Across the world, life expectancy is increasing. However, the years of life gained do not always correspond to healthy life years, potentially leading to an increase in frailty. Given the extent of population aging, the association between frailty and age and the impact of frailty on adverse outcomes for older people, frailty is increasingly being recognized to be a significant public health concern. Early identification of the condition is important to help older adults regain function and to prevent the negative outcomes associated with the syndrome. Despite the importance of diagnosing frailty, there is no definitive evidence or consensus of whether screening should be routinely implemented. A broad range of screening and assessment instruments have been developed taking a biopsychosocial approach, characterizing frailty as a dynamic state resulting from deficits in any of the physical, psychological and social domains, which contribute to health. All these aspects of frailty should be identified and addressed using an integrated and holistic approach to care. To achieve this goal, public health and primary health care (PHC) need to become the fulcrum through which care is offered, not only to older people and those that are frail, but to all individuals, favoring a life-course and patient-centered approach centered around integrated, community-based care. Public health personnel should be trained to address frailty not merely from a clinical perspective, but also in a societal context. Interventions should be delivered in the individuals' environment and within their social networks. Furthermore, public health professionals should contribute to education and training on frailty at a community level, fostering community-based interventions to support older adults and their caregivers to prevent and manage frailty. The purpose of this paper is to offer an overview of the concept of frailty for a public health audience in order to raise awareness of the multidimensional aspects of frailty and on how these should be addressed using an integrated and holistic approach to care.

Although Italy’s NHS is funded through general taxation, the private sector plays an important role in health service provision and financing. The aim of this paper was to identify the sociodemographic and health service organizational factors associated with the propensity to seek specialist care in the private sector. Data were retrieved from the national Istat survey “Health conditions and use of health services” carried out in 2012–2013. We selected adults with a specialty visit in the previous 12 months in the four most frequent medical specialties: ophthalmology, cardiology, obstetrics/gynecology and orthopedics. The study outcome was the choice to use a private service. In order to investigate the determinants of private use, we adopted the socio-behavioral model by Andersen and Newman, making a distinction between sociodemographic and healthcare organizational factors. The associations with the outcome were analyzed using chi-squared test, t-test and multivariable logistic regression analysis. Use of private care varied widely, from 26.3% for cardiology to 53.6% for obstetrics/gynecology. Females, patients with higher educational levels and patients with higher self-reported economic resources sought more frequently private healthcare for all specialties; younger patients and employed patients were more likely to seek private care for ophthalmic conditions. Exemption from copayment for public services reduced more than half the propensity to seek private care. Trust in this healthcare service was the main reason for private users (52.5%) followed by waiting time (26.7%) and physician choice (20.1%). The attitude of the population to use private services for specialist visits is linked both to sociodemographic and health services organizational factors: the former are unmodifiable while the latter are susceptible to managerial and health policy actions. In a public-financed, universal coverage system, policy makers may act upon the organizational factors that make private health facilities more attractive in order to reduce private care use.

Background: Prompt and efficient identification and stratification of patients who are frail is important, as this cohort are at high risk of adverse healthcare outcomes. Numerous frailty screening tools have been developed to support their identification across different settings, yet relatively few have emerged for use in emergency departments (EDs). This protocol provides details for a systematic review aiming to synthesize the accumulated evidence regarding the diagnostic accuracy and clinimetric properties of frailty screening instruments to identify frail older adults in EDs. Methods: Six electronic databases will be searched from January 2000 to March 2021. Eligible studies will include adults aged ≥60 years screened in EDs with any available screening instrument to identify frailty (even if not originally designed for this purpose). Studies, including case-control, longitudinal, and cohort studies, will be included, where instruments are compared to a reference standard to explore diagnostic accuracy. Predictive accuracy for a selection of outcomes, including mortality, institutionalization, and readmission, will be assessed. Clinical and methodological heterogeneity will be examined, and a random effects meta-analysis performed if appropriate. Conclusion: Understanding whether frailty screening on presentation to EDs is accurate in identifying frailty, and predicting these outcomes is important for decision-making and targeting appropriate management.

Community hospitals (CHs) could address the emerging complex care needs of patients. We investigated which characteristics of patients’ and CHs affect patient outcomes, in order to identify who could benefit the most from CH care and the best skill mix to deliver this care. We analysed all elderly patients discharged from the CHs of Emilia-Romagna, Italy. CH skill mix and care processes were collected with an ad hoc survey. The primary outcome was improvement in the Barthel index (BI) on discharge. Hierarchical regression analysis was performed to test the associations under study. 53% of the patients had a BI improvement ≥10. After adjusting for the diverse case mix of the patients, no significant association was found between CH characteristics and BI improvement. Patient characteristics explained only a portion of the variability in CH performance. Heterogeneity in case mix reflects the nature of CHs, which play context-specific roles as integrators between primary care services and hospitals. Residual variability in BI improvement rates across CHs might be attributed to aspects of care not detected in our survey. More research is needed to study the impact of CH skill mix and care processes on patient outcomes.