Reorganizing territorial healthcare to avoid inappropriate ED visits: does the spread of Community Health Centres make Walk-in-Clinics redundant?

BACKGROUND: Community care has recently been restructured with the development of Community Health Centres (CHCs), forcing a general rethink on the survival of previous organizational solutions adopted to reduce inappropriate ED access, for example Walk-in-Clinics (WiCs). METHODS: We focus on the Italian Emilia-Romagna Region that has made huge investments in CHC development, whilst failing to proceed at a uniform rate from area to area. Estimating panel count data models for the period 2015-2018, we pursue two goals. First we test the existence of a "CHC effect", choosing five urban cities with different degree of development of the CHC model and assessing whether, all else being equal, patients treated by GPs who have their premises inside the CHC show a lower need to seek inappropriate care (Aim 1). Second, we focus our attention on Walk-in-Clinics, investigating the long-established WiC in the city of Parma that currently coexists with three CHCs recently established in the same catchment area. In this case we try to assess whether, and to what extent, the progressive development of the CHCs in the city of Parma has been affecting the dynamics of WiC access (Aim 2). RESULTS: As regards Aim 1, we show that CHCs reduce the probability of inappropriate patient access to emergency care. As regards Aim 2, in the city of Parma patients whose GP belongs to the CHC are less likely to visit the WiC on a workday, with no significant change during the weekend when CHCs are closed, questioning the need to maintain them both in the same area when the CHC model is fully implemented. CONCLUSIONS: Our results confirm the hypothesis that expanding access to primary care settings diminishes inappropriate ED use. In addition, our findings suggest that where CHCs and WiCs coexist in the same area, it may be advisable to implement strategies that bring WiC activities into step with CHC-based general primary care reforms to avoid duplication

Risk Adjustment for CABG surgery: an administrative approach versus Euroscore

OBJECTIVE. To determine the ability of administrative data in predicting mortality for patients undergoing coronary artery bypass graft surgery (CABG). METHODS.Administrative databases on hospital discharge abstracts (SDO) of the Italian region Emilia Romagna and death registry data for year 2000. We used a multivariate logistic regression analysis to compare an ICD-9-CM risk adjustment approach based on administrative variables (such as age, gender, principal diagnosis, combined operation, previous cardiac surgery, emergency admission and Charlson comorbidity index) with a risk adjustment approach based on the clinical Euroscore to predict in-hospital and 60-day mortality and to assess hospital performance. Results. The risk adjustment approach based on ICD-9-CM data provides good explanatory ability in models assessing outcomes (the c statistics obtained are very close, c= 0.78 for in-hospital mortality in both approaches and c = 0.78 for the administrative model vs. 0.79 for the clinical one, considering 60-day mortality). CONCLUSIONS. With the growing completeness and accuracy of administrative data, this result seems to be of particular importance if we consider the possibility of adapting and applying administrative approaches to illnesses other than cardiovascular diseases, for which several clinical risk indexes - such as Euroscore - have been successfully developed

Selective referrals in a 'hub and spoke' institutional setting: The case of coronary angioplasty procedures

We analyse the highly-regulated cardiovascular sector of the health service in the Italian region of Emilia Romagna: this sector is characterised by strict regulatory control and a great emphasis on co-ordination and co-operation between public and private producers. These features have been even more marked since 2000, due to the adoption of the 'hub and spoke' organisational model, whereby a close relationship of selective referral from the network of satellite cardiology units (spokes) to the six Cardiac Surgical Centres (hubs) has been developed, so as to concentrate high risk procedures in highly specialised units. We focus on coronary angioplasty procedures (PTCA) and examine relations among centres before and after the official introduction of this hierarchical system completed the regionalisation of cardiovascular services. Secondly, since earlier regional efforts to reconfigure cardiovascular care by sending referrals to a few major centres may already have produced a high level of co-ordination among units, we investigate what happens to the volume-effect advantage across hospital categories with regard to the likelihood of adverse results for PTCA. We used descriptive statistics and logistic regression models to assess the existence of selective referrals and the concentration of clinical complexity in more specialised centres. Figures were taken from a regional administrative database based on hospital discharge abstracts (SDO) for the period 1998-2000. (C) 2002 Elsevier Science Ireland Ltd. All rights reserved

Different regional organisational models and the quality of health care: The case of coronary artery bypass graft surgery

Objectives: The Italian regions of Emilia-Romagna and Lombardy within the Italian National Health Service provide an opportunity to see if two different approaches to the organisation of care - one more hierarchical and planned, the other more competitive and market-like - influence its quality through examining the relationship between the number of coronary artery bypass grafts (CABGs) and the rate of in-hospital mortality using administrative data for the period 1996-1998. Methods: Descriptive statistics and logistic regression models were used. Results: The volume-outcome relation was statistically significant in both regions (odds ratio 0.71, P < 0.0001). Although CABG performance in Emilia-Romagna was slightly poorer than in Lombardy (OR 1.22, P < 0.05), the potential advantage in terms of the reduced risk of death for patients treated at high-volume versus low-volume hospitals was significantly greater. In Emilia-Romagna, the average performance advantage of high-volume units was more substantial in the case of private accredited hospitals than public hospitals (OR = 0.50, P < 0.0001 versus OR = 0.64, P < 0.0001). In Lombardy, the performance advantage of concentrating CABG procedures was greater in private research hospitals (OR = 0.67, P < 0.0001), whereas results were not statistically significant for the other types of hospital, indicating a good level of performance in both public and private hospitals even at low volumes. This also partially explained the lower mortality rate observed in that region. Conclusions: The degree of hierarchical regionalisation versus market-like arrangements characterising the two systems produced contrasting effects in terms of the quality of CABG surgery. Lombardy's more competitive environment appeared to achieve better performance in terms of a slightly lower probability of adverse outcomes, in a system with no formal assessment of population need and very high per capita revascularisation rates. To improve performance in the more hierarchical system adopted in Emilia-Romagna would require considerable effort to increase CABG surgery in low-volume cardiac units, and to sharpen performance incentives. © The Royal Society of Medicine Press Ltd 2003

Emergence of ciprofloxacin resistance in Escherichia coli isolates from outpatient urine samples

ABSTRACTThis study investigated the association between prescription of fluoroquinolones and emergence of ciprofloxacin resistance among Escherichia coli isolates in the urine of outpatients from whom a ciprofloxacin-sensitive E. coli strain had been isolated previously. Patients were identified and followed using the healthcare databases of Emilia-Romagna Region, Italy. The outcome of interest was the first isolation from urine of an E. coli strain resistant to ciprofloxacin. Prescription of fluoroquinolones during the previous 6 months was associated independently with the emergence of ciprofloxacin resistance; the strength of the association varied according to individual fluoroquinolone agents