Care pathways are widely used as evidence-based clinical governance tools to enhance the quality of care of groups of patients with a specific clinical problem and optimize the use of resources. However, it is often the case that there are differences between the recommended care pathway and the actual clinical practice. Recently, Process Mining (PM) techniques, a family of data-driven techniques from computer science that uses logs (execution traces) of a system to reason about its underlying process, have been applied in the healthcare context to map and analyze real-world practice patterns. In particular, PM helps to discover and analyze the sequence of activities, to highlight variances and possible sub-optimal management of the clinical paths in order to improve care quality and reduce the inefficient allocation of resources. Using the breast cancer pathway as a case study example, this study aims to describe the application of PM to administrative healthcare data of public hospitals of the Tuscany Region (Italy) and to offer insights about strengths and limitations in data management, information creation, and interpretation to support decision-making. The study revealed variations in the management of breast cancer care pathways across different public healthcare providers and with respect to the recommended guidelines. Key findings include instances of service duplication, delays, and bottlenecks, particularly in the diagnostic phase. The analysis also highlighted variations in healthcare costs, driven by differences in the frequency and types of diagnostic exams or visits performed. The findings have practical implications for enhancing the efficiency and quality of breast cancer care and provide a practical example of how the methodology can be applied to other healthcare contexts for similar benefits.

Cancer became a chronic disease that could be managed at home. Homecare supported person-centred care, which was guided by the Picker Principles defining key elements for care delivery. The study aimed to explore and appraise the dimensions underlying cancer patients' and caregivers' experience and expectations with Home Cancer Care, adopting a person-centerd care framework. We carried out a scoping review of the literature using three databases, PubMed, Scopus, and WoS for a total of 703 articles. PRISMA guidelines were followed. 57 articles were included in the review. The extracted data were categorized according to the type of care (Palliative, Support, Therapeutic, Recovery after transplant, Rehabilitation), the target population (patients or caregivers), the study design, and the principles related to patients and caregivers’ experience, classified through the Picker framework. The most common type of care in the home setting was palliative care. According to the Picker Principles, most of the studies reported “Emotional support, empathy and respect,” followed by “Clear information, communication, and support for self-care,” as key consideration for both patients and caregivers. The findings from these studies indicate many positive experiences regarding treatments, services, and interactions with health professionals. Caregivers' needs were most frequently (29

Breast cancer poses a global burden, with thousands of women undergoing surgery annually. Recently, there's a growing acknowledgment of the importance of developing a patient-centered care, leading to increased interest in Patient-Reported Outcome Measures (PROMs): this, in the oncology setting, translates into the distribution of validated tools like the BREAST-Q survey, that is specifically designed for breast cancer patients. Using data collected through the BREAST-Q survey in the University Hospital of Pisa (Italy) between 2018 and 2022, this research explores the causal relationship between the quality of pre-operative information provided by the surgeon to the patient and the post-surgery patient satisfaction with the results after surgery. We employ Item Response Theory (IRT) models to estimate patient-level fulfillment with pre-surgery information and post-surgery overall satisfaction. Then, using estimated traits, we assess the causal effect of information quality on post-surgery breast satisfaction through an Exposure Response Curve (ERC), accounting for various individual pre-exposure characteristics.

OBJECTIVES:Breast cancer poses a global burden on individuals and healthcare systems, with millions of women undergoing surgery annually. Recently, there has been growing recognition of the importance of patient-centered care, leading to increased interest in patient-reported outcome measures. In oncology, this has translated into the use of validated tools, such as the BREAST-Q survey, which is designed for a range of breast surgery procedures, and it is specifically applicable in breast cancer. Using BREAST-Q data collected at the University Hospital of Pisa (Italy) between 2018 and 2022 from a sample of 482 women, this study explores the causal relationship between the preoperative information provided by the breast surgeon and patients' postsurgery satisfaction. METHODS:We use Item Response Theory models to estimate patient-level satisfaction with presurgery information and with breast outcomes. Using these estimated latent traits, we assess the causal effect of satisfaction with presurgery information on postsurgery breast satisfaction through an exposure-response curve, accounting for various preexposure individual characteristics. RESULTS:Findings show a strong, positive, and statistically significant causal relationship between preoperative information and postoperative satisfaction. CONCLUSIONS:In a healthcare landscape increasingly constrained by time and resources, healthcare organizations should note the causal link between communication and patient-reported outcomes and strive to create environments that support meaningful patient-centered interactions.

PURPOSE:The aim of this study is to describe the application of the Learning from Excellence (LfE) approach in supporting a learning-oriented use of performance measures and continuous quality improvement in breast cancer (BC) care. DESIGN/METHODOLOGY/APPROACH:Using a mix-method research, the BC pathway is evaluated among 12 Italian regions/autonomous provinces sharing the same Performance Measurement System. The study was conducted in three stages: (1) identification of the best performing geographical areas through quantitative evidence; (2) analysis of the best practices with qualitative methods; (3) professional engagement and quality improvement, and involvement of stakeholders. FINDINGS:In the quantitative phase, the performances of 50 geographical areas were analyzed, leading to the identification of two best performing areas. After the characterization of the organizational determinants featuring the best performers' practices, the professionals were involved through on-site workshops, implementing a learning-oriented use of performance measures, benchmarking and team reflexivity on performance results. The intervention implied the modelling and assessment of the best performers' pathways, complementing performance measures with experience-based information. The models of the two areas were compared and hypothesis of care improvement were discussed. Feedback, reflexivity, networking and culture reinforcement were enacted among all the network professionals. In the last stage, the results were publicly presented allowing all stakeholders to recognize and appreciate the collaborative effort produced for the care of BC women and, leveraging on the logic of benchmarking, the stakeholders where able to identify generable performance improvements. ORIGINALITY/VALUE:This study provides evidence about the potential benefits of implementing LfE as a total quality management practice for care pathways.

Healthcare systems plan their activities to achieve efficiency and effectiveness, without addressing environmental and social sustainability. This paper describes a new approach adopted in Italy to plan and deliver health prevention services in an inner area of the Tuscany region (in Italy) to guarantee proximity of care and environmental and social sustainability. The project examines the design and delivery of cancer screening programmes using a mobile screening unit to maximise social benefits while minimising environmental waste. A cost analysis was developed to estimate the difference in CO2 equivalent emissions, travel costs, and productivity losses, comparing the current screening programmes against the introduction of a comprehensive full-service mobile screening unit. The results indicate that the new service model reduces direct non-medical costs incurred by the population and improves environmental sustainability. This alternative can reduce, annually, over 95000 euros in terms of travel costs and productivity losses, as well as 35 tons of CO2-equivalent travel emissions for a population of 59000 inhabitants in a mountainous area with around 6000 people involved in the screening programme. The study supports the need to adopt a new planning methodology that considers environmental, social, and financial sustainability jointly in the provision of public health services in rural areas.

AbstractProviding timely and satisficing End-of-Life care (EOLC) is a priority for healthcare systems since aging population and chronic diseases are boosting the global demand for care at end-of-life (EOL). In OECD countries the access to EOLC is insufficient. In Italy, the average rate of cancer patients assisted by the palliative care (PC) network at EOL was 28% in 2021, with high variability in the country. Among the Italian regions offering the best coverages, Tuscany has a rate of about 40%, but intraregional variation is marked as well. The study aims to explore the delivery of EOLC to adult cancer patients in public facilities in the Tuscany region through survey data collection among professionals. Two online surveys were delivered to Directors of community-based PC Functional-Units (FUs) and Directors of hospital-based medical-oncology units. All FU Directors responded to the survey (n = 14), and a response rate of 96% was achieved from hospital-unit Directors (n = 27). The results highlight the availability of numerous dedicated services, but reveal heterogeneity among and within organisations, including variations in the professionals involved, pathways, and tools adopted. Care continuity is supported by institutionalized collaboration between hospital and community settings, but hindered by fragmented care processes and heterogeneous transition pathways. Late referral to PC is perceived as a major constraint to EOLC. Developing structured pathways for patient transition to end-stage PC is crucial, and practices/processes should be uniformly implemented to ensure equity. Multi-professional care should be facilitated through tailored supporting tools. Both hospital-unit and FU Directors suggest developing shared pathways between organisations/professionals (82% and 80% respectively) and digital information sharing (61% and 80% respectively). Hospital and community-based professionals have similar perceptions about the concerns and challenges to EOLC provision in the region, but community-based professionals are more sensitive to the importance of improving communication on PC to the public and early discussing EOLC with caregivers. This finding suggests the need of enhancing hospital personnel’s awareness about these issues. Professional training and the capacity to assess patients’ needs and preferences should be improved. The identified needs can inform future research and interventions to improve the quality and outcomes of EOLC for cancer patients.

Objective To investigate end-of-life (EoL) care for heart failure (HF) in Tuscany (Italy) from healthcare professionals' perspective and identify areas for intervention. Methods All the directors of Cardiology units (n = 29) and palliative care (PC) units (n = 14) in Tuscany were surveyed on the practices of EoL care. Results Forty-five percent of cardiologists reported that their hospital had some EoL care services for HF patients. However, 75% did not have a multidisciplinary team providing EoL care for HF patients. Sixty-four percent stated that <25% of patients who might benefit from PC did receive it, and 18% stated that no patient received PC. For most of PC specialists, HF patients accounted for <25% of their patients. PC specialists believed that patients with cancer diseases were much more likely to receive PC than HF patients at EoL, and 36% judged that almost no HF patients were timely referred to hospice care. The majority of PC specialists reported that almost no HF patient prepared advance healthcare directives, as opposite to 57% for cancer patients, suggesting poor understanding or acceptance of their terminal condition. Conclusions The management of HF patients in the EoL stage in Tuscany is often suboptimal. EoL care should be implemented to ensure an adequate quality of life to these patients.

Background: Non-communicable diseases (NCDs) represent a global health challenge that requires coordination across various healthcare settings. Purpose: This study in Tuscany, Italy, investigates professional integration between primary care physicians (PCPs) and specialists in NCD management. Research Design: A self-developed survey was used to explore professionals’ views on clinical and organizational collaboration, accountability, and service improvement. Study Sample: The study involved primary care physicians (PCPs) and specialists working in the field of NCD management. Data Collection and/or Analysis: The survey gathered data on professionals' perceptions of clinical protocol use, care integration effectiveness, and other aspects of collaboration in NCD management. Results: Findings reveal disparities between PCPs and specialists in clinical protocol use and care integration effectiveness. Conclusions: The study emphasizes the need to reduce bureaucratic obstacles and enhance information sharing. Promoting peer relationships and innovative performance evaluation tools is vital for improving chronic disease management. This survey contributes valuable insights for the development of integrated care models, aiding healthcare decision-makers in enhancing chronic care system performance.

Background: Colon cancer imposes a significant burden on global healthcare systems, necessitating efforts to improve oncology care quality and patient outcomes. We studied the correlation between care quality and survival outcomes among colon cancer patients within the Ligurian Oncology Network (Italy).Methods: We developed an Overall Quality Score (OQS) to evaluate the impact of oncology care quality on survival outcomes within the Ligurian Oncology Network. OQS indicators were selected through expert consensus, covering screening, diagnosis, treatment, and follow-up. A sample of colon cancer patients diagnosed in 2012 was randomly selected from administrative healthcare data. Analyses were performed using two models: a binary model (High and Low OQS) and a stratified model (Low, Medium, and High OQS). Statistical analysis involved survival curves, log-rank tests, and Cox proportional hazards models using SAS 9.4.Results: Of 175 eligible colon cancer patients, 150 were included. Following a median follow-up of 7.6 years, a correlation between High-OQS (>= 65%) and prolonged disease-free survival was observed (unadjusted HR 0.57, 95%CI 0.33-0.99, log-rank p=0.041). The five-year disease-free survival rate for High-OQS patients was 70% (95%CI 57-80%), compared to 53% (95%CI 41-64%) for Low-OQS patients. Similarly, the five-year overall survival rate was 78% (95%CI 65-86%) for High-OQS patients, compared to 58% (95%CI 45-68%) for Low-OQS patients (unadjusted HR 0.56, 95%CI 0.31-1.00, log-rank p=0.048).Conclusions: Our findings highlight the potential impact of the patient journey on colon cancer survival outcomes. Optimising care pathways might improve patient outcomes in colon cancer management.

Background Type-2 diabetes (T2D) and hypertension (HTN) are two of the most prevalent non-communicable diseases (NCDs): they both cause a relevant number of premature deaths worldwide and heavily impact the national health systems. This study illustrates the impact of HTN and T2D in four European countries (Albania, Bulgaria, Greece and Spain) and compares their policies towards the monitoring and management of HTN and T2D and the prevention of NCDs as a whole. This analysis is conducted throughout the DigiCare4You Project (H2020)-which implements an innovative solution involving digital tools for the prevention and management of T2D and HTN.Methods The analysis is implemented through desk research, and it is enriched with additional information directly provided by the local coordinators in the four countries, by filling specific semi-structured forms.Results The countries exhibit significant differences in the prevalence of HTN and T2D and available policies and programs targeted to these two chronic conditions. Each country has implemented strategies for HTN and T2D, including prevention initiatives, therapeutic guidelines, educational programs and children's growth monitoring programs. However, patient education on proper disease management needs improvement in all countries, registries about patients affected by HTN and T2D are not always available, and not all countries promoted acts to contain the increasing rates of risk factors related to NCDs.Conclusions While political awareness of the risks associated with HTN, T2D and NCDs in general is growing, there is a collective need for countries to strengthen their policies for preventing and managing these chronic diseases.

This article aims to present the results of a national, cross-sectional, voluntary, online survey on the presence and roles of associations of breast cancer patients and volunteers in Italian specialist breast centres. The survey was developed according to standard methods. The questionnaire was pre-tested by a random sample of three breast centres, loaded onto the SurveyMonkey platform, and piloted by one volunteer breast centre. The breast centre clinical leads were invited to participate via email. A link to the online instrument was provided. No financial incentives were offered. The results were reported using standard descriptive statistics. The response rate was 82/128 (65%). Members of associations were routinely present in 70% Italian breast centres. Breast centres most often reporting their presence were those certified by the European Society of Breast Cancer Specialists. Patient support (reception and information, listening, identification of needs, and psychological support) was the primary area where associations were reported to offer services. The magnitude of this phenomenon warrants a study to investigate the impact of the activities of associations on the quality of life of patients and on the cost-benefit ratio of the service, and the modes of their interactions with the nursing staff and the medical staff.

Purpose Value-based healthcare suggested using patient-reported information to complement the information available in the medical records and administrative healthcare data to provide insights into patients' perceptions of satisfaction, experience and self-reported outcomes. However, little attention has been devoted to questions about factors fostering the use of patient-reported information to create value at the system level. Design/methodology/approach Action research design is carried out to elicit possible triggers using the case of patient-reported experience and outcome data for breast cancer women along their clinical pathway in the clinical breast network of Tuscany (Italy). Findings The case shows that communication and engagement of multi-stakeholder representation are needed for making information actionable in a multi-level, multispecialty care pathway organized in a clinical network; moreover, political and managerial support from higher level governance is a stimulus for legitimizing the use for quality improvement. At the organizational level, an external facilitator disclosing and discussing real-world uses of collected data is a trigger to link measures to action. Also, clinical champion(s) and clear goals are key success factors. Nonetheless, resource munificent and dedicated information support tools together with education and learning routines are enabling factors. Originality/value Current literature focuses on key factors that impact performance information use often considering unidimensional performance and internal sources of information. The use of patient/user-reported information is not yet well-studied especially in supporting quality improvement in multi-stakeholder governance. The work appears relevant for the implications it carries, especially for policymakers and public sector managers when confronting the gap in patient-reported measures for quality improvement.

IntroductionThe oncoplastic conservative surgery was developed as a natural evolution of traditional surgery, attempting to improve the therapeutic and aesthetic outcomes where tumor resection could be followed by not-adequate results. Our primary aim is to evaluate how patient satisfaction and quality-of-life after conservative oncoplastic surgery, using BREAST-Q (BCT Module), change pre- and post-operatively. The secondary aim is to compare patient-reported outcome after oncoplastic or traditional conservative surgery.Patients and methodsWe enrolled 647 patients who underwent traditional conservative surgery or oncoplastic surgery from January 2020 to December 2022. Only 232 women (35.9%) completed the BREAST-Q questionnaire on a web-based platform, at the preoperative phase and 3 months after treatment.ResultsThe average score of "Psychosocial well-being" and "Satisfaction with Breasts" 3 months after surgery showed a statistically significant improvement, while the average score for "Physical well-being: Chest" at 3 months showed a worsening compared to the baseline. "Sexual well-being" did not show statistically significant change. A significant difference between the post-operative outcome of oncoplastic surgery and traditional surgery was observed only for Physical well-being (better for traditional surgery).ConclusionsThe study showed significant improvement in patient-reported outcomes 3 months after the surgery, except for physical discomfort that increases especially after oncoplastic surgery. Furthermore, our data, as well as many others, point to the appropriateness of using OCS where there is an effective indication, while the perspective of patients cannot find significant superiority over TCS in any of the areas analyzed.

This paper employs mixed logit regression to investigate the effects of providers characteristics on women's choice of hospital for breast surgery. Patient level data are used to model choices in Tuscany region, Italy. In particular, we focus on the effects of travel time and hospital quality indicators including quality standard (volumes of breast surgery), measurement of process (waiting times) and quality of surgical procedures. Variation in preferences related to individual characteristics such as age, education and travel distance from the hospital are also considered. Findings show that, on average, women prefer closer hospital with longer waiting times and higher quality (high volumes of interventions). We found preference heterogeneity associated to education: travel distance affects choice especially among less educated women (regardless of age), while among younger women (<65 years), less educated ones prefer shorter waiting times. These results could be used to optimize the allocation of resources toward breast cancer units that meet quality and efficacy standards to increase the efficiency and responsiveness of breast cancer care.

The Comprehensive Geriatric Assessment (CGA) and the corresponding geriatric interventions are beneficial for community-dwelling older persons in terms of reduced mortality, disability, institutionalisation and healthcare utilisation. However, the value of CGA in the management of older cancer patients both in terms of clinical outcomes and in cost-effectiveness remains to be fully established, and CGA is still far from being routinely implemented in geriatric oncology. This narrative review aims to analyse the available evidence on the cost-effectiveness of CGA adopted in geriatric oncology, identify the relevant parameters used in the literature and provide recommendations for future research. The review was conducted using the PubMed and Cochrane databases, covering published studies without selection by the publication year. The extracted data were categorised according to the study design, participants and measures of cost-effectiveness, and the results are summarised to state the levels of evidence. The review conforms to the SANRA guidelines for quality assessment. Twenty-nine studies out of the thirty-seven assessed for eligibility met the inclusion criteria. Although there is a large heterogeneity, the overall evidence is consistent with the measurable benefits of CGA in terms of reducing the in-hospital length of stay and treatment toxicity, leaning toward a positive cost-effectiveness of the interventions and supporting CGA implementation in geriatric oncology clinical practice. More research employing full economic evaluations is needed to confirm this evidence and should focus on CGA implications both from patient-centred and healthcare system perspectives.

Background Despite recommendations, mammography screening is often insufficiently integrated into specialist breast centres. A national, cross-sectional, voluntary, online survey on this issue was carried out among the Italian breast centres associated with Senonetwork, the Italian network of breast cancer services. Methods A 73-item questionnaire was created, pre-tested and piloted. Centres integrating and not integrating a screening programme were compared using the unified theory of acceptance and use of technology (UTAUT) model. Centres’ clustering was performed using the Gower’s distance metric. Groups and clusters were compared with the equality-of-means test. Results The response rate was 82/128 (65%). Overall, 84% (69/82) breast centres reported a collaboration with a screening programme in performing and/or reading mammograms and in the diagnostic work-up of women with abnormal screening results. The same proportion was observed among those centres responding to all questions (62/74). Performance expectancies (or the perceived usefulness of integration in terms of clinical quality, patient convenience, ease of job, and professional growth), satisfaction and motivation were higher in those centres collaborating with the screening programme. Effort expectancy indicators (or the degree to which the respondents believe that the integration is easy to implement) and those concerning the existence of facilitating conditions were lower both in centres collaborating and not collaborating with the screening programme. Among the former, six clusters of centres, distributed from ‘no integration’ to ‘high’, were identified. In cluster analysis, the highest level of integration was associated with higher agreement that integration eases the job, offers better opportunities for professional growth, and makes the working environment more satisfactory. The least integrated cluster assigned the lowest score to the statement that local health authority made available the resources needed. Conclusions While confirming the positive effects of integrating screening programmes into breast centres, this survey has brought to light specific difficulties that must be faced. The results provide insights into the importance of integration focusing on the perspectives of professional career and motivation. The deficiency of facilitating conditions to integration is modifiable. Screening professionals’ societies may have a role as initiators of the integration. Other supporting actions may be included in health laws at the national and regional level.

This study aimed to estimate healthcare costs of diabetic foot disease (DFD) in a large population-based cohort of people with type-2 diabetes (T2D) in the Tuscany region (Italy). Administrative healthcare data of Tuscany region, with 2018 as the base year. Retrospective study assessing a longitudinal cohort of patients with T2D. Using administrative healthcare data, DFD were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification codes. We examined the annual healthcare costs of these clinical problems in patients with T2D between 2015 and 2018; moreover, we used a generalized linear model to estimate the total healthcare costs. Between 2015 and 2018, patients with T2D experiencing DFD showed significantly higher average direct costs than patients with T2D without DFD (p < 0.0001). Among patients with T2D experiencing DFD, those who experienced complications either in 2015–2017 and in 2018 incurred the highest incremental costs (incremental cost of € 16,702) followed by those with complications in 2018 only (incremental cost of € 9,536) and from 2015 to 2017 (incremental cost of € 800). DFD significantly increase healthcare utilization and costs among patients with TD2. Healthcare costs of DFD among patients with T2D are associated with the timing and frequency of DFD. These findings should increase awareness among policymakers regarding resource reallocation toward preventive strategies among patients with T2D.

In 2016, the Italian Group for Mammography Screening and the Italian College of Breast Radiologists by the Italian Society of Medical and Interventional Radiology recommended that screening programmes and specialist breast centres actively invite women with a history of breast cancer to follow-up imaging. A survey of breast centres associated with Senonetwork, the Italian network of breast cancer services, has offered the opportunity to assess the implementation of this recommendation. A national, cross-sectional, voluntary, online survey was developed, pre-tested, and administered during the months July–October 2020. Five of the 73 questionnaire items concerned breast cancer follow-up. The response rate was 82/128 (65%). Of the 82 respondent centres, 69 (84%) were involved in a screening programme. Fifty-six (68%) reported the presence of a programme of active invitation to breast cancer follow-up targeted at patients living in their catchment area, with a significant north-to-south gradient. Four centres (5%) reported that the screening programme was responsible for actively initiating follow-up during the 10-year period since diagnosis. Only after 10 years did the proportion increase moderately. Screening programmes have still a marginal role in active breast cancer follow-up.