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The aim of this study is to assess the long term cost-effectiveness of a multi-component intervention for the prevention of frailty in the elderly.

The growing demand for referrals is a main policy concern in health systems. One approach involves the development of demand management tools in the form of clinical prioritization to regulate patient referrals from primary care to specialist care. For clinical prioritization to be effective, it is critical that general practitioners (GPs) assess patient priority in the same way as specialists. The progressive development of IT tools in clinical practice, in the form of electronic referrals support systems (e-RSS), can facilitate clinical prioritization. In this study, we tested if higher use of e-RSS or higher use of high-priority categories was associated with the degree of agreement and therefore consensus on clinical priority between GPs and specialists. We found that higher use by GPs of the e-RSS tool was positively associated with greater degree of priority agreement with specialists, while higher use of the high-priority categories was associated with lower degree of priority agreement with specialists. Furthermore, female GPs, GPs in association with others, and GPs using a specific electronic medical record showed higher agreement with specialists. Our study therefore supports the use of electronic referrals systems to improve clinical prioritization and manage the demand of specialist visits and diagnostic tests. It also shows that there is scope for reducing excessive use by GPs of high-priority categories.

Recently new opportunities are emerging for improving the way patients with Haemophilia A are treated. Among these opportunities, efmoroctocog alfa is a first-in-class recombinant factor VIII-Fc fusion protein (rFVIIIFc) produced by recombinant DNA technology with an extended half-life compared with conventional FVIII preparations. The available evidence coming from an Italian HTA report indicates that efmoroctocog alfa provides an effective alternative to conventional FVIII preparations (including standard rFVIIIs) for the management of Haemophilia A. Moreover, by reducing the frequency of injections required, it has the potential to reduce treatment burden, and hence improve adherence to prophylaxis and patient Quality-of-Life.

Objectives: Benefits of school attendance have been debated against SARS-CoV-2 contagion risks. This study examined the trends of contagion before and after schools reopened across 26 countries in the European Union. Methods: We compared the average values of estimated Rt before and after school reopening, identifying any significant increase with a one-sample t-test. A meta-analysis and meta-regression analysis were performed to calculate the overall increase in Rt for countries in the EU and to search for relationships between Rt before schools reopened and the average increase in Rt afterward. Results: The mean reproduction number increased in 16 out of 26 countries. The maximum increase in Rt was reached after a mean 28 days. We found a negative relationship between the Rt before school reopening and its increasing after that event. By 45 days after the first day of school reopening, the overall average increase in Rt for the European Union was 23%. Conclusion: We observed a significant increase in the mean reproduction number in most European countries, a public health issue that needs strategies to contain the spread of COVID-19.

Background: It is important to understand the role of schools in the community transmission of SARS-CoV-2, bearing in mind that children and adolescents can spread the infection within families, even when their own symptoms are mild. The aim of this study was to examine the trends of contagion before and after schools reopened across 27 countries in the European Union. Methods: All data on the number of people testing positive for COVID-19 in each European country were collected from 20 days before schools reopened to 45 days afterwards. The Joinpoint regression method was used to detect single change points on the trend of contagion. The Bayesian Information Criterion (BIC) was used for model selection purposes. Results: We calculated 27 linear regression models for the daily case numbers of SARS-CoV-2 infection in the 27 countries from 20 days before schools reopened to 45 days afterwards. A significant increase in the number of daily infections was seen for 21 countries after a change point in the linear regression lines. The change points in different countries varied, ranging from 10 to 42 days after schools reopened, with the majority occurring beyond the 21st day. Conclusion: This study analysed the trend of SARS-CoV-2 transmission before and after schools reopened in Europe. We observed a significant increase in the number of new daily cases in most countries. This issue poses a public health problem that needs to be taken into account in deciding strategies to contain the spread of COVID-19.

Objectives To estimate the cost-effectiveness of the public colorectal cancer screening program in the Abruzzo region, Italy. Methods Cost-effectiveness was analysed using a two-armed Markov model comparing: (1) Abruzzo screening program based on biennial faecal immunochemical occult blood testing, with colonoscopy as second level test for individuals with positive results, with (2) Treatment of symptomatic patients according to the stage of the neoplasm. Transition probabilities were adjusted for accuracy of tests and incidence of colorectal cancer. Diagnosis-related groups’ charges and field collected data were used to estimate costs. Costs and benefits were discounted by 3.5%. Monte Carlo simulation confirmed the robustness of the model results. Results Assuming a compliance rate of 64.7%, the incremental cost-effectiveness ratio for the current colorectal screening program was €433.06/quality adjusted life year gained, considerably lower than conventional thresholds (around €30,000). Conclusion Early detection and intervention programs help to avoid a large number of highly debilitating and expensive cancer treatments. These results show that the screening program currently implemented in Abruzzo should be considered as a good investment in health.

Since 2007, Italian regions running large deficits underwent recovery plans (Piani di Rientro) imposed by the central government. The goal was twofold: regions were asked (i) to restore a balanced budget and (ii) to continue supply the set of services defined by the constitution. We investigate whether recovery plans have reached their objectives. Our evidence suggests that recovery plans have proved to be an effective mechanism to eliminate subnational governments deficits. We also do not find any significant effects on health care utilization and on citizens' health. Overall, spending efficiency has likely improved.

Supplemental material, MSC898732 Appendix for Economic evaluation of colorectal cancer screening programs: Affordability for the health service by Silvia Coretti, Matteo Ruggeri, Rossella Dibidino, Lara Gitto, Andrea Marcellusi, Francesco Saverio Mennini and Americo Cicchetti in Journal of Medical Screening

The aim of this paper is to provide an empirical framework based on a discrete-time Markov chain to assess the costs and benefits of Performance Based Agreements (PBAs) for the reimbursement of pharmaceuticals. We provide an empirical testing using a case study referring to a treatment recently approved for reimbursement in Italy. The implementation of this framework is challenging for the agencies dealing with pricing and reimbursement decisions given the uncertainty associated with the treatment effectiveness and safety. On the other hand, empirical evidence shows that the awareness of the expected costs associated with different reimbursement schemes is necessary to inform decision-makers.

Major depression (MD) is a major cause of disability and a significant public health problem due to strong physical and mental impairment, possible complications for patients (including suicides), serious social and working problems to the patient and his/her family. We provide an overview of the social cost of Major depression worldwide. We conducted a systematic literature review. Two search engines were queried. Screening of records and summary of evidence was performed by two researchers blindly. The review was conducted in accordance with the standards of the PRISMA guidelines. Twenty studies met the inclusion criteria. Despite the heterogeneity in terms of population, setting and estimation techniques, the studies showed that the largest share of the burden of disease is represented by indirect costs. Among direct healthcare costs, inpatient care represents the most significant item, followed by outpatient care. The average total direct cost of depression ranges between €508 and €24 069, depending on the jurisdiction where the analysis was run and the range of cost items included. Indirect costs range between €1963 and €27 364. Evidence on the cost of MD in some countries is currently lacking. A deeper understanding of the drivers of the economic burden of disease is a crucial starting point for studies concerned with the cost-effectiveness of new treatment strategies.

Selective internal radiation therapy is a form of intra-arterial brachytherapy used to treat primary liver cancer and liver metastases. This article aims to provide an overview of the clinical, economic, organizational legal, social and ethical impact of selective internal radiation therapy using SIR-Spheres Y-90 resin microspheres in the treatment of patients with unresectable, liver-dominant metastatic colorectal cancer who are refractory to or intolerant of chemotherapy. A systematic literature review was performed by querying PubMed, Scopus, EBSCO, CRD and GIN. Two reviewers blindly screened the records retrieved against predefined inclusion/exclusion criteria. The selected studies where summarized following a simplified version of the EuNetHTA Core Model® 2.1. The studies included evaluated selective internal radiation therapy in first-line or further-line treatment and showed a good safety and tolerability profile and significant improvement in efficacy expressed as time to liver progression, progression-free survival and overall survival. Selective internal radiation therapy should be provided in specialized centres and administered by a multidisciplinary team. A hub-and-spoke network could be a viable option to guarantee access to this technology across jurisdictions. The lack of a specific diagnosis-related group tariff accounting for the cost of the device could be seen as the major obstacle to a fair diffusion of this technology. The economic evaluations currently available show the cost-effectiveness of this technology in the population under study. Selective internal radiation therapy using SIR-Spheres Y-90 resin microspheres appears to be a clinically effective and cost-effective option in the treatment of metastatic colorectal cancer patients who are chemotherapy refractory or chemotherapy intolerant.

Abstract Background: Stroke has a significant disease burden in terms of acute and long-term disability in Italy and throughout the world. Endovascular treatments for the management of a stroke event have been coupled in the past years with the possibility to mechanically remove the occlusion by means of specially designed thrombectomy devices, and their exclusive use showed levels of effectiveness in line with those of the existing pharmacological treatments. Objective: To assess the cost-effectiveness of mechanical thrombectomy (MT) with the Solitaire Revascularization Device (stent retriever) for the treatment of acute ischemic stroke (AIS) in patients with large vessel occlusions (LVOs), comparing MT plus intravenous tissue plasminogen activation (MT plus IV t-PA) vs IV t-PA alone, in Italy. Methods: A Markov model was used to simulate costs and benefits of MT plus IV t-PA and IV t-PA alone over a 5-year time horizon and considering the perspective of the Italian National Health Service (NHS). Results are reported in terms of Incremental Cost Effectiveness Ratio (ICER). Deterministic and probabilistic sensitivity analyses are carried out in order to test the robustness of the results. Results: Total costs of MT plus IV t-PA and IV t-PA alone are equal to €31,798 and €34,855, respectively. The MT allows incremental QALYs for 0.77, determining a dominant ICER. The utilities associated to the mRS health states are the parameters with the highest impact on the results. Multiway sensitivity analyses determined a 90% probability of dominance. Conclusions: MT plus IV t-PA for AIS patients with LVO is cost-effective from year 1 through year 3, and cost-saving from year 4 onward in the Italian context, achieving better results, both in terms of efficacy and in terms of resource consumption.

Background: Many European countries experience health workforce skill-mix changes due to population ageing, multimorbidity and medical technology. Yet, there is limited cross-country research in hospitals. Methods: Cross-sectional, observational study on staff role changes and contributing factors in nine European countries. Survey of physicians, nurses and managers (n = 1524) in 112 hospitals treating patients with breast cancer or acute myocardial infarction. Group differences were analysed across country clusters (skill-mix reform countries [England, Scotland and the Netherlands] versus no reform countries [Czech Republic, Germany, Italy, Norway, Poland and Turkey]) and stratified by physicians, nurses and managers, using Chi-squared, Mann-Whitney U and Kruskal Wallis tests. Results: Nurses in countries with major skill-mix reforms reported more frequently being motivated to undertake a new role (66.5%) and having the opportunity to do so (52.4%), compared to nurses in countries with no reforms (39.2%; 24.8%; p < .001 each). Physicians and nurses considered intrinsic motivating factors (personal satisfaction, use of qualifications) more motivating than extrinsic factors (salary, career opportunities). Reported barriers were workforce shortages, facilitators were professional and management support. Managers' recruitment decisions on choice of staff were mainly influenced by skills, competences and experience of staff. Conclusion: Managers need to know the motivational factors of their employees and enabling versus hindering factors within their organisations to govern change effectively. (C) 2018 Elsevier B.V. All rights reserved .

Objectives: Hospital-based health technology assessment (HB-HTA) is becoming increasingly relevant because of its role in managing the introduction and withdrawal of health technologies. The organizational arrangement in which HB-HTA activities are conducted depends on several contextual factors, although the dominant models have several similarities. The aims of this study were to explore, describe, interpret, and explain seven cases of the application of HB-HTA logic and to propose a classification for HB-HTA organizational models which may be beneficial for policy makers and HTA professionals. Methods: The study was part of the AdHopHTA Project, granted under the European 7th Framework Research Programme. A case study methodology was applied to analyze seven HB-HTA initiatives in seven countries, with collection of qualitative and quantitative data. Cross-case analysis was performed within the framework of contingent organizational theory. Results: Evidence showed that some organizational or “structural” variables, namely the level of procedure formalization/structuration and the level of integration with other HTA bodies at the national, regional, and provincial levels, predominantly shape the HB-HTA approach, determining a contingency model of HB-HTA. Crossing the two variables, four options have emerged: integrated specialized HTA unit, stand-alone HTA unit, integrated-essential HTA, independent group unit. Conclusions: No one-best-way approach can be used for HTA at the hospital level. Rather, the characteristics of HTA models depend on many contextual factors. Such conceptualization may aid the diffusion of HB-HTA to inform managerial decision making and clinical practice.

Chronic Hepatitis C virus (cHCV) is a major health issue worldwide. New effective direct-acting anti-viral (DAA) drugs such as the combination sofosbuvir/velpatasvir, represent an important turning point, given the high sustained virologic response (SVR) rates associated with their use.

Background. Despite improvements in blood donor selection and screening procedures, transfusion recipients can still develop complications related to infections by known and emerging pathogens. Pathogen reduction technologies (PRT) have been developed to reduce such risks. The present study, developed whithin a wider health technology assessment (HTA) process, was undertaken to estimate the costs of the continuing increase in the use of platelet PRT in Italy. Materials and methods. A multidisciplinary team was established to perform the HTA and conduct a budget impact analysis. Quantitative data on platelet use were derived from the 2015 national blood transfusion report and from the Italian Platelets Transfusion Assessment Study (IPTAS). The current national fee of 60 Euro per platelet PRT procedure was used to quantify the costs to the Italian National Health Service (INHS). The analysis adopts a 3-year time-frame. In order to identify the impact on budget we compared a scenario representing an increased use of PRT platelets over time with a control scenario in which standard platelets are used. Results. Progressive implementation of PRT for 20%, 40% and 66% of annual adult platelet doses could generate an increase in annual costs for the INHS amounting to approximately 7, 14 and 23 million Euros, respectively. Use of kits and devices suitable for the treatment of multiple adult platelet doses in one PRT procedure could lower costs. Discussion. In order to fully evaluate the societal perspective of implementing platelet PRT, the increase in costs must be balanced against the expected benefits (prevention of transfusion-transmissible infections, white cell inactivation, extension of platelet storage, discontinuation of pathogen detection testing). Further studies based on actual numbers of platelet transfusion complications and their societal cost at a local level are needed to see the full cost to benefit ratio of platelet PRT implementation in Italy, and to promote equal treatment for all citizens.