[Young researchers no more young: who are we?]

To reflect on the present and the future of the "millennial" epidemiologists in Italy, the starting question is who are we? The online survey "I giovani ricercatori non più giovani: chi siamo? #GIOVANIDENTRO" was launched in 2022 and advertised at conferences of the Italian association of epidemiology to gather voices from all over Italy. Information on training, job position, attitudes and difficulties encountered in our profession and in scientific production activity has been collected and contextualized to answer the starting question and provide food for thought for the perspectives of our profession.

[Millennials looking for their place in epidemiology.]

The "millennial" epidemiologists, born between the beginning of the 80s and the end of the 90s, are the generation that most of all, today, lives between the present and the future of this discipline. This issue of Recenti Progressi in Medicina aims to talk about what young (and no longer young) epidemiologists and public health researchers are dealing with and to reflect on the most relevant topics in our field, with an eye to the future. Starting from the profile of the "millennial" epidemiologists in Italy and the topics on which they work, the issue develops through three parts dealing with relevant topics for the present and the future of Public health. The first part deals with the important issue of finding a balance between the protection of personal data and the protection of health through a dialogue between researchers, jurists and citizens. The second part aims to clarify the issue of big data and its implications for producing health. The third part touches on four relevant topics for the perspectives of epidemiology through reflections and application examples of machine learning, integration between pharmacoepidemiology and environmental epidemiology, health prevention and promotion involving citizens and other stakeholders, and epidemiology of mental health. In a constantly changing world, challenges for those who work to produce health are not lacking, as is the determination to face them. With this issue, we hope to contribute to the awareness of who we are and our potential, to help millennials (but not only) find their place in epidemiology, today and tomorrow.

[Protect your data and protect yourself: balancing privacy and health protection in Public health.]

The General data protection regulation (Gdpr) of 2016, implemented since 2018, has become a crucial issue in the field of epidemiology. The Gdpr concerns the protection of personal data, which includes all information that identifies or can identify a natural person, providing information about their habits, health status, and lifestyle, and regulates their processing. Epidemiological studies rely on the use of personal data and their interconnection. The introduction of this regulation is marking an important transition for the work of epidemiologists. There is a need to understand how this can coexist with the research activities that have always been carried out in epidemiology and public health. This section aims to lay the foundations for a discussion on the topic and provide a framework for researchers and epidemiologists that answers some of the doubts that accompany daily work.

Health impact of natural gas emission at Cava dei Selci residential zone (metropolitan city of Rome, Italy)

Natural gas hazard was assessed at Cava dei Selci, a residential neighbourhood of Marino (Rome) by a joint study of gas emissions and related health problems. Here a densely urbanized zone with 4000 residents surrounds a dangerous natural gas discharge where, along the years, dozens of animals were killed by the gas. Gas originates from Colli Albani volcano and consists mostly of CO₂ with ~ 1 vol% of H₂S. In recent years, several gas-related accidents occurred in the urbanized zone (gas blowouts and road collapses). Some houses were evacuated because of hazardous indoor air gas concentration. Gas hazard was assessed by soil CO₂ flux and concentration surveys and indoor and outdoor air CO₂ and H₂S concentration measurements. Open fields and house gardens release a high quantity of CO₂ (32.23 tonnes * day^-1). Inside most houses, CO₂ air concentration exceeds 0.1 vol%, the acceptable long-term exposure range. In several houses both CO₂ and H₂S exceed the IDLH level (Immediately Dangerous to Life and Health). An epidemiological cohort study was carried out on the residents of two Cava dei Selci zones with high (zone A) and medium (zone B) gas hazard exposure, using the rest of Marino as reference zone. We found excess mortality and emergency room visits (ERV) related to high exposure to CO₂ and H₂S; in particular, an increased risk of mortality and ERV for diseases of central nervous system (HR 1.57, 95% CI 0.76-3.25 and HR 5.82, 95% CI 1.27-26.56, respectively) was found among men living in zone A.

The National Outcomes Evaluation Programme in Italy: The Impact of Publication of Health Indicators

In Italy the National Outcomes Evaluation Programme, (P.N.E.) is the most comprehensive comparative evaluation of healthcare outcomes at the national level. The aim of this report is to describe the P.N.E. and some of the most relevant results achieved. The P.N.E. analysed 184 indicators on quality of care in 2015-2020 period. The data sources are the Italian Health Information Systems. The indicators reported were: proportion of surgery within 2 days after hip fracture in the elderly (HF), 30-day mortality after hospital admission for acute myocardial infarction (AMI), proportion of reoperations within 90 days of breast-conserving surgery and proportion of primary caesarean deliveries. Risk adjustment methods were used to take into account patients' characteristics. From 2010 to 2020 the proportion of interventions within 2 days after HF increased from 31.3% to 64.6%, the AMI 30-day mortality decreased from 10.4% to 8.3%, the proportion of reinterventions within 90 days of breast-conserving surgery decreased from 12.0% to 5.9% and the proportion of primary caesarean deliveries decreased from 28.4% to 22.7%. Results by area of residence showed heterogeneity of healthcare quality. We observed a general improvement in different clinical areas not always associated with a reduction of heterogeneity among areas of residence.

The impact of the SARS COV-2 pandemic on pediatric accesses in ED: A Healthcare Emergency Information System analysis

Background

The Emergency Department (ED) services play a fundamental role in managing the accesses of potential Sars-Cov-2 cases. The aim of this study is to evaluate the impact of the SARS COV-2 pandemic on pediatric accesses in Emergency Department of Lazio Region.

Methods

The population includes all pediatric accesses (0–17 years) in the ED of Lazio Region during 2019 and 2020. Accesses were characterized by age, week and calendar period. Four periods were defined: pre-lockdown, lockdown, post-lockdown and the second wave. The trend of ED accesses (total or for specific cause) in 2020 (by period and week) were compared to them occurred in 2019. ED visits have been described by absolute frequency and percentage variation. Percentage variation of adult was also reported to compare the trend in adult and young population. The Chi-square test was used to compare characteristics of admissions in 2019 and 2020.

Results

There is a large decrease of pediatric accesses in 2020 compared to 2019 (-47%), especially for younger age-classes (1–2 years: -52.5% and 3–5 years: -50.5%). Pediatric visits to ED in 2020 decreased following the same trend of adults, but more drastically (-47% vs -30%). ED accesses for suspected COVID-19 pneumonia trend show different characteristics between children and adults: in adults there is an increase in 2020, especially during the 2nd wave period (+321%), in children there is a decrease starting from the lockdown period to the achievement of the lowest level in December 2020 (-98%).

Conclusions

This descriptive study has identified a decrease of total pediatric accesses in ED in 2020 compared to 2019 and a different trend of accesses by adult and young population especially by cause. The monitoring of paediatric accesses could be a useful tool to analyse the trend of COVID-19 pandemic in Italy and to reprogramming of the healthcare offer according to criteria of clinical and organizational appropriateness.

[Geocoding one million of addresses using API: a semiautomatic multistep procedure]

OBJECTIVES

to geocode all residence addresses from Lazio Health Information System in order to obtain a geographical regional database.

DESIGN

a semiautomatic and multistep geocoding procedure using several tools and software.

SETTING AND PARTICIPANTS

all residence addresses of resident population of Lazio Region (Central Italy) in 2020.

MAIN OUTCOME MEASURES

geographic coordinates at residence addresses and accuracy level of geocoding procedure for more than 1 million of addresses.

RESULTS

the 99% of residence addresses in the Lazio Region have been geocoded thanks to the purposed procedure; almost 94% of the addresses have been geocoded with a good level of accuracy (more than 56% at civic number level). In the province of Rome, the percentage of addresses geocoded with a good level of accuracy is higher (97.1%), while in the province of Rieti and Frosinone is lower (82.7% and 84.2%, respectively).

CONCLUSIONS

this method is useful to obtain accurate geographic coordinates of residences of the entire regional population. This database will be useful for several epidemiological studies in the Region.

[Population segmentation as a tool for planning community healthcare networks: the key role of social and health information systems.]

INTRODUCTION

Due to the ongoing demographic and epidemiological changes, today stakeholders need to have available information, based on population stratification, in order to plan the most suitable organizational model to meet the population health needs.

METHODS

The legally adult population assisted and resident in Lazio Region on 31/12/2019 was equally and casually divided in two samples: the training sample (to define the model) and the validation sample (to measure model performances). On the base of the more complex model of Lazio Region, three population strata were defined: multi-chronic population, multi-chronic population with a high clinical complexity, multi-chronic population with socioeconomic vulnerability. Hospital discharge records were identified in the previous five years prior to 31/12/2019. Through appropriate classification models, it was evaluated the level with which the simplified system "from SDO" is able to approximate the more complex algorithm developed by the Lazio Region.

RESULTS

Model performances, which has examined only information "from SDO", results inadequate. In fact, the Positive Predictive Value (PVV) results equal to 46.3%, 16.3% and 30.3%, respectively for the three analyzed strata.

DISCUSSION

This study demonstrated that using the hospital system as the only Health Information System reduces the possibility to stratify and predict population health needs. For this reason, the improvement of the completeness and of the quality of data from different social and health information systems and their interconnection, represent the essential starting point. In addition, updating record track is needed to simplify the workload of compilers and improve data availability. These actions must also be accompanied by supportive interventions by central bodies for the regions that show the greatest weaknesses, as well as training actions that improve the level of knowledge of compilers.

[Spatial analysis for detecting clusters of cases during the COVID-19 emergency in Rome and in the Lazio Region (Central Italy)]

BACKGROUND

one of the most affected European countries by the COVID-19 epidemic is Italy; data show the strong geographical heterogeneity of the epidemic.

OBJECTIVES

to propose an analysis strategy to ascertain the non-random nature of the spatial spread of COVID-19 cases infection and identify any territorial aggregations, in order to enhance contact tracing activities in specific areas of the Lazio Region (Central Italy) and a large urban area as Rome.

METHODS

all cases of COVID-19 of the Lazio Region notified to the Regional Service for Epidemiology, Surveillance, and Control of Infectious Diseases (Seresmi) with daily updates from the beginning of the epidemic to April 27, 2020 were considered. The analyses were carried out considering two periods (the first from the beginning of the epidemic to April 6 and the second from the beginning of the epidemic to April 27) and two different levels of spatial aggregation: the entire Lazio region excluding the Municipality of Rome, where the 377 municipalities represent the area units, and the Municipality of Rome, where the area units under study are the 155 urban areas (ZUR). The Scan statistic of Kulldorff was used to ascertain the non-random nature of the spatial spread of infected cases and to identify any territorial aggregations of cases of COVID-19 infection, using a retrospective spatial analysis in two overlapping periods.

RESULTS

analysis was conducted at regional level in the two survey periods and revealed the presence of 7 localized clusters. In the Municipality of Rome, a single cluster (Historic Centre) was identified in the first period which includes 7 urban areas, while in the second period two distinct clusters (Omo and Farnesina) were observed.

CONCLUSIONS

Scan statistics are an important surveillance tool for monitoring disease outbreaks during the active phase of the epidemic and a useful contribution to epidemiological surveillance during the COVID-19 epidemic in a specific territory.

[Access to the Emergency Department in the time of COVID-19: an analysis of the first three months in the Lazio Region (Central Italy)]

OBJECTIVES

to evaluate the impact of the SARS-CoV-2 epidemic on the access to the emergency services of the Lazio Region (Central Italy) for time-dependent pathologies, for suspected SARS-CoV-2 symptoms, and for potentially inappropriate conditions.

DESIGN

observational study.

SETTING AND PARTICIPANTS

accesses to the emergency departments (EDs) of Lazio Region hospitals in the first three months of 2017, 2018, 2019, and 2020.

MAIN OUTCOME MEASURES

total number of accesses to the emergency room and number of specific accesses for cardio and cerebrovascular diseases, for severe trauma, for symptoms, signs, and ill-defined conditions, and for symptoms related to pneumonia.

RESULTS

in the first 3 months of 2019, there were 429,972 accesses to the EDs of Lazio Region; in the same period of 2020, accesses arise to 353,806, (reduction of 21.5%), with a 73% reduction in the last three weeks of march 2020 as compared with the corresponding period of 2019. Comparing the first 3 months of the 2017-2019 with 2020, the accesses for acute coronary syndrome and acute cerebrovascular disease decreased since the 10th week up to more than 57% and 50%, respectively. The accesses due to symptoms, signs, and ill-defined conditions, proxy of potentially inappropriate conditions, decreased since the 8th week, with a maximum reduction of 70%. Access to severe trauma decreased by up to 70% in the 11th week. The accesses for pneumonia increased up to a 70% increment in the 12th week.

CONCLUSIONS

the evaluation of accesses to emergency services during the SARS-CoV-2 epidemic can provide useful elements for the promotion and improvement of the planning, for the management of critical situations, and for the reprogramming of the healthcare offer based on clinical and organizational appropriateness.

Hospital admission for complicated diverticulitis is increasing in Italy, especially in younger patients: a national database study

BACKGROUND

Epidemiological studies show an increasing trend of hospitalization for acute diverticulitis (AD), but data regarding the trend in hospitalization for complicated AD in Italy are scarce. The aim of this study was to analyze the Italian trend in hospitalization for complicated AD, from 2008 to 2015.

METHODS

Using the Italian Hospital Information System, we identified all patients with complicated colonic AD as a discharge diagnosis. Age- and sex-specific rates for AD as well as type of hospital admission (emergency/elective), type of complication (peritonitis, obstruction, bleeding, abscess, fistula, perforation, sepsis) and type of treatment (medical/surgical), were analyzed.

RESULTS

A total of 41,622 patients with a discharge diagnosis of complicated AD were identified. Over the study period the admission rate grew from 8.8 to 11.8 per 100,000 inhabitants. The hospitalization rate was highest for patients ≥ 70 years, but the increase in the admission rate was higher among patients aged ≤ 60 years. There were more males in the group < 60 years and more females in the group ≥ 60 years old. The rate of emergency admissions associated with surgery showed a significant mean annual increase (+ 3.9% per year) in the rate of emergency admissions associated with surgery, whereas elective admissions for surgery remained stable. Peritonitis was the most frequent complication (35.5%). The rate of surgery increased in AD complicated by peritonitis (+ 5.1% per year), abscess (+ 5.8% per year) and decreased for obstruction (- 1.8% per year).

CONCLUSIONS

From 2008 to 2015, we documented an increasing rate of hospitalization for complicated AD, especially for younger patients, with an increase in surgery for peritonitis and abscess. Further studies are needed to clearly assess the risk factors for complications and risk of surgery.

Industrial air pollution and mortality in the Taranto area, Southern Italy: A difference-in-differences approach

BACKGROUND

A large steel plant close to the urban area of Taranto (Italy) has been operating since the sixties. Several studies conducted in the past reported an excess of mortality and morbidity from various diseases at the town level, possibly due to air pollution from the plant. However, the relationship between air pollutants emitted from the industry and adverse health outcomes has been controversial. We applied a variant of the "difference-in-differences" (DID) approach to examine the relationship between temporal changes in exposure to industrial PM₁₀ from the plant and changes in cause-specific mortality rates at area unit level.

METHODS

We examined a dynamic cohort of all subjects (321,356 individuals) resident in the Taranto area in 1998-2010 and followed them up for mortality till 2014. In this work, we included only deaths occurring on 2008-2014. We observed a total of 15,303 natural deaths in the cohort and age-specific annual death rates were computed for each area unit (11 areas in total). PM₁₀ and NO₂ concentrations measured at air quality monitoring stations and the results of a dispersion model were used to estimate annual average population weighted exposures to PM₁₀ of industrial origin for each year, area unit and age class. Changes in exposures and in mortality were analyzed using Poisson regression.

RESULTS

We estimated an increased risk in natural mortality (1.86%, 95% confidence interval [CI]: -0.06, 3.83%) per 1 μg/m³ annual change of industrial PM₁₀, mainly driven by respiratory causes (8.74%, 95% CI: 1.50, 16.51%). The associations were statistically significant only in the elderly (65+ years).

CONCLUSIONS

The DID approach is intuitively simple and reduces confounding by design. Under the multiple assumptions of this approach, the study indicates an effect of industrial PM₁₀ on natural mortality, especially in the elderly population.

[More equity in Lazio region health care: results from the Regional Outcome Evaluation Program (PReValE), 2012-2017]

OBJECTIVES

to evaluate equity in the Lazio regional Health System, both in terms of unequal access to health care among individuals with different educational levels and of heterogeneity in hospital performance, between 2012 and 2017.

DESIGN

retrospective cohort study.

SETTING AND PARTICIPANTS

all patients living in Lazio region and discharged from a regional facility between 2012 and 2017 were enrolled. Three cohorts of hospitalizations were selected: acute myocardial infarctions with ST segment elevation (STEMI), hip fractures, and deliveries.

MAIN OUTCOME MEASURES

the proportions of STEMIs with PCI within 90 minutes, of patients with a hip fracture who underwent surgery within 2 days, and of deliveries with primary caesarean section were evaluated, accounting for patient demographic characteristics and comorbidities that could affect the outcome under study. These proportions were calculated by education and by hospital of admission. The heterogeneity among facilities was assessed through the median odds ratio (MOR).

RESULTS

in Lazio region, between 2012 and 2017, an improvement of the quality of care was observed: in 2017, 50.4% of STEMI patients underwent to a PCI within 90 minutes, 54.4% of patients with a hip fracture underwent surgery within 2 days, and 26.2% of women had a C-section. In 2012, when comparing the adjusted proportions of outcomes by educational level, the probability of being treated with a PCI within 90 minutes for STEMIs and with surgery within 2 days for hip fractures was higher for graduated patients than for those with the lowest education. In contrast, graduated women had the highest risk of having a C-section. In 2017, there was no difference anymore between classes of education in STEMIs and C-sections, while in patients with hip fracture the difference was decreased, but still present. For hip fractures, a reduction of heterogeneity of hospital performances was also detected.

CONCLUSION

in Lazio region, a reduction in inequalities in access to health care was observed for different clinical areas. The "public disclosure" of the PReValE results and the management strategy applied in mid-2013 could have driven the overall improvement of the health system for the conditions under study, helping to achieve a fairer access to health.

Characteristics of ED crowding in the Lazio Region (Italy) and short-term health outcomes

The effect of emergency department (ED) crowding on patient care has been studied for several years in the scientific literature. We evaluate the association between ED crowding and short-term mortality and hospitalization in the Lazio region (Italy) using two different measures. A cohort of visits in the Lazio region ED during 2012-2014 was enrolled. Only discharged patients were selected. ED crowding was estimated using two measures, length of stay (LOS), and Emergency Department volume (EDV). LOS was defined as the interval of time from entrance to discharge; EDV was defined at the time of each new entrance in ED. The outcomes under study were mortality and hospitalization within 7 days from ED discharge. A multivariate logistic model was performed (Odds Ratios, ORs, 95% CI). The cohort includes 2,344,572 visits. ED crowding is associated with an increased risk of short-term hospitalization using both LOS and EDV as exposures (LOS 1-2 h: OR = 1.71, 95% CI 1.66-1.76, LOS 2-5 h: OR = 1.38, 95% CI 1.34-1.43, LOS > 5 h OR = 1.45 95% CI 1.40-1.50 compared to patients with 1 h of LOS; EDV 75°-95° percentile: OR = 1.02, 95% CI 0.99-1.05 and EDV > 95° percentile: OR = 1.06, 95% CI 1.01-1.11 compared to patients with a EDV < 75° percentile upon arrival). Increased risk of short-term mortality is found with increasing level of LOS. High levels of EDV at the time of patients' arrival and longer LOS in ED are associated with greater risks of hospitalization for patients discharged 7 days before. LOS in ED is also associated with an increased risk of mortality.

Patients who leave Emergency Department without being seen or during treatment in the Lazio Region (Central Italy): Determinants and short term outcomes

Background and Aims

Patients who leave Emergency Department before physician’s visit (LWBS) or during treatment (LDT) represent a useful indicator of the emergency care's quality. The profile of patients LWBS was described: they are generally males, young, with lower urgency triage allocation and longer waiting time. They have a greater risk of ED re-admission compared to discharged patients, but effect on hospitalization and mortality are more controversial. The aims of this study are to identify determinants and adverse short term outcomes for LWBS and LDT patients.

Methods

This is a retrospective cohort study that include all ED visits of LWBS, LDT and discharged patients in 2015 in the Lazio region, Central Italy. Determinants of LWBS or LDT were selected from gender, age, citizenship, residence area, triage category, chronic comorbidities, number of uncompleted ED visit in the previous year, mode of arrival in ED, time-band, day of the week, waiting time and ED crowding, using a multi-level logistic regression. A multivariate logistic regression was used to test if LWBS or LDT have a greater risk of short term adverse outcome compared to discharged patients.

Results

The cohort consists in 835,440 visits in ED, 86.8% subjects visited and discharged, 8.9% subjects are LWBS patients and 4.3% LDT. LWBS and LDT patients are mainly young, males, with a less severe triage, with long waiting times in ED. Moreover, ED crowding and leaving ED before physician’s visit in the previous year are risk factors of self-discharging. LWBS and LDT patients have a higher risk of readmission (LWBS: OR = 4.63, 95%CI 4.5–4.7; OR = 2.89, 95%CI 2.8–2.9; LDT: OR = 3.12, 95%CI 3–3.2; OR = 2.25, 95%CI2.2–2.3 for readmissions within 2 and 7 days respectively) and hospitalization (LWBS: OR = 3.65, 95%CI 3.4–3.9; OR = 2.25, 95%CI 2.1–2.4; LDT: OR = 3.96, 95%CI 3.6–4.3; OR = 2.62, 95%CI 2.4–2.8 for hospitalization within 2 and 7 days respectively). Furthermore, we find a mortality excess of risk for LWBS patients compared to the reference group (OR = 2.56, 95%CI1.6–4.2; OR = 1.7, 95%CI 1.3–2.2 within 2 and 7 days respectively).

Conclusions

Determinants of LWBS confirmed what already known, but LDT patients should be further investigated. There could be adverse health effects for people with LWBS and LDT behaviour. This could be an issue that the Regional Health System should deal with.

Volume and health outcomes: evidence from systematic reviews and from evaluation of Italian hospital data

BACKGROUND Improving quality and effectiveness of healthcare is one of the priorities of health policies. Hospital or physician volume represents a measurable variable with an impact on effectiveness of healthcare. An Italian law calls for the definition of «qualitative, structural, technological, and quantitative standards of hospital care». There is a need for an evaluation of the available scientific evidence in order to identify qualitative, structural, technological, and quantitative standards of hospital care, including the volume of care above or below which the public and private hospitals may be accredited (or not) to provide specific healthcare interventions. OBJECTIVES To identify conditions/interventions for which an association between volume and outcome has been investigated. To identify conditions/interventions for which an association between volume and outcome has been proved. To analyze the distribution of Italian health providers by volume of activity. To measure the association between volume of care and outcomes of the health providers of the Italian National Health Service (NHS). METHODS Systematic review An overview of systematic reviews was performed searching PubMed, EMBASE, and The Cochrane Library up to November 2016. Studies were evaluated by 2 researchers independently; quality assessment was performed using the AMSTAR checklist. For each health condition and outcome, if available, total number of studies, participants, high volume cut-off values, and metanalysis have been reported. According to the considered outcomes, health topics were classified into 3 groups: positive association: a positive association was demonstrated in the majority of studies/participants and/or a pooled measure (metanalysis) with positive results was reported; lack of association: both studies and/or metanalysis showed no association; no sufficient evidence of association: both results of single studies and metanalysis do not allow to draw firm conclusions on the association between volume and outcome. Analysis of the distribution of Italian hospitals by volume of activity and the association between volume of activity and outcomes: the Italian National Outcome evaluation Programme 2016 The analyses were performed using the Hospital Information System and the National Tax Register (year 2015). For each condition, the number of hospitals by volume of activity was calculated. Hospitals with a volume lower than 3-5 cases/year were excluded. For conditions with more than 1,500 cases/year and frequency of outcome ≥1%, the association between volume of care and outcome was analyzed estimating risk-adjusted outcomes. RESULTS Bibliographic searches identified 80 reviews, evaluating 48 different clinical areas. The main outcome considered was intrahospital/30-day mortality. The other outcomes vary depending on the type of condition or intervention in study. The relationship between hospital volume and outcomes was considered in 47 out of 48 conditions: 34 conditions showed evidence of a positive association; • 14 conditions consider cancer surgery for bladder, breast, colon, rectum, colon rectum, oesophagus, kidney, liver, lung, ovaries, pancreas, prostate, stomach, head and neck; • 11 conditions consider cardiocerebrovascular area: nonruptured and ruptured abdominal aortic aneurysm, acute myocardial infarction, brain aneurysm, carotid endarterectomy, coronary angioplasty, coronary artery bypass, paediatric heart surgery, revascularization of lower limbs, stroke, subarachnoid haemorrhage; • 2 conditions consider orthopaedic area: knee arthroplasty, hip fracture; • 7 conditions consider other areas: AIDS, bariatric surgery, cholecystectomy, intensive care unit, neonatal intensive care unit, sepsis, and traumas; for 3 conditions, no association was demonstrated: hip arthroplasty, dialysis, and thyroidectomy. for the remaining 10 conditions, the available evidence does not allow to draw firm conclusions about the association between hospital volume and considered outcomes: surgery for testicular cancer and intracranial tumours, paediatric oncology, aortofemoral bypass, cardiac catheterization, appendectomy, colectomy, inguinal hernia, respiratory failure, and hysterectomy. The relationship between volume of clinician/surgeon and outcomes was assessed only through the literature re view; to date, it is not possible to analyze this association for Italian health provider hospitals, since information on the clinician/surgeon on the hospital discharge chart is missing. The literature found a positive association for 21 conditions: 9 consider surgery for cancer: bladder, breast, colon, colon rectum, pancreas, prostate, rectum, stomach, and head and neck; 5 consider the cardiocerebrovascular area: ruptured and nonruptured abdominal aortic aneurysm, carotid endarterectomy, paediatric heart surgery, and revascularization of the lower limbs; 2 consider the orthopaedic area: knee and hip arthroplasty; 5 consider other areas: AIDS, bariatric surgery, hysterectomy, intensive care unit, and thyroidectomy. The analysis of the distribution of Italian hospitals concerned the 34 conditions for which the systematic review has shown a positive volume-outcome association. For the following, it was possible to conduct the analysis of the association using national data: unruptured abdominal aortic aneurysm, coronary angioplasty, hip arthroplasty, knee arthroplasty, coronary artery bypass, cancer surgery (colon, liver, breast, pancreas, lung, prostate, kidney, and stomach), laparoscopic cholecystectomy, hip fracture, stroke, acute myocardial infarction. For these conditions, the association between volume and outcome of care was observed. For laparoscopic cholecystectomy and surgery of the breast and stomach cancer, the association between the volume of the discharge (o dismissal) operating unit and the outcome was analyzed. The outcomes differ depending on the condition studied. The shape of the relationship is variable among different conditions, with heterogeneous slope of the curves. DISCUSSION For many conditions, the overview of systematic reviews has shown a strong evidence of association between higher volumes and better outcomes. The quality of the available reviews can be considered good for the consistency of the results between the studies and for the strength of the association; however, this does not mean that the included studies are of good quality. Analyzing national data, potential confounders, including age and comorbidities, have been considered. The systematic review of the literature does not permit to identify predefined volume thresholds. The analysis of national data shows a strong improvement in outcomes in the first part of the curve (from very low to higher volumes) for most conditions. In some cases, the improvement in outcomes remains gradual or constant with the increasing volume of care; in other, the analysis could allow the identification of threshold values beyond which the outcome does not further improve. However, a good knowledge of the relationship between effectiveness of treatments and costs, the geographical distribution and the accessibility to healthcare services are necessary to choose the minimum volumes of care, under which specific health procedures could not been provided in the NHS. Some potential biases due to the use of information systems data should also be considered. The different way of coding among hospitals could lead to a different selection of cases for some conditions. Regarding the definition of the exposure (volume of care), a possible bias could result from misclassification of health providers with high volume of activity. Performing the intervention in different departments/ units of the same hospital would result in an overestimation of the volume of care measured for hospital rather than for department/unit. For the conditions with a further fragmentation within the same structure, the association between volumes of discharge department and outcomes has also been evaluated. In this case, the two curves were different. The limit is to attribute the outcome to the discharge unit, which in case of surgery may not be the intervention unit. A similar bias could occur if the main determinant of the outcome of treatment was the caseload of each surgeon. The results of the analysis may be biased when different operators in the same hospital/unit carried out the same procedure. In any case, the observed association between volumes and outcome is very strong, and it is unlikely to be attributable to biases of the study design. Another aspect on which there is still little evidence is the interaction between volume of the hospital and of the surgeon. A MEDICARE study suggests that in some conditions, especially for specialized surgery, the effect of the surgeon's volume of activity is different depending on the structure volume, whereas it would not differ for some less specialized surgery conditions. The data here presented still show extremely fragmented volumes of both clinical and surgical areas, with a predominance of very low volume structures. Health systems operate, by definition, in a context of limited resources, especially when the amount of resources to allocate to the health system is reduced. In such conditions, the rationalization of the organization of health services based on the volume of care may make resources available to improve the effectiveness of interventions. The identification and certification of services and providers with high volume of activity can help to reduce differences in the access to non-effective procedures. To produce additional evidence to guide the reorganization of the national healthcare system, it will be necessary to design further primary studies to evaluate the effectiveness and safety of policies aimed at concentrating interventions in structures with high volumes of activity.

Trends in hospital admission for acute diverticulitis in Italy from 2008 to 2015

BACKGROUND

Epidemiological studies in Western countries have documented an increase of hospitalizations for acute diverticulitis (AD) but Italian evidence is scarce. The aim of the present study was to analyse the trend in hospitalization for AD, including in-hospital mortality, in Italy from 2008 to 2015.

METHODS

Through the Italian Hospital Information System of the National Health System, we identified diverticulitis of the colon as a discharge diagnosis. Age- and gender-specific rates of hospitalization for AD were assessed.

RESULTS

174,436 hospitalizations were identified with an increasing rate in 2008-2015 from 39 to 48 per 100,000 inhabitants (p < 0.001). The rate of hospitalization was higher for women, but the increasing trend over time was even more pronounced among men (mean increase per year 3.9% and 2.1% among men and women, respectively) (p < 0.001). The increased rate of hospitalization was accounted for by patients less than 70 years old, especially those under 60. In contrast, the hospitalization rate for older patients (age ≥ 70 years) was higher but remained unchanged during the study period. The number of patients with one hospital admissions was significantly higher than the number of patients with at least two hospitalizations (p < 0.001) and both groups showed a significant and comparable increase year by year. The overall in-hospital mortality rate increased from 1.2 to 1.5% (p = 0.017). More specifically, the increase was observed in patients at their first hospitalization [from 1 to 1.4% (mean increase per year of 3%, p = 0.003)]. An increase in mortality was most evident among women (from 1.4 to 1.8% p = 0.025) and in older patients [age 70-79 years from 1.2 to 1.7% (p = 0.034), ≥ 80 years from 2.9 to 4% (p = 0.001)].

CONCLUSIONS

In Italy, between 2008 and 2015, the rate of hospitalization for AD has been constantly increasing due to the hospitalization of younger individuals, especially men. There was a significant increase of in-hospital mortality especially among women, elderly and during the first hospitalization. These findings suggest the need for increased awareness and clinical skills in the management of this common condition.

The Tradeoff between Travel Time from Home to Hospital and Door to Balloon Time in Determining Mortality among STEMI Patients Undergoing PCI

BACKGROUND

In ST-segment elevation myocardial infarction (STEMI), even in presence of short door to balloon time (DTBT), timely reperfusion with percutaneous coronary intervention (PCI) is hampered by pre-hospital delays. Travel time (TT) constitutes a relevant part of these delays and may contribute to worse outcomes.

OBJECTIVE

To evaluate the relationship between TT from home to hospital and DTBT on 30-day mortality after PCI among patients with STEMI.

METHODS

We enrolled a cohort of 3,608 STEMI patients with a DTBT within 120 minutes who underwent PCI between years 2009 and 2013 in Lazio Region (Italy). We calculated the minimum travel time from residential address to emergency department where the first medical contact occurred. We defined system delay as the sum of travel time and DTBT time. Logistic regression models, including clinical and demographic characteristics were used to estimate the effect of TT and DTBT on mortality.

RESULTS

Among patients with 0-90 minutes of system delay, TT above the median value is positively associated with mortality (OR = 2.46; P = 0.009). Survival benefit associated with DTBT below the median results only among patients with TT below the median (OR for DTBT below the median = 0.39; P = 0.013), (OR for interaction between TT and DTBT = 2.36; p = 0.076).

CONCLUSION

TT affects survival after PCI for STEMI, even in the presence of health care systems compliant with current guidelines. Results emphasize the importance of health system initiatives to reduce pre-hospital delay. Utilization of TT can contribute to a better estimate of patient mortality risk in the evaluation of quality of care.

Morbidity and mortality of people who live close to municipal waste landfills: a multisite cohort study

BACKGROUND

The evidence on the health effects related to residing close to landfills is controversial. Nine landfills for municipal waste have been operating in the Lazio region (Central Italy) for several decades. We evaluated the potential health effects associated with contamination from landfills using the estimated concentration of hydrogen sulphide (H2S) as exposure.

METHODS

A cohort of residents within 5 km of landfills was enrolled (subjects resident on 1 January 1996 and those who subsequently moved into the areas until 2008) and followed for mortality and hospitalizations until 31 December 2012. Assessment of exposure to the landfill (H2S as a tracer) was performed for each subject at enrolment, using a Lagrangian dispersion model. Information on several confounders was available (gender, age, socioeconomic position, outdoor PM10 concentration, and distance from busy roads and industries). Cox regression analysis was performed [Hazard Ratios (HRs), 95% confidence intervals (CIs)].

RESULTS

The cohort included 242 409 individuals. H2S exposure was associated with mortality from lung cancer and respiratory diseases (e.g. HR for increment of 1 ng/m(3) H2S: 1.10, 95% CI 1.02-1.19; HR 1.09, 95% CI 1.00-1.19, respectively). There were also associations between H2S and hospitalization for respiratory diseases (HR = 1.02, 95% CI 1.00-1.03), especially acute respiratory infections among children (0-14 years) (HR = 1.06, 95% CI 1.02-1.11).

CONCLUSIONS

Exposure to H2S, a tracer of airborne contamination from landfills, was associated with lung cancer mortality as well as with mortality and morbidity for respiratory diseases. The link with respiratory disease is plausible and coherent with previous studies, whereas the association with lung cancer deserves confirmation.

Adherence to evidence-based drug therapies after myocardial infarction: is geographic variation related to hospital of discharge or primary care providers? A cross-classified multilevel design

OBJECTIVES

To measure the adherence to polytherapy after myocardial infarction (MI), to compare the proportions of variation attributable to hospitals of discharge and to primary care providers, and to identify determinants of adherence to medications.

SETTING

This is a population-based study. Data were obtained from the Information Systems of the Lazio Region, Italy (5 million inhabitants).

PARTICIPANTS

Patients hospitalised with incident MI in 2007-2010.

OUTCOME MEASURE

The outcome was chronic polytherapy after MI. Adherence was defined as a medication possession ratio ≥0.75 for at least three of the following drugs: antiplatelets, β-blockers, ACEI angiotensin receptor blockers, statins.

DESIGN AND ANALYSIS

A 2-year cohort study was performed. Cross-classified multilevel models were applied to analyse geographic variation and compare proportions of variability attributable to hospitals of discharge and primary care providers. The variance components were expressed as median ORs MORs. If the MOR is 1.00, there is no variation between clusters. If there is considerable between-cluster variation, the MOR will be large.

RESULTS

A total of 9606 patients were enrolled. About 63% were adherent to chronic polytherapy. Adherence was higher for patients discharged from cardiology wards (OR=1.56 vs other wards, p<0.001) and for patients with general practitioners working in group practice (OR=1.14 vs single-handed, p=0.042). A relevant variation in adherence was detected between local health districts (MOR=1.24, p<0.001). When introducing the hospital of discharge as a cross-classified level, the variation between local health districts decreased (MOR=1.13, p=0.020) and the variability attributable to hospitals of discharge was significantly higher (MOR=1.37, p<0.001).

CONCLUSIONS

Secondary prevention pharmacotherapy after MI is not consistent with clinical guidelines. The relevant geographic variation raises equity issues in access to optimal care. Adherence was influenced more by the hospital that discharged the patient than by the primary care providers. Cross-classified models proved to be a useful tool for defining priority areas for more targeted interventions.

Mortality and morbidity in a population exposed to multiple sources of air pollution: A retrospective cohort study using air dispersion models

BACKGROUND AND AIMS

A landfill, an incinerator, and a refinery plant have been operating since the early 1960s in a contaminated site located in the suburb of Rome (Italy). To evaluate their potential health effects, a population-based retrospective cohort study was conducted using dispersion modeling for exposure assessment.

METHODS

A fixed cohort was enrolled in the Rome Longitudinal Study in 2001, mortality and hospitalizations were followed-up until 2010. Exposure assessments to the landfill (H2S), the incinerator (PM10), and the refinery plant (SOX) were performed for each subject using a Lagrangian dispersion model. Individual and small-area variables were available (including exposures levels to NO2 from traffic and diesel trucks). Cox regression analysis was performed (hazard ratios, HRs, 95% CI) using linear terms for the exposures (5th-95th percentiles difference). Single and bi-pollutant models were run.

RESULTS

The cohort included 85,559 individuals. The estimated annual average exposures levels were correlated. H2S from the landfill was associated with cardiovascular hospital admissions in both genders (HR 1.04 95% CI 1.00-1.09 in women); PM10 from the incinerator was associated with pancreatic cancer mortality in both genders (HR 1.40 95% CI 1.03-1.90 in men, HR 1.47 95% CI 1.12-1.93 in women) and with breast morbidity in women (HR 1.13 95% CI 1.00-1.27). SOx from the refinery was associated with laryngeal cancer mortality in women (HR 4.99 95% CI 1.64-15.9) and respiratory hospital admissions (HR 1.13 95% CI 1.01-1.27).

CONCLUSIONS

We found an association of the pollution sources with some cancer forms and cardio-respiratory diseases. Although there was a high correlation between the estimated exposures, an indication of specific effects from the different sources emerged.

[Health impact assessment of airport noise on people living nearby six Italian airports]

BACKGROUND

aircraft noise has been associated with several health effects. Because of the great success of low-cost flights, small airports have been turned into international airports thus exposing nearby residents to an increase in noise levels and potential disturbances and health disorders.

OBJECTIVE

to estimate the exposure levels and evaluate the health impact of aircraft noise on residents nearby six airports in Italy (Rome: Ciampino; Milan: Linate and Malpensa; Pisa; Turin; Venice) focusing on hypertension, acute myocardial infarction (AMI), annoyance and sleep disturbances.

METHODS

residents in the local Municipalities considered at 31.12.2010 were included in the study and their addresses were geocoded. Aircraft noise exposure in 2011 was defined using the Integrated Noise Model linked to each participant's address. Lden (<55, 55-60, 61-65, 65-70 dB), Lnight, Leq (day and night) were calculated. Available exposure-response relationships were used to estimate the number of additional cases of hypertension, AMI, annoyance and sleep disturbances in the local population.

RESULTS

73,272 persons exposed to aircraft noise levels >55dB were considered: 55,915 (76.3%) were exposed to 55-60 dB; 16,562 (22.6%) to 60-65 dB; 795 (1.2%) to 65-70 dB. Exposure to aircraft noise levels above 55 dB was estimated to be responsible each year of 4,607 (95%CI 0-9,923) additional cases of hypertension; 3.4 (95%CI 0-10.7) cases of AMI; 9,789 (95%CI 6,895-11,962) cases of annoyance; 5,084 (95%CI 1,894-10,509) cases of sleep disturbances.

CONCLUSIONS

a significant impact of airport noise on the health of residents nearby six Italian airports was estimated. Epidemiological evaluation and noise mitigation measures should be introduced to protect the health of residents.

Mortality analysis by neighbourhood in a city with high levels of industrial air pollution

OBJECTIVES

Taranto, a city in south-eastern Italy, suffers serious environmental pollution from industrial sources. A previous cohort analysis found mortality excesses among neighbourhoods closest to industrial areas. Aim of this study was to investigate whether mortality also increased in other neighbourhoods compared to Apulia region.

METHODS

Standardized mortality ratios were computed. Number of deaths and of person-years at risk by neighbourhood came from the previous cohort study for 1998-2008 period. Reference population was Apulia region excluding Taranto province. A meta-analysis was conducted across less close neighbourhoods computing summary SMR estimates and evaluating heterogeneity.

RESULTS

For the entire city higher mortality values are confirmed for all causes, all malignant neoplasms and several specific sites, neurological, cardiac, respiratory and digestive diseases. High mortality values are not confined to neighbourhoods closest to industrial areas for lung cancer, cardiac, respiratory and digestive diseases, in both sexes, and among women for all malignant neoplasms and pancreatic cancer.

CONCLUSIONS

Increased mortality risks can also be observed in Taranto neighbourhoods not directly adjacent to industrial areas. Spatial trend, impact of socio-economic factors and duration of residence should be further explored.

[Residential cohort approach in industrial contaminated sites: the ERAS Lazio project]

The population-based cohort study is the best design for assessing the possible health effects resulting fromliving in contaminated sites. The ERAS (Epidemiology,Waste disposal, Environment and Health) Project was established to study the health of people living in close proximity to urban solid waste treatment (RU) plants in Lazio. It was conducted using an integrated approach, which consisted in studying mortality and hospital discharges of residential cohorts surrounding urban waste treatment plants. The level of exposure of each address was assigned using pollution dispersion models and studying the effects on mortality and hospital discharges. Further studies were conducted on residents of areas adjacent to waste disposal sites (includingMalagrotta in Rome), incinerators andmechanical biological treatment plants. The final version of the ERAS Report is available at www.eraslazio.it. The residential cohort approach and the combination of environmental and health-related information proved invaluable in the assessment of the health impact of solid waste treatment in Lazio.

[Occupational exposure to asbestos and incidence of malignant mesothelioma in the Lazio region, years 2001-2009: results of the activities of the regional register]

BACKGROUND

The Lazio Regional Mesothelioma Registry records the incident cases of Malignant Mesothelioma (MM) in residents in the Region since 2001.

OBJECTIVES

Estimate the incidence of MM in the Lazio Region (2001-2009) and assess possible asbestos exposures.

METHODS

The MM cases, notified by hospitals, regional protection and workplace safety units, Italian Workers' Compensation Authority, other regions, or extracted from hospital information systems and the regional registry of causes of death, are included in the register after analysis of diagnostic procedures (CT scan, chest X-ray, pathology reports and patients' records). Possible asbestos exposure is investigated by standardized interview and thereafter defined by a panel of experts, according to RENAM guidelines. The incidence of MM of the pleura and peritoneum (per 100,000 inhabitants) for the period 2001-2009 is calculated.

RESULTS

The incidence of MM among Lazio residents in the period 2001-2009 (600 cases) was estimated to be 1.8 among men and 0.5 among women per 100,000 inhabitants. Information on exposures was collectedfor 54% of the cases (251 men and 78 women); 72% of men (n. 179) and 9% of women (n. 7) had been occupationally exposed to asbestos. The study found that the largest number of cases with occupational exposure was among workers in the construction industry. The number of cases with unknown exposure was very high.

CONCLUSIONS

The registry's work revealed the existence of asbestos exposure circumstances that were not sufficiently characterized,for which it is suggested that more detailed industrial hygiene investigations be performed, as well as measurement of asbestos bodies and/or fibres in lung tissue.

[A cohort study on mortality and morbidity in the area of Taranto, Southern Italy]

INTRODUCTION

the area of Taranto has been investigated in several environmental and epidemiological studies due to the presence of many industrial plants and shipyards. Results from many studies showed excesses of mortality and cancer incidence for the entire city of Taranto, but there are no studies for different geographical areas of the city that take into account the important confounding effect of socioeconomic position.

OBJECTIVE

to assess mortality and hospitalization rates of residents in Taranto, Statte and Massafra through a cohort study,with a particular focus on residents in the districts closest to the industrial complex, taking into account the socioeconomic position.

METHODS

a cohort of residents during the period 1998-2010 was enrolled. Individual follow-up for assessment of vital status at 31.01.2010 was performed using municipality data. The census-tract socioeconomic position level and the district of residence were assigned to each participant, on the basis of the geocoded addresses at the beginning of the follow- up. Standardized cause specific mortality/ morbidity rates, adjusted for age, were calculated by gender and districts of residence. Mortality and morbidity Hazard Ratios (HR, CI95%) were calculated by districts and socioeconomic position using Cox models. All models were adjusted for age and calendar period, and were done separately for men and women.

RESULTS

321.356 people were enrolled in the cohort (48.9%males).Mortality/morbidity risks for natural cause, cancers, cardiovascular and respiratory diseases were found to be higher in low socioeconomic position groups compared to high ones. The analyses by districts have shown several excess mortality/morbidity risks for residents in Tamburi (Tamburi, Isola, Porta Napoli and LidoAzzurro), Borgo, Paolo VI and the municipality of Statte.

CONCLUSIONS

The results of this study showed a significant relationship between socioeconomic position and health status of people resident in Taranto. People living in the districts closest to the industrial zone have higher mortality/morbidity levels compared to the rest of the area also taking into account the socioeconomic position.

[Cancer incidence and mortality in the cohort of residents close to the Italian nuclear power plants of Borgo Sabotino and Garigliano]

INTRODUCTION

the potential health impacts due to the decommissioned Nuclear power plants (NPP) located in Borgo Sabotino and Garigliano in Central Italy (active from the early 1960s to the late 1980s) have raised several concerns. Brain, thyroid, breast and lung cancer and leukaemia have been associated with exposure to ionizing radiations, but the health effects of nuclear plants on the resident populations are controversial.

OBJECTIVE

to evaluate whether living close to NPPs is associated with an increased risk of cancer incidence and mortality.

METHODS

we defined a cohort of residents within 7 km from the NPPs during the period 1996-2002. Individual follow-up for vital status at 01.01.2007 was conducted using municipality data. Gender specific Standardized Incidence and Mortality Ratios, adjusted for age, were calculated (SIR and SMR) using the regional population as reference. Each participant's address was assigned to a distance from the NPP on the basis of a GIS. A relative risk (RR, CI95%), adjusted for age and socioeconomic status, was calculated in 3 bands of increasing radius from the plants: 0-2, 2-4, and 4-7 km (reference group), using a Poisson regression model.

RESULTS

the cohort was of 39,775 people, 32%of whom lived near (0-4 km) the NPP. No differences in mortality was found when comparing the cohort with the regional population; among women living within 7 km from the NPP, we found thyroid cancer incidence higher than expected (SIR 1.53 CI95% 1.18-1.95). However, when the analysis was conducted on the basis of the distance from the NPP, we found a statistically significant increase in male mortality only for causes unrelated to radiation exposure (all causes, stomach cancer, and cardiovascular diseases). No mortality excess was observed among women living close to the NPPs. No statistically significant distance-related gradient was observed for cancer incidence both in men and women.

CONCLUSIONS

living close to the NPP was not associated with mortality for causes related to radiation exposure. However, the results suggest to continue the epidemiological surveillance of the population.

[Epidemiologic studies on the health status of the population living in the Sacco River Valley]

OBIETTIVO: to analyze the health status of the population living in an area close to the Colleferro industrial plant.

SETTING AND PARTICIPANTS

the area of the Sacco River Valley, Central Italy nearby Rome, has been heavily polluted over the years by industrial wastes deriving from the chemical industrial plant in Colleferro. In 2006, it was discovered that the herds of livestock were contaminated by beta-hexachlorocycloexane (β-HCH, an industrial waste belonging, as well as lindane, to the group of hexachlorocycloexane isomers).

MAIN OUTCOME MEASURES

the analyses of mortality and morbidity were carried out for the 1998-2007 period (calculation of standardized mortality ratios, SMR), and for the period 2003-2007 (calculation of standardized hospitalization ratios, SHR), respectively. The general population in the Lazio Region has been considered as reference. In addition, a biomonitoring study was conducted on a sample of the population living in 4 areas of the Sacco River Valley with different levels of exposure and the following persistent organic pollutants were measured in the blood (α, β and γ-HCH, HCB p,p'-DDT and p,p'- DDE, 6 NDL-PCB congeners and 12 DL-PCBs, PCDDs and PCDFs), and heavy metals (Cd, Hg, Pb).

RESULTS

cancer mortality in men was increased in the area (SMR=1.20), especially for specific cancer sites (stomach, larynx, lungs, pleura, myeloma); in women an excess of mortality from diabetes was detected (SMR=1.44). The analysis of morbidity indicated an excess of hospitalization for various cancers (larynx, myeloma) in men, for respiratory illness and asthma in both genders and for thyroid disease in women. The biomonitoring study found high mean concentration of β-HCH (mean: 99.05 ng/g fat, SD=121.3), with higher levels in the population living along the river (mean=150 ng/g fat; SD=153.5), likely occurred through water and local food.

CONCLUSION

the area of Colleferro has been polluted by multiple sources and the human population has been exposed to industrial chemicals, toxic substances in the workplace, and to the cumulative accumulation of organic pesticides especially through water and food.