Primary Health Care quality in Italy: a literature overview

In this section we report the results of a literature overview about studies on quality of primary care since the year 2000conducted by Roberto Buzzetti as contribution to the European project MOCHA (Models of Child Health Appraised). Alessandra Buja, Michele Grandolfo e Carmen Verga callaborated to the overewiew.

The literature review covers selectively international and national publications, as well as various projects designed for enhancing the quality of care and the culture of performance evaluation in primary care. However, this work is not a systematic review of the existing literature, which would require considerable resources. On the contrary, it is a first attempt at indexing systematically the main articles on a subject that is extremely broad and has been rarely – if ever – reviewed. Covering in detail the topic of the quality of primary care would require additional work, namely, assessing the main dimensions of health care quality (i.e., effectiveness, efficiency, safety, appropriateness, accessibility, acceptability, fairness of care) and their application in many fields, such as vaccine coverage, the care provided by general practitioners and primary care paediatricians (with several clinical and organizational audit studies), community medicine, primary prevention, early diagnosis, care, rehabilitation, palliation, etc.

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OECD Reviews of Health Care Quality: Italy 2014 – Raising standards

Executive summary

This report reviews the quality of health care in Italy. It begins by providing an overview of policies and practices aimed at supporting quality of care (Chapter 1). The report then focuses on three areas that are of particular importance for Italy’s health system at present: the role of primary care (Chapter 2), improving the training of the health care workforce (Chapter 3) and improving systems for monitoring and improving the quality of care in a regionalised health system (Chapter 4). In examining these areas, this report examines the quality of care currently provided, seeks to highlight best practices, and provides a series of targeted assessments and recommendations for further improvements to quality of care.

The Italian Servizio Sanitario Nazionale (or National Health Service, SSN) was established in 1978 to grant universal access to a uniform level of care throughout Italy, free at the point of use, financed by general taxation. The Ministry of Health fulfils the function of the overall steward of the health system and defines the livelli essenziali di assistenza (or essential level of care, LEA) to be delivered across the country. Beyond this, Italy’s 21 regions and autonomous provinces (R&AP) are responsible for the actual planning and delivery of services. Articulation between central government’s steering role and regional government’s delivery role is expressed in the Patto per la salute (Pact for health), a three-year plan that is agreed jointly between central and regional governments.

In recent years, however, many regional health budgets ran into substantial deficit, leading to central authorities to imposing Piani di Rientro (Recovery Plans) on ten of them, of which eight are on-going. These plans signalled the introduction of a dominant new player in national health care policy – the Ministry of Finance. Although the Ministry of Health maintained its role in ensuring that essential levels of care were provided at regional level, the Ministry of Finance became actively involved in designing and approving health care delivery. To a large extent, then, the focus of this abrupt resumption of central control was financial and quality of care risked becoming secondary.

Italy is facing, therefore, two major challenges. The first is to ensure that ongoing efforts to contain health system spending do not subsume health care quality as a fundamental governance principle. The second must be to support those R&AP with weaker infrastructure and capacity to deliver care of equal quality to the best performing areas. A more consolidated and ambitious approach to quality monitoring and improvement at a system level is needed. Over the past decade, a range of quality-related activities have been developed, with varying depth and scope, and with little co-ordination across these approaches by central agencies. Different accreditation models have been developed, for example, and performance management tools used by R&AP are diverse, making comparison against national standards difficult and limiting the accountability of providers toward users. These divergent approaches must now be consolidated. At the same time, other key quality strategies are poorly developed or absent. Requirements for recertification and for professional development are not established and payment systems do not systematically reward improvements in clinical care and patient outcomes. These deficiencies must be addressed to ensure that Italian health care quality architecture is comparable to the best seen in OECD health systems. 

Primary health care in Italy performs well – rates of avoidable hospitalisation are amongst the lowest in the OECD. Italy faces, however, a growing ageing population and a rising burden of chronic conditions, which are likely to result in higher health care costs and place further pressures on the primary care sector. Whilst the management of chronic conditions requires a co-ordinated patient-centered response from a wide range of health professionals, the Italian health care system has traditionally been characterised by a high level of fragmentation and a lack of care coordination. Italy has made considerable efforts to experiment with new models of community care services (such as community care networks and community hospitals) that aim at achieving greater co-ordination and integration of care. Although the expansion of community care services is an appropriate policy response to meet the growing demand for health care, they are still unevenly distributed across Italian regions. Greater guidance and support from national authorities is needed to ensure a more consistent approach. At the same time, there are other shortcomings in Italy’s primary care sector that require attention to guarantee high quality primary care. Efforts are needed to increase transparency, develop performance measurement and strengthen accountability in the sector. The development of a set of standards around the processes and outcomes of primary care, the setting-up of smarter payment system, and increase the involvement of primary care physicians in preventive activities are options that Italy should consider pursuing if it is to meet the challenge of an increasing burden of long-term conditions.

The medical workforce delivers, in general, care of a high quality. Looking to secure this high performance for the decades to come, and push back against any regional disparities in quality and outcomes, Italy has also been taking important steps towards ensuring nationally cohesive workforce training programmes. However, going forward, good medical education and nationally standardised continuing medical education may not be enough to secure a high quality, high performing medical workforce. There is scope to look to the scientific literature, and the experiences of other OECD countries, to try to maximise the impact of medical education, from the undergraduate level and beyond. This chapter suggests ways that Italy could promote workforce quality when selecting future medical professionals prior to undergraduate education, and ways to improve the quality of undergraduate medical teaching. There are also opportunities to maximise the positive impact of Italy’s existing continuing medical education programme, as well as a need for Italy to eventually develop more modern models of workforce quality insurance, including a move to continuing professional development, and using data to encourage health professionals to reflect on their practice.

Italy’s regions and autonomous provinces (R&AP) differ substantially. GDP per capita varies more than two-fold and unemployment rates more than four-fold. Italian health care services, being fully regionalised, reflect this heterogeneity. Whilst it cannot be said that any one region delivers consistently “poor” health care, it is clear that some regions struggle to provide the same quality as others. Large numbers of patients move between regions in search of health care, with northern R&AP being net importers. Italy has established a number of mechanisms to try and ensure an evenness of approach to quality measurement and improvement. These include activities to ensure dialogue between national and regional authorities as well as professionally led initiatives to measure quality consistently. While it would be unrealistic and undesirable to seek complete homogeneity in how regional health systems are configured, more can be done to achieve a more even approach to quality measurement and improvement across R&AP.

Key priorities are to develop a more consistent approach to using information to manage performance and strengthen local accountability. Ensuring that regional resource allocation has a focus on quality, and is linked to incentives for quality improvement, will also be important. Actions that strengthen the regional approach to health care governance and delivery in Italy are also needed. Developing the responsibilities and capacities of the national authorities whose role is to support the R&AP should continue. Reframing governance as a whole, such that quality improvement is emphasised as much as financial control, is also necessary.

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Italian Ministry of Health – General directive for administrative activities and management

Pursuant to Articles 4 and 14 of Legislative Decree No 165 of 30 March 2001 – Year 2015

(Ministero della Salute – Direttiva generale per l’attività amministrativa e la gestione – Ai sensi degli articoli 4 e 14 del decreto legislativo 30 marzo 2001, n. 165 – Anno 2015)


2.4. Promoting the quality and appropriateness of health care. ….. 15
2.4.1. Standard healthcare costs and requirements……………………… 15
2.4.2. Reorganization of primary and hospital care………………………. 16
2.4.3. Quality of health services and humanization of c………………… 17…the definition of tools that foster efficiency, appropriateness and quality of health care interventions, ensuring an appropriate assessment, especially in relation to general primary care, paediatric primary care, psychiatry, management of elderly and disabled people in the area, pain and palliative care, creation of preferential pathways for oncology and for the treatment of cardiovascular disease, diabetes and metabolic diseases, also through the implementation of a National Program for the Promotion of Quality and Safety of Care. This is consistent with what is stated in the conclusions of the European Council… … to go on the path of humanizing the care through a global analysis of the real needs, contexts, relationships between people and their environments, individual and group cognitive and emotional processes, in order to identify latent needs and contextualize the explicit requests …..

2.4.4. The National Health Plan…………………………………………………………… 19
2.4.5. National Outcome Plan (PNE)…………………………………………………….. 20
2.4.6. Initiatives on SSN staff……………………………………………………………… 20  

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Italian health surveillance and Control System (SiVeAS)

(SiVeAS – Sistema nazionale di Verifica e controllo sull’Assistenza Sanitaria)

The purpose of SiVeAS is to verify the compliance with the criteria for the appropriateness and quality of health care services, consistent with the Essential Levels of Care, and the efficiency criteria in the use of production factors, in accordance with the provided funding.


  1. to provide general support in order to produce tools for evaluating and implementing good practice (efficiency, effectiveness and quality of health care) in the various regional areas
  2. To ensure all the activities required for the support and control of the Regions involved in deficit-return plans.


  • Monitoring Essential Levels of Care
  • Promotion and evaluation of management efficiency
  • Promotion and evaluation of effectiveness and quality
  • Promotion and Appraisal of Appropriateness
  • Accreditation and Organization of provided services
  • Accessibility
  • Healthcare Assistance
  • International comparisons and data base integrations
  • Support to the regions with a deficit-return plan

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The Italian health surveillance (SiVeAS) prioritization approach to reduce chronic disease risk factors

Simoes EJ1, Mariotti S, Rossi A, Heim A, Lobello F, Mokdad AH, Scafato E.

Int J Public Health. 2012 Aug;57(4):719-33. doi: 10.1007/s00038-012-0341-5. Epub 2012 Feb 14.

OBJECTIVE: Because public health funds are limited, programs need to be prioritized.

METHODS: We used data on 15 risk factors from Italy’s public health surveillance to inform prioritization of programs. We ranked risk factors using a score based on the product of six criteria: deaths attributable to risk factors; prevalence of risk factors; risk factor prevalence trend; disparity based on the ratio of risk factor prevalence between low and high education attainment; level of intervention effectiveness; and cost of the intervention.

RESULTS: We identified seven priorities: physical inactivity; cigarette smoking (current smoking); ever told had hypertension; not having blood pressure screening; ever told had high cholesterol; alcohol (heavy drinking); not eating five fruits and vegetables a day; and not having a fecal occult blood test.

CONCLUSIONS: This prioritization method should be used as a tool for planning and decision making.

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National observatory on the health in the Regions – Catholic University Project – Rome

(Osservatorio nazionale sulla salute nelle regioni – Progetto Università Cattolica – Roma)


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Center for Research on Health and Social Care Management – CERGAS Bocconi – Primary Care Observatory

(Centro di Ricerche sulla Gestione dell’Assistenza Sanitaria e Sociale (CERGAS) – Bocconi – Osservatorio Cure Primarie)

The Observatory of Primary Care was born in 2015 with the aim of analyzing and representing the current scenario of Territorial Assistance and Primary Care in Italian healthcare local Unit; performing a benchmarking comparison based on the most innovative and effective experiences within the different geographic areas; facilitating the activation of replication / dissemination mechanisms within the national system of such good practices in the organization of assistance on the territory.
The research activity focuses on:

  • User access to services and pathways
  • Models implemented for Service management
  • Coordination of services and various care settings
  • Integration among professionals
  • Computerization of territorial care
  • Strategic goals and evolution of primary care

At present 11 local health Units take part of the Observatory.

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ISTUD Foundation, Vance Cittadinanzattiva, Card, Agenas and Federsanità ANCI promote research to monitor the situation of primary care in Italy

(Fondazione ISTUD, Vance Cittadinanzattiva, Card, Agenas e Federsanità ANCI promuovono una ricerca per monitorare la situazione delle cure primarie in Italia)

Home care is an important way of providing medical, rehabilitative, nursing, rehabilitation, care facilities to people who, for reasons related to disability or other limitations of their autonomy, are unable to go to hospitals or outpatient facilities to undergo the cures they need.

Health and social workers of the Local Health Units provide these treatments. The quality of home care is closely linked to the efficiency of the organization of the territorial districts, which must coordinate the takeover. The ISTUD Foundation since 2009 has organized the first National Observatory on Home Care, titled “Addressing guidelines to make home care effective for all citizens”.

The results of these researches highlighted that Italians like to be treated, assisted and rehabilitated at home.

This year, the ISTUD Foundation project is expanding and, taking the name of “National Observatory of Primary Care”, aims to map out the Italian situation of primary care offerings in individual regions. The objective of the research is to identify and evaluate the territorial assistance models emerging from the ongoing experiments in Italy, to define the network models that can be realized in the medium to short term that meet the needs of the territory; to evaluate open issues: association in jagged territories, cities and rural areas, contracts to be concluded with Regional Health Systems, ways of allocating resources and reimbursement of benefits; to evaluate the critical areas of the processes.

The data collected from this research will be organized in a report that will be available on the Cure at Istud Foundation House, and presented during a scheduled event by the end of November.

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National Observatory on the Condition of People with Disabilities

(Osservatorio Nazionale sulla condizione delle persone con disabilità)

The Observatory is a consultative technical and scientific support to the development of national policies on disability, mainly aimed to:

  • promotion of implementation of the UN Convention on the Rights of Persons with Disabilities;
  • preparation of a bi-annual action program in order to promotion of the rights and integration of people with disabilities;
  • collection of statistical data and realization of studies and research on the subject;
  • report on the state of implementation of disability policies.

Here is a summary of the points in which the Bi-Year Action Program for Disability is articulated:

  • Recognition / Disability Certification Reform
  • Policies, services and organizational models for independent living and inclusion in society
  • Health, Right to Life, Enabling and Rehabilitating
  • Educational Processes and School Inclusion
  • Jobs and Employment
  • Promotion and implementation of the principles of accessibility and mobility

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A noteworthy site is that of the APRIRE Association (Network of Primary Care) that contains an extensive database of primary care documentation (in Italian)

Studi, esperienze, strumenti di lavoro

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Genitori più: Let’s take care of their lives

(Progetto “Genitori più”: prendiamoci cura della loro vita)

The Ministry of Health, in collaboration with the Italian Pediatric Federation and Unicef, has decided to extend the “Parents Plus” campaign, which was launched in 2006 in the Veneto region on an experimental level throughout the country. The involved regions are: Veneto (Lead Region): Abruzzo, Calabria, Emilia Romagna, Friuli Venezia Giulia, Lazio, Molise, Piedmont, Puglia, Sardinia, Umbria and Valle d’Aosta.
These initiative addresses parents to promote the health of children starting from seven simple actions:
• Taking folic acid
• not smoking
• breastfeeding
• sleep supine position
• safe transport (car seats)
• adhering to all vaccinations
• reading a book.
These actions can help prevent serious risks of different kinds such as congenital malformations, low birth weight, SIDS, infections, road trauma, obesity, cognitive and relational difficulties. The aim of the awareness campaign is to talk to parents in a simple and plain language to informe and alert about the child’s health, from birth to all lifelong.

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Some papers about vaccines

Increasing childhood immunization coverage by establishing structured relationships with pediatricians and family practitioners

Russo F1, Pozza F, Napoletano G.

Ann Ig. 2012 Jan-Feb;24(1 Suppl 1):7-13 – Article in Italian

An immunization strategy can take advantage of various tools, among which the pediatrician and family practitioner These figures, have been assigned the role of accompanying the child and his/her family throughout development. One of the objectives of this role is also to take a major part in the support of immunization coverage of infants, especially in light of the sospension of required immunizations in the Veneto Region. For this reason it is necessary to open dialogue on immunizations together with pediatricians and family physicians. In addition, training of these professional figures, together with healtcare operators who work in the immunization clinics, has allowed the formation and standardization of the network, as the persons who attend the immunization clinics are no longer passive users but persons who require information exchange in order to make an informed choice about immunizations for their children. Surveillance of vaccination coverage is a useful tool for evaluating the trend in vaccination refusals, and in particular it takes into consideration the motivation behind the refusal to adhere to the polio vaccine recommendations even if for now the coverage is maintained above 95%. Concluding, another strong point for the immunization program is “Genitori Più” which finds its continuity with the Regional Prevention Plan.

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A survey on childhood vaccination coverage in the Campania region

(Studio sulle coperture vaccinali dell’infanzia nella regione Campania)

Crescenzo Bove1, Anna Luisa Caiazzo2, Rosa Castiello3, Annarita Citarella4, Angelo D’Argenzio5, Maria Antonietta Ferrara6, Franco Giugliano7, Giovanni Morra8, Carmelo Padula9, Antonino Parlato10, Rocco Parrella11, Filomena Peluso12, Andrea Simonetti13, Elvira Lorenzo14, Vittorio Pagano14, Silvia Andreozzi15, Mauro Bucciarelli15 e Michele Grandolfo15

1ASL CE1, 2ASL SA1, 3ASL SA3, 4ASL BN, 5ASL CE2, 6ASL AV2, 7ASL NA5, 8ASL NA4, 9ASL AV1,10ASLNA2, 11ASL SA2, 12ASL NA3, 13ASL NA1, 14Osservatorio Epidemiologico Regionale, Napoli, 15Laboratorio di Epidemiologia e Biostatistica, ISS

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Evaluation of immunization practices in Naples-Italy.

Simonetti Andrea

This paper reports the results of a survey on vaccination coverage among children born in January 1995 and residing at the beginning of the study (March 1998) in the city of Naples, Italy. The percentages vaccinated, at various times from birth, with oral polio vaccine (OPV), have been compared with those found in a similar survey conducted at the end of 1985 regarding the cohort of children born in June 1983. By the fourth month of life 67% of the 1995 cohort were vaccinated with the first doses of OPV, an increase of about 26% on that found in the 1983 cohort. Similar results were found with the second doses. Among the 1995 cohort 49% were vaccinated with the third dose of OPV within the thirteenth month of life; the corresponding value for the 1983 cohort was 33%. Within the twenty-fourth month of life, in the 1995 cohort, 86% completed the primary cycle of vaccination with OPV; the corresponding figure for the 1983 cohort was 65%. At the end of the third year of life 80% of the 1995 cohort received the fourth dose of OPV. A significant association has been found between socioeconomic status and coverage level.

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Progress in the elimination of measles and congenital rubella in Central Italy

Bechini A(1), Levi M, Boccalini S, Tiscione E, Panatto D, Amicizia D, Bonanni P.

(1) Department of Health Sciences; University of Florence; Florence, Italy – Hum Vaccin Immunother. 2013 Mar;9(3):649-56. Epub 2013 Jan 4. 

Despite the launch of a WHO European Region strategic plan 2005-2010 for eliminating measles and rubella and preventing congenital rubella (CR) infection, measles and rubella are still circulating in Europe. Increased transmission and outbreaks of measles in Europe were still observed in 2011. In Italy, the objectives of the National Plan (2003-2007) for measles elimination have not yet been achieved. The goal of measles elimination and incidence reduction of CR cases has been postponed to 2015 by the Italian Ministry of Health through the implementation of the new National Plan 2010-2015 which will require (1) the achievement of more than 95% coverage with 1 dose and two doses of measles containing vaccine (MCV), respectively, within 24 mo and within 12 y of age; (2) supplementary vaccination activities aimed at susceptible populations including adolescents, young adults and those at risk (health care and educational workers, military, groups “hard to reach” like nomads); and in addition, (3) reduction to less than 5% in the proportion of susceptible women of childbearing age (especially immigrant women). Experiences at regional level, like in Tuscany, have shown promising results in order to create an integrated surveillance system between regional and local health authorities, university and laboratory and in the future, to validate elimination. Moreover, the evaluation of all preventive activities performed in Tuscany during the last decade, immunization coverage data, sero-epidemiological population profile and incidence of measles and rubella cases has highlighted critical points which should be improved and good practices already implemented which should be maintained in the future in order to reach the new goals.

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Description of two measles outbreaks in the Lazio Region, Italy (2006-2007). Importance of pockets of low vaccine coverage in sustaining the infection.

Curtale F (1), Perrelli F, Mantovani J, Ciofi degli Atti M, Filia A, Nicoletti L, Magurano F, Borgia P, Di Lallo D.

(1) Unit of Infecious Diseases and Vaccination, Department of Health Prevention and Promotion, Laziosanita’ Agenzia di Sanita’ Pubblica, Via Santa Costanza 53, 00198 Roma, Italy. – – BMC Infect Dis. 2010 Mar 11;10:62. doi: 10.1186/1471-2334-10-62.

BACKGROUND: Despite the launch of the national plan for measles elimination, in Italy, immunization coverage remains suboptimal and outbreaks continue to occur. Two measles outbreaks, occurred in Lazio region during 2006-2007, were investigated to identify sources of infection, transmission routes, and assess operational implications for elimination of the disease. METHODS: Data were obtained from several sources, the routine infectious diseases surveillance system, field epidemiological investigations, and molecular genotyping of virus by the national reference laboratory. RESULTS: Overall 449 cases were reported, sustained by two different stereotypes overlapping for few months. Serotype D4 was likely imported from Romania by a Roma/Sinti family and subsequently spread to the rest of the population. Serotype B3 was responsible for the second outbreak which started in a secondary school. Pockets of low vaccine coverage individuals (Roma/Sinti communities, high school students) facilitated the reintroduction of serotypes not endemic in Italy and facilitated the measles infection to spread. CONCLUSIONS: Communities with low vaccine coverage represent a more serious public health threat than do sporadic susceptible individuals. The successful elimination of measles will require additional efforts to immunize low vaccine coverage population groups, including hard-to-reach individuals, adolescents, and young adults. An enhanced surveillance systems, which includes viral genotyping to document chains of transmission, is an essential tool for evaluating strategy to control and eliminate measles.

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The “Birth patway”

(Il percorso nascita nella prospettiva del Progetto obiettivo materno infantile – Pomi – Istituto Superiore di Sanità

Pre- and post-natal assistance: promotion and assessment of operational models quality. The 2008-2009 and 2010-2011 surveys.

Laura Lauria, Anna Lamberti, Marta Buoncristiano, Manila Bonciani and Silvia Andreozzi – 2012, iii, 176 p. Rapporti ISTISAN 12/39 (in Italian)

In the National Health Program 1998-2000, the Italian Ministry of Health introduced a plan to improve maternal and child health. The Istituto Superiore di Sanità (the National Institute of Health in Italy) had the task of helping the Local Health Units (LHU) to implement the plan recommendations for pre- and post-natal assistance and evaluating the effectiveness of the implemented activities. Thus, in 25 LHU, two population-based follow-up surveys were conducted in 2008-2009 and in 2010-2011 before and after the programme implementation. Although a private and medicalized maternal assistance model persists, the results show a general improvement in pre- and post-natal care indicators as attendance to antenatal classes, information received by the mothers during and after pregnancy, counselling in puerperium offered by the public family care centres, and breastfeeding. The assistance by public family care centres and the attendance to antenatal classes have a positive effect on natal care indicators. It is worthy empowering these services and giving a suitable training to the involved health personnel. Key words: Pregnancy assistance; Health care models evaluation; Antenatal classes; Family Care Centres.

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The surveillance system OKkio alla SALUTE: results 2010.

(Istituto Superiore di Sanità – “OKKIO ALLA SALUTE” project)

Angela Spinelli, Anna Lamberti, Paola Nardone, Silvia Andreozzi and Daniela Galeone –  2012, xii, 139 p. Rapporti ISTISAN 12/14 – in Italian

In 2007 the Italian Ministry of Health promoted OKkio alla SALUTE, national nutritional surveillance system based on biannual cross-sectional surveys and coordinated by the National Institute of Health. It aims to estimate the prevalence of overweight and obesity among primary schoolchildren and to examine the behavioral factors associated. In the second round of data collection, carried out in 2010, of the 42,549 students weighed and measured with a standardized methodology 34% were overweight or obese. 9% of the children did not have breakfast and 68% consumed mid-morning calorific snacks; 23% did not consume fruits and vegetables daily; 22% of the children usually practiced physical activity for one hour a week. The methodology has been validated in collaboration with INRAN and some communication tools developed with the project Pinc. This surveillance system is a valuable tool to monitor the evolution of the obesity and may help to promote public health interventions.

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Related articles:
  1. Epidemiol Prev. 2016 Mar-Apr;40(2):145. doi: 10.19191/EP16.2.P145.071. – OKkio alla salute 2014: hours of sleep in Italian 8-9-year-old children – Article in Italian – Lauria L(1), Pizzi E(1), Nardone P(1), Buoncristiano M(1), Bucciarelli M(1), Galeone D(2), Spinelli A(1); Gruppo OKkio alla salute 2014 – (1) Centro nazionale di epidemiologia, sorveglianza e promozione della salute, Istituto superiore di sanità, Roma; (2) Ministero della salute, Segretariato generale, Roma. – DOI: 10.19191/EP16.2.P145.071 PMID: 27290894
  2. Epidemiol Prev. 2016 Jan-Feb;40(1):74. doi: 10.19191/EP16.1.P074.017 – Maternal perception of their children’s weight and lifestyles – Article in Italian – Lauria L(1), Pizzi E(1), Nardone P(1), Buoncristiano M(1), Bucciarelli M(1), Galeone D(2), Spinelli A(1); Gruppo OKkio alla salute 2014 – (1) Centro nazionale di epidemiologia, sorveglianza e promozione della salute, Istituto superiore di sanità, Roma. (2) – DOI: 10.19191/EP16.1.P074.017 PMID: 26951705
  3. Ann Ist Super Sanita. 2015;51(4):371-81. doi: 10.4415/ANN_15_04_20 – Dietary habits among children aged 8-9 years in ItalyLauria L(1), Spinelli A(1), Cairella G(2), Censi L(3), Nardone P(1), Buoncristiano M(1); 2012 Group OKkio alla SALUTE – (1) Centro Nazionale di Epidemiologia, Sorveglianza e Promozione della Salute, Istituto Superiore di Sanità, Rome, Italy. (2) Servizio Igiene Alimenti e della Nutrizione, Asl RM B, Rome, Italy. (3) Consiglio per la Ricerca in Agricoltura e l’Analisi dell’Economia Agraria, Centro di Ricerca per gli Alimenti e la Nutrizione, Rome, Italy. – OBJECTIVE: To describe dietary habits and related geographic and socio-demographic characteristics among children aged 8-9 years in Italy. MATERIALS AND METHODS: Data from the 2012 national nutritional surveillance system collected from children, parents and teachers, have been linked to determine the children’s eating habits. Logistic regression analyses were used to investigate the association between incorrect dietary habits and their potential predictors. RESULTS: Of the 46 307 children, 8.6% skipped breakfast, 48.8% did not eat vegetables and 28.7% did not eat fruit daily, 64.8% ate an abundant mid-morning snack, 41.4% drank sugary beverages and 12.5% drank carbonated beverages at least once a day. Three or more incorrect habits were found in 43.9% of the children. Incorrect dietary habits were more common among children with lower socio-economic conditions, who were resident in the South of the country and who spent more time watching TV. CONCLUSION: In Italy, unhealthy dietary habits are common among children. The deficiencies identified may well be a harbinger of future public health problems. – DOI: 10.4415/ANN_15_04_20 PMID: 26783227 [Indexed for MEDLINE]
  4. Epidemiol Prev. 2015 Sep-Dec;39(5-6):380-5 – Dietary behaviour of children attending primary school in Italy found by the surveillance system “OKkio alla salute” – Article in Italian – Nardone P(1), Lauria L(2), Buoncristiano M(2), Pizzi E(2), Galeone D(3), Spinelli A(2); Gruppo OKkio alla salute 2008/9-2014 – (1) Centro nazionale di epidemiologia, sorveglianza e promozione della salute, Istituto superiore di sanità, Roma. (2) Centro nazionale di epidemiologia, sorveglianza e promozione della salute, Istituto superiore di sanità, Roma. (3) Ministero della salute, Segretariato generale, Roma – OBJECTIVES: to describe the dietary behaviour of children attending primary school and the school activities which promote healthy dietary habits. DESIGN OF THE STUDY: surveillance system with biannual prevalence studies. SETTING AND PARTICIPANTS: the fourth round of data collection of the surveillance system OKkio alla salute took place in 2014, promoted and financed by the Ministry of Health and coordinated by the National Institute of Health in collaborations with all regions. 2,408 schools, 48,426 children and 50,638 parents participated. Stratified cluster sampling (with third grade classes as units) was used; information was collected using questionnaires completed by children, parents, teachers and head-teachers. OUTCOME MEASURES: consumption of breakfast, mid-morning snack, fruit and vegetables, sweetened and gassy drinks; school initiatives to promote healthy dietary habits. RESULTS: 31% of children have an adequate breakfast and 8% skip this meal; 52% consume an energy-dense mid-morning snack; 25% do not eat fruit and vegetables daily; 41% drink sweetened/gassy beverages daily. The unhealthy dietary habits are more common among children who have less educated parents or live in the South (more deprived area of the Country). Data show an improvement in the period 2008-2014, except in the consumption of fruit and vegetables. 74% of the schools include nutritional education in the curriculum, 66% have started initiatives of healthy dietary habits and 55% distribute healthy food; 35% involve parents in their initiatives. In the schools of the South nutritional education and involvement of parents are more frequent, while the distribution of healthy food and refectories are less common. CONCLUSIONS: the high frequency of unhealthy dietary behaviour and their geographic and social inequalities show that there is a great potential for improvement. Schools are very involved in initiatives of promotion, but they need more support from the institutions and involvement of the families. – PMID: 26554690 [Indexed for MEDLINE]
  5. Epidemiol Prev. 2015 Jul-Aug;39(4):269 – Eating habits and physical activity improve thanks to the interventions of Italian schools – Article in Italian – Nardone P(1), Buoncristiano M(1), Lauria L(1), Pizzi E(1), Bucciarelli M(1), Spinelli A(1), Vienna A(2), Galeone D(3); Gruppo OKkio alla salute 2014 – (1) Centro nazionale di epidemiologia, sorveglianza e promozione della salute, Istituto superiore di sanità, Roma. (2) Ministero dell’istruzione, dell’università e della ricerca, Roma. (3) – PMID: 26499240 [Indexed for MEDLINE]
  6. Epidemiol Prev. 2015 May-Jun;39(3):209 – Does the environment around italian schools promote healthy choices for children? Let’s give the floor to headteachers – Article in Italian – Lauria L(1)(2), Spinelli A(1)(2), Nardone P(1)(2), Pizzi E(1)(2), Buoncristiano M(1)(2), Bucciarelli M(1)(2), Galeone D(2)(3); Gruppo OKkio alla salute 2014 – (1) Centro nazionale di epidemiologia, sorveglianza e promozione della salute, Istituto superiore di sanità, Roma. (2) (3) Ministero della salute, Segretariato generale, Roma – PMID: 26407460 [Indexed for MEDLINE]
  7. Ann Ig. 2015 Mar-Apr;27(2):432-46. doi: 10.7416/ai.2015.2030 – Effects of a school based intervention to promote healthy habits in children 8-11 years old, living in the lowland area of Bologna Local Health UnitSacchetti R(1), Dallolio L(2), Musti MA(3), Guberti E(4), Garulli A(5), Beltrami P(3), Castellazzi F(3), Centis E(3), Zenesini C(3), Coppini C(4), Rizzoli C(4), Sardocardalano M(4), Leoni E(2) – (1) Department of Education Studies “Giovanni Maria Bertin”, University of Bologna, Italy. (2) Department of Biomedical and Neuromotor Sciences, Unit of Hygiene, Public Health and Medical Statistics, University of Bologna, Italy. (3) Department of Public Health, Section of Epidemiology, Health Promotion and Risk Communication, Local Health Unit of Bologna, Italy. (4) Department of Public Health, Section of Food Hygiene and Nutrition, Local Health Unit of Bologna, Italy. (5)Department of Public Health, Section of Sport Medicine, Local Health Unit of Bologna, Italy – BACKGROUND: A school based health promotion intervention was performed with the aim of increasing physical activity and improving the dietary habits of primary school pupils, using integrated educational strategies involving schools, families, public bodies, sports associations and public health operators. METHODS: The intervention concerned 11 classes during 3 school years from 2009-10 (231 third-year school children) to 2011-12 (234 fifth-year school children). Information was collected both before and after the intervention about the dietary habits and the physical activities practised by the children, using the questionnaires of the project !OKkio alla Salute! which were administered to both children and parents. At the same time anthropometric measurements were taken (height, weight, BMI) and motor skills were assessed using standardized tests: Sit & Reach, medicine-ball forward throw, standing long jump, 20 m running speed, and forward roll. At the end of the intervention 12 different expected outcomes were assessed (5 about dietary habits, 5 about motor habits, 1 about anthropometric characteristics, 1 about motor skills). RESULTS: At baseline, 35.8% of the children show excess weight (23.4% overweight; 12.4% obese); this percentage falls to 29.3% (25.3% overweight; 4% obese) after the intervention (p <0.05). The dietary habits improve from the pre- to the post-intervention: there is a rise in the percentage of children who receive an adequate mid-morning snack (p <0.0001), a fall in the percentage of children who consume snacks and drinks after the dinner (p <0.01), and an increase in the percentage of those who take five or more portions of fruits and vegetables daily. The motor habits do not improve in the same way, since there is the increasing tendency with age to skip from a regular daily practice of physical exercise to favour of the occasional practice of a sport. The motor performances, compared after normalization for modifications due to the process of growth, improve between the third and fifth years of primary school, but with no significant differences. To achieve this objective more focused measures are necessary in the administration of moderate to intense physical exercise. CONCLUSIONS: The results point to a positive assessment of the intervention, thus highlighting the importance of planning integrated and multisectorial actions in school-based programmes to promote correct dietary and motor habits and for the control of body weight, also involving non scholastic areas. – PMID: 26051142 [Indexed for MEDLINE]
  8. Epidemiol Prev. 2015 Mar-Apr;39(2):139 – In Italy the prevalence of sedentary habits among children is decreasing – Article in Italian – Buoncristiano M(1)(2), Nardone P(1)(2), Lauria L(1)(2), Spinelli A(1)(2), Bucciarelli M(1)(2), Galeone D(2)(3); Gruppo OKkio alla salute – (1) Centro nazionale di epidemiologia, sorveglianza e promozione della salute, Istituto superiore di sanità, Roma. (2) (3) Ministero della salute, Segretariato generale, Roma – PMID: 26036745 [Indexed for MEDLINE]
  9. Epidemiol Prev. 2015 Mar-Apr;39(2):139 – Unhealthy eating habits among children aged 8-9 are still common in Italy – Article in Italian – Lauria L(1)(2), Spinelli A(1)(2), Nardone P(1)(2), Buoncristiano M(1)(2), Bucciarelli M(1)(2), Galeone D(2)(3); Gruppo OKkio alla salute – (1) Centro nazionale di epidemiologia, sorveglianza e promozione della salute, Istituto superiore di sanità, Roma. (2) (3) Ministero della salute, Segretariato generale, Roma – PMID: 26036744 [Indexed for MEDLINE]
  10. Epidemiol Prev. 2015 Jan-Feb;39(1):64 – Sociodemographic variation in childhood overweight and obesity in Italy in 2014 – Article in Italian –Nardone P, Spinelli A, Lauria L, Buoncristiano M, Bucciarelli M, Galeone D; Gruppo OKkio alla SALUTE – PMID: 25855552 [Indexed for MEDLINE]
  11. Epidemiol Prev. 2015 Jan-Feb;39(1):63 – Italy 2014: childhood obesity is decreasing – Article in Italian – Spinelli A, Nardone P, Buoncristiano M, Lauria L, Bucciarelli M, Galeone D; Gruppo OKkio alla SALUTE – PMID: 25855551 [Indexed for MEDLINE]
  12. Eur J Clin Nutr. 2015 May;69(5):603-8. doi: 10.1038/ejcn.2014.188. Epub 2014 Sep 17 – Severe obesity prevalence in 8- to 9-year-old Italian children: a large population-based studyLombardo FL(1), Spinelli A(1), Lazzeri G(2), Lamberti A(1), Mazzarella G(3), Nardone P(1), Pilato V(2), Buoncristiano M(1), Caroli M(4); OKkio alla salute Group 2010 – (1) National Center of Epidemiology, Surveillance and Health Promotion, National Institute of Health, Rome, Italy. (2) CREPS-Research Centre for Health Promotion and Education, Department Molecular and Developmental Medicine, University of Siena, Siena, Italy. (3) Health Authority NA3 Sud, Vico Equense, Naples, Italy. (4)Brindisi Local Health Authority, Brindisi, Italy – BACKGROUND AND OBJECTIVES: Little information is available on severe obesity in childhood. This study estimates the prevalence of severe obesity in 8- to 9-year-old children resident in Italy and its association with gender, age, geographical area and parents’ nutritional status and education using the World Health Organization (WHO) and International Obesity Task Force (IOTF) criteria. SUBJECTS/METHODS: A nationally representative sample of grade 3 Italian students was measured in 2010 (N=42,431) using standardized instruments and methodology. Severe obesity in children was assessed using definitions provided by the WHO and by the IOTF. Prevalence was estimated within categories of sociodemographic variables and their independent effects were estimated using multivariate logistic regression. RESULTS: The estimated prevalence of severe obesity in 2010 was 4.5% (95% confidence interval (CI): 4.2-4.7) according to the WHO definition and 2.7% (95% CI: 2.5-2.9) with IOTF cutoffs. These values were slightly lower than those observed in 2008. The prevalence was higher in males, in 8-year-old children and in the South. Parental low education and high body mass index were strongly associated with childhood severe obesity. CONCLUSION: According to the definition used, between 30,000 and 50,000 children aged 8-9 years suffer severe obesity in Italy. – DOI: 10.1038/ejcn.2014.188 PMID: 25226821 [Indexed for MEDLINE]
  13. Public Health Nutr. 2014 Dec;17(12):2715-20. doi: 10.1017/S1368980013003030. Epub 2013 Nov 15 – Dressed or undressed? How to measure children’s body weight in overweight surveillance?Censi L(1), Spinelli A(2), Roccaldo R(1), Bevilacqua N(1), Lamberti A(2), Angelini V(1), Nardone P(2), Baglio G(2) – (1) Agricultural Research Council,Food and Nutrition Research Centre (CRA-NUT),Via Ardeatina 546,00178 Rome,Italy. (2) National Centre for Epidemiology,Surveillance and Health Promotion,National Institute of Health (Istituto Superiore di Sanità),Rome,Italy – OBJECTIVE: To simplify body weight measurement and, particularly, to encourage children and their parents to participate in the Italian nutritional surveillance system OKkio alla SALUTE, children were measured with clothes and then the weight was corrected for the estimated weight of the clothes. In the present study we compared the children’s weight measured in underwear, as recommended by the WHO (WWHO), with that obtained using the OKkio alla salute protocol (WOK) and investigated how the latter affects the calculation of BMI and the assessment of overweight and obesity prevalence. DESIGN: Weight (twice in close sequence, with and without clothing) and height were measured. A checklist was used to describe the type of clothing worn. The estimated weight of clothing was subtracted from the WOK. BMI was calculated considering both values of weight and height; ponderal status was defined using both the International Obesity Task Force and WHO BMI cut-offs. SETTING: Thirty-seven third grade classes of thirteen primary schools in Rome and in two towns in the Lazio Region were recruited. SUBJECTS: The anthropometric measurements were taken on 524 children aged 8-9 years. RESULTS: The error in the calculation of BMI from WOK was very low, 0·005 kg/m2 (95 % CI -0·185, 0·195 kg/m2); the agreement between the percentages of overweight (not including obesity) and obese children calculated with the two methods was very close to 1 (κ = 0·98). CONCLUSIONS: The error in BMI and in nutritional classification can be considered minor in a surveillance system for monitoring overweight/obesity, but eases the procedure for measuring children. – DOI: 10.1017/S1368980013003030 PMID: 24477177 [Indexed for MEDLINE]
  14. Ig Sanita Pubbl. 2012 May-Jun;68(3):473-82 – Childhood obesity: know it to prevent itBozzola M, Bozzola E, Abela S, Amato S – Pavia University – Obesity can be defined as an excess of adipose tissue. It is associated to a significantly increased risk of cardiovascular disease, hypertension, diabetes mellitus and hypercholesterolemia. The results of the Italian survey called OKkio alla salute (2010), which was attended over 42’000 students of third-class of primary school and 44’000 parents, confirm bad eating habits, sedentary lifestyles and excess weight. In particular, 22,9% of the children resulted overweight and 11,1% obese. The prevalence of obesity is higher in the south of Italy than in the north and in males rather than in females. Moreover, parents do not always have a real idea of the physical aspect of their son: 36% of the mothers of overweight or obese children are do not believe their child is overweight. Just 29% of them think that the quantity of food eaten by their child is excessive. The relative risk for an obese child to become an obese adult increases with the age and is directly correlated to the severity of overweight. Among obese children of preschool age, 26 to 41% will be an obese adult., Among scholar children, the percentage increases to 69%. The paper describes a multidisciplinary approach the disease, in fact, dietary and behavioural modifications, associated with physical activity, have the purpose of educate overweight and of preventing the onset of complications or reducing their severity if already present and reversible. – PMID: 23064142 [Indexed for MEDLINE]
  15. Ann Ig. 2012 Jan-Feb;24(1 Suppl 1):33-6 – Improving dietary habits in the effective prevention of excess weight and obesity – Article in Italian – Alonzo, Camerlinghi G, Chioffi L, Credali M, Guberti E, La Rocca M, Marconi P, Panunzio M, Pontieri V, Silvestri M, Tripodi A, Ugolini G, Fardella M – SIAN ASP Catania – – The new research survey “Okkio alla salute”, conducted in children in the 3rd year of elementary school, has confermed the worrisome phenomenon of the high number of obese and overweight children. Therefore, it is necessary, also in light of the few available resources, to fight back against this phenomenon that has been demonstrated to be a cause of disabling illnesses in adults. There must therefore be collaboration between Departments of Prevention and Hygiene and Nutrition services (SIAN) to build valid and efficient pathways. In this presentation we describe some national projects carried out by various local health agencies to address this health problem. – PMID: 22880383 [Indexed for MEDLINE]
  16. Epidemiol Prev. 2011 Sep-Dec;35(5-6 Suppl 2):82-3 – Overweight and obesity among children. 1 out of 4 is overweight, 1 out of 9 is obese – Article in Italian – Spinelli A, Lamberti A, Buoncristiano M, Nardone P, Baglio G; Gruppo OKkio alla salute 2010 – Reparto Salute Della Donna e dell’Età Evolutiva, Centro Nazionale di Epidemiologia, Sorveglianza e Promozione Della Salute, Istituto Superiore di Sanità, Roma – PMID: 22166871 [Indexed for MEDLINE]
  17. Nutr J. 2011 Jul 19;10:76. doi: 10.1186/1475-2891-10-76 – Relationship between 8/9-yr-old school children BMI, parents’ BMI and educational level: a cross sectional survey – Lazzeri G, Pammolli A, Pilato V, Giacchi MV – CREPS-Research Center for Health Education and Promotion, University of Siena, Siena, Italy. – – BACKGROUND: Parents are responsible not only for the genetic structure of their children, but also for passing onto them their behaviours and attitudes toward life. The aim of this study was to analyse the connection between school-age children’s obesity and that of their parents as well as between child obesity and parents’ educational level, as a proxy indicator of the socio-economic status (SES) of families in Tuscany. METHODS: The children sample was selected from “OKkio alla salute 2010” (a cross sectional survey carried out by the Italian Institute of Health) and consisted of 1,751 (922 males and 855 females) 8-9 year-old school children. Weight and height were measured by ad hoc trained personnel, and Body Mass Index (BMI) categories were calculated using Cole et al.’s cut-off. Parents’ weight, height and educational level were collected by a self-administered questionnaire. The educational levels were classified as high, medium and low. RESULTS: The prevalence of obese children increased along the parents’ BMI category: from 1.4% for underweight mothers to 30.3% for obese mothers and from 4% for under-normal-weight fathers to 23.9% for obese fathers (p < 0.001). An inverse relationship was observed between the parents’ educational level and child obesity, the lowest educational level corresponding to the highest prevalence of obese children: 9.3% for mothers with a low educational level compared to 5.8% for mothers with a high educational level (p = 0.15); similarly, the corresponding prevalence for fathers was 9.5% compared to 4.5% (p = 0.03). CONCLUSION: Parents’ obesity and the cultural resources of the family, particularly the father’s, seem to influence the prevalence of overweight and obesity in Tuscan children. – DOI: 10.1186/1475-2891-10-76 PMCID: PMC3160354 PMID: 21771312 [Indexed for MEDLINE]
  18. Ann Ig. 2010 Nov-Dec;22(6):555-62 – Surveillance system OKkio alla SALUTE: the role of primary school in the promotion of healthy life style–results in 2008 –Article in Italian –Lamberti A(1), Spinelli A, Baglio G, Nardone P, Silani MT, Mastantuono E, Teti S, Menzano MT, Galeone D; Gruppo OKkio alla salute 2008 – Centro Nazionale Epidemiologia, Sorveglianza e Promozione della Salute, Istituto Superiore di Sanità, Roma – – In 2007 the Italian Ministry of Health/CCM promoted and funded the project “System of surveys of behavioral risks in ages 6-17”, coordinated by the National Institute of Health. One of the aims of the project is the definition and implementation of a data collection system on the weight of primary school children, their eating habits, physical activity and school initiatives favoring the healthy growth of children, called “OKkio alla SALUTE”. In 2008 the first survey of OKkio was conducted in 18 Italian regions. 45,590 third grade school children in 2610 classes participated. Information was collected from 2461 schools. The responses of the head teachers showed that 64% of the schools have a canteen, used by 70% of children. Only 12% of schools include the provision of a balanced mid-morning snack. Frequently there are educational activities related to physical activity and healthy eating that, in some cases, also involve the families of the children. 29% of the schools cannot guarantee two hours of physical activity as suggested by the school curriculum because of the lack or inadequacy of the gym or the structure of the timetables. The information gathered through the cooperation of school administrators, teachers and health workers, has helped to describe the major health educational activities of the school, that is confirmed to be the ideal venue for promoting healthy lifestyles in young people. – PMID: 21425652 [Indexed for MEDLINE]
  19. G Ital Cardiol (Rome). 2010 May;11(5 Suppl 3):87S-89S – Strategies for cardiovascular prevention in children – Article in Italian – Spinelli A(1), Nardone P, Lamberti A, Baglio G; Gruppo OKkio alla salute 2008 – Centro Nazionale di Epidemiologia, Sorveglianza e Promozione della Salute, Istituto Superiore di Sanità, Roma – – PMID: 20879489 [Indexed for MEDLINE]
  20. Ann Ig. 2008 Jul-Aug;20(4):337-44 – Promotion of healthy life style and growth in primary school children (OKkio alla SALUTE) – Article in Italian – Spinelli A, Baglio G, Cattaneo C, Fontana G, Lamberti A; Gruppo OKkio alla SALUTE; Coorte PROFEA anno 2006 – Centro Nazionale di Epidemiologia, Sorveglianza e Promozione della Salute, Istituto Superiore di Sanità, Roma – – In October 2007, the Italian Ministry of Health, the Centre for Disease Control and the Regions entrusted the National Institute of Health with the coordination of the initiative “Okkio alla Salute”–Promotion of healthy lifestyle and growth in primary school children. This programme is linked to the European programme “Gaining health” and the National Plan for Prevention. The objective of the project was to develop and maintain a monitoring system for both the health services and the schools that could also be used to better target public health interventions. The first national survey to estimate the prevalence of overweight and obesity in children and to collect information on diet and physical activity has been conducted in close collaboration with the individual regions. In the first nine months of the project, 1025 health workers and approximately 1500 school teachers have received training, and, using standardised methods, they have collected data and weighed and measured nearly 45000 third grade students (median age 8.8 years) in 2000 schools throughout the country. Participation rates have exceeded 95%. The results obtained to date indicate that the methodology is sustainable using existing health and educational resources and can be adopted as a national surveillance system.

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Some relevants papers from Istituto Superiore di Sanità

The effect of contraceptive counselling in the pre and post-natal period on contraceptive use at three months after delivery among Italian and immigrant women

Laura Lauria, Serena Donati, Angela Spinelli, Manila Bonciani and Michele E. Grandolfo(*)

Centro Nazionale di Epidemiologia, Sorveglianza e Promozione della Salute, Istituto Superiore di Sanità, Rome, Italy – Ann Ist Super Sanità 2014 | Vol. 50, No. 1: 54-61 DOI: 10.4415/ANN_14_01_09

Introduction. Contraceptive counselling in the pre and post-natal period may be important for the use of postpartum contraception and prevention of induced abortion. This paper evaluates the use of postpartum contraceptives and the factors associated with it in a sample of Italian and immigrant women.

Materials and methods. Data are drawn from two population-based follow-up surveys conducted to evaluate the quality of maternal care in 25 Italian Local Health Units in 2008/9 and 2010/1. Descriptive analyses and logistic regression models for complex survey data were used.

Results. The use of effective contraceptives in the postpartum period is similar between Italians and immigrants (65%). Fifty-nine percent of Italians and 63% of immigrants received contraceptive counselling by natal care services. Women who received counselling are more likely to use effective contraceptives (Italians OR = 2.55 95% CI 2.06 – 3.14; immigrants OR = 4.01 95% CI 2.40 – 6.70).

Conclusions. This study supports the notion that health professionals should take every opportunity during pregnancy, childbirth and puerperium to provide information and counselling to improve knowledge and awareness of contraception.

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Prevalence of breastfeeding in Italy: a population based follow-up study

Laura Lauria, Angela Spinelli and Michele Grandolfo*

Centro Nazionale di Epidemiologia, Sorveglianza e Promozione della Salute, Istituto Superiore di Sanità, Rome, Italy – Ann Ist Super Sanità 2016 | Vol. 52, No. 3: 457-461 DOI: 10.4415/ANN_16_03_18 

Introduction. Breastfeeding is widely recommended. Updated data are needed to assess its prevalence and the effectiveness of interventions. Breastfeeding practices in Italy need to be promoted and monitored with updated and standard data The objective of this study is to provide estimates of the prevalence of breastfeeding and exclusively breastfeeding and to identify factors that may be modified to improve them.

Materials and methods. Two population-based follow-up surveys were conducted to evaluate the quality of maternal care in 25 Local Health Units (LHUs) in Italy during 2008-2011. Women were interviewed soon after giving birth and after 3, 6 and 12 months. Breastfeeding prevalences were estimated. A logistic regression model was used to investigate factors associated with exclusive breastfeeding at 3 months.

Results. Breastfeeding and exclusively breastfeeding prevalence estimates were 91.6% and 57.2% at discharge, 71.6% and 48.6% at 3 months, 57.7% and 5.5% at 6 months. At 12 months, 32.5% were still breastfeeding. Women who are more likely to exclusively breastfeed at 3 months are multiparous, more educated, resident in the north/center, have attended antenatal classes and groups of breastfeeding support, have practiced the skin-to-skin contact in hospital and have initiated breastfeeding early.

Conclusion. In Italy many mothers do not comply with breastfeeding recommendations. The promotion and support of breastfeeding is still necessary in Italy and still needs to be monitored with representative data. Actions should aim at empowering women, reducing social inequalities and improving practices in hospitals and maternal care services which encourage breastfeeding.

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Women’s knowledge and periconceptional use of folic acid: data from three birth centers in Italy

Laura Lauria1, Giulia Adinolfi2, Francesca Bartolomeo3, Emanuela Petruccelli2, Michele Grandolfo1

1Centro Nazionale di Epidemiologia, Sorveglianza e Promozione della Salute, Istituto Superiore di Sanità, Rome, Italy, 2 Facoltà di Medicina e Chirurgia. Corso di Laurea in Ostetricia. Università degli Studi di Roma “Tor Vergata”, 3 Facoltà di Medicina e Chirurgia. Corso di Laurea in Ostetricia. Università degli Studi di Bari “Aldo Moro” – RARE DISEASES AND ORPHAN DRUGS An International Journal of Public Health. July 2014, Volume 1, Number 3 page 98

The Italian strategy to prevent neural tube defects is based on the periconceptional use of folic acid. This strategy implies a good capacity of control by women over their reproductive choices.

Three sample surveys of delivering women were conducted in three birth centers in two Italian cities. Overall, 973 wom­en were interviewed through a structured questionnaire. Information on women’s socio-demographic characteristics, knowledge and use of folic acid and on counselling received by health professional in anticipation of and during pregnancy were collected. Logistic regression models were used to explore factors associated with the outcome variables.

The prevalence of periconceptional use of folic acid was 37.9%. Before or during pregnancy, about half of the women had received partial information on what folic acid is and its benefits but only half of them received information on the correct period of assumption. Internet is a primary source of information for women who have the ability to search for the information they need, and these are the more educated. Older women, better educated, and Italians were more likely to plan a pregnancy, to know the correct period of folic acid assumption and to take it. Among multiparous women, those who received correct informa­tion during the previous pregnancy were more likely to use periconceptional folic acid in the present pregnancy OR=6.83 (95% CI:3.58-13.0).

The provision of information on the correct period of assumption of folic acid is associated with better knowledge and with its increasing use. Investing on provision of information instead of the directive approach represented by the compulsory fortifi­cation of food, appears an appropriate action. The prevalence of periconceptional use of folic acid is an expression of the level of women’s empowerment which the public health services should always aim to improve. 

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Some examples of interesting articles from PubMed  

Applying a set of indicators to evaluate the primary health care

Russo AG, Greco MT – Article in Italian

Epidemiol Prev. 2017 Jan-Feb;41(2):91-101. doi: 10.19191/EP17.2.P91.028

OBJECTIVES: to develop a system of indicators to monitor the quality of health care, in terms of safety, effectiveness, and appropriateness to allow the integrated promotion of the welfare of the effectiveness and quality.

DESIGN: retrospective study.

SETTING AND PARTICIPANTS: all general practitioners (GPs) with at least 100 patients in loading at 1.1.2015 were included. The setting chosen is the Primary Care of the Agency for Health Protection of the Province of Milan (Northern Italy).

MAIN OUTCOME MEASURES: for each GPs 39 indicators were calculated, including 7 on the mix of patients, 4 on prevention, 5 on ER, 5 on hospital admissions, 8 on outpatient, and 10 on pharmaceutical prescription. The correlations between individual indicators were considered and patterns to classify the GPs were determined by the factor analysis and the multiple correspondence analysis.

RESULTS: among the expected correlations, we observed those between institutional colorectal screening and institutional breast cancer screening. Among not-expected correlations, the one between pump-inhibitor drugs and routines blood chemistry in the population between 20 and 50 years identifies a positive association between two practices of unrecognized clinical validity. Classifying the 2,217 GPs on the basis of the maximum factorial score, six main factors were identified.

CONCLUSION: using approaches based on multivariate methods, interventions aimed at changing the profile of MMG exerting the government primary health care can be proposed, not only by means of system rules or approaches based on economic incentives, but on complex governance mechanisms.

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Patient-Centered Cancer Care Programs in Italy: Benchmarking Global Patient Education Initiatives

Truccolo I

In Italy, educational programs for cancer patients are currently provided by the national government, scientific societies, and patient advocate organizations.

Several gaps limit their effectiveness, including the lack of coordinated efforts, poor involvement of patient feedback in the planning of programs, as well as a lack of resources on innovative cancer-related topics.

This process is parallel to a strong shift in the attitude of patients towards health in general and taking charge of their own health conditions in particular.

The National Cancer Institute in the USA and the Organization of European Cancer Institutes encourage comprehensive cancer centers in providing educational programs conceived to overcome these gaps.

The goal of this paper is to identify and describe the key elements necessary to develop a global patient education program and provide recommendations for strategies with practical examples for implementation in the daily activities of cancer institutes.

A multidisciplinary committee was established for patient education, including patient representatives as equal partners, to define, implement, verify, and evaluate the fundamental steps for establishing a comprehensive education program.

Six essential topics were identified for the program: appropriate communication of cancer epidemiology, clinical trial information, new therapeutic technologies, support in the use of medicines, psycho-oncological interventions, age-personalized approaches, and training programs for healthcare providers.

Integration of these topics along with patient feedback is the key to a successful model for educational programs.

An integrated educational program can transform a comprehensive cancer center to an institution that provides research and care for and with patients.

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An audit about clinical governance skills in Italian medical managers

Tafuri S

BACKGROUND: The objective of this study is to describe the knowledge and skills of managers working in health organizations in the Region of Puglia (South of Italy) on the principles and tools of clinical governance.

METHODS: A KAP (Knowledge, Attitudes and Practice) survey was conducted using a questionnaire.

The target population of the survey was represented by Hospital Directors and Managers of local health care structures (Primary Care Districts, Public Health Departments, and Mental Health Departments).

RESULTS: 92 managers participated at the study (response rate was 90.2%).

98.9% of respondents reported being aware of the concept of clinical governance and believe that clinical governance is an appropriate strategy for the continuous improvement in quality of services. 96.7% of respondents had heard of Evidence Based Practice and 80.6% reported using the method of EBP in nursing practice.

The availability of guidelines for consultation was reported by 54.9% of respondents.

Of those interviewed, 79.8% knew about Health Technology Assessment.

95.5% reported they have heard of clinical audit and 98.9% knowing the concept of risk management.

CONCLUSION: In our survey, an high value judgment about clinical governance was reported by medical managers.

The lower attitudes towards the use of the tools of clinical governance highlights an important discrepancy with respect to knowledge and opinions, which becomes more evident in community care structures.

Above and beyond training managers, it is also necessary to change training methods used on all health personnel, which should be oriented towards EBM in order to build an adaptable organizational climate.

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Accreditation of birth centres: advantages for newborns

Dotta A

Accreditation or certification of Health Care Providers is a crucial tool to improve health care quality, and to promote excellence. Excellent healthcare should have the following six characteristics: Safe, Effective, Person-centred, Timely, Efficient, Equitable.

Safety in health care should consider the analysis and reduction of medical systematic errors and their related patients’ harm.

In 1999 the U.S. Institute of Medicine defined medical errors as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.

In neonatal intensive care units and pediatric intensive care units the areas most frequently associated with medical errors are medication, including prescribing, preparation, administration and monitoring; health-care associated infections; mechanical ventilation; events related to the use of medical devices or procedures and, more recently, caregivers fatigue and communication strategies.

In Italy, Maternal-Neonatal Health is one of the national priorities, but there are still wide and deep differences among Regions.

In 2008, more than 9% of the deliveries occurred in Hospitals with less than 500 births per year, a volume considered too small to guarantee optimal standard of care.

In 2010, the National Government and the Regional Health Authorities agreed to set to 1000 births/year the standard threshold for Hospital Birth Centers, considering the same volume for obstetric-gynecologic and neonatal-pediatrics Units.

Despite most indicators attest the good performance of the National health care, a further area to be addressed is the perception of its quality by the people.

The discrepancy between quality of care and its public perception is in fact reported in many industrialized countries.

Accreditation programs can improve the availability and access to a standardized quality of care. A well-established worldwide accreditation program is led by Joint Commission International (JCI).

As far as accreditation of perinatal care is regarded, in 2010 the U.S. Joint Commission has defined a set of measures known as the perinatal care core measure set, which consider elective delivery, cesarean section, antenatal steroids, healthcare-associated bloodstream infections in newborns, exclusive breastmilk feeding.

In Italy, the 2011-2013 National Health Care Plan underline the need for developing and implementing certification programs for Hospital Birth Centers.

In 2011, a multidisciplinary working group (Italian Group for Safe Birth) has thus been established.

CONCLUSION: the main goal of each Health Care Organization should be to achieve the best quality and safety. Health Care Organizations must reduce random variations and improve activities by a standardized process whose results can be measured both in terms of patients outcome and in terms of transparency of each activity. Newborn and infants are one of the weakest population group; to improve their health outcome is thus mandatory to do all efforts to obtain a safe, effective, efficient and patient-centered health care assistance.

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Establishing the Baby-Friendly Community Initiative in Italy: development, strategy, and implementation

Bettinelli ME

BACKGROUND: The Baby-Friendly Hospital Initiative (BFHI), developed by the World Health Organization and the United Nations Children’s Fund (UNICEF) to promote breastfeeding in maternity facilities worldwide, has had a global impact on breastfeeding outcomes, but other interventions are needed both before and after hospital discharge to meet the recommended targets at 6 months.

The Baby-Friendly Community Initiative (BFCI), a multifaceted program for community-based breastfeeding promotion that is complementary to the BFHI, addresses this challenge.

OBJECTIVE: To describe the development, strategy, and implementation of the BFCI in Italy.

METHODS: In 2006, UNICEF Italy created a working group to develop the BFCI for the Italian health system. A review of the different BFCI models worldwide was conducted.

A preliminary adaptation of tools to Italian community health care settings was developed in 2007, when the Italian BFCI Seven Steps were published.

Two years later, UNICEF Italy launched the Standards for Best Practice for both hospitals and communities, based on 2009 BFHI and UNICEF UK BFCI materials.

OUTCOMES: The main outcome was to promote this process in Italian regional health systems and develop tools to assess compliance with the BFCI criteria. There is now one fully accredited Baby-Friendly Community in Italy, and 17 other communities are working on the various stages.

CONCLUSIONS: The BFCI, a complex program that involves participation, training, audits, a continuous flow of feedback, and provision of resources for health workers and families, is now a reality in Italy.

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Primary paediatric care models and non-urgent emergency department utilization: an area-based cohort study

Farchi S

BACKGROUND: The aim of this study was to evaluate the association between different primary paediatric practice models (individual, network -affiliated but in separate office-, and group practice) and non urgent utilization of the Emergency Department (ED).

METHODS: The data sources were: the 2006 Regional Paediatric Patient files (0-6 years old), the Regional Community-based paediatrician (CBP) file and the 2006 Emergency Information System. We recorded and studied the ED visits of children, excluding planned ED visits, visits for trauma/poisoning and those that were assigned non deferrable/critical triage codes.

A multivariate logistic regression was applied to estimate the adjusted odds ratio of an ED visit. The exposure was the type of paediatric practice that served the child: individual, network or group practice. Various characteristics of the child were considered.

RESULTS: The cohort was composed of 293,662 children. In the 2006, 43,347 ED visits occurred (147.6 per 1000).

Multivariate logistic models showed lower ED use for group paediatrician patients (OR 0.84; 95%CI 0.73-0.96) and for network paediatrician patients (OR 0.92; 95%CI 0.85-1.00) compared to patients served by an individual practice.

CONCLUSIONS: This study shows that there is a weak association between the type of paediatrician primary practice and emergency department use. Our results highlight the necessity to continue to improve the organization of paediatrician primary practice, in order to increase patient access to primary paediatric care.

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Preventable hospitalization and access to primary health care in an area of Southern Italy.

Rizza P

BACKGROUND: Ambulatory care-sensitive conditions (ACSC), such as hypertension, diabetes, chronic heart failure, chronic obstructive pulmonary disease and asthma, are conditions that can be managed with timely and effective outpatient care reducing the need of hospitalization. Avoidable hospitalizations for ACSC have been used to assess access, quality and performance of the primary care delivery system.

The aims of this study were to quantify the proportion of avoidable hospital admissions for ACSCs, to identify the related patient’s socio-demographic profile and health conditions, to assess the relationship between the primary care access characteristics and preventable hospitalizations, and the usefulness of avoidable hospitalizations for ACSCs to monitor the effectiveness of primary health care.

METHODS: A random sample of 520 medical records of patients admitted to medical wards (Cardiology, Internal Medicine, Pneumology, Geriatrics) of a non-teaching acute care 717-bed hospital located in Catanzaro (Italy) were reviewed.

RESULTS: A total of 31.5% of the hospitalizations in the sample were judged to be preventable. Of these, 40% were for congestive heart failure, 23.2% for chronic obstructive pulmonary disease, 13.5% for angina without procedure, 8.4% for hypertension, and 7.1% for bacterial pneumonia.

Preventable hospitalizations were significantly associated to age and sex since they were higher in older patients and in males. The proportion of patients who had a preventable hospitalization significantly increased with regard to the number of hospital admissions in the previous year and to the number of patients for each primary care physician (PCP), with lower number of PCP accesses and PCP medical visits in the previous year, with less satisfaction about PCP health services, and, finally, with worse self-reported health status and shorter length of hospital stay.

CONCLUSION: The findings from this study add to the evidence and the urgency of developing and implementing effective interventions to improve delivery of health care at the community level and provided support to the usefulness of avoidable hospitalizations for ACSCs to monitor this process.

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Paediatric utilization of an emergency department in Italy

Pileggi C

BACKGROUND: The purpose of this study was to determine the frequency and characteristics of paediatric attendance as a source of medically non-urgent problems at an accident and emergency department (ED) of a public non-teaching hospital in Crotone (Italy).

METHODS: For each patient aged 16 years or younger, there were collected information on demographics and socioeconomic characteristics, medical history, route of referral, clinical complaints that they presented at the moment of their presentation at the ED, duration of presenting problems prior to arrival, hour of arrival, day of the week of arrival, and reason for attending the ED. Data about the consultation process and the final decision made were also recorded.

RESULTS: Of a total of 980 patients included in the study, 27.6% had conditions that were definitely non-urgent. Multiple logistic regression analysis showed that the visit was non-urgent in younger population, in females, and in those attending the ED on the weekend.

The results of the second multivariable regression analysis model indicate that patients who did not receive medical or surgical examination at the ED, with problems of longer duration prior to arrival at the ED, with non-traumatic injuries, and who did not require inpatient hospital admission were more likely to use the ED as a source of non-urgent care.

The most frequent presenting problems for patient visits to ED were injury, respiratory diseases, and digestive symptoms.

CONCLUSION: A closer cooperation within the health care organization system to provide a service responsive to the real needs of patients is essential.

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Spending on pharmaceuticals in Italy: macro constraints with local autonomy

Mapelli V

Italy has a national health service (SSN) that is moving toward decentralization and empowerment of local health enterprises (LHEs)-the arms of the regions for delivering health services. Drug policy and spending decisions are both influenced by central government and local authorities.

At the “macro” level, the government holds the power to decide the amount of drug expenditure, currently at 13% of total SSN expenditure; the pricing policy, price negotiation, reference price, and price cuts; criteria for reimbursement, inclusion in the positive list, and restrictive notes; and the copayments and exemptions.

So far, the government concern has been predominantly on cost containment, and its approach in selecting drugs for reimbursement has been cost minimization.

Italy has no centralized office for health technology assessment and this hinders the search for an efficient use of drugs.

At the “micro” level, however, the LHEs are showing a great vitality in fostering a better use of drugs by general practitioners. One of the tools employed is local voluntary agreements between LHEs and general practitioners (GPs) that may be supported by economic incentives, in cash or in kind.

In 2000 there were 61 agreements in place, 31% of total LHEs, which concerned the respect of drug expenditure ceilings and the local development and implementation of clinical guidelines (47% of LHEs). A traditional and widespread tool for controlling drug expenditure is providing GPs with regular reports on their drug prescriptions (59% of LHEs).

Monitoring, moral suasion, and clinical guidelines are the main incentives for efficiency at local level, but focus on health outcomes is limited.

The cost-containment mentality still prevails and the use of drug budget for purchasing better health is at its very early stage.

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What kind of primary care for Italy? Juridical and organizational peculiarities of primary care after the Balduzzi reform

Alizzi A, Campagna M

This paper deals with the issue of primary care in Italy, and intends to contribute to the discussion on the current critical issues as well as on how to reorganize it.

The economical sustainability of health services is the most difficult challenge lying ahead for welfare systems, especially in Southern Europe countries. Among them, Italy presents an high degree of inconsistency and contradiction in how social protection expenditure is composed. In particular, in the health sector, the redistribution of resources between hospital assistance and primary care, favoring the latter, is the area where the most urgent work is needed. However, the reorganization of primary care must go through a series of juridical obstacles whose regulation is incoherent and less effective than the regulation offered by the “hospital model”.

The first paragraph introduces and synthetically deals with some macro-variables, defined as extra-sectorial, which are deemed to be relevant for the purpose of our work. Paragraph 3 and 5 offer an historical analysis of sectorial regulation, till the novelties introduce by the 2012 Balduzzi reform. Paragraph 4 deals with the peculiar legal framework of general medicine practitioners, trying to outline the related criticalities. Finally, paragraph 6, by capitalizing on some effective policy interventions on primary care promotion carried out in South Korea and Denmark, tries to outline some useful hints for Italy.

The data hereby utilized principally refer to the last two years – a pretty stable time frame after the 2007 financial crisis – and are provided by eminent international as well as national institutions.


  1. Introduction
  2. (Some) significant extra-sectorial macro-variables for organizing primary care
  3. The role of primary care in the public health system
  4. Conventioned doctors: a troubled history
  5. Primary care in the Balduzzi reform
  6. The cases of Denmark and South Korea: some advice for Italy

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PICENUM study – Performance Indicators Continuous Evaluation as Necessity for Upgrade in Medicine

Gli Indicatori di Performance nella pratica clinica: uno strumento per la rilevazione epidemiologica, per il miglioramento continuo della qualità e per l’integrazione tra Medicina Generale e Medicina Ospedaliera

Paolo Misericordia*, Nicola Blasi^, Vincenzo Landro*, Giovanni Olimpi*, Paolo Simoni^

* Medici di Medicina Generale della Provincia di Ascoli Piceno ^ Dirigente Medico Unità Operativa di Medicina – Ospedale Civile di Fermo – ASUR Marche – Zona Territoriale 11 di Fermo

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AHRQ prevention quality indicators to assess the quality of primary care of local providers: a pilot study from Italy

Manzoli L, Flacco ME, De Vito C, Arcà S, Carle F, Capasso L, Marzuillo C, Muraglia A, Samani F, Villari P.

BACKGROUND: Outside the USA, Agency for Healthcare Research and Quality (AHRQ) prevention quality indicators (PQIs) have been used to compare the quality of primary care services only at a national or regional level. However, in several national health systems, primary care is not directly managed by the regions but is in charge of smaller territorial entities. We evaluated whether PQIs might be used to compare the performance of local providers such as Italian local health authorities (LHAs) and health districts.

METHODS: We analysed the hospital discharge abstracts of 44 LHAs (and 11 health districts) of five Italian regions (including ≈18 million residents) in 2008-10. Age-standardized PQI rates were computed following AHRQ specifications. Potential predictors were investigated using multilevel modelling.

RESULTS: We analysed 11 470 722 hospitalizations. The overall rates of preventable hospitalizations (composite PQI 90) were 1012, 889 and 988 (×100 000 inhabitants) in 2008, 2009 and 2010, respectively. Composite PQIs were able to differentiate LHAs and health districts and showed small variation in the performance ranking over years.

CONCLUSION: Although further research is required, our findings support the use of composite PQIs to evaluate the performance of relatively small primary health care providers (50 000-60 000 enrollees) in countries with universal health care coverage. Achieving high precision may be crucial for a structured quality assessment system to align hospitalization rate indicators with measures of other contexts of care (cost, clinical management, satisfaction/experience) that are typically computed at a local level.

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Migrant health in Italy: the right and access to healthcareas an opportunity for integration and inclusion

Barsanti S, Nuti S – Working paper n. 04/2013

This paper analyses migrant access to health care through the Italian legal framework and the use of health care services. In both analyses, an underlying gap and critical issues are demonstrated for migrants regarding their knowledge of the health care system as well as the accessibility and use of health services. In particular, immigrants have a lower hospitalisation rate than the native population. However, hospitalisation for some events (i.e., injuries, infectious disease) is higher for migrants than for natives. The results suggest that the health care system is unable to ensure an equitable use of the same services between populations with identical needs (horizontal equity) or accessibility for specific conditions prevalent in the migrant population (vertical equity).Moreover, the main entry point for migrants to the health care system(the maternal pathway and women’s health services) could be the first step for a more comprehensive process of integration and communication. In Italy, the immigrant population is growing and the differences in access to care are demonstrated. Consequently, it is necessary to rethink a possible model of integration and welfare for the migrant population, where access to the healthcare system is not only a desired result but also an opportunity for integration and inclusion.

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The health of asylum seekers and unaccompanied minors. What needs and what protection?

Merotta V

This paper enquires the health conditions of two groups of migrant considered to be more at risk due to their legal status – neither legal nor illegal. These groups encompass diverse people – asylum seekers, refugees and unaccompanied minors. These categories considered are far from being representative of the actual spectrum of people at risk of social exclusion. However, the paper builds on the lack of literature on the matter at the Health and welfare section of the ISMU Foundation and to the relevance of the topic being within the EU public debate (e.g. the refugees crisis) and in the international agendas.

Each case study opens with an overview of the legal provisions and moves on to describing how the reception system works, with particular attention to healthcare services. The analysis focuses on health not by simply looking at healthcare services, but rather by seeing it as strongly linked to other important elements such as nutrition, education and social security. “Personal health is essential to enjoy human rights, and underpins participation to the social, political and economic life” (Abbondanti, 2013).

In Italy health is enshrined as a fundamental rights by art. 32 of the Constitution, which forbids all kind of discrimination on the basis of on citizenship. This applies to regular registered migrants (including refugees), asylum seekers and undocumented migrants, and all irregular categories. Everyone has the right to receive emergency and essential healthcare, but also specific treatments if necessary. Dependant family members regularly residing in Italy can also access healthcare services.

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Primary assistance in prevention and promotion of health: a reading of regional plans for prevention – Graduation Thesis 2016-2017

Il coinvolgimento dei medici di assistenza primaria nella prevenzione e promozione della salute: una lettura dei piani regionali della prevenzione – Tesi di laurea anno 2016-2017

Relatore: Alessandra Buja – Laureanda: Laura Doppio

Background: health promotion and prevention are key elements of the healthcare system, whose planning in Italy is defined nationally (in PNPs), regional (PRP) and in the Autonomous Provinces (PPPs), cyclically updated. Many actors are involved within these Plans, and among them, the involvement of the General Practitioner (GP) and of the Family Pediatrician is described.

Aim: the purpose of the study is the systematic analysis of the 21 PRPs and PPPs to define the role assigned to primary care physician as either a direct issuer of planned interventions, or as part of the organizational-functional processes or in the advocacy process of the various actions described in the plans.

Methodology: the design of the study is descriptive and evaluative. All the PRPs and PPPs drawn up by all Italian Regions and Autonomous Provinces for the fouryear period 2014-2018 have been considered. The statistical unit considered was the Health Promotion or Prevention Program, each evaluated according to a set of variables shared with the Ministry of Health.

Results: in the 21 PRPs and PPPs examined, 1651 programs have been identified that meet all the macro-objectives and health needs defined by the Ministry of Health. Primary care physicians are involved in a total of 409 programs, mostly as part of the organisational-functional processes. The health needs to which they are most involved are related to the prevention of domestic accidents (involved in 42% of the programs addressed to this aim), of infectious (41%) and non-transmissible diseases (33%). The greatest involvement of primary care physician takes place in the interventions thought to be carried out in the healthcare and community facilities and in those dedicated to elderly (45%) and children in pre-school age (41%). In 104 programs, primary care physicians play the role of issuer; 88 of these take place in the healthcare facilities and 73 in the community; 58 programs aim to the adult group; the contrast to chronic illnesses comes up as the health need with the highest number of programs (37 out of 104).

Conclusions: the evaluation of PRPs and PPPs has highlighted some critical issues. The involvement of primary care physicians turns out to be different among the various Regions and Autonomous Provinces. It is evident that they are predominantly called into question in the struggle against chronic and infectious diseases. They are often involved in organizational-functional actions, but these are not always followed by actions on final targets. Their involvement could be increased in projects to be carried out on children, adolescents and for occupational health.

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More details in Italian

More details in Italian about: Italian health surveillance and Control System (SiVeAS)

Il SiVeAS, Sistema nazionale di verifica e controllo sull’assistenza sanitaria è stato istituito con Decreto 17 giugno 2006 presso il Ministero della salute, in attuazione dell’articolo 1, comma 288, della legge 23 dicembre 2005, n. 266.

Il supporto tecnico è assicurato dalla Direzione generale della programmazione sanitaria, dei livelli di assistenza e dei principi etici di sistema del Dipartimento della qualità del Ministero della salute.

ll SiVeAS ha l’obiettivo di provvedere alla verifica del rispetto dei criteri di appropriatezza e qualità delle prestazioni sanitarie erogate, coerentemente con quanto previsto dai Livelli Essenziali di Assistenza, e dei criteri di efficienza nell’utilizzo dei fattori produttivi, compatibilmente con i finanziamenti erogati.

Al SiVeAS, inoltre, la legge Finanziaria 2007 ha affidato l’attività di affiancamento alle Regioni con Piani di rientro, di cui articolo 1, comma 180 legge n. 311/2004 (Legge Finanziaria 2005).
Pertanto, il Ministero, attraverso l’attività del SiVeAS, svolge due fondamentali compiti:

  1. assicurare un supporto generale per la produzione di strumenti valutativi ed implementativi di buone pratiche sul versante dell’efficienza, dell’efficacia e della qualità dell’assistenza sanitaria nei vari ambiti regionali
  2. garantire tutte le attività necessarie per l’affiancamento ed il controllo delle Regioni impegnate nei Piani di rientro.

Al fine del perseguimento di tali obiettivi, le linee di attività attualmente in corso possono ricondursi a due macro-aree, tra di loro interdipendenti:

  1. l’area delle garanzie del raggiungimento degli obiettivi del Servizio Sanitario Nazionale
  2. l’area dell’affiancamento alle Regioni che hanno stipulato l’accordo di cui all’art.1, comma 180 della legge n.311/2004, comprensivo di Piano di rientro dai disavanzi.

L’area delle garanzie risponde alle esigenze di supporto al livello centrale del Servizio Sanitario Nazionale per le proprie attività relative a:

  • il sistema di garanzie di cui al D.M. 12 dicembre 2001, attuativo dell ’art. 9 del Decreto Legislativo 18 febbraio 2000, n.56
  • la verifica dei Livelli Essenziali di Assistenza, ai sensi dell’Intesa Stato-Regioni 23 marzo 2005.

L’area dell’affiancamento risponde alle esigenze di supporto al Ministero nelle attività di programmazione, gestione e valutazione dei Servizi Sanitari Regionali nelle Regioni che hanno stipulato l’accordo di cui all ’art. 1, comma 180 della legge n.311/2004, che prevedeva la sottoscrizione di Piano di rientro dai disavanzi.
Di seguito si riportano le linee di attività, nelle quali sono state articolate le due macro-aree sopra richiamate:

  1. Monitoraggio dei Livelli Essenziali di Assistenza
  2. Promozione e valutazione dell’efficienza gestionale
  3. Promozione e valutazione dell’efficacia e della qualità
  4. Promozione e valutazione dell’Appropriatezza
  5. Accreditamento e organizzazione dell’offerta
  6. Accessibilità
  7. Assistenza Socio Sanitaria
  8. Confronti internazionali e integrazioni delle basi-dati
  9. Affiancamento alle Regioni con Piano di rientro dal disavanzo

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More details in Italian about: ISTUD Foundation, Vance Cittadinanzattiva, Card, Agenas and Federsanità ANCI promote research to monitor the situation of primary care in Italy

Le cure domiciliari sono una importante modalità di erogazione di trattamenti medici, riabilitativi, assistenziali, infermieristici, prestati a soggetti che, per motivi legati a disabilità o altre limitazioni della propria autonomia, non sono in grado di recarsi presso ospedali o strutture ambulatoriali per sottoporsi alle cure di cui hanno bisogno.

A fornire queste cure sono professionisti sanitari e sociali per conto della Asl, su segnalazione del medico di famiglia. E’ evidente come la qualità delle cure domiciliari sia strettamente legata all’efficienza dell’organizzazione dei distretti territoriali, che devono coordinare la presa in carico. Ma qual è la situazione nel nostro Paese, quanto a questo tipo di cure? A occuparsene, da anni, è la Fondazione ISTUD, che dal 2009 ha organizzato il primo Osservatorio Nazionale sulle Cure a Casa dal titolo “Le linee di indirizzo per rendere la cura a casa un servizio effettivo per tutti i cittadini”, declinando di anno in anno il progetto su diverse sfaccettature delle cure domiciliari.
I dati emersi nelle ricerche degli anni scorsi hanno sostanzialmente messo in evidenza il fatto che essere curati, assistiti e riabilitati in casa sia una modalità gradita dagli italiani. (qui i risultati della ricerca del 2011), anche se i problemi non mancano.

Quest’anno il progetto della Fondazione ISTUD si allarga e, prendendo il nome di “Osservatorio Nazionale delle Cure Primarie” si pone l’intento di mappare la situazione italiana dell’offerta di cure primarie nelle singole regioni. Scopo della ricerca, identificare e valutare i modelli di assistenza territoriale emergenti dalle sperimentazioni in corso in Italia, definire i modelli di network realizzabili nel medio-breve termine che rispondano ai fabbisogni del territorio; valutare questioni aperte: associazionismo in territori frastagliati, città e zone rurali, contratti da stipulare con il SSR, modalità di assegnazione delle risorse e di rimborso delle prestazioni; valutare le aree critiche dei processi.

Per fare questo, il progetto prevede sia una ricerca tramite consultazione di tutti i documenti ufficiali di Regioni e fonti secondarie, sia la diretta consultazione dei soggetti interessati, ovvero professionisti sanitari e pazienti. A questo proposito, i cittadini sono quindi invitati a partecipare a un questionario utile a raccogliere dati per poter avere una quadro quanto più veritiero dell’organizzazione dell’assistenza primaria in Italia. Grazie ad un maggior numero di testimonianze sarà possibile presentare efficacemente le istanze dei cittadini ai decision maker della sanità . Chi volesse partecipare al questionario non dovrà far altro che colegarsi on line al sito web della Fondazione ISTUD a questo link.

I dati raccolti da questa ricerca saranno organizzati in un report che sarà disponibile sul sito Cure a casa di Fondazione Istud, e presentati nel corso di un evento in programma per la fine di novembre.
Accanto a Fondazione ISTUD e Vance, i promotori di questa ricerca sono Cittadinanzattiva, Card, Agenas e Federsanità ANCI.

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More details in Italian about: National Observatory on the Condition of People with Disabilities

Dopo l’approvazione, da parte del Consiglio dei Ministri, del secondo Programma di azione biennale per la promozione dei diritti e l’integrazione delle persone con disabilità, oggi arriva anche la firma del Ministro del Lavoro e delle Politiche Sociali, Giuliano Poletti, al decreto di ricostituzione dell’Osservatorio Nazionale sulla condizione delle persone con disabilità.

L’Osservatorio ha funzioni consultive e di supporto tecnico-scientifico per l’elaborazione delle politiche nazionali in materia di disabilità, con particolare riferimento alla:

  • promozione dell’attuazione della Convenzione ONUsui diritti delle persone con disabilità;
  • predisposizione di unprogramma di azione biennale per la promozione dei diritti e l’integrazione delle persone con disabilità;
  • promozione dellaraccolta di dati statistici e della realizzazione di studi e ricerche sul tema;
  • predisposizione della relazione sullostato di attuazione delle politiche sulla disabilità.

Qui una sintesi dei punti in cui si articola il Programma di azione biennale per la disabilità.

Riforma del Riconoscimento/certificazione della condizione di disabilità – Da raggiungere superando un sistema già il precedente Programma aveva ampiamente descritto come obsoleto, complesso, generatore di possibili diseguaglianze, in ogni caso lontano dallo spirito e dalla lettera della Convenzione ONU.

Politiche, servizi e modelli organizzativi per la vita indipendente e l’inclusione nella società – Così leggiamo: Deve essere realizzato uno sforzo straordinario di innovazione e di formazione degli operatori. Il Programma d’Azione propone nuovi criteri di qualità e accreditamento dei servizi, l’adozione di linee guida per promuovere i processi di vita indipendente e la deistituzionalizzazione e una revisione dei nomenclatori di servizi e prestazioni per accogliere una nuova generazione di interventi per la promozione della partecipazione e eguaglianza delle persone con disabilità. Il Programma d’Azione riprende e sostiene con forza la proposta di abrogazione dell’interdizione.

Salute, diritto alla vita, abilitazione e riabilitazione – Il Programma individua tutta una serie di azioni specifiche e puntuali per arricchire e consolidare i Livelli Essenziali di Assistenza e l’integrazione sociosanitaria. Tra i temi il Nomenclatore tariffario delle protesi, la necessità di un intervento specifico e mirato in tema di qualità della diagnosi e intervento a favore della popolazione con disabilità intellettiva e disturbo psichiatrico, l’attuazione della recente Legge sull’Autismo e delle indicazioni delle linee guida sull’Autismo.

Processi formativi ed inclusione scolastica – La linea di intervento su scuola e formazione delinea una serie di azioni che dovrebbero essere orientate nel senso di consolidare e rendere più efficace il processo di inclusione scolastica ma anche formazione dei docenti.

Lavoro e occupazione- Qui si prevedono interventi per aggiornare aspetti specifici della la normativa per renderla più efficace nell’offrire occasioni di lavoro e la sicurezza dei lavoratori. Linee di lavoro specifiche riguardano la qualità dei servizi di collocamento mirato su tutto il territorio nazionale.

Promozione e attuazione dei principi di accessibilità e mobilità – Rispetto a questi tempi, tra le altre cose, la linea progettuale indica la necessità di procedere ad una importante revisione delle normativa italiana in tema di accessibilità dell’ambiente fisico, urbano ed architettonico, che, sebbene a suo tempo innovativa e all’avanguardia, necessita oggi di essere aggiornata per consentire una piena adozione e diffusione dei principi della progettazione universale.

  • promozione dell’attuazione della Convenzione ONU sui diritti delle persone con disabilità;
  • predisposizione di un programma di azione biennale per la promozione dei diritti e l’integrazione delle persone con disabilità;
  • promozione della raccolta di dati statistici e della realizzazione di studi e ricerche sul tema;
  • predisposizione della relazione sullo stato di attuazione delle politiche sulla disabilità.

Qui una sintesi dei punti in cui si articola il Programma di azione biennale per la disabilità.

Riforma del Riconoscimento/certificazione della condizione di disabilità – Da raggiungere superando un sistema già il precedente Programma aveva ampiamente descritto come obsoleto, complesso, generatore di possibili diseguaglianze, in ogni caso lontano dallo spirito e dalla lettera della Convenzione ONU.

Politiche, servizi e modelli organizzativi per la vita indipendente e l’inclusione nella società – Così leggiamo: Deve essere realizzato uno sforzo straordinario di innovazione e di formazione degli operatori. Il Programma d’Azione propone nuovi criteri di qualità e accreditamento dei servizi, l’adozione di linee guida per promuovere i processi di vita indipendente e la deistituzionalizzazione e una revisione dei nomenclatori di servizi e prestazioni per accogliere una nuova generazione di interventi per la promozione della partecipazione e eguaglianza delle persone con disabilità. Il Programma d’Azione riprende e sostiene con forza la proposta di abrogazione dell’interdizione.

Salute, diritto alla vita, abilitazione e riabilitazione – Il Programma individua tutta una serie di azioni specifiche e puntuali per arricchire e consolidare i Livelli Essenziali di Assistenza e l’integrazione sociosanitaria. Tra i temi il Nomenclatore tariffario delle protesi, la necessità di un intervento specifico e mirato in tema di qualità della diagnosi e intervento a favore della popolazione con disabilità intellettiva e disturbo psichiatrico, l’attuazione della recente Legge sull’Autismo e delle indicazioni delle linee guida sull’Autismo.

Processi formativi ed inclusione scolastica – La linea di intervento su scuola e formazione delinea una serie di azioni che dovrebbero essere orientate nel senso di consolidare e rendere più efficace il processo di inclusione scolastica ma anche formazione dei docenti.

Lavoro e occupazione- Qui si prevedono interventi per aggiornare aspetti specifici della la normativa per renderla più efficace nell’offrire occasioni di lavoro e la sicurezza dei lavoratori. Linee di lavoro specifiche riguardano la qualità dei servizi di collocamento mirato su tutto il territorio nazionale.

Promozione e attuazione dei principi di accessibilità e mobilità – Rispetto a questi tempi, tra le altre cose, la linea progettuale indica la necessità di procedere ad una importante revisione delle normativa italiana in tema di accessibilità dell’ambiente fisico, urbano ed architettonico, che, sebbene a suo tempo innovativa e all’avanguardia, necessita oggi di essere aggiornata per consentire una piena adozione e diffusione dei principi della progettazione universale.

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More details in Italian about: A survey on childhood vaccination coverage in the Campania region

Il Piano Sanitario Nazionale 1998-2000 ha indicato come obiettivi il raggiungimento, entro il 2° anno di vita, di una copertura di almeno il 95% per le vaccinazioni contro poliomielite (OPV), difterite, tetano e pertosse (DTP), morbillo, rosolia e parotite (MRP), Haemophilus influenzale tipo b (HIB) ed epatite B (HBV).

L’attività di monitoraggio e di valutazione epidemiologica della profilassi vaccinale, per definire il raggiungimento degli obiettivi, è una delle funzioni più importanti dei servizi pubblici. Oltre a misurare la copertura vaccinale è anche importante misurare il timing, cioè la tempestività con cui le vaccinazioni stesse vengono eseguite. La tempestività è importante per l’effettivo controllo delle malattie prevenibili con vaccino ed è un predittore delle coperture vaccinali (1); se le vaccinazioni sono eseguite in ritardo rispetto al calendario non è verosimile che saranno raggiunte elevate coperture. La tempestività è anche importante per la prevenzione delle malattie, in quanto il calendario per le vaccinazioni tiene conto delle età in cui il rischio di contrarre la malattia è maggiore.

La maggior parte degli studi relativi alla copertura vaccinale riguarda aree geografiche ampie e generalmente non forniscono stime a livello locale. Tuttavia, anche in aree in cui la copertura vaccinale raggiunge un più che accettabile livello generale (> 95%), è importante accertare l’eventuale esistenza di potenziali epidemici locali (2), risultato di livelli di copertura vaccinale sub-ottimali, ad esempio a livello di Distretto sanitario.

In tale contesto si inserisce l’indagine campionaria sulle coperture vaccinali promossa dalla regione Campania, coordinata dai Servizi di Epidemiologia e Prevenzione con la consulenza dell’Istituto Superiore di Sanità (ISS), condotta nel 2000-01. Obiettivo dell’indagine è la stima delle coperture vaccinali, a età definite, nei Distretti sanitari delle ASL della Campania.

Dalle liste anagrafiche dei Comuni sono stati selezionati, per ciascun Distretto, tutti i nati in un definito arco temporale, centrato attorno al 30 giugno 1998, sufficiente per la costituzione di un campione di circa 100 unità tale da garantire una precisione delle stime del 6%, su prevalenze attese dell’ordine del 90%. In collaborazione con le Unità Operative Materno Infantili e con le Unità Operative Prevenzione Collettiva dei Distretti sanitari è stata recuperata la storia vaccinale (data in cui sono state effettuate le vaccinazioni OPV, HBV, HIB, DTP e contro il morbillo – in Campania viene utilizzato perlopiù il vaccino MRP) dall’anagrafe vaccinale; in caso d’informazione mancante o incompleta è stata attivata un’adeguata indagine (telefonica, con cartolina-invito, visita domiciliare) per la verifica della documentazione delle vaccinazioni eventualmente eseguite anche privatamente e il recupero degli inadempienti. All’inizio dello studio (fine 2000) tutte le unità campionarie avevano almeno 24 mesi di vita. Per la valutazione del rispetto del calendario vaccinale sono state calcolate le percentuali di vaccinati per tutte le profilassi considerate, le percentuali di vaccinati al 4°, 7° e 12° mese di vita per OPV1, cioè la 1a dose del vaccino antipolio, al 7°, 12° e 24° mese per OPV2, al 12°, 15° e 24° mese per OPV3 e al 15°, 18° e 24° mese per il morbillo. Per l’analisi dei dati è stato utilizzato il software Epi Info. Stime di coperture vaccinali e relativi intervalli di confidenza a livello di ASL e regionale, sono stati calcolati pesando, rispettivamente, per il numero dei nati nei Distretti e nelle ASL.

I risultati fanno riferimento a tutti i 113 Distretti delle 13 ASL della Campania. Per la coorte di nati nel 1998 risulta una copertura vaccinale del 95,8% per OPV3, del 96,0% per DTP3, del 95,9% per HBV3, del 21,4% per HIB3 e del 65,0% per vaccini contenenti il morbillo. Percentuali di coperture vaccinali superiori al 95% per la 1a e la 3a dose antipolio si riscontrano, rispettivamente, nel 96% e nel 79% dei Distretti. Coperture sub-ottimali (85-89%) con OPV3 sono state registrate nell’8% dei Distretti.

Riguardo i ritardi vaccinali, nel 39% dei Distretti si raggiunge il 90% di vaccinati con la 1a dose di OPV entro il 4° mese di vita, mentre solo nel 3% dei Distretti, sempre entro il 4° mese, non viene superato il 70% di copertura. Per la 3a dose di OPV, il 37% dei Distretti non supera il 50% di copertura entro il 12° mese; entro tale mese di vita in nessun Distretto viene raggiunta una copertura superiore al 90%, mentre il 25% raggiunge una percentuale compresa tra il 70 e il 90%.

Le coperture vaccinali per DTP e HBV sono risultate simili a quelle per OPV. Riguardo l’HIB, di recente introduzione per la coorte di nati studiata, solo nel 4% dei Distretti si è registrata una copertura vaccinale con tre dosi superiore al 70%.

Inoltre, nel 23% dei Distretti si è superata una copertura dell’85% con vaccini contenenti il morbillo, mentre nel 22% tale copertura è risultata inferiore al 50%.

Le coperture vaccinali per OPV, DTP e HBV risultano eccellenti nella generalità dei casi, mentre in pochi Distretti di alcune ASL persistono livelli sub-ottimali di immunizzazione. Riguardo la vaccinazione contro il morbillo è necessario intensificare gli sforzi nella maggioranza dei Distretti, per raggiungere in breve tempo l’obiettivo del 95% di copertura, condizione necessaria, assieme al recupero dei suscettibili nelle altre classi di età in occasioni delle altre scadenze vaccinali obbligatorie (4a dose antipolio, 4a antidiftotetanica e ciclo antiepatite B a 12 anni); il fine è quello di ottenere l’interruzione della circolazione delle infezioni corrispondenti.

Altro elemento di riflessione che impone un impegno specifico dei servizi riguarda il ritardo vaccinale, in parte dovuto, ad esempio per le prime dosi, a una scorretta interpretazione del calendario vaccinale (entro il 3° mese di vita significa dal 60° e non dal 90° giorno), in parte a difficoltà operative nella ricerca attiva dei ritardatari, tanto che nel 38% dei Distretti non si raggiunge il 50% di vaccinati con OPV3 entro il 12° mese di vita.

Se si tiene conto che prevalentemente ritardi vaccinali importanti sono associati a condizioni socio-economiche degradate e che tali condizioni sono fattore di rischio per la maggiore precocità delle infezioni, si comprende come tali ritardi debbano essere significativamente ridotti per prevenire le complicanze dovute alle infezioni da pertosse e da Haemophilus influenzae contratte nel 1° anno di vita.

Riguardo il controllo della poliomielite, il ciclo composto dalle prime due dosi con vaccino Salk (IPV) e le ultime due con quello Sabin (OPV), impone un rigoroso rispetto del calendario vaccinale, pena la creazione di carenze temporali dell’herd immunity prodotta, come è noto, solo dall’OPV. Tali potenziali epidemici sono a rischio di attivazione se si tiene conto dei flussi migratori che coinvolgono il nostro Paese.

(per ulteriori informazioni:

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More details in Italian about: The “Birth patway”

6 maggio 2010 – Sono stati presentati all’Iss i primi risultati di due progetti finanziati dal Ccm-ministero della Salute: “Percorso nascita: promozione e valutazione della qualità dei modelli operativi” e “Sperimentazione di un modello di assistenza post partum per le donne straniere”. Questi progetti hanno come riferimento normativo il Progetto obiettivo materno infantile (Pomi), varato nel 2000, alla cui stesura l’Iss ha dato un contributo determinante grazie al patrimonio di conoscenze ed esperienze accumulate con l’attività di ricerca, anche operativa, e delle indagini svolte dal 1980 dal reparto Salute della donna e dell’età evolutiva del Cnesps (prima del 2003, reparto di Indagini campionarie di popolazione del Leb).

Il primo progetto consiste di due sottoprogetti:

  • assistenza alle 25 Asl aderenti a progettazione operativa, implementazione, monitoraggio e valutazione (mediante indagini campionarie condotte all’inizio e un anno dopo l’implementazione) delle attività svolte secondo le raccomandazioni del Pomi
  • indagine sul percorso nascita delle donne con cittadinanza straniera in 17 centri nascita italiani con consistente afflusso di partorienti straniere.

Il secondo progetto riguarda la sperimentazione di un modello di offerta attiva di visite post partum per le donne straniere, applicato a Torino, Milano, Roma e Palermo.

Le presentazioni testimoniano consistenti variazioni tra le Regioni e anche tra le Asl in una stessa Regione nel quadro epidemiologico del percorso nascita in Italia, con non poche divergenze rispetto a quanto raccomandato sulla base delle prove di efficacia e dal Pomi. Si evidenzia in molti aspetti la straordinaria disponibilità delle donne a rimettersi in discussione e ad adottare comportamenti che favoriscono esiti migliori (per esempio: se fumano, smettono in gravidanza e non riprendono se allattano al seno; assumono di più acido folico in periodo periconcezionale). I risultati indicano anche che, mentre le pratiche raccomandate dal Pomi producono migliori esiti, quelle non raccomandate producono danni. In particolare emerge l’importanza dei consultori familiari nel produrre migliore qualità, confermando la giustezza dell’investimento che su questi servizi fa il Pomi.

Rispetto al passato, il percorso nascita tra le donne straniere non si discosta più negli indicatori significativi da quello tra le donne italiane. Permangono però ancora differenze su cui lavorare. Infine, l’assistenza post partum effettuata dai consultori familiari si conferma efficace nel produrre migliore salute.

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More details in Italian about: PICENUM study – Performance Indicators Continuous Evaluation as Necessity for Upgrade in Medicine

Dopo aver individuato, su un campione di n. 10 Medici di Medicina Generale (MMG) della Azienda Sanitaria Unica Regionale (ASUR) Marche – Zona Territoriale 11, le patologie croniche ad alta prevalenza e ad elevata richiesta di impegno e risorse per la Medicina Generale (MG), è stato costruito un set di 36 Indicatori di Performance (IP), di processo e di esito, per le patologie individuate, accreditati da società internazionali specializzate nella valutazione della qualità in ambito sanitario.

Gli indicatori così selezionati sono stati applicati, in fasi successive, ai database (software Millewin) di 47 MMG della provincia di Ascoli Piceno. Sono stati così ottenute delle Pe rformance Measures (PMs) utili alla analisi dei processi assistenziali ed il cui monitoraggio nel tempo diventa importante elemento in un percorso di miglioramento continuo della qualità; i dati sinora raccolti evidenziano un progressivo aumento nella registrazione delle diagnosi ed un incremento consistente nella adesione agli IP selezionati.

Considerando che nel periodo di riferimento, l’unica “variabile” inserita nel sistema è stata la misurazione e la rilevazione dei dati registrati, è lecito supporre che i miglioramenti ottenuti siano da attribuire alla stessa applicazione degli IP e alla consapevolezza dei MMG entrati nello studio di essere sottoposti ad un processo di audit. Contemporaneamente un analogo set di indicatori, selezionato con le stesse modalità, è stato applicato alle Schede di Dimissione Ospedaliera (SDO) di 23 UU.OO. di Medicina Interna della Regione Marche, riferite a ricoveri effettuati dal 1997 al 2002, per le patologie più frequenti alla prima diagnosi di dimissione, gettando le basi per una forte integrazione tra la medicina delle cure primarie e quella delle cure secondarie sia nei percorsi di prevenzione-diagnosi-cura che nel metodo di lettura di rispettivi indicatori di processo e di esito. La prospettiva è quella di implementare sempre più marcatamente nella Regione Marche la valutazione dei processi assistenzial i utilizzando lo strumento degli IP.

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