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Background: Moral distress has frequently been investigated in single healthcare settings and concerning a single type of professional. This study aimed to describe the experience of moral distress in all the types of professionals providing daily care to elderly patients and residents. Methods: The Grounded Theory approach, developed by Corbin and Strauss, was used. This study included participants from hospital and nursing homes of northern Italy. Purposive and theoretical sampling was used. Between December 2020 and April 2021, semi-structured interviews were conducted. Results: Thirteen participants were included in the study. Four categories were derived from the data: talking and listening, care provider wellbeing, decision making, protective factors, and potential solutions. The core category identified was “sharing daily”. Interviewees confirm how hard it may be to communicate to the elderly, but at the same time, how adequate communication with the leader is a protective factor of moral distress. They also confirm how communication is key to managing or downsizing misunderstandings at all levels. Findings highlight the scarcity of operators as a fundamental trigger of moral distress. Conclusions: Many determinants of this phenomenon lie behind the direct control of professionals, but education can help them learn how to prevent, manage, or downsize the consequences.

Background and purpose: Innovations able to maintain patient safety while reducing the amount of transfusion add value to orthopedic procedures. Opportunities for improvement arise especially in elective procedures, as long as room for planning is available. Although many strategies have been proposed, there is no consensus about the most successful combination. The purpose of this investigation is to identify information to support blood management strategies in fast-track total joint arthroplasty (TJA) pathway, to (i) support clinical decision making according to current evidence and best practices, and (ii) identify critical issues which need further research. Methods and materials: We identified conventional blood management strategies in elective orthopedic procedures. We performed an electronic search about blood management strategies in fast-track TJA. We designed tables to match every step of the former with the latter. We submitted the findings to clinicians who operate using fast-track surgery protocols in TJA at our research hospital. Results: Preoperative anemia detection and treatment, blood anticoagulants/aggregants consumption, transfusion trigger, anesthetic technique, local infiltration analgesia, drainage clamping and removals, and postoperative multimodal thromboprophylaxis are the factors which can add best value to a fast-track pathway, since they provide significant room for planning and prediction. Conclusion: The difference between conventional and fast-track pathways does not lie in the contents of blood management, which are related to surgeons/surgeries, materials used and patients, but in the way these contents are integrated into each other, since elective orthopedic procedures offer significant room for planning. Further studies are needed to identify optimal regimens.

Healthcare performances have been for long evaluated according to outcomes and costs.What still needs to be defined is which outcomes are the most relevant to the patient, and which costs any supplier is capable to reduce, or increase, to the funder. If technical efficiencies during healthcare production and delivery may continue to evolve, the opportunities for further savings are likely to decrease. Major improvement could be achieved from better definition of outcomes that really matters to patients and stakeholders, that is measuring the real value. Many purchasers are shifting from a traditional approach based on single-unit cost-saving to a more holistic approach, encompassing longlasting performance evaluation, including the highest possible number of stakeholders and wider sets of indicators. Value-based procurement (VBP) has been defined as achieving "outcomes that matter to people at the lowest possible cost". Although this approach may appear complicated in practice, it was already proven successful in different countries, medical and surgical applications, and has also been endorsed by some important international institutions. The scope of this review is to introduce VBP from a theoretical and an empirical level, referring to relevant practices and challenges which emerged in the current institutional, clinical and academic debate. VBP seems to be a promising solution to improve healthcare efficiency and fairness, provided a clear conception of what is value and a permanent collaboration between clinicians and scientists. When different dimensions of value (i.e., personal, technical, allocative and societal) are supported by well-designed study to identify the respective outcomes, it becomes easier to find better solutions in support of healthcare quality and sustainability.

Background: Since 1997, nursing ethics research has focused on solving ethical dilemmas, enhancing decision-making strategies, and introducing professional education. Few studies describe the triggers of ethical dilemmas among primary care nurses. The aim of this study was to explore the moral distress and ethical dilemmas among primary care nurses. Methods: A scoping review was performed following Arskey and O’Malley’s framework. PubMed, CINAHL, PsycINFO, Embase, and Scopus were searched systematically to retrieve relevant titles and abstracts. A temporal filter was applied to focus on the most recent literature (years of 2010–2020). The research was completed on 17 November 2020. Results: Of 184 articles retrieved, 15 were included in the review. Some (n = 7) studies had a qualitative design, and the most productive country was Brazil (n = 7). The total number of nurses involved in quantitative studies was 1137 (range: 36–433); the total number of nurses involved in qualitative studies was 144 (range: 7–73). Three main focus areas were identified: (a) frequent ethical conflicts and moral distress episodes among nurses working in primary care settings; (b) frequent moral distress measures here employed; (c) coping strategies here adopted to prevent or manage moral distress. Conclusion: Further research is needed to examine the differences between moral distress triggers and sources of ethical dilemmas among the different care environments, such as primary care and acute care settings.

Fragility fractures pose a serious threat to patient health, quality of life, and healthcare sustainability. In order to reduce their clinical, social, and economic burden, a Fracture Liaison Service (FLS) was introduced in a high volume orthopedic hospital in 2017. The purpose of this retrospective observational study is to describe the FLS protocol, introduce its preliminary outcomes, and provide an early evaluation in light of international guidelines and recommendations. All the performances suggested by the International Osteoporosis Foundation (IOF) are provided under the same institution by which a patient is admitted for surgery. Clinical indicators from patient history and administrative indicators from the hospital database have been used to estimate the spread of fragility fracture prevention and the degree of patient compliance to these programs. The research included 403 patients. Although, almost 1/3 were admitted for the second fragility fracture, only half received anti-osteoporotic treatment before it. The degree of prevention was even lower in the case of patients admitted for the first fragility fracture. The risk of being affected by a secondary fracture was seven times higher when patients did not attend any follow-up or diagnostic exam. In order to identify the main determinants of compliance with FLS and perform a cost-effectiveness analysis on a larger sample, it is fundamental to integrate data from different providers.

Background: The number of patients undergoing joint arthroplasty is increasing worldwide. An Enhanced Recovery After Surgery (ERAS) pathway for hip and knee arthroplasty was introduced in an Italian high-volume research hospital in March 2018. Methods: The aim of this mixed methods observational study is to perform a health technology assessment (HTA) of the ERAS pathway, considering 938 procedures performed after its implementation, by means of a hospitalbased approach derived from the EUnetHTA (European Network for Health Technology Assessment) Core Model. The assessment process is based on dimensions of general relevance, safety, efficacy, effectiveness, economic and financial impact, equity, legal aspects, social and ethical impact, and organizational impact. A narrative review of the literature helped to identify general relevance, safety and efficacy factors, and a set of relevant sub-dimensions submitted to the evaluation of the professionals who use the technology through a 7-item Likert Scale. The economic and financial impact of the ERAS pathway on the hospital budget was supported by quantitative data collected from internal or national registries, employing economic modelling strategies to identify the amount of resources required to implement it. Results: The relevance of technology under assessment is recognized worldwide. A number of studies show accelerated pathways to dominate conventional approaches on pain reduction, functional recovery, prevention of complications, improvements in tolerability and quality of life, including fragile or vulnerable patients. Qualitative surveys on clinical and functional outcomes confirm most of these benefits. The ERAS pathway is associated with a reduced length of stay in comparison with the Italian hospitalization average for the same procedures, despite the poor spread of the pathway within the country may generate postcode inequalities. The economic analyses show how the resources invested in training activities are largely depreciated by benefits once the technology is permanently introduced, which may generate hospital cost savings of up to 2054,123.44 € per year. Conclusions: Galeazzi Hospital's ERAS pathway for hip and knee arthroplasty results preferable to traditional approaches following most of the HTA dimensions, and offers room for further improvement. The more comparable practices are shared, the before this potential improvement can be identified and addressed.