Zoino, Claudia (2023) Modello innovativo per la medicina territoriale. [Tesi di dottorato]

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Abstract

The aging population and the rise of chronic-degenerative diseases have reshaped the healthcare landscape, advocating for a shift from hospital-centric care to the paradigm of "territorial medicine." This transition places the focus on providing care for chronic diseases directly in the patients' residences, placing the patient at the core of their healthcare journey. The recent pandemic has underscored the crucial need to strengthen territorial medicine services, revealing disparities among Italian regions. With a specific focus on home palliative care, integrated into the National Health System in 1999, this study delves into the innovative model implemented by ASL Napoli 1 Centro. This unique model addresses complex demographic challenges, especially in neighborhoods marked by high levels of deprivation. The study, conducted exclusively in the municipality of Naples, a city with diverse socio-economic and healthcare structures, involves a retrospective analysis of the UOSD database over three years (2020-2022). Collected patient data includes age, gender, district of residence, address, enrollment date, decease date, and pathology type. Additionally, a semi-structured qualitative interview was conducted with the UOSD manager, Dr. Antonio Maddalena. The statistical analysis of home palliative care data for neoplastic diseases, performed using Stata 15 software, utilized the χ²-test and Fisher's exact test to examine correlations between variables such as gender, type of neoplasia, and decease, with a significance threshold set at P<0.05. Georeferencing of patients' health districts during the considered period employed Google Earth OpenGL, followed by coordinate processing through the Geographic Information System (QGIS.org, 2023), resulting in a map illustrating service density variations across districts. Results indicate that 5427 patients were enrolled for home palliative care during the study period, comprising 48% women and 52% men, with an average age of 72 years. The average survival period was less than one year. Geographical analysis unveiled significant disparities in the activation of home palliative care across different city neighborhoods, suggesting service density variations. Despite the Covid-19 pandemic, the service for terminally ill oncology patients remained stable, showcasing the adaptability and efficiency of the organizational model. However, challenges emerged in enrollment times and the cultural perception of palliative care as a precursor to death. A proposed organizational model features a single supra-district central unit, comprising specialized palliative care physicians and nurses. Patients submit requests to this unit, and physicians conduct preliminary enrollment visits before forwarding requests to UOSD with accurate medical histories and the requested service level (I-II-III). This streamlined approach aims to reduce service activation times to approximately 72 hours. A Gantt chart visually represents the four-stage chronology (T0-T1-T2-T3) required for implementing the new organizational model. The data collection process revealed fragmentation in UOSD's database implementation, likely linked to non-uniform data entry. Thus, a new database, ensuring uniformity, was proposed and developed. In conclusion, amidst demographic aging and socio-economic disparities, ensuring continuity and coherence in care delivery represents a primary priority. This priority is driven not only by the perspective of enhancing healthcare appropriateness and reducing unnecessary hospitalizations but also, and most importantly, by the aim to generate value for the patient. Lastly, our contribution lies in proposing a model aligned with Article 32 of the Italian Constitution, seeking to reduce hospitalization costs and ensuring a dignified end-of-life experience for every Neapolitan and Italian citizen.

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