OBJECTIVE: To examine potential changes in quality of care associated with a recent financing system implementation in Italy: in 1995, hospital financing reform implemented in Italy included the introduction of a DRG-based hospital financing system with the goals of controlling the growth of hospital costs and making hospitals more accountable for their productivity. DATA SOURCES: Hospital discharge abstract data from 1993 through 1996 for all hospitals (N=32) in the Friuli-Venezia-Giulia region of Italy. Regional population data were used to calculate rates. STUDY DESIGN: Changes between 1993 and 1996 in hospital admissions, length of stay, mortality rates, severity of illness, and readmission rates were studied for nine common medical and surgical conditions: appendicitis, diabetes mellitus, colorectal cancer, cholecystitis, bronchitis/chronic obstructive pulmonary disease (COPD), bacterial pneumonia, coronary artery disease, cerebrovascular disease, and hip fracture. PRINCIPAL FINDINGS: The total number of ordinary hospital admissions decreased from 244,581 to 204,054 between 1993 and 1996, a population-based decrease of 17.3 percent (p<.001). The mean length of stay decreased from 9.1 days to 8.8 days, resulting in a 21.1 percent decrease in hospital bed days (p<.001). Day hospital use increased sevenfold from 16,871 encounters in 1993 to 108,517 encounters in 1996. The largest decrease in hospital admissions among study conditions was a 41 percent decrease for diabetes (from 2.25 per 1,000 in 1993 to 1.31 in 1996, p<.001). For eight of the nine conditions, severity of illness increased. Differences between severity-adjusted expected and observed in-hospital mortality rates were small. CONCLUSIONS: Observed trends showed a decrease in ordinary hospital admissions, an increase in day hospital admissions, and a greater severity of illness among hospitalized patients. There was little or no change in mortality and readmission rates. Administrative data can be used to track changes in patterns of care and to identify potential quality problems deserving further review.

Impact of a DRG-based hospital financing system on quality and outcomes of care in Italy.

Background: Several large controlled trials have shown that β blockers given to patients with heart failure (New York Heart Association functional class II–IV) reduce morbidity and mortality Despite these impressive results, implementing the use of β blockade in clinical practice appears slow and difficult The BRING-UP study was designed to tackle this problem

Objectives: To accelerate the adoption of β blockade in clinical practice; to provide an epidemiological estimate of the proportion of patients with heart failure suitable for this treatment in general cardiology care; and to assess effectiveness of these drugs outside the setting of clinical trials

Methods: The design of the study and recommendations derived from available evidence on the use of β blockers were discussed with cardiologists during regional meetings All consecutive heart failure patients in a one month period, whether treated or not with β blockers, were eligible for the study In each patient, the decision to prescribe a β blocker was a free choice for the participating physicians All centres were provided with carvedilol, metoprolol, and bisoprolol at appropriate doses; the choice of the drug and dosage was left to the responsible clinician All patients were followed for one year

Results: 197 cardiological centres enrolled 3091 patients, 249% of whom were already on β blocker treatment at baseline β Blockers were newly prescribed in 327% of cases, more often in younger and less severely ill patients The mean daily dose of the drugs used at one year corresponded to about 70% of the maximum dose used in clinical trials Starting treatment with β blockers did not affect the prescription or dosage of other recommended drugs The overall rate of β blocker treatment increased over the year of the study from 249% to 497% During the 12 month period, 351 deaths occurred (118%) In multivariate analysis, the use of β blockers was independently associated with a better prognosis, with a relative risk of 060 and a lower incidence of hospital admissions for worsening heart failure

Conclusions: The implementation of β blockers in clinical practice is feasible and could be accelerated These drugs are associated with a lower mortality and reduced hospital admission rates, not only in clinical trials but also in the normal clinical setting

https://heart.bmj.com/content/heartjnl/89/3/299.full.pdf

Treatment of chronic heart failure with β adrenergic blockade beyond controlled clinical trials: the BRING-UP experience

Many multiple sclerosis (MS) prevalence studies in Italian northern and central areas, since 1980, have put Italy in a high risk zone; none concerns southern Italy. The MS registry of Salerno Center was reviewed, including the city and 16 towns at different distances (9-149 km) better connected to our Center. Population screened: 259 681 persons (Salerno = 136 678; province = 123 003). Prevalence day was December 31, 2005. Data on 186 patients were collected of which 55 were males, 131 females; crude total prevalence = 71.6263 (62.03-82.303, ranging from 50.1128 (Oliveto Citra) to 431.499 (Controne). Salerno prevalence rate is 70.9697 (57.41-86.583); standardized = 72.02. Incidence rate ranges from 2.38585 (1.6-3.39) (1991-95) to 4.31997 (3.24-5.6) (2001-05). Our data can be underestimated because some patients could have skipped the local center. This emphasizes that the results, except for Sardinia, are comparable to Italian literature data. They confirm that this territory is a high risk area for MS. There is also an indirect indication against a latitude gradient for MS.

Prevalence and incidence of multiple sclerosis in Salerno (southern Italy) and its province.

Participation versus education: the GISSI story and beyond.

Objectives To assess the proportion of high-risk coronary artery disease (CAD) patients who received lipid lowering drug treatment (LLDT) and met the LDL-Cholesterol (LDL-C) goal of 100 mg/dl defined by the third report of the U.S. National Cholesterol Education Program (NCEP). Methods In 86% (n = 1095) of the 1268 consecutive Italian patients, who were enrolled in the GENICA study after undergoing quantitative coronary angiography for suspected coronary artery disease between 1999 and 2001, the levels of total serum cholesterol, HDL-cholesterol, triglycerides, and LDL-C were measured and accurate information on current LLDT were available. All patients were classified according to the NCEP. Results Seventy-four percent of the patients (n = 805) had established CAD and cardiovascular events and therefore were candidates for secondary prevention with LLDT; 69% of them had concomitant hyperlipidemia. Only 57% of the patients with CAD and hyperlipidemia were on LLDT. Of the 1052 patients who were at the highest risk class according to NCEP, only 34.2% and 16.7% were on LLDT and reached the LDL-C goal, respectively. Conclusions Only 1 patient of 6 in the highest-risk class according to the NCEP accomplished the LDL-C goal. Accordingly, in the field of secondary prevention of coronary artery disease, the implementation of guidelines that emerged from scientific evidence into clinical practice with LLDT still requires major efforts.

Rovelli F

Papers

Health services: an Italian market.