*2.2. Health Care System*

The Italian health care system is essentially region-based [22]. In the Veneto Region, the regional authorities take full responsibility for organizing and administering public-financed health care through their regional health departments in accordance with a national health plan designed to assure an equitable provision of comprehensive care throughout the country. Responsibility for planning health care is shared by the central governmen<sup>t</sup> and the regional authorities.

The regional authorities coordinate and control local health units (LHU) (Regional Law No. 19/2016), each of which is a separate unit within the National Health System (NHS) that plans and delivers health care services to its local community, based on a regional health plan, and determines the regional health care reorganization, specific for each region.

In the Veneto Region, the hospital network includes seven large "hubs" with regional or provincial catchment areas, and 20 local "spokes" each serving around 200,000 residents. There are also 40 smaller "node-in-the-net" hospitals that provide integrative or specific health services (such as mental health services or rehab clinics).

The LHUs are responsible for assessing needs and providing comprehensive care to their local population, either using their own staff and facilities or contracting the services out to public hospital enterprises and for-profit and non-profit independent hospitals and specialist outpatient service providers. Private providers must be accredited and have a contract with the LHU.

Tax contributions allocated to the National Health Fund are redistributed horizontally between the regions using a weighted capitation mechanism. LHU services are financed by the regional governments. Each LHU is managed and governed by a general manager appointed by the regional department of health, based on his/her professional qualifications and technical skills. This general manager appoints a financial manager and a medical director.

Services are structured according to a typical division-based model. Each division has financial autonomy over, and technical responsibility for one of three different health care system areas (Legislative decrees No. 502/1992 and No. 229/1999): directly-managed acute care and rehabilitation hospitals, health districts, and health promotion.

### *2.3. The Veneto Region's AMI Network*

The managemen<sup>t</sup> of Acute Myocardial Infarction (AMI) has been tackled from an organizational standpoint by adopting a 'hub and spoke' organizational model since 2008 [23]. The approach is based on the consensus document approved by the Italian Association of Hospital Cardiologists (Associazione Nazionale Medici Cardiologi Ospedalieri, ANMCO) and the Italian Society for Telemedicine (Società Italiana per la salute digitale e la Telemedicina, SIT) [24].

A characteristic of the Veneto Region's network lies in allowing a selective referral from satellite cardiology units (spokes) to cardiac surgical centers (hubs) with a CCL that operates 24 h a day and takes patients for primary PCI immediately.

A pre-hospital 12-lead ECG is remotely transmitted from every ambulance and every ER to the nearest cardiology unit, where the ECG-based diagnosis can be confirmed by skilled operators with direct access to the CCL at the hub hospital, possibly with fast tracks to bypass the ER, or Coronary Care Unit, or Cardiac Intensive Care Unit. A particular feature of this organizational model is that it goes beyond the borders of the single Local Health Districts: patients are admitted to the nearest CCL anywhere in the Veneto Region, considering only the geographical distance and journey time.

This model is based on the assumption that: (i) primary PCI performed as fast as possible and in good time is the preferred treatment strategy for ST-Elevation Myocardial Infarction (STEMI), as recommended by the European Society of Cardiology (ESC); (ii) the delay due to health care system organizational issues can be reduced by implementing a network enabling spoke hospitals to transfer patients promptly to a hub center for PCI, and by ensuring an efficient ambulance transfer service if the Cardiac Catheterization Laboratory (CCL) can be activated by the ambulance en route to hospital; (iii) high-level, expensive skills are needed for certain situations and complex diseases, and cannot be made available everywhere, but should be concentrated instead at highly-specialized regional centers (hubs) to which patients from local hospitals (spokes) can be promptly referred.
