An Innovative Disease-net Management Model for Non-communicable Diseases (SIDERA^B)

The EQ-5D-5L (EQ-5D-5L, The EuroQol Group, 1990; Janssen et al.,2013) is a measure of health status that consists of the EQ-5D descriptive system and of the EQ visual analogue scale (EQ VAS). The descriptive system comprises five dimensions: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. Each dimension has 5 levels: no problems, slight problems, moderate problems, severe problems, and extreme problems. A total of 3125 possible health states are defined, ranging from 1111 (no problems in all dimensions) to 5555 (extreme problems in all dimensions). The EQ VAS records the patient's self-rated health on a vertical visual analogue scale, where the endpoints are labeled 'The best health you can imagine' (scored as "100") and 'The worst health you can imagine' (scored as "0").

The Kansas City Cardiomyopathy Questionnaire (KCCQ) is a 23-item self-administered questionnaire developed to independently measure the patient's perception of their health status over six domains: symptoms;physical function;quality of Life; social Limitation; Self-efficacy; symptom Stability. Summary scores will be computed: the "Clinical Summary Score" including total symptom and physical function scores; the" Overall Summary Score" including the total symptom, physical function, social limitations and quality of life scores. KCCQ responses are provided along a rating scale continuum with equal spacing from worst to best.

The PDQ-39 (Jenkinson, 1997; ad. it.: Galeoto et al., 2018) is a 39-item self-administered questionnaire. It offers a patient-reported measure of health status and quality of life and is the most frequently used disease-specific health status measure and assesses how often people affected by Parkinson's experience difficulties across 8 dimensions of daily living including relationships, social situations, and communication. The score for each question ranges from zero (0) to four (4): "never"=0; "occasionally"=1; "sometimes"=2; "often"= 3; "always"=4. the final score is the result of the following equation: the sum of each question score divided by the result times 4 (the maximal score for each question), divided by the total number of questions. This result is multiplied times by 100. Each dimension score ranges from 0 to 100 in a linear scale, in which zero is the best and 100 the worst quality of life.

SGRQ (Jones, P. W., Quirk, F. H., \& Baveystock, C. M. 1991) is a disease-specific instrument designed to measure impact on overall health, daily life, and perceived well-being in patients with obstructive airways disease. It is composed of two parts with three components: Part 1: Symptoms component (frequency \& severity) with a 1, 3 or 12-month recall (best performance with 3- and 12-month recall); Part 2: Activities that cause or are limited by breathlessness; Impact components (social functioning, psychological disturbances resulting from airways disease) refer to current state as the recall. Scaling of items is heterogenous, with Part I (Symptoms) adopting several scales and Part II (Activity and Impacts) adopting a dichotomous (true/false) scale except for last question (4-point Likert scale). Scores range from 0 to 100, with higher scores indicating more limitations.

The MS (Archbold et al., 1990; Pucciarelli et al., 2016; ad. it.: Dellafiore et al., 2018) is a 15-item instrument that measures mutuality in care-relationship. Each item is scored on a 5-point Likert-type scale from 0 ( not at all ) to 4 ( a great deal ). The total scale score ranges from 0 to 60: higher scores mean greater mutuality.

The Psychological Well-Being Scale is a self-report measure of eudaimonic well-being evaluated through six dimensions: autonomy, environmental mastery, personal growth, positive relations with others, purpose in life, and self-acceptance. In this trial, we will evaluate only environmental mastery. Participants respond using a six-point format: strongly disagree (1), moderately disagree (2), slightly disagree (3), slightly agree (4), moderately agree (5), strongly agree (6). Responses to negatively scored items are reversed in the final scoring procedures so that high scores indicate high self-ratings on the dimension assessed.

LOT-R (Scheier, Carver \& Bridges, 1994) is a 10-item measure of dispositional optimism as a single bipolar dimension. Of the 10 items, 3 items measure optimism, 3 items measure pessimism, and 4 items serve as fillers. Respondents rate each item on a 4-point scale: 0 = strongly disagree, 1 = disagree, 2 = neutral, 3 =agree, and 4 = strongly agree. Scoring of the scale is based on summing the items that measure optimism and the (reverse scored) items that measure pessimism (score range 0-30 with higher values reflecting greater optimism and lower values reflecting higher pessimism).

The CD-RISC 10 (Campbell-Sills\& Stein, 2007) is a self-report measure of resilience. The 10 item version (score range 0-40, with higher scores reflecting greater resilience) comprises items 1, 4, 6, 7, 8, 11, 14, 16, 17, 19 from the original scale, and was developed by Drs. Campbell-Sills and Stein, at the University of California, San Diego, on the basis of factor analysis.

The PANAS (Watson et al, 1988) is a self-report questionnaire. The list is split up into two segments, or mood scales. One scale measures a person's positive emotion and the other scale measures the negative. Each segment has ten terms, which can be rated on a scale of 1 to 5 to indicate the extent to which the respondent agrees that this applies to him. The final score of the PANAS Scale / Positive and Negative Affect Schedule (PANAS) test is the sum of the 10 terms on the positive scale and the sum of the 10 terms on the negative scale. The value assigned is positive for answers on the positive scale and negative for answers on the negative scale.

6' Minute Walking Test (6MWT) is has been validated as a general indicator of overall physical performance and mobility for older people (Duncan et al 1993, Harad et al 1999). The total distance walked is measured. The Rating of Perceived Exertion will be also recorded to gain additional information.

It is a measure of performance. To test functional lower limb strength and dynamic balance through repeated sit-to-stand activity. Scoring: record the number of complete stands performed in 30 seconds. Use of arms to push off or incomplete stands do not count. If a patient cannot stand even once then the score for the test is zero.

MDS-UPDRS part-III (Goetz et al., 2008) with 27 items. Performance measure. Administered by the clinician. Each parkinsonian sign or symptom is rated on a 5-point Likert-type scale (ranging from 0 to 4), with higher scores indicating more severe impairment. The total UPDRS score ranging from 0-108 in which zero is the best and 100 the worst possible disability.

Picture Interpretation test 360 (Serino et al, 2017) Scoring: Time to correct identification of the scene, with range 0-180 seconds Higher values represent a worse outcome.

The Montreal Cognitive Assessment (MoCA) total score ranging from 0 to 30. Higher values represent a worse outcome.

measure of Ejection Fraction using echocardiography as surrogate markers

the measure of FEV1% using spirometry as surrogate marker