Health system governance

2020 National Outcomes Programme

The 2020 edition of the National Outcomes Programme (Programma Nazionale Esiti - PNE) was presented on 1 March 2021. Developed by AGENAS, on behalf of the Health Ministry and in collaboration with the Istituto Superiore di Sanità and the Epidemiology Department of Local Health Unit Roma 1, the PNE aims to assess efficiency, appropriateness and safety of healthcare services provided by the National Health System, as well as equity of access to such services. To this end, 177 indicators are analyzed (72 measuring care outcomes and procedures, 75 investigating volumes of activity and 30 assessing hospitalization rates) in relation to nine clinical areas: cardio- and cerebrovascular, digestive, musculoskeletal, paediatric, maternity and perinatal, respiratory, oncological, urogenital and infectious diseases.

Key data

While data confirmed a gradual improvement in the quality of care across all the investigated clinical areas, further efforts should be made to overcome existing issues, such as the fragmented nature of healthcare delivery in hospitals, and to reduce local differences.

Below are some key data.

Cardio- and cerebrovascular area

• Acute myocardial infarction: hospital admissions continued to gradually decline (123,327 in 2019 compared to 135,621 in 2012), as a result of the adoption of health policies aimed at reducing risk behaviours (e.g. tobacco smoking, sedentary lifestyles, alcohol use and unbalanced diets), and improvements in the diagnostic coding of infarction. The 30-day mortality rate after admission for acute myocardial infarction (AMI) also continued to decrease (from 10.0% in 2012 to 7.9% in 2019). This overall reduction was accompanied by low interregional variability and moderate variations between facilities.
• Coronary artery bypass graft (CABG): the number of isolated CABG operations (i.e. not combined with heart valve procedures or endarterectomy) dropped from 16,060 in 2012 to 14,185 in 2019 (-11.7%). This can be attributed to both a simultaneous increase in the number of non-isolated CABG operations and the growing use of (less invasive) angioplasty procedures for the treatment of blocked coronary arteries. Despite fluctuating over the years, the 30-day mortality rate after admission for CABG recorded an overall decline (from 2.6% in 2012 to 1.7% in 2019).
• Ischemic stroke: hospital admissions for ischemic stroke gradually decreased from 92,595 in 2012 to 83,829 in 2019. The 30-day mortality rate also declined compared to 2012 (from 11.9% to 10.0%), despite fluctuations and significant interregional variability.

Musculoskeletal area

• Fractured neck of femur: the number of operations for fractured neck of femur increased between 2012 and 2019 (from 84,698 to 94,643). In the last year of assessment, 426 (61.7%) of the 690 facilities that performed this type of surgery reached the minimum annual threshold of 75 operations.
• Joint replacement: the number of knee replacement operations increased (from 65,545 in 2012 to 87,921 in 2019), but only 34.6% of the 729 hospital facilities that performed this type of surgery in 2019 reached or exceeded an annual volume of 100 operations. Hip replacement operations (up from 97,355 in 2012 to 115,988 in 2019) were performed in 757 hospital facilities, only 415 (54.8%) of which reached an annual volume of at least 100 operations. Shoulder replacement operations (up from 5319 in 2012 to 11,219 in 2019) were carried out in 625 hospital facilities, only 215 (34.4%) of which reached or exceeded an annual volume of 15 operations.

Perinatal area

• Birth facilities: the number of maternities in our country declined over time (441,078 in 2018 and 417,144 in 2019). As required by the State-Regions Agreement of 16 December 2010, the Ministry of Health established a minimum annual threshold of 500 maternities for birth facilities (Decree n. 70 of 2 April 2015). Despite that, 6.8% of all maternities took place in facilities that did not reach such threshold: 17.6% of them were based in Lazio, 13.4% in Sicily and 10.6% in Campania.
• Birthing methods: the median caesarean section rate progressively decreased (from 25.3% in 2012 to 21.5% in 2019), but was still well above the 10%-15% rate recommended by the World Health Organization (WHO). Inter- and intraregional differences persisted in 2019: in some southern regions, findings included median values above the standards and primary caesarean section rates exceeding 50% (Sicily, Apulia) and even 60% (Campania, Calabria) in some facilities. While the vaginal delivery rate among women with prior caesarean sections gradually increased, percentages remained quite low (5.5% in 2012 and 10% in 2019). Interregional variability was once again observed.

Oncological surgery

• Breast cancer. The PNE uses an annual threshold of 135 procedures: in 2019, 152 facilities reached or exceeded an annual volume of 135 operations, with 136 of them performing more than 150.
• Other tumours. In 2019, 12,166 lung cancer operations were carried out in 178 hospital facilities: 134 performed more than 5 procedures, with 77 of them (57.5%) reaching or exceeding an annual volume of 50 operations (minimum volume identified as being associated with more favourable outcomes). In 2019, 5824 stomach cancer operations were carried out in 534 facilities: 249 performed up to 5 procedures/year; of the remaining facilities, only 78 (27.4%) reached an annual volume of at least 20, and 39 (13.7%) performed more than 30. A total of 2710 pancreatic cancer operations were carried out in 2019 in 230 facilities, only 17 of which exceeded an annual volume of 30 procedures, accounting for 52.8% of all such admissions across the country.

The PNE data provide valuable information on the challenges facing the health system, which need to be carefully monitored to record variations between regions and changes over time, but also with a view to refocusing healthcare services once the COVID-19 emergency is over.