Healthcare and performance evaluation 2024: Bolzano hosts the event organized by the Network of Regions, coordinated by the MeS Laboratory of the Institute of Management of the Sant'Anna School of Advanced Studies in Pisa

The results of the performance of the healthcare services of the Autonomous Provinces of Trento and Bolzano, seven regions (Basilicata, Friuli-Venezia Giulia, Lombardy, Puglia, Tuscany, Umbria, Veneto) and the Sant'Andrea University Hospital in Rome were presented. The strengths and weaknesses relating to systemic challenges (economic sustainability, personnel policies, and digital transformation), demographic challenges (aging and declining birth rates), and regional performance were identified

• All results are available online on the portal: www.performance.santannapisa.it
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Assessing the performance of healthcare services in regions, companies, and districts and presenting the data for 2024: this was the topic at the center of the debate at the Network of Regions event, hosted by the Autonomous Province of Bolzano and coordinated by the MeS Management and Healthcare Laboratory of the Institute of Management of the Sant'Anna School of Advanced Studies in Pisa.

The Network of Regions, established in 2008 with the aim of promoting a culture of discussion and mutual improvement through systematic benchmarking, is based on a collaborative and voluntary approach. It currently includes the two Autonomous Provinces of Trento and Bolzano and seven Italian regions (Basilicata, Friuli-Venezia Giulia, Puglia, Tuscany, Umbria, Veneto, and Lombardy) and the Sant'Andrea University Hospital in Rome.

“This year, based on over 200 indicators analyzed, we have proposed three major areas for reflection,” said Prof. Milena Vainieri, scientific director of the Network's performance evaluation system and director of the Management and Health Laboratory (MeS) at the Institute of Management of the Sant'Anna School of Advanced Studies in Pisa. "The first area concerns system challenges: economic sustainability, personnel policies, and digital transformation. The second addresses demographic challenges, such as aging and declining birth rates, reinterpreting indicators for maternal and child health and proposing a new synthesis on the ‘elderly and frailty’ pathway. The third reflection is dedicated to the role of districts in the governance of territorial performance, contributing to the debate on the implementation of territorial care reform."

After institutional greetings from the Councilor for Health of the Autonomous Province of Bolzano, Hubert Messner, and Prof. Sabina Nuti, former rector of the Sant'Anna School of Advanced Studies and founder of the Management and Health Laboratory, the main results were presented by researchers from the Management and Health Laboratory.

System challenges: greater efficiency compared to previous years

With regard to system challenges in the hospital sector, greater efficiency has been observed: the average cost per DRG point (i.e., the cost per admission for the same type of care) has fallen from around €7,000 to €6,640 in the regions of the Network. However, per capita healthcare expenditure borne by the public sector has increased (+6% on average) and expenditure directly borne by households has also risen, indicating growing pressure on the economic sustainability of the system. On the personnel policy front, there are positive signs: the percentage of staff absences is falling (albeit with significant regional differences: ranging from 9.56% in the Bolzano public administration to 16.38% in Umbria). Gender equality in access to top positions is also improving, although only a few companies have achieved a satisfactory balance. As regards digital healthcare, despite substantial investment in recent years, there are still significant disparities in the implementation of services between regions. A survey of the population over 45 shows that online booking services are known and used by about half of the population (ranging from 51% to 74%), while access to digital health data remains more limited (ranging from 35% to 69%), a sign of uneven adoption.

Demographic challenges: declining birth rates and aging population

The analysis of the challenges focused on the demographic challenges of birth rates and aging population, offering reflections on how to interpret maternal and child health data in light of the birth and fertility situation in Italy. The average age of Italian women at the birth of their first child is the highest in Europe and the fertility rate is among the lowest in European countries. This means that nulliparous women are on average older than in other European countries. As a result, the 15% target set by the World Health Organization for the caesarean section rate, adjusted for the main causes that can generally lead to a caesarean section (nulliparous women, full-term pregnancy, single pregnancy, and vertex presentation), may be more difficult to achieve in Italian regions. Currently, the range for the regions in the network varies from 13.40% in the autonomous province of Trento to 25.25% in Basilicata. Alongside the demographic decline in births, Italy is also experiencing a substantial aging of its population. To address this challenge, a new pentagram has been proposed that captures the path of the elderly and frailty, including indicators ranging from prevention and health promotion to the outcomes of home and residential care.

Organisational models in the territory: the centrality of territorial healthcare

The last challenge concerns organisational models in the territory and, in particular, the role of districts.

In recent years, the Network's performance evaluation system has extended its analysis to the district level, providing indicators and summaries useful for the reorganisation of territorial care. Data on variability between districts, healthcare providers, and regions have been presented, which are useful for understanding the weight of the different levels of governance. For example, in the rate of access to emergency rooms—an indirect indicator of the effectiveness of the local network—about 50% of the variability is attributable to the regions, and 42% to the districts. When socio-demographic variables (population density, proportion of foreigners, over-75s, income) are included, the regional weight rises to 72%, while the district weight falls to 22.6%. The picture is different for the rate of avoidable hospitalizations (COPD, diabetes, heart failure): here, the district accounts for 60% of the variability, highlighting the importance of local management of chronic conditions. The role of the district is even more pronounced in family planning services (measured by the teenage pregnancy rate), where it accounts for 80% of the variability. Finally, for antidepressant use among 18-25 year olds, the variability is more evenly distributed: 39% at the regional level, with a similar share for the districts. These data show that strengthening the districts is central to the governance of local healthcare.

During the morning, two in-depth presentations were given: the first on the role of the human factor in healthcare, by Prof. Nicola Bellè, head of the Behavioural Insight Unit at the MeS laboratory, and the second on the challenges of long-term care and the management of non-self-sufficiency, held by Prof. Cristiano Gori, full professor of social policy at the University of Trento and promoter of the Pact for a New Welfare on Non-Self-Sufficiency. The morning session was concluded by Prof. Milena Vainieri, who led a series of institutional presentations involving leading representatives from the national and regional healthcare scene: Americo Cicchetti (Ministry of Health expert for the analysis and evaluation of public policies and spending review), Lucia Lispi (Director of Office 6 - Monitoring and Verification of LEAs and Recovery Plans - of the Ministry of Health), Antonio D'Urso (Director of the Department of Health and Social Policies, Autonomous Province of Trento), Federico Gelli (Director of Health, Welfare and Social Cohesion, Tuscany Region), Hubert Messner (Councilor for Health Prevention and Health, Autonomous Province of Bolzano) Mario Tonina (Councilor for Health, Trento). The discussion focused on the challenges of performance evaluation systems in long-term care and in the field of social and health integration.

The closing remarks by the Rector of the Sant'Anna School of Advanced Studies, Prof. Nicola Vitiello, emphasized the need to expand evaluation systems to areas that are still relatively unexplored, such as rehabilitation, and the importance of using existing technologies to transform the paradigm of care.

Credit by: Lukas Raffl/Azienda sanitaria Alto Adige ASAA