Does breast cancer screening level health inequalities out? A population-based study in an Italian region.

BACKGROUND: Although population-based screening has the potential to reduce inequalities in breast cancer survival, evidence on this topic is controversial. The objective of this study was to evaluate whether the full implementation of a mammography screening programme in Emilia-Romagna in Italy had an impact on variations in breast cancer survival by educational level. METHODS: A cohort study was performed, including all women <70 years and residing in Emilia-Romagna who had infiltrating breast cancer registered in 1997-2000 (transitional screening period) or 2001-03 (consolidation screening period). Cancer cases were retrieved from the regional Breast Cancer Registry and followed up for 5 years. Educational level was determined from census data and allocated to cancer cases by individual record linkage. Age at diagnosis was classified into two groups (30-49, 50-69: screening target population). RESULTS: A total of 9639 cases were analyzed. In the 1997-2000 period, low-educated women had significantly lower survival compared with high-educated women, both in the younger and in the older age-groups. After the full implementation of the screening programme, these differences decreased in both age-groups, until disappearing completely among women in the age-group invited to screening. CONCLUSIONS: Our findings suggest that a fee-free population-based organized mammography screening programme with active invitation of the whole target population could be effective in reducing differences in survival in the population targeted by the screening.

Variation among local health units in follow-up care of breast cancer patients in Emilia-Romagna, Italy.

AIMS AND BACKGROUND: This study examines the patterns of follow-up care for breast cancer survivors in one region in Italy. METHODS AND STUDY DESIGN: This retrospective analysis included 10,024 surgically treated women, with incident cases of breast cancer in the years 2002-2005 who were alive 18 months after their incidence date. Rates of use of follow-up mammograms, abdominal echogram, bone scans and chest x-rays were estimated from administrative data and compared by Local Health Unit (LHU) of residence. Logistic regression analyses were performed to assess possible "overuse", accounting for patient age, cancer stage, type of surgery and LHU of residence. RESULTS: A total of 7168 (72.1%) women received a mammogram within 18 months of their incidence date, while 6432 (64.2%) had an abdominal echogram, 3852 (38.4%) had a bone scan and 5231 (52.2%) had a chest x-ray. The rates of use of abdominal echograms, bone scans and chest x-rays were substantially higher in the population of breast cancer survivors than in the general female population. Taking account of patient age, cancer stage at diagnosis and type of surgery, multivariate analyses demonstrated significant variation in the use of these tests by LHU of residence. CONCLUSIONS: The observed variation in the use of abdominal echograms, bone scans and chest x-rays supports the conclusion that there is substantial misuse of these tests in the population of postsurgical breast cancer patients in the Emilia-Romagna region in Italy. In the absence of a documented survival benefit, overtesting has both a human and financial cost. We recommend additional review of the methods of follow-up care in breast cancer patients in the LHUs of Emilia-Romagna, with the aim of developing, disseminating and evaluating the implementation of specific guidelines targeting primary care physicians and oncologists providing care to breast cancer survivors. Patient education materials may also help to reduce unnecessary testing.

Evaluation of a pilot surgical adverse event detection system for Italian hospitals.

OBJECTIVE: To devise an adverse event (AE) detection system and assess its validity and utility. DESIGN: Observational, retrospective study. SETTING: Six public hospitals in Northern Italy including a Teaching Hospital. PARTICIPANTS: Eligible cases were all patients with at least one admission to a surgical ward, over a 3-month period. INTERVENTIONS: Computerized screening of administrative data and review of flagged charts by an independent panel. MAIN OUTCOME MEASURES: Number of records needed to identify an AE using this detection system. RESULTS: Out of the 3310 eligible cases, 436 (13%) were extracted by computerized screening. In addition, out of the 2874 unflagged cases, 77 randomly extracted records (3%) were added to the sample, to measure unidentified cases. Nursing staff judged 108 of 504 (21%) charts positive for one or more criteria; surgeons confirmed the occurrence of AEs in 80 of 108 (74%) of these. Compared with random chart review, the number of cases needed to detect an AE, with the computerized screening suggested by this study, was reduced by two-thirds, although sensitivity was low (41%). CONCLUSIONS: This approach has the potential to allow the timely identification of AEs, enabling to quickly devise interventions. This detection system could be of true benefit for hospitals that intend assessing their AEs.

Using administrative data to identify and stage breast cancer cases: implications for assessing quality of care.

AIMS AND BACKGROUND: The study evaluated the use of Italian hospital discharge data (SDO, scheda di dimissione ospedaliera) for identifying women with incident breast cancer, determining stage at diagnosis and assessing quality of care. STUDY DESIGN: Women aged 20+ years residing in the Regione Emilia-Romagna, Italy, between 2002 and 2005 were studied. Case identification using algorithms based on ICD-9-CM codes on hospital discharge data were compared with AIRTUM-accredited cancer registry data. Sensitivity, specificity and positive predictive value were computed overall, by age and cancer stage. Compliance with guidelines for radiation therapy using registry and hospital data were compared. RESULTS: A total of 11,615 women was identified by AIRTUM-accredited cancer registries as incident cases, whereas 10,876 women were identified by the SDO algorithm. Sensitivity was 84.8%, specificity was 99.9%, and the positive predictive value was 90.6%. Of the 1,022 who were false positives, 363 (35.5%) were women identified in registry data as having an incident case prior to 2002 and therefore were not included in the analysis. There were 1,761 false negatives; nearly 50% were over 70 years of age or did not undergo a surgical procedure and therefore were not included in our SDO-based case finding. Sensitivity declined as the patient population became older. However, we observed relatively good positive predictive value for all age groups. Algorithms using the SDO data did not clearly identify specific cancer stages. However, the algorithm may have utility where stages are grouped together for use in quality measures. CONCLUSIONS: Cases were identified with good sensitivity, specificity and positive predictive value with SDO data, with better rates than similar previously published algorithms based on Italian data. These hospital claims-based algorithms facilitate quality of care analyses for large populations when registry data are not available by identifying individual women and their subsequent use of health care services.

[Public reporting on individual hospitals' quality: the risk of misinformation]. / Segnalare ai cittadini la qualità degli ospedali: il rischio della cattiva informazione.

OBJECTIVE: increasingly information on individual hospital' clinical performance is disclosed to the general public through lay mass media. Usually the explicit goal of those initiatives is to guide citizens' choice identifying the "best", centres. However, these efforts rely either on simplistic approaches in comparing the clinical performance of individual hospitals or on inadequate quality indicators. Therefore, this information may easily misguide the general public. In this paper, in order to highlight the problems implied, we consider two recent cases of mass media reporting on hospitals' quality. METHODS: Two recent cases of mass media reporting on cardiac surgery centres' quality are considered: the BPAC study "Esiti a breve termine di interventi di by-pass coronarico nelle cardiochirurgie italiane" coordinated by the Italian Institute of Health, and the publication by the news magazine Panorama of the list of the "best" Italian cardiac surgery centres based on a reputational index. RESULTS: The first example points out the problems implied by presenting hospitals' clinical performance through league tables. Using the Markov Chain Monte Carlo method, this study shows how the conclusions merely based on ranking--even when these are based on a sensible quality indicator--can be potentially misleading. As for the second case study, it is shown the inadequacy of the quality indicator (the reputation index) adopted. CONCLUSION: despite the growing awareness in the health services community of the technical problems implied by describing and comparing the quality of care provided by individual hospitals, "real life" examples of provision of information on quality of care by the mass media to the general public appear to be largely unsatisfactory and potentially misleading.

Development and assessment of a priority score for cataract surgery.

BACKGROUND: Point-count measures of clinical priority are increasingly put forward for managing waiting lists. However, their development does not consider explicitly the appropriateness of the indications. Furthermore, an estimate of their effect in clinical practice is needed, assessing the amount of gains and losses in terms of time waited for patients with different priority scores. METHODS: We developed appropriateness criteria for cataract surgery using the RAND method and applied them to a sample of 567 patients consecutively placed on a waiting list for cataract surgery. In addition, clinicians were asked to express the priority attributed to each patient using a 10-cm visual analogue scale, where 0 = minimal priority and 10 = maximum priority. We developed a priority score, using regression analysis to identify the set of clinical characteristics that best predicted clinicians' priority rating and to estimate their individual weight. We used a computer simulation model to compare mean waiting times with management of the waiting list using the priority score and using the "first-come, first-served" approach. RESULTS: Overall, 332 patients (60.8%) were referred for cataract surgery for indications deemed appropriate, and their mean priority rating was 5.9 (95% confidence interval [CI] 5.7-6.1). The corresponding figures for the 201 (36.8%) uncertain indications and the 13 (2.4%) inappropriate indications were 4.5 (95% CI 4.1-4.7) and 2.6 (95% CI 1.3-3.9) respectively. The clinical characteristics included in the priority score (visual acuity in the operated eye and in the contralateral eye, visual function and ability to live or work independently) accounted for 35% of the variance in clinicians' ratings of priority. In the computer simulation model, patients with the highest priority experienced a variable reduction in mean waiting time (9% to 27%) depending to how time spent waiting was integrated into the clinical score. INTERPRETATION: We conclude that the use of priority ratings in the management of a waiting list for cataract surgery leads to results that maintain the desirable coherence between priority and appropriateness of indication. The results also suggest that the implementation in clinical practice of priority scores may be worth the effort, given the potential reduction in waiting time for patients at high priority.