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ABSTRACT: BACKGROUND: Coronary heart disease is the leading cause of mortality in the world. One of the outcome indicators recently used to measure hospital performance is 30-day mortality after acute myocardial infarction (AMI). This indicator has proven to be a valid and reproducible indicator of the appropriateness and effectiveness of the diagnostic and therapeutic process for AMI patients after hospital admission. The aim of this study was to examine the determinants of inter-hospital variability on 30-day in-hospital mortality after AMI in Tuscany. This indicator is a proxy of 30-day mortality that includes only deaths occurred during the index or subsequent hospitalizations. METHODS: The study population was identified from hospital discharge records (HDRs) and included all patients with primary or secondary ICD-9-CM codes of AMI (ICD-9 codes 410.xx) that were discharged between January 1, 2009 and November 30, 2009 from any hospital in Tuscany. The outcome of interest was 30-day all-cause in-hospital mortality, defined as a death occurring for any reason in the hospital within 30 days of the admission date. Because of the hierarchical structure of the data, with patients clustered into hospitals, random-effects (multilevel) logistic regression models were used. The models included patient risk factors and random intercepts for each hospital. RESULTS: The study included 5,832 patients, 61.90% male, with a mean age of 72.38 years. During the study period, 7.99% of patients died within 30 days of admission. The 30-day in-hospital mortality rate was significantly higher among patients with ST segment elevation myocardial infarction (STEMI) compared with those with non-ST segment elevation myocardial infarction (NSTEMI). The multilevel analysis which included only the hospital variance showed a significant inter-hospital variation in 30-day in-hospital mortality. When patient characteristics were added to the model, the hospital variance decreased. The multilevel analysis was then carried out separately in the two strata of patients with STEMI and NSTEMI. In the STEMI group, after adjusting for patient characteristics, some residual inter-hospital variation was found, and was related to the presence of a cardiac catheterisation laboratory. CONCLUSION: We have shown that it is possible to use routinely collected administrative data to predict mortality risk and to highlight inter-hospital differences. The distinction between STEMI and NSTEMI proved to be useful to detect organisational characteristics, which affected only the STEMI subgroup.
BMC Medical Research Methodology 11/2012; 12(1):170. · 2.67 Impact Factor
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ABSTRACT: To analyze physical restraint use in an Italian acute psychiatric ward, where mechanical restraint by belt is highly discouraged but allowed.
Data were retrospectively collected from medical and nursing charts, from January 1, 2005, to December 31, 2008. Physical restraint rate and relationships between restraints and selected variables were statistically analyzed.
Restraints were statistically significantly more frequent in compulsory or voluntary admissions of patients with an altered state of consciousness, at night, to control aggressive behavior, and in patients with "Schizophrenia and other Psychotic Disorders" during the first 72 hr of hospitalization.
Analysis of clinical and organizational factors conditioning restraints may limit its use.
Perspectives In Psychiatric Care 04/2012; 48(2):95-107. · 1.30 Impact Factor
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ABSTRACT: This study, carried out in the context of a collaborative care program for common mental disorders, is aimed at identifying the predictors of Primary Care Physician (PCP) referral to Community Mental Health Center (CMHC) and patterns of care. Patients with depression or anxiety disorders who had a first contact with CMHCs between January 1, 2007-December 31, 2009 were extracted from Bologna Local Health Authority database. A classification and regression tree procedure was used to determine which combination of demographic and diagnostic variables best distinguished patients referred by PCPs and to identify predictors of patterns of care (consultation, shared care, and treatment at the CMHC) for patients referred by PCPs. Of the 8570 patients, 57.4% were referred by PCPs. Those less likely to be referred by PCPs were living in the urban area, suffered from depressive disorder, and were young. As to the pattern of care, patients living in the urban area were more likely to receive shared care compared with those living in the nonurban area, while the reverse was true for consultation. Predictors of CMHC treatment were depression and young age. Prospective studies are needed to assess length, quantity, and quality of collaborative treatment for common mental disorder delivered at any step of care.
International journal of family medicine. 01/2012; 2012:507464.
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Ilaria Tarricone,
Elisa Stivanello,
Silvia Ferrari,
Niccolò Colombini,
Emilio Bolla,
Mauro Braca,
Cinzia Giubbarelli,
Chiara Costantini,
Sara Cazzamalli, Stefano Mimmi,
Dario Tedesco,
Marco Menchetti,
Marco Rigatelli,
Elisa Maso,
Matteo Balestrieri,
Simone Vender,
Domenico Berardi
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ABSTRACT: Many studies indicate that migrants in western countries have limited access to and low utilization of community mental health centres (CMHCs) despite the high prevalence of mental disorders.
We aimed to compare migrant pathways to care across four CMHCs located in different Italian provinces and to identify pathway to care predictors.
Migrants attending the four CMHCs between 1 July 1999 and 31 December 2007 were included in the study. Data were gathered retrospectively from clinical data sets and chart review.
Five hundred and eleven (511) migrants attended the four CMHCs, 61% were referred by GPs or other health services and 39% followed non-medical pathways to care (self-referral or through social and voluntary organizations), with important site variations. Younger age and being married were predictors of medical pathways to care; lacking a residence permit and having a diagnosis of substance abuse were related to non-medical pathways.
Pathways to CMHCs are complex and influenced by many factors. Non-medical pathways to care seem to be frequent among migrants in Italy. More attention should be paid to developing psychiatric consultation liaison models that also encompass the social services and voluntary organizations.
International Journal of Social Psychiatry 08/2011; 58(5):505-11. · 1.15 Impact Factor
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ABSTRACT: The growing burden of chronic diseases encourages health care systems to shift services and resources toward primary care. In this sector, general practitioners (GPs) play a key role, and several collaborative organizational models have been implemented in the attempt to improve the clinical effectiveness of GPs, their adherence to evidence-based guidelines, and their capacity to work in multiprofessional teams. However, evidence of the impact of different organizational models is sparse, and little is known about the contribution of these models to the good management of chronic diseases.
The aim of this study was to examine the relationship of individual sociodemographic characteristics of GPs and collaborative organizational models with the adherence of physicians to evidence-based guidelines for four major chronic diseases (diabetes, heart failure, stroke, and post-acute myocardial infarction).
Evidence-based indicators for the management of the selected chronic diseases were identified on the basis of the most recent international guidelines. Multilevel logistic regression models were used to identify the correlates of adherence to guidelines, taking into account patient characteristics and comorbidities.
Participation in group practice was associated with different indicators of adherence to guidelines for the management of diabetes and one indicator of post-acute myocardial infarction, whereas other organizational arrangements were linked to GPs' clinical behavior to a lesser degree. Female gender and younger age of GPs were associated with good management of diabetes.
The relative impact of efforts at organizational design in primary care should be evaluated in more detail before further investments are made in this direction. Our findings suggest that the professional attitude of GPs (of which gender and age can be considered proxies) is equally, if not more, important than their organizational arrangement. Hence, attention should be paid to how organizations and managerial tools can support the consolidation and spread of this attitude.
Health care management review 06/2011; 37(1):67-76. · 1.30 Impact Factor
