Background: Few studies evaluated the clinical outcomes of Community Acquired Pneumonia (CAP), Hospital-Acquired Pneumonia (HAP) and Health Care-Associated Pneumonia (HCAP) in relation to the adherence of antibiotic treatment to the guidelines of the Infectious Diseases Society of America (IDSA) and the American Thoracic Society (ATS) in hospitalized elderly people (65 years or older). Methods: Data were obtained from REPOSI, a prospective registry held in 87 Italian internal medicine and geriatric wards. Patients with a diagnosis of pneumonia (ICD-9 480-487) or prescribed with an antibiotic for pneumonia as indication were selected. The empirical antibiotic regimen was defined to be adherent to guidelines if concordant with the treatment regimens recommended by IDSA/ATS for CAP, HAP, and HCAP. Outcomes were assessed by logistic regression models. Results: A diagnosis of pneumonia was made in 317 patients. Only 38.8% of them received an empirical antibiotic regimen that was adherent to guidelines. However, no significant association was found between adherence to guidelines and outcomes. Having HAP, older age, and higher CIRS severity index were the main factors associated with in-hospital mortality. Conclusions: The adherence to antibiotic treatment guidelines was poor, particularly for HAP and HCAP, suggesting the need for more adherence to the optimal management of antibiotics in the elderly with pneumonia
AimsTo compare the effectiveness of integrated care with that of the diabetes clinic care model in terms of mortality and hospitalisation of type 2 diabetes patients with low risk of complications.MethodsOut of 27234 people with type 2 diabetes residing in the province of Reggio Emilia on 31/12/2011, 3071 were included in this cohort study as eligible for integrated care (i.e., low risk of complications) and cared for with the same care model for at least two years. These patients were followed up from 2012 to 2016, for all-cause and diabetes-related mortality and hospital admissions. We performed a Poisson regression model, using the proportion of eligible patients included in the integrated care model for each general practitioner as an instrumental variable.Results1700 patients were cared for by integrated care and 1371 by diabetes clinics. Mortality rate ratios were 0.83 (95%CI 0.60–1.13) and 0.95 (95%CI 0.54–1.70) for all-cause and cardiovascular mortality, respectively, and incidence rate ratios were 0.90 (95%CI 0.76–1.06) and 0.91 (95%CI 0.69–1.20) for all-cause and cardiovascular disease hospitalisation, respectively.ConclusionFor low risk patients with type 2 diabetes, the integrated care model involving both general practitioner and diabetes clinic professionals showed similar mortality and hospitalisation as a model with higher use of specialized care in an exclusively diabetes clinic setting.
Background Inappropriate prescribing of diagnostic procedures leads to overdiagnosis, overtreatment and resource waste in healthcare systems. Effective strategies to measure and to overcome inappropriateness are essential to increasing the value and sustainability of care. We aimed to describe the determinants of inappropriate reporting of the clinical question and of inappropriate imaging and endoscopy referrals through an analysis of general practitioners’ (GP) referral forms in the province of Reggio Emilia, Italy. Methods A clinical audit was conducted on routinely collected referral forms of all GPs of Reggio Emilia province. All prescriptions for gastroscopy, colonoscopy, neurological and musculoskeletal computerised tomography (CT) and magnetic resonance imaging (MRI) from 2012 to 2017 were included. The appropriateness of referral forms was assessed using Clinika VAP software, which combines semantic analysis of clinical questions and available metadata. Local protocols agreed on by all physicians defined criteria of appropriateness. Two multilevel logistic models were used to identify multiple predictors of inappropriateness of referral forms and to analyse variability among GPs, primary care subdistricts and healthcare districts. Results Overall, 37% of referral forms were classified as inappropriate, gastroscopy and CT showed higher proportions of inappropriate referrals compared to colonoscopy and MRI. Inappropriateness increased with patient age for CT and MRI; for gastroscopy, it was lower for patients aged 65–84 compared to those younger, and for colonoscopy, it was higher for older patients. Fee exemptions were associated with inappropriateness in MRI referral forms. The effect of GPs’ practice organization was consistent across all tests, showing higher inappropriateness for primary care medical networks than in primary care medical groups. Male GPs were associated with inappropriateness in endoscopy, and older GPs were associated with inappropriateness in musculoskeletal CT. While there was moderate variability in the inappropriate prescribing among GPs, there was not among the healthcare districts or primary care subdistricts. Conclusions Routinely collected data and IT tools can be useful to identify and monitor diagnostic procedures at high risk of inappropriate prescribing. Assessing determinants of inappropriate referral makes it possible to tailor educational and organizational interventions to those who need them.
Gout/allopurinol intake has a high prevalence in elderly patients acutely admitted to hospital and are associated with renal and cardiovascular diseases, an increased rate of adverse events and a high degree of drug consumption. In contrast, this finding did not affect the length of hospitalization nor hospital mortality.
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