The 15 Italian hospitals of excellence: performance, regional gaps and challenges for public health

Meanwhile, summarising the main data of the 2024 National Outcomes Programme was Health Minister Orazio Schillaci, who hosted the presentation at the ministry's headquarters in Rome: 'The 2025 edition,' he recalled, 'coincides with the tenth anniversary of the entry into force of Ministerial Decree 70/2015 and gives us the opportunity to take stock of the evolution of the National Health Service. The data of this edition confirm a fundamental principle: when the system operates with national standards based on precise regulatory references and with effective monitoring tools, the system improves overall. The concentration of complex casuistry in centres that guarantee high volumes of activity - correlated with greater effectiveness - has recorded notable improvements: among others, I would like to mention breast surgery, which has gone from 72% in 2015 to 90% in 2024 in almost 10 years, as well as lung cancer (from 69% to 83%) and prostate cancer (from 63% to 82%)," the minister pointed out.
What does this data tell us? That in recent years," Schillaci went on to say, "a higher quality and safety of care has been guaranteed in the oncology area, thanks to the propulsive capacity of Ministerial Decree 70, which has led to the concentration of more complex operations in qualified facilities and, therefore, in the hands of more expert operators. With regard to the maternal-child area, there has been a gradual reduction in caesarean sections, which have fallen from 25% in 2015 to 22% in 2024, and the percentage of vaginal deliveries after caesarean section has slowly increased. So these are steps forward, but we must and can do better to increase clinical appropriateness in this area'. Outcomes are also improving: for example, the mortality rate for isolated coronary artery bypass falls to 1.5 per cent, and that following heart valve surgery to 2 per cent.

"However, there is no shortage of criticalities," the minister warned, "In fact, as in other areas of healthcare, a significant North-South divide remains. I am thinking of the concentration of complex oncological procedures, which in the South still struggles to reach the expected standards, especially for pancreatic cancer (only 28% in high-volume centres) and rectal cancer. The timeliness of access to life-saving procedures also varies considerably between the North and the South, as does clinical appropriateness in the maternal and child sphere, with particular reference to primary and repeat caesarean sections'.

"This year's novelty," emphasised Giovanni Baglìo, coordinator of the Agenas National Outcomes Programme, "is the 10th anniversary of the issuance of Ministerial Decree 70, and the reflection focuses on the extent to which this instrument has succeeded in influencing processes and outcomes with respect to thresholds. The general consideration is that the system is able to evolve when there are clear references at the national level and when monitoring systems manage to photograph and support change. Where this does not happen or has not happened, the system struggles to evolve or even goes backwards'. Translated: where Ministerial Decree 70 produced thresholds, that is, it set standards and was transposed, improvements are there. But the thresholds at the time were not set for all areas and improvement has occurred where the monitoring systems have worked: there are cases where this has happened and others where something has gone wrong.

The case of oncological surgery, a two-faced Janus from the point of view of outcomes, is emblematic: on the one hand, there is the virtuous case of malignant breast cancer, where today almost 90 per cent of cases are concentrated in high-volume centres. This is no coincidence: for this type of cancer, Ministerial Decree 70 had produced national evaluation thresholds and devices, such as the Pne, but also regional ones, making it possible to monitor the trend, and there has been a broad mobilisation of the regions and professionals. It is quite a different matter for rectal cancer: here, in the absence of national thresholds, the monitoring systems have acted with difficulty because this tumour has often been confused and amalgamated with colon cancer, which is an entirely different type of pathology and requires surgery of a different complexity. Even for rectal cancer there is a worsening: high volume facilities are decreasing and the capacity to concentrate operations has fallen from 30 per cent to 22 per cent. But why have the thresholds not been produced for some pathologies? 'Because for some pathologies the literature has increased in the meantime, there is more documentation on the existence of a relationship between volumes and outcomes, and therefore DM 70 must be updated to redefine the thresholds that are there and insert new ones. Ten years ago breast cancer was a priority on which we rightly focused, but other important pathologies have remained in the shadows,' Baglìo further explains.

A discourse that does not only apply to oncology: in the cardiovascular area, in 10 years there has been a 21% decrease in heart attacks, but above all, the caseload has been concentrated in qualified facilities thanks to the cardiological emergency networks where there are hub and spoke centres. A person with a heart attack therefore today has a high probability of ending up in qualified facilities. The case of coronary artery bypass surgery is different: here it is difficult to concentrate operations because there are too many cardiac surgeries and because the caseload is shrinking in the face of the difficulty of concentrating patients in highly qualified facilities. Here too, a greater effort should be made from the point of view of regional planning and networks, and this is what the data should be used for.

Crucial, then, is the issue of governance: the Pne data are needed to govern the system, but the compass of Ministerial Decree 70/2015 must be updated. This is an issue on which the ministry has formally started a table for years, but we are still waiting for a decree with new thresholds - which must be maintained just like the indicators - on problematic aspects of care management.

On the caesarean section front, we are clearly on the upswing compared to the years when Italy was running at 40%, and if in recent years we have seen a minimal reduction," Agenas explains, "it is because the big drop in operations had already taken place. However, Italy is still well above the 15% standard set by the World Health Organisation (WHO): caesarean sections are falling slightly from 25% in 2015 to 22% in 2024, but with large differences between North and South, with median values in the South often above 25% with peaks of 30 and 35%. Moreover, there are areas of the country where birthplaces below 500 deliveries per year continue to be kept open, despite the law requiring their closure. More generally, there is less recourse to surgery for an event that should be as natural as childbirth in public hospitals and high-volume centres, generating a high level of inappropriateness.

Tracing plastically the fracture that remains between the North and South of the country with the South at a disadvantage is the list of excellences: only the Aou Federico II of Naples in Campania is among the 15 facilities assessed out of at least 6 areas that have reached a 'high' or 'very high' level. The others are divided between Lombardy (5 centres), Veneto (3 centres), Emilia-Romagna (2 centres), then Tuscany, Marche and Umbria, each with one centre. This means that the big facilities are almost all in the North and this remains a problem, even if the South shows progress over time. The crux for 2024 remains the great fragmentation in oncology, for example, with the pancreas centres still in a dramatic condition, and the gap also remains in the maternal-child area.

In the meantime, the Regions that accumulate the 15 top facilities in all areas are celebrating Pne: 'These numbers,' explains Lombardy's Councillor for Welfare Guido Bertolaso, with the 5 super-promoted centres, 'are not the result of chance, but of the integrated work of hospitals, professionals, and regional governance. Our priority remains that of guaranteeing safe, timely and adequate care for the needs of a large and complex population. The Pne results confirm that we are on the right track and stimulate us to continue with further investments and improvements'. Two hospitals in Emilia Romagna are at the top: 'A result that fills us with pride and is further proof of the level of excellence of our regional healthcare system,' emphasises the councillor for Health Policies, Massimo Fabi. 'Even more important, because the certification comes from an authoritative and 'third' observatory such as Agenas, the government agency. The report," he continues, "contains very positive data in all the evaluation items and for numerous facilities, confirming the excellent work carried out every day by doctors, nurses, and health workers in our Region."
The Marche Region then recalls that in that region, "the one to excel, once again, is the Umberto I - Lancisi Hospital of Ancona, which reaches high/very high levels in seven areas evaluated. These areas are: cardiovascular, nervous system, respiratory, general surgery, oncological surgery, osteomuscular, and nephrology. "We know," commented Health Councillor Paolo Calcinaro, "that there is still a lot of work to be done on various issues, but what comes out of the national level is a fact about which there must be awareness: Marche has many excellences, high levels in many areas and in various facilities. I applaud Torrette and its team, from the wards to emergency/urgency. Now let us continue working on the issues to be improved, first and foremost on waiting list times, a national problem and not a regional one'. For Umbria, it is President Stefania Proietti who comments: "The fact that the region does not have any structures that have fallen behind on quality standards, and that several garrisons are showing concrete improvements, confirms the commitment of the professionals and company management. We will continue to work tirelessly to guarantee public health and healthcare services that are increasingly effective and close to the citizens'.

Minimally invasive surgery is among the novelties of this latest edition of the National Outcomes Programme: this approach exposes the patient to fewer complications such as infections. Ditto for robotics, which must be monitored because for some areas there is a lack of evidence. In general, the data are satisfactory thanks to an increasingly widespread use of these techniques, especially in the urological field, also with the overcoming of the "open" approach (with percentages even higher than 80%).
The monitoring of the territory is still around the corner: for the moment we still look at the data of the Hospital Discharge Cards and this means that today quality is measured indirectly, using indicators of avoidable hospitalisation, that is, hospitalisations that would be avoidable if the territorial assistance were of a good level.
On heart failure the data show that there has been no improvement and above all that there is wide variability within territories, which is probably an indirect measure of the fact that territorial care is not uniform. Even more striking is this data for diabetes: in the South, medium- and long-term complications are greater, and the most impactful one, limb amputation, still shows a hospitalisation rate twice the national median.