Impact of the Multidisciplinary Cancer Team on the Diagnostic and Therapeutic Care Pathway of Early Breast Cancer Patients and Perception of Team Members: The Experience of a Cancer Centre in Italy

Literature on the role of multidisciplinary team (MDT) in cancer is still controversial. We aimed to investigate MDT impact on a panel of indicators in breast cancer care in a single-center retrospective study performed in a Cancer Reference Center in Italy. We analysed the diagnostic and therapeutic care pathway (DTCP) of 266 early breast cancer patients managed by our MDT during 2019-2020. Process indicators reflecting the change of the diagnostic and therapeutic care pathways occurred after the MDT discussion were computed. Further, the performance of some quality care indicators in breast cancer care since the establishment of the MDT activity and the breast cancer MDT members' perceptions were also investigated. According to our study, the MDT approach improves breast cancer management by increasing the completion of staging and by encouraging neo-adjuvant treatment and an appropriate and faster surgery. In MDT members' perspective it also improves decision-making and training and creates a positive work environment. Globally, our study encourages MDT rollout in breast cancer care. However, to enhance the reliability and comparability of the results of studies investigating MDT effectiveness in clinical practice, shared guidelines on its operationalisation are strongly desirable.

Do newly arrived migrants represent a COVID-19 burden? Data from the Italian information flow

Background

Migrants who reach host countries irregularly are often perceived as increasing the COVID-19 burden. Italy is a transit and destination country for migrants who cross the Central Mediterranean route. During the pandemic, all migrants who disembarked on the Italian shores have been COVID-19 tested and quarantined. To investigate the incidence of SARS-CoV-2 infection in this population, the INMP, together with the Italian Ministry of the Interior, set a specific information flow collecting data about the infection and possible outcomes.

Methods

The observation period was from January 2021 to January 2022. COVID-19 tests used were molecular and antigenic. Positive cases detected both at the arrival and during the quarantine period, have been registered on an ad hoc INMP online platform. Migrants’ SARS-CoV-2 incidence rate (per 1,000) - with 95% CI - was therefore calculated. The Incidence Ratio (IR) was used to compare the migrants’ incidence rate with that of the resident population in Italy, in the same period and corresponding age group.

Results

Among 70,512 migrants (91% males and 9% females, all <60years old) who landed in Italy during the observation period, 2,861 tested positive, with an incidence rate of 40.6 (39.1-42.1) cases per 1,000. In the same period, an incidence rate of 177.6 (177.5-177.8) has been recorded in the resident population, with an IR of 0.22 (0.22-0.23). 89.9% of cases were males and almost half (49.6%) belonged to the age group 25-39years old. 99% of cases reported no symptoms, no relevant comorbidity has been reported and no cases have been hospitalized.

Conclusions

Our findings clearly highlight the low rate of SARS-CoV-2 infection in migrants reaching Italy by sea with an incidence rate that is roughly a quarter of that of the resident population, encouraging the opportunity to investigate the reasons for such an observation. Moreover, our study confirms the “healthy migrant effect” in migrants reaching Italy by sea.

Key messages

Implementation of resilience training programmes in children and adolescents: value and barriers

Background

Emotional distress increasingly represents a major burden in children and adolescents (C&A), especially in conflict zones where its prevalence is estimated to reach 70%. Resilience training programmes (RTPs) are interventions that seek to enhance resilience in individuals or groups pursuing mental distress prevention. Literature suggests RTPs be particularly effective in C&A; however, their effectiveness and value for public health are still unclear.

Methods

A scoping review was performed in order to summarize evidence regarding the implementation and effectiveness of RTPs in children and adolescents. A search string has been built according to the PICO model and launched on PubMed, PsycInfo, Academia databases. Additional references were identified by a hand-search in Google Scholar. Studies included were narratively summarized according to topics that emerged.

Results

18 articles were finally included in the review. Main issues were 1) RTPs seem to be more effective in adolescents rather than in children; 2) COVID-19 pandemic has raised the attention towards RTPs in C&A; 3) beyond conflict zones their implementation is increasingly recognized in supporting C&A management of daily stressors and traumas also in C&A with disabilities; 4) school is identified as the key setting for RTPs; 5) the high heterogeneity in RTPs approaches, contexts and study samples limits a conclusive effectiveness assessment.

Conclusions

Our findings highlighted how RTPs are increasingly recognized as a tool to improve C&A cognitive and behavioral functioning and resilience to external stressors, getting greater interest in the COVID-19 pandemic. Despite relevant theoretical support and promising study results, RTPs still lack strong evidence supporting their embracement by policymakers and effective implementation in public health policy. In order to not miss this chance, more efforts are needed in strengthening RTPs conceptualization and cost-effectiveness studies.

Key messages

• RTPs are a promising tool to enhance the resilience of children and adolescents gaining increasing interest due to the COVID-19 pandemic.

• More studies are needed to provide a strong evidence base that supports their acknowledgment by policymakers and their implementation in public health policies.

The Italian Roma, Sinti and Travellers Health Project for equity in access to care

Issue

In 2015, Italy approved the National Action Plan for Health for and with Roma, Sinti and Travellers (RSC); however, it is still not fully applied at a local level. The INMP (funded by the National Operational Programme for Social Inclusion), implemented the “Health Project - Promotion of strategies and tools for equity in access to health care for RSC”, aimed to support the implementation of the Plan by Local Health Authorities (ASL).

Description

The project lasted from March 2019 to December 2021. INMP worked with 7 ASL to design interventions and develop tools to address RSC health needs. The SODA (Strategic Options Development and Analysis) method as a participatory process aimed at identifying strategies and models for the execution of the Plan among relevant stakeholders was used. Moreover, RSC communities’ engagement strategies and a community-based Proximity Public Health (PPS) approach were adopted in designing and developing health promotion interventions.

Results

INMP performed 38 interviews with ASL health operators highlighting barriers and strategies in the local implementation of the Plan. Tools orienting to social and health services and health education materials for hard-to-reach groups were produced. A training course for 14 RSC facilitators and 5 training courses attended by over 200 NHS operators have been organized. ASL were supported in developing health promotion initiatives, based on the engagement of both local RSC communities and third sector entities.

Lessons

The project has enabled the ASL to develop local protocols for the implementation of the Action Plan. In line with this capacity-building activity, the project trained both health operators and RSC facilitators fostering the dissemination of the PPS culture in designing and providing care for hard-to-reach groups. Given the positive results obtained, INMP is still collaborating with both ASL and the Third Sector on additional activities related to the Project in 2022.

Key messages

COVID-19 and religion: evidence and implications for future public health challenges

Background

Religious and cultural beliefs strongly influence people's attitudes and behaviors that, in turn, may positively or negatively affect both individual and public health. In this regard, we aimed to collect and analyze evidence on the impact of religion in the current COVID-19 pandemic.

Methods

We performed a scoping review investigating both scientific and grey literature available on the topic from the onset of the pandemic to September 2021. Pubmed, Web of Science and Google Scholar were investigated and a hand-search on Google was also performed. Studies dealing with religion and COVID-19 were included and narratively summarized according to topics.

Results

46 articles were included in the review. Predominant topics emerged were 1) religious pilgrimages and rituals worldwide being relevant to COVID-19 outbreaks, especially in the first pandemic wave 2) difficulties to engage the Closed Religious Communities (e.g. Haredi, Amish, etc.) in which community way of life, restrictions in using media and resistance to comply to preventive measures were identified as significant COVID-19 risk 3) COVID-19 unofficial treatments and vaccine hesitancy also supported by concerns on the religious acceptability of vaccine composition or firm interpretation of the Ramadan fasting 4) a fuel of religious discrimination 5) religious communities and leaders strongly trusted in conveying COVID-19 information.

Conclusions

Our findings highlighted how religion has represented both a risk for the spreading of the virus and a precious opportunity to convey evidence-based and culturally-sensitive COVID-19 information engaging people in fighting the pandemic. To be prepared for similar future challenges, scientists, politicians and health professionals need to acknowledge the role that culture and religion have in influencing people's lives to design specific health policies and strategies to ensure that all people are effectively engaged in health production and protection.

Key messages

Support Asylum and Vulnerabilities through e-health: SAVe as a healthcare continuity tool

Issue

Migrants and refugees (M&Rs) could present different vulnerabilities and health conditions. The high geographical and setting mobility of migrants within the reception system as well as the legal and administrative variability can impact negatively the continuity of care of eventual vulnerabilities and diseases.

Description of the practice

The Italian National Institute for Health Migration and Poverty developed an IC platform to take care of migrant's health over its migration pathway in the hosting country. SAVe guarantees both the health assessment at the border and the following steps of clinical care. It offers specialized tools guiding health professionals to evaluate M&Rs' vulnerabilities as well as infectious and chronic diseases. The electronic system is compliant with the EU-GDPR and includes validated tools such as the WHO (Five) WBI, the EASO tool for special needs identification, the Italian guidelines on Border health checks and the Italian protocol for the unaccompanied minors' age assessment.

Results

The system is being implemented in 4 Italian Regions, where over 28,000 migrants are hosted in reception structures and is expected to be used in the whole Italian reception system. The migrant person is also given the opportunity to save, store and use his health records even in case of relocation to another country.

Lessons

SAVe is turning out as an innovative tool to evaluate vulnerabilities and health of M&Rs who are present in Italy. The use of validated and evidence-based tools improves the confidence of doctors in detecting vulnerabilities and social determinants of health. Its spread at National level is expected to guarantee the continuity of care. Further, the interoperation between SAVe and the National Health File would allow health data collection from the first arrival of migrant until its full integration in the country.

Key messages

SAVe is designed to evaluate comprehensively the health of M&Rs, increase the continuity of care and optimize the healthcare resources. Its socio-health and evidence based approach encourages the use as a benchmark for health data collection and health information sharing.

Managing the pandemic in the reception system for migrants: the Italian experience

Issue

Italy represents a well-known European transit and destination country for Migrants and Refugees (M&Rs) with more than 77.000 migrants currently hosted in the reception system. Pandemic did not impact the M&Rs' influx with more than 30.000 disembarked in 2020. In line with the WHO and international organizations alerts to protect the health of M&Rs, Italy included M&Rs in its pandemic response.

Description of the practice

With the mandate of the Ministry of Health and thanks to the collaboration with the Ministry of the Interior and other institutional and governmental bodies, the Italian National Institute for Health, Migration and Poverty developed a comprehensive strategy to protect M&Rs' health in Italy during the COVID-19 pandemic, either into the reception system and outside.

Results

Interim evidence - based operating procedures including instructions regarding the early detection and the management of potential suspected and confirmed COVID-19 cases, from the first arrival throughout the entire reception system path, have been published. A national survey on the incidence of COVID-19 cases in the reception system has been performed in 2020. Dedicated information flows on the incidence of COVID-19 cases at the arrival in Italy and in the reception system and a periodic monitoring of the implementation of the afore-mentioned operating procedures have been established in 2021. Data collected have shown a daily mean incidence ratio lower for migrants hosted in the reception system than for the general population, as well as the same regarding the new COVID-19 cases among newly arrived migrants.

Lessons

The strategy adopted was found to be effective in protecting M&Rs' health during the pandemic. In particular, the Italian reception system has globally shown a good performance in limiting the COVID-19 spread. Moreover, the influx of newly arrived migrants did not represent an additional epidemiological risk in terms of burden of infection.

Key messages

The production of evidence-based procedures and the establishment of effective information flows have proved to be effective in managing and monitoring the pandemic in regards to M&Rs. The Italian reception system has turned to play as a protective factor in limiting the COVID-19 spread and the systematic screening of newly arrived M&Rs did not shown an additional COVID-19 burden.

Global health challenges: Are future physicians prepared? The results of a 4 years training experience

Background

Current health challenges are highlighting as Global Health (GH) is a discipline of growing importance for future physicians. Although its training is globally recommended, it has not universally entered the curricula of degree courses in Medicine and Surgery. A cycle of 6 seminars in global health has been promoted by researchers and public health residents of the Center for Research and Studies in GH of the Università Cattolica del Sacro Cuore (UCSC) in Rome, and offered for 4 consecutive years to medical students attending the UCSC.

Objectives and Methods

Main goal was increasing students knowledge and awareness in global health issues exploring their needs and perceptions about the impact of the topic on their future career. Two-hours frontal lessons held by experts and practical sessions (PBL) facilitated by promoters were planned on topics as determinants and inequalities in health, UHC, fragile and vulnerable population as migrants and victims of violence, SDGs, AIDS and emerging infectious diseases,international cooperation, maternal-child health. A pre-course, single event and post-course questionnaire was administered to participants.

Results

A mean of 48 students (± 15.7SD), 66.7% females, attending mainly the second(40.4%) and the third year (39%), joined each event. The analysis of the pre-course questionnaire has highlighted students' interest in healthcare inequalities, pandemics, migration, health in developing countries, healthcare systems. At the end, 92% of participants has considered the course interesting, 87% stated that the topic should be part of the degree course and 78% that it will influence their career. The methodology was considered adequate in 94% of cases underlining its strong incentive to work in team.

Conclusions

The strong interest of medical students in acquiring skills in global health seems to firmly encourage its inclusion and strengthening in study plans to prepare them properly to face the future challenges in health.

Key messages

Medical students consider the global health training relevant for their career encouraging its inclusion in the Medicine and Surgery curriculum. Practical sessions and team work could be useful tools to adequately train the future health workforce.

FRESHER and RARE 2030: scanning the horizon emerging trends in health and healthcare

Background

Health and healthcare are facing novel challenges ranging from broad, shifting trends to emerging innovative technologies and social practices. Foresight methodology aims to analyse emerging trends, building different future scenarios and identifying policy options to support the policy dialogue.

Methods

FRESHER and RARE 2030 are two EU-H2020 projects. FRESHER- FoRESight for hEalth policy development and Regulation (2016-2018) aimed at representing long term alternative health Scenarios testing future policies to tackle the burden of Non-Communicable Diseases. A micro-simulation model, specifically enhanced by the project, also computed the health outcomes of the different four Scenarios. Rare 2030-Foresight in Rare Diseases Policy (2019-2020) uses a participatory approach to identify the most relevant trends, anticipate their influence over the next decade and propose policy recommendations that could lead to a better future for people living with Rare Diseases. Different in scope, these projects share common features. Both follow a four steps foresight methodology: horizon scanning, trends identification and ranking, scenarios building, back-casting and policy elaboration. Taking a participatory approach, these studies apply structured qualitative tools, involve a wide range of stakeholders and include regional case studies.

Results

20 trends emerged as key for the future of health and healthcare, among them: demographic change, rise of inequality, urbanisation, climate change and low carbon development, innovation in medicine, citizens empowerment and the potential for big data and Artificial Intelligence application.

Conclusions

The 20 trends analysed offering a litmus test for future proofing current health and healthcare policies. Foresight has proven to be a valid methodology to gather collective intelligence for identifying emerging trends and scenarios, evaluating risks and opportunities, setting long term goals and helping the decision making in health.

Key messages

To promote a transition toward better health policies, it is crucial supporting the collaborative attitude and ensuring a greater involvement of citizens and patients in the decision making. The importance and unpredictability recognized to the equity trend in both projects reveals the need for urgent actions to ensure the future access to better health and care to all European citizens.

Paying attention to personnel in organizational changes: the impact of hospital mergers

Background

The importance of paying attention to personnel satisfaction for the well-being of an organization is clearly stated also in healthcare organization. The trend of mergers of healthcare organizations represents an evident case of organizational change that could undermine personnel satisfaction if not adequately managed. The aim of our study was to investigate the impact of hospital merger on personnel perceptions and satisfaction.

Methods

A systematic review of the literature was carried out by querying scientific databases and grey literature. A search string was built using keywords including: merger, healthcare, personnel, satisfaction and synonyms. Inclusion criteria were primary studies reporting the outcome of interest and set in hospitals that has undergone a merger. Studies characteristics such country setting, design and time frame of the study, number and role of personnel interviewed and main findings were extracted and narratively synthesized.

Results

Search resulted in 3662 studies of which 9 were finally included in the analysis. Studies were mainly represented by post-merger qualitative research (77.8%) of which 55.6% semi and 54.4% structured interviews. Sample size ranged from 14 to 3119 and was represented by unspecified employees (55.6%), nurses and hospital executives (22.2% both). Findings showed that hospital executives consider merger positively especially regarding increased negotiation skills and costs reduction. Conversely, the other personnel mainly expressed critical issues as differences in organization of hospitals merged, goals and confirmation uncertainty, communication impairment and especially no involvement in follow-up in the post-merger phase.

Conclusions

The merger process strongly impacts healthcare personnel satisfaction, depending on the role played in the organization. If an initial enthusiasm and staff engagement in pre-merger phase is seen, this is not generally followed by their proper involvement over time.

Key messages

As personnel satisfaction and perceptions are strongly related to healthcare quality, they represent a central point in the merger process of healthcare organization. More attention must be paid to follow-up staff satisfaction after the merger in a continuous staff engagement to ensure the success of merger process as well as that of all organizational changes.

Migrants and access to healthcare: the Italian public health residents action plan

Background

Fighting health inequalities have been included in the WHO Sustainable Development Goals as a priority. Migrants are between the most vulnerable individuals and healthcare interventions, also during the post-migration period, should be oriented, context-specific and aimed at identifying reasons underlying inequalities, as suggested by the recent WHO report ’No public health without migrant health’. The “Inequality Working Group” of the Italian network of public health (PH) residents of the Italian Society of Hygiene, Preventive Medicine and Public Health (SItI) aims at identifying an interdisciplinary approach suitable to detect barriers to healthcare access for migrants in different Italian regions. Secondly, we aspire to develop some strategies to overcome unequal healthcare access.

Methods

Focus group methodology was applied to set working group educational needs, priorities of action and working plan. Moreover, we implemented a network between various professionals involved in migrant healthcare, particularly with the Regional Groups of the Italian Society of Migration Medicine (SIMM).

Results

After a period of peer-to-peer education about social determinants of health and migration, we reviewed Italian policies about migrants’ healthcare and considered potential discrepancies from WHO recommendations. Furthermore, we mapped practices regarding access to care for migrant population and we focused on causes underlying unequal healthcare access.

Conclusions

Although with regional differences, migrants have limited access to healthcare services and therefore represent a vulnerable subpopulation.

Key messages

Fighting against the barriers that limit access to care for migrants is a priority for health systems. PH residents have a relevant role in identifying and defining critical issues, designing enforcement measures and implementing advocacy actions.

Facing climate change challenges: the Italian Public Health Residents response

Background

Climate change (CC) is one of the most important global issues, and exerts a strong impact on public health (PH). Correlation between CC and PH is a matter of concern in the whole scientific community and requires an interdisciplinary approach. Nevertheless, the need to take action on CC sometimes contrasts with national and local policies, involved professionals’ training and citizens’ education. In order to face these challenges, the Italian network of public health residents “Consulta Specializzandi” of the Italian Society of Hygiene, Preventive Medicine and Public Health (SItI) decided to create a specific working group.

Objectives

Main objectives are education of PH residents and practitioners on CC, argument disclosure among the SItI and creation of interdisciplinary networks to promote and extend group activities. Secondary objective is development of a study to identify the gap between scientific evidence, recommendations and guidelines, and the European, national and local policies, with the aim of promoting bottom-up researches and good practices in CC management.

Results

The group was created in January 2019; activities started in March. Firstly we defined priorities and work mode. Then we analyzed scientific evidence and promoted self-training on the link between environment and CC and on the impact of CC on individual and public health. Finally, through attendance at workshops and scientific events, we began to train other PH residents and practitioners and started to create networks with other scientific societies, research centers and foreign academies, in order to promote international research, advocacy and disclosure between different institutions regarding the relationship between CC and PH.

Conclusions

The group has already partially achieved its main objectives, especially increasing awareness and training in CC and related issues. Further activities will permit to strength interdisciplinary networks and to move to secondary objectives.

Key messages

CC severely impacts society. Yet there is no widespread feeling of urgency to act towards its causes and consequences. A change in mindset is mandatory, from individual citizens to decision makers. PH residents and practitioners must be the main actors in training and education, advocacy, disclosure and network creation in CC research and management.

The effect of multifactorial lifestyle interventions on cardiovascular risk factors: a systematic review and meta-analysis of trials conducted in the general population and high risk groups

Cardiovascular diseases (CVDs) are the leading cause of premature mortality and disability accounting for one third of all deaths worldwide with considerable impacts on economics and on the quality of life. The evidence suggests that a multifactorial lifestyle intervention might have a role in the CVDs risk reduction, especially in the risk populations, nonetheless the effects on modifiable CVDs risk factors have not been completely explored. Our work aimed at evaluating the impact of multifactorial lifestyle interventions on cardiovascular risk modification, both in the general and risk population. A systematic review and meta-analysis of the randomized controlled trials (RCTs) were performed by including articles published up to April 16th, 2016. RCTs were selected if they had investigated the impact of multifactorial lifestyle interventions on lipids, blood pressure, BMI and waist circumference, smoking and physical activity. Changes in the level of modifiable risk factors from baseline were evaluated. Search resulted in 19,847 studies, of which 36 were included in the analysis. Compared to a usual care, the multifactorial lifestyle intervention is able to lower the blood pressure, total cholesterol, BMI and waist circumference, at both 6 and 12months, and to increase physical activity at 12months. Better results were obtained in primary prevention and in moderate and high risk groups. Multifactorial lifestyle interventions clearly represent a valid tool for reducing the cardiovascular risk factors and should be implemented in the risk groups and in primary prevention.