Prevalence, characteristics, and patterns of health care use for chronic headache in two areas of Italy. Results of a questionnaire interview in general practice

We set out to define the prevalence, clinical features and severity of chronic headache among the affiliates of two groups of general practitioners (GPs) and to illustrate the diagnostic and therapeutic modalities employed. A semistructured questionnaire was completed for 2291 children and adults, seen at office or home consultations over a 6-month period by 44 GPs in two areas of Northern Italy (Varese and Sondrio) and Southern Italy (San Giovanni Rotondo), to assess the presence and the clinical features of chronic headache, the severity of the disease (i.e. the degree of interference with work and daily living activities), the diagnostic work-up, and the main treatment modalities. GPs attempted the classification of headache according to the International Headache Society (IHS) criteria. The sample comprised 910 men and 1381 women aged 2-92 years; 39% of cases reported chronic headache (Varese/Sondrio 40%; San Giovanni Rotondo 38%; men 28%; women 47%). Headache was mostly present for> 10 years, with one to three attacks/month lasting 4-24 h. Headache was mild in 18% of cases, moderate in 29%, severe in 24%, and very severe in 29%. Diagnostic assessment and treatment varied in the study areas. Diagnostic work-up, hospital admissions, referral to headache centres, and treatment modalities tended to be correlated with headache severity. The GPs could not classify headache using the IHS categories in 27% of cases (Varese/Sondrio 11%; San Giovanni Rotondo 78%). An inverse correlation was found between case classification and use of subsidiary diagnostic and therapeutic aids. Chronic headache is common among individuals seen in general practice. The patterns of health care use tend to be correlated to its severity. A better knowledge of the IHS criteria may be directly related to lower management costs.

The costs of childhood epilepsy in Italy: comparative findings from three health care settings

PURPOSE

To determine the direct costs of epilepsy in a child neurology referral population, stratified by disease, duration, and severity, comparing three different health care settings [i.e., teaching or clinical research (CR) hospitals, general hospitals, and outpatient services].

METHODS

Patients were accepted if they had confirmed epilepsy and were resident in the center catchment area. Eligible subjects were grouped in the following categories: (a) newly diagnosed patients; (b) patients with epilepsy in remission; (c) patients with active non-drug-resistant epilepsy; and (d) those with drug-resistant epilepsy. Over a 12-month period, data regarding the consuming of all resources (i.e., consultations, tests, hospital admissions, drugs), were collected for each patient. Using the Italian National Health Service tariffs, the unit cost of each resource was calculated and indicated in Euros, the European currency.

RESULTS

A total of 189 patients was enrolled by two teaching-CR hospitals, two general hospitals, and two outpatient services. The patients were evenly distributed across the four categories of epilepsy. The mean annual cost per person with epilepsy was 1,767 Euros. Drug-resistant epilepsy was the most expensive category (3,268 Euros) followed by newly diagnosed epilepsy (1,907 Euros), active non-drug-resistant epilepsy (1,112 Euros), and epilepsy in remission (844 Euros). Costs were generally highest in teaching-CR hospitals and lowest in outpatient services. Hospital services were the major cost in all epilepsy groups, followed by drugs.

CONCLUSIONS

The cost of epilepsy in children and adolescents in Italy tends to vary significantly depending on the severity and duration of the disease Hospitals services and drugs are the major sources of costs. The setting of health care plays a significant role in the variation of the costs, even for patients in the same category of epilepsy.

Chronic symmetric symptomatic polyneuropathy in the elderly: a field screening investigation of risk factors for polyneuropathy in two Italian communities. Italian General Practitioner Study Group (IGPST)

A total of 4191 patients 55 years and older were screened for clinical features and risk factors of polyneuropathy by 27 general practitioners (GPs) in two areas of Italy (Varese and San Giovanni Rotondo). Polyneuropathy was diagnosed in the presence of two or more symptoms associated with bilateral impairment of at least two of the following: strength, sensation, tendon reflexes. A risk factor for polyneuropathy (associated disease or neurotoxic agent) was recorded based on its presence in the GP's records, the presence of specific treatments, or an affirmative answer to the interviewer's question. The prevalence of polyneuropathy among patients with no recognized exposure to diseases or neurotoxic agents was 1.6% (Varese 1.6%; San Giovanni Rotondo 1.8%). The corresponding values were 11.8% (Varese 11.8%; San Giovanni Rotondo 11.9%) for patients with one risk factor, and 17.3% (Varese 19.2%; San Giovanni Rotondo 13.0%) for patients with two risk factors. Combining the two populations, the prevalence of polyneuropathy was highest in diabetics (18.3%), followed by patients with a diagnosis of alcoholism (12.5%), non-alcoholic liver disease (10.9%), and tumor (7.1%). Diabetes was the commonest independent risk factor for polyneuropathy (odds ratio 11.3), followed by alcoholism (7.4), non-alcoholic liver disease (4.9), and tumor (2.6).

Diabetic polyneuropathy in the elderly. Prevalence and risk factors in two geographic areas of Italy. Italian General Practitioner Study Group (IGPSG)

OBJECTIVE

To assess the prevalence and the risk factors of diabetic polyneuropathy in representative samples of elderly individuals.

PATIENTS

4191 subjects 55 years and older from two areas of Italy were screened by their general practitioners (GPs) and those positive for neuropathic symptoms were subjected to a standard clinical examinations.

METHODS

The screening questionnaire included a list of clinical conditions possibly causing polyneuropathy, including diabetes. In patients with diabetes, the date of diagnosis, the most recent fasting and post-prandial blood glucose value and glycosylated hemoglobin were sought. Probable polyneuropathy was diagnosed through impairment of 2 or 3 nerve functions (strength, sensation, tendon reflexes) in the extremities with symmetrical and distal distribution.

RESULTS

The sample included 347 patients with diabetes (8.3%). Sixty-six of them (19%) had symptoms and signs consistent with probable polyneuropathy (overall prevalence 1.6%). The disease prevailed in women and in subjects aged 75 years and older. Diabetic patients with polyneuropathy had a longer disease course (P < 0.02) and high mean fasting (P < 0.001) and post-prandial (P < 0.02) blood glucose.

CONCLUSION

Diabetic polyneuropathy in the elderly is a fairly common clinical condition prevailing in women and in subjects 75 years and older. Risk factors for polyneuropathy include prolonged disease duration and high mean fasting and post-prandial blood glucose.

The prevalence of parkinsonism in Italy: an epidemiological survey of the disease in general practice. The Italian General Practitioner Study Group (IGPSG)

The prevalence and characteristics of parkinsonism have been assessed in two separate geographic areas in Italy (Arcisate and San Giovanni Rotondo). A total of 28,377 patients of 23 general practitioners (GPs) were the reference population. Fifty-eight patients were traced by the GP as having typical parkinsonian features or being treated with antiparkinson drugs. Among 53 subjects, 21 of them untreated, parkinsonism was subsequently confirmed neurologically. The overall crude prevalence rate was 1.87 cases per 1,000 (Arcisate 1.81; San Giovanni Rotondo 2.01). The age- and sex-adjusted prevalence rates were 1.84 in Arcisate and 2.04 in San Giovanni Rotondo. After exclusion of drug-related parkinsonism, the rates were 1.48 and 1.90, respectively. Even with some inconsistencies within the two study areas, the prevalence tended to be higher in San Giovanni Rotondo, to prevail in women, and to increase significantly with age. Presumed etiological factors for parkinsonism were recorded in 34% of the cases (mostly drugs). In two thirds of the cases the disease ran a mild course. The present study shows that the GP proves a valuable reference for surveys of parkinsonism in Italy.

Chronic symmetric polyneuropathy in the elderly. A field screening investigation in two regions of Italy: background and methods of assessment. The Italian General Practitioner Study Group (IGPSG)

There are no data on the prevalence and other epidemiologic characteristics of chronic symmetric polyneuropathy (CSP) in the community. This study was designed to assess the prevalence and risk factors of CSP in well-defined elderly (55 years and older) populations from two separate areas in Italy. Thirty-five general practitioners working in the two areas were invited to interview a random sample of patients requesting consultation. They used a pretested questionnaire which focused on selected symptoms of polyneuropathy, common risk factors for CSP, and current drug treatments. Patients giving affirmative answers to the questions on screening symptoms received a further clinical evaluation by a neurologist. Details are given of the general characteristics of the study areas and populations, the methods of case ascertainment, the validation of the screening instruments, and the results of a pilot study.

Prognosis of myasthenia gravis: a multicenter follow-up study of 844 patients

The prognosis of myasthenia gravis (MG) was assessed retrospectively using life-table analysis in 844 patients followed up for a mean period of 5 years in 3 major Italian centers. The chance of achieving at least a 1-year remission after treatment withdrawal (complete remission) was assessed as a specific end-point in the whole population and in selected subgroups with reference to the principal prognostic variables. The cumulative probability of complete remission was 1% by 1 year, 8% by 3 years, 13% by 5 years, and 21% by 10 years. The only variables correlated to the chance of complete remission were younger age at onset of MG, lower severity of symptoms at onset and nadir, and shorter disease duration at diagnosis. In addition, thymectomy and early surgery seemed to influence the chance of remission. Other factors (including the presence of thymoma) did not significantly influence the outcome of the disease.

Antiepileptic drugs as 'tracers' of disease. A calculation of the prevalence of epilepsy through an analysis of drug consumption. The Group for the Study of Epilepsy in General Practice

Antiepileptic drug (AED) consumption, expressed according to a standardized measurement of the average daily doses of each active principle (the defined daily dose, DDD), was assessed as a source of morbidity data to calculate the prevalence of AED takers. In a population of 51,220 from three areas in Italy (Arcisate, Treviglio, S. Giovanni Rotondo) all the patients treated with AEDs, traced by the local general practitioners, were examined by a neurologist. The diagnosis of epilepsy was confirmed in 199 of 223 AED takers, giving an overall prevalence rate of 3.94 per 1,000 (Arcisate 3.96; Treviglio 4.04; S. Giovanni Rotondo 3.89). There was a significant overlap between the observed and expected number of AED takers (the latter obtained from regional sales and expressed in DDD). Prevalence rates calculated from drug sales were 5.58 in Arcisate and 6.11 in Treviglio. The ratio of patients with epilepsy to AED takers in the two areas was 0.7 and corresponded to the mean proportion of AEDs prescribed for epilepsy in the years 1983-1988 by a sample of Italian physicians. Although the prevalence rate calculated from AED sales tends to approximate that of treated epilepsy, AEDs can be reasonably used as 'tracers' of disease for the easy access to drug sales in Italy, the appropriateness of the DDD as a standard measure of the daily doses of AED, the steady pattern of consumption, the comparability of data covering different areas and periods, and the stable proportion of drugs delivered for epilepsy.