[Regional autonomy in health already exists and it produces inequality.].

In Italy an institutional reform is underway which includes an uneven power shift from the central government to the local regional authorities. Amid growing concern about the impact of this reform on the equality of individual rights and the balanced development of the country as a whole, the health system could possibly exemplify the effects of regional autonomy, since health care was largely regionalized in 2001 through a selective change of the Italian constitutional law. Twenty years later, according to the results of this study, very large differences exist among regions in per capita health expenditures, up to a 40% gap between the highest spending region (Emilia-Romagna) and the lowest (Calabria).

[Specialists, generalists and the importance of people.].

The health systems of developed countries are now made by specialists and specialties and the resulting fragmentation of competences makes it increasingly difficult to consider the patient/person as a whole. An orchestra director is needed, a generalist, however generalists are a few and are generally confined to primary care. Perhaps hospital generalists should be introduced and a new training model for the generalist should be devised.

[The integration between clinical care and population health is a priority for the health system.].

Between the end of the 19th and the beginning of the 20th century the growth of scientific knowledge made it possible a wider understanding of disease mechanisms and promoted multiple government actions in several countries to improve urban hygiene, to ameliorate living conditions, and to enrich daily nutrition in order to better population health. However, during a few following decades, research progress and industrial development induced radical changes in medicine as new diagnostic tools and effective treatment capabilities became available to be administered to single patients for specific ailments. The individualized nature of these novel interventions rapidly took their control away from the public sphere into the domain of multiple bilateral relationships between patient and physician.

[The tale of illness and illness as a tale.].

The practice of medicine is something different from the knowledge of disease mechanisms and cannot be performed without the relationship with the patient. Nothing new: in 1927 - when medicine already seemed to be receiving an extraordinary boost from technology - Francis Peabody emphasised the importance of considering the patient «at the centre of his home, his work, his relationships and friends, his joys and sorrows, his hopes and fears». In the same years, Virginia Woolf came to similar conclusions but reversed the point of observation.

[To understand and to act the complexity of the health system.].

Complexity can be rigorously defined to become a major instrument for interpreting organizations, including health care systems. Complexity analysis tools can effectively describe the adaptive capacity, the intrinsic interdependency, and the autonomous transformation drive of health systems. Therefore, a study of health care organizations as complex adaptive systems (Cas) provide useful keys to understand their functioning and to manage effectively their ongoing changes.

[Effectiveness and efficiency: has the time come?].

The different attitude of health professionals and health system administrators towards efficiency and effectiveness reveals an inner health systems tension between the logic of producing and that of caring. This tension entails the risk of dire consequences for universalist health protection systems, as it pushes towards a dissociation in which care relationships are privatized, to safeguard them from the constraints of efficiency, while forms of access inequality are generated. However, efficiency in the production of health does not mean cuts but quality of care and quality in operational choices.

GRADE EVIDENCE TO DECISION (EtD) FRAMEWORK FOR COVERAGE DECISIONS.

Objectives: Coverage decisions are decisions by third party payers about whether and how much to pay for technologies or services, and under what conditions. Given their complexity, a systematic and transparent approach is needed. The DECIDE (Developing and Evaluating Communication Strategies to Support Informed Decisions and Practice Based on Evidence) Project, a GRADE (Grading of Recommendations Assessment, Development and Evaluation) Working Group initiative funded by the European Union, has developed GRADE Evidence to Decision (EtD) framework for different types of decisions, including coverage ones.

[DECIDE: developing and evaluating communication strategies to support informed decisions and practice based on evidence].

Healthcare systems are offered with a wide range of technologies and services, but they have to cope with decreasing resources and the uncertainty about what is effective and more appropriate. Making decisions about health care interventions is complex. Decisions should be informed by the best available evidence, being comprehensive to take into account all the relevant aspects (e.

[LARS Research Project. Nursing Research Laboratory of the Health Regional Agency of the Friuli Venezia Giulia Region. Observational study on the outcomes of organizative models of medical wards on nurses, patients and organization].

Unlabelled: No large scale studies have been conducted in Italy to assess factors that influence hospital nurses' satisfaction.

Aims: To explore the relationship between participative organizative models and outcomes on nurses (work satisfaction, burnout, intention to stay), patients (satisfaction with quality of care) and organization (nurses turnover).

Materials And Methods: This multicentre regional study involves 20 acute medical wards and more than 500 nurses.

[Functional recovery in post-acute rehabilitation: patient characteristics and treatment effect].

Objective: Most studies on the effectiveness of rehabilitation consider only particular rehabilitation treatments for particular conditions, and do not give a global vision of the issue. This study evaluated the effectiveness of various types of post acute rehabilitative care in patients with different diagnoses by investigating the association between treatments and functional gain by type of impairment and severity on admission.

Design, Setting And Participants: Information on the characteristics of patients and the rehabilitative treatments was collected using an Italian version of the Minimum Data Set-Post Acute Care.

Toward a new payment system for inpatient rehabilitation. Part II: Reimbursing providers.

Background: The major fault with existing reimbursement systems lies in their failure to discriminate for the effectiveness of stay, both when paying per day and when paying per episode of treatment.

Objectives: We sought to define an average length of effective stay and recovery trends by impairment category, to design a prospective payment system that takes into account costs and expected recovery trends, and to compare the calculated reimbursement with the predicted costs estimated in a previous study (Saitto C, Marino C, Fusco D, et al. A new prospective payment system for inpatient rehabilitation.

Toward a new payment system for inpatient rehabilitation. Part I: Predicting resource consumption.

Background: The measures of clinical status used to predict costs must pay the most attention possible to medical conditions and clinical complexity. Length of stay (LOS), which has been used as a proxy for resource consumption, is not a direct measure of costs. Classification and regression trees, which are used in defining iso-resource groups, can be affected by overfitting and are based on a priori choices of the splitting attributes.

Differences in access to coronary care unit among patients with acute myocardial infarction in Rome: old, ill, and poor people hold the burden of inefficiency.

Background: Direct admission to Coronary Care Unit (CCU) on hospital arrival can be considered as a good proxy for adequate management in patients with acute myocardial infarction (AMI), as it has been associated with better prognosis. We analyzed a cohort of patients with AMI hospitalized in Rome (Italy) in 1997-2000 to assess the proportion directly admitted to CCU and to investigate the effect of patient characteristics such as gender, age, illness severity on admission, and socio-economic status (SES) on CCU admission practices.

Methods: Using discharge data, we analyzed a cohort of 9127 AMI patients.

Diabetes management by hospital-affiliated diabetes centres in Lazio, Italy.

Background: In Italy, diabetes centres are considered to provide adequate care but little is known about their performance.

Methods: Inpatient and outpatient administrative databases were used to select and study a cohort of 2,568 diabetic patients. Adherence to guidelines and effect of patient characteristics and diabetes centre on treatment was assessed.

A follow-up analysis of transient ischemic attack patients suggests unsatisfactory disease management and possible underutilization of carotid endarterectomy in Lazio, Italy.

We evaluated the disease management of transient ischemic attack in patients admitted to Lazio hospitals from July 1997 to June 1998. We assessed the effects of patient characteristics including chronic comorbidities on the use of diagnostic procedures, endarterectomy, and on the risk of adverse cerebrovascular outcome or death. There were 2,608 patients in the study who were followed up over a 18- to 30-month period.

Outcome of patients with cardiac diseases admitted to coronary care units: a report from Lazio, Italy.

Background: Coronary care units (CCUs) currently treat a variety of diseases, but little is known about the effectiveness of CCUs on heart conditions other than acute myocardial infarction.

Objectives: The objectives of this study were to evaluate the association between direct admission to CCUs and the risk of inhospital death in patients with heart disease, to investigate factors affecting direct admission to a CCU, and to assess the effect of CCU admission on the use of invasive procedures in patients with arrhythmias.

Research Design: We conducted a retrospective analysis of discharge-abstract data from Lazio, Italy, hospitals.

[Supply of outpatient care in the Lazio region: geographic distribution and characteristics of outpatient clinics].

Outpatient care accounts every year for a large share of the National Health Fund spending, however characteristics of supply have not been thoroughly investigated. Objective of the study is the description of the outpatient care system of Lazio region and of the main characteristics of outpatient clinics, through indicators obtained using data from the Outpatient Care Information System (SIAS) for 1999. Outpatient clinics were classified into three categories: ASL managed clinics, private clinics and hospital trusts.