Equity in the recovery of elective and oncological surgery volumes after the COVID-19 lockdown: a multicentre cohort study in Italy

BACKGROUND

The COVID-19 pandemic has had, and still has, a profound impact on national health systems, altering trajectories of care and exacerbating existing inequalities in health. Postponement of surgeries and cancellation of elective surgical procedures have been reported worldwide. In Italy, the lock-down measures following the COVID-19 pandemic caused cancellations of surgical procedures and important backlogs; little is known about potential social inequalities in the recovery process that occurred during the post-lockdown period. This study aims at evaluating whether all population social strata benefited equally from the surgical volumes' recovery in four large Italian regions.

METHODS

This multicentre cohort study covers a population of approximately 11 million people. To assess if social inequalities exist in the recovery of eight indicators of elective and oncological surgery, we estimated Risk Ratios (RR) through Poisson models, comparing the incidence proportions of events recorded during COVID-19 (2020-21) with those in pre-pandemic years (2018-19) for each pandemic period and educational level.

RESULTS

Compared to 2018-19, volumes of elective surgery showed a U-shape with the most significant drops during the second wave or the vaccination phase. The recovery was socially unequal. At the end of 2021, incidence proportions among highly educated people generally exceeded the expected ones; RRs were 1.31 (95%CI 1.21-1.42), 1.24 (95%CI 1.17-1.23), 1.17 (95%CI 1.08-1.26) for knee and hip replacement and prostatic surgery, respectively. Among low educated patients, RR remained always < 1. Oncological surgery indicators showed a similar social gradient. Whereas volumes were preserved among the highly educated, the low educated were still lagging behind at the end of 2021.

CONCLUSIONS

Surgical procedures generally returned to pre-pandemic levels but the low educated experienced the slowest recovery. An equity-oriented appraisal of trends in healthcare provision should be included in pandemic preparedness plans, to ensure that social inequalities are promptly recognised and tackled.

Gender and Age Influence on Emergency Department Visits for Non-Suicidal Self-Injuries in School Aged Children in Italy: An 11 Years Retrospective Cross-Sectional Study

Objectives: Non-suicidal self-injury (NSSI) poses a threat in developmental ages, yet there is a scarcity of studies on NSSI trends, especially those in emergency departments (ED). Methods: The aim of this cross-sectional study is to describe trends in ED visits for NSSI among young people aged between 5 and 19 years in Italy from 2011 to 2021 in Piedmont. From the ministerial ED discharge information system, all occurring NSSIs were identified by medical report and/or ICD9CM code and reported as a population rate and a visit rate on all ED requests. Results: The general rate of ED visits remained stable, with around 210,000 (55% males) visits each year, along the whole period from 2011 to 2019, then halved during 2020 and 2021. The NSSI population and visits rates increased from 2013, peaking in 2019 at a rate of around 25 and 23 NSSI visits (girls) and 76 and 69 NSSI (boys) per 100,000 ED visits. In 2020 and 2021, the rate of NSSI visits increased, particularly in girls and among older adolescents. Conclusion: The gradual increase of NSSI over the last decade is a rising public health issue, which deserves wider attention to ensure early detection and prevention.

Pathological and virological insights from an outbreak of European brown hare syndrome in the Italian hare (Lepus corsicanus)

European brown hare syndrome (EBHS) is a highly contagious and fatal viral disease, mainly affecting European brown hares (Lepus europaeus). The etiological agent, EBHS virus (EBHSV), belongs to the Lagovirus genus within the Caliciviridae family. The Italian hare (Lepus corsicanus) is endemic to Central-Southern Italy and Sicily and is classified as a vulnerable species. L. corsicanus is known to be susceptible to EBHS, but virological data available is scarce due to the few cases detected so far. In this study, we describe the occurrence of EBHS in two free-ranging L. corsicanus, found dead in a protected area of Central Italy. The two hares were identified as L. corsicanus using phenotypic criteria and confirmed through mitochondrial DNA analysis. Distinctive EBHS gross lesions were observed at necropsy and confirmed by subsequent histological examination. EBHSV was detected in the livers of the two animals initially using an antigen detection ELISA, followed by an EBHSV-specific reverse transcription-PCR, thus confirming the viral infection as the probable cause of death. The EBHS viruses detected in the two hares were identical, as based on blast analysis performed for the VP60 sequences and showed 98.86% nucleotide identity and 100% amino acid identity with strain EBHSV/GER-BY/EI97.L03477/2019, isolated in Germany in 2019. Phylogenetic analysis places our virus in group B, which includes strains that emerged after the mid-1980s. This study supports previous reports of EBHS in L. corsicanus and further expands the knowledge of the pathological and virological characteristics of the etiological agent. The ability of EBHSV to cause a fatal disease in the Italian hare represents a serious threat to the conservation of this vulnerable species, especially in populations kept in enclosed protected areas.

Paediatric hospitalizations over three waves of COVID-19 (February 2020 to May 2021) in Italy: determinants and rates

Background

After a pneumonia outbreak in late 2019 in China, a new virus related to the Coronaviridae strain, called Severe Acute Respiratory Syndrome-Coronavirus-2 (SARS-CoV-2), was identified as the pathogen of an emerging disease known as COronaVIrus Disease 19 (COVID-19). Preliminary evidence outlines a higher prevalence in adults and lower susceptibility in children. However, recent epidemiologic research highlighted that transmissibility and susceptibility among children and adolescents become higher due to new virus variants. Infections among youth arises with mainly respiratory and gastrointestinal symptoms and malaise. Nevertheless, critical illness affects new-borns and fragile children, requiring hospitalization and possibly intensive care support. Aim of this study was to examine the impact of COVID-19 pandemic on hospital admissions among children and adolescents aged 0 to 17 years over three waves of COVID-19 (from February 2020 to May 2021) in Piedmont, a large Italian region, and to investigate the possible determinants of hospitalizations.

Methods

A meta-analysis for risk assessment was performed over three waves of COVID-19 (from February 2020 to May 2021). Data were extracted from the official Italian National Information System and ISTAT.

Results

Overall, 442 paediatric patients were enrolled and admissions concerned mostly the age group 0-4 years (60.2%). Trends of hospitalization showed a slight increase of paediatric admissions already in March 2020 and a rise during second and third waves (November 2020, March 2021). Paediatric age-grouped hospitalizations (0-4; 12-17; 5-11) reproduced an analogous trend. The children and adolescent hospitalization rate appeared lower than overall population with a moderate slope of increase in comparison with population slope. Monthly hospitalization rate (per 100,000) of children and adolescents aged 0-17 years reproduced the increasing trend of hospitalization numbers. This trend was influenced, in particular, by the trend of hospitalization rates for children aged 0-4 years. The meta-analysis for risk assessment showed a decreased likelihood of rescue of hospitalizations in female, 5-11 and 12-17 age groups. Conversely, the meta-analysis showed a positive association between foreign nationality and hospitalizations.

Conclusions

Our results show a comparable trend of paediatric hospital admissions for COVID-19 and of the entire population hospitalizations over three waves. COVID-19 hospital admissions increase with a bimodal age distribution and the most admissions are among patients aged ≤4 or 5-11 years. Significant predictive factors of hospitalization are identified.

Genomics Insight into cfr-Mediated Linezolid-Resistant LA-MRSA in Italian Pig Holdings

The cfr genes encode for a 23S rRNA methyltransferase, conferring a multiresistance phenotype to phenicol, lincosamide, oxazolidinone, pleuromutilin, and streptogramin A antibiotics. These genes have been described in staphylococci, including methicillin-resistant Staphylococcus aureus (MRSA). In this study, we retrospectively performed an in-depth genomic characterisation of three cfr-positive, multidrug-resistant (MDR) livestock-associated (LA) MRSA clonal complexes (CCs) 1 and 398 detected in different Italian pig holdings (2008–2011) during population studies on Italian livestock (2008–2014). We used a combined Illumina and Oxford Nanopore Technologies (ONT) whole genome sequencing (WGS) approach on two isolates (the 2008 CC1 and the 2010 CC398 isolates, but not the 2011 CC1 isolate). Interestingly, the three isolates presented different cfr variants, with only one displaying a linezolid-resistant phenotype. In isolate 2008 CC1, the cfr gene was identified within a Tn558 composite transposon-like structure flanked by IS elements located on a novel 44,826 bp plasmid. This represents the first report of CC1 LA-MRSA harbouring the cfr gene in its functional variant. Differently, cfr was chromosomally located in isolate 2010 CC398. Our findings have significant public health implications, confirm the need for the continuous genomic surveillance of cfr-positive zoonotic LA-MRSA, and backdate cfr presence in LA-MRSA from Italian pigs to at least 2008.

Incidence and mortality of spinal cord injury from 2008 to 2020: a retrospective population-based cohort study in the Piedmont Region, Italy

STUDY DESIGN

Retrospective population-based cohort study.

OBJECTIVES

To determine the incidence and mortality of spinal cord injuries (SCI) in the Piedmont Region of Northwestern Italy.

SETTING

Publicly-funded SCI rehabilitation centres in the Piedmont Region.

METHODS

Administrative databases were used to identify individuals at their first admission to a SCI rehabilitation centre from January 1st, 2008 to December 31st, 2020. Cases were stratified by age and aetiology (traumatic SCI, TSCI; non-traumatic SCI, NTSCI). Age- and aetiology-specific incidence rate and person-year mortality rates were calculated for each year. Case lethality was reported as deaths among prevalent cases for each year.

RESULTS

A total of 892 cases were identified (56.4% TSCI). The average annual crude incidence rate was 17.9 per million population, decreasing from 26.0 in 2008 to 10.8 in 2020. Young adults and the elderly represented the majority of TSCI and NTSCI cases, respectively. Of the 235 individuals who died during the study period, 58.3% had NTSCI. The mortality rate per 1000 person-years decreased from 16.3 in 2009 to 8.5 in 2020, while case lethality more than tripled (from 17.2 in 2009 to 57.1 in 2020).

CONCLUSIONS

We identified a decreasing trend in SCI incidence and mortality rates, with an increased case lethality over the study period, especially in NTSCI. Given these changes in the epidemiology of SCI, community services offered after rehabilitation should be strengthened to enhance their effectiveness and contribute to increased survival in this population.

Ten-Year Trend in Emergency Department Visits for Sexually Transmitted Infections among Adolescents: A Retrospective Cross-Sectional Study in Italy

Sexually transmitted infections (STIs) are frequently underdiagnosed, representing a serious public health concern, especially during adolescence and in more vulnerable communities.

AIM

to describe the last ten years of emergency department (ED) visits for STIs among adolescents.

METHODS

a retrospective cross-sectional observation was carried out in the Piedmont region in Italy. Data were retrieved through the Italian National Information System database. ED visits related to specific ICD-9-CM codes carried out on 11 to 19-year-old youths between 2011 and 2020 were investigated. Age-specific, crude, and standardized rates and admission ratios, with 95% confidence intervals (CIs), were calculated to estimate the STI trend.

RESULTS

from a total of 1,219,075 ED visits, 339 were related to STIs, representing an increasing ratio of 28 per 100,000 visits, primarily in females. Most infections occurred in girls (83.5%) and among 17 to 19-year-olds (71.5%). A drop in both ED visits and STI cases was observed in 2020. Genital Herpes and Genital Warts were more frequent in girls while Gonorrhea was more frequent in boys.

CONCLUSIONS

the increasing trend of ED visits for STIs, particularly in girls, represents an emerging relevant public health issue that needs to be urgently tackled.

Eating Disorders in Hospitalized School-Aged Children and Adolescents during the COVID-19 Pandemic: A Cross-Sectional Study of Discharge Records in Developmental Ages in Italy

Eating disorders (EDs) are characterized by behavioral and cognitive aspects that result in a significant impairment of an individual's well-being. COVID-19 pandemic consequences negatively impacted healthcare services and people's mental health. Particularly, in developmental ages, difficulties in coping with the situation could have had an impact on eating behaviors. Therefore, the aim of this study was to assess EDs' hospitalization trend before, during and after the pandemic peak to evaluate whether it has been influenced. A retrospective cross-sectional study was conducted on the hospital discharge forms of patients from 5 to 19 years old in Piedmont, which is a region in northern Italy. Overall, hospitalization, age, and gender-specific rates due to EDs that occurred in 2020 and 2021 were compared to those that occurred in 2018-2019. Since 2020, there has been a 55% reduction in overall hospitalizations, while the total proportion of EDs admissions has doubled from 2020 to 2021 (from 13.9‱ to 22.2‱). Significant hospitalization rate increases were observed both in 15-19 and in 10-14 females' age groups in 2021. Non-significant increases were observed in all males' age groups. The increase in hospitalizations for EDs should be further investigated, as it might be the tip of an iceberg not yet acknowledged.

Indirect impact of Covid-19 on hospital care pathways in Italy

Earlier in 2020, seven Italian regions, which cover 62% of the Italian population, set up the Mimico-19 network to monitor the side effects of the restrictive measures against Covid-19 on volumes and quality of care. To this aim, we retrospectively analysed hospital discharges data, computing twelve indicators of volume and performance in three clinical areas: cardiology, oncology, and orthopaedics. Weekly indicators for the period January–July 2020 were compared with the corresponding average for 2018–2019; comparisons were performed within 3 sub-periods: pre-lockdown, lockdown, and post-lockdown. The weekly trend of hospitalisations for ST-segment elevation myocardial infarction (STEMI) showed a 40% reduction, but the proportion of STEMI patients with a primary PTCA did not significantly change from previous years. Malignant neoplasms surgery volumes differed substantially by site, with a limited reduction for lung cancer (< 20%) and greater declines (30–40%) for breast and prostate cancers. The percentage of timely surgery for femoral neck in the elderly remained constantly higher than the previous 2 years whereas hip and knee replacements fell dramatically. Hospitalisations have generally decreased, but the capacity of a timely and effective response in time-dependent pathways of care was not jeopardized throughout the period. General trends did not show important differences across regions, regardless of the different burden of Covid-19. Preventive and primary care services should adopt a pro-active approach, moving towards the identification of at-risk conditions that were neglected during the pandemic and timely addressing patients to the secondary care system.

Monitoring adherence to pharmacological therapy and follow-up examinations among patients with type 2 diabetes in community pharmacies. Results from an experience in Italy

Introduction

Type 2 diabetes is an important public health issue, yet adherence to drugs and regular clinical follow-up is still suboptimal. This study aims to evaluate a community pharmacy programme for monitoring and enhancing adherence to prescribed pharmacological therapies and recommended examinations among patients with confirmed diabetes.

Methods

The intervention was conducted in different Italian areas between April 2017 and January 2018. All adult patients who entered a pharmacy with a personal prescription for any antidiabetic drug and agreed to participate, were interviewed. Those found to be non-adherent received counselling from the pharmacists. All patients were invited for a follow-up interview after 3 months.

Results

Overall, 930 patients were enrolled and completed the baseline interview. We found low rates of non-adherence, ranging from 8% to 13% for prescribed pharmacological therapies, and 11–29% for the recommended clinical examinations. Non-adherence to oral therapies was higher among younger and recently diagnosed patients; that to clinical examinations was higher in men, those with an intermediate duration of diabetes and less educated patients. Large geographical differences persisted after the adjustment for individual factors. Only 306 patients (32.9%) returned for the follow-up interview, most of whom were already adherent at baseline.

Conclusions

Poor adherence to drugs or clinical examinations is not easy to identify in the usual operating setting of community pharmacies. Furthermore, the majority of patients did not return for follow-up, making it impossible to evaluate the efficacy of the pharmacists’ counselling. It might be more effective to plan interventions addressed to specific subgroups of patients or areas.

Novel IncFII plasmid harbouring blaNDM-4 in a carbapenem-resistant Escherichia coli of pig origin, Italy

Objectives

To the best of our knowledge, we describe the first evidence in Europe of an MDR, bla_NDM-4-positive Escherichia coli isolated from a food-producing animal, harboured by a novel IncFII plasmid of which we report the complete sequence.

Methods

One bla_NDM-4-positive E. coli isolated in 2019 from the caecal contents of a fattening pig in Italy was in-depth characterized by combined bioinformatic analysis of Oxford Nanopore long reads and Illumina short reads, for in silico typing, determination of the bla_NDM-4 genetic context and full reconstruction of the bla_NDM-4–carrying plasmid.

Results

The isolate belonged to ST641 and to the genoserotype O108:H23 and tested positive for different virulence genes and plasmid replicons. The MDR phenotype of resistance to all β-lactams, carbapenems, sulfamethoxazole and trimethoprim was mediated by bla_TEM-1B, bla_NDM-4, sul1/sul3 and dfrA12, respectively. The bla_NDM-4 gene was harboured by a novel 53 043 bp IncFII plasmid (pMOL412_FII) composed of four main genetic regions, including an MDR region (MRR-NDM-4) of 16 kb carrying bla_NDM-4 and several antimicrobial resistance genes located in a class 1 integron. pMOL412_FII was closely related to another ∼90.3 kb plasmid (pM109_FII) harbouring bla_NDM-4 in an E. coli isolated from a human patient in Myanmar.

Conclusions

To the best of our knowledge, we have identified for the first time in Europe an NDM-producing Enterobacterales in livestock and resolved the complete sequence of the novel pMOL412_FII plasmid harbouring bla_NDM-4 in an MRR. A global One Health approach, comparing genomic data from different sources and geographical areas, may help to trace back and control possible plasmid-borne carbapenemase gene transmission between animals and humans and along the food chain at international level.

Plasmodium matutinum Transmitted by Culex pipiens as a Cause of Avian Malaria in Captive African Penguins (Spheniscus demersus) in Italy

Avian malaria is a parasitic disease of birds caused by protozoa belonging to the genus Plasmodium, within the order Haemosporida. Penguins are considered particularly susceptible, and outbreaks in captive populations can lead to high mortality. We used a multidisciplinary approach to investigate the death due to avian malaria, occurred between 2015 and 2019, in eight African penguins (Spheniscus demersus) kept in two Italian zoos located in central Italy, and situated about 30 km apart. We also provided information about the presence and circulation of Plasmodium spp. in mosquitoes in central Italy by sampling mosquitoes in both zoos where penguin mortalities occurred. In the eight dead penguins, gross and histopathological lesions were consistent with those previously observed by other authors in avian malaria outbreaks. Organs from dead penguins and mosquitoes collected in both zoos were tested for avian malaria parasites by using a PCR assay targeting the partial mitochondrial conserved region of the cytochrome b gene. Identification at species level was performed by sequencing analysis. Plasmodium matutinum was detected in both dead penguins and in mosquitoes (Culex pipiens), while Plasmodium vaughani in Culex pipiens only. Parasites were not found in any of the PCR tested Aedes albopictus samples. Based on our phylogenetic analysis, we detected three previously characterized lineages: Plasmodium matutinum LINN1 and AFTRU5, P. vaughani SYAT05. In Culex pipiens we also identified two novel lineages, CXPIP32 (inferred morphospecies Plasmodium matutinum) and CXPIP33 (inferred morphospecies P. vaughani). Significantly, LINN1 and AFTRU5 were found to be associated to penguin deaths, although only LINN1 was detected both in penguins (along the years of the study) and in Culex pipiens, while AFTRU5 was detected in a single penguin dead in 2017. In conclusion, in our study Plasmodium matutinum was found to cause avian malaria in captive penguins kept in Europe, with Culex pipiens being its most probable vector. Our results are in agreement with previous studies suggesting that Culex pipiens is one of the main vectors of Plasmodium spp. in Europe and the Northern Hemisphere. Zoos maintaining captive penguins in temperate areas where Culex pipiens is abundant should be well aware of the risks of avian malaria, and should put every effort to prevent outbreaks, in particular during the periods when the number of vectors is higher.

Decreasing educational differences in mortality over 40 years: evidence from the Turin Longitudinal Study (Italy)

BACKGROUND

Recent studies suggest that inequalities in premature mortality have continued to rise over the last decade in most European countries, but not in southern European countries.

METHODS

In this study, we assess long-term trends (1971-2011) in absolute and relative educational inequalities in all-cause and cause-specific mortality in the Turin Longitudinal Study (Turin, Italy), a record-linkage study including all individuals resident in Turin in the 1971, 1981, 1991 and 2001 censuses, and aged 30-99 years (more than 2 million people). We examined mortality for all causes, cardiovascular disease (CVD), all cancers and specific cancers (lung, breast), as well as smoking and alcohol-related mortality.

RESULTS

Overall mortality substantially decreased in all educational groups over the study period, although cancer rates only slightly declined. Absolute inequalities decreased for both genders (SII=962/694 in men/women in 1972-1976 and SII=531/259 in 2007-2011, p<0.01). Among men, absolute inequalities for CVD and alcohol-related causes declined (p<0.05), while remaining stable for other causes of death. Among women, declines in absolute inequalities were observed for CVD, smoking and alcohol-related causes and lung cancer (p<0.05). Relative inequalities in all-cause mortality remained stable for men and decreased for women (RII=1.92/2.03 in men/women in 1972-1976 and RII=2.15/1.32 in 2007-2011). Among men, relative inequalities increased for smoking-related causes, while among women they decreased for all cancers, CVD, smoking-related causes and lung cancer (p<0.05).

CONCLUSIONS

Absolute inequalities in mortality strongly declined over the study period in both genders. Relative educational inequalities in mortality were generally stable among men; while they tended to narrow among women. In general, this study supports the hypothesis that educational inequalities in mortality have decreased in southern European countries.

The impact of migration in all-cause mortality: the Turin Longitudinal Study, 1971-2005

North-western Italy has a long history of domestic influx, however little is known on how migrant mortality compares to mortality at the local level. While geographic mortality gradients may play a role, conceptualizations developed for international migration may also be relevant. Using this theoretical framework, the study investigated immigrant-native differentials in the north-western city of Turin through a 34-year follow-up that was facilitated by the Turin Longitudinal Study. The study population comprised inhabitants of age 30-74 years at the 1971 census. Survival trajectories were modelled through the Gompertz distribution and were examined for nativity status, birthplace, length of stay and age at arrival (the last two variables were combined). All estimates were adjusted for socio-economic factors. Overall, the risk of dying for internal migrants was lower, compared to locals, and consistent with geographic gradients. However, this pattern hid significant differences mediated by both age at arrival and length of stay. The advantage appeared to be exclusive to young and adult migrants, despite differentials narrowing over time. Immigrants who arrived after age 44 suffered instead a progressively greater excess risk, compared to natives, as residence increased. The dissipation of the health advantage found in internal migrants, along with poor health outcomes amongst people older at arrival, raises concern about immigrants from developing countries who need to endure a more demanding journey and adjustment to the new environment. The study indicated, through lengthy longitudinal data, that immigrant-native differentials were best explained by the stratified variable 'length of stay by age at arrival' and this should inform future studies.

Characterization of Salmonella occurring at high prevalence in a population of the land iguana Conolophus subcristatus in Galápagos Islands, Ecuador

The aim of the study was to elucidate the association between the zoonotic pathogen Salmonella and a population of land iguana, Colonophus subcristatus, endemic to Galápagos Islands in Ecuador. We assessed the presence of Salmonella subspecies and serovars and estimated the prevalence of the pathogen in that population. Additionally, we investigated the genetic relatedness among isolates and serovars utilising pulsed field gel electrophoresis (PFGE) on XbaI-digested DNA and determined the antimicrobial susceptibility to a panel of antimicrobials. The study was carried out by sampling cloacal swabs from animals (n = 63) in their natural environment on in the island of Santa Cruz. A high prevalence (62/63, 98.4%) was observed with heterogeneity of Salmonella subspecies and serovars, all known to be associated with reptiles and with reptile-associated salomonellosis in humans. Serotyping revealed 14 different serovars among four Salmonella enterica subspecies: S. enterica subsp. enterica (n = 48), S. enterica subsp. salamae (n = 2), S. enterica subsp. diarizonae (n = 1), and S. enterica subsp. houtenae (n = 7). Four serovars were predominant: S. Poona (n = 18), S. Pomona (n = 10), S. Abaetetuba (n = 8), and S.Newport (n = 5). The S. Poona isolates revealed nine unique XbaI PFGE patterns, with 15 isolates showing a similarity of 70%. Nine S. Pomona isolates had a similarity of 84%. One main cluster with seven (88%) indistinguishable isolates of S. Abaetetuba was observed. All the Salmonella isolates were pan-susceptible to antimicrobials representative of the most relevant therapeutic classes. The high prevalence and absence of clinical signs suggest a natural interaction of the different Salmonella serovars with the host species. The interaction may have been established before any possible exposure of the iguanas and the biocenosis to direct or indirect environmental factors influenced by the use of antimicrobials in agriculture, in human medicine or in veterinary medicine.

The influence of socioeconomic status on utilization and outcomes of elective total hip replacement: a multicity population-based longitudinal study

OBJECTIVE

In countries with universal health coverage, socioeconomic status is not expected to influence access to effective treatment and its prognosis. We tested whether socioeconomic status affects the rates of elective total hip replacement and whether it plays a role in early and late outcomes.

DESIGN

Multicity population-based longitudinal study.

SETTING AND PARTICIPANTS

From Hospital Registries of four Italian cities (Rome, Milan, Turin, and Bologna), we identified 6140 residents aged 65+ years undergoing elective total hip replacement in 1997-2000.

MAIN OUTCOME MEASURES

An area-based (census block) income index was used for each individual. Poisson regression yielded rate ratios (RR) of population occurrence by income level. Logistic regression estimated odds ratios (OR) of selected outcomes within 90 days. Cox proportional hazard models evaluated effects of income on rates of revision of total hip replacement and mortality up to 31 December 2004. Analyses were adjusted for age, gender, city of residence, and coexisting medical conditions.

RESULTS

Low-income people were less likely than high-income counterparts to undergo total hip replacement [RR = 0.87, 95% confidence interval (CI) 0.81-0.95]; the effect was stronger among those aged 75+ years (RR = 0.76, 95% CI = 0.66-0.86). Low income was associated with higher risk of acute adverse medical events (P trend = 0.05) and of general infections and decubitus ulcer (P trend = 0.02) within 90 days. The effects were even higher among those aged 75+ years. No effects were found either for orthopaedic complications within 90 days or for revision and mortality.

CONCLUSIONS

Total hip replacement is underutilized among elderly deprived individuals. Disadvantaged patients seem more vulnerable to acute adverse medical events after surgery. The evidence of unmet need and poor prognosis of low social class people has important implications for health care policy.