administrative data from the Hospital Information System in Lazio Region. We also assessed the relationship between the presence of neurology services and the outcome. We found 12,781 incident episodes of stroke (main diagnosis ICD-9: 430-431-434-436) (49.3% male, mean age = 74 years) admitted in 126 hospitals in the Lazio region for the period 1999-2000. From the hospital discharge abstracts we collected patient demographic and clinical data. The hospitals were classified in centres with and without neurology services. Admissions to hospitals with neurology services were evaluated as predictors of in-hospital mortality after adjustment for gender, age, residence, education, source of admission, type of stroke, heart disease, kidney disease and history of atrial fibrillation. In-hospital mortality (within 30 day) was 25.1%. Female gender, advanced age, residence in Rome, urgent transport, kidney disease and history of atrial fibrillation were associated with an increased risk. Hemorrhagic stroke (ICD-9 = 430-431) had a worse outcome than ischemic stroke (ICD-9 = 434) and acute undefined cerebrovascular disease (ICD-9 = 436). Patients admitted to hospitals with neurology services showed a significantly decreased risk (OR = 0.88, IC95% = 0.79-0.98), particularly in occlusion of cerebral artery (ICD-9 = 434) and in undefined cerebrovascular disease (ICD-9 = 436). Demographic and clinical variables are associated with the outcome of hospitalised stroke patients. Admissions of acute stroke patients in specialized hospitals seem to play a role in reducing the risk of in-hospital mortality.

Obiettivi: istituire un Premio annuale regionale gestito dall’Agenzia di Sanità Pubblica della Regione Lazio che, formalizzando un riconoscimento alle organizzazioni ed ai professionisti, sostenendo attività di MCQ in tutti gli ambiti dell’organizzazione e la diffusione dei risultati, favorisca l’attuazione delle politiche sanitarie regionali.Metodi: in stretta correlazione con il Piano Sanitario Regionale 2002-2004, il Premio, istituito nel maggio 2002, si rivolge a tutte le strutture sanitarie accreditate del Lazio. Si propone quale strumento di promozione e sensibilizzazione alla cultura della qualità dell’assistenza, coinvolgendo i professionisti in iniziative aziendali od interaziendali sistemiche orientate al paziente. Per partecipare al Premio, ogni Azienda presenta un progetto, scelto tra le iniziative di MCQ ultimate, che rappresenti l’eccellenza raggiunta e documentata. L’intento è quello di favorire un approccio positivo al processo valutativo e di dimostrare lo sforzo continuo delle strutture sanitarie regionali, promovendo il cambiamento, l’empowerment, la learning organization, il confronto tra pari, la responsabilizzazione di tutti i livelli organizzativi. Il Premio costituisce un’incentivazione per il raggiungimento di risultati di eccellenza: un percorso educativo di apprendimento organizzativo. Il processo valutativo del Premio si articola in tre fasi: screening iniziale dell’ASP, cross evaluation e visita da parte di un team di esperti dei finalisti. Come premessa, è stata condotta un’analisi della letteratura esistente in materia: lo Sviluppo Integrato della Qualità di J. Øvretveit, basato sulla centralità del paziente nel processo assistenziale, è stato scelto quale modello teorico.Risultati: successo dell’iniziativa in considerazione dell’adesione di 53 Aziende sulle 115 della Regione, e ricezione dei documenti progettuali di 33 Aziende. Hanno fatto parte della commissione per la visita del team di esperti, membri ASP, ASSR e giornalisti.Conclusioni: l’ASP in virtù dei risultati conseguiti in termini di partecipazione, ha constatato la validità del modello e pertanto, oltre alla prevista cerimonia di premiazione (dicembre 2002), ha avviato la seconda Edizione.

Obiettivi: 1) Descrivere l’andamento dei ricoveri ospedalieri per patologie respiratorie acute e croniche concomitanti alle epidemie stagionali da virus influenzale dal 1999 al 2003, in relazione con la segnalazione dei casi di sindrome influenzale (ILI) da parte dei medici sentinella. 2) Misurare l’eccesso dell’ospedalizzazione influenza-correlata nelle diverse fasce di età rispetto ai periodi non epidemici. 3) Analizzare le modificazioni del ricorso al ricovero ospedaliero in relazione al tasso di copertura della vaccinazione antinfluenzale nella popolazione anziana, su scala regionale e nelle diverse ASL.Metodi: sono stati estratti dal Sistema InformativoOspedaliero i ricoveri per patologie respiratorieinfluenza-correlate (codici ICD9-CM: 480-487; 460-466; 490-496) relativi agli anni 1999-2003.L’incidenza di ILI è stata stimata sulla base dellesegnalazioni dei medici sentinella afferenti allarete FLU-ISS dell’Istituto Superiore di Sanità.Per il calcolo dei tassi di copertura è stato utilizzato l’archivionominativo dei soggetti vaccinati contro l’influenza,attivo nella regione Lazio dal 1999. Nel periodo considerato sono stati messi in relazione i tassi di ospedalizzazione età-specifici, le incidenze di ILI e le coperture vaccinali. L’eccesso di ospedalizzazione è stato misurato confrontando i tassi relativi ai periodi epidemici e non epidemici.Risultati: i tassi di ospedalizzazione per malattie respiratorie sono risultati costantemente superiori nei periodi di maggiore circolazione virale, in particolare negli ultrasessantaquattrenni. Con il progressivo aumento del tasso di copertura vaccinale regionale (da circa il 25% della stagione 1999-2000 a oltre il 60% della stagione 2002-2003) non si è registrata una corrispondente diminuzione dei ricoveri ospedalieri per patologie influenza-correlate.L’analisi per ASL ha evidenziato differenti livelli di correlazione fra i fenomeni considerati.Conclusioni: la presente analisi descrittiva sottolineail sostanziale impatto delle epidemie di sindrome influenzale sul ricorso ai servizi sanitari della regioneLazio. Contestualmente, l’incremento della copertura vaccinale non sembra correlarsi a una riduzionedell’incidenza di ILI e dei tassi di ospedalizzazione durante le stagioni epidemiche considerate.

PRUO, a modified version of AEP, is a widely used clinical-based tool to evaluate hospital appropriateness in Italy. We developed the APPRO method for assessing organizational appropriateness using administrative data. APPRO estimates the amount of inappropriate hospitalisation, giving consideration to severity of illness through APR-DRG classification system. The aims of the study were to: measure the agreement between evaluators using PRUO; investigate the relation between APR-DRG severity subgroups and PRUO assessment; asses the validity of APPRO method comparing its performance to PRUO results. We selected 361 hospital episodes assigned to DRG 39 ("lens procedures with or without vitrectomy") and 242 hospital episodes assigned to DRG 183 ("miscellaneous of digestive disorders, age17") from three hospitals in 2000. Clinical records were independently evaluated by two pairs of physicians using PRUO. Proportions of inappropriate episodes by hospital and DRG were also estimated through APPRO using data from Lazio regional hospital information system. The agreement between the two pairs of evaluators was high (k=0.93; p0.0001). We observed no statistically significant association between APR-DRG severity subgroups and inappropriate hospitalisation found by PRUO. APPRO underestimates rates of inappropriate hospitalisation compared to PRUO. It depends on the different characteristics of the tools and particularly on the caution of APPRO in performing the evaluation using routine data.