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.

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.

A nationwide survey of Italian Centers for Cognitive Disorders and Dementia on the provision of care for international migrants.

BACKGROUND: More than 500,000 dementia cases can be estimated among migrants living in Europe. There is the need to collect "real world" data on the preparedness of healthcare services to support the inclusion of migrants in the public health response to dementia. The present study aimed (i) to estimate the number of migrants referred to Italian memory clinics (Centers for Cognitive Disorders and Dementia [CCDDs]) and (ii) to identify possible barriers and resources for the provision of diversity-sensitive care. METHODS: A survey of all Italian CCDDs was conducted between December 2020 and April 2021. An online questionnaire was developed to obtain information on the number of migrants referred to Italian CCDDs in 2019, the challenges encountered in the diagnostic approach, and possible facilitators in the provision of care. RESULTS: Overall, 343 of the 570 contacted CCDDs completed the survey questionnaire (response rate: 60.2%). Nearly 4527 migrants were referred to these services in 2019. Migrants accounted for a median 1.1% (IQR: 0.9%-2.8%) of overall CCDD referrals. More than one-third of respondents reported that the number of migrants referred to their facilities had increased in the last 5 years. The overall quality of the migrants' cognitive assessment was deemed to be very poor or insufficient in most cases. A minority of CCDDs had translated information material on dementia and reported the possibility to contact cultural mediators and interpreters. CONCLUSIONS: A relevant number of migrants are being referred to Italian CCDDs that are still not adequately prepared to deliver diversity-sensitive care and support.

Impact of the COVID-19 pandemic on access to healthcare services amongst patients with multiple sclerosis in the Lazio region, Italy.

BACKGROUND AND PURPOSE: Multiple sclerosis (MS) is a complex chronic, autoimmune inflammatory disease involving multidisciplinary assessments and interventions. Access to outpatient specialist and home healthcare services was explored during the pandemic outbreak and the lockdown amongst MS patients in the Lazio region. Adherence to disease-modifying therapies (DMTs) is also described. METHODS: A population-based study was conducted using regional healthcare administrative databases. A validated algorithm was used to identify MS cases over the period 2011-2018. The numbers of specialist and home-based services were compared between 2019 and 2020. The medication possession ratio was used to measure adherence to DMTs. RESULTS: A total of 9380 MS patients were identified (68% women). A decline in the number of outpatient care services between March and June 2020 compared to the previous year was observed, in particular for rehabilitation (-82%), magnetic resonance imaging (-56%) and neurological specialist services (-91%). Important year-to-year variations were observed in May and June 2020 in home-based nursing and medical care (-91%) and motor re-education services (-74%). Adherence to DMTs was higher in the first 4 months of 2019 compared to the same period of 2020 (67.1% vs. 57.0%). CONCLUSIONS: A notable disruption of rehabilitative therapy and home-based services as well as in DMT adherence was observed. Since the pandemic is still ongoing and interruption of healthcare services could have a major impact on MS patients, it is necessary to monitor access of MS patients to healthcare resources in order to ensure adequate treatments, including rehabilitative therapies.

The issue of dementia in migrants and ethnic minorities: the perspective of National Dementia Plans.

BACKGROUND: The occurrence of dementia among individuals with a migration background and composing ethnic minorities is being recognized as a global public health issue. AIMS: In the present study, we sought to explore if and how this phenomenon is mentioned and addressed by the existing National Dementia Plans (NDPs). METHODS: The 32 NDPs listed on the Alzheimer's Disease International (ADI)'s website were considered for the present analysis. First, the plans mentioning the issue of dementia among migrants and/or ethnic minorities were identified. Subsequently, the sections addressing this topic and the pertaining proposed actions were analyzed and their contents were unbundled in descriptive categories. RESULTS: Overall, nine NDPs (28.1% of the total), namely those promulgated by Australia, Austria, England, Israel, Norway, Switzerland, Taiwan, United States, and Wales, mentioned the issue of dementia among migrants and/or ethnic minorities and only eight proposed targeted actions to tackle this issue. With few exceptions, the proposed strategies were only marginally dashed within NDPs and crucial information on their objectives, timeline, conduction, and monitoring was missing. DISCUSSION AND CONCLUSIONS: To our knowledge, this is the first attempt to describe and discuss how the issue of dementia among migrants and ethnic minority groups is addressed within NDPs. The issue of dementia in migrants and ethnic minorities is assuming a growing relevance under a of global health perspective. The timely identification and implementation of dedicated policies at the national and international level are fundamental to limit its future clinical and socioeconomic burden.

[Increased offer of renal transplantation and better outcomes in the Lazio Region, Italy 2008-2017]. / Aumento dell'offerta di trapianto di rene e miglioramento degli esiti nella regione Lazio, anni 2008-2017.

OBJECTIVES: 1. to describe temporal trend (2008-2017) in kidney transplant (KT) provision in the Lazio Region; 2. to measure KT outcomes by comparing three different time periods; 3. to estimate the prevalence of individuals with functioning kidney transplant. DESIGN: cross sectional (objective 1); cohort study (objectives 2 and 3). SETTING AND PARTICIPANTS: the study population included people residing in Lazio Region who received a kidney transplant between 2008 and 2017. Participants were selected through the integration of data from different sources: the Hospital Information System, the Regional Register of Dialysis and Transplantation, and the Regional Waiting List for Kidney Transplantation. MAIN OUTCOME MEASURES: standardised KT incidence rates x100,000 by year and age-specific rates were calculated separately for men and women. Mortality and failure of KT were considered as outcomes at one year; for both outcomes, the cumulative incidence x100 and raw and adjusted (by gender and age) incidence rates x100,000 person-day were calculated using a Poisson model. Raw and standardised prevalence rates x100,000 of people residing in Lazio Region with functioning KT at 31.12.2016 were calculated. RESULTS: in the study period, 1,646 KTs were performed. The KT rate increased significantly overtime, ranging between 2.9 in 2008 and 3.6 in 2017. Rates were higher for men compared to women. For men aged 65+ incidence KT rate increased significantly: 3.5 in 2008 and 7.1 in 2017. Among women, there was an increasing trend in the age groups 0-18 and 35-49 years. The one-year mortality rate decreased from 11.9 in 2008-2010 to 4.2 in 2014-2016. The failure rate was stable: 21.4 in 2008-2010 and 19.2 in 2014-2016. The number of individuals with functioning kidney transplant was 1,148. The standardised prevalence rate was 25.8 in men and 14.6 in women. CONCLUSIONS: increased offer of renal transplantation and better outcomes were observed in Lazio region. The proposed methodology is useful for the construction of indicators to monitor over time both KT provision and outcomes.

[Urban health and inequalities in highly socially marginalised settings in Rome]. / Salute urbana e disuguaglianze a Roma in contesti a elevata marginalità sociale.

OBJECTIVES: to describe hospitalisation, access to emergency care, and mortality of people living in marginalized urban areas which include public housing buildings in the North-West suburb of Rome, and to compare the results with those observed among people living in the neighbouring area. DESIGN: cross sectional study. SETTING AND PARTICIPANTS: resident population in the XIII and XIV Municipality of Rome, subdivided into five urban areas, in 2011-2018. MAIN OUTCOME MEASURES: hospitalisation, access to emergency care, and mortality rates and rates ratios based on hospital discharges and emergency department visits derived from the Health Information Systems and from the Mortality Registry of Lazio Region (Central Italy), stratified by urban areas. RESULTS: the results show a higher use of hospital assistance and emergency care services as well a higher mortality among residents of urban areas characterized by marginalization and social disadvantage in the North-West suburb in Rome, compared to the surrounding area. The association is stronger for the residents of ex-Bastogi, a compound particularly marginalised and socially disadvantaged, where excesses in hospitalisation, emergency care admission, and mortality of +60%, +150%, and +140%, respectively, occurred. CONCLUSIONS: the excesses of hospital use, emergency care visits, and mortality observed among the residents of marginalized urban areas suggest the need to reorganize the preventive and primary care services considering the socioeconomic disadvantage in such housing contexts. The use of both qualitative and quantitative approaches allows to understand the complexity of such contexts.

A Systematic Review of Case-Identification Algorithms Based on Italian Healthcare Administrative Databases for Three Relevant Diseases of the Nervous System: Parkinson's Disease, Multiple Sclerosis, and Epilepsy.

BACKGROUND: Parkinson's Disease (PD), Multiple Sclerosis (MS), and Epilepsy are three highly impactful health conditions affecting the nervous system. PD, MS, and epilepsy cases can be identified by means of Healthcare Administrative Databases (HADs) to estimate the occurrence of these diseases, to better monitor the adherence to treatments, and to evaluate patients' outcomes. Nevertheless, the absence of a validated and standardized approach makes it hard to quantify case misclassification. OBJECTIVES: to identify and describe all PD, MS, and epilepsy case-identification algorithms by means of Italian HADs, through the review of papers published in the past 10 years. METHODS: this study is part of a project that systematically reviewed case-identification algorithms for 18 acute and chronic conditions by means of HADs in Italy. PubMed was searched for original articles, published between 2007 and 2017, in Italian or English. The search string consisted of a combination of free text and MeSH terms with a common part that focused on HADs and a disease-specific part. All identified papers were screened by two independent reviewers. Pertinent papers were classified according to the objective for which the algorithm had been used, and only articles that used algorithms for primary objectives (I disease occurrence; II population/cohort selection; III outcome identification) were considered for algorithm extraction. The HADs used (hospital discharge records, drug prescriptions, etc.), ICD-9 and ICD-10 codes, ATC classification of drugs, follow-back periods, and age ranges applied by the algorithms have been reported. Further information on specific objective(s), accuracy measures, sensitivity analyses and the contribution of each HAD, have also been recorded. RESULTS: the search strategy led to the identification of 70 papers for PD, 154 for MS, and 100 for epilepsy, of which 3 papers for PD, 6 for MS, and 5 for epilepsy were considered pertinent. Most articles were published in the last three years (2014-2017) and focused on a region-wide setting. Out of all pertinent articles, 3 original algorithms for PD, 4 for MS, and 4 for epilepsy were identified. The Drug Prescription Database (DPD) and Hospital Discharge record Database (HDD) were used by almost all PD, MS, and epilepsy case-identification algorithms. The Exemption from healthcare Co-payment Database (ECD) was used by all PD and MS case-identification algorithms, while only 1 epilepsy case-identification algorithm used this source. All epilepsy case-identification algorithms were based on at least a combination of electroencephalogram (EEG) and drug prescriptions. An external validation had been performed by 2 papers for MS, 2 for epilepsy, and only 1 for PD. CONCLUSION: the results of our review highlighted the scarce use of HADs for the identification of cases affected by neurological diseases in Italy. While PD and MS algorithms are not so heterogeneous, epilepsy case-identification algorithms have increased in complexity over time. Further validations are needed to better understand the specific characteristics of these algorithms.

[Immigrants' health and socioeconomic inequalities of overall population residing in Italy evaluated through the Italian network of Longitudinal Metropolitan Studies]. / Salute degli immigrati e disuguaglianze socioeconomiche nella popolazione residente in Italia valutate attraverso la rete degli Studi Longitudinali Metropolitani.

INTRODUCTION: Describing and monitoring socioeconomic inequalities in health are the prerequisite for planning equity policies. In Italy, some cities have integrated personal information from the municipal registries with Census data and with data from healthcare information systems to set up Longitudinal Metropolitan Studies (LMS). Under the coordination of the Italian National Institute for Health, Migration, and Poverty (NIHMP), six cities in the LMS network have contributed to the present monograph: Turin, Venice, Reggio Emilia, Modena, Bologna, and Rome. MORTALITY RESULTS. Significant socioeconomic differences by level of education were seen in all the participating centres. People who live alone or in single-parent households are more likely to die, as are those living in a substandard dwelling. Immigrants resident in the six cities included in the study showed lower all-cause mortality than Italians (males: MRR 0.83; 95%CI 0.78-0.90 - females: MRR 0.70; 95%CI 0.64-0.77). Sub-Saharan Africans experienced a significant higher mortality than Italians (males: MRR 1.33; 95%CI 1.12-1.59 - females: MMR 1.69; 95%CI 1.31-2.17). Immigrants had a neonatal and post-neonatal mortality risk about 1.5 times higher than Italians (neonatal: OR 1.71; 95%CI 1.22-2.39 - post-neonatal: OR 1.63; 95%CI 1.03-2.57). A difference between Italians and immigrants was also observed for mortality in children aged 1-4 years, though less marked (OR 1.24; 95%CI 0.73-2.11). Excesses concerned particularly immigrants from North Africa and from sub-Saharan Africa as well as those residing in Italy for >5 years. HOSPITALISATION RESULTS. Hospitalisation rates are lower for immigrants than for Italians, except when due to infectious diseases, blood disorders, and, among women, for reasons linked to pregnancy and childbirth. Avoidable hospitalisation rates of adults from low migratory pressure Countries are lower than or equal to those of Italians. On the contrary, adults from low migratory pressure Countries show higher avoidable hospitalisation rates compared to Italians in every cohort, with the exception of Rome (RR 0.81; 95%CI 0.78-0.85), with RR ranging from 1.08 (95%CI 0.96-1.22) in Venice to 1.64 (95%CI 1.47-1.83) in Modena. CONCLUSIONS: Maternal and child health is the most critical area of health for immigrant population. Considering the importance that the issue of health equity has taken on in the political agenda, the data presented in this volume are a great asset, particularly in light of the long recession and the social crisis that have impacted the Country.

Quality improvement strategies at primary care level to reduce inequalities in diabetes care: an equity-oriented systematic review.

BACKGROUND: There is evidence that disparities exist in diabetes prevalence, access to diabetes care, diabetes-related complications, and the quality of diabetes care. A wide range of interventions has been implemented and evaluated to improve diabetes care. We aimed to review trials of quality improvement (QI) interventions aimed to reduce health inequities among people with diabetes in primary care and to explore the extent to which experimental studies addressed and reported equity issues. METHODS: Pubmed, EMBASE, CINAHL, and the Cochrane Library were searched to identify randomized controlled studies published between January 2005 and May 2016. We adopted the PROGRESS Plus framework, as a tool to explore differential effects of QI interventions across sociodemographic and economic factors. RESULTS: From 1903 references fifty-eight randomized trials met the inclusion criteria (with 17.786 participants), mostly carried out in USA. The methodological quality was good for all studies. Almost all studies reported the age, gender/sex and race distribution of study participants. The majority of trials additionally used at least one further PROGRESS-Plus factor at baseline, with education being the most commonly used, followed by income (55%). Large variation was observed between these studies for type of interventions, target populations, and outcomes evaluated. Few studies examined differential intervention effects by PROGRESS-plus factors. Existing evidence suggests that some QI intervention delivered in primary care can improve diabetes-related health outcomes in social disadvantaged population subgroups such as ethnic minorities. However, we found very few studies comparing health outcomes between population subgroups and reporting differential effect estimates of QI interventions. CONCLUSIONS: This review provides evidence that QI interventions for people with diabetes is feasible to implement and highly acceptable. However, more research is needed to understand their effective components as well as the adoption of an equity-oriented approach in conducting primary studies. Moreover, a wider variety of socio-economic characteristics such as social capital, place of residence, occupation, education, and religion should be addressed.

Estimating dementia cases in the immigrant population living in Italy.

INTRODUCTION: The phenomenon of dementia among immigrants and ethnic minorities represents an emerging challenge for Western countries. The aim of the present study was to estimate the number of dementia cases among immigrant subjects residing in Italy and in each Italian region to provide pivotal information on the magnitude of such public health issue. METHOD: The number of immigrant individuals, aged 65 years or older, living in Italy and in the 20 Italian regions was derived by the 2017 data of the National Institute for Statistics. The dementia prevalence rates were taken from the European data provided by the Neurologic Diseases in the Elderly Research Group. The estimated dementia cases were calculated by multiplying the number of immigrants with the age- and sex-specific prevalence rates. RESULTS:  Overall, 186,373 older immigrant subjects lived in Italy in January 2017. Nearly 7700 dementia cases were estimated in this population (5022 among women, 2725 among men). When considering each specific Italian region, the number of estimated cases ranged from 19 (Basilicata) to 1500 (Lombardia) with a marked inter-regional variability. DISCUSSION: Our findings indicate that the occurrence of dementia among immigrants and ethnic minorities constitutes a novel but already relevant issue for our healthcare systems. A non-negligible number of immigrant individuals is probably already seeking or might seek help for cognitive disturbances, thus potentially referring to general practitioners and/or to the Italian dementia services. The forecasted increasing magnitude of this phenomenon reinforces the need for tailored and locally oriented initiatives and policies.

Gender Differences in Heroin Addiction and Treatment: Results from the VEdeTTE Cohort.

BACKGROUND: Gender differences strongly affect heroin addiction, from risk factors to patterns of consumption, access to treatments, and outcomes. OBJECTIVES: To investigate gender differences in the VEdeTTE cohort of heroin addicts. METHODS: VEdeTTE is a cohort of 10,454 heroin users enrolled between 1998 and 2001 in 115 public drug treatment centres in Italy. Clinical and personal information were collected at intake through a structured interview. Treatments were recorded using a standardized form. Gender differences were explored with regard to characteristics at intake, treatments, and retention in methadone maintenance and therapeutic community. Cox Proportional models were carried out to identify risk factors for treatment abandon. RESULTS: Compared with men, at their first access to treatment women with drug addiction were younger, more frequently married, legally separated, divorced or widow, unemployed though better educated, HIV+; more frequently they lived with their partner and sons. They reported a higher use of sedatives, but a lower use of alcohol; more frequently they had psychiatric comorbidity, including depression, self-injuries, and suicide attempts. Psychotherapy was more frequently prescribed to women, pharmacological treatments to men. Methadone maintenance was less frequently abandoned by women. Drug abuse severity factors predicted abandon of methadone among women. High methadone doses and the combination with psychotherapy improved treatment retention in both genders. Low education level and severity factors among women and young age among men predicted abandon of therapeutic community. CONCLUSIONS: Gender differences in the VEdeTTE cohort suggest the need of a gender sensitive approach to improve treatment outcomes among heroin addicts.

[Audit and feedback, and continuous quality improvement strategies to improve the quality of care for type 2 diabetes: a systematic review of literature]. / Audit e feedback e interventi di continuous quality improvement per il miglioramento della qualità delle cure nella gestione del diabete di tipo 2: una revisione sistematica della letteratura scientifica.

OBJECTIVES: we analysed evidence on effective interventions to improve the quality of care and management in patients with diabetes type 2. This review focuses particularly on audit and feedback intervention, targeted to healthcare providers, and continuous quality improvement (CQI) involving health professionals and health care systems, respectively. METHODS: we searched The Cochrane Library, PubMed, and EMBASE (search period: January 2005-December 2015) to identify systematic reviews (SR) and randomized controlled trials (RCTs) considering patients' outcomes and process measures as quality indicators in diabetes care. Selection of studies and data extraction were carried out independently by two reviewers. Methodological quality of individual studies was assessed using the checklist «Assessment of methodological quality of systematic review¼ (AMSTAR) and the Cochrane's tool, respectively. We produced summaries of results for each study design. RESULTS: the search process resulted in 810 citations. One SR and 7 RCTs that compared any intervention in which audit and feedback and CQI was a component vs. other interventions were selected. The SR found that audit and feedback activity was associated with improvements of glycaemic (mean difference: 0.26; 95%CI 0.08;0.44) and cholesterol control (mean difference: 0.03; 95%CI -0.04;0.10). CQI interventions were not associated with an improvement of quality of diabetes care. The RCTs considered in this review compared a broad range of interventions including feedback as unique activity or as part of more complex strategies. The methodological quality was generally poor in all the included trials. CONCLUSIONS: the available evidence suggests that audit and feedback and CQI improve quality of care in diabetic patients, although the effect is small and heterogeneous among process and outcomes indicators.

[Socioeconomic position and appropriate antiplatelet therapy after percutaneous coronary intervention: a population-based cohort study in Rome (Lazio Region, Central Italy)]. / Posizione socioeconomica e aderenza alla terapia antiaggregante post angioplastica coronarica: uno studio epidemiologico a Roma.

OBJECTIVES: to evaluate the association between socioeconomic position (SEP) and adherence to appropriate antiplatelet therapy (AAT) after percutaneous coronary intervention (PCI) in the year following the discharge. DESIGN: according to scientific guidelines, AAT for PCI patients consists of Clopidogrel for a minimum of 1 month and ideally up to 12 months after discharge, and with Acetylsalicylic Acid (ASA) indefinitely. For each patient, drug claims over a 1-year period after discharge were retrieved from Regional Drug Dispense Registry. Drug use was measured with Proportion of Days Covered (PDC). PDC was computed dividing the total number of dispensed Defined Daily Dose by each patient's follow-up time. Dual antiplatelet therapy with PDC ≥75% and single therapy based on Clopidogrel with PDC ≥75% were considered as AAT. We used a composite area-based index of socioeconomic position by census block of residence built using the 2001 census of Rome, assuming 5 levels (from 1 =High SEP to 5 =Low SEP). SETTING AND PARTICIPANTS: study population of 5,901 patients resident in Rome, who underwent their first PCI during 2006-2007 were selected from the Hospital Information System. MAIN OUTCOME MEASURES: proportions of patients treated with AAT by SEP was measured for the overall year and by semester. The association between SEP and adherence to AAT was estimated through logistic regression models adjusting for factors selected by a stepwise procedure (gender, age, comorbidities, discharged from cardiology or coronary care unit, new user of antiplatelet drugs). RESULTS: 76% of the study population were men, 96% were aged more than 44 years, and 63% belonged to medium-low SEP. In the 1-year follow-up, the proportion of patients adherent to appropriate antiplatelet therapy was 65%; SEP was associated with AAT (OR high vs. low SEP 1.26; 95%CI 1.05-1.51; p trend =0.002). CONCLUSIONS: during the year after discharge, adherence to AAT of PCI patients was unsatisfactory and it decreased overtime more in medium-low SEP patients than in high SEP patients. Strategies to improve adherence to AAT among patients who underwent PCI need to be identified taking into account the multifactorial nature of poor medication adherence, and in particular patients' socioeconomic position.

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.

Changes in the effects of heat on mortality among the elderly from 1998-2010: results from a multicenter time series study in Italy.

BACKGROUND: This multicenter study is aimed at estimating changes in the effect of high temperatures on elderly mortality before and after the 2003 heat waves and following the introduction of heat prevention activities. METHODS: A total of sixteen cities were included in the study. City-specific relationships between maximum apparent temperature (MAT) and elderly daily mortality before (1998-2002) and after (2006-2010) intervention were modelled through non-linear distributed lag models and estimates were combined using a random effect meta-analysis. We estimated the percentage change in daily mortality for 3°C variations in MAT above the 25th percentile of the June city-specific 1998-2002 distribution. A time-varying analysis was carried out to describe intra-seasonal variations in the two periods. RESULTS: We observed a reduction in high temperatures' effect post intervention; the greatest reduction was for increases in temperature from 9°C to 12°C above the 25th percentile, with a decrease from +36.7% to +13.3%. A weak effect was observed for temperatures up to 3°C above the 25th percentile only after. Changes were month-specific with a reduction in August and an increase in May, June and September in 2006-2010. CONCLUSIONS: A change in the temperature-mortality relationship was observed, attributable to variations in temperature distributions during summer and to the introduction of adaptation measures. The reduction in the effect of high temperature suggests that prevention programs can mitigate the impact. An effect of lower temperature remains, indicating a relevant impact of temperature at the beginning of summer when the population has not yet adapted and intervention activities are not fully operational.

Socioeconomic inequalities in health status and survival: a cohort study in Rome.

OBJECTIVES: To analyse the association between individual and contextual socioeconomic position (SEP) with health status and to investigate the role of SEP and baseline health status on survival. DESIGN: Cross-sectional and cohort study. SETTING: Rome, Italy. PARTICIPANTS, PRIMARY AND SECONDARY OUTCOMES: We selected the 25-99 year-olds included in the Rome 2011 census cohort. As a measure of health status on the census reference date (09 October 2011), we used the presence of chronic or rare conditions from the Disease-Related Co-payment Exemption Registry, a database implemented to provide free care to people with chronic or rare diseases. We used logistic regression to analyse the association between both individual (educational attainment) and contextual SEP (neighbourhood real estate price quintiles) with baseline health status. We analysed the role of SEP and the presence of chronic or rare conditions on 5-year survival (until 31 December 2016) using accelerated failure time models with Weibull distribution, reporting time ratios (TRs; 95% CI). RESULTS: In middle-aged, subjects with low SEP (either individual or contextual) had a prevalence of chronic conditions comparable with the prevalence in high SEP individuals 10 years older. Adjusted logistic models confirmed the direct association between SEP and baseline health status in both women and men. The lowest educated were up to 67% more likely to have a chronic condition than the highest educated, while the difference was up to 86% for lowest versus highest contextual SEP. Low SEP and the presence of chronic conditions were associated with shorter survival times in both sexes, lowest versus highest educated TR was TR=0.79 for women (95% CI: 0.77 to 0.81) and TR=0.71 for men (95% CI: 0.70 to 0.73). The contextual SEP shrunk survival times by about 10%. CONCLUSION: Inequalities were present in both baseline health and survival. The association between SEP and survival was independent of baseline health status.

Validation of a Classification Algorithm for Chronic Kidney Disease Based on Health Information Systems.

Background: Chronic kidney disease (CKD) is a common condition, characterized by high burden of comorbidities, mortality and costs. There is a need for developing and validating algorithm for the diagnosis of CKD based on administrative data. Methods: We validated our previously developed algorithm that used administrative data of the Lazio Region (central Italy) to define the presence of CKD on the basis of serum creatinine measurements performed between 2012 and 2015 at the Policlinico Gemelli Hospital. CKD and advanced CKD were defined according to eGFR (<60 and <30 mL/min/1.73 m2, respectively). Sensitivity, specificity, positive and negative predictive values (PPV/NPV) were computed. Results: During the time span of the study, 30,493 adult participants residing in the Lazio Region had undergone at least 2 serum creatinine measurements separated by at least 3 months. CKD and advanced CKD were present in 11.1% and 2.0% of the study population, respectively. The performance of the algorithm in the identification of CKD was high, with a sensitivity of 51.0%, specificity of 96.5%, PPV of 64.5% and NPV of 94.0%. Using advanced CKD, sensitivity was 62.9% (95% CI 59.0, 66.8), specificity 98.1%, PPV 40.4% and NPV 99.3%. Conclusion: The algorithm based on administrative data has high specificity and adequate performance for more advanced CKD; it can be used to obtain estimates of prevalence of CKD and to perform epidemiological research.

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.

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.