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31 January 2023 | Policy Analysis
National Action Plan on Antimicrobial Resistance 2022–2025
7.4. Health care quality
Italy reports good results for many but not all of the indicators that investigate the quality of care. In primary care, the country has low prescription volumes of opioids and benzodiazepines compared with the rest of Europe, as appropriateness in prescription may also be imputable to reimbursement and prescribing procedures and guidelines (OECD/EU, 2020). In contrast, policies need to be put in place to fight the spread of antimicrobial resistance. In 2017, patients were prescribed 28 defined diurnal dosages of antibiotics per 1000 people in primary care in comparison to a median of 18 doses among OECD countries in 2017, ranking Italy the second highest in terms of antibiotic use (OECD, 2021b). More recent data shows that Italy was among the top five consumers of antibiotics among EU countries in 2020 (ECDC, 2022).
Indicators of avoidable hospitalization for ambulatory-sensitive conditions have been improving in recent years. These are defined as admissions for medical problems that are potentially avoidable if they are effectively managed in outpatient settings. In general, with reference to the standardized (daily and ordinary) hospitalization rate per 1000 inhabitants, the overall hospitalization rate in 2019 was 129.8 per 1000, lower than the established national benchmark. In 2019, 12.3 daily and ordinary hospitalizations per 1000 were potentially inappropriate, as defined by the Prime Ministerial Decree of 12 January 2017, with the trend during 2016–2019 showing noteworthy improvements.
Italy has among the lowest hospitalization rates in the EU for diabetes, and for asthma and chronic obstructive pulmonary disease (COPD) (OECD, 2021b) (Fig7.3). For example, the hospitalization rate in adults for complications due to diabetes has shown a slight reduction, going from 0.42% in 2016 to 0.38% in 2019. Despite variability among regions, this value does not go above 0.6% (AGENAS, 2020) and observed differences have no geographically defined patterns, probably partly reflecting different prevalence of the disease among the Italian regions.
Fig7.3
The 2019 standardized hospitalization rate for children (under 18 years) for asthma was 0.40 per 1000 people (11% lower than in 2018), while for gastroenteritis, it was 1.64 per 1000 people (2% higher as compared with 2018) (ONSRI, 2020). An above-average rate was detected in a few regions, thus highlighting regional disparities. A declining trend has been seen for COPD in adults: the hospitalization rate for this clinical condition reduced from 2.35% in 2012 (AGENAS, 2020) to 1.07% in 2020 (AGENAS, 2021). In this case, though, a moderate inter- and intraregional variability is still noticeable. Of course, the possibility of these measures being linked to differences in prevalence in more polluted areas must be taken into consideration. Less favourable results are recorded for congestive heart failure.
In terms of the effectiveness of secondary care, 30-day mortality after admission from acute myocardial infarction (AMI) is a measure of the quality of hospital care for life-threatening conditions. In Italy, this mortality rate has improved over the past decade and compares well with other EU countries, with rates that are among the lowest in Europe, along with countries such as France, Germany and Spain (Fig7.4).
Fig7.4
Shedding light on the effectiveness and quality of preventive care, several national screening plans were put in place over the last decade to promote screening for common types of cancer such as breast, cervical and colorectal cancers. Although these programmes are offered free of charge for their respective target populations, coverage remains limited. Only about 61% of women in the target age group of those aged 50–69 were screened for breast cancer over the two years leading up to 2019, which is slightly above the EU average of 59% but considerably lower than, for example, the Nordic countries where breast cancer screening rates are over 80%. Screening rates for cervical cancer are much lower, with only 39% of women aged 20–69 screened over the past three years, compared with the EU average of 58 %. The COVID-19 pandemic saw the temporary suspension and delays in cancer screening programmes, with an impact on uptake rates in 2020 compared with 2019: early evidence suggests that screening rates for breast cancer fell by 38%, while those for cervical and colorectal cancer also fell by 43% and 48%, respectively.
Despite relatively low screening rates, five-year survival rates following diagnosis for these and other cancers are similar to other EU countries (Fig7.5), suggesting that the health system is generally able to provide effective and timely treatments for patients with the most common forms of cancer. However, caution is needed in interpreting these results due to the time lag in the data – the most recent available cancer survival rates cover the years 2000–2014.
Fig7.5
Antimicrobial resistance (AMR) remains a major public health concern in the European Union/European Economic Area (EU/EEA), with estimates showing that each year more than 670 000 infections are due to bacterial resistance to antibiotics and approximately 33 000 people die as a direct consequence. If no action is taken, it is estimated that AMR will result in a loss of US$100 trillion in economic output each year by 2050 and most importantly in the loss of 10 million lives worldwide. Antibiotics are used too much and often inappropriately, although there are signs of improvement. Italy is a country with a high rate of resistance, and the regional situation is patchy. Approximately one-third of deaths caused by AMR in Europe occur in Italy (c. 11 000).
On the verge of being finally approved is the new National Action Plan on Antimicrobial Resistance 2022–2025 (Piano Nazionale di Contrasto all’Antibiotico-Resistenza 2022–2025 – PNCAR) drafted by the Ministry of Health to outline the strategic guidelines and operational directions required to address the emergence of AMR over the following years, at the national, regional and local levels through a multidisciplinary vision and a multi-sector “One Health” approach.
Replacing the previous plan (PNCAR 2017–2020), the new Plan provides a strategy to combat antibiotic resistance based on inclusive governance. It is organized into four cross-cutting areas:
- Training;
- Information, communication and transparency;
- Research, information and bioethics;
- National and international cooperation
and three vertical pillars dedicated to key preventative interventions and controls:
- the integrated surveillance and monitoring of antibiotic resistance, antibiotic use, care-related infections and environmental monitoring;
- the prevention of care-related infections in hospital and community settings and infectious diseases and zoonoses (diseases that can be transmitted between animals and humans via direct or indirect contacts);
- the appropriateness of antibiotic use in both human and veterinary settings and proper drug management and disposal.
In addition, the Plan has six main objectives:
- reinforcing the One Health approach through the development of coordinated national surveillance of AMR and antibiotic use, preventing the spread of AMR in the environment;
- strengthening Healthcare Associated Infections (HCAI) prevention and surveillance in hospitals and community settings;
- promoting the appropriate use of antibiotics and to reduce the frequency of infections caused by resistant microorganisms among humans and animals;
- fostering innovation and research on the prevention, diagnosis and treatment of antibiotic-resistant infections;
- strengthening national cooperation and Italy's participation in international initiatives in combating AMR;
- improving public awareness and promoting training of health and environmental professionals on countering AMR.
The Plan also includes several practical recommendations aimed at various stakeholders (manufacturers, pharmacists, health professionals and patients). For example, it recommends that general practitioners and paediatricians prescribe antibiotics following guidelines based on the latest scientific evidence; it also recommends that schools implement programs and actions to promote awareness and to help counteract AMR.