Prevalence of schizophrenia spectrum disorders in the Lazio region, Italy: use of an algorithm based on health administrative databases.

BACKGROUND: Mental healthcare provision is undergoing substantial reconfiguration in many regions of the world. Such changes require a broad, evidence-based approach incorporating epidemiological data and information on local needs. The objective of this study was to estimate the prevalence of schizophrenia spectrum disorders (SSD) in the Lazio region and its geographical distribution using regional administrative healthcare databases. METHODS: Cases of SSD (15-64 years old) were identified using an algorithm based on data from the hospital discharge registry (ICD IX CM: 295, 297, 298 [excl. 298.0], 299) and the ticket exemption database [code 044], between 2006 and 2019. We calculated crude, age- and gender-specific prevalence estimates on December 31, 2019. We also calculated age- and gender-adjusted prevalence to compare prevalence in different regional areas. RESULTS: We identified 18,371 cases. The overall prevalence was 5.03 per 1000 population (95% CI 4.96-5.10). Age-adjusted prevalence estimates were 4.18 (95% CI 4.09-4.27) per 1000 for women and 5.92 (95% CI 5.81-6.04) per 1000 for men. The prevalence was higher among older age groups, in both genders. There were differences in prevalence within the region, ranging from 4.25/1000 in the province of Viterbo to 5.42/1000 in Rome and 6.02/1000 in the province of Frosinone. When we analysed the subcategories of SSD, the three most frequent conditions were schizophrenia, schizoaffective disorder, and psychosis NOS. In general, the prevalence was higher in men for all the conditions but delusional disorders and brief psychosis. CONCLUSIONS: Our results show that the overall prevalence of SSD among adults in the Lazio region is similar to those published in previous reviews, but an uneven regional distribution was observed. While possible underestimation must be considered, administrative databases represent a valuable source of information for epidemiological surveillance and healthcare planning.

Impact of COVID-19 on foreign population resident in urban areas of Italy: selection of indicators, data sources, and definition of geographical stratification levels / Impatto del COVID-19 negli stranieri residenti nelle aree urbane in Italia: la scelta degli indicatori, delle fonti informative e la definizione dei livelli di stratificazione del territorio.

OBJECTIVES: to describe indicators, data sources, and levels of geographical stratification used within the framework of the CCM project "Epidemiological Surveillance and Control of COVID-19 in Metropolitan Urban Areas and for the containment of SARS-CoV-2 circulation in the immigrant population in Italy". DESIGN: population-based observational study based on data from the Integrated Covid-19 Surveillance System and the archive of hospital discharge records. SETTING AND PARTICIPANTS: interregional collaborative project. Resident population in 5 Italian Regions (Piedmont, Emilia-Romagna, Tuscany, Lazio, and Sicily). MAIN OUTCOMES MEASURES: crude and age-standardized rates of diagnostic test utilization and positivity, hospitalization (in any department and in intensive care unit), and mortality in COVID-19 cases. RESULTS: starting from the set of 11 indicators from the Italian National Institute for Health, Migration and Poverty (INMP) project "Epidemiology of SARS-CoV-2 Infection (COVID-19) and Use of Health Services in the Immigrant Population and Vulnerable Population Groups in Italy", the five most effective indicators for CCM purposes were identified. The INMP project highlighted higher rates of test access and positivity among Italians compared to foreigners, higher standardized hospitalization rates among foreigners, and higher standardized mortality rates among Italians, with geographical and temporal heterogeneity. The intersection between the DEGURBA (degree of urbanisation) classification and altimetric zones defined five levels of territorial stratification characterized by decreasing population density. Approximately 81% of the population involved in the CCM project resided in the first two levels; 43% of Italians lived in areas with intermediate population density in hilly or plain areas, while 48% of foreigners were concentrated in densely populated areas. CONCLUSIONS: sharing the collaborative approach and a research methodology already tested, integrated with the analysis of disaggregated indicators by morphological, functional, and administrative characteristics of the residential territory, allowed for assessing differences in the impact of the pandemic between Italians and foreigners residing in more or less densely populated areas.

[Impact of the SARS-CoV-2 epidemic on the immigrant population by urbanisation degree in five Italian Regions (Piedmont, Emilia-Romagna, Tuscany, Lazio, and Sicily)]. / Impatto dell'epidemia da SARS-CoV-2 nella popolazione immigrata per grado di urbanizzazione in Piemonte, Emilia-Romagna, Toscana, Lazio e Sicilia.

BACKGROUND: according to the literature, socially disadvantaged strata of the population, including immigrants, have been more vulnerable to the risk of SARS-CoV-2 infection due to greater exposure and less opportunity to protect themselves, and to COVID-19 complications due to metabolic and clinical risk factors as well as to healthcare access barriers. Two Italian projects - coordinated by the Italian National Institute for Health, Migration and Poverty and the Italian National Centre for Disease Prevention and Control - set up an epidemiological surveillance to monitor the temporal trends of the SARS-CoV-2 pandemic in five Italian regions using validated indicators. OBJECTIVES: to identify differences between Italians and immigrants in terms of the epidemic evolution and its health consequences, and to investigate possible differences by urbanisation degree and region of residence. DESIGN: cross sectional study. SETTING AND PARTICIPANTS: resident population in five Italian regions: Piedmont, Emilia-Romagna, Tuscany, Lazio, and Sicily. MAIN OUTCOMES MEASURES: frequencies of positive tests, routine hospitalisations, and deaths related to COVID-19 were collected, with respect to the period between 22.02.2020 and 31.01.2021. Data were aggregated by week, region, degree of urbanisation, gender, age (5-year classes), and citizenship (Italian/foreigner). Crude and standardised rates of the outcomes considered were calculated, stratified by gender, citizenship, region, and aggregated by pandemic macro-period. RESULTS: the study population counts approximately about 23 million residents as of 01.01.2020 (9.4% immigrants). During the period of interest, 1,542,458 cases of infection were recorded, whereas hospitalisations amounted to 175,979, and deaths to 44,867. Lower crude rates of hospitalisations and deaths were observed among immigrants compared to Italians. The age-standardised hospitalisation rates, on the other hand, showed an opposite trend and were significantly higher among immigrants, due to the excess observed in urban areas, especially in periods of epidemic peak, both for males (weekly mean standardised rate: 34.6 per 1,000 of foreign residents vs 24.3 of Italians over the period October 2020-January 2021) and females (23.2 vs 15.1 over the period February-April 2021). These differences seem to be more pronounced in the central regions and tend to disappear for residents in scarcely populated areas. Standardised mortality rates were higher among immigrants, both men and women, from October 2020 and more markedly in February-April 2021 among men. CONCLUSIONS: the impact of COVID-19 was stronger among immigrants in relation to hospitalisation, especially during epidemic peak periods and in some regions. The difference in the impact on mortality was smaller. There is some heterogeneity among regions and urban areas that is worth considering in the planning of interventions and integration policies.

[Development of a recommendations document in an emergency context]. / Lo sviluppo di un documento di raccomandazioni in un contesto di emergenza.

Italy is a destination country for a growing international migration, accounting for 8.4% of the total population. The COVID-19 pandemic has increased the difficulties in accessing healthcare services among immigrants, and barriers due to linguistic and cultural differences had a significant impact during the pandemic. This paper presents the methodology used in the project 'Epidemiological surveillance and control of COVID-19 in metropolitan urban areas for the containment of SARS-CoV-2 circulation in the immigrant population in Italy', carried out with the technical and financial support of the Italian Ministry of Health. This methodology is aimed to identify and select statements available in the literature, transferable to the Italian context, on the topic of interventions deemed useful in reducing the impact of the COVID-19 pandemic on the foreign population in urban/metropolitan settings.In February 2022, a systematic search was conducted in databases such as Medline, Embase, and Web of Science, as well as on national and international websites (WHO, Italian Institute of Health, and CDC), and on 'RecMap' (included in the 'COVID19 Recommendations' website) to identify guidelines containing recommendations on the management and prevention of COVID-19 among immigrants. The selected recommendations were divided into intervention areas (infection control, vaccination, screening, planning and monitoring, healthcare systems). In the first phase, a group of researchers independently assessed the inclusion of recommendations through three rounds of consensus. The Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool was used to assess the quality of the included guidelines. In the second phase, an external group of experts independently evaluated the relevance of the included recommendations using a Likert scale. The document is the result of a collaborative work based on evidence from the literature available until that time. The adaptation and adoption of recommendations already formulated by other international organizations on the topic of preparedness and response to the COVID-19 pandemic, evaluated through a consensus process with experts, can be a valid method aimed at producing documents to inform and guide those involved in the care of immigrants in Italy, as well as promoting inclusive forms of prevention in emergency contexts.

Socioeconomic Inequalities Worsen the Risk of Death in CKD: A Population-Based Cohort Study in Italy.

BACKGROUND: Few studies have explored the impact of socioeconomic position on chronic kidney disease (CKD). This study aims to fill this gap using a large Italian cohort of CKD patients. METHODS: We analyzed a cohort of incident CKD cases from the Lazio regional Health Information System from 1 January 2012 to 31 December 2021. We used the deprivation index (DI), a 5-category census-block indicator that integrates several dimensions of disadvantage. The outcomes were mortality and end-stage kidney disease (ESKD). We characterized the health status of patients in the two years before CKD identification and followed each subject from the index date to the end of follow-up, i.e., the date of the outcome, of emigration, or 31 December 2022, whichever came first. We used Cox proportional hazard models to investigate the association between DI and outcomes (HR, 95% CI). RESULTS: From 2012 to 2021, 127,457 new cases (55.9% men) were diagnosed. The average age was 72.2 (± 13.7) for men and 74.4 (± 14.8) for women. During an average follow-up of 4.3 years (± 3.2), 57,158 patients (45%) died, and 5,994 developed ESKD (5%). The age-adjusted association between DI and mortality was higher in men than in women (p-value interaction = 0.02), HRs for the extreme categories of DI (very high vs. very low) were 1.16, 95% CI 1.12-1.21 for men, and 1.08, 95% CI 1.04-1.13, for women). There was no evidence of association between DI and ESKD. CONCLUSIONS: In this population, socioeconomic disadvantage is associated with a higher risk of death but not of ESKD in CKD patients.

[Survey on maintenance immunosuppressive therapy in patients undergoing solid organ transplantation: experiences from Italian transplant centers.] / Terapia immunosoppressiva di mantenimento nei pazienti sottoposti a trapianto di organo solido: survey delle esperienze dai centri-trapianto italiani.

The post-organ transplant immunosuppressive therapy includes the administration of tacrolimus (Tac) or cyclosporine (CsA), along with antimetabolites (Antim) or mTOR inhibitors, with or without prednisone. A survey was conducted to investigate clinical experience regarding the use, efficacy, safety profile, and determinants of choice of maintenance immunosuppressive therapies. The questionnaire was sent to healthcare workers of 45 transplant centers specializing in kidney (K), liver (L), heart (H), and lung (P) transplants. Seventy-one responses were received from 15 Italian regions. The indicated first-choice therapy was Tac + Antim, except in the hepatic field where Tac monotherapy was favored. According to 44.1% of respondents, the first-choice therapy has changed over the last 15 years due to the replacement of CsA with Tac and increased use of mTOR inhibitors. Regarding the determinants of the index therapy, the choice of schemes to be applied depends mainly on international guidelines, previous experience, and internal protocols within the facility (80.3%; 54.9%; 50.7%, respectively). Compared to standard therapy, the criteria guiding the prescription of different therapies mainly involve the presence of comorbidities (K: 81.3%; L: 88.2%; H: 73.3%; P: 85.7%) and the evaluation of specific clinical parameters of the recipient. Additionally, the majority of respondents are in favor of using generic versions where available. The survey reveals dimensions not detectable by current healthcare administrative flows; such integrations provide a broader picture of the factors influencing the choice of post-transplant immunosuppressive therapeutic schemes.

Incidence and prevalence of Amyotrophic Lateral Sclerosis in three Italian Regions: a study based on health administrative databases.

OBJECTIVES: to estimate Amyotrophic Lateral Sclerosis (ALS) incidence and prevalence in three Italian Regions (Lazio, Tuscany, and Umbria), using health administrative databases. DESIGN: retrospective population-based study. SETTING AND PARTICIPANTS: ALS patients residing in Lazio, Umbria, and Tuscany were identified through an algorithm based on three different administrative databases: hospital discharge records, exemptions from health care co-payment, and emergency departments (study period 2014-2019). Crude, age- and gender-specific prevalence were calculated on 31.12.2019 and incidence rates of ALS were standardised by region, year, and gender between 2014-2019. Using a clinical dataset available in the Lazio Region, the proportion of individuals residing in the region correctly identified as ALS cases by the algorithm were calculated. MAIN OUTCOMES MEASURES: prevalence and incidence rates. RESULTS: a total of 1,031 ALS patients (>=18 years) were identified: 408 cases in Tuscany, 546 in Lazio, and 77 in Umbria. ALS standardised prevalence (per 100,000) was similar among regions: 12.31 in Tuscany, 11.52 in Lazio, and 9.90 in Umbria. The 5-year crude rates were higher in men, and in people aged 65-79 years. Among 310 patients included in the clinical dataset, 263 (84.8%) were correctly identified by the algorithm based on health administrative databases. CONCLUSIONS: ALS prevalence and incidence in three Central Italy Regions are rather similar, but slightly higher than those previously reported. This finding is plausible, given that previous results relate to at least ten years ago and evidenced increasing trends. Overall, the results of this paper encourage the use of administrative data to produce occurrence estimates, useful to both epidemiological surveillance and research and healthcare policies.

EASY-NET Program: Effectiveness of an Audit and Feedback Intervention in the Emergency Care for Acute Conditions in the Lazio Region.

The EASY-NET network program (NET-2016-02364191)-effectiveness of audit and feedback (A&F) strategies to improve health practice and equity in various clinical and organizational settings), piloted a novel and more structured A&F strategy. This study compared the effectiveness of the novel strategy against the sole periodic dissemination of indicators in enhancing the appropriateness and timeliness of emergency health interventions for patients diagnosed with acute myocardial infarction (AMI) and ischemic stroke in the Lazio Region. The efficacy of the intervention was assessed through a prospective quasi-experimental design employing a pre- and post-intervention (2021-2022) comparison with a control group. Participating hospitals in the Lazio Region, where professional teams voluntarily engaged in the intervention, constituted the exposed group, while the control group exclusively engaged in routine reporting activities. Effectiveness analysis was conducted at the patient level, utilizing regional health information systems to compute process and outcome indicators. The effectiveness of the intervention was evaluated using difference-in-difference models, comparing pre- and post-intervention periods between exposed and control groups. Estimates were calculated in terms of the difference in percentage points (PP) between absolute risks. Sixteen facilities for the AMI pathway and thirteen for the stroke pathway participated in the intervention. The intervention yielded a reduction in the proportion of 30-day readmissions following hospitalization for ischemic stroke by 0.54 pp in the exposed patients demonstrating a significant difference of -3.80 pp (95% CI: -6.57; -1.03; 5453 patients, 63.7% cases) in the exposed group compared to controls. However, no statistically significant differences attributable to the implemented A&F intervention were observed in other indicators considered. These results represent the first evidence in Italy of the impact of A&F interventions in an emergency setting, utilizing aggregated data from hospitals involved in the Lazio Region's emergency network.

Drug utilization in patients starting haemodialysis with a focus on cardiovascular and antidiabetic medications: an epidemiological study in the Lazio region (Italy), 2016-2020.

BACKGROUND: Entering dialysis is a critical moment in patients' healthcare journey, and little is known about drug therapy around it. A study funded by the Italian Medicines Agency offered the opportunity to leverage data from the Lazio Regional Dialysis and Transplant Registry (RRDTL) and perform an observational study on drug use patterns before and after initiating chronic dialysis. METHODS: Individuals initiating dialysis in 2016-2020 were identified from RRDTL, excluding patients with prior renal transplantation, stopping dialysis early, or dying within 12 months. Use of study drugs, predefined by clinicians, in the two years around the index date was retrieved from the drug claims register and described by semester. For each drug group, proportions of users (min 2 claims in 6 months) by semester, and intensity of treatment in terms of Defined Daily Doses (DDDs) for cardiovascular and antidiabetic agents were compared across semesters, stratifying by sex and age. RESULTS: In our cohort of 3,882 patients we observed a general increase in drug use after initiating dialysis, with the mean number rising from 5.5 to 6.2. Cardiovascular agents accounted for the highest proportions, along with proton pump inhibitors and antithrombotics over all semesters. Dialysis-specific therapies showed the most evident increase, in particular anti-anaemics (iron 4-fold, erythropoietins almost 2-fold), anti-parathyroids (6-fold), and chelating agents (4-fold). Use of cardiovascular and antidiabetic drugs was characterised by significant variations in terms of patterns and intensity, with some differences between sexes and age groups. CONCLUSIONS: Entering dialysis is associated with increased use of specific drugs and goes along with adaptations of chronic therapies.

Covid-19 vaccination among migrants in Rome, Italy.

Migrants may be susceptible to vaccine barriers and hesitancy. We evaluated the association between migrant status, as measured by the citizenship from a High Migratory Pressure Country (HMPC), and COVID-19 vaccination uptake in the resident population in Rome, Italy. We also investigated sex differences. We followed participants for vaccination against COVID-19 in 2021. We calculated crude- and adjusted-vaccination rates and Cox hazard ratios of vaccination for migrants compared to Italians. Among migrants from HMPCs, we estimated HRs for females compared to males, stratifying by geographical area of origin. Models were adjusted for age and deprivation index and stratified by infection history. In 2021, among 1,731,832 18-64-year-olds, migrants were 55% less likely to uptake at least one COVID-19 vaccine dose than their Italian counterpart. Past SARS-CoV-2 infection reduced the difference between migrants and Italians to 27%. Among migrants from HMPCs, we observed a slight excess of vaccination uptake among females compared to males. Focusing on geographical areas, we observed that only females from central-western Asia were 9% less likely to uptake vaccination than males. Health communication strategies oriented to migrants and considering their different languages, cultures, and health literacy should be adopted for prevention before emergencies.

Determinants of immunosuppressive therapy in renal transplant recipients: an Italian observational study (the CESIT project).

BACKGROUND: Very scanty evidence is available on factors influencing the choice of immunosuppressive drug therapy after kidney transplantation. METHODS: An Italian multiregional real-world study was conducted integrating national transplant information system and claims data. All patients undergoing kidney transplantation for the first time during 2009-2019 (incident patients) were considered. Multilevel logistic models were used to estimate Odds Ratio (OR) and corresponding 95% Confidence intervals. Factors with statistically significance were identified as characteristics associated with treatment regimens: cyclosporin-CsA vs tacrolimus-Tac and, within the latter group, mTOR inhibitors vs mycophenolate-MMF. RESULTS: We identified 3,622 kidney patients undergoing transplantation in 17 hospitals located in 4 Italian regions, 78.3% was treated with TAC-based therapy, of which 78% and 22% in combination with MMF and mTOR, respectively. For both comparison groups, the choice of immunosuppressive regimens was mostly guided by standard hospital practices. Only few recipient and donor characteristics were found associated with specific regimen (donor/receipt age, immunological risk and diabetes). CONCLUSIONS: The choice of post-renal transplant immunosuppressive therapy seems to be mostly driven by standard Centre practices, while only partially based on patient's characteristics and recognized international guidelines.

EASY-NET Program: Methods and Preliminary Results of an Audit and Feedback Intervention in the Emergency Care for Acute Myocardial Infarction in the Lazio Region, Italy.

Within the EASY-NET network program (NET-2016-02364191), Work Package 1 Lazio evaluates the effectiveness of a structured audit and feedback (A&F) intervention compared with the web-based regional periodic publication of indicators in improving the appropriateness and timeliness of emergency healthcare for acute myocardial infarction (AMI). This work describes the A&F methodology and presents the results of the first feedback delivered. The intervention involves sending periodic reports via e-mail to participating hospitals. The feedback reports include a set of volume and quality (process and outcome) indicators, calculated by facility through the health information system of the Lazio Region and compared with regional mean, target values and values calculated for hospitals with similar volumes of activity. Health managers and clinicians of each participating hospital represent the "feedback recipients". They are invited to organize clinical and organizational audit meetings to identify possible critical issues in the care pathway and define, where necessary, improvement actions. A total of 16 facilities are involved. Twelve facilities present high volumes in all volume indicators, while three facilities present low volumes for each indicator. Concerning the quality indicators, four facilities do not present critical indicators or had average results, three facilities do not present critical indicators but show average results in at least one of the indicators and six facilities present a critical value for at least one of the indicators. The first report highlighted some critical issues in some facilities on several indicators. During the audit meetings, each facility analyzes these issues, defining appropriate improvement actions. The outcome of these actions will be monitored through subsequent reporting to support the continuous care quality improvement process.

Developing a Questionnaire Evaluating Knowledge, Attitudes and Behaviors on Audit & Feedback among General Practitioners: A Mixed Methods Study.

BACKGROUND: Audit and Feedback (A&F) is one of the most common strategies used to improve quality in healthcare. However, there is still lack of awareness regarding the enabling factors and barriers that could influence its effectiveness. The aim of this study was to develop a questionnaire to measure the knowledge, attitudes and behaviors of general practitioners (GPs) regarding A&F. The study was performed in the context of the EASY-NET program (project code NET-2016-02364191). METHODS: The survey was developed according to two steps. Firstly, a scoping review was performed in order to map the literature on the existing similar instruments with the aim of identifying the sub-domains and possible items to include in a preliminary version of the questionnaire. In the second phase, the questionnaire was reviewed by a multidisciplinary group of experts and administrated to a convenience sample in a pilot survey. RESULTS: Ten papers were included in the scoping review. The survey target and development methodology were heterogenous among the studies. The knowledge, attitudes and behaviors domains were assessed in six, nine and seven studies, respectively. In the first step, 126 pertinent items were extracted and categorized as follows: 8 investigated knowledge, 93 investigated attitudes, and 25 investigated behaviors. Then, 2 sub-domains were identified for knowledge, 14 for attitudes and 7 for behavior. Based on these results, a first version of the survey was developed via consensus among two authors and then revised by the multidisciplinary group of experts in the field of A&F. The final version of the survey included 36 items: 8 in the knowledge domain, 19 in the attitudes domain and 9 in the behaviors domain. The results of the pilot study among 15 GPs suggested a good acceptability and item relevance and accuracy, with positive answers totaling 100% and 93.3% in the proposed questions. CONCLUSIONS: The methodology used has shown to be a good strategy for the development of the survey. The survey will be administrated before and after the implementation of an A&F intervention to assess both baseline characteristics and changes after the intervention.

Trend and determinants of mortality in incident hemodialysis patients of the Lazio region.

BACKGROUND: . In the last decades some studies observed a moderate progressive decrease in short-term mortality in incident hemodialysis patients. The aim of the study is to analyse the mortality trends in patients starting hemodialysis using the Lazio Regional Dialysis and Transplant Registry. METHODS: . Patients who started chronic hemodialysis between 2008 and 2016 were included. Annual 1-year and 3-year Crude Mortality Rate*100 Person Years (CMR*100PY) overall, by gender and age classes were calculated. Cumulative survival estimates at 1 year and 3 years since the date of starting hemodialysis were presented as Kaplan-Meier curves for the three periods and compared using the log-rank test. The association between periods of incidence in hemodialysis and 1-year and 3-year mortality were investigated by means of unadjusted and adjusted Cox regression models. Potential determinants of both mortality outcomes were also investigated. RESULTS: . Among 6,997 hemodialysis patients (64.5% males, 66.1% over 65 years old) 923 died within 1 year and 2,253 within 3 years form incidence; CMR*100PY were 14.1 (95%CI: 13.2-15.0) and 13.7 (95%CI: 13.2-14.3), respectively; both remained unchanged over the years. Even after stratification by gender and age classes no significant changes emerged. Kaplan-Meier mortality curves did not show any statistically significant differences in survival at 1 year and 3 years from hemodialysis incidence across periods. No statistically significant associations were found between periods and 1-year and 3-year mortality. Factors associated with a greater increase in mortality are: being over 65 years, born in Italy, not being self-sufficient, having systemic versus undetermined nephropathy, having heart disease, peripheral vascular disease, cancer, liver disease, dementia and psychiatric illness, and receiving dialysis by catheter rather than fistula. CONCLUSIONS: . The study shows that the mortality rate in patients with end-stage renal disease starting hemodialysis in the Lazio region was stable over 9 years.

[The EASY-NET research programme: background, structure, and methodology]. / Il programma di rete EASY-NET: razionale, struttura e metodologie.

This is the first contribution of a series of interventions describing the EASY-NET research program (Bando Ricerca Finalizzata 2016, funds 2014-2015; NET-2016-02364191). Here, the objective is to illustrate the background and the research question, the structure and organization, the methodologies and the expected results of the programme. The main theme is audit&feedback (A&F), a proven and widespread technique for improving the quality of health care. EASY-NET, funded by the Italian Ministry of Health and by the governments of the participating Italian Regions, starts its research activities in 2019 with the aim of evaluating the effectiveness of A&F in improving care for different clinical conditions in various organizational and legislative contexts. The research network involves seven Italian Regions, each conducting specific research activities described by as many work packages (WP): Lazio (the leading Region, coordinator of the research activities), Friuli Venezia Giulia, Piedmont, Lombardy, Emilia-Romagna, Calabria, and Sicily. The involved clinical areas include the management of chronic diseases, emergency care for acute conditions, surgery in the oncological area, the treatment of heart disease, obstetrics, and the use of caesarean section and post-acute rehabilitation. The involved settings concern the community, the hospital, the emergency room, and the rehabilitation facilities. Different experimental or quasi-experimental study designs are applied in each WP to achieve specific objectives of the specific clinical and organizational context. In all WPs, the process and outcome indicators are calculated on the basis of the Health Information Systems (HIS) and, in some cases, they are integrated with measures obtained from ad hoc data collections. The programme aims to contribute to the scientific evidence on A&F also exploring the obstacles and favourable factors for its effectiveness and to promote its implementation in the health service, with the ultimate aim of improving the access to healthcare and the health outcomes for citizens.

Case Identification and Characterization of Migrants with Dementia in the Lazio Region Using Health Administrative Data.

BACKGROUND: A crucial step for planning effective public health policies for migrants with dementia is the collection of data on the local dimensions of the phenomenon and patients' characteristics. OBJECTIVE: This study aimed to identify and characterize migrants with dementia in the Lazio region using health administrative databases. METHODS: Residents with dementia aged 50 years or older, living in the Lazio region as of December 31, 2018, were identified using a validated algorithm based on hospital discharge(s), claims for antidementia drugs, and co-payment exemption for dementia. Migrants were defined as people born abroad and grouped in migrants from High Migratory Pressure Countries (HMPCs) and Highly Developed Countries (HDCs). Overall and age-specific prevalence rates were estimated in native- and foreign-born patients. RESULTS: Dementia was ascertained in 38,460 residents. Among them, 37,280 (96.9%) were born in Italy, 337 (0.9%) were migrants from HDCs, and 843 (2.2%) from HMPCs. Dementia prevalence was higher among natives (1.15%, 95% CI 1.14-1.16) relative to migrants from HDCs (0.60%, 95% CI 0.54-0.67) and HMPCs (0.29%, 95% CI 0.27-0.31). The prevalence of comorbidities did not differ between groups. Migrants with dementia had a lower likelihood of receiving antidementia treatments compared with natives (51.6% in migrants from HDCs, 49.3% in migrants from HMPCs, and 53.5% among Italians). CONCLUSION: Routinely collected data in healthcare administrative databases can support the identification of migrants with dementia. Migrants exhibited a lower age-standardized prevalence of registered dementia and lower access to dedicated treatments than Italians. These findings are suggestive of underdiagnosis and undertreatment of dementia in migrants.

SARS-CoV-2 spread and area economic disadvantage in the italian three-tier restrictions: a multilevel approach.

BACKGROUND: To face the second wave of COVID-19, Italy implemented a tiered restriction system with different limitation levels (yellow = medium; orange = medium-high, red = high) at the beginning of November 2020. The restrictions systematically reduced the transmission of SARS-CoV-2 with increasing strength for increasing tier. However, it is unknown whether the effect of limitations was equal between provinces with different socioeconomic levels. Therefore, we investigated the association between the province's socioeconomic level and SARS-CoV-2 infection daily reproduction number in each restriction level. METHODS: We measured the province's socioeconomic level as the percentage of individuals whose 2019 total yearly income was lower than 10,000€, using the measure as a proxy of economic disadvantage. We estimated the daily reproduction number (Rt) at the province level using the SARS-CoV-2 daily incidence data from November 2020 to May 2021. We then used multilevel linear regression models with random intercepts stratified by restriction level to estimate the association between economic disadvantage and Rt. We also adjusted the analyses for potential confounders of the association between the province's economic disadvantage and the Rt: the percentage of people with 0-5 years, the quartiles of population density, and the geographical repartition. RESULTS: Overall, we found increasing Rt in yellow (+ 0.004 p < 0.01, from Rt = 0.99 to 1.08 in three weeks) and containing effects for the orange (-0.005 p < 0.01, from Rt = 1.03 to 0.93) and the red tier (-0.014 p < 0.01, from Rt = 1.05 to 0.76). More economically disadvantaged provinces had higher Rt levels in every tier, although non-significantly in the yellow level (yellow = 0.001 p = 0.19; orange = 0.002 p = 0.02; red = 0.004 p < 0.01). The results showed that the association between economic disadvantage and Rt differed by level of restriction. The number of days into the restriction and the economic disadvantage had statistically significant interactions in every adjusted model. Compared to better off, more economically disadvantaged provinces had slower increasing trends in yellow and steeper Rt reductions in orange, but they showed slower Rt reductions in the highest tier. CONCLUSION: Lower tiers were more effective in more economically disadvantaged provinces, while the highest restriction level had milder effects. These results underline the importance of accounting for socioeconomic level when implementing public health measures.

[Fifteen ways to optimize feedback.] / Quindici modi per ottimizzare il feedback.

This article proposes a series of insights that are drawn from the most up-to-date scientific literature and functional for an optimal implementation of Audit & Feedback (A&F). The focus is on the "feedback" component of the methodology. Some key issues of the feedback are the capability to address changes perceived as priorities for the recipients, recommend actions that bring real improvements, and allow the people to whom recommendations are addressed to manage them. Other suggestions concern how to share the data: it is important to provide feedback as soon as possible, multiple times, starting from individual rather than general data, and including comparisons able to promote the desired change. Other operational indications concern the most effective way to display the feedback, such as tightly linking the graphical representation and the summary message, presenting the feedback in multiple ways, and simplifying the message to minimize cognitive overload. Finally, some suggestions are about how to transmit feedback: tailor interventions according to the specific barriers of a given clinical-organizational context, provide short and easily understandable messages followed by more details, emphasize the credibility of information, increase motivation to change practice, and encourage participatory feedback construction rather than passive delivery. It also proposes an analysis of some of the challenges related to the design of A&F interventions translatable into improvements in practice starting from the context of the Easy-Net network program.

Identification of dementia and MCI cases in health information systems: An Italian validation study.

Introduction: The identification of dementia cases through routinely collected health data represents an easily accessible and inexpensive method to estimate the prevalence of dementia. In Italy, a project aimed at the validation of an algorithm was conducted. Methods: The project included cases (patients with dementia or mild cognitive impairment [MCI]) recruited in centers for cognitive disorders and dementias and controls recruited in outpatient units of geriatrics and neurology. The algorithm based on pharmaceutical prescriptions, hospital discharge records, residential long-term care records, and information on exemption from health-care co-payment, was applied to the validation population. Results: The main analysis was conducted on 1110 cases and 1114 controls. The sensitivity, specificity, and positive and negative predictive values in discerning cases of dementia were 74.5%, 96.0%, 94.9%, and 79.1%, respectively, whereas in detecting cases of MCI these values were 29.7%, 97.5%, 92.2%, and 58.1%, respectively. The variables associated with misclassification of cases were also identified. Discussion: This study provided a validated algorithm, based on administrative data, which can be used to identify cases with dementia and, with lower sensitivity, also early onset dementia but not cases with MCI.

Incidence and Outcomes of SARS-CoV-2 Infection in Older Adults Living with Dementia: A Population-Based Cohort Study.

BACKGROUND: The identification of risk factors for SARS-CoV-2 infection and mortality in patients with dementia is a key aspect to support clinical decisions and public health interventions. OBJECTIVE: To assess the incidence of SARS-CoV-2 infection and COVID-19 related death in a cohort of patients with dementia residing in the Lazio region and to investigate predicting factors for both infection and mortality. METHODS: This population-based study used information from administrative databases and the SARS-CoV-2 infection surveillance system. Patients with dementia (age ≥65) were enrolled as of December 31, 2019 and followed-up until February 28, 2021. Cumulative risk of infection and death within 60 days of infection onset, and age-standardized incidence (SIR) and mortality (SMR) ratios were calculated. Logistic regression models were applied to identify factors associated with infection and mortality. RESULTS: Among 37,729 dementia patients, 2,548 had a diagnosis of SARS-CoV-2 infection. The crude risk of infection was 6.7%. An increase in risk of infection was observed both in women (SIR 1.72; 95% CI 1.64-1.80) and men (SIR 1.43; 95% CI 1.33-1.54). Pneumonia, cerebrovascular and blood diseases, femur fracture, anxiety, antipsychotic and antithrombotic use were associated with an increased risk of infection. The crude risk of death was 31.0%, the SMRs 2.32 (95% CI 2.05-2.65) for men, and 2.82 (95% CI 2.55-3.11) for women. Factors associated with mortality included: male gender, age ≥85, symptoms at the diagnosis, antipsychotic and systemic antibiotics treatment. CONCLUSION: These findings emphasize the need of close and tailored monitoring of dementia patients to reduce the impact of COVID-19 on this fragile population.