[A&F to monitor and promote quality in healthcare during the COVID-19 emergency: the EASY-NET work]. / A&F per il monitoraggio e la promozione della qualità delle cure in emergenza COVID-19: il lavoro di EASY-NET.

We are presenting here the findings of the reaction to the COVID-19 epidemic during the period March to June 2020 of those centres participating in the research EASY-NET which is on-going in Italy, funded by the Ministry of Health and co-founded by the Regional Health Authorities. The objective of EASY-NET is to evaluate the effectiveness of the audit and feedback (A&F) strategies in different clinical and organizational settings in seven regions. As a negative consequence of the COVID-19 epidemic, the activities of the project have suddenly slowed down; nevertheless, the COVID-19 epidemic represented an opportunity to apply the A&F methodology and support the healthcare within the regional authorities in order to manage and monitor the impact of this new disease. The reaction to the crisis on behalf of EASY-NET was inconsistent across the participating regions for various reasons. Factors which influenced the reaction levels in relation to the rapidity and efficiency of the implementation of the A&F strategies were as follows: the varying epidemiological impact of the COVID-19 epidemic in the various territories, the different clinical and organizational context and availability of expert research teams together with A&F procedures which had already been tested before the start of the epidemic.

Socioeconomic inequalities in mortality in 16 European cities.

AIMS: To explore inequalities in total mortality between small areas of 16 European cities for men and women, as well as to analyse the relationship between these geographical inequalities and their socioeconomic indicators. METHODS: A cross-sectional ecological design was used to analyse small areas in 16 European cities (26,229,104 inhabitants). Most cities had mortality data for a period between 2000 and 2008 and population size data for the same period. Socioeconomic indicators included an index of socioeconomic deprivation, unemployment, and educational level. We estimated standardised mortality ratios and controlled for their variability using Bayesian models. We estimated relative risk of mortality and excess number of deaths according to socioeconomic indicators. RESULTS: We observed a consistent pattern of inequality in mortality in almost all cities, with mortality increasing in parallel with socioeconomic deprivation. Socioeconomic inequalities in mortality were more pronounced for men than women, and relative inequalities were greater in Eastern and Northern European cities, and lower in some Western (men) and Southern (women) European cities. The pattern of excess number of deaths was slightly different, with greater inequality in some Western and Northern European cities and also in Budapest, and lower among women in Madrid and Barcelona. CONCLUSIONS: In this study, we report a consistent pattern of socioeconomic inequalities in mortality in 16 European cities. Future studies should further explore specific causes of death, in order to determine whether the general pattern observed is consistent for each cause of death.

Social inequalities in total and cause-specific mortality of a sample of the Italian population, from 1999 to 2007.

BACKGROUND: There is extensive documentation on social inequalities in mortality across Europe, showing heterogeneity among countries. Italy contributed to this comparative research, through longitudinal systems from northern or central cities of the country. This study aims to analyse educational inequalities in general and cause-specific mortality in a sample of the Italian population. METHODS: Study population was selected within a cohort of 123,056 individuals, followed up for mortality through record linkage with national archive of death certificates for the period 1999-2007. People aged between 25 and 74 years were selected (n = 81,763); relative risks of death by education were estimated through Poisson models, stratified according to sex and adjusted for age and geographic area of residence. Heterogeneity of risks by area of residence was evaluated. RESULTS: Men and women with primary education or less show 79% and 63% higher mortality risks, respectively, compared with graduates. Mortality risks seem to frequently increase with decreasing education, with a significant linear trend among men. For men, social inequalities appear related to mortality due to diseases of the circulatory system and to all neoplasms, whereas for women, they are related to inequalities in cancer mortality. CONCLUSIONS: Results from the first follow-up of a national sample highlight that Italy presents significant differences in mortality according to the socio-economic conditions of both men and women. These results not only challenge policies aimed at redistributing resources to individuals and groups, but also those policies that direct programmes and resources for treatment and prevention according to the different health needs.

Workplace stress and prescription of antidepressant medications: a prospective study on a sample of Italian workers.

PURPOSE: The main aim of this study was to examine prospectively the relationship between antidepressant prescriptions (ADP), as a proxy of depressive symptoms, and work-related stress, measured according to the demand-control model. METHODS: A cohort of 2,046 union workers who participated in a survey on working conditions and health in 1999-2000 was followed up to 2005, through the Regional Drug Prescription Register, for an ADP. The relative risks associated with demand, control and job strain were estimated using Poisson regression, adjusting for age, sex and other workplace factors (shift work, overtime, loud noise and psychological violence). RESULTS: In final multivariable models, high demand significantly increased the risk of depressive symptoms among blue collars (RR = 1.82), whereas among white collars, it was significantly protective (RR = 0.38). No significant relationship was found for job control or strain in either occupational class. CONCLUSIONS: The direct association observed elsewhere among blue collars between depressive symptoms and demand was confirmed, but not for job control or job strain. It cannot be ruled out that the association with demand was at least in part determined by reverse causation, due to exposure over-reporting among subjects with subclinical depressive symptoms at baseline. The protective effect of demand among white collars is not consistent with the literature and may be attributable to the particular characteristics of this sample, which included mainly workers employed in public administrative positions.

Temporal and geographic heterogeneity of the association between socioeconomic position and hospitalisation in Italy: an income based indicator.

BACKGROUND: The inverse association between socioeconomic position (SEP) and health has been extensively explored in Italy; however few studies have been carried out on the relationship between income inequalities and health status or health services utilisation, particularly at a local level.The objective of this study is to test the association between the demand for hospital care and a small area indicator based on income in four Italian cities, over a four-year period (1997-2000), in the adult population. METHODS: Census Block (median 260 residents) Median per capita Income (CBMI) was computed through record linkage between 1998 national tax and local population registries in the cities of Rome, Turin, Milan and Bologna (total population approximately 5.5 million). CBMI was linked to acute hospital discharges among residents, based on patient's residence.Age-standardized gender-specific hospitalisation rates were computed by CBMI quintiles (first quintile indicating lowest income), overall, and by city and year. Heterogeneity of the association between income level and hospitalisation was analysed through a Poisson model. RESULTS: We found an inverse association between small area income level and hospitalisation rates, which decreased continuously from 153 per 1000 inhabitants in the first quintile to 107 per 1000 inhabitants in the fifth quintile. Income differences in hospitalisation were confirmed in each city and year. However, the magnitude of the association and the absolute level of hospitalisation rates were quite different in each city and tended to slightly decrease over time in all cities considered, except Bologna. CONCLUSION: Our study confirms an inverse association between income level and the use of hospitalization in four Italian cities, using a small area economic indicator, based on population tax data. Further analysis of the association between income and cause-specific hospitalization rates will allow to better understand the capability of the Italian National Health System to compel with socio-economic inequalities in health needs.Furthermore the SEP indicator we propose can represent a contribution to the improvement of tools for monitoring inequalities in health and in health services utilization.

Income level and chronic ambulatory care sensitive conditions in adults: a multicity population-based study in Italy.

BACKGROUND: A relationship between quality of primary health care and preventable hospitalizations has been described in the US, especially among the elderly. In Europe, there has been a recent increase in the evaluation of Ambulatory Care Sensitive Conditions (ACSC) as an indicator of health care quality, but evidence is still limited. The aim of this study was to determine whether income level is associated with higher hospitalization rates for ACSC in adults in a country with universal health care coverage. METHODS: From the hospital registries in four Italian cities (Turin, Milan, Bologna, Rome), we identified 9384 hospital admissions for six chronic conditions (diabetes, hypertension, congestive heart failure, angina pectoris, chronic obstructive pulmonary disease, and asthma) among 20-64 year-olds in 2000. Case definition was based on the ICD-9-CM coding algorithm suggested by the Agency for Health Research and Quality - Prevention Quality Indicators. An area-based (census block) income index was used for each individual. All hospitalization rates were directly standardised for gender and age using the Italian population. Poisson regression analysis was performed to assess the relationship between income level (quintiles) and hospitalization rates (RR, 95% CI) separately for the selected conditions controlling for age, gender and city of residence. RESULTS: Overall, the ACSC age-standardized rate was 26.1 per 10.000 inhabitants. All conditions showed a statistically significant socioeconomic gradient, with low income people being more likely to be hospitalized than their well off counterparts. The association was particularly strong for chronic obstructive pulmonary disease (level V low income vs. level I high income RR = 4.23 95%CI 3.37-5.31) and for congestive heart failure (RR = 3.78, 95% CI = 3.09-4.62). With the exception of asthma, males were more vulnerable to ACSC hospitalizations than females. The risks were higher among 45-64 year olds than in younger people. CONCLUSIONS: The socioeconomic gradient in ACSC hospitalization rates confirms the gap in health status between social groups in our country. Insufficient or ineffective primary care is suggested as a plausible additional factor aggravating inequality. This finding highlights the need for improving outpatient care programmes to reduce the excess of unnecessary hospitalizations among poor people.

Analyzing differences in the magnitude of socioeconomic inequalities in self-perceived health by countries of different political tradition in Europe.

The objectives of this study are to describe, for European countries, variations among political traditions in the magnitude of inequalities in self-perceived health by educational level and to determine whether these variations change when contextual welfare state, labor market, wealth, and income inequality variables are taken into account. In this cross-sectional study, the authors look at the population aged 25 to 64 in 13 European countries. Individual data were obtained from the Health Interview Surveys of each country. Educational-level inequalities in self-perceived health exist in all countries and in all political traditions, among both women and men. When countries are grouped by political tradition, social democratic countries are found to have the lowest educational-level inequalities.

[Testing of interventions for prevention of heat wave related deaths: results among frail elderly and methodological problems]. / Sperimentazione di interventi di prevenzione di danni alla salute da ondate di calore: risultati sulla popolazione anziana fragile e problemi metodologici.

OBJECTIVE: to evaluate the impact of a programme based on soft home care services and an offer of social caretaking, compared to one based only on soft home care, for the prevention of heat-related health events among clinically and/or functionally frail elderly. DESIGN: cluster randomised controlled trial. SETTING AND PARTICIPANTS: the study population included 2,612 persons over 75 years of age living alone in the city of Turin, North-West Italy, who were classified as clinically (hospitalization with specific diagnoses before summer 2004) and/or functionally (were receiving a disability pension) frail. MAIN OUTCOME MEASURES: a programme' s impact was evaluated on the basis of the hospitalizations and deaths that occurred during summer 2004, using gender-specific multilevel logistic regression models, controlling first for age and then also for education and income. RESULTS: among males, a weak protection against emergency hospitalization was observed within the group randomised to soft home care services and offer of social caretaking, compared to the only soft home care group (OR=0.33, 95% CI=0.11; 0.96). Among females, the programme including social caretaking seemed to lower the overall risk of hospitalization (OR=0.96, 95% CI=0.93; 0.98). CONCLUSION: this study has two important public health implications: first, it highlights the potential impact of programmes based on both soft home care and offer of social caretaking; second, it helps to raise awareness, both among health/social work and in the community, of the need for protection during summer periods for the elderly.

LIFE Med Hiss: An innovative cohort design for public health.

The aim of MED HISS methodology was to test the effectiveness of a low-cost approach to study long-term effects of air pollution, applicable in all European countries. This approach is potentially exportable to other environmental issues where a cohort representative of the country population is needed. The cohort is derived from the National Health Interview Survey, compulsory in European countries, which has information on individual lifestyle factors. In Life Med Hiss approach, subjects recruited have been linked at individual level with health data and have been then followed-up for mortality and hospital admissions outcomes. Exposure values of air pollution (PM2.5 and NO2) have been assigned using national dispersion models, enhanced by the information derived from monitoring station with data fusion techniques, and then upscaled at municipality level (highest level of detail achievable for the Italian Survey). Results for mortality have been used to test the effectiveness of this methodology and are encouraging if compared with European ones. The advantages of this technique are summarized below: •It uses a cohort already available and compulsory in European countries•It uses air quality modelling data, available for most of the countries•It permits to implement versatile environmental surveillance systems.

[Socio-economic status and family profile indicators: methodological issues in studying the burden of caregiving for terminally ill cancer patients]. / Indicatori di stato socio-economico e profili familiari: problemi metodologici nello studio dell'impatto sulle famiglie della fase terminale della malattia oncologica.

INTRODUCTION: The quality of care received by terminally ill cancer patients depends heavily on socio-economic conditions and family resources, especially because of the current increase in home care assistance. OBJECTIVE: To validate the demographic information on educational level which is recorded in the registries of residents in Italian towns; to compare simple indicators of socio-economic status and family profiles with composite indicators in their ability to predict the economic and social impact of the disease. DESIGN: A two-level probabilistic sample of cancer deaths from the Italian Survey on Dying Of Cancer. PARTICIPANTS: 2000 deaths were sampled; caregivers were identified and interviewed between 4 and 12 months after the patient's death. METHODS: We calculated Cohens kappa for educational level as reported in the registry, and in the questionnaire. We constructed a composite indicator of socio-economic status and family profile using a cluster analysis; its association with the impact on finances and quality of daily life was compared with that from the educational level reported in the questionnaire and with a previously derived indicator of family profile. RESULTS: The weighted kappa of the two sources used for educational level was 0.60 (CI 95% 0.55-0.64). Of the two indicators, educational level and socio-economic status (6 groups), only the later showed a significant association with the outcomes "difficulties" in sustaining the costs of treatment" and "use of entire savings for the illness". The composite indicator of family profile (7 groups) was significantly associated with all outcomes considered. Log-likelihood was significantly better with model using the composite and the prior indicators of family profile than in models without them. Models that included educational level and prior indicator of family profile (7 groups) were more adaptable than models with the composite indicators. CONCLUSIONS: The good level of agreement between the two sources regarding educational level suggests that the registry is an adequate data source, when other information is lacking. Our study did not reveal which of the indicators we used is the best, at least with regard to the outcomes we considered.

The Role of Contextual Socioeconomic Circumstances and Neighborhood Poverty Segregation on Mortality in 4 European Cities.

Several studies have recognized the health disadvantage of residents in socioeconomically deprived neighborhoods, independent of the influence of individual socioeconomic conditions. The effect of neighborhood socioeconomic deprivation on general mortality has appeared heterogeneous among the cities analyzed: the underlying mechanisms have been less empirically explored, and explanations for this heterogeneous health effect remain unclear. The present study aimed to: (1) analyze the distribution of socioeconomically disadvantaged persons in neighborhoods of 4 European cities-Turin, Barcelona, Stockholm and Helsinki-trying to measure segregation of residents according to their socioeconomic conditions. Two measuring approaches were used, respectively, through dissimilarity index and clustering estimated from Bayesian models. (2) Analyze the distribution of mortality in the above mentioned cities, trying to disentangle the independent effects of both neighborhood socioeconomic deprivation and neighborhood segregation of residents according to their socioeconomic conditions, using multilevel models. A significantly higher risk of death was observed among residents in more deprived neighborhoods in all 4 cities considered, slightly heterogeneous across them. Poverty segregation appeared to be slightly associated with increasing mortality in Turin and, among females and only according to dissimilarity, in Barcelona. Few studies have explored the health effects of social clustering, and results could inform urban policy design with regard to social mix.

Educational inequalities in cause-specific mortality in middle-aged and older men and women in eight western European populations.

BACKGROUND: Studies of socioeconomic disparities in patterns of cause of death have been limited to single countries, middle-aged people, men, or broad cause of death groups. We assessed contribution of specific causes of death to disparities in mortality between groups with different levels of education, in men and women, middle-aged and old, in eight western European populations. METHODS: We analysed data from longitudinal mortality studies by cause of death, between Jan 1, 1990, and Dec 31, 1997. Data were included for more than 1 million deaths in 51 million person years of observation. FINDINGS: Absolute educational inequalities in total mortality peaked at 2127 deaths per 100000 person years in men, and at 1588 deaths per 100000 person years in women aged 75 years and older. In this age-group, rate ratios were greater than 1.00 for total mortality and all specific causes of death, apart form prostate cancer in men and lung cancer in women, showing increased mortality in low versus high educational groups. In men, cardiovascular diseases accounted for 39% of the difference between low and high educational groups in total mortality, cancer for 24%, other diseases for 32%, and external causes for 5%. Among women, contributions were 60%, 11%, 30%, and 0%, respectively. The contributions of cerebrovascular disease, other cardiovascular diseases, pneumonia, and COPD strongly increased by age, whereas those of cancer and external causes declined. Although relative inequalities in total mortality were closely similar in all populations, we noted striking differences in the contribution of specific causes to these inequalities. INTERPRETATION: Research needs to be broadened to include older populations, other diseases, and populations from different parts of Europe. Effective interventions should be developed and implemented to reduce exposure to cardiovascular risk factors in low-educational groups.

Socioeconomic inequalities in coronary heart disease in Italy: a multilevel population-based study.

This longitudinal study evaluates the role of individual and contextual socioeconomic determinants in the socioeconomic inequalities in incidence and mortality for coronary events in Turin, Italy, using hierarchical models. All residents aged 35-74 at the start of 1997 were included in the study population. We considered as outcomes all incident cases and deaths that occurred in the study population in the period 1997-2002. The socioeconomic indicators were educational level, job status and median income per census tract. A neighbourhood deprivation index was also used, which combines, in an aggregated measure, a series of poor individual socioeconomic conditions. The analyses were performed using hierarchical Poisson models, with individuals (n = 523,755) considered as level I units and neighbourhoods (n = 23) as level II units. Among men, we observed an inverse gradient in incidence by educational level and an excess risk for persons who were not actively employed. More marked excesses were found for mortality (RR: 1.63; 95% CI: 1.05-2.55, for unemployed persons compared to employed persons). Among women, greater socioeconomic differences were observed for both incidence and mortality; all of the individual indicators contributed to these differences. The differentials in mortality were particularly great for the retired and for housewives (RR: 1.98; 95% CI: 1.40-2.81). Slight excesses in incidence were observed among men for the most deprived areas. The results of this study reveal that job status is the most important individual factor explaining socioeconomic inequalities for coronary events, whereas context seems to play a marginal role.

Factors other than risks in the workplace as determinants of socioeconomic differences in health in Italy.

To evaluate differences in mortality by social class and to determine the impacts of socioeconomic factors on health inequalities in Italy, mortality data from 1981-2001 were analyzed as a function of social class in Turin, controlling for occupational risks, housing conditions, and education. For general and cause-specific mortality, the weight of each socioeconomic indicator was evaluated on population-attributable fraction to social class. Among men, mortality risk was significantly higher in unskilled blue-collar workers (RR = 1.45). Among women, the differences by social class were slighter. Education and economic status mostly explain the mortality differences by social class in men, while economic status showed the highest contribution in women.