Italy: Health System Review

This analysis of the Italian health system reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. Italy has a regionalized National Health Service (SSN) that provides universal coverage largely free of charge at the point of delivery, though certain services and goods require a co-payment. Life expectancy in Italy is historically among the highest in the EU. However, regional differences in health indicators are marked, as well as in per capita spending, distribution of health professionals and in the quality of health services. Overall, Italy's health spending per capita is lower than the EU average and is among the lowest in western European countries. Private spending has increased in recent years, although this trend was halted in 2020 during the coronavirus disease 2019 (COVID-19) pandemic. A key focus of health policies in recent decades was to promote a shift away from unnecessary inpatient care, with a considerable reduction of acute hospital beds and stagnating overall growth in health personnel. However, this was not counterbalanced by a sufficient strengthening of community services in order to cope with the ageing population's needs and related chronic conditions burden. This had important repercussions during the COVID-19 emergency, as the health system felt the impact of previous reductions in hospital beds and capacity and underinvestment in community-based care. Reorganizing hospital and community care will require a strong alignment between central and regional authorities. The COVID-19 crisis also highlighted several issues pre-dating the pandemic that need to be addressed to improve the sustainability and resilience of the SSN. The main outstanding challenges for the health system are linked to addressing historic underinvestment in the health workforce, modernizing outdated infrastructure and equipment, and enhancing information infrastructure. Italy's National Recovery and Resilience Plan, underwritten by the Next Generation EU budget to assist with economic recovery from the COVID-19 pandemic, contains specific health sector priorities, such as strengthening the country's primary and community care, boosting capital investment and funding the digitalization of the health care system.

A composite index of avoidable hospitalization to assess primary care quality: an Italian experience

Background

In Italy, primary care (PC) ensures universal health coverage while containing costs. However, the assessment of its quality still remains an issue. Evidence has shown that high-quality outpatient care, through timely interventions to prevent complications of “ambulatory care sensitive conditions”, may avoid hospitalization. Aim of the study is to analyse the performance of PC in the Italian regions, using a composite and synthetic index of avoidable hospitalizations.

Methods

Hospital discharge data from 119 Italian geopolitical areas were analysed for the 2017-2019 triennium and for 2020, separately. According to the “Italian National Outcomes Evaluation Programme” methodology, 9 avoidable hospitalization indicators covering 5 nosological fields (infectious, respiratory, metabolic, cardiovascular and mental diseases) were combined in a synthetic index, calculated as the weighted mean of their standardized scores (with equal weights for each field). Using “natural breaks” technique, the areas were grouped into 5 clusters: “high”, “medium-high”, “medium”, “medium-low” and “low”.

Results

The analysis showed a marked heterogeneity at intra-regional level for the pre-pandemic triennium, with areas of homogeneity in regions with higher levels of hospitalization. The “medium” cluster, which is the widest, included 36 areas variously distributed across regions. The comparison with 2020 confirmed the geographical patterns observed for the previous triennium, despite a general reduction in hospitalizations due to the pandemic.

Conclusions

As a proxy indicator of PC quality, this index can aid decision makers in prioritizing quality improvement actions. However, in order to obtain a comprehensive evaluation, a joint reading of this index with other healthcare indicators is recommended.

Key messages

• High-quality PC is essential in maintaining appropriate hospitalization levels.

• The composite synthetic index proposed could aid PC quality assessment.

Psychological Impact of the COVID-19 Pandemic on Pregnant Women

OBJECTIVE

The aim of this study is to assess the impact of the COVID-19 pandemic on mental health, type of delivery, and neonatal feeding of pregnant women with or without SARS-CoV-2 infection during gestation.

STUDY DESIGN

The study was conducted online, and anonymous survey was distributed to mothers that delivered during the COVID-19 pandemic.

RESULTS

The survey was completed by 286 women, and 64 women (22.4%) had COVID-19 during pregnancy. Women that had SARS-CoV-2 infection during pregnancy or at time of delivery had a significantly higher probability of being separated from the newborn (p < 0.0001) and a significantly lower probability of breastfeeding (p < 0.0001). The Edinburg Postnatal Depression Scale, to assess if mothers had symptoms of postnatal depression, showed that items suggestive of postnatal depression were relatively frequent in the whole cohort. However, women with SARS-CoV-2 infection during pregnancy reported higher probability of responses suggestive of postnatal depression in eight out of 10 items, with statistically significant differences in three items.

CONCLUSION

The COVID-19 pandemic affected the type of delivery and breastfeeding of pregnant women, particularly when they had SARS-CoV-2 infection. This, in turn, had an impact on the psychological status of the interviewed mothers, aspects that could benefit of special support.

A shared battle against cancer: overcoming screening uptake differences within European countries

Cancer is the second leading cause of dead in Europe and it is responsible of more than 30% of all deaths. For this reason, European Union (EU) identified the battle against cancer as a priority for the European Research Program 2021-2027.About 40% of total deaths for cancers could be prevented with screening.Validated screening test are available for breast (BC), cervical (CC) and colorectal cancers (CRC).

In 2003 the Recommendation of the European Council indicated the right timing and the population target but, nowadays, the percentage of screening within EU is low and consistent differences persist among States.In 2020 there are still countries that don't have population-based screening programs. Last data available for all 28 EU countries are referred to 2014. Data were retrieved from “Osservasalute” reports and Global Burden of Disease database.Pearson test and a paired t test were used to describe correlation between mortality and screening coverage rates.

In 2014 the mean percentage of screening was 70.7% for CC, 68.7% for BC and 31.3% for CRC and the mean of mortality rate was of 2.1, 10.4 and 17.2 for 100,000, respectively.The rate of mortality did not change significantly in 2017 (2, 10 and 16 for 100,000 respectively).The median coverage is 67 for BC [IR: 43-91], 21.4 for CRC [IR: -3-46] and 70.6 for CC [IR: 54-87]. Pearson test resulted in a negative correlation for all three cancers equal to -0.045, -0.060 and -0.561, respectively.A higher adherence to screening programs is significantly associated to lower mortality rates in all the three types of cancer (p &lt; 0.01).

Even if many factors determine the rate of cancer mortality, screening represents the best method to early diagnosis and treatment.Up-to-date data are needed to correctly monitor progress towards the common goal of reaching the entire target population with screenings.A strong leadership at international level is necessary to improve screening programs all over EU and support screening campaigns.

Key messages

Screening is one of the most efficient and life-saving way to prevent cancer. It is needed to improve screening adherence through population-based programmes both at international and national level. Last data available for all EU countries are referred to 2014. It is necessary to update the data in order to enhance the understanding of screening efficiency.

[The supply of long-term care services for the elderly in Italian regions]

In Italy, as in other European Countries, ageing population drives policymakers to redesign the Long Term Care (LTC) system for the elderly. This study analyses the LTC supply for elderly considering the distribution of different components: formal care (institutional and alternative), and informal one in Italian regions. An observational, cross-sectional, ecological study was carried out using statistical data drawn from the Italian National Institute of Statistics and Ministry of Health referred to 2004. Factorial analysis selected the most important components of LTC phenomenon. These components were used for the application of cluster analysis. Cluster Analysis was performed on main components of Factorial Analysis. Then, the ratio of mean value in each cluster on national mean value was calculated for each indicator. Factorial analysis showed three factors characterized by autovalue > 1 that accounted for 61% of the total variance. Cluster analysis highlighted four groups of regions with different way of supply. High level of home care (141,9) and social network (121,3) emerged in group 1. High level of family who received help and family paying a caregiver (108,3 e 121,1) resulted in group 2. High level of no profit LTC (168) supply was reported in group 3. High level of public residential care (451,4) was found in group 4. These remarkable differences in the way of service supply, highlight the need of improvement of the information system on LTC. Thus LTC policy and practice might be better supported both in planning and organizational targets.

Towards a common disability assessment framework: theoretical and methodological issues for providing public services and benefits using ICF

PURPOSE

To report on the preliminary results of an Italian project on the implementation of an ICF-based protocol for providing public services and benefits for persons with disabilities.

METHODS

The UN Convention on the Rights of persons with disabilities (UNC) was mapped to the ICF, and core elements were implemented in an ICF-based evaluation protocol. A person-environment interaction classification (PEIC) tree was also developed for defining evaluation outputs.

RESULTS

The PEIC and the ICF-based protocol are the guideline and the data interpretation source, respectively, for providing public services and benefits. They enable to assign persons to different services, from surveillance and monitoring to facilitator provision or sustain over time, to barrier removal or to the reorganisation of environmental factors provision. A detailed description of the target intervention is made available through the implementation of a protocol, which points out the effect of personal support and other environmental factors.

CONCLUSIONS

The detailed description of functioning and disability provided by our methodology can help policy makers and administrators in decision making, on the basis of a description of real needs, and in targeting person-tailored interventions.

An ecological study on the relationship between supply of beds in long-term care institutions in Italy and potential care needs for the elderly

Background

The ageing population in Europe is putting an ever increasing demand on the long-term care (LTC) services provided by these countries. This study analyses the relationship between the LTC institutional supply of beds and potential care needs, taking into account the social and health context, the supply of complementary and alternative services, along with informal care.

Methods

An observational, cross-sectional, ecological study was carried out. Statistical data were obtained from the Italian National Institute of Statistics and Ministry of Health. Indicators, regarding 5 areas (Supply of beds in long term care institutions, Potential care needs, Social and health context, Complementary and alternative services for the elderly, Informal care), were calculated at Local Health Unit (LHU) level and referred to 2004.

Two indicators were specifically used to measure supply of beds in long term care institutions and potential care needs for the elderly. Their values were grouped in tertiles. LHU were classified according to the combination of tertiles in three groups: A. High level of supply of beds in long term care institutions associated with low level of potential care needs; B. Low level of supply of beds in long term care institutions associated with high level of potential care needs; C. Balanced level of supply of beds in long term care institutions with potential care needs. For each group the indicators of 5 areas were analysed.

The Index Number (IN) was calculated for each of these indicators.

Results

Specific factors that need to be carefully considered were highlighted in each of the three defined groups. The highest level of alternative services such as long-stay hospital discharges in residence region (IN = 125), home care recipients (HCR) (IN = 123.8) were reported for Group A. This group included North regions. The highest level of inappropriate hospital discharges in (IN = 124.1) and out (IN = 155.8) the residence region, the highest value of families who received help (IN = 106.4) and the lowest level of HCR (IN = 68.7) were found in Group B. South regions belong to this group. The highest level of families paying a caregiver (IN = 115.8) was shown in Group C. Central regions are included in third group.

Conclusion

Supply of beds in long term care institutions substantially differs across Italian regions, showing in every scenario some imbalances between potential care needs and other studied factors. Our study suggests the need of a comprehensive rethinking of care delivery "system".

[Public health care system in the Italia regions.]

The National Health Plan 2006-2008 underlines the need to overcome the differences that exist in the health care services of the Italian regions. Because the health care systems are organised differently on the territory, the Regions provide different answers to the health needs of their residents. Therefore, the purpose of this document is that of analysing the characteristics of the Italian public health care system in 2003. While in the first part, the health system is described region by region, in the second part, a cluster analysis is used to describe the local health authorities. The results show that while both the first and second level assistance have become stronger, the centrality of the hospital system has decreased, even though it still occupies a dominant position.