Objective - Following the introduction of guidelines of rational drug use, the pharmacoepidemiology of psychotropic drugs was investigated in a sample of long-stay patients living in a Italian psychiatric hospital. Design - Aprospective, longitudinal two-year follow-up study was carried out. Information about sociodemographic and clinical characteristics of the inpatientpopulation, and about medications prescribed, was collected at baseline and after one and two years of follow-up. Setting - Three wards of the psychiatric hospital of Milan. Main outcome measures - Number of patients taking psychotropic drugs, number of patients taking more than one neuroleptic or benzodiazepine, mean neuroleptic dose, psychopatological status according to the Brief Psychiatric Rating Scale (BPRS). Results 70 patients were recruited and followed for two years. At follow-up a reduction in the number of patients taking neuroleptic drugs was recorded, together with a 50% decrease in the number of patients taking more than one neuoleptic. A reduction in the use of depot formulations was in addition shown. Patients taking benzodiazepines decreased of 50%. According to the BPRS, no psychopatological changes were observed during the study. Conclusions - These data suggest that education in psychopharmacology may guide towards a more rational use of drugs; longitudinal clinical audits should be implemented to monitor everyday practice.

Objective – The study of the relation between treatment costs and disability of psychiatric patient groups. Design – Perspective assessment of costs and disability of 1371 adult psychiatric patients in charge at two Operative Psychiatric Units (OPU), followed during an average period of 9 months. Data are related to all OPU's psychiatric services, including ambulatory, full or half-residential and psychiatric departments of acute hospital services. Setting — OPUs of Magenta (MI) and Desio (MI). Methods – The disability level has been measured by Health of the Nation Outcome Scales (HoNOS) filled in at the inclusion of the patient in the study and every three—months on average thereafter. Besides other HoNOSs have been filled in both at admission and discharge from psychiatric departments of acute hospitals, Residential Centres of psychiatric Therapies and Rehabilitation and Guarded Communities. All patients have been grouped using the main psychiatric diagnosis (first digit ICD—10) and the maximum disability level shown in the whole period of the study. Direct costs of publicly financed psychiatric services have only been considered. Their attribution to each patient has been made applying standard costs or tariffs (diagnostic procedures) to the data perspectively collected by the regional Register and a purposely designed protocol. Results – Total cost of 1371 patients has been 9771.1 million lire with a cost per patient of 7127000 lire (sd 19499000) and a cost per «day in charge» of 27172 lire (sd 68358). The cost per day has been found unrelated with the length of observed time frame. At the inclusion the mean level of disability has been 4.26 points (sd 3.73) and 3.19 points (sd 3.26) at the end of the study. Its value, measured at maximum level shown by each problem in the whole period of study, has been 6.00 points (sd 4.64). Disability and treatment cost of each patient did result directly related (r = 0.626, p = 0.0001). All patients have been grouped in 12 classes with a significant (p = 0,0001) overall difference on both their disability level and treatment cost. Conclusion – All adult psychiatric patients could be grouped in disability related classes which sometimes have also a different treatment cost. A study on a greater number of patients is needed to confirm these results. It may also provide a more reliable basis for a new financing system of psychiatric services.

Aims – We wanted to investigate to what extent and in what characteristics the patients cared in the psychiatric residential facilities (RF) were similar to those in the day-centres (DC), and whether 6-month improvements in the two settings were comparable. Methods – We described 141 patients admitted to the RF and 180 in DC of three mental health service networks in Milan and near Milan. They were evaluated again after six months. Results – In both groups, we identified subgroups of more intensive treatment: 45% of those in residential treatment were in high intensity rehabilitation facilities, and those who followed a residential program of >12 hours/week were 53%. The mean duration of treatment in the residential treatment was 40 months (SD 55.7) and in DC 49.6 months (49.3). The two groups differed in the overall scores of the HoNOS, but differences emerged in the subscales relative to daily life activities and living conditions. Among those in RF, about half had a house, versus 99% among those in DC. After six months, clinically significant modifications were small in both groups. Conclusions – Residential patients had more needs than DC patients. It is possible that some of the residential patients might be treated with intensive DC program, but the absence of a home for the majority of residential facilities patients makes this unlikely.

Declaration of Interest: None.

Aims – To evaluate the quality of acute psychiatric care concerning the management of violent behaviour and rapid tran-quilization. Methods – Data concerning 13 indicators, drawn from NICE recommendations, were collected in 19 Departments of Mental Health, in the frame of the SIEP-DIRECT's Project, to evaluate the implementation of NICE recommendations in Italian Mental Health Services. Results – In about two thirds of Departments of Mental Health (DMHs) professionals were trained in the management of violent behaviour, while written procedures existed only in one fourth of DMHs. About a half of the professionals working in Psychiatric Wards in General Hospital were trained in rapid tranquilization, while procedures on this topic are practically absent and specific care for monitoring intensively the heavily sedated patient was not frequent. Conclusions – Management of violent behaviour and rapid tranquilization are two critical areas in the care performed by Psychiatric Wards in General Hospital. Training on these topics is more frequent than implementation of procedures. NICE recommendations and SIEP indicators are useful tools for improving the quality of acute psychiatric care.

Declaration of Interest: None.

I provvedimenti legislativi (L. 502/92 e L. 517/93) che hanno prodotto la cosiddetta aziendalizzazione della Sanità hanno anche modificato il suo sistema di finanziamento: da un finanziamento dei fattori produttivi, a pie' di lista, a un finanziamento a prestazione con un sistema tariffario.

La Regione Lombardia, che ha particolarmente enfatizzato nel sistema sanitario riformato la separazione tra soggetto erogatore dei servizi (l'Azienda Ospedaliera) e il soggetto acquirente (l'ASL), per poter finanziare il servizio psichiatrico, erogato dall'Azienda Ospedaliera, ha esteso il sistema delle tariffe anche alla psichiatria, prevedendo attraverso atti regionali una puntuale valorizzazione di tutte le attività psichiatriche sia territoriali sia residenziali e semiresidenziali.

È risultato subito evidente che questo sistema presenta delle criticità, in parte contingenti: in particolare i DRG non descrivono in maniera adeguata la complessità del caso, mentre le tariffe delle prestazioni ambulatoriali non coprono adeguatamente i costi.

A fronte di queste criticità alia psichiatria si aprono due strade possibili: sottoporre a revisione DRG e tariffe oppure, in alternativa, remunerare i servizi sulla base dei bisogni di cura dei pazienti e della complessità dei trattamenti richiesti.

Il progetto ha rappresentato un notevole sforzo organizzativo, che ha coinvolto per un anno un ampio numero di DSM/UOP, di operatori e di pazienti.

La ricerca ha dimostrato che, all'interno e tra i Dipartimenti di Salute Mentale:

• possibile costruire un network di ricerca,

• che possono essere utilizzati nella routine strumenti per la valutazione della gravità e dell'esito,

• possibile raccogliere ampi campioni di pazienti rappresentativi della realtà clinica dei servizi,

• gruppi di clinici possono collaborare tra loro per raccogliere dati sull'effective-ness e sui costi dei trattamenti.

La possibilità di costruire un network di ricerca nei servizi clinici richiede uno sforzo organizzativo e ha un costo. Per fare questo sono necessari una struttura centrale in grado di dare supporto formativo, epidemiologico, informatico e di analisi, un sistema strutturato di incentivi scientifici e la restituzione agli operatori “in tempo reale” delle informazioni ricavate dalla ricerca.

Questa ricerca ha portato ad una estesa conoscenza sulle caratteristiche sociodemografiche e cliniche (diagnosi e gravità) dei pazienti in trattamento nei servizi di salute mentale: il campione indagato è il più ampio oggi raccolto in Italia. La ricerca è anche stata la prima esperienza nazionale di stima dei costi per 50 strutture, con analisi dei costi standard delle singole prestazioni e del pattern di trattamento annuo e relativi costi.