Search

Ambulatory procedures are an essential component of health care both for their number and for their cost. We aim therefore to identify and to quantify the volume of ambulatory procedures performed in Milan during 2003. The data come from the Outpatient Care Information Report that collect much information by characteristics of patient, health care institution and procedure categories. The analyses in this report are based on absolute measures, utilization rates and concentration index. During the year 2003 nearly 20 millions of ambulatory procedures were performed in the public and private outpatient facilities of Milan for the resident population. The average annual rate was 15 procedures per person. Utilization varied according to patient age and sex, higher in women and in the elderly group, statistically significant variability is observed (p<0.001). Outpatient care accounts for high density supply (124 specialty points for 100,000 inhabitants). Utilization rate was not homogenous both for the medical specialties and for the geographical district distribution, all that, it seems depending on the activity concentration differences and complexity supply of services than on a different distribution of health needs. This analysis may be useful as methodological starting point for further investigating current outpatient care data and for identifying those sectors in need of corrective actions.

It has been carried out a survey to evaluate the appropriateness of hospital stay in a university hospital. The aims of the study were: to determine the amount of inappropriate hospital admissions and inappropriate days of stay in relation to either wards and characteristics of admission; to analyse the reasons for inappropriate patient stay. A randomised sample stratified by ward of discharge of 224 medical records were analysed using the Italian version of the Appropriateness Evaluation Protocol. 37.9% of the hospital admissions and 18.9% of hospitalisation days were judged to be inappropriate. The main reasons for categorising an admission or a day of stay as inappropriate were a) delay in performing elective surgery procedures; b) that the patient's problem could be treated on an outpatient basis; c) delay in performing diagnostic examinations. The univariate statistical analysis showed an association between appropriateness of hospital stay and gender age, ward of discharge, length of hospital stay and DRG type (medical/surgical). The study highlights a lower level of inappropriateness compared to the results of other investigations. Hints were also identified for achieving an improved efficiency at hospital level.

Aim: To determine the rates of psychiatric hospitalisation and to evaluate the predictors of readmissions in a cohort of 887 schizophrenic patients at their "first" psychiatric admission., Methods: Data were collected using the hospital discharge database of the Lazio region, Italy. The cohort included patients admitted to a psychiatric ward in 1999, with a main diagnosis of schizophrenia and no prior psychiatric hospitalisation during the 5 years preceding the index admission. Psychiatric readmissions were considered up to year 2004. Kaplan-Meier survival curves and logistic procedures were performed to estimate the cumulative readmission incidence and ORs of readmissions for potential confounders., Results: During the 4-year follow-up, 44.3% of the patients were readmitted at least once. An active treatment among community psychiatric facilities at the time of index admission predicted a higher readmission risk. However, for those who experienced their first admission in a private ward readmission risk was consistently higher, whether or not having had such a treatment., Conclusions: Risk of readmission in a psychiatric ward appears to be related to the level of integration with mental health community facilities, while length of stay is strongly affected by service system variables. Possible uses of medical information systems in this field are described.

To measure the level of not appropriated hospital use for some DRG's a Lombardia Region AEP version was applied to two units in the Ospedale Maggiore in Milano. The aims of the study was to evaluate the level of appropriateness in Neurology and Dermatology wards for some DRG's which are at risk to be applied in not appropriated way, to study the reasons of not appropriated use, to educate medical doctors in neurology and dermatology to apply for the right level of care for they patients and to highlight some limits of the Lombardia Regional protocol.

Italian version of Appropriateness Evaluation Protocol (AEP) is a tool for evaluating the appropriateness of hospitalization for acute patients. In particular, it aims to verify and quantify the reasons of appropriateness associated to the day of admission and the single days of hospital stay. The aim of the present paper is to evaluate the appropriateness of ordinary, 2-3 days lasting, hospital admissions within an university hospital. We examined a sample of 518 hospital admissions: 370 admissions (71%) lasting 2 days, and 148 admissions (29%) lasting 3 days. Results analysis showed different levels of appropriateness between the 2-days and the 3-days admissions: the appropriate admissions were 18% in the sample of the 2-days admissions and 38% in the sample of 3-days admissions. Most inappropriate days of admission and stay in hospital are due to attended or to the execution of diagnostic procedures. In order to evaluate accuracy by means of AEP methodology, it is necessary to improve the quality of medical documentation using standardized medical records. AEP, in the framework of the continuous quality improvement, is a valid tool to reorganise health care processes.

The Region of Latium has been operating an Outpatient Care Information System (SIAS) since 1997 to monitor the supply of outpatient care in a territory with a population of over five million. The present work has the aim of describing the outpatient care in the region, in terms of number of facilities involved by category (public and private, operating in the regional public health system) and volume of procedures rendered to residents in 2001. Of the 971 outpatient facilities operating in hospitals and elsewhere--37% state managed and 67% private--distributed in a non-uniform manner throughout the region, the majority is concentrated in the city of Rome, which by itself accounts for 49% of its total amount of facilities, and in a lesser measure in the other provincial capitals (Viterbo, Rieti, Frosinone, Latina). In 2001, 71 million procedures were performed, comprising 17 million prescriptions, for an economic value of over 400 million Euros. The three specialties of greatest use were Lab Analysis, Physical Therapy and Rehabilitation, and Radiology, making up 88% of the total outpatient procedures performed within the precinct of the regional health service, in respective measures of 57%, 27%, and 4%. It is noted that the public facilities are prevalently polyspecialistic while a great number of private facilities are monospecialistic and perform procedures almost exclusively (96%) in the three specialties of greatest use. The other specialties which receive notable use are Cardiology, Eye Care, Orthopedics and Neurology. In general, the greater the number of facilities there are in either the public or private sector, the greater the level of activity in terms of procedures performed, with the exception of the area of Physical Therapy and Rehabilitation where the correlation is inversely proportioned; in fact, for this specialty the public facilities, which are represented in a much greater number throughout the region, supply only 7% of the volume of activity.

Aim: This study aims to evaluate the management of intensive care beds according to the demands received by the SUEM 118 of Padua. It has been carried out by examining the reports drawn up by SUEM physicians from October 1996 to December 2001. The study rated the number of patients for whom an admission to the Intensive Care Unit (ICU) was required, according to the specific clinical situation at the moment of the request. A secondary objective was to evaluate if the critically ill patients had been admitted and treated in the most appropriate medical facility., Methods: The research is based on 7 087 reports concerning a population of adult and pediatric patients for whom an ICU bed was required in the period previously mentioned. For each report, it analyses the following data (keeping them anonymous): date of demand, main pathology and severity of clinical condition, sex and age, provenence and destination., Results: Even though the number of annual demands for an ICU bed made to SUEM Central 118 has remained unchanged (approximately 1 350 per year), the number of beds made available in the operating rooms of the Hospital of Padua markedly increased. What has been experienced so far, and the data collected in this study has revealed, was that the requests for an intensive treatment for the overall population (hospitalized and non hospitalized) increased disproportionally in relation to the availability of ICU beds. In fact, the total number of hospitalizations in the different ICUs rose steadily year by year (from 3 495 in 1996 to 4 640 in 2001)., Conclusion: The Hospital of Padua is a landmark center for patients who need specialized treatment. It is therefore important to increase the assistance and safety standards of its ICUs. In recent years there has been a great need for specialized ICUs either for more aggressive procedures (neurosurgical, cardiosurgical, respiratory, cardiologic, etc.) or for the increased use of adequate and invasive treatment for advanced diseases. The available resources of ICU beds should be more rationally distributed between the peripheral and the Regional Hospitals, since the activation of an ICU bed in the operating theatre is a valid, transient option.

In 1999 an Italian version of the AEP was applied to some units of the IRCCS Ospedale Maggiore di Milano and a modified AEP version was used to evaluate the day hospital activity. The main aims of the study were: to establish the appropriateness of the utilisation of beds and of day hospital activity and to calculate the costing of the misuse of hospital resources. 267 admission days were evaluated and 31.5% were not appropriated; whereas of 3,248 days of stay 37% were found not appropriated. The day hospital activity was evaluated through 300 record referred to 570 days of treatment and 13% of them were not appropriated. The cost of the 1,201 not appropriated hospital days was over 351.000. The not appropriated level of hospital utilisation in the IRCCS Ospedale Maggiore di Milano is similar to what is reported in national and international literature. Our study highlights some limits in the application of the AEP protocol at high specialised hospital units.

Background: We evaluated the appropriateness of indications to echocardiography for ambulatory patients performed during 4 weeks in 21 laboratories in Tuscany and Umbria, Italy., Methods: We collected the following data: the appropriateness of the prescription (according to the guidelines of the Italian Federation of Cardiology), the prescribing physician (cardiologist vs non-cardiologist), the synthetic result (normal vs abnormal) and the clinical utility (useful vs useless) of each exam., Results: We evaluated 2848 prescriptions (patients: 1450 males, 1398 females; mean age 62 years, range 15-90 years). The indications to test were of class I (appropriate) in 43.6%, of class II (of doubtfully appropriateness) in 36.8% and of class III (inappropriate) in 19.6% of the cases. In 60.8% of the cases the exam was considered abnormal. In particular, an abnormal result was found in 83.8% of class I, in 56.6% of class II and in 17.8% of class III exams (p < 0.05). The exam was considered useful in 51.1% of the cases. In particular, a useful result was found in 78.9% of class I, in 39% of class II and in 12.1% of class III exams (p < 0.05). Cardiologists prescribed 856/2848 tests (30%). Their indications were of class I in 58.8%, of class II in 29.8% and of class III in 11.4% of the cases vs 37, 39.9 and 23.1% of non-cardiologists' prescriptions (p < 0.05). Abnormal findings were found in 74.3% of cardiologist- vs 55% of non-cardiologist-prescribed examinations (odds ratio 2.45, 95% confidence interval 2.04-2.92; p < 0.05); similarly, clinically useful information could be derived from 63.1% of cardiologist- vs 46% of non-cardiologist-prescribed examinations (odds ratio 2.07, 95% confidence interval 1.75-2.45; p < 0.05)., Conclusions: In Tuscany and Umbria, Italy, about half of the prescriptions for echocardiography can be considered inappropriate; appropriately prescribed exams more often provide abnormal and useful results; cardiologist-prescribed exams are significantly more appropriate, abnormal and useful.

Background: We evaluated the appropriateness of indications to Holter monitoring performed on ambulatory patients during 4 weeks in 21 laboratories in Tuscany and Umbria, Italy., Methods: We collected the following data: the appropriateness of the prescription (according to the guidelines of the Italian Federation of Cardiology), the prescribing physician (cardiologist vs non-cardiologist), the synthetic result (normal vs abnormal) and the clinical utility (useful vs useless) of each exam., Results: We evaluated 863 prescriptions (population: 435 males, 428 females; mean age 64 years, range 15-90 years). The indications to the test were of class I (appropriate) in 59.6%, of class II (doubtfully appropriate) in 11.7%, and of class III (inappropriate) in 28.7% of the cases. In 33% of the cases the exam was considered abnormal. In particular, an abnormal result was found in 37.9% of class I, in 36.7% of class II, and in 24.5% of class III exams (p < 0.05). The exam was considered useful in 46.7% of the cases. In particular, a useful result was found in 59.2% of class I, in 45.5% of class II, and in 21% of class III exams (p < 0.05). Cardiologists prescribed 373/863 tests (43.2%). Their indications were of class I in 67.6%, of class II in 12% and of class III in 24% of the cases vs 53.7, 11.4 and 34.9% of non-cardiologists' prescriptions (p < 0.05). Abnormal findings were found in 40% of cardiologist- vs 27.6% of non-cardiologist-prescribed examinations (odds ratio 1.74, 95% confidence interval 1.31-2.32; p < 0.05); similarly, clinically useful information could be derived from 59.8% of cardiologist- vs 36.7% of non-cardiologist-prescribed examinations (odds ratio 2.56, 95% confidence interval 1.94-3.37; p < 0.05)., Conclusions: In Tuscany and Umbria, Italy, about 40% of Holter exams are inappropriate; appropriately prescribed exams are more often abnormal and useful; cardiologist-prescribed exams are significantly more appropriate, abnormal and useful.

Background: We evaluated the appropriateness of the indications to exercise testing for ambulatory patients performed during 4 weeks in 21 laboratories in Tuscany and Umbria, Italy., Methods: We collected the following data: the appropriateness of the prescription (according to the guidelines of the Italian Federation of Cardiology), the prescribing physician (cardiologist vs non-cardiologist), the synthetic result (normal vs abnormal) and the clinical utility (useful vs useless) of each exam., Results: We evaluated 1158 prescriptions (population: 822 males, 336 females; mean age 60 years, range 16-82 years). Prescriptions were of class I (appropriate) in 38.9%, of class II (of doubtful appropriateness) in 52.5% and of class III (inappropriate) in 8.6% of the cases. In 14.2% of the cases the exam was abnormal: it was abnormal in 35.5% of class I, in 26.6% of class II and in 23% of class III exams (p < 0.05). The exam was useful in 51.6% of the cases; it was useful in 62.4% of class I, in 50.2% of class II and in 13% of class III exams (p < 0.05). Cardiologists required 596/1158 tests (51.5%). Their indications were included in class I in 45.6%, in class II in 49.7% and in class III in 4.7% of the cases vs 31.7, 55.5 e 12.8% of non-cardiologists' prescriptions (p < 0.05). The test was abnormal in 35.7% of cardiologist vs 23.5% of non-cardiologist-prescribed examinations (odds ratio 1.81, 95% confidence interval 1.4-2.34; p < 0.05); the test was useful in 64.4% of cardiologist vs 38.2% of non-cardiologist-prescribed exams (odds ratio 2.92, 95% confidence interval 2.3-3.71; p < 0.05)., Conclusions: In Tuscany and Umbria, Italy, less than half of exercise testing procedures are appropriate; appropriately-prescribed exams are more often abnormal and useful; cardiologist-prescribed exams are significantly more appropriate, abnormal and useful.

Background: We evaluated the appropriateness of the prescription of echocardiography, exercise testing, Holter monitoring and vascular sonography for ambulatory patients, performed during 4 weeks in 21 outpatient laboratories in Tuscany and Umbria, Italy., Methods: We collected the following data: the appropriateness of the prescription (according to the guidelines of the Italian Federation of Cardiology), the prescribing physician (cardiologist vs noncardiologist), the synthetic result (normal vs abnormal) and the clinical utility (useful vs useless) of each exam., Results: We evaluated 5614 prescriptions (patients: 3027 males, 2587 females; mean age 63 years, range 14-96 years). The indication to the test was of class I (appropriate) in 45.3%, of class II (doubtfully appropriate) in 34.8% and of class III (inappropriate) in 19.9% of the cases. The test was abnormal in 58.3% of class I exams vs 17% of class III exams (p < 0.05). The test was useful in 72.4% of class I exams vs 17.1% of class III exams (p < 0.05). The test was prescribed by a cardiologist in 1882 cases (33.5%). Cardiologist-prescribed exams were of class I in 57.3%, of class II in 32.4% and of class III in 10.3% of the cases vs 39.2, 36.1 and 24.7% of non-cardiologist-prescribed exams (p < 0.05). Cardiologist-prescribed exams were abnormal in 53.4% of the cases vs 39% of those of non-cardiologists' (odds ratio 1.76, 95% confidence interval 1.58-1.97; p < 0.05). Cardiologist-prescribed exams were useful in 64.7% of the cases vs 44.4% of those of non-cardiologists' (odds ratio 2.26, 95% confidence interval 2.02-2.53; p < 0.05)., Conclusions: In Tuscany and Umbria, Italy, less than half of the prescriptions for non-invasive diagnostic tests are appropriate: appropriately prescribed exams more often provide abnormal and useful results; cardiologist-prescribed exams are more often appropriate, abnormal and useful.

Technological development of ultrasound has allowed diagnosis of diseases that one would be able to see later. These easy and harmless examinations have produced an increasing in demand not always justified, as one could think to reach simply a shining diagnosis. The authors evaluated the appropriate use of each color-doppler sonography request in agreement with published guidelines. Nine hundred eighty six requests were examined in three months: 60.2% of them were not appropriate. Carotid-vertebral arteries were the group with higher inappropriate use (67.9%) and also the urgent exams have 21.9% of inappropriate use. When clinical reason was missing in the request, the inappropriate use reached 70%. The 52.9% of examinations have not revealed any vascular pathology and among appropriate exams the 31.7% was disease free. Although angiology clinical guidelines have been recently published in Italy, the data suggest a poor clinical valuation of suspected vascular patient (70% of not appropriate examination when clinical problem was lacking); this may be the answer for both the enormous color-doppler requests, high inappropriate use and normal results. Authors think that a way to lower this high grade of color-doppler exams may be to take in appropriate consideration clinical approach, fact that also permit a correct interpretation of ultrasonographic data.

Background: Admission to Pediatric Departments for 0/18- year-old patients is an important issue for the best organization of pediatric hospital assistance. Aim of the study. To locate adolescent health care and identify the percentage of adolescent admissions to Pediatric Departments in an Italian region (Tuscany)., Methods: Adolescent health care in pediatric departments and pediatric admissions (0-18 years old) in 1999 into the reference hospital of Pisa and into 5 other regional hospitals in Tuscany are reported. The percentages of patients, subdivided by age, hospitalyzed in Pediatric Departments have been determined., Results: In 1999 the admissions for subjects aged 0 to 18 years were 12573 of which 4966 adolescents (39.6 %). The percentage of adolescent admissions is not smaller than children's admissions (aged 0 to 1 year: 16.2%; aged 2 to 5 years: 26.2%; aged 6 to 9 years: 17.8%; aged 10 to 14 years: 20.4%; aged 15 to 18 years: 19.2%). Analysis by age demonstrated a continuous decrease of patient percentages admitted to Pediatric Departments with the increased age. A minority of 15/18- year-old subjects has been admitted to Pediatric Departments., Conclusions: The percentage of adolescent admissions is similar to there of children. Most adolescents are admitted to structures unsuitable for assistance to subjects aged 0 to 18 years. These data underline the necessity for a strong recovery of adolescent admissions to pediatric structures also equipping suitable nursing rooms.

The organizational appropriateness of hospital stays is an expression of a hospital's efficiency and aim of the management control. The AEP (American Version)/PRUO (Italian Version) protocol is specific for measuring the organizational appropriateness of hospital stays. The aim of this study is the comparative analysis of the organizational appropriateness of hospital stays in Careggi Hospital of Florence and in all hospital Departments in 1995 and 1998. In 1998 the AEP/PRUO protocol was applied to 2148 samples of hospital stays out of 38,968 eligible hospitalizations, and in 1995 a sample of 1989 hospital stays out of 35,108. In 1998 2,148 admissions and 15,338 days of hospitalization were tested. In 1995, 1989 admission days and 12,264 days of hospitalization were tested, 63 departments were studied. In 1995 the first edition of the protocol was applied, in 1998 the second. A sample of 218 of the 1998 hospital stays was tested with both editions to evaluate the impact of differences. In 1998, with the second edition of the protocol, the inappropriateness rate of admission days and hospitalization days and the rate of in-patients inappropriate hospital stays was respectively 38.0%, 43.8% and 18.5%. Compared with 1995 results, the rates increased +6.2%, 6% and +7.5% respectively. Instead, with the first edition of the protocol, the rates were 29.7%, 37.6% and 10.7% and, compared with 1995, they were reduced -2.1%, -0.6% and -0.3%. The longitudinal multilevel analysis has allowed the evaluation of the performance of each department.

The prevalence of comorbidities in patients dismissed from hospitals has already been investigated to obtain economical, administrative and epidemiological information, or for health insurance-related problems. Originally designed for billing purposes, administrative data could be the basis for clinical research as well, although the clinical element has somehow been disregarded till now. The aim of this research is (i) to study the prevalence, and (ii) to evaluate the clinical relevance of comorbidities in patients dismissed from a Department of Internal Medicine. In a recent series of 1605 patients (since the Diagnosis-Related Groups-DRG-based hospital financing system has come into common use in Italy) comorbidities have been observed in 92.65% of the cases, while the percentage of comorbidities was rated as 71.97% in a previous series of 2551 patients dismissed from the same Department before the introduction of the DRG system. In the recent series, the prevalence of a single comorbid condition and of two and of three comorbid conditions was 19.50, 32.89 and 47.61%, respectively. In any case, the so-called comorbid conditions were active diseases requiring medical investigation and therapy. They included hypertensive heart disease, ischemic heart disease and angina, arrhythmias, peripheral vascular diseases, chronic bronchitis, chronic hepatitis, liver cirrhosis, diabetes, metabolic disorders, etc. In conclusion, patients referred to a Department of Internal Medicine have a high severity of illness due not only to the gravity of the primary diagnosis but also to the number and seriousness of comorbid conditions. For these patients more hospital resources and a high level of professional skill are required.

Even though genetically determined, bacterial resistance to antibiotics are perpetuated only when a continual selection is present. Bacterial resistance caused by use of antibiotics is evident in the hospital setting. Since it has been demonstrated in the absence of section bacteria tend to return to a sensitive phenotype, the A. suggests that only with the rational use of antibiotics is the prevention of bacterial resistance possible.

A retrospective review and evaluation of systemic cephalosporin therapy in 15 hospitals of various italian Regions was conducted. In any hospital the Pharmacy Service has examined a random sample of medical records of hospitalized patients exposed to cephalosporin therapy over a twelve month period (January-December 1976). In the years 1974-1976 were also examined the consumption and cost for Penicillin G, Ampicillin and Cephalosporins. A standard protocol and methodology for homogeneous collection of data was developed. On the base of collected data, the patterns of choice, the rational and irrational use, the role of cephalosporins in hospital practice are discussed.