Osteoradionecrosis incidence in pre-radiation teeth extractions: A prospective study

AIMS

To evaluate osteoradionecrosis (ORN) incidence in a cohort of patients undergoing tooth extraction (TE) before radiotherapy (RT) for head and neck cancers.

METHODS

The study protocol was approved by the Ethics Committee of Università Cattolica del Sacro Cuore (ID-2132) and registered at clinicaltrials.gov (ID: NCT04009161). TE was performed in case of signs of pericoronitis, periapical lesions, restorative impossibility, severe periodontitis. ORN was defined as exposed bone at an unhealed post-extraction socket in the absence of oncological recurrence. The RT plans were reviewed, and each post-extractive socket was contoured to calculate the received radiation dose.

RESULTS

In total, 156 patients with 610 TE were enrolled. The mean follow-up was 567 days. ORN was diagnosed in four patients (2.6% of patients and 0.7% of TE). Need for osteotomy and radiation dose at the extraction site were associated with ORN (OR for osteotomy: 21.9, 95% CI: 2.17-222.2, p = 0.009; OR for RT dose: 1.1, 95% CI: 1-1.15, p = 0.05).

CONCLUSIONS

TE appears to be a significant risk factor for ORN, particularly when osteotomy is required, and post-extraction sockets receive a high RT dosage. This study proposes a decision-making algorithm for TE and outlines a straightforward surgical protocol.

A cost-effectiveness analysis of an integrated clinical-radiogenomic screening program for the identification of BRCA 1/2 carriers (e-PROBE study)

Current approach to identify BRCA 1/2 carriers in the general population is ineffective as most of the carriers remain undiagnosed. Radiomics is an emerging tool for large scale quantitative analysis of features from standard diagnostic imaging and has been applied also to identify gene mutational status. The objective of this study was to evaluate the clinical and economic impact of integrating a radiogenomics model with clinical and family history data in identifying BRCA mutation carriers in the general population. This cost-effective analysis compares three different approaches to women selection for BRCA testing: established clinical criteria/family history (model 1); established clinical criteria/family history and the currently available radiogenomic model (49% sensitivity and 87% specificity) based on ultrasound images (model 2); same approach used in model 2 but simulating an improvement of the performances of the radiogenomic model (80% sensitivity and 95% specificity) (model 3). All models were trained with literature data. Direct costs were calculated according to the rates currently used in Italy. The analysis was performed simulating different scenarios on the generation of 18-year-old girls in Italy (274,000 people). The main outcome was to identify the most effective model comparing the number of years of BRCA-cancer healthy life expectancy (HLYs). An incremental cost-effectiveness ratio (ICER) was also derived to determine the cost in order to increase BRCA carriers-healthy life span by 1 year. Compared to model 1, model 2 increases the detection rate of BRCA carriers by 41.8%, reduces the rate of BRCA-related cancers by 23.7%, generating over a 62-year observation period a cost increase by 2.51 €/Year/Person. Moreover, model 3 further increases BRCA carriers detection (+ 68.3%) and decrease in BRCA-related cancers (- 38.4%) is observed compared to model 1. Model 3 increases costs by 0.7 €/Year/Person. After one generation, the estimated ICER in the general population amounts to about 3800€ and 653€ in model 2 and model 3 respectively. Model 2 has a massive effect after only one generation in detecting carriers in the general population with only a small cost increment. The clinical impact is limited mainly due to the current low acceptance rate of risk-reducing surgeries. Further multicentric studies are required before implementing the integrated clinical-radiogenomic model in clinical practice.

Insights on DRGs, guideline compliance and economic sustainability. The case of mastectomy with immediate breast reconstruction

Background

Immediate breast reconstruction is recommended for eligible patients undergoing mastectomy, raising the issue of economic sustainability of both mastectomy and breast reconstruction performed within the same hospitalization, as opposed to two surgical procedures in two different hospitalizations.

Study design

A retrospective analysis was conducted to compare economic sustainability of mastectomies with or without immediate breast reconstruction.

Methods

Economic data on hospitalizations for mastectomy in a Teaching Hospital between 1 January 2019 and 31 March 2021 were analyzed to assess their sustainability.

Results

338 admissions were selected (63.9% with immediate breast reconstruction (CI 99%: 57.2% to 70.6%). Compared to mastectomy alone, mastectomy with immediate breast reconstruction had higher cost of € 2,245 (p < 0.001), with operating rooms and devices as main cost drivers. Current reimbursements rates (which are the same for mastectomy alone and for mastectomy with immediate breast reconstruction) led to an average loss of € 1,719 for each mastectomy with immediate breast reconstruction.

Conclusion

Current DRGs reimbursement rates for hospital admissions for breast cancer surgery do not guarantee immediate breast reconstruction's economic sustainability. DRGs system should be revised, or other solutions as bundled payment should be implemented in the light of the costs of innovation in healthcare, considering mastectomy and breast reconstruction steps in a path of linked actions aimed at improving patients' health.

The value of uterine oncological surgery in a University Hospital. Results of a break-even analysis

Background

Robotic surgery has many clinical advantages but high costs, raising the issue of healthcare sustainability. This study aims to a comparative analysis of the value, in terms of costs and outcomes, of robotic, laparoscopic, and laparotomy surgery for uterine cancer in a University Hospital.

Methods

An observational retrospective study was carried out on hospitalizations between 1 Jan 2019 and 31 Oct 2021 for uterine cancer surgery. DRG amount, costs, economic margins and 30-days readmissions percentage (mean values and 95% CIs) were calculated for robotic, laparoscopic and laparotomy surgery. Student’s t and Chi-square tests were used to assess differences and the break-even point was calculated.

Results

1336 hospitalizations were analyzed, 366 with robotic, 591 with laparoscopic, and 379 with laparotomy surgery. Robotic surgery compared to laparoscopic and laparotomy ones showed a significant difference (p &lt; 0,001) for economic margin, which was largely negative (-1069.18 €; 95%CI: -1240.44 - -897.92 €) mainly due to devices cost (3549.37 €; 95%CI: 3459.32 € - 3639.43 €), and a lower 30-days readmissions percentage (1.4%; 95%CI: 0.2% - 2.6%) with a significant difference only versus laparotomy (p = 0.029). Laparoscopic compared to laparotomy surgery showed a significantly (p &lt; 0,001) more profitable economic margin (1692.21 €; 95%CI: 1531.75 € - 1852.66 €) without a significant difference for 30-days readmissions. The break-even analysis showed that, on average, for every uterine cancer laparoscopic elective surgery, 1.58 elective robotic surgeries are sustainable for the hospital (95% CI: 1.23 - 2.06).

Conclusions

The systematic application of the break-even analysis will allow defining over time the right distribution of robotic, laparoscopic and laparotomy surgeries’ volumes to perform in order to ensure both quality and economic-financial balance and therefore value of uterine oncological surgery in the University Hospital.

Key messages

• The value-based healthcare approach, defined as the measured improvement in a patient’s health outcomes in relation to its cost, finds effective application in uterine cancer surgery.

• The use of the break-even approach allows to promote the value-based view by identifying a useful criterion for the planning and governance of interventions for uterine malignancies.

Hospital networks in Italy: state of the art and future pespectives. Insights from a qualitative research study

Background Hospitals have undergone important that changes that have led, in recent decades at the international level, to the need for greater integration between hospitals and local healthcare services. The main institutional networks that have been developed in Italy are, as commended by the institutional levels, of 4 main types: the Emergency-Urgency Network, the Time-Dependent Networks, the Oncological Networks, and the Networks with primary care settings. It was important to assess the state of the art and analyze it in relation to possible future developments. Objective The aim of the study was to collect insights from both evidence-based knowledge and personal experience gained by experts in the field regarding the current condition and possible future developments of hospital networks. Material and methods A qualitative research methodology was chosen. Four mini-focus group meetings were organized among participants with proven expertise on the subject. Discussions were guided by four open-ended questions corresponding to the four areas of interest. Directed content analysis was chosen as the methodology for data analysis and final reporting of results. Results Four main categories were explored: "hospital networks and complexity", "hospital networks complexity and the need for integration", "levers for hospital networks governance" and "the COVID-19 challenge and future developments for hospital networks". In particular, the participants found that it is important to understand healthcare systems as complex systems and, therefore, to study the properties of complex systems. In this way it is possible to achieve value-based healthcare in complex contexts. It is also necessary to keep in mind that complexity represents a challenge for coordination/ integration in hospital networks. Mintzberg identified specific mechanisms to achieve it. Of them, mutual adaptation is the key to self-organization. Valentijn showed the organizational levels on which coordination/integration has to be obtained. Hospital network governance should include both hierarchy and self-determination logic to achieve integration in each of the four levels. The participants identified three key levers for governing complex organizations: "education", which consists of multi-professional and multi-level training in governance in complex systems; "information" consisting in considering the data registering as an integral part of the clinical care process to informative value; "leadership", which consists in convincing actors, directed towards personal gains, to achieve valuable goals. Finally, the challenge that COVID-19 served as an incentive for future developments of hospital networks. Discussion Various common points between the definitions of network and complex systems can be found. It is important to study the properties of complex systems in order to achieve value-based healthcare in the hospital networks context. The insights gained should be useful for all professionals from and across all levels of healthcare organizational responsibility, being able to orient roles and actions to achieve coordination/integration inside hospital networks. Conclusions Complexity literature can help understand how to achieve coordination/integration in healthcare settings and find levers for effective governance. It is important to study the current situation to anticipate and, possibly govern, future developments. In conclusion, governance of hospital networks should be interpreted as coordination/integration inside and across multiple organizational levels of co-responsibility.

Case report of polymyalgia rheumatica in a male patient with three different neoplasms treated with pembrolizumab

In this manuscript we aim to describe a particular case of a 63 years-old man who developed three different malignancies (one was a rare case of breast cancer) among nearly five years. In particular, for the diagnosis of melanoma, he was treated with pembrolizumab, a PD-1 inhibitor. After few months of treatment with pembrolizumab, the patient reported the onset of musculoskeletal symptoms such as inflammatory pain at the shoulders and morning stiffness, with raised CRP and ESR and imaging evidence of bursitis and tenosynovitis. A polymyalgia-like syndrome was diagnosed. Understanding if these manifestations are linked to the use of pembrolizumab or to a paraneoplastic syndrome, and how to manage the patient, was the real challenge.

Implementation level of best practice policies by Italian government for healthier food environments

Background

Government actions play a critical role in shaping healthy food environments, which can improve population's diet and decrease the burden of disease. This study aims to determine and compare the level of policy implementation for healthy food environments in Italy with reference to international benchmarks and make prioritized recommendations based on the identified implementation gaps.

Methods

The Healthy Food Environment Policy Index (Food-EPI) tool from the International Network for Food and Obesity/NCDs Research, Monitoring and Action Support (INFORMAS) was adapted for the Italian context. This tool includes two components, thirteen domains and fifty good practice indicators, which were verified with experts from National Health Institute (NHI). Evidence for implementation was gathered and summarized for all fifty indicators from data sources such as governmental websites, non-government organizations publications and websites and via direct contact with government officials. After collecting all evidence, experts from the NHI verified the completeness and accuracy of it. The evidence document will be presented to stakeholders, aiming to seek consensus on the priority actions to be implemented by the Italian Government to improve food environments.

Results

The evidence for policy implementation concerning Italy varied among domains and indicators. We found the highest level of evidence within three domains: Food Composition (2/2 indicators), Food Labelling (3/4 indicators) and Food Promotion (4/5 indicators). The domains with less identified evidence were Food Prices (1/4 indicators), Food Retail (0/4 indicators), Food Trade and Investment (0/2 indicators) and Platforms and Interaction (1/4 indicators).

Conclusions

The evidence summarization and the upcoming stakeholders' meeting to rate the level of implementation for each indicator in Italy, have the potential to improve government commitment to shape healthier food environments.

Key messages

Food environment policies, implemented by the government, play a key role in the health of the population, decreasing the burden of disease. Several food environment policies have been implemented and supported by the Italian government but there are still some priority actions to be taken towards healthier food environments.

Systematic review on multidisciplinarity and management of multimorbid chronic patients in hospital

Multimorbidity requires that many physicians shift the focus of the care they provide towards the management of multiple chronic conditions such as heart diseases, diabetes, chronic obstructive pulmonary disease and mental illness. The aim of this systematic review is to summarize the scientific evidence on the effects of Multidisciplinary Teams (MDT) on chronic patients' management in hospital settings, evaluating outcomes, costs and workload.

Medline, Scopus and Ovid were queried for relevant articles using the Population-Intervention-Context-Outcome (PICO) model. Selected articles were assessed for quality and risk of bias using the National Institutes of Health Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Data were analyzed using descriptive statistics, and comparison among comorbid patients with at least one mental illness versus those without was performed using Chi-square test (p &lt; 0,05).

Out of 7332 records, 7 studies met the inclusion criteria and 85 indicators were identified: 52% improved significantly, 46% did not show any variation and 2% (nausea and delirium) worsened. In particular, in-hospital mortality was significantly reduced in 65% of the studies describing such indicator. The presence of a mental illness showed a statistically significant increase of length of stay (p &lt; 0,05), hence related to a lower bed-day saving, while no statistically significant effect was observed on 30-day readmissions (p = 0,13). In addition, few studies highlighted that a higher workload leads to greater burn-out rates.

MDT meetings represent a fundamental step in a complex path care. They are useful to discuss clinical cases to define their diagnosis and to formulate shared treatment plans in order to deliver personalized treatment options and appropriate follow-up. These findings should stimulate decision makers to invest in the development of MDT and further research should be conducted to evaluate team efficacy.

Key messages

Successful management of chronic diseases can be enhanced by Multidisciplinary Teams. Caregivers can be involved in this relational process to ensure a better path care.

Leadership styles and job satisfaction. Results of a systematic review

Background

Healthcare organizations are social systems in which human resources are generally the most important factor for the provision of care. In these contexts, leadership plays a key role in providing effective and efficient care and results in positive outcomes for professionals, patients and work environment. The aim of this review was to identify and analyze the knowledge present to date in literature concerning the correlation between leadership styles and nurses' job satisfaction.

Methods

A systematic review of the literature was carried out on Medline and CINAHL databases between June and October 2019 by using a specific search algorithm. The following inclusion criteria were set: focus on the impact of different leadership styles on nurses' job satisfaction; secondary care; nursing setting; full-text available; English or Italian language.

Results

6681 titles, 410 abstracts and 57 full texts were analyzed. The 12 selected studies considered 7 leadership styles: Transformational, Transactional, Passive-Avoidant, Laissez-Faire, Resonant, Authentic and Servant. Four studies (33%) considered only 1 style, 3 studies (25%) 2 styles, 4 studies (33%) 3 styles and only one study (9%) considered 4 styles. Transformational and Transactional styles were the most represented (75% and 67% respectively). Most of the studies conducted (88%) showed a significant correlation, both positive and negative, between the adopted Leadership style and the nurses' job satisfaction.

Conclusions

In a complex and constantly evolving context, healthcare organizations need to guarantee not only technical and professional competence, but also satisfaction as a motivational lever for health workers. It is therefore necessary to identify and fill the gaps in leadership abilities as a present and future objective in order to positively affect health professionals' job satisfaction and therefore healthcare quality indicators.

Key messages

Job satisfaction plays a key role in healthcare and nursing as a motivational lever for health workers. Leadership styles directly impact on nurses' job satisfaction which in turn affects healthcare quality and patient outcomes.

Impact of clinical risk management in pediatric intensive care units: a systematic review

Background

Clinical risk is the probability that a patient is the victim of an adverse event attributable to medical care, albeit unintentionally; clinical risk management is therefore a key area for the quality of healthcare, especially in care-intensive settings; even more for pediatric patients. The objective of this review is to assess the impact of the application of tools and methodologies for clinical risk management in pediatric care-intensive settings.

Methods

Pubmed and Web of Science were queried to carry out a systematic review, using the PICO methodology to formulate the research strategy and query (June 2019). Application experiences of clinical risk management that had quantitative and qualitative impacts in pediatric intensive care units were included.

Results

A total of 1178 papers were reviewed and 22 articles were included, most of them from the US (8). Out of the 22 experiences described, 11 were related to reactive management tools, 7 to proactive tools; 4 experiences reported the use of both reactive and proactive tools; 11 articles made explicit a reduction in adverse events following the intervention in the study (29.8%-78.8%, p &lt; 0.001); 8 articles made explicit organizational changes triggered by the intervention; 2 proactive tools were also used in order to specifically assess the economical savings related to the changes that occurred as a result of the intervention; 1 article compared two reactive clinical risk management systems in the same context, underlining that a more innovative system tended to highlight more systemic errors, while a more traditional one focused on errors that were less common but potentially more dangerous; 14 studies were specifically dedicated to risk in drug management.

Conclusions

The application of clinical risk management tools made changes in pediatric intensive care units; the integrated use of different methodologies, both proactive and passive, for the management of clinical risk is highlighted in many studies.

Key messages

Methodologies for clinical risk management can have significant impacts on organizational processes and outcomes of pediatric intensive care units, improving safety of patient and operators. The simultaneous use of several clinical risk management tools, both proactive and reactive, is increasingly widespread.

The impact of Multidisciplinary Tumor Boards on breast cancer care: results of a systematic review

A Multidisciplinary Tumor Board (MTB) is a group of professionals from different clinical areas that meets to examine oncological patients to face multiple aspects of the pathology. MTBs represent an effective way for clinical decision making and management of complex diseases like cancer that needs an integrated approach. They have the potential to implement patient's care optimizing both evaluation and treatment. The aim of this study was to evaluate the clinical and organizational impact and benefits of MTBs on breast cancer cases.

The databases investigated to carry out the research were Pubmed and Web of Science. Only Italian and English articles focused on breast cancer patients evaluated through MTB approach were included. No time restriction was adopted. Articles about other types of cancer were not included; systematic reviews and non-peer reviewed papers such as editorial and commentaries were excluded from the study.

The research found 5163 publications; duplicated records were omitted. 5086 articles were excluded through the analysis of title and abstract; after full text reading 52 studies were excluded. Only 25 publications fulfilled the inclusion and exclusion criteria. Two articles considered the impact of MTB on overall survival; 1 publication studied the effect of diagnostic changes; 7 articles examined the impact of MTBs on cancer treatment; 2 studies analysed the effects on clinical performance. Other publications examined secondary outcomes and indicators.

MTB has been described to have a positive impact on breast cancer. It improves overall survival (substantial results for over 65), diagnostic accuracy (up to 65%) and treatment scheme making it more adherent to guidelines (28%-93,1%). Furthermore, MTB makes patient's management more functional and avoids inappropriate interventions.

Further studies are needed to deepen on some topics such as the economic aspects and the importance of the participation of general practitioners to MTBs.

Key messages

MTB could improve patient’s care and clinical management of cancer. It is necessary to study if greater accuracy in patient’s management could have economic impact as it avoids inappropriate procedures.

Measuring organizational performance. A review of the dimensions of hospital performance indicators

Key messages

Main dimensions of performance indicators: efficiency, effectiveness, patient centeredness, safety. More emphasis to sustainability and appropriateness to align with today’s healthcare challenges.

Healthcare costs and outcomes: a value-based assessment tool for Clinical Governance

Issue/problem

Health systems sustainability is a critical public health issue. A value-based approach is essential to improve patient-centeredness, appropriateness, quality and funding allocation in healthcare.

Description of the problem

This project was aimed to develop an innovative transferable tool to assess value-based activities in Hospital by monitoring care pathways costs and outcomes. Main questions were to: assess cost and outcome variance in homogeneous groups of patients; evaluate clinical activities contribution to the hospital budget; identify and monitor critical points. In 2018 a Business Intelligence system fed by different Hospital datasets was developed and tested in a Teaching Hospital in Rome to quantify and integrate data on pathways efficacy and costs. It was based on an algorithm of 20 indicators related to Women and Child Care Pathways.

Results

Preliminary results showed a great variance for the same intervention/procedure concerning length of stay (3-8 days), waiting times (1-4 days), innovative technologies costs (2000-6000€) and obsolete reimbursement rates (2000-5000€) that do not guarantee adequate economic contribution margins. Improvement actions were defined concerning pathways’ workflow and organizational appropriateness. The need for negotiations with Ministry of Health was highlighted, aimed to update reimbursement rates.

Lessons

The tool, built on a value-based process view, allowed analyzing online outcomes and costs data aggregated by path, benchmarking results, identifying critical issues and providing improvement solutions. It turned out to be an innovative methodology - also applicable in other settings/countries - to trigger changes in health management and pursue quality and efficiency in healthcare.

Key messages

Value-based healthcare is the new public health paradigm. Assessing simultaneously Hospital costs and outcomes is a valuable way to derive overall healthcare value, improve quality and rationalize resources allocation.

Balanced Scorecard for performance assessment in healthcare settings: a review of literature

Background

The Balanced-Scorecard (BSC) is a management tool developed in the early 1990s to balance the impact of financial and non-financial parameters and analyse the organisational performance in private companies according to four determinants. The original BSC has spread to different sectors in the last decades, including healthcare services, in numerous amended versions. The aim of our project was to identify potential indicators of BSC for performance evaluation in general hospitals.

Methods

We performed a systematic review of literature on Pubmed and Web of Science using the search string “balanced scorecard AND healthcare AND indicators”. We found 102 papers; 80 papers were removed for irrelevance, absence of full text or performance indicators. We only considered articles that followed the classic structure of BSC (Customer, Internal Processes, Financial, and Learning and Growth). The indicators listed in them were classified according to the four determinants of organisational performance.

Results

Eight articles out of 22 followed the classic structure of the BSC. The most represented category was Internal Processes (59 indicators), followed by Learning and Growth (52), Customer (40) and Financial (33). The number of common/overlapping indicators was low (5 for Internal Processes and 4 for the three other categories).

Conclusions

While BSC has spread to different settings, the list of indicators used in the classic four determinants for performance evaluation is heterogeneous. While common points can be identified between indicators, our review highlighted that every BSC is developed in a unique way which makes it difficult to identify a general framework adaptable to different hospital settings.

Key messages

The use of the Balanced Scorecard as management tool has spread to healthcare settings in the last decade. Indicators in BSC for healthcare settings are heterogeneous and only a limited number follow the standard structure of BSC.

Hospital contextual factors affecting the use of health technologies: a systematic review

Background

Healthcare systems are facing great challenges due to increased share of aging population, growing health needs and economic restraints. To keep a high quality of assistance it is important to invest in health technologies (HTs) that have the potential of improving health outcomes. Even though a lot of guidance does exist on how HTs should be introduced, used and dismissed, there is a surprising gap in literature concerning the awareness of hospitals in the actual utilization of HTs, namely utilization in daily practice after formal adoption.

Methods

We performed a systematic literature review of qualitative and quantitative studies aimed at investigating hospital contextual factors that influence the actual utilization of HTs at hospital level. PubMed, Scopus, Web of Science, Econlit and Ovid were searched to retrieve studies published in English from 1st January 2010 to 31st May 2018.

Results

A total of 33 studies were included mostly addressing information and communication technologies (ICTs). Findings suggest that contextual factors that impact on actual utilization of HTs at hospital level are ascribable to four main families: financial factors, leadership styles, human resource management and hospital infrastructure. It emerges also that involving professionals at all levels and planning people’s work and competencies are major determinants of HTs actual utilization.

Conclusions

The evidence suggests that several contextual factors play a major role in HTs actual utilization at hospital level even though data are mostly referred to ICTs being the other HTs unexplored. Indeed, findings from this study suggest that numerous items should be evaluated when considering to use a new HTs at hospital level. Nevertheless, evidence regarding actual utilization of medical and surgical HTs is still lacking and future research is needed.

Key messages

Financial factors, leadership styles, human resource management, hospital infrastructure are relevant determinants of actual utilization of new HTs at hospital level. The evidence on contextual factors that influence actual utilization of HTs is mostly referred to ICTs and further research is indeed deserved.

Disinvestment in healthcare: an overview of HTA agencies and organizations activities at European level

Background

In an era of a growing economic pressure for all health systems, the interest for “disinvestment” in healthcare increased. In this context, evidence based approaches such as Health Technology Assessment (HTA) are needed both to invest and to disinvest in health technologies. In order to investigate the extent of application of HTA in this field, methodological projects/frameworks, case studies, dissemination initiatives on disinvestment released by HTA agencies and organizations located in Europe were searched.

Methods

In July 2015, the websites of HTA agencies and organizations belonging to the European network for HTA (EUnetHTA) and the International Network of Agencies for HTA (INAHTA) were accessed and searched through the use of the term “disinvestment”. Retrieved deliverables were considered eligible if they reported methodological projects/frameworks, case studies and dissemination initiatives focused on disinvestment in healthcare.

Results

62 HTA agencies/organizations were accessed and eight methodological projects/frameworks, one case study and one dissemination initiative were found starting from 2007. With respect to methodological projects/frameworks, two were delivered in Austria, one in Italy, two in Spain and three in U.K. As for the case study and the dissemination initiative, both came from U.K. The majority of deliverables were aimed at making an overview of existing disinvestment approaches and at identifying challenges in their introduction.

Conclusions

Today, in a healthcare context characterized by resource scarcity and increasing service demand, “disinvestment” from low-value services and reinvestment in high-value ones is a key strategy that may be supported by HTA. The lack of evaluation of technologies in use, in particular at the end of their lifecycle, may be due to the scant availability of frameworks and guidelines for identification and assessment of obsolete technologies that was shown by our work. Although several projects were carried out in different countries, most remain constrained to the field of research. Disinvestment is a relatively new concept in HTA that could pose challenges also from a methodological point of view. To tackle these challenges, it is necessary to construct experiences at international level with the aim to develop new methodological approaches to produce and grow evidence on disinvestment policies and practices.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-2941-0) contains supplementary material, which is available to authorized users.

Emergency Department crowding and hospital bed shortage: is Lean a smart answer? A systematic review

OBJECTIVE

Emergency Departments (EDs) worldwide face the challenges of crowding, waiting times, and cost containment. This review aims to provide a synthesis of the current literature focused on how Lean Thinking Principles and tools can be applied in an ED to address overcrowding and hospital admissions.

MATERIALS AND METHODS

Primary studies showing Lean interventions and implementation in ED visits, not requiring additional resources measuring specific outcomes (i.e. length of stay, patient volume, patient satisfaction, waiting times for the first visit, waiting times for diagnostic results, left without being seen) were selected. PubMed, Scopus, CINAHL, EconLit, NHS Economic Evaluation Database, Business Sources Complete, and Health Technology Assessment were used to conduct searches. Full-text articles of all potentially relevant publications were reviewed for eligibility. Discrepancies were resolved through discussion by all reviewers. Quality assessment and critical appraisal of selected studies were also evaluated by applying the Quality Improvement Minimum Quality Criteria Set.

RESULTS

Nine before-and-after studies met these eligibility criteria. Management of patient flow was the main intervention. Almost all studies showed EDs performance improvement: increased patient volume, decreased length of stay and number of patients left without being seen, reduced costs, and increased patient satisfaction. Only one case reported worse results after Lean intervention implementation.

CONCLUSIONS

Though Lean Principals have been used in healthcare for many years conclusion of their effects could still not be drawn. Surely, human-centered approach, top management support, work standardization, resources allocation and adaptation to the local context seem to be crucial for success. Furthermore, higher quality studies are needed: specific research design, appropriate statistical tests and outcome measures are needed. Before large-scale implementation, further studies are needed to evaluate the true ability of Lean interventions to improve healthcare delivery.

Epidemiology of essential hypertension: the role of genetic polymorphism

Over the past 20 years, the interest of the scientific community was increasingly placed in the field of genetic epidemiology and molecular genetics of blood pressure control. This paper explores references related to essential hypertension, gene and genetic epidemiology indexed in the MedLine health science database during the period 1980-2001. A systematic literature search was performed using selected keywords, such as 'genetic', 'genome' or a combination of words. We considered the study heading and evaluated the time profile of published articles. A total number of 3116 publications was collected and analyzed. Allelic distribution for the most studied polymorphisms of the renin-angiotensin system in different world populations was reviewed and reported together with a detection of their frequency in Italy: essential hypertensive patients (n = 90), healthy unrelated subjects (n = 300). Molecular variants at angiotensinogen (M and T), angiotensin II type 1 receptor (A and C) and angiotensin-converting enzyme (D and I) genes were analyzed by amplified fragment length polymorphism. A significant association was detected by chi2 analysis for angiotensinogen and angiotensin II-type I receptor allele distribution in hypertensive patients, in accordance with previous reports. Genetic data and methods are contributing more and more to epidemiological studies of complex diseases, and their application is influenced by information availability and Genome Project results.