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Published in: BMC Health Services Research 1/2015

Open Access 01-12-2015 | Research article

Making patient centered care a reality: a survey of patient educational programs in Italian Cancer Research and Care Institutes

Authors: C. Cipolat Mis, I. Truccolo, V. Ravaioli, S. Cocchi, L. Gangeri, P. Mosconi, C. Drace, L. Pomicino, A. Paradiso, P. De Paoli

Published in: BMC Health Services Research | Issue 1/2015

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Abstract

Background

Educational intervention represents an essential element of care for cancer patients; while several single institutions develop their own patient education (PE) programs on cancer, little information is available on the effective existence of PE programs at the level of research and care institutes. In Italy such institutes - Istituti di Ricovero e Cura a Carattere Scientifico - are appointed by the Ministry of Health, and 11 (Cancer Research & Care Istitute-CRCI) of the 48 are specific for cancer on the basis of specific requirements regarding cancer care, research and education. Therefore, they represent an ideal and homogeneous model through which to investigate PE policies and activities throughout the country. The objective of this study was to assess PE activities in Italian CRCI.

Methods

We carried out a survey on PE strategies and services through a questionnaire. Four key points were investigated: a) PE as a cancer care priority, b) activities that are routinely part of PE, c) real involvement of the patients, and d) involvement of healthcare workers in PE activities.

Results

Most CRCI (85 %) completed the survey. All reported having ongoing PE activities, and 4 of the 11 considered PE an institutional activity. More than 90 % of CRCI organize classes and prepare PE handouts, while other PE activities (e.g., Cancer Information Services, mutual support groups) are less frequently part of institutional PE programs. Patients are frequently involved in the organization and preparation of educational activities on the basis of their own needs. Various PE activities are carried out for caregivers in 8 (73 %) out of 11 institutes. Finally, health care workers have an active role in the organization of PE programs, although nurses take part in these activities in only half of CRCI and pharmacists are seldom included.

Conclusions

The information arising from our research constitutes a necessary framework to identify areas of development and to design new strategies and standards to disseminate the culture of PE. This may ultimately help and stimulate the establishment of institutional integrated PE programs, including policies and interventions that can benefit a significant proportion of cancer patients.
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Literature
2.
go back to reference Stevenson E, Crossan K. Patient education: history, development and current directions of the American Cancer Society and National Cancer Institute. Semin Oncol Nurs. 1991;7:135–42.CrossRefPubMed Stevenson E, Crossan K. Patient education: history, development and current directions of the American Cancer Society and National Cancer Institute. Semin Oncol Nurs. 1991;7:135–42.CrossRefPubMed
3.
go back to reference Shields CG, Coker CJ, Poulsen SS, Doyle JM, Fiscella K, Epstein RM, et al. Patient-centered communication and prognosis discussions with cancer patients. Patient Educ Couns. 2009;77:437–42.CrossRefPubMedPubMedCentral Shields CG, Coker CJ, Poulsen SS, Doyle JM, Fiscella K, Epstein RM, et al. Patient-centered communication and prognosis discussions with cancer patients. Patient Educ Couns. 2009;77:437–42.CrossRefPubMedPubMedCentral
4.
go back to reference Aujoulat I, d’Hoore W, Deccache A. Patient empowerment in theory and practice: polysemy or cacophony? Patient Educ Couns. 2007;66:13–20.CrossRefPubMed Aujoulat I, d’Hoore W, Deccache A. Patient empowerment in theory and practice: polysemy or cacophony? Patient Educ Couns. 2007;66:13–20.CrossRefPubMed
5.
go back to reference Hoving C, Visser A, Mullen PD, van den Borne B. A history of patient education by health professionals in Europe and North America: from authority to shared decision making education. Patient Educ Couns. 2010;78:275–81.CrossRefPubMed Hoving C, Visser A, Mullen PD, van den Borne B. A history of patient education by health professionals in Europe and North America: from authority to shared decision making education. Patient Educ Couns. 2010;78:275–81.CrossRefPubMed
6.
go back to reference Deccache A, van Ballekom K. From patient compliance to empowerment and consumer’s choice: evolution or regression? An overview of patient education in French speaking European countries. Patient Educ Couns. 2010;78:282–7.CrossRefPubMed Deccache A, van Ballekom K. From patient compliance to empowerment and consumer’s choice: evolution or regression? An overview of patient education in French speaking European countries. Patient Educ Couns. 2010;78:282–7.CrossRefPubMed
7.
go back to reference Anderson RM, Funnell MM. Patient empowerment: myths and misconceptions. Patient Educ Couns. 2010;79:277–82.CrossRefPubMed Anderson RM, Funnell MM. Patient empowerment: myths and misconceptions. Patient Educ Couns. 2010;79:277–82.CrossRefPubMed
9.
go back to reference Workman T, Maurer M, Carman K. Unresolved tensions in consumer engagement in CER: a US research perspective. J Comp Eff Res. 2013;2:127–34.CrossRefPubMed Workman T, Maurer M, Carman K. Unresolved tensions in consumer engagement in CER: a US research perspective. J Comp Eff Res. 2013;2:127–34.CrossRefPubMed
10.
go back to reference Barello S, Graffigna G. Engaging patients to recover life projectuality: an Italian cross-disease framework. Qual Life Res. 2015;24:1087–96.CrossRefPubMed Barello S, Graffigna G. Engaging patients to recover life projectuality: an Italian cross-disease framework. Qual Life Res. 2015;24:1087–96.CrossRefPubMed
11.
go back to reference Graffigna G, Barello S, Libreri C, Bosio CA. How to engage type-2 diabetic patients in their own health management: implications for clinical practice. BMC Public Health. 2014;14:648.CrossRefPubMedPubMedCentral Graffigna G, Barello S, Libreri C, Bosio CA. How to engage type-2 diabetic patients in their own health management: implications for clinical practice. BMC Public Health. 2014;14:648.CrossRefPubMedPubMedCentral
12.
go back to reference Hoerger M, Epstein RM, Winters PC, Fiscella K, Duberstein PR, Gramling R, et al. Values and options in cancer care (VOICE): study design and rationale for a patient-centered communication and decision-making intervention for physicians, patients with advanced cancer, and their caregivers. BMC Cancer. 2013;13:188.CrossRefPubMedPubMedCentral Hoerger M, Epstein RM, Winters PC, Fiscella K, Duberstein PR, Gramling R, et al. Values and options in cancer care (VOICE): study design and rationale for a patient-centered communication and decision-making intervention for physicians, patients with advanced cancer, and their caregivers. BMC Cancer. 2013;13:188.CrossRefPubMedPubMedCentral
13.
go back to reference Chelf JH, Agre P, Axelrod A, Cheney L, Cole DD, Conrad K, et al. Cancer-related patient education: an overview of the last decade of evaluation and research. Oncol Nurs Forum. 2001;28:1139–47.PubMed Chelf JH, Agre P, Axelrod A, Cheney L, Cole DD, Conrad K, et al. Cancer-related patient education: an overview of the last decade of evaluation and research. Oncol Nurs Forum. 2001;28:1139–47.PubMed
14.
go back to reference Stepan KA, Gonzalez AP, Pyle ND, Villejo LA, Cantor SB. Initiative to standardize a clinical trial educational program. Oncol Nurs Forum. 2010;37:535–9.CrossRefPubMed Stepan KA, Gonzalez AP, Pyle ND, Villejo LA, Cantor SB. Initiative to standardize a clinical trial educational program. Oncol Nurs Forum. 2010;37:535–9.CrossRefPubMed
15.
go back to reference Ellis PM, Butow PN, Tattersall MH. Informing breast cancer patients about clinical trials: a randomized clinical trial of an educational booklet. Ann Oncol. 2002;13:1414–23.CrossRefPubMed Ellis PM, Butow PN, Tattersall MH. Informing breast cancer patients about clinical trials: a randomized clinical trial of an educational booklet. Ann Oncol. 2002;13:1414–23.CrossRefPubMed
16.
go back to reference Friedman AJ, Jones JM, Nyhof-Young J, Wiljer D, Catton P: Surveying the landscape: the status of cancer patient education in Canada. Longwoods Rev 2005 Feb:1–7. Friedman AJ, Jones JM, Nyhof-Young J, Wiljer D, Catton P: Surveying the landscape: the status of cancer patient education in Canada. Longwoods Rev 2005 Feb:1–7.
17.
go back to reference Falvo DR. Effective Patient Education. A guide to increased compliance. 3rd ed. Philadelphia: Jones & Bartlett Pub; 2011. Falvo DR. Effective Patient Education. A guide to increased compliance. 3rd ed. Philadelphia: Jones & Bartlett Pub; 2011.
20.
go back to reference Mullins CD, Abdulhalim AM, Lavallee DC. Continuous patient engagement in comparative effectiveness research. JAMA. 2012;307:1587–8.CrossRefPubMed Mullins CD, Abdulhalim AM, Lavallee DC. Continuous patient engagement in comparative effectiveness research. JAMA. 2012;307:1587–8.CrossRefPubMed
21.
go back to reference Mercieca C, Cassar S, Borg AA. Listening to patients: improving the outpatient service. Int J Health Care Qual Assur. 2014;27:44–53.CrossRefPubMed Mercieca C, Cassar S, Borg AA. Listening to patients: improving the outpatient service. Int J Health Care Qual Assur. 2014;27:44–53.CrossRefPubMed
23.
go back to reference Deriu PL, La PL, Pierotti M, Collazzo R, Paradiso A, Belardelli F, et al. Accreditation for excellence of cancer research institutes: recommendations from the Italian Network of Comprehensive Cancer Centers. Tumori. 2013;99:293e–8.PubMed Deriu PL, La PL, Pierotti M, Collazzo R, Paradiso A, Belardelli F, et al. Accreditation for excellence of cancer research institutes: recommendations from the Italian Network of Comprehensive Cancer Centers. Tumori. 2013;99:293e–8.PubMed
24.
go back to reference Colombo C, Moja L, Gonzalez-Lorenzo M, Liberati A, Mosconi P. Patient empowerment as a component of health system reforms: rights, benefits and vested interests. Intern Emerg Med. 2012;7:183–7.CrossRefPubMed Colombo C, Moja L, Gonzalez-Lorenzo M, Liberati A, Mosconi P. Patient empowerment as a component of health system reforms: rights, benefits and vested interests. Intern Emerg Med. 2012;7:183–7.CrossRefPubMed
25.
go back to reference Mayor S: OECI accreditation: is yours a top-class cancer centre? Cancerworld 2012;7:37–41. Mayor S: OECI accreditation: is yours a top-class cancer centre? Cancerworld 2012;7:37–41.
26.
go back to reference Truccolo I, Bianchet K, Capello F, Russell-Edu W, Dal Maso L, Colombatti A, et al. A pilot project of a cancer patient library in Italy: results of a customer-satisfaction survey and its products. Health Info Libr J. 2006;23:266–74.CrossRefPubMed Truccolo I, Bianchet K, Capello F, Russell-Edu W, Dal Maso L, Colombatti A, et al. A pilot project of a cancer patient library in Italy: results of a customer-satisfaction survey and its products. Health Info Libr J. 2006;23:266–74.CrossRefPubMed
27.
go back to reference Jones JM, Papadakos J, Bennett C, Blacker S, Catton P, Harth T, et al. Maximizing your Patient Education Skills (MPES): a multi-site evaluation of an innovative patient education skills training course for oncology health care professionals. Patient Educ Couns. 2011;84:176–84.CrossRefPubMed Jones JM, Papadakos J, Bennett C, Blacker S, Catton P, Harth T, et al. Maximizing your Patient Education Skills (MPES): a multi-site evaluation of an innovative patient education skills training course for oncology health care professionals. Patient Educ Couns. 2011;84:176–84.CrossRefPubMed
28.
go back to reference Papadakos J, Bussiere-Cote S, Abdelmutti N, Catton P, Friedman AJ, Massey C, et al. Informational needs of gynecologic cancer survivors. Gynecol Oncol. 2012;124:452–7.CrossRefPubMed Papadakos J, Bussiere-Cote S, Abdelmutti N, Catton P, Friedman AJ, Massey C, et al. Informational needs of gynecologic cancer survivors. Gynecol Oncol. 2012;124:452–7.CrossRefPubMed
29.
go back to reference Ness SM, Kokal J. Cancer Patient Education Network (CPEN) Celebrates 25 Years. J Cancer Educ. 2015;30:207–8.CrossRefPubMed Ness SM, Kokal J. Cancer Patient Education Network (CPEN) Celebrates 25 Years. J Cancer Educ. 2015;30:207–8.CrossRefPubMed
30.
go back to reference Goss C, Mosconi P, Renzi C, Deledda G. Participation of patients and citizens in healthcare decisions in Italy. Z Evid Fortbild Qual Gesundhwes. 2011;105:277–82.CrossRefPubMed Goss C, Mosconi P, Renzi C, Deledda G. Participation of patients and citizens in healthcare decisions in Italy. Z Evid Fortbild Qual Gesundhwes. 2011;105:277–82.CrossRefPubMed
31.
go back to reference Nemetz S, Giarelli E. Improving the quality of life through education: a pilot program of symptom management classes for oncology patients. Am J Nurs. 2002;102 Suppl 4:40–2.CrossRefPubMed Nemetz S, Giarelli E. Improving the quality of life through education: a pilot program of symptom management classes for oncology patients. Am J Nurs. 2002;102 Suppl 4:40–2.CrossRefPubMed
32.
go back to reference Davey HM, Armstrong BK, Butow PN. An exploratory study of cancer patients’ views on doctor-provided and independent written prognostic information. Patient Educ Couns. 2005;56:349–55.CrossRefPubMed Davey HM, Armstrong BK, Butow PN. An exploratory study of cancer patients’ views on doctor-provided and independent written prognostic information. Patient Educ Couns. 2005;56:349–55.CrossRefPubMed
33.
go back to reference Rutten LJ, Arora NK, Bakos AD, Aziz N, Rowland J. Information needs and sources of information among cancer patients: a systematic review of research (1980–2003). Patient Educ Couns. 2005;57:250–61.CrossRefPubMed Rutten LJ, Arora NK, Bakos AD, Aziz N, Rowland J. Information needs and sources of information among cancer patients: a systematic review of research (1980–2003). Patient Educ Couns. 2005;57:250–61.CrossRefPubMed
34.
go back to reference The librarian’s role in the provision of consumer health information and patient education. Medical Library Association. Consumer and Patient Health Information Section (CAPHIS/MLA). Bull Med Libr Assoc 1996, 84:238–239. The librarian’s role in the provision of consumer health information and patient education. Medical Library Association. Consumer and Patient Health Information Section (CAPHIS/MLA). Bull Med Libr Assoc 1996, 84:238–239.
35.
go back to reference Holmberg SB. Cancer information for the public and for health personnel. Nord Med. 1990;105:158–9.PubMed Holmberg SB. Cancer information for the public and for health personnel. Nord Med. 1990;105:158–9.PubMed
36.
go back to reference Morra ME, van Nevel JP, Nealon EO, Mazan KD, Thomsen C. History of the Cancer Information Service. J Natl Cancer Inst Monogr. 1993;14:7–33.PubMed Morra ME, van Nevel JP, Nealon EO, Mazan KD, Thomsen C. History of the Cancer Information Service. J Natl Cancer Inst Monogr. 1993;14:7–33.PubMed
37.
go back to reference Truccolo I, Bufalino R, Annunziata MA, Caruso A, Costantini A, Cognetti G, et al. National Cancer Information Service in Italy: an information points network as a new model for providing information for cancer patients. Tumori. 2011;97:510–6.PubMed Truccolo I, Bufalino R, Annunziata MA, Caruso A, Costantini A, Cognetti G, et al. National Cancer Information Service in Italy: an information points network as a new model for providing information for cancer patients. Tumori. 2011;97:510–6.PubMed
38.
go back to reference Bernhard J, Butow P, Aldridge J, Juraskova I, Ribi K, Brown R. Communication about standard treatment options and clinical trials: can we teach doctors new skills to improve patient outcomes? Psychooncology. 2012;21:1265–74.CrossRefPubMed Bernhard J, Butow P, Aldridge J, Juraskova I, Ribi K, Brown R. Communication about standard treatment options and clinical trials: can we teach doctors new skills to improve patient outcomes? Psychooncology. 2012;21:1265–74.CrossRefPubMed
39.
go back to reference Anderson RT, Kimmick GG, McCoy TP, Hopkins J, Levine E, Miller G, et al. A randomized trial of exercise on well-being and function following breast cancer surgery: the RESTORE trial. J Cancer Surviv. 2012;6:172–81.CrossRefPubMed Anderson RT, Kimmick GG, McCoy TP, Hopkins J, Levine E, Miller G, et al. A randomized trial of exercise on well-being and function following breast cancer surgery: the RESTORE trial. J Cancer Surviv. 2012;6:172–81.CrossRefPubMed
40.
go back to reference Matzat J. Self-help meets science: Patient participation in guideline development. Z Evid Fortbild Qual Gesundhwes. 2013;107:314–9.CrossRefPubMed Matzat J. Self-help meets science: Patient participation in guideline development. Z Evid Fortbild Qual Gesundhwes. 2013;107:314–9.CrossRefPubMed
41.
go back to reference Beishon M. Jan Geissler: We, the patients [Cover Story]. Cancerworld. 2010;34:4–11. Beishon M. Jan Geissler: We, the patients [Cover Story]. Cancerworld. 2010;34:4–11.
42.
go back to reference Groene O, Klazinga N, Wagner C, Arah OA, Thompson A, Bruneau C, et al. Investigating organizational quality improvement systems, patient empowerment, organizational culture, professional involvement and the quality of care in European hospitals: the ‘Deepening our Understanding of Quality Improvement in Europe (DUQuE)’ project. BMC Health Serv Res. 2010;10:281.CrossRefPubMedPubMedCentral Groene O, Klazinga N, Wagner C, Arah OA, Thompson A, Bruneau C, et al. Investigating organizational quality improvement systems, patient empowerment, organizational culture, professional involvement and the quality of care in European hospitals: the ‘Deepening our Understanding of Quality Improvement in Europe (DUQuE)’ project. BMC Health Serv Res. 2010;10:281.CrossRefPubMedPubMedCentral
43.
go back to reference Truccolo I, Cipolat MC, Cervo S, Dal ML, Bongiovanni M, Bearz A, et al. Patient-Centered Cancer Care Programs in Italy: Benchmarking Global Patient Education Initiatives. J Cancer Educ 2015 [Epub ahead of print]. Truccolo I, Cipolat MC, Cervo S, Dal ML, Bongiovanni M, Bearz A, et al. Patient-Centered Cancer Care Programs in Italy: Benchmarking Global Patient Education Initiatives. J Cancer Educ 2015 [Epub ahead of print].
44.
go back to reference Balogh EP, Ganz PA, Murphy SB, Nass SJ, Ferrell BR, Stovall E. Patient-centered cancer treatment planning: improving the quality of oncology care. Summary of an Institute of Medicine workshop. Oncologist. 2011;16:1800–5.CrossRefPubMedPubMedCentral Balogh EP, Ganz PA, Murphy SB, Nass SJ, Ferrell BR, Stovall E. Patient-centered cancer treatment planning: improving the quality of oncology care. Summary of an Institute of Medicine workshop. Oncologist. 2011;16:1800–5.CrossRefPubMedPubMedCentral
45.
go back to reference Lamiani G, Barello S, Vegni E, Moja EA. “Diabetes is for me …”: the health care workers perspective. Assist Inferm Ric. 2009;28:138–46.PubMed Lamiani G, Barello S, Vegni E, Moja EA. “Diabetes is for me …”: the health care workers perspective. Assist Inferm Ric. 2009;28:138–46.PubMed
46.
go back to reference Behar-Horenstein LS, Guin P, Gamble K, Hurlock G, Leclear E, Philipose M, et al. Improving patient care through patient-family education programs. Hosp Top. 2005;83:21–7.CrossRefPubMed Behar-Horenstein LS, Guin P, Gamble K, Hurlock G, Leclear E, Philipose M, et al. Improving patient care through patient-family education programs. Hosp Top. 2005;83:21–7.CrossRefPubMed
47.
go back to reference Kuhrik M, Kuhrik NS, Deshields TL, O’Neill J, Zubal B. Developing and implementing a local education and support program for patients with gastrointestinal stromal tumors (GISTs). J Cancer Educ. 2010;25:543–7.CrossRefPubMed Kuhrik M, Kuhrik NS, Deshields TL, O’Neill J, Zubal B. Developing and implementing a local education and support program for patients with gastrointestinal stromal tumors (GISTs). J Cancer Educ. 2010;25:543–7.CrossRefPubMed
48.
go back to reference Kaye J, Curren L, Anderson N, Edwards K, Fullerton SM, Kanellopoulou N, et al. From patients to partners: participant-centric initiatives in biomedical research. Nat Rev Genet. 2012;13:371–6.CrossRefPubMedPubMedCentral Kaye J, Curren L, Anderson N, Edwards K, Fullerton SM, Kanellopoulou N, et al. From patients to partners: participant-centric initiatives in biomedical research. Nat Rev Genet. 2012;13:371–6.CrossRefPubMedPubMedCentral
49.
go back to reference Giacalone A, Talamini R, Fratino L, Simonelli C, Bearz A, Spina M, et al. Cancer in the elderly: the caregivers’ perception of senior patients’ informational needs. Arch Gerontol Geriatr. 2009;49:e121–5.CrossRefPubMed Giacalone A, Talamini R, Fratino L, Simonelli C, Bearz A, Spina M, et al. Cancer in the elderly: the caregivers’ perception of senior patients’ informational needs. Arch Gerontol Geriatr. 2009;49:e121–5.CrossRefPubMed
50.
go back to reference Leveque D, Delpeuch A, Gourieux B. New anticancer agents: role of clinical pharmacy services. Anticancer Res. 2014;34:1573–8.PubMed Leveque D, Delpeuch A, Gourieux B. New anticancer agents: role of clinical pharmacy services. Anticancer Res. 2014;34:1573–8.PubMed
51.
go back to reference Hutchison C, Cowan C, Paul J. Patient understanding of research: developing and testing of a new questionnaire. Eur J Cancer Care (Engl). 2007;16:187–95.CrossRef Hutchison C, Cowan C, Paul J. Patient understanding of research: developing and testing of a new questionnaire. Eur J Cancer Care (Engl). 2007;16:187–95.CrossRef
52.
go back to reference Barello S, Graffigna G, Vegni E, Savarese M, Lombardi F, Bosio AC. ‘Engage me in taking care of my heart’: a grounded theory study on patient-cardiologist relationship in the hospital management of heart failure. BMJ Open. 2015;5:e005582.CrossRefPubMedPubMedCentral Barello S, Graffigna G, Vegni E, Savarese M, Lombardi F, Bosio AC. ‘Engage me in taking care of my heart’: a grounded theory study on patient-cardiologist relationship in the hospital management of heart failure. BMJ Open. 2015;5:e005582.CrossRefPubMedPubMedCentral
53.
go back to reference Spencer J. Patients in health professional education: so much known, so much yet to understand. Med Educ. 2010;44:9–11.CrossRefPubMed Spencer J. Patients in health professional education: so much known, so much yet to understand. Med Educ. 2010;44:9–11.CrossRefPubMed
54.
55.
go back to reference Fox N, Ward K. Health identities: from expert patient to resisting consumer. Health (London). 2006;10:461–79.CrossRef Fox N, Ward K. Health identities: from expert patient to resisting consumer. Health (London). 2006;10:461–79.CrossRef
56.
go back to reference Schulz PJ, Nakamoto K. Patient behavior and the benefits of artificial intelligence: the perils of “dangerous” literacy and illusory patient empowerment. Patient Educ Couns. 2013;92:223–8.CrossRefPubMed Schulz PJ, Nakamoto K. Patient behavior and the benefits of artificial intelligence: the perils of “dangerous” literacy and illusory patient empowerment. Patient Educ Couns. 2013;92:223–8.CrossRefPubMed
57.
go back to reference Towle A, Bainbridge L, Godolphin W, Katz A, Kline C, Lown B, et al. Active patient involvement in the education of health professionals. Med Educ. 2010;44:64–74.CrossRefPubMed Towle A, Bainbridge L, Godolphin W, Katz A, Kline C, Lown B, et al. Active patient involvement in the education of health professionals. Med Educ. 2010;44:64–74.CrossRefPubMed
Metadata
Title
Making patient centered care a reality: a survey of patient educational programs in Italian Cancer Research and Care Institutes
Authors
C. Cipolat Mis
I. Truccolo
V. Ravaioli
S. Cocchi
L. Gangeri
P. Mosconi
C. Drace
L. Pomicino
A. Paradiso
P. De Paoli
Publication date
01-12-2015
Publisher
BioMed Central
Published in
BMC Health Services Research / Issue 1/2015
Electronic ISSN: 1472-6963
DOI
https://doi.org/10.1186/s12913-015-0962-5

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