Background In Italy, primary care (PC) ensures universal health coverage while containing costs. However, the assessment of its quality still remains an issue. Evidence has shown that high-quality outpatient care, through timely interventions to prevent complications of “ambulatory care sensitive conditions”, may avoid hospitalization. Aim of the study is to analyse the performance of PC in the Italian regions, using a composite and synthetic index of avoidable hospitalizations. Methods Hospital discharge data from 119 Italian geopolitical areas were analysed for the 2017-2019 triennium and for 2020, separately. According to the “Italian National Outcomes Evaluation Programme” methodology, 9 avoidable hospitalization indicators covering 5 nosological fields (infectious, respiratory, metabolic, cardiovascular and mental diseases) were combined in a synthetic index, calculated as the weighted mean of their standardized scores (with equal weights for each field). Using “natural breaks” technique, the areas were grouped into 5 clusters: “high”, “medium-high”, “medium”, “medium-low” and “low”. Results The analysis showed a marked heterogeneity at intra-regional level for the pre-pandemic triennium, with areas of homogeneity in regions with higher levels of hospitalization. The “medium” cluster, which is the widest, included 36 areas variously distributed across regions. The comparison with 2020 confirmed the geographical patterns observed for the previous triennium, despite a general reduction in hospitalizations due to the pandemic. Conclusions As a proxy indicator of PC quality, this index can aid decision makers in prioritizing quality improvement actions. However, in order to obtain a comprehensive evaluation, a joint reading of this index with other healthcare indicators is recommended. Key messages • High-quality PC is essential in maintaining appropriate hospitalization levels. • The composite synthetic index proposed could aid PC quality assessment.

Background and objective: There are limited data on the clinical impact of Covid–19 in patients with acute myocardial infarction (AMI). Aim of this work is to assess the impact of Covid–19 infection on mortality in AMI patients admitted during the national outbreak in Italy. Methods Retrospective nationwide cohort study enrolling consecutive AMI patients admitted between March,11st and May 3rd, 2020 (national outbreak) and the equivalent periods of the previous 5 years in Italy. The main outcomes were 30–day and 6–month all–cause mortality. Results The actual number of AMI admission during the 2020 outbreak in Italy was significantly reduced as compared to that expected based on the trend of the previous 5 years (STEMI: 4048 vs 5523, p<0.0001; NSTEMI: 4981 vs 8633, p<0.0001). A Covid–19 diagnosis was reported in 4.2% of STEMI and 3.5% of NSTEMI patients. In STEMI patients the 2020 expected rate of 30–day and 6–month mortality was 9.2% and 12.6%, compared to observed rates of 10.8% (p=0.016) and 14.4% (p=0.017), respectively. In NSTEMI patients the 30–day and 6–month expected mortality rates in 2020 were 6.5% and 12.2%, compared to observed rates of 8.3% (p=0.001) and 13.6% (p=0.041), respectively. Excluding patients diagnosed with Covid–19, the mortality rates become consistent with the trend of the previous 5–year for STEMI, but remain higher for NSTEMI. After multivariate adjustment, diagnosis of Covid–19 resulted an independent predictor of both 30–day mortality (OR=4.7, p<0.0001 for STEMI; OR=4.5, p<0.0001 for NSTEMI) and 6–month mortality (OR=3.6, p<0.0001 for STEMI; OR=3.8, p<0.0001 for NSTEMI). Conclusion During the 2020 national outbreak in Italy, a concomitant diagnosis of Covid–19 was associated with a significantly higher rate of mortality in both STEMI and NSTEMI patients. Excluding patients diagnosed with Covid–19, the mortality rates become consistent with the previous 5–year trend for STEMI, while they remain higher for NSTEMI.