This article is more than 5 years old. Information may no longer be current.
Republic of San Marino upgrades ophthalmology services to reach a higher standard
The country's ophthalmology department features updated technology and a multispecialty team approach to treatment.
Click Here to Manage Email Alerts
San Marino, one of the world’s smallest countries, recently introduced revolutionary changes in the way eye care is organized and delivered, adopting a technologically updated, patient-centered, integrated approach to services.
The leader of this project, Alessandro Mularoni, MD, was appointed head of ophthalmology in June 2015, with carte blanche for introducing innovation.
“Until June 2015, ophthalmology was limited to ambulatory care. Patients were seen, diagnosed and then referred to specific tertiary care centers in Italy for more specialized examinations and treatments as well as for most surgical procedures. Within a short time, we have been able to become a comprehensive, independent service, which attracts patients also from the neighboring regions of Italy,” Mularoni said.
The Republic of San Marino is an enclaved microstate within the Italian territory. It has an area of just over 61 km2 and a population of about 32,000. Thanks to the favorable tax system and efficient public administration, San Marino’s economy includes a fairly large manufacturing sector and a well-developed tertiary sector, maintains the lowest unemployment rate in Europe, and has a state budget surplus and no national debt. Despite its small size, it has no youth emigration, while several cross-border workers commute from neighboring cities.
Residents are entitled to free, comprehensive health care. One central hospital with five operating rooms and a day surgery unit offers a wide range of services covering all specialties. Primary care is provided by general practitioners within the territory.
Boosting workforce, technology, research
“Within our project for ophthalmology, we have enlarged and better equipped our diagnostic unit. We have now the most updated instruments for A-to-Z eye care, including tomography, aberrometry, pachymetry, ecography A, B and UBM, biometry and fluoroangiography systems, confocal microscopy, OCT and latest-generation OCT angiography, argon and YAG laser. We have fully equipped our day surgery and OR with operating microscopes, phaco and vitrectomy systems. We are now able to provide the full range of surgical procedures for both the anterior and posterior segment,” Mularoni said.
Orthoptics services have been enhanced with the employment of a second orthoptist and streamlined to provide population screenings from the age of 3 years, using and updating the electronic medical record system.
Within the project, the ophthalmologists employed by the hospital have doubled from four to eight, covering all subspecialties. In addition, four external consultants — one for surgical retina, one for medical retina, one for dry eye and one for glaucoma — visit the hospital quarterly.
“They visit selected patients, perform surgery in some cases and hold teaching sessions within our internal project for continuous education,” Mularoni said.
“We have also embarked in a research project on genetics because we have endemic glaucoma and maculopathy in our territory and because our entire population is registered within our EMR system. Hopefully this will help us improve prevention and treatment of these diseases,” he said.
Access to premium procedures, intravitreal injections
Free health care in San Marino includes premium IOLs and intravitreal injections, Mularoni said.
“We believe that multifocal and, even more, toric lenses are a worthwhile investment and in the long term cost less to the system than prescription glasses or contact lenses,” he said.
“As far as intravitreal injections are concerned, we have started performing them a month after I was appointed. We have a hospital pharmacy that prepares Avastin (bevacizumab, Genentech/Roche), and we are allowed to use it in the eye without the restrictions imposed by the Italian health authorities,” he said. “Quite a few Italian patients seek treatment here now.”
The small size of the republic is an advantage in terms of workflow. The first intravitreal injection is administered at the time of diagnosis. Eye examination, fluorescein angiography, OCT and the injection, if needed, are performed on the same day, and patients can rely on a regular monitoring and re-treatment schedule.
“Our aim was to set up a flexible, smooth and efficient system where the patient gets the best of care in an optimized sequence, saving time and money and minimizing the burden of multiple visits, transportation and help from carers,” Mularoni said.
Mularoni predicts a volume of approximately 500 intravitreal procedures per year, including residents of San Marino and non-residents from Italy.
An integrated team approach
A multispecialty team approach has also been adopted. The ophthalmologist can rely on an easily accessible network of other specialists, including a diabetologist, neurologist, pediatrician, endocrinologist and whoever else is needed. Many of the visits are planned as a team consultation, with all the specialists present to get the full picture of the patient’s condition and to develop a personalized, integrated treatment plan.
“It’s an effective strategy, much appreciated by the patients. It is also a time investment that pays in the end because we do an immediate, complete, team-based assessment of the case, face to face with the patients. It saves them the burden of coming back several times to see us individually, and it saves us the back and forth of information, reports, reviews and requests for consultations and prescriptions,” Mularoni said.
Bocconi University of Milan is currently studying the impact of this model of patient care on the saving of hospital costs and social costs.
Finally, the ophthalmic industry has been involved in organizing internal lunchtime symposia to present its products to physicians, orthoptists and nurses.
“Forty minutes to talk to all of us together rather than meet quickly in between patients in the office or in the corridors. This is part of our team philosophy, much appreciated by all the parties involved,” Mularoni said.
In 2017, the live surgery sessions of the Italian Association of Cataract, Refractive and Corneal Surgery (AICCER) will be held at and broadcasted from the San Marino ophthalmology department, which is a significant achievement and a rewarding sign of appreciation for the progress made. – by Michela Cimberle
- For more information:
- Alessandro Mularoni, MD, can be reached at Ospedale di Stato della Repubblica di San Marino Via Scialoja 20, Repubblica di San Marino; email: alessandro.mularoni@iss.sm.
Disclosure: Mularoni reports no relevant financial disclosures.