Regional Health Agency Research Articles

CPC-018 AnETh: An Original Tool For Assessing, Promoting and Improving Your Patient Education (PE) Programme

BackgroundIn France, the annual self-assessment of PE programmes is recommended by the Regional Health Agencies. This analytical approach, necessarily time-consuming and structured, is a challenge for any team. However, it...

Patient mobility for cardiac problems: a risk-adjusted analysis in Italy

BackgroundThe Italian National Health System was revised in the last 20 years, introducing new elements such as efficacy, efficiency and competitiveness. Devolution to regional authorities has created a quasi-market system where patients can choose the hospital in which to be treated. Patient mobility therefore becomes an indicator of perceived hospital quality and of financial flows between the regions of Italy. Previous studies analyzed patient mobility in general or by specific disease/diagnosis-related groups but there is a lack of research on the influence of severity of patient condition. The aim of the study was to describe patient mobility, crude and stratified by disease severity, in cardiac surgery units of three health areas (HAs) in Tuscany (Italy).MethodsIn this retrospective observational study, data was gathered from hospital discharge records obtained from the Tuscan Regional Health Agency, Italy. The three HAs (HA1, HA2, HA3) recorded 25,017 planned hospitalizations in cardiac surgery units in the period 2001–2007. Patients were stratified in four All Patient Refined Diagnosis Related Group (APR-DRG) severity levels. Gandy’s nomogram was used to describe how HAs met health care demand and their capacity to attract patients. Cuzick’s test was used to identify significant differences in time trends.ResultsRaw data showed that the HAs met their own local health care demand. Stratifying by APR-DRG severity, it emerged that capacity to meet local demand remained unchanged for zero-to-minor severity levels, but one HA was less able to meet demand for moderate severity levels or to attract patients from other HAs and Regions of Italy. In fact, HA3 showed a decrease in admissions of local residents.ConclusionsThe study highlights important differences between the three HAs that were only revealed by severity stratification: unlike HA3, HA1 and HA2 seemed able to deal with local demand, even after severity stratification. Planners and researchers can benefit from risk stratification data, which provides more elements for correct comparisons and interventions. In the context of patient mobility, the present study is a step in that direction.

Éducation thérapeutique du patient : état des lieux des programmes en région Provence-Alpes-Côte d’Azur en 2008 avant la parution des textes officiels sur les autorisations de l’Agence régionale de santé

BackgroundAt the request of the Hospitalization Regional Agency (ARH) – in the context of the 2007–2011 plan aimed at improving the quality of life for patients affected by chronic diseases – the purpose of this work was to draw up a clear assessment of the 2008 Therapeutic Education programmes in the Provence-Alpes-Côte d’Azur (PACA) region. The study was carried out before the publication of the therapeutic education statutory orders and ARS (regional health agency) authorizations. MethodsCross-sectional study, carried out in the three sectors of medical management in the region – namely health-care institutions, ambulatory structures and health networks – made it possible to identify, first, which structures had actually launched therapeutic education programmes and then, how the procedures had been designed and set up. ResultsAmong all the medical structures investigated, the study has listed 491 programmes, heterogeneously located throughout the PACA region. These programmes primarily target diabetes, respiratory and cardiovascular diseases. Their main objectives are the patients’ quality of life, adherence to treatment and protective health behaviour (health improvement). The hospitalization sector programmes preferentially target the 30 to 60years old, whereas the ambulatory and health networks programmes are more inclined to target the over 60years old part of the population. More than 50% of the professionals involved in the programmes have never benefited from a specific training concerning the patients’ therapeutic education. ConclusionThis study has pointed out a great number of important aspects which need drastic improvement in terms of therapeutic education organization – the involvement and training of health professionals, for instance.

Overwhelming Sepsis after a Cat Bite

In mid-June, a 52-year-old man presented to the emergency department with fever, chills and a rapidly progressing erythema on his right hand without regional lymphadenopathy, a few days after being bitten by his domestic cat. The patient resided in a rural area and had a history of chronic alcohol consumption. The cat lived primarily outdoors and its immunization status was unknown. Pasteurella multocida cellulitis was suspected, oral amoxicillin-clavulanate was prescribed and the patient was discharged. Three days later, the cellulitis regressed completely but the patient sought medical attention for persisting fever and new-onset jaundice and dyspnea. On physical examination, he was hypotensive, exhibited hepatosplenomegaly and presented a centimetric necrotic ulcer on his right hand. The patient’s hematological results revealed leukopenia, thrombopenia and an elevated international normalized ratio. His biochemistry results revealed acute renal and liver failure. His chest radiograph was normal. The patient’s condition rapidly deteriorated to septic shock and multiple organ failure. He required mechanical ventilation, vasopressive support and renal replacement therapy. Intravenous piperacillin-tazobactam and vancomycin were empirically started; he was transferred to a tertiary care hospital the next day. On arrival to the intensive care unit, a septic workup was repeated and the patient’s hand ulcer was surgically debrided and tissue was sent for culture. Antibiotic treatment was switched to intravenous meropenem and vancomycin for sepsis of unknown origin. The patient developed further ascites. A percutaneous cholecystostomy was performed for suspected acalculous cholecystitis. The bile and the cloudy ascitic fluid were also cultured. Despite aggressive medical therapy, the patient’s condition failed to improve during the following two days and the family decided not to further pursue active treatments. At the time of the patient’s death, viral hepatitis serology and all bacterial cultures were negative. The following day, the aerobic blood cultures showed small Gramnegative coccobacilli. What is the diagnosis? DIAGNOSIS After four days of incubation, the plates of aerobic blood cultures grew small grey colonies on chocolate agar and on initial sheep blood agar. The same isolate was identified in all other specimens (necrotic ulcer, bile, ascites and endotracheal secretion). Laboratory technicians were instructed to handle the plates inside the biosafety cabinet because Francisella tularensis was suspected. The Gram stain of the colonies showed the same tiny Gram-negative coccobacilli. The organism was tetramethyl-oxidase negative, weakly catalase positive and nonmotile. The isolate was sent to the provincial reference laboratory, which confirmed the identification of F tularensis. Following the postmortem diagnosis, an investigation headed by the regional public health agency revealed that the cat was still in good health and its serology for F tularensis was negative. Other domestic and wild animals in the area also tested negative. There were no other cases of tularemia reported in the region during the rest of the summer. Nevertheless, informational pamphlets on tularemia were distributed to local small game hunters and warnings were published in regional newspapers to increase public awareness. DISCUSSION

Set-up of a multidisciplinary care for neurologic patients’ pressure sores

Multidisciplinary care of pressure sores is organized in the department of physical medicine and rehabilitation of R.-Poincare hospital since 2010. The patients’ selection is performed after a telephone conversation (214 patients in 2011). Patients from Ile de France area with neurological pathologies are selected for the follow-up (spinal cord injury, multiple sclerosis, spina bifida). A physician and a nurse see together the patients the first time. The follow-up is secondary performed essentially by a nurse. Two times per month, patients with a surgical indication are showed to a plastic surgeon. Two thirds of the patients need a medical healing, one third need a surgical procedure. One important part of the follow-up is dedicated to prevention and information of patients. A physiotherapy or occupational therapy evaluation is proposed to patients according to their needs (transfers, wheelchair choice, cushion, home and car layouts. . ..). A social, psychological and dietetic follow-up is proposed to the patients. A program of therapeutic education is organized since 2011, validated by the regional health agency. Among 110 patients followed-up during 2011, 84 benefit from a therapeutic education program. One multidisciplinary consultation is organised each month including PMR physicians, plastic surgeon, nurses, physiotherapist, occupational therapist, dietician, social worker. Five to six patients with complex medical history are seen each month to discuss the therapeutic strategy. Collaboration is also necessary with internal medicine department (infectious and nutritional disorders) and orthopedic surgery department (bone infection). If urological or bowel-stomy are necessary, specialized surgeons are requested. Pressure sores care need a multidisciplinary team involving numerous stakeholders. Prevention, therapeutic education, medical and surgical care are the different elements to organize in order to ensure an optimal care of patients.

A report on the large measles outbreak in Lyon, France, 2010 to 2011

In 2010 and 2011, the city of Lyon, located in the Rhône-Alpes region (France), has experienced one of the highest incidences of measles in Europe. We describe a measles outbreak in the Lyon area, where cases were diagnosed at Lyon University hospitals (LUH) between 2010 and mid-2011. Data were collected from the mandatory notification system of the regional public health agency, and from the virology department of the LUH. All patients and healthcare workers who had contracted measles were included. Overall, 407 cases were diagnosed, with children of less than one year of age accounting for the highest proportion (n=129, 32%), followed by individuals between 17 and 29 years-old (n=126, 31%). Of the total cases, 72 (18%) had complications. The proportions of patients and healthcare workers who were not immune to measles were higher among those aged up to 30 years. Consequently, women of childbearing age constituted a specific population at high risk to contract measles and during this outbreak, 13 cases of measles, seven under 30 years-old, were identified among pregnant women. This study highlights the importance of being vaccinated with two doses of measles vaccine, the only measure which could prevent and allow elimination of the disease.

Institutional change and Institutional Integration in France: Health Regional Agencies. What consequences for the development integrated services delivery?

Institutional change and Institutional Integration in France: Health Regional Agencies. What consequences for the development integrated services delivery?

Institutional change and Institutional Integration in France: Health Regional Agencies what consequences for the development of integrated services delivery?

The International Journal of Integrated Care (IJIC) is an online, open-access, peer-reviewed scientific journal that publishes original articles in the field of integrated care on a continuous basis.IJIC has an Impact Factor of 5.120 (2020 JCR, received in June 2021)The IJIC 20th Anniversary Issue was published in 2021.

Integrating a framework for conducting public health systems research into statewide operations-based exercises to improve emergency preparedness

BackgroundDue to the uncommon nature of large-scale disasters and emergencies, public health practitioners often turn to simulated emergencies, known as “exercises”, for preparedness assessment and improvement. Under the right conditions, exercises can also be used to conduct original public health systems research. This paper describes the integration of a research framework into a statewide operations-based exercise program in California as a systems-based approach for studying public health emergency preparedness and response.MethodsWe developed a research framework based on the premise that operations-based exercises conducted by medical and public health agencies can be described using epidemiologic concepts. Using this framework, we conducted a survey of key local and regional medical and health agencies throughout California following the 2010 Statewide Medical and Health Exercise. The survey evaluated: (1) the emergency preparedness capabilities activated and functions performed in response to the emergency scenario, and (2) the major challenges to inter-organizational communications and information management.ResultsThirty-five local health departments (LHDs), 24 local emergency medical services (EMS) agencies, 121 hospitals, and 5 Regional Disaster Medical and Health Coordinators/Specialists (RDMHC) responded to our survey, representing 57%, 77%, 26% and 83%, respectively, of target agencies in California. We found two sets of response capabilities were activated during the 2010 Statewide Exercise: a set of core capabilities that were common across all agencies, and a set of agency-specific capabilities that were more common among certain agency types. With respect to one response capability in particular, inter-organizational information sharing, we found that the majority of respondents’ comments were related to the complete or partial failure of communications equipment or systems.ConclusionsUsing the 2010 Statewide Exercise in California as an opportunity to develop our research framework, we characterized several aspects of the public health and medical system’s response to a standardized emergency scenario. From a research perspective, this study provides a potential new framework for conducting exercise-based research. From a practitioner’s perspective, our results provide a starting point for preparedness professionals’ dialogue about expected and actual organizational roles, responsibilities, and resource capacities within the public health system. Additionally, the identification of specific challenges to inter-organizational communications and information management offer specific areas for intervention.

National Health Surveys and Health Policy: Impact of the Jamaica Health and Lifestyle Surveys and the Reproductive Health Surveys

Over the last six decades, comprehensive national health surveys have become important data-gathering mechanisms to inform countries on their health status and provide information for health policy and programme planning. Developing countries have only recently begun such surveys and Jamaica has been at the forefront of this effort. Jamaica's Reproductive Health Surveys and programme response to their findings have resulted in an almost 50% reduction infertility rates over three decades as well as a 40% reduction in unmet contraceptive needs and a 40% reduction in unplanned pregnancies over the last two decades. The Jamaica Health and Lifestyle Surveys have served to reinforce the major burden that non-communicable diseases place on the society and the extent to which these are driven by unhealthy lifestyles. These surveys have shown that obesity, hypertension, diabetes and dyslipidaemia affect approximately 50%, 25%, 10% and 10% of the adult population, respectively. These surveys have documented low rates of treatment and control for these chronic non-communicable diseases despite two major policy initiatives, the National Programme for the Promotion of Healthy Lifestyles and the creation of the National Health Fund which subsidizes healthcare provision for chronic diseases. In order to maximize the uptake of the findings of future surveys into effective health policy, there will need to be effective collaborations between academia, policy-makers, regional and international health agencies, non-government organizations and civil society. Such collaborations should take into account the social, political and economic issues, thus ensuring a more comprehensive approach to health policy and result in improvement of the nation's health status and by extension national development.

Characterization and burden of Campania children health migration across Italian regions during years 2006–2010: chance and/or necessity?

BackgroundTo evaluate medical, economical and sociological variables underlying avoidable pediatric migration from Campania region.MethodsAnalysis of years 2006–2010 hospital discharge records, extracted from the archive of Regional Health Agency (ArSan), classified by Major Diagnostic Categories, Aggregate Clinical Codes, Discipline of dismissal, Local Health Authorities of residence, and age group 0–14 years (excluding those of healthy newborns). Sociological variables were evaluated by questionnaires.ResultsA total of 68,316 hospital discharge records were released by extra-regional structures. Major diagnostic categories and Discipline of dismissal indicated that the most implicated diseases (nervous system and mental disorders, hematology-oncology, and bone diseases) were not always of very high complexity. The total cost paid by the Campania Region was 124.700.000 Euros. The need for more specialized hospital pediatric units and/or with more pediatric subspecialties in the native region was pointed out by most of the self-administered questionnaires.ConclusionsPediatric migration is an important phenomenon with evident implications. The identification of the most concerned sub-specialties here reported can give useful information aiming to assist in the improvement of the existing pediatric resources in Campania region in the wider context of the national global child health advancement.

Conception d’un programme d’éducation thérapeutique pour les patients porteurs de lymphœdème : « Vivre avec un lymphœdème »

Lymphedema is a chronic condition considered to be rare in its primary form and potentially frequent in women after breast surgery for cancer: 27,000 new cases annually. Therapeutic management is a serious challenge. In France, the health authorities (Haute Autorité de santé [HAS]) have recently proposed that appropriate management practices for lymphedema include "patient education". The HAS and the National institute for health care prevention and education also published a methodology guide devoted to structuring a therapeutic education program for patients with chronic disease. Current hospital regulations state that this education program is part of the care to be delivered to patients with chronic disease and that it must comply with the national directives. The purpose of our present work was to present the concept and the contents of a patient education program entitled "Live with lymphedema" designed for patients with lymphedema and developed within the inpatient-outpatient network GRANTED in Sud-Isère. A standard detailed educative approach was applied. It was designed after the educational program for patients with lower limb arterial occlusive disease authorized by the Rhône-Alpes regional health agency. It was adapted to the specific problematic of patients with lymphedema, including medical management, rehabilitation, dermatology and nutritional aspects. It was developed in cooperation with patients and favors local associative actions. The specifically structured program included three therapeutic education consultations and five workshops. Less than one year after its institution, more than 30 patients have participated in the program. We report a structured patient education program designed for patients with lymphedema. This program was authorized by the Rhône-Alpes regional health agency in March 2011 and is in compliance with the national directives and HAS guidelines.

Les principes de l’éducation thérapeutique du patient

Therapeutic patient education (TPE) has an important role in chronic medical diseases, which affect an estimated 15 million patients in France. From a legal perspective, TPE programs must conform to specifications established by a national decree and be authorized by the Regional Health Agency. Guidelines from French National Authority for Health and National Institute for prevention and health education provide recommendations on the practice of TPE. TPE must conform to a rigorous methodology in terms of program implementation and skills development of the care providers. TPE programs must be integrated into standard patient care and are generally carried out by a group of health professionals. A personalized approach to patient education initially includes education regarding the diagnosis, also known as a “shared educational assessment”, consisting of individualized education, group educational sessions and an evaluation. Care providers should adopt an educational posture during interviews and group activities, which consequently promote listening, patient expression, patient understanding and the formulation of appropriate educational goals. To achieve these goals, formal TPE training of care providers is essential.

The response of the Liguria Region (Italy) to the pandemic influenza virus A/H1N1sv.

Influenza is a cause of acute respiratory disease. It has a typical epidemic nature during the winter season, but may also assume a pandemic pattern when a completely new virus spreads among humans. Influenza places a heavy economic and healthcare burden on both the National Health Service and society. During the 2009/2010 influenza pandemic season, the Liguria Region drew upon the specific skills of the various sectors of the Department of Health and Social Services. In collaboration with the Department of Health Sciences of the University of Genova, the Regional Health Agency (RHA) and other public organizations, steps were taken to address the issues of technical and scientific updating and the coordination of all the departments of Local Healthcare Units in Liguria. The main activities conducted at the regional level provided an adequate response to the influenza pandemic. These activities focused on Local and National Influenza Surveillance Systems, the regional Pandemic Plan, vaccination strategies for seasonal and pandemic influenza, and the communication of data from monitoring programs (sentinel physicians--syndromic surveillance). The prevention of influenza transmission and containment of epidemics and pandemics require effective communication strategies that should target the whole population.

Investigation on seasonal influenza vaccination among children with high-risk medical conditions who live in the area of Local Health Agency 4 "Chiavarese".

The Italian Ministry of Health recommends influenza vaccination in patients with chronic diseases associated with an increased risk of influenza complications. We estimated the number of patients aged from 6 months to 14 years with chronic diseases living in the area of Local Health Agency 4 "Chiavarese". In order to estimate the number of children with chronic diseases, we evaluated data from three sources: the Health Charge Exemption Records Office; the "Nocchiero Project", implemented by the Regional Health Agency in 2009, and independent pediatricians. The pediatric population in the district of Local Health Agency 4 "Chiavarese" consists of 16,118 subjects. The percentage of children with high-risk medical conditions is 4.14% of the pediatric population according to records of health-charge exemption, 6.36% according to the "Nocchiero Project" data and 3.38% according to the data provided by pediatricians. In the 2010-2011 influenza vaccination campaign, 415 children were vaccinated at Local Health Agency 4 "Chiavarese"; 335 of these had chronic diseases. Vaccination coverage was estimated as 50.07% on the basis of the list of patients exempt from health care charges, as 65.68% by the independent pediatricians and as 31.45% according to the "Nocchiero Project" data. Our investigation underlines the difficulty of dividing subjects into different risk categories. The data provided by independent pediatricians yielded higher estimates of vaccination coverage in pediatric patients than the data from the other two sources. Estimates of vaccination coverage vary according to the source of data. However, pediatricians seem to be the most reliable source, as they know their patients better. Collaboration between health authorities and independent pediatricians should therefore be improved in order to obtain the best results in terms of influenza prevention in high-risk groups.

Potentially inappropriate drug prescription in the elderly in France: a population-based study from the French National Insurance Healthcare system

Inappropriate prescribing is a known risk factor for adverse drug event occurrence in the elderly. In various countries, several studies have used insurance healthcare databases to estimate the national prevalence of potentially inappropriate medications (PIM) in the elderly, as defined by explicit PIM lists. Recently, a representative sample of the French National Insurance Healthcare database, known as the "Echantillon Généraliste des Bénéficiaires" (EGB), was created, making it possible to assess the quality of drug prescription in France. Our objective was to evaluate the prevalence and the regional distribution of PIM prescription in the elderly aged 75years and over in France, using the French PIM list and the EGB database. The list of drugs reimbursed to patients aged 75years and over from 1 March 2007 to 29 February 2008 was extracted from the EGB. Drugs were classified as inappropriate using the French PIM list. A PIM user was defined as a person receiving at least one PIM reimbursement during the study period. Interregion variability was estimated from logistic regression. In 53.6% (95% CI: 53.0-54.1) of the elderly aged 75years and over, at least one PIM was given during the study period. The three main drug groups identified were cerebral vasodilators (19.4%), drugs with antimuscarinic properties (19.3%), and long half-life benzodiazepines (17.8%). There was an important disparity in PIM prescription among the French regions. In 14 out of 22 regions, the risk of PIM prescription was significantly elevated. This geographical variation differed for the different drug groups. PIM prescription in the elderly is a major and worrying problem in France. As in other countries, recent accessibility of the National Insurance Healthcare database makes it possible to create local indicators that the regional health agencies could use to manage public health policy in closer alignment to the needs of the patients within each French region.

Analysis and proposed model of family caregivers' relationships with home health providers and perceptions of the quality of formal services.

Relationships between families and home health nurses promote effective care and service access for those at end of life, positive caregiver experiences, and satisfaction with care. This study explores family caregivers' accounts of relationships with home care nurses; findings inform a model of relationships and satisfaction with home health services. Ethnographic, qualitative interviews were conducted with 26 bereaved caregivers in one Western Canadian regional health agency. Data analysis was informed by symbolic interactionism. Participants described their relationships with home care nurses and spoke about their assessments of the care provided. Findings highlighted the importance of the length, frequency, and continuity of contact, conversation, socializing, and sharing information. Participants were cognizant of their own and care recipients' roles in building relationship. Nurse behaviors demonstrating affection, acknowledgment, commitment, and understanding were appreciated. A model links relationship preconditions, relational demonstrations, and perceived care quality and may be used to identify points of intervention.

Bevacizumab and irinotecan in patients with recurrent glioblastoma (GBM): Results of a retrospective cohort study of the OMIT Bretagne and Pays de la Loire.

2086 Background: The OMIT (Drugs and Emerging Therapeutics Observatory) is a French structure created in 2003 by the Regional Health Agencies of Western France (Bretagne and Pays de la Loire). This network gathers clinical data from 50 public and private institutions. Its medical staff (oncologists, surgeons, pharmacists, biologists, etc) has a global reflection on drugs management in cancer patients and is also a task force for French Health Authorities. Despite several promising publications (Vredenburgh Clin Cancer Res 07, Kreisl JCO 09, Friedman JCO 09), the approval of bevacizumab in recurrent glioblastoma patients was declined, in November 2009, by European Medical Agencies. Methods: The aim of this retrospective study was to evaluate the objective responses, progression free survival, overall survival and tolerance of bevacizumab and irinotecan in community practice and, eventually, to define relevant criteria of responders. The data of 162 patients out of 200, treated between July 2007 and June 2010, have already been analysed. Results: 65% males, 35% females, mean age: 53 years [51-55]. 87% of the patients underwent a complete or partial tumor resection and 89% received the Stupp protocol as first line therapy. 31% discontinued treatment before 3 months. At 3 months, objective responses were observed in 43% of the patients and disease stabilization was achieved in 42% of them. The progression free survival and overall survival were respectively 5.57 months IC95% [4.88-6.25] and 8.07 months IC95% [7.11-9.03]. Grade 3-4 toxicities included haematologic (10%) and digesitve toxicities (4%), vein thrombosis and pulmonary embolism (3%), high blood pressure (1%), intratumoral bleeding (1%), asthenia (1%) and others (2%). They were mainly manageable. Updated results will be presented at the meeting. Conclusions: The first results of this cohort show that, after 3 months of treatment, 85% of the patients obtained a clinical benefit. Overall survival is comparable to those reported in other retrospective studies. Cost effectiveness and cost utility studies are necessary. A prospective study is needed to identify prognostic and predictive factors.

Précarité, tarification à l’activité et planification sanitaire et sociale : étude pilote à l’hôpital Lariboisière de Paris

Objectives This paper considers the specific administrative procedures set up by managers of public healthcare establishments and those responsible for health and welfare policies to care for low-income pregnant women for whom 100% of the “price per act” (T2A) is refunded. What are the limitations and what improvements can be suggested? Patients and method The results are based on an analysis of data from semi-structured interviews, legislation and documents. Results The State, health insurance systems, public health establishments, local authorities, charities and outpatient services are involved in handling low-income parturients in different services and different establishments, both locally and regionally. A health and welfare policy comprising specific, coordinated actions and measures has been developed. The T2A “price per act” system may threaten its survival: the limited number of front-line facilities is often saturated and demand is increasing, treatment is often reduced to reactive management leading to unwanted readmissions, ethics are sometimes called into question and there is a risk of patient selection. Discussion and conclusion This pilot study provided some encouraging information but also indicated the limitations of the approach adopted. However, it was still of interest to see whether it was possible to use this approach, which did not require considerable resources, to reveal useful markers. This appeared to be the case. Regional Health Agencies (ARS) and local authorities could support the system. Additional funding is needed.

Improving Stroke Care: A French Health-Care Organiser's Perspective

The French national action plan: 'Stroke 2010-2014' results from years of increasing concern related to stroke, initially carried by stoke physicians and progressively shared by all other health professionals and more recently by administration and politicians. Its aim is the development not only of stroke care networks, but also of prevention and health education. Its success will mainly depend on the reactivity of the regional health agencies; therefore it is important to maintain political momentum and pressure.