Impact of migration on diabetes burden: audit in the metropolitan area of Bologna, Italy.

PURPOSE: To investigate the impact of diabetes in immigrants on the Italian healthcare system, as well as their compliance with standard protocols of control and treatment. METHODS: The prevalence of immigrants with diabetes living in the metropolitan area of Bologna (about 1 million inhabitants) in 2019 was investigated using a database containing all subjects in active follow-up for diabetes, based on antidiabetic drug use, disease-specific copayment exemption, ICD-9 codes, continuous care in diabetes units. Country of origin was derived from fiscal code. RESULTS: The overall prevalence of diabetes (n = 53,941; 51.8% males, median age 64) was 6.1% in both Italy-born and immigrant cohorts. Immigrant prevalence was 12.4%, moderately higher than that observed in the total population (12.2%). Diabetes risk was increased in the whole immigrant cohort (odds ratio (OR) 1.74; 95% Confidence Interval (CI) 1.69-1.79). Among cases with incident diabetes, the proportion of immigrants (median age, 49 vs. 65 in Italy-born individuals) increased progressively from 11.7% to 26.5% from 2011 to 2019 (males, 8.9-21.0%; females, 14.9-32.8%) in all age groups, particularly in young adults, but also in older subjects. Metabolic control was lower in immigrants, as was adherence to shared diagnostic and therapeutic protocols, without systematic differences in antidiabetic drug use, but much lower use of drugs for comorbid conditions. CONCLUSIONS: The population with diabetes in the metropolitan area of Bologna is rapidly changing. Quality improvement initiatives are needed to reduce the burden for the universalistic Italian health care system generated by the rapidly-growing high-risk immigrant population.

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.

Containment of carbapenem-resistant Enterobacterales colonisations and infections: Results from an integrated infection control intervention in a large hospital trust of northern Italy.

PURPOSE: We describe the results of an infection control intervention, implemented in 4 tertiary hospitals in Romagna, Italy, aiming at containing the spread of carbapenem-resistant Enterobacterales (CRE). METHODS: The intervention consisted of rectal screening in patients at risk for CRE; pre-emptive contact precaution waiting for screening results; timely notification of CRE identification and concomitant computerized alert; contact precaution for confirmed CRE-positive patients. We performed an interrupted time series analysis to compare the incidence of CRE bacteraemia, of other CRE infections, and CRE-positive rectal swabs in the pre and postintervention period (January 2015-July 2017 and August 2017-June 2020, respectively). RESULTS: 4,332 CRE isolates were collected. Klebsiella pneumoniae was the most represented pathogen (n = 3,716, 85%); KPC production was the most common resistance mechanism (n = 3,896, 90%). The incidence rate of CRE bacteraemia significantly decreased from 0.554 to 0.447 episodes per 10.000 patient days in the early postintervention period (P = .001). The incidence rate of other CRE infections significantly decreased from 2.09 to 1.49 isolations per 10.000 patient days in the early postintervention period (P = .021). The monthly number of rectal swabs doubled in the postintervention period and there was a significant reduction trend of CRE-positive swabs, sustained over time (P < .001). CONCLUSIONS: The infection control intervention was successful in containing the spread of CRE infections and colonisations.

Abrupt CO2 release to the atmosphere under glacial and early interglacial climate conditions.

Pulse-like carbon dioxide release to the atmosphere on centennial time scales has only been identified for the most recent glacial and deglacial periods and is thought to be absent during warmer climate conditions. Here, we present a high-resolution carbon dioxide record from 330,000 to 450,000 years before present, revealing pronounced carbon dioxide jumps (CDJ) under cold and warm climate conditions. CDJ come in two varieties that we attribute to invigoration or weakening of the Atlantic meridional overturning circulation (AMOC) and associated northward and southward shifts of the intertropical convergence zone, respectively. We find that CDJ are pervasive features of the carbon cycle that can occur during interglacial climate conditions if land ice masses are sufficiently extended to be able to disturb the AMOC by freshwater input.

WITHDRAWN: Printed educational materials: effects on professional practice and health care outcomes.

BACKGROUND: It is often assumed that merely providing information in an accessible form will influence practice. Although such a strategy is still widely used in an attempt to change behaviour, there is a growing awareness that simply providing information may not lead to appropriate changes in the practice of health care professionals. OBJECTIVES: To assess the effects of printed educational materials in improving the behaviour of health care professionals and patient outcomes. SEARCH STRATEGY: We searched the Cochrane Effective Practice and Organisation of Care Group specialised register, reference lists of articles, and contacted content area experts. SELECTION CRITERIA: Randomised trials, interrupted time series analyses and non equivalent group designs with pre-post measures of interventions comparing 1. Printed educational materials versus a non-intervention control; and 2. Printed educational materials plus additional implementation strategies versus printed educational materials alone. The participants were any health care professionals provided with printed educational materials aimed at improving their practice and/or patient outcomes. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted data and assessed study quality. MAIN RESULTS: Eleven studies were included involving more than 1848 physicians. It proved impractical to examine the impact of interventions quantitatively because of poor reporting of results and inappropriate primary analyses. Nine studies examined comparison 1. Estimates of the benefit from printed educational materials ranged from -3% to 243.4% for provider outcomes, and from -16.1% to 175.6% for patient outcomes, although the practical importance of these changes is, at best, small. Six studies (seven comparisons) examined comparison 2. Benefits attributable to additional interventions ranged from -11.8% to 92.7% for professional behaviour, and -24.4% to 74.5% for patient outcomes. Two of the 14 estimates of professional behaviour, and two of the 11 estimates of patient outcomes were statistically significant. AUTHORS' CONCLUSIONS: The effects of printed educational materials compared with no active intervention appear small and of uncertain clinical significance. These conclusions should be viewed as tentative due to the poor reporting of results and inappropriate primary analyses. The additional impact of more active interventions produced mixed results. Audit and feedback and conferences/workshops did not appear to produce substantial changes in practice; the effects in the evaluations of educational outreach visits and opinion leaders were larger and likely to be of practical importance. None of the studies included full economic analyses, and thus it is unclear to what extent the effects of any of the interventions may be worth the costs involved.

Chemotherapy for advanced non-small-cell lung cancer: how much benefit is enough?

PURPOSE: To estimate the impact of chemotherapy on survival of patients with advanced non-small-cell lung cancer (NSCLC). METHODS: Randomized controlled trials (RCTs) published in the English-language medical literature between 1970 and 1991 were identified through MEDLINE and the reference lists of relevant articles. Six RCTs that accounted for 635 patients and compared first-line chemotherapy with supportive care in advanced NSCLC and reported survival up to at least 1 year were identified. Cumulative proportions of survival at 3, 6, 9, and 12 months for chemotherapy and control groups were derived from survival curves. RESULTS: Within each study, the effect of chemotherapy was estimated with a pooled relative risk (RR) across the four 3-month periods. An overall estimate of the RR of death at 1 year (RRM-H) was then calculated and a survival curve for chemotherapy-treated patients was constructed applying the pooled estimate of the RR (RRW) for each 3-month period. Overall, chemotherapy was associated with a 24% (95% confidence interval [CI], 13% to 34%) reduction in the probability of death when compared with supportive care. However, the effect of treatment appeared to decrease significantly after the first 6 months from therapy inception and the mean potential gain in survival, as compared with supportive care, was approximately 6 weeks (95% CI, 1 to 10). CONCLUSION: Chemotherapy is effective in the treatment of advanced NSCLC, but its impact on the length of survival is limited. Future RCTs should still include an untreated control group and should measure quality of life in addition to survival.

[From the Mailing List SIN: Epidemic of infections caused by 'aquatic' bacteria in patients undergoing hemodialysis via central venous catheters]. / Dalla Mailing-List soci SIN (ML-SIN). Epidemia di infezioni causate da batteri 'acquatici' in pazienti emodializzati tramite cateteri venosi centrali.

UNLABELLED: Bacteremia due to central venous catheter (CVC) infection is the most frequent complication of CVC use as vascular access for hemodialysis (HD). We report a case of an epidemic of CVC infections caused by 3 strains of unusual bacteria: Ralstonia pickettii (Rp), Leifsonia xyli/Leifsonia aquatica (Lxa), Tsuckamurella strandjordae (Ts). From 20/8/01 to 30/9/01, 23 of 35 patients dialyzed via CVCs experienced intra-HD pyrogenic reactions. Their hemocultures were positive for: Rp (14 pts), Lxa (3 pts), Rp+Lxa (5 pts) and Rp+Ts (1 pt). The hemocultures of 12/35 asymptomatic pts were positive for: Rp 2 pts, Lxa 2 pts, Rp+Lxa 2 pts, Ts 1 pt, Rp+Ts 1 pt. The epidemiological and microbiological analyses of environmental samples failed to identify the source of the epidemic. Actions taken were: a) replacement of the batches of disposable materials; b) removal of CVCs in cases where possible to prepare a different access; c) treatment of the infections with intra-CVC antibiotic lock therapy. No relapses were recorded until April 2002, when 8 pts had again pyrogenic reactions due to Rp. After quick substitution of the CVC and repetitions of the action a), no relapses of pyrogenic reactions were observed. CONCLUSIONS: 1) given the characteristics of Rp, Lxa and Ts, saprophytes of moist environments, the most plausible source of the epidemic was a low-charge contaminated solution that was not identified due to low sensitivity of environmental sample culturing methods; 2) antibiotic lock therapy is a viable option for the conservative treatment of CVC infections.

[Cochrane EPOC group: closing the gap between quality assurance and organization of care research and front line professionals]. / Cochrane EPOC group: chiudere il gap tra ricerca sul miglioramento della qualità dei servizi sanitari e professionisti sul campo.

Keeping physicians informed on an ongoing basis is a new challenge for continuing medical education and quality assurance. In Italy over the last 5 years interest in evidence based literature is growing. This is demonstrated by the launch of an Italian edition of Clinical Evidence and by the growing number of guidelines and systematic reviews produced by Italian authors and institutions. However, there is some uncertainty concerning the familiarity of Italian policy makers and public health physicians with the evidence-based resources, including also how to access them. This article attempts to close this gap, by describing the activities of the Cochrane Collaboration and, within it, of the Cochrane Effective Practice and Organisation of Care Group (EPOC), both aim to prepare and maintaining SR of health care interventions. Specifically, the EPOC group develops systematic reviews of professional, financial, organisational and regulatory interventions that are designed to improve professional practice and the delivery of effective health services. EPOC has 31 reviews and 24 protocols published in Issue 4, 2004 of the Cochrane Library and has developed standard methods to assist people, such as quality criteria for study design specific to health services research. The EPOC specialized register contains details of over 2200 studies that fall within the group's scope. Systematic reviews provide a valuable and efficient source of information for policy makers and health care professionals aimed at implementing effective and efficient strategies to encourage medical behavioural change and deliver of high quality services.

A randomized clinical trial comparing radiation therapy v radiation therapy plus cis-dichlorodiammine platinum (II) in the treatment of locally advanced non-small cell lung cancer.

Cis-Dichlorodiammine platinum (II) (cis-DDP) was demonstrated to be a potentiator of radiation therapy (RT) in experimental tumor models and in cultured cells. To assess the effectiveness of a combined modality treatment including RT and a weekly low-dose administration of cis-DDP, from January 1986 to June 1987, 95 patients with unresectable locally advanced non-small cell carcinoma of the lung (stage IIIa, b) were randomized for study. Fifty patients received RT alone at doses of 50 Gy; 45 patients received the same RT plus cis-DDP 15 mg/m2 IV weekly. An overall response rate of 50% and 64% was observed in the RT and RT + cis-DDP group, respectively. No statistically significant differences were detected with regard to median survival time (11 months for RT v 16 months for RT + cis-DDP) and progression-free interval (7 months in the RT arm v 9 months in the RT + cis-DDP arm), but the patterns of the first failure appeared to be affected by treatment. In fact, a lower number of intrathoracic relapses was observed in the RT + cis-DDP arm (12 in the RT + cis-DDP v 23 in the RT arm). Toxicity was mild and the feasibility of this schedule must be remarked. A better local control of disease can be obtained using cis-DDP as a radiation potentiator, but the true influence of this combined modality treatment on the length of survival, and the optimal cis-DDP timing and dosage are still to be evaluated in further clinical trials.

Role of the neuronal histaminergic system in the regulation of somatotropic function: comparison between the neonatal and the adult rat.

To study possible age-related differences in the role of neuronal histaminergic pathways in the control of GH secretion, the effects of alpha-fluoromethylhistidine (alpha-FMH), an irreversible inhibitor of histamine (HA) synthesis, were examined on basal and opioid-induced GH release in neonatal and adult rats. The mechanisms involved in such effects were evaluated by measuring pituitary GH mRNA levels and hypothalamic levels of GH-releasing hormone (GHRH) and somatostatin (SRIF) mRNAs. Daily injection of alpha-FMH (20 mg/kg, s.c.) in pups of either sex, from birth until 10 days of age, caused a significant increase in baseline plasma GH and potentiated the GH response to the [Met5]-enkephalin analog FK 33-824 (1 mg/kg, s.c.) administered 3 h after the last alpha-FMH injection. GH and SRIF mRNA levels were significantly higher in alpha-FMH-treated pups than in controls, whereas no difference was observed in GHRH mRNA levels. In young adult male rats, acute administration of alpha-FMH (100 mg/kg, s.c., 3 h before) did not change significantly basal GH levels but potentiated FK 33-824 (0.3 mg/kg, intracarotid)-induced stimulation of GH secretion. Repeated administration of alpha-FMH (200 micrograms/rat, i.c.v., for 3 days) failed to modify basal and FK 33-824-induced GH secretion, caused a significant reduction in hypothalamic GHRH mRNA levels and left SRIF and GH mRNAs unchanged. These findings indicate that HA exerts an inhibitory effect on GH secretion in both neonatal and adult rats. The different effects of short-term HA depletion on hypothalamic and pituitary indices of somatotropic function observed at the two age periods may be ascribed to the immaturity of the HA system in early postnatal life and to a different functional role of GH-regulatory factors during ontogeny.

Mechanism of action of Hexarelin. I. Growth hormone-releasing activity in the rat.

We have reported Hexarelin (HEXA), an analog of growth hormone-releasing peptide 6 (GHRP-6), potently stimulates growth hormone (GH) secretion in infant and adult rats. This study was undertaken to further investigate Hexarelin's mechanisms of action. In 10-day-old pups, treatments with HEXA (80 micrograms/kg, b.i.d.) for 3-10 days significantly enhanced, in a time-related fashion, the GH response to an acute HEXA challenge. Qualitatively similar effects were elicited in pups passively immunized against growth hormone-releasing hormone (GHRH) from birth. In adult male rats, a 5-day pretreatment with HEXA (150 micrograms/kg, b.i.d.) did not enhance the effect of the acute challenge, and the same pattern was present after a 5-day pretreatment in male rats with surgical ablation of the mediobasal hypothalamus (MBH-ablated rats). In addition, in adult sham-operated rats, Hexarelin (300 micrograms/kg, i.v.) induced a GH response greater (p < 0.05) than that induced by GHRH (2 micrograms/kg, i.v.). However, in MBH-ablated rats 7 days after surgery, GHRH was significantly (p < 0.05) more effective than HEXA, and 30 days after surgery HEXA and GHRH evoked similar rises of plasma GH. Finally, the in vitro Hexarelin (10(-6) mol/l) effect was transient while GHRH (10(-8) mol/l) induced a longer lasting and greater GH release. Three different mechanisms, not mutually exclusive, are postulated for Hexarelin stimulation of GH secretion in vivo: a direct action on the pituitary, though of minor relevance; an indirect action that involves release of GHRH, of relevance only in adult rats; and an action through the release of a still unknown hypothalamic "factor", which in infant and adult rats elicits GH release acting sinergistically with GHRH.

Appropriateness and variation of surgical treatment of breast cancer in Italy: when excellence in clinical research does not match with generalized good quality care. Progetto Oncologia Femminile.

To assess appropriateness of surgical care delivered to breast cancer patients in Italy and quantify the use of unnecessary radical procedures, a retrospective charts review of patients treated in 1988-1989 was conducted. A series of 1724 consecutive patients (median age 61 years; range 17-89) treated in 63 hospitals selected from within 8 regions with newly diagnosed operable breast carcinoma was evaluated. Overall, 541 (38%) patients had inappropriate surgery with more than two thirds of it being accounted for by the use of unnecessary mutilating Halsted mastectomy. Substantial geographic variation emerged in the overall rates of appropriateness (range 88-52%) which were not substantially affected by allowance for imbalances in patient- and hospital-related variables. Despite the important contribution given by Italian clinical researchers to the demonstration that less radical surgery can be as good as more radical procedures, still a substantial proportion of breast cancer patients are treated too aggressively. Besides pointing to the urgent need of interventions aimed at facilitating the process of technology transfer in order to promote more appropriate surgical care, these results suggest that efforts to increase patients' participation into treatment decision and awareness about alternative treatment options are warranted.

Novel hexarelin analogs stimulate feeding in the rat through a mechanism not involving growth hormone release.

Growth hormone-releasing peptides (GHRPs) are a class of small peptides that stimulate growth hormone (GH) release in several animal species, including the human. Moreover, GHRPs injected into the brain ventricles stimulate feeding in the rat. The aim of this study was to evaluate the GH-releasing properties of a series of novel GHRP analogs and the possible existence of functional correlations between the GH-releasing activity and the effects on feeding behavior. Two well-known hexapeptides, GHRP-6 and hexarelin, given s.c., dose dependently stimulated both GH release and feeding behavior in satiated rats. However, in a series of tri-, penta- and hexapeptide analogs of hexarelin, some compounds were active either on GH release or on eating behavior. Interestingly, even minor structural modifications resulted in major changes of the pharmacological profile. We conclude that GHRPs have orexigenic properties after systemic administration which are largely independent from the effects they exert on GH release.

Impact of regionalisation of cardiac surgery in Emilia-Romagna, Italy.

STUDY OBJECTIVE: Assessment of the impact of the regionalisation of cardiac surgery through the organisational form of a hub&spoke model introduced in the year 2000. DESIGN: Case mix adjusted before (1998-1999)-after (2000-2002) comparison of: (a) in-hospital and 30 days mortality rates; (b) proportion of patients timely (within one day) referred for surgery from spoke to hub centres; (c) patients' waiting times to surgery. SETTING: Emilia-Romagna, an Italian region with four million residents. PATIENTS: 16,512 patients aged > or =18 years and referred to cardiac surgery over the period 1998-2002. MAIN RESULTS: Overall, taking into account differences in case mix across the whole study period, the implementation of the regionalisation policy was associated with a 22% reduction (OR: 0.79, 95%CI: 0.66 to 0.93) in in-hospital mortality rate. The corresponding figure for 30 day mortality was 18% (OR: 0.82: 95%CI: 0.69 to 0.98). The individual centres' volume of cases changed over the study period for all hospitals but two, and the biggest reduction in mortality was seen at the centre with the largest increase in caseload. CONCLUSIONS: This study provides additional evidence on the benefit of regionalisation of cardiac surgery interventions. The system allowed each centre to reach the minimum caseload required to assure good quality of care. These findings suggest that policies aimed at increasing cooperation rather than competition among health service providers have a positive impact on quality of care. Timely referrals for surgery increased by 21% (95%CI: 1.12 to 1.31), and mean waiting times were reduced by 7.5 average days (95%CI: -10.33 to -4.71).

Systematic reviews of the effectiveness of quality improvement strategies and programmes.

Systematic reviews provide the best evidence on the effectiveness of healthcare interventions including quality improvement strategies. The methods of systematic review of individual patient randomised trials of healthcare interventions are well developed. We discuss methodological and practice issues that need to be considered when undertaking systematic reviews of quality improvement strategies including developing a review protocol, identifying and screening evidence sources, quality assessment and data abstraction, analytical methods, reporting systematic reviews, and appraising systematic reviews. This paper builds on our experiences within the Cochrane Effective Practice and Organisation of Care (EPOC) review group.

Breast cancer surgery in 30 Italian general hospitals.

The utilization of limited surgery in patients with breast cancer operated between September 1986 and July 1988 was assessed using information collected within a cohort subsequently enrolled in a randomized clinical trial testing the efficacy of post-surgical follow up. Overall 30% had limited surgery, 61% had other more radical procedures and 9% are still undergoing an unnecessary Halsted mastectomy. Several factors were related to the lower likelihood of getting a conservative procedure: geographic distribution, age, level of education, quadrant and nodal state. The paper discusses the implications of these findings in view of the otherwise growing consensus that more radical surgery should be abandoned.

Cost effectiveness of screening for subclinical hypothyroidism in the elderly. A decision-analytical model.

OBJECTIVE: The value of early detection of subclinical hypothyroidism is the object of a long lasting debate. In this study, we assessed the cost effectiveness of a policy based upon screening for this condition through thyroid-stimulating hormone (TSH), triiodothyronine (T3) and thyroxine (T4) serum level measurements in the elderly. DESIGN: A Markov model was developed where hypothetical elderly patients (i.e. > or = 60 years of age), who attend general practitioner (GP) clinics for periodic health examinations in a primary-care setting in Italy, made transitions between health states at annual interval for 15 years, thus allowing an estimation of the average cost and of the expected average number of quality-adjusted life-years (QALY). In this model, patients were assumed to be seen at annual intervals by GPs for clinical examination and serum cholesterol level measurement, to which a TSH, T3 and T4 serum measurement was added. In the base-case analysis, TSH was measured every 5 years and, if abnormal, T3 and T4 serum levels were also determined. Costs were analysed from the perspective of the Italian National Health Service (NHS) and reflected 1996 values. MAIN OUTCOME MEASURES AND RESULTS: In the base-case analysis, the additional benefit estimated from testing a female population for subclinical hypothyroidism every 5 years was 0.36 QALY, with a cost per QALY gained of 668,298 lire (L). The expected gain in QALY for men was 0.20 and the cost per QALY gained was L270,322. In general, the best cost-effectiveness profile was seen with testing every 3 years. Results were sensitive to variations in the prevalence of disease among the target population, both in men and women. CONCLUSIONS: Our study indicates that a screening policy for subclinical hypothyroidism in the elderly population could be worthwhile. However, as the costs could be significant when applied at the population level, this policy deserves further assessment through well-designed primary research.

Physicians' view of practice guidelines. A survey of Italian physicians.

After more than 10 years of development, two different views of practice guidelines are emerging: either as an educational tool for the medical profession, or as a forum where health care issues can be debated by physicians and non-medical groups. Physicians use practice guidelines in the former model to set their own standards of good quality care, while the latter approach needs contributions from other components in order to decide what should be provided by our health care systems. In a survey of Italian physicians' opinions and attitudes toward practice guidelines, responders supported the "narrowest" model. More than 80% stated that improvement of quality of care and reduction of variation in clinical and practice styles should be the aim of practice guidelines, without representatives from outside the medical profession being involved (61%, 79% and 86% disagreed with a possible involvement, respectively, of patients, health care administrators and representatives of the public at large). Overall, 38% of physicians had a positive attitude toward guidelines viewed as a quality assurance tool for the medical profession. Overall, physicians seem to ignore that the need to rationalize health care calls for input from other professions and members of society. Indeed, most of the issues facing medicine today are mainly a matter of how much value our societies attach to the benefit expected from the available health services. The answers as to what should be done in health care probably cannot be left to the medical profession alone.

Mass media interventions: effects on health services utilisation.

BACKGROUND: The mass media frequently cover health related topics, are the leading source of information about important health issues, and are targeted by those who aim to influence the behaviour of health professionals and patients. OBJECTIVES: To assess the effects of mass media on the utilisation of health services. SEARCH STRATEGY: We searched the Cochrane Effective Practice and Organisation of Care Group specialised register (1996 to 1999), MEDLINE, EMBASE, Eric, PsycLit (to 1999), and reference lists of articles. We hand searched the journals Communication Research (February 1987 to August 1996), European Journal of Communication (1986 to 1994), Journal of Communication (winter 1986 to summer 1996), Communication Theory (February 1991 to August 1996), Critical Studies in Mass Communication (March 1984 to March 1995) and Journalism Quarterly (1986 to summer 1996). SELECTION CRITERIA: Randomised trials, controlled clinical trials, controlled before-and-after studies and interrupted time series analyses of mass media interventions. The participants were health care professionals, patients and the general public. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted data and assessed study quality. MAIN RESULTS: Twenty studies were included. All used interrupted time series designs. Fifteen evaluated the impact of formal mass media campaigns, and five of media coverage of health-related issues. The overall methodological quality was variable. Six studies did not perform any statistical analysis, and nine used inappropriate statistical tests (ie not taking into account the effect of time trend). All of the studies apart from one concluded that mass media was effective. These positive findings were confirmed by our re-analysis in seven studies. The direction of effect was consistent across studies towards the expected change. REVIEWER'S CONCLUSIONS: Despite the limited information about key aspects of mass media interventions and the poor quality of the available primary research there is evidence that these channels of communication may have an important role in influencing the use of health care interventions. Although the findings of this review may be affected by publication bias, those engaged in promoting better uptake of research information in clinical practice should consider mass media as one of the tools that may encourage the use of effective services and discourage those of unproven effectiveness.

Mass media interventions: effects on health services utilisation.

BACKGROUND: The mass media frequently cover health related topics, are the leading source of information about important health issues, and are targeted by those who aim to influence the behaviour of health professionals and patients. OBJECTIVES: To assess the effects of mass media on the utilisation of health services. SEARCH STRATEGY: We searched the Cochrane Effective Practice and Organisation of Care Group specialised register, MEDLINE, EMBASE, Eric, PsycLit, and reference lists of articles. We hand searched the journals Communication Research (February 1987 to August 1996), European Journal of Communication (1986 to 1994), Journal of Communication (winter 1986 to summer 1996), Communication Theory (February 1991 to August 1996), Critical Studies in Mass Communication (March 1984 to March 1995) and Journalism Quarterly (1986 to summer 1996). SELECTION CRITERIA: Randomised trials, controlled clinical trials, controlled before-and-after studies and interrupted time series analyses of mass media interventions. The participants were health care professionals, patients and the general public. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted data and assessed study quality. MAIN RESULTS: Seventeen studies were included. All used interrupted time series designs. Fourteen evaluated the impact of formal mass media campaigns, and three of media coverage of health related issues. The overall methodological quality was variable. Six studies did not perform any statistical analysis, and seven used inappropriate statistical tests (ie not taking into account the effect of time trend). All of the studies apart from one concluded that mass media was effective. These positive findings were confirmed by our re-analysis in seven studies. The direction of effect was consistent across studies towards the expected change. The pooled effect sizes for studies assessing the impact of mass media on similar aspects of care revealed an effect upon the utilisation of health services that could not be explained by chance alone, ranging from -1.96 (95%CI -1. 19 to -2.73) for campaigns promoting immunisation programmes, to -1. 12 (95%CI -0.49 to -2.36) for those concerning cancer screening. REVIEWER'S CONCLUSIONS: Despite the limited information about key aspects of mass media interventions and the poor quality of the available primary research, there is evidence that these channels of communication may have an important role in influencing the use of health care interventions. Those engaged in promoting better uptake of research information in clinical practice should consider mass media as one of the tools that may encourage the use of effective services and discourage those of unproven effectiveness.