Reducing the burden of travel and environmental impact through decentralization of cancer care

Abstract

Life expectancy, quality of life and satisfaction of oncologic patients highly depend on access to adequate specialized services, that consider their conditions in a holistic way. The present study aims to evaluate the introduction of oncology services in an outpatient setting in a mountain village in Northern Italy. The initiative is evaluated using the three pillars of sustainability (social, economic and environmental) as dimensions that are often overlooked by healthcare policy makers. Using micro data on 18,625 interventions, we estimate the number of kilometers saved by patients (reduction of “travel burden” as indicator of social sustainability), the additional travel costs for the NHS (indicator of economic sustainability) and the implied reduction of CO₂ emissions (indicator of environmental sustainability). Over the period July 2016–2021, the decentralized health center delivered 2,292 interventions saving 218,566 km for a corresponding value of €131,140. The additional costs for the NHS was €26,152. The reduction of CO₂ emissions was 32.37 Tons (€5,989). Overall, the socio-economic benefit of reducing travel of care for the patients residing in this remote valley was €110,976. This study adds original understanding of the benefits of decentralizing oncologic care and shows its operational feasibility conditions. Given the modest number of similar projects, it provides evidence to policy makers and, especially, managers who are faced with the challenge to implement the decentralization of specialized services.

Keywords

community care cancer economic evaluation environmental sustainability

Introduction

The landscape of cancer care has been changing: compared to the past, early diagnosis and innovative treatments allow patients to live longer and to conduct their daily activities more normally.¹ However, better outcomes and quality of life often depend on regular access to healthcare facilities for exams, therapies, visits and other health services.² Geographical distance from oncological centers may hamper access to these services and creates a travel burden on patients.¹ Such burden on patients and their caregivers is also of financial nature and can have detrimental effects on time of diagnosis, appropriateness of therapies, outcome and quality of life.^3,4 Thus, the decentralization of parts of oncological services can contribute to improve access and reduce the burden of travel for already fragile patients.

Moreover, in the health economic literature, the link between the environment and health outcomes has long been documented.^5–7 Climate change is already impacting health in several ways, for example by leading to death and illness from increasingly frequent extreme weather events, such as heatwaves, storms and floods, the disruption of food systems, increases in zoonoses, food, water and vector-borne diseases, without forgetting severe mental health issues that these phenomena leave to affected people.⁸ In particular, the World Health Organization (WHO) estimates that environmental impacts are expected to cause approximately 250,000 additional deaths per year, between 2030 and 2050. The WHO has emphasized that many factors combine together to influence the health of individuals and communities: whether people are healthy or not, is determined by their circumstances and environment. To a larger extent, factors such as where we live, the state of our environment, genetics, our income and education level, and our relationships with friends and family all have considerable impacts on health, whereas the more commonly considered factors such as access and use of health care services often have less of an impact. Therefore, integrative thinking is increasingly being considered in academic curricula, clinical practice, ministries of health and livestock/agriculture and international organizations.⁹ Evidence for added value of a coherent application of more integrative approach, such as “One Health”, compared to separated sectorial thinking is now growing.^9,10 As a matter of fact, the One Health approach arises from the need to address health threats in the animal-human-environment interface in an integrated way, by designing and implementing programs, policies, legislation and research where multiple sectors work together to achieve better public health outcomes.

Environmental objectives are also starting to be adopted by healthcare policy makers. For instance, the National Health Service (NHS) in the United Kingdom (UK) was the world’s first national health system to commit to reaching net zero for directly controlled carbon emissions by 2040.¹¹ Health systems have a variety of levers to reduce their carbon footprints, such as their supply chains, estates and facilities, pharmaceuticals and medical devices, care pathways, and staff and patients’ travel.^12,13 Healthcare decisions are often based on clinical guidelines and health technology assessments (HTAs) issued by governmental agencies, such as the National Institute for Health and Care Excellence (NICE) in UK. Accounting for a broader range of outcomes beyond health, such as environmental impacts, would allow decision makers to better maximize social welfare, assuming sustainability and environmental protection are valued by societies. This is a key step to ensure high-quality, cost-effective health care is consistently delivered across the country, while contributing to the sustainability and health of the ecosystem as a whole.¹⁴

In this context, the Italian National Recovery and Resilience Plan (NRRP) strongly supports the development of community care.¹⁵ European funds are to be used to build community centers every 50,000 patients and community hospitals (with 20–40 beds) every 100,000 patients.¹⁶ The Plan does not strictly define which care services are to be offered in these settings, leaving freedom and autonomy of choice to the regional and local contexts. Therefore, there is the need to produce robust evidence on which low-intensity care services can be decentralized and provided outside acute hospitals and how these decentralization processes can be implemented. The present paper answers to this need by studying a relevant decentralization experience of oncological care in the Italian context, shedding light on its feasibility, economic consequences, impact and potential transferability.

The present study has a twofold objective. The first is to describe the introduction of oncology services in a “House of Health”, an outpatient and community care center situated in Bettola, a mountain village in Northern Italy, through the model of an itinerant specialists’ team moving from the hub hospital. This experience constitutes a service innovation in healthcare (e.g. Ostrom et al., 2015), of potential inspiration for other contexts, considering the Italian NRRP’s goal to develop community care. The second objective is to test an evaluation approach that integrates dimensions that are often overlooked by healthcare policy makers, i.e. social costs and environmental impacts. Our aim is to assess the decentralization initiative using the three pillars of sustainability (social, environmental and economic)¹⁷ as evaluation framework: (a) firstly, we measure the reduction of patients’ travel burden (social); (b) secondly, we calculate the savings of CO₂ emissions derived from avoided trips by patients (environmental); (c) thirdly, we evaluate the overall cost for NHS and society (economic). This approach could be used on other innovations of the same type and ensure sustainability as well as their coherence with overall health planning.

Theoretical background

In recent decades, scientific research in the field of service management and service design has developed considerably in various sectors and areas, producing analyses on organizational behavior,¹⁸ systems design,¹⁹ service innovation,²⁰ and experience-centric services.²¹ Starting from a “simple” service design²², service management has become rather an overall managerial approach, which at 360 degrees aims at the development of innovative, personalized services, able to give appropriate answers to the changing needs of users.²³ To do this, an essential aspect of service management is to consider the users’ perspective, both expressed and latent needs, in order to make services increasingly user-centric.²⁴ This is even more relevant and crucial in the healthcare sector, where there are some specificities that make the service management and user/patient-centeredness approach even more essential²⁵: it is first of all a sector in which the degree of information asymmetry is maximum, and this inevitably places the patient in a condition of greater dependence, that circumscribes and limits their ability and freedom of choice²⁶; secondly, the patient represents a particular type of user and physiologically different from the “healthy” user.²⁷ Finally, health care can be classified as a “need service”, given that the patient needs care because of his state of health and is not expressing his own free choice of consumption, as happens with “want services” (ibid.). For these reasons, the design of healthcare services inspired by the principles of patient-centeredness²⁸ consider not only the purely clinical conditions of patients, but also their cultural and family background, spending capacity, mental health status, degree of support from potential caregivers, etc. This “holistic” consideration of the patient is linked to the concept of service innovation in healthcare, understood as that transformative process that “creates value for customers, employees, entrepreneurs, partners and communities through new and/or improved service offerings, service processes and business models of services”.^29,30 Implementing innovation in organizational contexts requires redesigning some aspects of the organizations themselves, from structures to processes, with strong impacts on service models.³¹ Sometimes health systems fail to provide treatments that have been shown to be cost-effective and involve an increase in the patient’s quality of life, continuing to use treatments that work less and are more expensive. In this regard, in recent years, service design and service management has been presented as a valid approach to address challenges within the public sector³² and as a catalyst for organizational change and transformation,³³ also underlining how the redesign of services often involves a multi-level transformation, since the service involves the organization, its employees and users.³⁴

In this sense, the experience of the House of Health in Bettola offers an example of service innovation, by decentralizing part of the care pathway for oncologic patients living in a remote area and thus with greater difficulties for acceding to hub hospitals situated in the urban cities. In fact, following the definition of Greenhalgh et al. (2004) of innovation in the provision and organization of services in the health sector, Bettola’s experience represents:

• “a set of behaviors, routines and modalities…” (the itinerant oncology team that once a week moves from the hub hospital in Piacenza to the House of Health in Bettola);

• …together with any associated technology and administrative system” (a specific information system is used that allows the exchange of information relating to patients under treatment between hospital specialists and Bettola’s clinical staff);

• “…who are perceived as new by some of the key stakeholders” (patients being treated in Bettola, residing there or in neighboring municipalities);

• “…related to the provision or support of health care” (the oncological care offered in Bettola, such as clinical evaluation of patients, blood samples, non-invasive instrumental examinations, any invasive ultrasound-guided invasive diagnostic-therapeutic procedures, etc.);

• “…in discontinuity with the previous practice” (the service was activated in 2016 as part of a reorganization plan of the corporate care network that concentrated high complexity in large hospitals and decentralized low-complexity but high-frequency cases in outpatient settings);

• “…aimed at improving health outcomes, administrative efficiency, cost-effectiveness or user experience” (the primary and explicit objective of decentralization in Bettola is to reduce the travel burden of patients and promote therapeutic adherence and therefore health outcomes);

• “…implemented through actions planned and coordinated by individuals, teams or organizations.” (the project was adopted thanks to the initiative of the head of oncology in Piacenza, supported by the Director General of the Local Health Authority, and carried out by the team of specialists and nurses who exchange between Piacenza and Bettola).

Methods

Setting

The study was conducted in the Local Health Authority of Piacenza (HCP) serving about 283,000 residents in the Province of Piacenza in the Italian Region of Emilia-Romagna. The HCP is part of the NHS and covers all residents in a vast and mainly hilly and mountainous area.³⁵ Population living in these areas are largely dispersed and older than that of the rest of the territory. Residents are covered by the HCP that runs a hub hospital, two smaller hospitals, a community hospital, 8 community centers and a number of outpatient clinics and intermediate facilities. Oncological services are delivered by the Oncology-Hematology Department based in the hub hospital of Piacenza and operating in the other two smaller hospitals, the community hospital and the House of Health of Bettola, the setting of our study. The are no other oncological facilities in the entire province but residents, according to the Italian legislation, are free to seek care in any other Italian NHS-accredited provider in Italy.³⁶

Since July 2016 patients living in the Val Nure, where Bettola is located, are offered the possibility to receive care at its community center that has no beds but only an oncological suite and ambulatory for visits, in addition to other community health services. The Val Nure, specifically the “Valnure Valchero Union”, whose inhabitants can have access to the oncology ambulatory of Bettola, comprises 8 territorial units corresponding to six municipalities, with about 34,775 inhabitants in 2022. Bettola is midway between the Hospital of Piacenza and the most distant municipality of the Valley.

Each Monday patients are seen by a nurse who collects information and blood tests from the patient, visit the patient and transmits electronically all data to the Oncology unit of Piacenza Hospital. There, oncologists discuss the case and decide course of action. They, then, send the request of individual therapy to the Hospital Pharmacy. The following morning therapies prepared by the pharmacy are delivered by a car to the community center. At the same time, an oncologist and an oncology nurse reach the facility from the Piacenza Hospital to visit the patients, administer the therapies and perform any other activity on site. Oncologists and oncology nurses received special training to manage possible emergency and at the center is available an ambulance in case of transportation needs. The facility is equipped to perform electrocardiographs and echographia.

Study design

We conducted a retrospective observational study where we compared the place of care of oncologic patients residing in Val Nure before and after the activation of oncological services at the House of Health of Bettola.

Study population and services used

The study population comprises all oncological patients, resident in Val Nure, that were treated at the HCP in the period 2011–2021 and in the community center of Bettola in the period 2016–2021, or elsewhere. Patients were identified through the Hospital Discharge Records (SDO in italian) and the Ambulatory Records (ASA in italian) using the codes presented in Table 1.

Table 1.

List of services to identify the cohort of oncologic patients (2011–2021).

Source	Service name	Service code
Hospital admmission, including day-hospital (SDO)	Chemioterapies and anti-neoplastic immunotherapies	V58.1
Ambulatory Record (ASA)	Infusion of cancer therapies (up to 30 min)	992501
	Oral and intra-muscular treatments (up to 30 min)	8901F0
	Oncology visit (control)	89.01.F
	Injections and infusions of anti-tumoral treatments	99.25
	Oncology visit	89.7B.6

Unit of analysis is each intervention (visit, infusion or other health care act). In particular, we considered patients’ visits and access to the House of Health for the procedures for cancer treatment listed in Table 2. Codes for oncologic visits and treatment were validated with a clinician expert in oncology and an epidemiologist.

Table 2.

List of services used for the analysis of the travel burden.

Source	Service name	Service code
Hospital admission (including day-hospital)	Injections and infusions of chemiotherapies	99.25
	Dressings	96.59
	Antineoplastic chemiotherapies and immunotherapies	V58.1
	Injections or infusions or other therapies	99.29
Ambultory care	Dressings	96.59
	Blood sampling	91.49.2
	Antitumoral therapy with infusion (up to 30 min)	9925.01
	Oral, subcutaneous or intra-muscolar antitumoral therapies (up to 30 min)	89.01.F
	Oncology visits (control)	89.01.F
	Injection infusion of antitumoral therapies	99.25
	Oncology visits	89.7B.6

Measures

For each patient we identified the place of care and calculated the distance (in km) between the municipality of residence and the place where the service was delivered, and compared how this changed before and after the opening of the oncologic service in the House of Health of Bettola. We transformed the distance in costs by using the official reimbursement set by the Italian Automobile Club for an average car (0.6 € per km).³⁷ We also transformed the distance in kilometers into CO₂ emissions according to the values provided by the European Environment Agency for the period 2016–2020 (122.3 g of CO₂ per km).³⁸ These values were used to calculate costs and CO₂ emission per patient and for the transport of professional and drugs from the Hospital of Piacenza to the House of Health of Bettola. We then calculated total annual cost and for the 11 years period and annually, according to NHS and social perspectives including the externalities due to the emission of CO₂. For each service delivered we multiplied the distance to consider the access to the facility requires two return trips. We only doubled the costs for the transfer of the personnel and the therapies as the service is only provided once a week. To calculate the social cost of the CO₂ we used a recent article published in Nature that provides an estimate of $185 per ton CO₂.³⁹ To convert this value we used an exchange between US Dollar and Euro equal to one as it reflects its overall average during the period taken into consideration.

Statistical analysis

We employed a linear mixed effects model with patient random intercept to account for within person correlation given that patients undertake multiple treatment sessions

y_{i t} = β_{0} + β_{1} {A G E}_{i} + β_{2} {S E X}_{i} + β_{3} X_{i t} + β_{4} {P P}_{t} + β_{5} {T R E N D}_{i t} + u_{i} + ε_{i t}

Where

y_{i t}

represents km traveled by patient i at time t (time of the visit), AGE is a dummy for patients over 65 at baseline visit, SEX is a dummy for male, X and PP are our main variables of interest and measure, respectively, whether the service was delivered in Bettola and whether it was after July 2016 (date of the opening of Bettola). TREND accounts for a linear time effect.

u_{i}

is a random effect for the person. With

u_{i} \sim N (0, σ_{u}^{2})

and

ϵ_{i t} \sim N (0, σ_{e}^{2})

Distance and costs

In order to estimate the social costs of the opening of the oncologic services at Bettola we multiplied by four the parameter estimated from the equation above for the patients. Concerning the costs for the NHS we estimated that two independent cars travelled from Piacenza to Bettola each week (52 weeks). The difference between the two costs was then used to calculated CO₂ emissions and their costs.

Results

In the 2010–2021 period 1,125 patients residing in Val di Nure had a cancer diagnosis. Sixty-seven percent were more than 65 years of age at the time of enrollment and 52 percent were female. Cases had a peak in 2010–2011 and since then stabilized between 80 and 90 interventions per year. In the period July 2016-December 2021, 157 patients were treated in Bettola, for a total of 2,292 interventions, about 417 per year (Table 3).

Table 3.

Descriptive characteristics of patients (N = 1,125).

Patient	N	(%)
Sex
F	586	52.09
M	539	47.91
Age
0–64	364	32.36
65+	761	67.64
Municipality of residence
Bettola	189	16.8
Farini	118	10.49
Ferriere	107	9.51
Gropparello	157	13.96
Ponte dell'Olio	303	26.93
Vigolzone	251	22.31

Overall patients received 18,625 services (Table 4), of which 2,292 were delivered at the House of Health of Bettola since July 2016. Data have jumped in 2017 due to the reclassification of activities ruled by the Region; some services were unpacked and registered as more than one service. About 50% of services were first or follow-up visits and the remaining administrations of drugs or medications.

Table 4.

Place and time of oncologic interventions in the period 2011-2021.

	Before Jul 2016		After Jul 2016		Total
	N	(%)	N	(%)	Total
Hospital care	2,434	52.04	1,515	10.86	3,949
Ambulatory care	2,243	47.96	10,141	72.71	12,384
Bettola health centre	0	0	2,292	16.43	2,292
Total	4,677	100	13,948	100	18,625

Since July 2016 there is a modest reduction in the number of kilometers travelled by all residents of Val Nure, meaning that an important part of interventions requires anyway access to the hospital hub. However, those who could and opted to be taken care in Bettola saved about 23 km (one way). On average males travelled 4.4 km more than women and patients over 65 1.4 km more than younger patients. There is a modest trend toward increasing the number of kilometers over time (Table 5).

Table 5.

Estimates of patient random intercept model on distance (km) from municipality of residence and place of treatment: beta coefficients and their standard error (SE).

	All visits (hospital and ambulatory care)	Only ambulatory care
Treatment after Jul 2016	−1.306***	−0.265
Treatment after Jul 2016	(0.461)	(0.387)
Being treated in bettola	−23.84***	−22.28***
Being treated in bettola	(0.444)	(0.33)
Males	4.358***	2.744*
Males	(1.403)	(1.563)
Age 65+ (ref. 0–64)	1.354**	1.408**
Age 65+ (ref. 0–64)	(0.663)	(0.568)
Year	0.881***	0,214
Year	(0.229)	(0.158)
Constant	32.46***	31.25***
Constant	(1.119)	(1.161)
Observations	18,625	14,676
Number of patients	1,125	951

***p < .01; **p < .05; *p < .1; standard error in parenthesis.

After the opening of the Oncology service in Bettola the percentage of patients seeking care outside the HCP dropped from 6% to 1.8%. Similarly, the percentage of patients receiving oncological care outside Emilia-Romagna Region decreased from 2.7% to 1.7%, as shown in Table 6.

Table 6.

Intra and inter-regional hospital and ambulatory patients’ mobility.

	Before Jul 2016		After Jul 2016		Chi2, 1 df	p-value
	N	(%)	N	(%)	Chi2, 1 df	p-value
Intra-regional mobility (% patients seeking health care outside HCP) N = 18,625	282	6.03	258	1.85	217.36	<0.001
Inter-regional mobility (% patients seeking health care outside of Emilia-Romagna Region) N = 18,085	120	2.73	229	1.67	19.66	<0.001

Table 7 presents a synthesis of economic and social results. Over the period 2016–2021 patients saved 218,566 km saving €131,140. The additional travel burden for the NHS was 43,586 km costing €26,152. Overall the opening of Bettola allowed to save 174,980 km corresponding to economic savings for €104,988. This net reduction of travelling implied a reduction of 32.37 tons of CO₂. Its corresponding value is €5,989. Overall, the reduction of the burden of travel due to the availability had an economic overall value of €110,976 for the entire 6 years period.

Table 7.

Estimate of social and NHS costs attributable to the opening of oncologic service at the health centre of Bettola.

	Km saved by patients		Additional km attributable to the delivery of service in Bettola		Net km saved attributable to the opening of oncologic care in Bettola		Tons of Co2 saved		Total social net cost savings
	Km	Costs (euro)	Km	Costs (euro)	Km	Savings (euro)	Tons of Co2	Savings (euro)	Total social net cost savings
Total	218,566	131,140	43,586	26,152	174,980	104,988	32.37	5,989	110,976
Annual	41,958	25,175	7925	4,755	34,034	20,420	6.30	1,165	21,585

Discussion and conclusion

There is robust evidence of significant geographical variations in time of diagnosis, treatment and outcomes of cancer.^40–43 These variations tend to disadvantage patients living in rural and remote areas. Improving access to adequate services to cancer patients is generally advocated to reduce these disparities and the Italian NHS openly promotes equal access on the basis of needs as a fundamental right.³⁶ The Italian NRRP aims to improve access through the development of community care and this study shows the feasibility and positive impact on patients’ travel burden of this strategy. Given that a large part of the Italian territory is mountainous and hilly, with dispersed and aged population, oncology care appears one area where this decentralization can be pursued. Reducing burden of care increases compliance and access to treatment reduces financial costs to patients and their caregivers and may improve outcome and quality of life.¹ In this study we prove that economic benefits for patients are substantial and that, overall, from a societal perspective the decentralization of cancer care is cost-saving. Likely, this is also the first study that estimates the benefits due to the reduction of CO₂ emissions.

In addition, it is appropriate to remember that it has been shown that there is a positive relationship between the volume of patients treated and clinical outcomes in centralized settings, highlighting the importance of concentrated expertise.⁴⁴ However, in this case the quality of care is kept homogeneous between the different settings (House of Health of Bettola vs Piacenza’s Hospital) also thanks to the maintenance of common parts of the care pathway. First of all, the patients taken in at Bettola are always discussed collegially with the medical-nursing staff of the Oncology Unit of Piacenza’s hospital in order to share choices and assess the possibility of inclusion in research protocols. Moreover, as already pointed out, the prescription of anticancer and/or supportive treatment is made by the oncologist of the hospital digitally, after viewing the haemato-chemical examinations carried out the day before the therapy. Lastly, chemotherapy drugs are prepared in Piacenza at the anti-blastic drugs unit and brought to the oncology outpatient clinics at Bettola, guaranteeing safety and fairness in their preparation.

The experience presented here shows the strength of a micro-oncological network, where the hub hospital manages the delivery of service in decentralizing settings while maintaining cooperation to plan care on individual patients. The oncology activities of the Bettola House of Health are performed by the oncology specialists and nurses, who move from the main hospital to the internal areas according to an itinerant team model. This model, implemented for all the peripheral supply points, guarantees a homogeneous approach to management and continuity of care for all patients regardless of their place of residence: in fact, it is always the same doctors who perform the services in the hospital who perform them in the area. The team that travels to the territory was created on a voluntary basis but with a preference for profiles with experience in resuscitation, intensive care and emergency care.

Another recent study has investigated this case using a qualitative approach with interviews with the clinical and administrative staff of the House of Health of Bettola³⁵ From this study, it resulted that doctors and nurses do not receive any form of monetary incentive but a strong value orientation emerged with respect to the issue of equal access to care, promoted also thanks to the leadership of the head physician of the Piacenza oncology unit. It also emerged that moving to the territory is experienced, by clinicians and nurses, as professionally and humanly enriching and as a “break” from hospital routine. In addition, the qualitative investigation reported that, even if based on few interviews, the decentralized service was highly appreciated also by the patients, who value the possibility to be treated near home and in a more familiar, welcoming facility, rather in a huge and disorienting hub hospital. Finally, it should be noted that, compared to hospital facilities, the care provided in Bettola allows a deeper and more continuous relationship to be established between patients and operators because the latter are always the same. Its exportation to other areas in Italy and abroad appears feasible even if the special configuration of the Health Authority of Piacenza favored the entire project of integration between hospital and community care. All facilities are indeed under the same organization and the are no other oncology providers in the Piacenza Health Authority’s territory. The above-mentioned study indeed investigated the determinants and managerial drivers that made this decentralization possible, finding that the success of the case relies on: (a) the convergence of management and clinical leadership, (b) the favorable institutional configuration of the Health Authority of Piacenza, that already integrates hospital and territorial services, (c) the motivation of professionals, (d) the benefits perceived by patients and (e) a careful attention to logistic issues regarding pharmaceuticals transportation and communication procedures between the hospital and the House of Health of Bettola.

This contribution reports the costs for patients, society and environment and clearly shows that society at large benefits from such a form of decentralization of oncological care and appears sustainable from the perspective of the NHS.³⁵ Nevertheless, this type of experiences is for the moment exceptional in the Italian context since cases of decentralization in oncology are still quite rare. Looking through the three dimensions of sustainability it seems that the social one is the most considered: indeed, there were especially equity concerns that motivated the decision to open a cancer care setting to favor a valley that was particularly disadvantaged. This was the reasoning on which the leader of the initiative (the Director of the Oncology Unit) and the Director General of the Piacenza Health Authority agreed on and with which motivated the personnel to take part to the project. The environmental impact was not an explicit objective of the project, but resulted in a beneficial consequence of it, making it possible for patients to avoid trips and thus limit the quantity of CO₂ emissions. On the other hand, it has to be recognized that this is a low-scale experience, regarding a very limited number of patients and it may arise concerns relative to the overall cost-effectiveness of the initiative. The study showed that, whether explicitly or not, decisions in healthcare management have to necessarily deal with the dimensions of sustainability: social, environmental and economic. Decision-makers are then called to set priorities and make compromises, choosing, in each case, which dimension should be prioritized and which one can be “put in the background”.

The paper contributes to the debate on decentralization of care pathways, analyzing a single case with specific characteristics (decentralization of oncological care services in a mountain village in Northern Italy). It is therefore acknowledged the limitation of the present study in terms of generalizability of results and implications. Moreover, the replicability of the initiative in other contexts, outside the hospital setting, depends radically on a series of organizational, institutional and, more generally, environmental context variables. It remains fundamental to understand that each reality has its own specificities and that, therefore, the diffusion of territorial oncology in the NHS can only take place with specific choices that find in established realities a moment of inspiration and not a model to be replicated.

With respect to the methodology used, this could be further improved by integrating additional dimensions of analysis and social determinants of health. However, one of the main limitations remain the scarce availability of data or difficulty in tracing data back to a specific object. The approach adopted to evaluate the Bettola initiative, albeit with its limitations, could be transferred to other health or public sector initiatives. Accounting for a broader range of outcomes, such as environmental impact, would allow decision makers to better maximize social welfare, assuming sustainability and environmental protection are valued by societies.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Roche.

ORCID iDs

Giovanni Fattore

Michela Bobini

Francesca Meda

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