Balancing Benefits and Harms of COVID-19 Vaccines: Lessons from the Ongoing Mass Vaccination Campaign in Lombardy, Italy

Background. Limited evidence exists on the balance between the benefits and harms of the COVID-19 vaccines. The aim of this study is to compare the benefits and safety of mRNA-based (Pfizer-BioNTech and Moderna) and adenovirus-vectored (Oxford-AstraZeneca) vaccines in subpopulations defined by age and sex. Methods. All citizens who are newly vaccinated from 27 December 2020 to 3 May 2021 are matched to unvaccinated controls according to age, sex, and vaccination date. Study outcomes include the events that are expected to be avoided by vaccination (i.e., hospitalization and death from COVID-19) and those that might be increased after vaccine inoculation (i.e., venous thromboembolism). The incidence rate ratios (IRR) of vaccinated and unvaccinated citizens are separately estimated within strata of sex, age category and vaccine type. When suitable, number needed to treat (NNT) and number needed to harm (NNH) are calculated to evaluate the balance between the benefits and harm of vaccines within each sex and age category. Results. In total, 2,351,883 citizens are included because they received at least one dose of vaccine (755,557 Oxford-AstraZeneca and 1,596,326 Pfizer/Moderna). A reduced incidence of COVID-19-related outcomes is observed with a lowered incidence rate ranging from 55% to 89% and NNT values ranging from 296 to 3977. Evidence of an augmented incidence of harm-related outcomes is observed only for women aged <50 years within 28 days after Oxford-AstraZeneca (being the corresponding adjusted IRR of 2.4, 95% CI 1.1−5.6, and NNH value of 23,207, 95% CI 10,274−89,707). Conclusions. A favourable balance between benefits and harms is observed in the current study, even among younger women who received Oxford-AstraZeneca.

Influenza Vaccination Effectiveness in Paediatric ‘Healthy’ Patients: A Population-Based Study in Italy

Background: Seasonal influenza can cause serious morbidity, mortality, and financial burden in pediatric and adult populations. The influenza vaccine (IV) is considered the most effective way to prevent influenza and influenza-like-illness (ILI) complications. Objective: To assess the effectiveness of the IV in a cohort of healthy children in Italy. Methods: From the Pedianet database, all healthy children aged six months–14 years between 2009–2019 were enrolled. Cox proportional-hazards models were fitted to estimate hazard ratios and the 95% confidence interval for the association between IV exposure during each season of interest (from October to April of each year) with incident influenza/ILI. Exposure was considered as a time-varying variable. Vaccine effectiveness (VE) was calculated as (1-HR) × 100. The additive and prolonged effects of IV were evaluated across the seasons. Results: We found a high IV effectiveness among healthy children. No additional or prolonged effects were found. Conclusion: Our data indicates that IV was effective in preventing influenza/ILI in healthy children. Therefore, IV should be encouraged and provided free of charge to healthy children in all the Italian regions every year, reducing disease spread and lowering the burden on the pediatric population.

Ethnic, clinical, and pharmacological predictors of high social dependence in COVID-19 patients admitted to post-acute care

The COVID-19 epidemic affected both acute hospitals and post-acute care, which experienced various degrees of overcrowding. We evaluated all the patients admitted to a post-acute care facility during the second wave of the epidemic to detect features possibly associated with social frailty. We analyzed the socio-demographic characteristics and comorbidities of the patients and the pattern of their previous hospitalization as available in their discharge letter. In addition, we evaluated their clinical features and tests on admission to post-acute care. We found that COVID-19 patients without social problems had distinctive features. Those with a higher need for specific pharmacological treatments during their stay in an acute hospital were less likely to be admitted to post-acute care for concomitant social problems ( p < 0.05 for all types of medication). They were also more likely to be native (p = 0.02), obese (p = 0.009), and with hypertension (p = 0.03). Patients with social problems usually stayed longer and were less frequently discharged home with a negative swab (p = 0.0009). In COVID-19 patients, recognition of distinctive features predicting that their need for a longer hospital stay is due to social problems can lead to more appropriate discharge and to more appropriate use of post-acute care.

The role of maternal age on the risk of preterm birth among singletons and multiples: a retrospective cohort study in Lombardy, Norther Italy

Background

All over the world, especially in the developed countries, maternal age at birth is rising. This study aimed to assess the role of maternal age on the occurrence of preterm birth (PTB) in a large birth cohort of Lombardy Region, Northern Italy.

Methods

This population-based study used data from regional healthcare utilization databases of Lombardy to identify women who delivered between 2007 and 2017. PTBs were defined as births before 37 completed weeks of gestation and considered according to the gestational age (two categories: < 32 weeks and 32 to 36 weeks). Six maternal age groups were defined (< 20, 20–24, 25–29, 30–34, 35–39, ≥40 years). Logistic regression models were fitted to estimate the crude and adjusted odds ratio (aOR) and the corresponding 95% confidence interval (CI) for PTB among different maternal age groups. Analyses were separately performed according to type of pregnancy (singletons and multiples). Reference group was the age group with the lowest frequency of PTB.

Results

Overall, 49,759 (6.6%) PTBs were observed, of which 41,807 were singletons and 7952 were multiples. Rates of PTB were lowest in the women aged 25–29 years among singletons and in the 30–34 years old group among multiples. Our results described a U-shaped association between maternal age and risk of PTB. In particular, the risk of a singleton PTB between 32 and 36 weeks was significantly higher for women aged less than 20 years (aOR = 1.16, CI 95%: 1.04–1.30) and more than 40 years (aOR = 1.62 CI 95%: 1.54–1.70). The highest risk of a multiple delivery between 32 and 36 weeks was observed among women aged less than 25 years and more than 40 years (aOR = 1.79, CI 95%: 1.01–3.17, aOR = 1.47, CI 95%: 1.16–1.85 and aOR = 1.36, CI 95%: 1.19–1.55 respectively for < 20, 20–24 and > 40 age categories). PTB before 32 completed weeks occurred more frequently in the same age categories, except that among multiples no association with advanced maternal age emerged.

Conclusion

Our study suggested that, after adjustment for potential confounders, both advance and young maternal age were associated with an increased risk of PTB.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04552-y.

Protective action of natural and induced immunization against the occurrence of delta or alpha variants of SARS-CoV-2 infection: a test-negative case-control study

BACKGROUND

The evolution of SARS-CoV-2 has led to the emergence of several new variants, and few data are available on the impact of vaccination on SARS-CoV-2 variants. We aimed to assess the association between natural (previous infection) and induced (partial or complete vaccination) exposure to SARS-CoV-2 and the onset of new infection supported by the delta variant, and of comparing it with that supported by alpha.

METHODS

We performed a test-negative case-control study, by linking population-based registries of confirmed diagnoses of infection with SARS-CoV-2, vaccinations against Covid-19 and healthcare utilization databases of the Italian Lombardy Region. Four hundred ninety-six persons who between 27 December 2020 and 16 July 2021 had an infection by the delta variant were 1:1 matched with citizens affected by alphavariant and 1:10 matched with persons who had a negative molecular test, according to gender, age and date of molecular ascertainment. We used a conditional logistic regression for estimating relative risk reduction of either variants associated with natural and/or induced immunization and corresponding 95% confidence interval (CI).

RESULTS

Previous infection was associated with 91% (95% CI 85% to 95%) reduced relative risk of reinfection, without evidence of significant differences between delta and alpha cases (p=0.547). Significant lower vaccinal protection against delta than alpha variant infection was observed with reduced relative risk associated with partial vaccination respectively of 29% (7% to 45%), and 62% (48% to 71%) (p=0.001), and with complete vaccination respectively of 75% (66% to 82%) and 90% (85% to 94%) (p=0.003).

CONCLUSIONS

Lower protection towards infections caused by the delta variant with respect to alpha variant was noticed, even after the completion of the vaccination cycle. This finding would support efforts to maximize both vaccine uptake with two doses and fulfilment with individual protection measures, especially as the delta variant is rampant worldwide presently.

Cost-Effectiveness of Posthospital Management of Acute Coronary Syndrome: A Real-World Investigation From Italy

OBJECTIVES

This study aimed to assess the cost-effectiveness profile of adherence to recommendations for the community management of patients discharged with a diagnosis of acute coronary syndrome (ACS).

METHODS

The cohort of 50 282 residents in the Lombardy Region (Italy) who were discharged with a diagnosis of ACS during 2011 to 2015 was followed up until 2018. Adherence to selected recommendations including drug therapies (DTs), outpatient controls, and rehabilitation, experienced during the first year after index discharge, was considered. Adherent and nonadherent cohort members were matched on high-dimensional propensity scores. Composite clinical outcomes (cardiovascular hospital admissions and all-cause mortality) and healthcare costs were assessed for a time horizon of 5 years. Cost-effectiveness profile of adherence to recommendations was measured through the incremental cost-effectiveness ratio, that is, the incremental cost for 1 day free from the composite clinical outcome.

RESULTS

Adherence to DTs, outpatient controls, and rehabilitation, respectively, regarded 39%, 81%, and 3% of cohort members. Compared with nonadherent patients, those adherent to DTs, outpatient controls, and rehabilitation had (1) a delay in the occurrence of the composite clinical outcome of 50, 43, and 73 days, respectively, and (2) lower (on average, €199 per year for DTs) and higher costs (€292 and €1024 for outpatient controls and rehabilitation). Cost-effectiveness profiles were better for patients with myocardial infarction than those with angina and for patients with more severe clinical complexity than those with milder conditions.

CONCLUSIONS

Health-related and economic benefits are expected from improving adherence to international guidelines recommendations concerning outpatient treatments and monitoring of patients with ACS.

Eight Good Reasons for Careful Monitoring and Evaluation of the Vaccine Campaign against COVID-19: Lessons Learned through the Lombardy Experience for Dealing with Next Challenges

Background: Using the knowledge gained during the first eleven months of the vaccine campaign in Lombardy, Italy, we provide an overview of the benefits of using reliable, complete, and rapidly available observational data to monitor the progress of the vaccine strategy. Methods: A population-based platform was implemented by linking four registries reporting individual data on: (i) date, type, and dose of vaccine dispensed; (ii) SARS-CoV-2 infections and hospital admissions and deaths due to COVID-19; (iii) inpatient diagnoses and outpatient services supplied by the Regional Health Services (RHS); and the (iv) health registry reporting and updating data on patient status. Background, methods, findings, and implications of eight COVID-19 relevant questions are reported. Results: Before starting the vaccine campaign, we identified high-risk individuals who need to be prioritized. During the vaccine campaign, we: (i) monitored the trend in the speed of the vaccine campaign progression and the number of prevented clinical outcomes; (ii) verified that available vaccines work in real-life, assessed their effectiveness-harm profile, and measured their reduced effectiveness against the delta variant. Finally, we studied the reduced effectiveness of the vaccine over time and identified risk factors of post-vaccine infection and severe illness. Conclusions: The correct use of rapidly available observational data of good quality and completeness generates reliable evidence to promptly inform patients and policymakers.

Does the mental health system provide effective coverage to people with schizophrenic disorder? A self-controlled case series study in Italy

PURPOSE

To measure indicators of timeliness and continuity of treatments on patients with schizophrenic disorder in 'real-life' practice, and to validate them through their relationship with relapse occurrences.

METHODS

The target population was from four Italian regions overall covering 22 million beneficiaries of the NHS (37% of the entire Italian population). The cohort included 12,054 patients newly taken into care for schizophrenic disorder between January 2015 and June 2016. The self-controlled case series (SCCS) design was used to estimate the incidence rate ratio of relapse occurrences according to mental healthcare coverage.

RESULTS

Poor timeliness (82% and 33% of cohort members had not yet started treatment with psychosocial interventions and antipsychotic drug therapy within the first year after they were taken into care) and continuity (27% and 23% of patients were persistent with psychosocial interventions, and antipsychotic drug therapy within the first 2 years after starting the specific treatment) were observed. According to SCCS design, 4794 relapses occurred during 9430 PY (with incidence rate of 50.8 every 100 PY). Compared with periods not covered by mental healthcare, those covered by psychosocial intervention alone, antipsychotic drugs alone and by psychosocial intervention and antipsychotic drugs together were, respectively, associated with relapse rate reductions of 28% (95% CI 4-46%), 24% (17-30%) and 44% (32-53%).

CONCLUSION

Healthcare administrative data may contribute to monitor and to assess the effectiveness of a mental health system. Persistent use of both psychosocial intervention and antipsychotic drugs reduces risk of severe relapse.

Neuroadrenergic activation in obstructive sleep apnoea syndrome: a new selected meta-analysis - revisited

BACKGROUND

Neuroadrenegic overdrive occurs in obstructive sleep apnoea syndrome (OSAS). However, the small sample size of the microneurographic studies, heterogeneity of the patients examined, presence of comorbidities, represented major weaknesses not allowing to precisely define the main features of the phenomenon, particularly in nonobese patients.

OBJECTIVE

This meta-analysis detected 14 microneurographic studies based on muscle sympathetic nerve activity (MSNA) quantification in uncomplicated OSAS of different clinical severity.

METHODS

The evaluation was extended to the relationships of MSNA with heart rate, anthropometric and blood pressure values, metabolic variables, apnoea-hypopnea index and oxygen saturation.

RESULTS

MSNA is activated markedly and almost homogeneously between studies, showing a progressive increase from the healthy state to mild, moderate and severe OSAS (46.03, 48.32, 71.84, 69.27 bursts/100 heart beats). Of special interest are the findings that MSNA is significantly related to the apnoea-hypopnea index, a marker of OSAS severity (r = 0.55, P  = 0.04) but not to BMI, as it occurs in OSAS associated with obesity, and heart rate is significantly and directly related to MSNA and apnoea-hypopnea index (r = 0.68 and r = 0.60, respectively P = 0.03 and P = 0.02), thus representing a surrogate marker of the sympathetic overdrive.

CONCLUSION

OSAS, even when uncomplicated by other cardiometabolic disease, displays a marked sympathetic activation, reflected by the MSNA and heart rate behaviour, becoming a target of therapeutic interventions aimed at exerting sympathomoderating effects, such as continuous positive airway pressure.

From contact coverage to effective coverage of community care for patients with severe mental disorders: A real-world investigation from Italy

OBJECTIVES

To measure the gap between contact and effective coverage of mental healthcare (MHC).

MATERIALS AND METHODS

45,761 newly referred cases of depression, schizophrenia, bipolar disorder, and personality disorder from four Italian regions were included. A variant of the self-controlled case series method was adopted to estimate the incidence rate ratio (IRR) for the relationship between exposure (i.e., use of different types of MHC such as pharmacotherapy, generic contact with the outpatient services, psychosocial intervention, and psychotherapy) and relapse (emergency hospital admissions for mental illness).

RESULTS

11,500 relapses occurred. Relapse risk was reduced during periods covered by (i) psychotherapy for patients with depression (IRR 0.67; 95% CI: 0.49 to 0.91) and bipolar disorder (0.64; 0.29 to 0.99); (ii) psychosocial interventions for those with depression (0.74; 0.56 to 0.98), schizophrenia (0.83; 0.68 to 0.99), and bipolar disorder (0.55; 0.36 to 0.84), (iii) pharmacotherapy for patients with schizophrenia (0.58; 0.49 to 0.69), and bipolar disorder (0.59; 0.44 to 0.78). Coverage with generic care, in absence of psychosocial/psychotherapeutic interventions, did not affect risk of relapse.

CONCLUSION

This study ascertained the gap between contact and effective coverage of MHC and showed that administrative data can usefully contribute to assess the effectiveness of a mental health system.

The future of research in hematology: Integration of conventional studies with real-world data and artificial intelligence

Most national health-care systems approve new drugs based on data of safety and efficacy from large randomized clinical trials (RCTs). Strict selection biases and study-entry criteria of subjects included in RCTs often do not reflect those of the population where a therapy is intended to be used. Compliance to treatment in RCTs also differs considerably from real world settings and the relatively small size of most RCTs make them unlikely to detect rare but important safety signals. These and other considerations may explain the gap between evidence generated in RCTs and translating conclusions to health-care policies in the real world. Real-world evidence (RWE) derived from real-world data (RWD) is receiving increasing attention from scientists, clinicians, and health-care policy decision-makers - especially when it is processed by artificial intelligence (AI). We describe the potential of using RWD and AI in Hematology to support research and health-care decisions.

Effects of SARS-CoV-2 pandemic on follow-up and pharmacological treatment of chronic diseases in undocumented migrants

Background

All over the world, the COVID-19 pandemic, not unlikely other epidemics, has hit harder people in low socioeconomic conditions.

In Western countries, undocumented migrants are a growing component of this disadvantaged segment of the population.

Their health conditions are frequently burdened by a number of chronic conditions, and they experience many difficulties in accessing public health services. Frequently, the only medical assistance they can get is provided by non-governmental organisations.

Methods

We studied the medical records (including pharmacological treatments) of all patients attending the outpatient clinics of Opera San Francesco (OSF; a big charity in Milano, Italy), in the first 5 months of 2020. These comprise the outbreak of the pandemic and the lockdown period. The 1914 patients (1814 undocumented migrants and 100 Italians) seen during the lockdown were compared with those seen in the same period of 2019 and with those seen in the preceding months of 2020. We especially focused on three chronic conditions: cardiovascular diseases, diabetes and psychiatric disorders.

Results

The number of consultations during the first 5 months of 2020 was much smaller than that of the same period of 2019. During the lockdown, we found 4048 consultations for 1914 patients, while they were 8051 in the same period of 2019 and 5681 in the first 2 months of 2020.

The quantity of medicines dispensed by OSF showed a marked decrease in the period of the study and mainly during the lockdown.

The decrease in consultations and dispensation of medicines was most evident for psychiatric patients and almost not existent for patients with diabetes. Female patients suffered a more pronounced reduction.

Conclusions

Western countries need strategies to better assist the very poor during epidemics.

Differences among different groups of disadvantaged persons should be taken into account when designing recovery plans.

Use of Antibiotic Treatment in Pregnancy and the Risk of Several Neonatal Outcomes: A Population-Based Study

BACKGROUND

Limited evidence is available on the safety and efficacy of antimicrobials during pregnancy, with even less according to the trimester of their use.

OBJECTIVE

This study aimed to evaluate the association between exposure to antibiotics therapy (AT) during pregnancy and short-term neonatal outcomes.

METHODS

We considered 773,237 deliveries that occurred between 2007-2017 in the Lombardy region of Italy. We evaluated the risk of neonatal outcomes among infants that were born to mothers who underwent AT during pregnancy. The odds ratios and the hazard ratios, with the 95% confidence intervals, were estimated respectively for early (first/second trimester) and late (third trimester) exposure. The propensity score was used to account for potential confounders. We also performed subgroup analysis for the class of AT.

RESULTS

We identified 132,024 and 76,921 singletons that were exposed to AT during early and late pregnancy, respectively. Infants born to mothers with early exposure had 17, 11, and 16% increased risk of preterm birth, low birth weight, and low Apgar score, respectively. Infants that were exposed in late pregnancy had 25, 11, and 13% increased risk of preterm birth, low birth weight, and low Apgar score, respectively. The results were consistent in the subgroup analysis.

CONCLUSION

Our results suggested an increased risk of several neonatal outcomes in women exposed to ATs during pregnancy, albeit we were not able to assess to what extent the observed effects were due to the infection itself. To reduce the risk of neonatal outcomes, women that are prescribed AT during pregnancy should be closely monitored.

Stratification of the risk of developing severe or lethal Covid-19 using a new score from a large Italian population: a population-based cohort study

OBJECTIVES

To develop a population-based risk stratification model (COVID-19 Vulnerability Score) for predicting severe/fatal clinical manifestations of SARS-CoV-2 infection, using the multiple source information provided by the healthcare utilisation databases of the Italian National Health Service.

DESIGN

Retrospective observational cohort study.

SETTING

Population-based study using the healthcare utilisation database from five Italian regions.

PARTICIPANTS

Beneficiaries of the National Health Service, aged 18-79 years, who had the residentship in the five participating regions. Residents in a nursing home were not included. The model was built from the 7 655 502 residents of Lombardy region.

MAIN OUTCOME MEASURE

The score included gender, age and 29 conditions/diseases selected from a list of 61 conditions which independently predicted the primary outcome, that is, severe (intensive care unit admission) or fatal manifestation of COVID-19 experienced during the first epidemic wave (until June 2020). The score performance was validated by applying the model to several validation sets, that is, Lombardy population (second epidemic wave), and the other four Italian regions (entire 2020) for a total of about 15.4 million individuals and 7031 outcomes. Predictive performance was assessed by discrimination (areas under the receiver operating characteristic curve) and calibration (plot of observed vs predicted outcomes).

RESULTS

We observed a clear positive trend towards increasing outcome incidence as the score increased. The areas under the receiver operating characteristic curve of the COVID-19 Vulnerability Score ranged from 0.85 to 0.88, which compared favourably with the areas of generic scores such as the Charlson Comorbidity Score (0.60). A remarkable performance of the score on the calibration of observed and predicted outcome probability was also observed.

CONCLUSIONS

A score based on data used for public health management accurately predicted the occurrence of severe/fatal manifestations of COVID-19. Use of this score may help health decision-makers to more accurately identify high-risk citizens who need early preventive or treatment interventions.

Burden of Healthcare-Associated Infections in Sicily, Italy: Estimates from the Regional Point Prevalence Surveys 2016-2018

An assessment of the burden of healthcare-associated infections (HAIs) in terms of disability-adjusted life years (DALYs) is useful for comparing and ranking HAIs and to support infection prevention and control strategies. We estimated the burden of healthcare-associated pneumoniae (HAP), bloodstream infection (HA BSI), urinary tract infection (HA UTI), and surgical site infection (SSI) in Sicily, Italy. We used data from 15,642 patients aged 45 years and above, identified during three repeated point prevalence surveys (PPSs) conducted from 2016 to 2018 according to the European Centre for Disease Prevention and Control protocol. The methodology of the Burden of Communicable Diseases in Europe project was employed. The selected HAIs accounted for 8424 DALYs (95% uncertainty interval (UI): 7394–9605) annually in Sicily, corresponding to 344 DALYs per 100,000 inhabitants aged 45 years and above (95% UI: 302–392). Notably, more than 60% of the burden was attributable to HAP, followed by HA BSI, SSI, and HA UTI. The latter had the lowest burden despite a relatively high incidence, whereas HA BSI generated a high burden even through a relatively low incidence. Differences between our estimates and those of European and Italian PPSs encourage the estimation of the burden of HAIs region by region.

Cost-effectiveness of the adherence with recommendations for clinical monitoring of patients with diabetes

BACKGROUND AND AIMS

To validate a set of indicators for monitoring the quality of care of patients with diabetes in 'real-life' practice through its relationship with measurable clinical outcomes and healthcare costs.

METHODS AND RESULTS

A population-based cohort study was carried out by including the 20,635 patients, residents in the Lombardy Region (Italy), who in the year 2012 were newly taken-in-care for diabetes. Adherence with clinical recommendations (i.e., controls for glycated haemoglobin, lipid profile, urine albumin excretion and serum creatinine) was recorded during the first year after the patient was taken-in-care, and categorized according whether he/she complied with none or almost none (0 or 1), just some (2) or all or almost all (3 or 4) the recommendations, respectively denoted as poor, intermediate and high adherence. Short- and long-term complications of diabetes, and healthcare cost incurred by the National Health Service, were assessed during follow-up. Compared with patients with poor adherence, those with intermediate and high adherence respectively showed (i) a delay in outcome occurrence of 13 days (95% CI, -2 to 27) and 23 days (9-38), and (ii) a lower healthcare cost of 54 € and 77 €. In average, a gain of 18 Euros and 15 Euros for each day free from diabetic complication by increasing adherence respectively from poor to intermediate and from poor to high were observed.

CONCLUSION

Close control of patients with diabetes through regular clinical examinations must be considered the cornerstone of national guidance, national audits, and quality improvement incentive schemes.

Adherence to Treatment by Initial Antihypertensive Mono and Combination Therapies

BACKGROUND

Aim of our study was to compare adherence to antihypertensive drug therapy between newly treated patients in whom monotherapy or a 2-drug single-pill combination (SPC) was initially dispensed.

METHODS

The 63,448 residents of Lombardy Region (Italy), aged 40-80 years, who were newly treated with antihypertensive drugs during 2016, were identified and followed for 1 year after the first prescription. The outcome of interest was adherence to drug therapy that was measured according to the "proportion of days covered" (PDC) criterion, i.e., the ratio between the number of days in which the drug was available and the days of follow-up. Patients who had a PDC >75% and <25% were defined as highly and poorly adherent to drug therapy, respectively. Log-binomial regression models were fitted to compare the propensity to treatment adherence between the initial therapeutic strategies, after adjusting for baseline demographic and clinical covariates.

RESULTS

About 46% and 17% of patients showed high and poor adherence, respectively. Compared with patients under initial monotherapy (85%), those who were initially treated with a SPC (15%) had higher propensity to be highly adherent and a lower propensity to be poorly adherent to antihypertensive treatment (risk ratio: 1.18, 95% confidence interval 1.16-1.21; 0.42, 0.39-0.45, respectively). This was the case regardless the sex, the age, the patient clinical status, and with almost any type of SPC.

CONCLUSIONS

In a real-life setting, patients who were initially prescribed a 2-drug SPC exhibited more frequently a good adherence to antihypertensive treatment than those starting with a single drug.

Change in healthcare during Covid-19 pandemic was assessed through observational designs

Objective

Methodological challenges for investigating the changes in healthcare utilization during COVID-19 pandemic must be considered for obtaining unbiased estimates.

Study design and setting

A population-based study in the Lombardy region (Italy) measured the association between the level of epidemic restrictions (increasing exposure during pre-epidemic, post-lockdown, and lockdown periods) and the recommended healthcare (outcome) for patients with schizophrenia, heart failure, chronic obstructive pulmonary disease, breast cancer, and pregnancy women. Two designs are applied: the self-controlled case series (SCCS) and the usual cohort design. Adjustments for between-patients unmeasured confounders and seasonality of medical services delivering were performed.

Results

Compared with pre-epidemic, reductions in delivering recommended healthcare during lockdown up to 73% (95% confidence interval: 63%–80%) for timeliness of breast cancer surgery, and up to 20% (16%–23%) for appropriated gynecologic visit during pregnancy were obtained from SCCS and cohort design, respectively. Healthcare provision came back to pre-epidemic levels during the post-lockdown, with the exception of schizophrenic patients for whom the SCCS showed a reduction in continuity of care of 11% (11%–12%).

Conclusion

Strategies for investigating the changes in healthcare utilization during pandemic must be implemented. Recommendations for taking into account sources of systematic uncertainty are discussed and illustrated by using motivating examples.

Multi-centric assessment of COVID-19 immunization access and demand among undocumented migrants

Background

Marginalization of undocumented migrants raises concerns about equitable access to COVID-19 immunization. This study describes their self-perceived accessibility of and demand for COVID-19 immunization.

Methods

A multi-centric cross-sectional survey was conducted in 4 health facilities providing care to undocumented immigrants in the USA, Switzerland, Italy, and France in February-April 2021. A convenience sample of minimum 100 patients per study site was recruited. Data was collected using an anonymous structured questionnaire including demographic variables, health status, and drivers/barriers for COVID-19 immunization. Descriptive statistics were used to characterize the primary and secondary outcomes: self-perceived accessibility of and demand for COVID-19 immunization.

Results

812 migrants completed the survey (54.3% Geneva, 17.5% Baltimore, 15.5% Milan, and 12.7% Paris). 60.9% were women, the median age was 40 years old (range 17-76), and 19 nationalities were represented: 55.9% Latin America, 12.7% Africa, 11.2% Western Pacific, 7.9% Eastern Mediterranean, 7.6% Europe, 4.7% Asia. Among participants, 14.1% and 26.2% reported prior COVID-19 infection and fear of developing severe COVID-19, respectively. Underlying co-morbidities were common (29.5%). Self-perceived accessibility of COVID-19 immunization was high (86.4%), yet demand was low (41.1%) correlating with age, co-morbidity, and views on immunization which were better for immunization in general (77.3%) than immunization against COVID-19 (56.5%). Hesitancy was mostly due to fear of adverse reactions (39.2%).

Conclusions

In this multi-centric study, undocumented migrants generally believed they would access local COVID-19 immunization programs. Yet, despite positive views about immunization in general, they reported limited confidence in COVID-19 immunization and willingness to be immunized.

Key messages

Self-perceived accessibility of COVID-19 immunization is high, yet demand is limited. COVID-19 immunization campaigns may engage communities and leverage confidence in immunization in general to address concerns about COVID-19 immunization.

Adherence to Lipid-Lowering Treatment by Single-Pill Combination of Statin and Ezetimibe

INTRODUCTION

Although several studies have shown that a simplified cardiovascular drug treatment leads to better treatment adherence, limited and conflicting findings have been reported on the separate or single-pill combination of the now recommended association between a statin and ezetimibe. We addressed this issue in a large cohort of patients newly treated with statins to whom ezetimibe was additionally administered, either separately or as a single-pill combination.

METHODS

A total of 256,012 patients (age 40-80 years) from the Lombardy Region (Italy) newly treated with statins during 2011-2013 were followed until 2018 to identify those to whom ezetimibe was added. The 2881 and 5351 patients who started a two-pill or a single-pill combination, respectively, of statin and ezetimibe were identified and matched for propensity score. Adherence to drug therapy at 1 year was measured as the ratio between the number of days in which the drug was available and the days of follow-up (the proportion of days covered; PDC). Patients who had a PDC > 75% or < 25% were, respectively, defined as highly and poorly adherent to drug therapy. Analysis was extended to the association between adherence and the risk of fatal/non-fatal cardiovascular events.

RESULTS

Compared to those prescribed a two-pill combination, those prescribed a single-pill combination had an 87% (75-99%) greater odds of being highly adherent and a 79% (72-84%) lower odds of being poorly adherent to treatment. These advantages were manifest in all strata of age, sex, and clinical profile. The risk of cardiovascular outcomes decreased by 55% in patients with high adherence compared to those with low adherence.

CONCLUSION

Patients who were prescribed a single-pill combination of statin/ezetimibe more frequently exhibit a good adherence and less frequently bad adherence to treatment than those prescribed a two-pill combination of these drugs.

Comparing medication persistence among patients with type 2 diabetes using sodium-glucose cotransporter 2 inhibitors or glucagon-like peptide-1 receptor agonists in real-world setting

AIM

To assess and compare the persistence with drug therapy between patients treated with glucagon-like peptide-1 receptor agonists (GLP1-RA) and sodium-glucose cotransporter-2 inhibitors (SGLT2-I) therapy.

METHODS

The 126,493 residents of the Lombardy Region (Italy) aged ≥ 40 years newly treated with metformin during 2007-2015 were followed until 2017 to identify those who started therapy with GLP1-RA or SGLT2-I. To make GLP1-RA and SGLT2-I users more comparable, a 1:1 matched cohort design was adopted. Matching variables were sex, age, and adherence to the first-line therapy with metformin. Log-binomial regression models were fitted to estimate the propensity to 1-year treatment persistence in relation to the therapeutic strategy.

RESULTS

The final matched cohort was composed by 1,276 GLP1-RA─SGLT2-I pairs. About 24% and 29% of cohort members respectively on GLP1-RA and SGLT2-I discontinued the drug treatment. Compared with patients starting SGLT2-I, those on GLP1-RA had 15% (95% confidence interval, 3-25%) lower risk of discontinuation of the treatments of interest and 45% (28-57%) lower risk of discontinuing any antidiabetic drug therapy. Persistence was better among GLP1-RA users who received a once-weekly administration.

CONCLUSIONS

In a real-life setting, patients who were prescribed a GLP1-RA exhibited more frequently better persistence to treatment than those prescribed a SGLT2-I therapy.