Italy

Primary Care Pediatrics in Italy: Eighteen Years of Clinical Care, Research, and Teaching Under a National Health Service System

Stefano del Torso, MD*; Roberto Bussi, MD*; and Thomas G. DeWitt, MD

Since 1978 the Italian National Health Service (NHS) has provided pediatric primary care to children through the use of community-based pediatricians (pediatra di base).

The Italian NHS requires that all children have an identified primary care provider, either a pediatrician or a family practitioner, depending on the patient's age. Italian NHS pediatricians work in their own private offices, providing primary care for patients from birth to 14 years of age and are compensated under a capitation system. The NHS p secondary and tertiary care in the 0 to 6 age range, while parents can choose between a pediatrician or a general practitioner for their children’s care between 6 and 14 years of age.

Over 10 years ago Italian primary care pediatricians recognized the necessity of adapting their practice to the needs of a changing health care system as well as the new morbidity of childhood illnesses as described by Haggerty.

In Italy there are almost 6000 NHS primary care pediatricians (1994 data) taking care of more than 4 million patients from birth to 14 years of age, the majority of these patients are less than 6 years old.

The Veneto region in Northern Italy, where the Italian authors practice, has approximately 4.3 million inhabitants. Of these, 562 000 are less than 14 years old and 233 000 are less than 6 years old. In this area there are 435 practicing pediatricians. In the 0 to 6-year-old age group 85% of patients are under a pediatrician's care. The remaining 15% live in rural and mountain areas where only NHS family physicians are available, as most of the pediatricians are located in larger towns with more than 5000 inhabitants. The pediatric coverage drops to 54% in the total 0 to 14-year-old age group in the Veneto region and 44% in Italy; as in the United States, parents tend to use more general practitioners as primary care providers for their children after 6 years of age. Acute, chronic, and preventive care, through both office and home visits, are provided by the pediatricians, who are reimbursed under a capitated system that pays about $8.50 a month per patient. The NHS pediatrician cares for an average of 700 up to a maximum of 1000 patients, is available for patients from 8 AM to 8 PM, Monday to Friday and 8 AM to 2 PM on Saturday and, performs 4000 to 4500 visits a year. In addition to acute ambulatory and home care, responsibilities include coordinating the care of chronically ill patients, consulting with subspecialties, performing well baby health checks and all certifications for school activities, parent's absence from work, indemnities, and social welfare. Pediatricians, as well as general practitioners in the Italian NHS, are not allowed by law to take care of their patients during hospital admissions. Solo practices, mostly without nursing or secretarial staff, account for 95% of pediatric primary care practices and the pediatrician's expenses are mostly limited to telephone and office overhead in addition to travel expenses for home visits. Immunizations are usually performed by a different NHS community service. The NHS provides night and weekend phone coverage as well as urgent home care to all patients, using moonlighting nonpediatrician physicians. Both these services are provided to all patients free of charge. The major advantage of this system for the community is that health care is available to all children without any out-of-pocket expenses: health care costs are paid by tax money with a levy on gross income from 5% to 10%, paid principally by the employer with some employee contribution. Functionally, because all health care is funded through the government, the Italian NHS is a single payor system. This allows patients to choose their primary care physician/pediatrician, in contrast to the United States, where the employer may direct that choice. However, there is some restriction on the parents' choice of primary care providers for their children, due to the NHS limitation, by law, of a maximum of 1000 patients per pediatrician and a relative shortage of community-based pediatricians. Over the years, this system has been instrumental in building a trusting therapeutic relationship between parents, children, and their pediatrician. In the first patient satisfaction survey performed in Italy in the Veneto region, pediatricians in the system scored highest among all other NHS services.The Italian NHS, which accounts for approximately 8.5% of the gross domestic product (1994 data), is trying to control the increasing costs of health care by limiting physicians' reimbursements and applying copayments to laboratory tests and NHS subspecialty consultations. This has been done without offering incentives for cost saving to physicians, which may negatively affect the patient-physician relationship. As in the United States, it is anticipated that in the future the NHS will also implement quality assurance standards using outcome assessments in primary care. As it currently functions, however, the Italian health care system has resulted in a perinatal mortality of 9.5/1000 births, a neonatal mortality of 5.9/1000 live births, and an infant mortality of 8.1/1000 births.

The following national pediatric associations are involved in research in Italy: the Italian Society of Pediatrics (SIP-Societá Italiana di Pediatria) is the predominantly academic society; the Italian Federation of Pediatricians (FIMP-Federazione Italiana Medici Pediatri) is the trade organization of community-based practicing pediatricians, responsible for the development and evaluation of continuing medical education programs for its members; and the Pediatric Cultural Association (ACP-Associazione Culturale Pediatri), formed by community primary care pediatricians and hospital and academic pediatricians, who focus on research and education in general pediatrics. To address issues that face primary care child health providers in Italy, the previously mentioned 29 local associations of primary care pediatricians (affiliated with the ACP) have undertaken multicenter collaborative studies and developed practice guidelines through generalist/subspecialist discussions.
These studies have focused on common pediatric problems not usually addressed by research based in academic centers. For example, projects independently organized by Veneto's community pediatricians, include organizational issues of the pediatric practice, quality assurance, pharmacoeconomics of antibiotic therapy, practitioner education concerning counseling and structured paper medical records. All of these studies have been funded by the primary care pediatricians' associations, either at the regional or national level, with one exception that was partially funded by Veneto's Department of Health. Because all pediatric primary care in Italy functions under a capitated system with a single payor, Italian community pediatricians have neither had the need for sophisticated accounting and billing systems, nor, due to reduced needs for office staff, high overhead costs and administrative commitments found in the United States. In the Veneto region this situation has allowed information systems experts, community pediatricians, and members of the Associazione per la Ricerca e Formazione in Pediatria (APREF) the ability to collaboratively focus on the development of an electronic medical record system for pediatric primary care, that serves as a powerful data collecting instrument. To assess the impact that NHS-imposed demands has had on practicing pediatricians, this electronic system will link affiliated practices in the near future. Using statistical analysis modules developed by the same research group, data will eventually be gathered to measure and analyze the quality of services provided. It is anticipated that similar systems will be implemented elsewhere in Italy.

The process of becoming a pediatrician and selecting a career path in Italy begins with a university-based residency program in pediatrics (currently 4 years long, and as of next year, 5 years long) following common national requirements published by the Italian Department of Education. Residents must take yearly examinations and develop a research project that is presented at the end of the residency to become fully certified. This university certification (Diploma di Specialita) is valid nationwide. There is no national board examination. When fully certified as a pediatrician, one can apply for a job in a hospital (NHS), at a university, or as a primary care pediatrician (NHS). This process involves presenting a curriculum vitae, certifications of postgraduate training, and proof of working experience (locums, etc). Hospital and university positions, which require a copy of all publications as part of the application, are filled by a vote of committees from the respective institution. With regard to NHS primary care positions, there is a list of available pediatricians published yearly by the Health Department of the Regione and a list of possible (theoretical) vacancies published twice yearly. These possible vacancies are calculated considering the number of children living in the area. A pediatrician can apply for each vacant position and the local health authorities must call the pediatricians who have applied according to their rank in the regional list. They cannot select, but only ask if the next pediatrician is available to take the job. Continuing Medical Education (CME) is required by the NHS contract for primary care pediatricians. Each regional Health Department is responsible for the creation its own CME programs and must collaborate with the FIMP. This process usually includes the regional academic institutions. For the first time in Italy, the Regione Veneto Department of Health has designated the organization CESPER (Centro Studi per Ricerca e Formazione in pediatria territoriale), that represents both the Veneto-based primary care pediatricians' associations and FIMP, as the only entity for accrediting CME activity for community primary care pediatricians. Italian pediatricians read the Rivista Italiana di Pediatria (Italian Journal of Pediatrics [SIP]), which focuses on subspecialty pediatrics; Medico e Bambino (Doctor and Child, ACP), which is mostly practice-oriented and subscribed to by pediatricians and family physicians; the Italian translation of Pediatrics (which is a condensation of two issues into one through a selection of articles made by two scientific supervisors); and Pediatrics in Review, which is fully translated. In addition, most pediatricians also read many of the foreign journals, such as Lancet, the New England Journal of Medicine, Archives of Pediatrics and Adolescent Medicine, and the British Medical Journal in their untranslated form. Although primary care is clearly the critical base of any health care system, relatively few studies have addressed the information needs and concerns facing the practicing pediatrician with regard to the changing health care systems. These issues ultimately require incorporation into the education of pediatric residents and practitioners. In Italy there is not a formal regulatory organization corresponding to the Residency Review Committee in the United States; a committee of academic physicians provides general guidelines for post graduate training to be approved by the Italian Department of Education. The requirements for pediatric training in Italy recently published by the Department of Education do not include community-based primary care experiences and unlike the Residency Review Committee guidelines, encourage only in-hospital training experiences.Because of its intrinsic structure, the medical education system in Italy, based in hospitals and universities, may encounter some difficulty in effectively training residents for their future careers as competent, community-based, general pediatricians.  Presentations given by community-based primary care pediatricians to pediatric residents at the University of Padova created an impetus for an educational pilot study involving primary care pediatricians and residents of the Universities of Padova, Verona, Trieste, and Milano-Monza. In these institutions, residents have been placed in primary care pediatricians' offices for a month long rotation. A formal faculty development program to enhance the teaching abilities of the practitioners has also been organized. After these initial activities, a work group in pediatric primary care education produced a proposal for future primary care training in pediatric residency programs in Italy.This suggests that in Italy:

• The resident should attend the primary  care pediatricians'  offices once a week beginning in the second and/or third  year of the 5 years of postgraduate training;

• Clinical  problems that have a unique primary care dimension should be discussed in seminars scheduled throughout  the program and require the participation of all residents and  primary care preceptors;

• A teaching/learning plan and educational  methodology should be developed through a process of evaluation and  feedback, that could provide structure for the community  experience and serve as a powerful method of ongoing improvement for the  resident, the preceptor, and the residency program itself.
   
   
  Padova Italy; and the ‡Division of General and Community Pediatrics,

  Children’s Hospital Medical Center, Cincinnati Ohio.
  Received for publication Feb 23, 1996; accepted Jul 30, 1996.
  Address correspondence to: Thomas G. DeWitt, MD, Division of General
  and Community Pediatrics, Children’s Hospital Medical Center, 3333
  Burnet Ave, Cincinnati, OH 45229–3039.
  PEDIATRICS (ISSN 0031 4005). Copyright © 1997 by the American Academy
  of Pediatrics.