The impact of the COVID-19 pandemic on the use of Emergency Departments in Italy

Background

During 2020, COVID-19 had a diversified distribution in Italy, the first nation in Europe to experience the outbreak of the epidemic. This was linked to geographical differences in population density and distribution of healthcare facilities, including Emergency Departments (EDs). This study aims to assess the impact of the pandemic on ED utilization in 2020 across different subpopulations and geographical locations in Italy.

Methods

We used anonymized data from a survey conducted by the Italian National Institute of Statistics on 25,000 families to analyze the yearly rate of people who used EDs from 2015 to 2020. The rate of persons who accessed ED services in 2020 per 1,000 population was compared with those of the previous non-pandemic years.

Results

The number of people accessing EDs in 2020 was 32.3% lower, although this reduction was not uniform across the 21 regions / autonomous provinces. People aged 0-14 years experienced the highest reduction in ED visits. In 2020, low educational level people exhibited a steeper reduction in the use of EDs.

Conclusions

This study shows a significant drop in EDs use especially by children; the population section mostly affected by the effects of the pandemic. This study also confirms that education and socio-economic status are important determinants of ED use. The heterogeneous reduction in ED use across the regions of Italy highlights the need to further investigate the impact of this pattern on the health of the population, as well as to define adequate preparedness strategies to face future emergencies.

Trust and its relations to vaccine beliefs: a latent class analysis on 140,000 individuals worldwide

Background

Research shows that vaccine-related beliefs (i.e., about efficacy, safety, purpose) may reflect a host of within-person and contextual factors yielding homogeneous subgroups of individuals. This study aims to characterize distinct subgroups of people and identify ideal targets for tailored public health interventions to increase vaccine adherence.

Methods

Latent class analysis was used to derive subgroups based on unique response profiles using the 2019 Gallup survey of 140 countries (>140,000 individuals). We modeled a composite of vaccine beliefs as a distal outcome examining differences for the obtained classes, with and without covariates in the model.

Results

A 5-class model fit best with classes distinguished primarily on whether individuals possessed or sought personal knowledge about science, medicine, and health, whether they trusted science, scientists and have confidence in the healthcare system. The lowest levels of vaccine beliefs were reported by a class not endorsing any of these indicators and the highest levels by a class endorsing all the indicators (p < 0.001). Age class showed a U-shaped relation with vaccine beliefs, while higher educational level (p = 0.025), higher subjective income (p = 0.006) and employment (p < 0.001) were related to higher vaccine beliefs. Country-level income was moderately related to class membership and vaccine beliefs were higher in lower-income countries (p < 0.001).

Conclusions

Our findings suggest that more work is needed to improve trust in science and medical providers. Tailored interventions grounded in a community-based and empowering approach with the collaboration of multiple stakeholders seems to be needed to improve vaccination rates. This can only be achieved when individuals trust science, scientists and healthcare providers and accrue the necessary wisdom to make good healthcare decisions that affect not only themselves but their fellow citizens.

Key messages

• Efforts to alter vaccine beliefs should touch on where people access information on science and health, the processes that build trust, and their belief whether science improves well-being.

• Public health interventions should focus on reassuring individuals that science and health workers are benevolent. An essential first step in the health worker-patient relations is building trust.

The impact of the SARS-CoV-2 pandemic on cause-specific- mortality: a systematic literature review

Background

Although investigating the patterns of COVID-19 excess mortality (EM) is relevant, understanding the effects of the pandemic on cause-specific mortality is even crucial and should also be assessed, as this metric allows for a more detailed analysis of the true impact of the pandemic. The aim of this systematic literature review is to estimate the impact of the pandemic on different causes of death, providing a quantitative and qualitative analysis of the phenomenon.

Methods

We searched MEDLINE to identify studies that reported cause-specific mortality during the COVID-19 pandemic. We adopted several inclusion criteria: original article; assessed at least one cause-specific mortality during the pandemic; assessed causes of deaths using the ICD-10 classification; reporting of at least one of the following outcomes: cause-specific mortality estimates or cause-specific EM; full-length articles. Several relevant data were extracted (e.g. publication year, data stratification, territory, country income level, all-cause EM, and cause-specific mortality, etc.).

Results

The search identified 548 articles. After title, abstract and full-text screening, we extracted relevant data from the final set of 14 articles. Cause-specific mortality was reported using different units of measurement. Only 9 studies reported the statistical significance and/or confidence intervals. The most frequently analyzed causes of death were cardiovascular diseases (n = 11), cancer (n = 7), diabetes (n = 6), and suicide (n = 5). We found very heterogeneous patterns of cause-specific mortality, for all the specific causes of deaths, except for suicide and road accident.

Conclusions

The impact of the pandemic on cause-specific deaths has been very heterogeneous and the analyses conducted so far are not exhaustive. We advocate for the urgent need to find a consensus to define uniform methodological approaches to establish the true burden of the COVID-19 pandemic on non-COVID-19 mortality.

Key messages

• We reviewed the body of literature to estimate the impact of the COVID-19 pandemic on different causes of death, and to provide a quantitative and qualitative analysis of the phenomenon.

• We did not identify unique patterns of cause-specific mortality due to too varied approaches in terms of disease classification and coding, and methodologies used for estimating mortality.

Perceived quality and willingness to continue using telemedicine services in patients with diabetes

Background

Plenty of literature reported the applicability and usefulness of telemedicine and teleassistance (TMTA) services in the management of diabetes and other chronic conditions. Specifically, TMTA proved to be effective for conditions that require radical lifestyle modifications, tailored pharmacological interventions, and periodic monitoring of clinical health status. The purpose of this study is to investigate the individual and contextual determinants of the perceived quality (PQ) of the telemedicine and teleassistance (TMTA) services and the willingness to continue (WC) with them among patients with diabetes using TMTA during the COVID-19 pandemic in one large region of Italy (Emilia-Romagna).

Methods

A structured survey was administered to patients with type 1 and 2 diabetes who used TMTA services during the first wave of the COVID-19 pandemic. The questionnaire was comprised of questions on TMTA service experience and participants’ socio-demographic characteristics. Multiple regression models investigated the independent factors associated with PQ (score 1-100) and WC (yes/no).

Results

The final analysis included 569 patients with diabetes (54.7% female), with an average age of 58.1 years. TMTA services’ PQ and WC were high. A higher education (OR = 1.83; 95%CI 1.04, 3.31) and being unemployed (OR = 2.57; 95%CI 1.17, 6.02) were factors associated with an increased WC. Older age was negatively related to PQ (b = −3.6; 95%CI −6.8, −0.29). Perceived support from TMTA service was positively associated with PQ (b = 10.1; 95%CI 5.1, 15) and WC (OR = 2.03; 95%CI 1.07, 3.85). Perceived increase in disease self-management was positively associated with PQ (b = 5.3; 95%CI 0.24, 10) and WC (OR = 7.11; 95%CI 4.04, 12.8).

Conclusions

Our study identified several determinants of PQ and WC. These socio-demographic and patient-perception related factors should be considered in the implementation of care pathways integrating in-person visits with TMTA services.

Key messages

• Socio-demographic factors play a crucial role in TMTA acceptance and should be taken into due consideration when implementing health pathways integrating in-person visits with TMTA services.

• Health workers should always try to improve patients’ self-management skills and should always make patients feel supported. This is also true in the digital health era.

Potential association between working memory and physical fitness status: the BRAVE study

Introduction

The World Health Organization launched a global action plan targeted to obtain a 15% relative reduction in the global prevalence of physical inactivity in adolescents by 2030 also promoting school-based PA interventions and programs in school. Active Breaks (ABs) are a school-based intervention consisting of short bursts (5-15 minutes) of Pa led by teachers or peer. Many researches investigated the implementation of ABs into primary school setting as a strategy to reduce sedentary behaviour, improve cognitive and physical function. However, this kind of intervention has not extended to secondary school, especially in Italian context. For this reason we started the BRAVE study to evaluate the potential effect of implementing ABs in secondary school. The study is currently in the administration phase of ABs to adolescents The preliminary analysis aims to underline a potential association between working memory performance (WM) and physical fitness status among secondary school students at baseline.

Methods

In March 2022 we conducted baseline assessment in a secondary school in Valsamoggia (Bologna, Italy). Working memory was evaluated using backward digit span while physical fitness status was assessed using three different fitness test: standing long-jump (SLJ), six minute Cooper Test (6MCT) and Shuttle run test (SR).

Results

A total of n = 125 adolescent, mean age 12.79±0.89, were enrolled in the study. After performing a regression analysis we found that WM is significantly associated only with age of student (b = 0.2, 95%CI 0.25, 0.11 p = 0.02). A trend also emerged between WM performance and SLJ but with no statistically significant differences (b = 0.160, 95%CI 0.03, 0.02, p = 0.09). The 6MCT and HT have no relevant associations with WM score.

Conclusions

These preliminary results suggest that age is associated with cognitive performance but no positive association were found between WM score and physical fitness status excepted for a small trend with SLJ test.

Key messages

• Age is related to WM in adolescent students.

• ABs interventions could represent a valid strategy to encourage movement, improve cognitive and physical fitness performance.

Semi-Automatic Knowledge Extraction from COVID-19 Scientific Literature: the COKE Project

Background

The COVID-19 pandemic highlighted the importance of rapidly updating scientific information. However, the guidelines’ drafting process is highly time- and resource-consuming. The COKE Project aims to accelerate and streamline the extraction and synthesis of scientific evidence. To do so, the Project used deep learning to implement a semi-automated system that enhances the systematic literature review processes. We aim to show some preliminary results on the automatic classification of abstract sentences in papers related to COVID-19.

Methods

The tool is based on Natural Language Processing algorithms to detect and classify PICO elements and medical terms and organize abstracts accordingly. We built a BERT + bi-LSTM language model. The tool was trained on a corpus of 24,668 abstracts unrelated to COVID-19. We assessed the tool performance in a specific topic related to COVID-19 that has not been covered during training. To carry out manual validation, we randomly selected 50 abstracts. Abstract sentences were classified by 2 domain experts into 7 types: Aim (A), Participants (P), Intervention (I), Outcome (O), Method (M), Results (R), and Conclusion (C). The performance of the tool was compared with that of the experts in terms of precision, recall, and F1.

Results

The classifier proved to have a 76% overall accuracy. Precision, recall, and F1 were above 75% for all types of sentences except I, M, and P.

Conclusions

The results indicate a promising ability of the semi-automated classifier to predict expert-validated labels on abstracts of different topics. Our proposed tool is expected to significantly reduce the effort for producing medical guidelines and therefore have a strong, positive impact, particularly in emergency scenarios. The COKE Project also represents a call-to-action for similar initiatives, aimed at enhancing the information extraction process in medicine.

Key messages

• A rapidly changing healthcare requires fast decisions supported by scientific evidence. This is not compatible with the human limits in cognitive skills that reduce the ability to extract information.

• The COKE Project aims to speed up the creation of healthcare guidelines, semi-automating parts of the workflow, and supporting the human-performed process of extracting and analyzing contents.

Parents’ perception of overweight-obese children Quality of Life in different settings

Background

Children's Health-Related Quality of Life (HRQoL) has been frequently investigated, in particular among individuals affected by chronic diseases. It is reported that agreement between child and parent ratings regarding the child's HRQoL is strongly influenced by the latter's health status. To our knowledge, there is no evidence of how this agreement is related to different healthcare settings. Thus, our study aims to examine the relationship between child's and parent-proxy reported HRQoL of similar overweight/obese children according to the recruitment setting.

Methods

A cross-sectional study was conducted among 68 overweight/obese children, aged 6-10, recruited in a primary school (Group1, G1) and in a hospital outpatient clinic (Group2, G2) of Imola (Italy) in 2019. HRQoL was assessed using Italian version 4.0 of the Pediatric Quality of Life (PedsQL) questionnaire. For each child, we obtained self-reported children's and parents' perceived children's HRQoL total score (5 questions investigating Physical Health domain and 10 questions investigating Psychosocial Health domain divided in Emotional, Social and School Functioning).

Results

In G1 there were n = 42 overweight/obese children and in G2 n = 26. The correlation between children's reported and parents' perceived HRQoL scores is lower in G1 (Physical Health: r=-0,17; Psychosocial Health: r = 0.38) compared to G2 (Physical Health: r = 0.80; Psychosocial Health: r = 0.66). Notably, in G1, parents tend to overestimate their children's HRQoL, specifically in the Physical Health domain.

Conclusions

Correlation between children's and parents' HRQoL scores is higher in the clinical setting compared to the school setting. Implementing this questionnaire on a large scale would allow us to identify settings which need awareness-raising initiatives to improve parents' knowledge about their children's health.

Key messages

Parents’ overestimate children’s HRQoL in the school setting, particularly in the Physical Health domain. Children’s HRQoL misinterpretation might determine less targeted actions to improve their wellbeing and highlights the need for raising parents’ awareness about obesity and its effects on children.

Association between economic growth, mortality and healthcare spending in 31 high-income countries

Background

During the last decades, countries' healthcare spending has grown continuously, becoming a major expenditure item and threatening the overall sustainability of healthcare systems. Plenty of literature shows conflicting evidence about the relationship between economic variations and measurable health outcomes. This study aims to investigate the association between GDP, population mortality and healthcare spending in OECD high-income countries.

Methods

We conducted a cross-sectional study using panel data across 31 high-income countries from 2000 to 2017. Socioeconomic data for every year and each country were extracted from WHO and OECD Database. The association between current healthcare expenditure (CHE), GDP and mortality rate (MR) was investigated through a random-effects model. To control for possible reverse causality, we adopted a test of Granger causality for heterogeneous panel data models.

Results

The results of the random-effects model show that the MR has no statistically significant effect on CHE. We found no statistically significant association between countries' MR and GDP when the latter is the dependent variable. Our results show that an increase in GDP is associated with a significant increase of CHE (b = 0.066, p < 0.001) and CHE is significantly associated with an increase in GDP (b = 3.188, p < 0.001). The Granger causality analysis shows a unidirectional association between MR and CHE, with MR influencing CHE, albeit with a small statistical significance (p = 0.045). Between GDP and CHE, the causality is bidirectional, while between GDP and MR we found no causality.

Conclusions

In this study, we found a strong two-way relationship between GDP and CHE, both in the causality analysis and in the random-effect panel model. Our analysis highlights the economic multiplier effect of CHE. In the debate on the optimal allocation of resources often resulting from economic crises, this evidence should be taken into due consideration.

Key messages

Policymakers worldwide need to recognize the economic impact of healthcare spending when allocating financial resources. Spending on health leads to economic growth. In light of the current health-economy dichotomy, it is important to produce robust scientific evidence supporting healthcare spending.

Does parents’ educational level affect children's sedentary behaviour? A cross sectional analysis

Background

Evidence links sedentary behaviours (SB) with poorer health outcomes; i.e. higher screen time is associated with poorer fitness and cardiometabolic health, as well as unfavourable measures of adiposity, mental health and social behaviour in children. The WHO guidelines for children recommend reaching at least an average of 60 min per day of physical activity (PA). Several studies show a correlation between parental education (PE) and children PA levels. This study aims to analyse the influence that PE has on childrens' sedentary lifestyle and PA habits in Italian society.

Methods

We conducted a cross-sectional analysis among 428 children aged 6-11 recruited in a primary school of Calderara di Reno (Italy) in 2017. Children's and parents' information were collected at baseline (i.e. age, BMI, occupation, instruction). PA level and SB were evaluated using a weekly diary investigating screen time (PC and TV), sports practice and active play (i.e: running, jumping, riding a bike, etc.). We investigated the relationship between lifestyles and PE (high school degree or lower vs college degree or higher) through multiple linear regression models adjusted for age and gender.

Results

Our models show that fathers' educational level is not related to children's SB. PA habits and weekly sports activities are not related to PE. On the other hand, higher mothers' educational level shows to be linked to a decreased TV screen time (p = 0.003) and time spent using a computer (p = 0.035). Notably, older children spend more time using PCs or devices (p = 0.001), net of confounding variables.

Conclusions

Our findings show that mothers' educational level positively influences children's lifestyle. This result might be related to the fact that, in the Italian context, mothers are usually the principal children's caregiver influencing their daily routine. In light of this, mothers might be considered a primary target when implementing public health interventions to reduce children's SB.

Key messages

Higher mothers’ educational level is positively associated with healthier lifestyles in children, in particular in determining a less sedentary behaviour. Fathers' degree of education does not display any impact on children's attitude toward sports and PA.

Exploring children breakfast habits using Zoom8-questionnaire: Results from the I-MOVE Study

Background

Scientific evidence widely argues that consuming breakfast daily is considered a good habit which positively affects health and academic performance, especially in children. In order to be adequate, according to national requirements, breakfast should include a portion of milk or yogurt and one grain based product, providing about 15-20% of the daily recommended energy intake. The aim of this study was to analyse breakfast habits in a convenience sample of primary school children inside the Imola Active Breaks Study.

Methods

A cross-sectional study was conducted in a sample of children, aged 6-10, recruited in a primary school of Imola (Emilia Romagna region, Italy). The Zoom8 self-reported questionnaire, which investigates dietary habits and lifestyle aspects were administered to parents to explore the children's breakfast habits.

Results

A total of 155 children were recruited in November 2019. Breakfast was consumed daily by 117 children (75%), 4-6 times/week by 12 (7%), 2-4 times/week by 4 (3%), and 22 (14%) did not answer. Concerning dairy products' consumption: 50 (32%) children reported milk or yogurt, 47 (30%) milk, 6 (4%) yogurt, 9 (6%) neither of them and 43 (28%) gave no answer. Mostly all the children consumed at least one of these products: biscuits, cakes, croissants, industrial snacks or cereals. 108 children (70%) recognised that the consumption of a dairy and a carbohydrate product represent an adequate breakfast.

Conclusions

The findings suggested that the majority of children consumed one grain based product for breakfast, but most of them were high in sugar and fat content (industrial snacks and croissants). Still not every child had breakfast daily nor had a portion of a dairy product. Measurements should be taken to avoid skipping breakfast and to promote a more balanced breakfast. It would be advisable to analyse in detail the frequency of consumption of each food group and their energy intake.

Key messages

Breakfast consumption positively affects children’s health and academic performance. Health Promotion should stimulate daily consumption of breakfast and improve its quality and energy intake.

Meals adequacy during weekdays and weekends in an Italian primary school children sample

Background

Between 15 and 50% of European children aged 6-9 are overweight or obese and this number is rising dramatically over time, making it one of the most important public health challenges. Selection of healthy food and a balanced diet are key when addressing this obesity epidemic. At the same time, it is essential to consider schools' role and parents' influence on children's dietary habits. This study aims to assess the adequacy of meals during the weekdays (WD) and weekends (WE), therefore highlighting the critical moments where schools' and parents' involvement needs to be of greater impact.

Methods

A cross-sectional study was conducted among 428 children aged 6-11 recruited in a primary school of Calderara di Reno (Italy) in 2017. A weekly diary was administered between May and June 2017 to explore the dietary habits of the participants. Every day for each meal (breakfast, morning snack, lunch, dinner) it was required to report what types of food and beverages were consumed, and where (home/school). The adequacy of each meal was determined by using national guidelines. A McNemar test was performed to evaluate the differences in meal adequacy between the WD and WE.

Results

Our analysis showed that meals consumed at school, i.e. morning snacks and lunches, were more adequate during WD than WE (69.6% vs 22.2%, 53.5% vs 32.5%; P-value <0.001), underlying the positive influence of school. On the other hand, breakfasts and dinners were more adequate during WE than WD (64.5% vs 51.4%, 23.8% vs 15.7%; P-value <0.001); this difference might be partially explained by the different amount of time parents have for food preparation during workdays versus weekends.

Conclusions

Further preventive interventions should address childrens' and parents' home dietary routine as a tool to improve meal adequacy at home and therefore reduce childhood obesity. Parental school-based interventions could have a key role in changing childrens' dietary habits.

Key messages

Our study showed a significant difference of healthy dietary habits between meals served at school during weekdays and at home during weekends, highlighting a higher dietary adequacy in the first ones. The results underline the importance of implementing educational programs addressing childrens’ and their parents' home meals routine and dietary habits.

Small-scale spatial analysis shows the specular distribution of excess mortality between the first and second wave of the COVID-19 pandemic in Italy

OBJECTIVES

The objective of the study is to compare excess mortality (EM) patterns and spatial correlation between the first and second wave of the pandemic in Lombardy, the Italian region that paid an extremely high COVID-19-related mortality toll in March and April 2020.

STUDY DESIGN

We conducted a longitudinal study using municipality-level mortality data.

METHODS

We investigated the patterns and spatial correlation of EM of men aged ≥75 years during the first two pandemic waves (March-April 2020 vs November 2020) of COVID-19, using the mortality data released by the Italian National Institute of Statistics. EM was estimated at the municipality level to accurately detect the critical areas within the region.

RESULTS

The areas that were mostly hit during the first wave of COVID-19 were generally spared by the second wave: EM of men aged ≥75 years in the municipality of Bergamo plummeted from +472% in March and April to -13% in November, and in Cremona the variation was from +344% to -19%. Conversely, in November 2020 EM was higher in some areas that had been protected in the first wave of the pandemic. Spatial correlation widely corroborates these findings, as large sections of the hot spots of EM detected in the first wave of the pandemic changed into cold spots in the second wave, and vice versa.

CONCLUSIONS

Our results reveal the specular distribution of EM between the first and second wave of the pandemic, which may entail the consequences of social distancing measures and individual behaviors, local management strategies, 'harvesting' of the frailer population and, possibly, acquired immune protection. In conclusion, our findings support the need for continuous monitoring and analysis of mortality data using detailed spatial resolution.

Scientific literature response in Pubmed for the novel Coronavirus outbreak: a literature analysis

Background

Recent events highlight how emerging and re-emerging pathogens are actually becoming global challenges for public health. In December 2019, a novel coronavirus (SARS-CoV-2) has emerged. This has suddenly turned out into a global health concern which has led to a very high number of papers published in the scientific literature. Aim of this research is to focus on the bibliometric aspects in order to give researchers a glimpse on what is published in the first 30-days of a global epidemic outbreak.

Methods

We searched MEDLINE (PubMed) electronic database in order to find all relevant studies in the first 30-days from the first publication (which appeared on Pubmed at 14/01/2020), meaning the period 15/01/2020-13/02/2020. We used the following search string: coronavirus* OR Pneumonia of Unknown Etiology OR Covid-19 OR nCoV. We placed a language restriction for English, but no publication status or study design limit was put in place for our search.

Results

From the initial 462 identified articles, 234 articles were found as pertinent and read in extenso in order to classify them. The vast majority of papers come from China, UK and USA. 66.2% of the papers were Editorials, comments, letters or other kind of mainly reported data. 10.7% of papers were secondary literature papers (mainly narrative reviews). The remaining 23.1% were original primary studies. Only 17.5% of the sources used data which were directly collected on the field.

Conclusions

Almost all of data came from China. Even if some preferential channels were guaranteed for publishing those results in the most important journals, it appears that the vast majority of publication in scientific literature in the first 30-days of an epidemic outbreak is based more on reported data and comments, and only a small fraction of the papers have primary data collected in the field. Nevertheless the whole international literature depends on that type of data sources in the early days of the epidemic.

Key messages

This is the first bibliometric research in Pubmed Database on the first 30 days of publications regarding the novel Coronavirus (2019-nCoV) outbreak of 2019.

The vast majority of publication in the first 30-days of an epidemic outbreak are reported data or comments, and only a small fraction of the papers has directly collected data.