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This report reviews the quality of health care in Italy, seeks to highlight best practices, and provides a series of targeted assessments and recommendations for further improvements to quality of care. Italy’s indicators of health system outcomes, quality and efficiency are uniformly impressive. Life expectancy is the fifth highest in the OECD. Avoidable admission rates are amongst the very best in the OECD, and case-fatality after stroke or heart attack are also well below OECD averages. These figures, however, mask profound regional differences. Five times as many children in Sicily are admitted to hospital with an asthma attack than in Tuscany, for example. Despite this, quality improvement and service redesign have taken a back-seat as the fiscal crisis has hit. Fiscal consolidation has become an over-riding priority, even as health needs rapidly evolve. Italy must urgently prioritise quality of its health care services alongside fiscal sustainability. Regional differences must be lessened, in part by giving central authorities a greater role in supporting regional monitoring of local performance. Proactive, coordinated care for people with complex needs must be delivered by a strengthened primary care sector. Fundamental to each of these steps will be ensuring that the knowledge and skills of the health care workforce are best matched to needs.

The Italian health care system delivers high quality of primary care services as demonstrated by rates of avoidable hospitalisation that are amongst the lowest in the OECD. Italy faces, however, a growing ageing population and a rising burden of chronic conditions, which are likely to result in higher health care costs and place further pressures on the primary care sector. Whilst the management of chronic conditions requires a co-ordinated patientcentered response from a wide range of health professionals, the Italian health care system has traditionally been characterised by a high level of fragmentation and a lack of care co-ordination. Italy has made considerable efforts to experiment with new models of community care services that aim at achieving greater co-ordination and integration of care. Although the expansion of community care services is an appropriate policy response to meet the growing demand for health care, they are still unevenly distributed across Italian regions and autonomous provinces. Greater guidance and support from national authorities is needed to ensure a more consistent approach. At the same time, there are other shortcomings in Italy’s primary care sector that require attention to guarantee high-quality primary care. Efforts are needed to increase transparency, develop performance measurement and strengthen accountability in the sector. The development of a set of standards around the processes and outcomes of primary care, the setting-up of smarter payment systems and an increase in the involvement of primary care physicians in preventive activities are options that Italy should consider pursuing if it is to meet the challenge of an increasing burden of long-term conditions.

This report reviews the quality of health care in Italy. It begins by providing an overview of policies and practices aimed at supporting quality of care (Chapter 1). The report then focuses on three areas that are of particular importance for Italy’s health system at present: the role of primary care (Chapter 2), improving the training of the health care workforce (Chapter 3) and improving systems for monitoring and improving the quality of care in a regionalised health system (Chapter 4). In examining these areas, this report examines the quality of care currently provided, seeks to highlight best practices, and provides a series of targeted assessments and recommendations for further improvements to quality of care.

Whilst it cannot be said that any one region delivers consistently “poor” health care, it appears that some regions struggle to provide the same quality as others. Italy has established a number of mechanisms to try and ensure an evenness of approach to quality measurement and improvement. These include activities to ensure dialogue between national and regional authorities as well as professionally led initiatives to measure quality consistently. While it would be unrealistic and undesirable to seek complete homogeneity in how regional health systems are configured, more can be done to achieve a more even approach to quality measurement and improvement across R and AP. Key priorities are to develop a more consistent approach to using information to manage performance and strengthen local accountability. Ensuring that regional resource allocation has a focus on quality, and is linked to incentives for quality improvement, will also be important. Actions that strengthen the regional approach to health care governance and delivery in Italy are also needed. Developing the responsibilities and capacities of the national authorities whose role is to support the R and AP should continue. Reframing governance as a whole such that quality improvement is emphasised as much as financial control is also necessary.

Italy’s indicators of health system outcomes, quality and efficiency are uniformly impressive. Life expectancy, at 82.3 years, is the fifth highest in the OECD. Admission rates for asthma, chronic pulmonary disease and diabetes (markers of the quality of primary care) are amongst the very best in the OECD, and case-fatality after stroke or heart attack (markers of the quality of hospital care) are also well below OECD averages. Good health care is achieved at low cost – at USD 3 027 per capita, Italy spends much less than neighbouring countries such as Austria (USD 4 593), France (USD 4 121) or Germany (USD 4 650). These remarkable figures, however, mask profound regional differences. Five times as many children in Sicilia are admitted to hospital with an asthma attack than in Toscana, for example. Despite this, quality improvement and service redesign have taken a backseat as the economic crisis has hit. Financial consolidation has become an over-riding priority, even as health needs rapidly evolve. Dementia prevalence, healthy life years and daily activities limitations at age 65, for example, are all worse in Italy than OECD averages and Italian children are amongst the most overweight in the OECD. To address these challenges, Italy must urgently prioritise quality of its health care services alongside economic sustainability. Regional differences must be lessened, in part by giving central authorities a greater role in supporting regional monitoring of local performance. Proactive, co-ordinated care for people with complex needs must be delivered by a strengthened primary care sector. Fundamental to each of these steps will be ensuring that the knowledge and skills of the health care workforce are best matched to needs.

There are a range of laws and regulations in Italy that in various ways address quality of care to ensure effective, safe and patient-centered health service delivery. The devolution of power to regions has, however, resulted in a range of quality initiatives at regional level: some regions have very well developed approaches towards the systematic measurement and management of quality improvement while other regions still have rather weak quality governance models. The challenge for Italy will be to achieve a more comprehensive and uniform approach towards quality monitoring and improvement throughout the country. Some steps have already been taken in this direction, but more could be done to guide all regions towards the robust quality improvement for the health system. A stronger central role for the Ministry of Health and/or its agencies (such as AGENAS), the development of more robust inspection functions to monitor minimum levels of care and patient safety standards are key priorities. Efforts are also needed to develop a stronger information infrastructure which, used appropriately, can contribute to quality improvement efforts. Data should be used more effectively as part of ongoing initiatives around performance monitoring of both health providers and health care facilities. A strategic focus on increasing patient involvement is also needed to steer more systematic quality improvement. 1

This chapter considers how effective Italy’s medical education system, and in particular the continuing medical education system, are for securing a high quality workforce of health professionals. The relatively good results that Italy’s health system is delivering suggest that the medical workforce is, in general, providing care of a high quality. Looking to secure this high performance for the decades to come, and push back against any regional disparities in quality and outcomes, Italy has also been taking important steps towards ensuring nationally cohesive workforce training programmes. However, going forward, good medical education and nationally standardised continuing medical education may not be enough to secure a high quality, high performing medical workforce. There is scope to look to the scientific literature, and the experiences of other OECD countries, to try to maximise the impact of medical education, from the undergraduate level and beyond. This chapter suggests that Italy could promote workforce quality when selecting future medical professionals prior to undergraduate education, and ways to improve the quality of undergraduate medical teaching. There are also opportunities to maximise the positive impact of Italy’s existing continuing medical education programme, and this chapter suggests that there is a need for Italy to eventually develop more modern models of workforce quality insurance, including a move to continuing professional development, and using data to encourage health professionals to reflect on their practice. 3

This report is the seventh of a series of publications reviewing the quality of health care across selected OECD countries. As health costs continue to climb, policy makers increasingly face the challenge of ensuring that substantial spending on health is delivering value for money. At the same time, concerns about patients occasionally receiving poor quality health care have led to demands for greater transparency and accountability. Despite this, there is still considerable uncertainty over which policies work best in delivering health care that is safe, effective and provides a good patient experience, and which quality-improvement strategies can help deliver the best care at the least cost. OECD Reviews of Health Care Quality seek to highlight and support the development of better policies to improve quality in health care, to help ensure that the substantial resources devoted to health are being used effectively in supporting people to live healthier lives.