Hospital admission for digestive diseases: Gastroenterology units offer a more effective and efficient care.

BACKGROUND: Digestive diseases imply a substantial burden for health care systems. Effectiveness of specialized gastroenterology care has been demonstrated in a few real life surveys. AIMS: To perform an in-depth analysis of Hospital Discharge Records (HDRs) of patients admitted for digestive diseases (DDs) from all Italian regions over the years 2010-2014. METHODS: Data on National HDRs were provided by the Italian Health Ministry. RESULTS: During the years 2010-2014, a mean of 949,830 patients with DDs were admitted to hospital per year, representing 10.0% of all admissions in Italy. Only 7.4% of patients with DDs were admitted to Gastroenterology units due to the limited number of the specialty-focused beds (3.4/100,000 inhabitants). DDs urgent admissions in Gastroenterology units represented 33% of admissions. The mean length of stay was 8.1 days in Gastroenterology units, as opposed to 8.3 in other units. Mortality rate for DDs altogether, for urgent admissions, and for urgent admissions with bleeding were 2.2%, 1.7%, 2.2% in Gastroenterology units, and 3.1%, 3.9%, 3.5% in other units, respectively. DDs admissions were appropriate in 81.3% in Gastroenterology units as opposed to 66.6% in all other units. CONCLUSIONS: Gastroenterology units offer a better specific care in terms of length of hospital stay and mortality even for patients admitted for emergent conditions.

White paper of Italian Gastroenterology: delivery of services for digestive diseases in Italy: weaknesses and strengths.

In 2011 the three major Italian gastroenterological scientific societies (AIGO, the Italian Society of Hospital Gastroenterologists and Endoscopists; SIED, the Italian Society of Endoscopy; SIGE, the Italian Society of Gastroenterology) prepared their official document aimed at analysing medical care for digestive diseases in Italy, on the basis of national and regional data (Health Ministry and Lombardia, Veneto, Emilia-Romagna databases) and to make proposals for planning of care. Digestive diseases were the first or second cause of hospitalizations in Italy in 1999-2009, with more than 1,500,000 admissions/year; however only 5-9% of these admissions was in specialized Gastroenterology units. Reported data show a better outcome in Gastroenterology Units than in non-specialized units: shorter average length of stay, in particular for admissions with ICD-9-CM codes proxying for emergency conditions (6.7 days versus 8.4 days); better case mix (higher average diagnosis-related groups weight in Gastroenterology Units: 1 vs 0.97 in Internal Medicine units and 0.76 in Surgery units); lower inappropriateness of admissions (16-25% versus 29-87%); lower in-hospital mortality in urgent admissions (2.2% versus 5.1%); for patients with urgent admissions due to gastrointestinnal haemorrhage, in-hospital mortality was 2.3% in Gastroenterology units versus 4.0% in others. The present document summarizes the scientific societies' official report, which constitutes the "White paper of Italian Gastroenterology".

Hospital care services for digestive diseases in Italy: the first quantitative assessment.

The scarcity of human and structural resources for specialized gastroenterology care is a problem in many Western countries. Data regarding the resources for Italian Gastroenterology, so far lacking, have been thus searched and evaluated. Based on an agreement protocol between the Italian Association of Hospital Gastroenterologists and Endoscopists (AIGO) and the Ministry of Health, national data regarding all Institutions providing gastroenterological care were analysed. Hospital beds in Gastroenterology units are presented by region, regimen of stay and per million inhabitants as of January 2011. Association of Hospital Gastroenterologists and Endoscopists also performed a survey of gastroenterology units in all Italian regions regarding number of ordinary/day hospital beds and the number of staff gastroenterologists. The Ministry data showed a total of 174 Gastronterology Units in Italy, a total of 2062 hospital beds for the discipline, for a proportion of 34.2 beds per million inhabitants. The Association of Hospital Gastroenterologists and Endoscopists survey showed a total of 1425 gastroenterologists in Italy. These data should represent a key reference for appropriate planning of specialized care for digestive diseases.

Seasonal variations in injury rates in children: evidence from a 10-year study in the Veneto Region, Italy.

The objective of this study was to investigate the long term trend of pediatric injuries in Veneto Region (North-East of Italy) over 10 years, evaluating if seasonality in injury hospitalisations exists. Regional data on hospital admissions during the period 2000-2009 were analysed. Injury was defined as any condition identified by the International Classification of Diseases, 9th edition, Clinical Modification (ICD-9-CM) codes 800-999, excluding late effects from injury (ICD-9-CM codes 905-909), and complications of surgical and medical care, not classified elsewhere (ICD-9-CM code 995-999) in the first diagnostic field. Cyclic trends in seasonality of injuries were tested with Nam test. Thirty-five thousand seven hundred and fifty-one hospitalisations due to an injury have been recorded. Significant seasonal variation in hospitalisations for injuries was observed, with a summer to winter ratio ranging from 1.8 for minor injuries to 2.0 for severe injuries (p <0.001). The observed pattern of increased admission in the summer months should guide resource planning and implementation of preventive strategies.

Increasing incidence and mortality of infective endocarditis: a population-based study through a record-linkage system.

BACKGROUND: Few population-based studies provide epidemiological data on infective endocarditis (IE). Aim of the study is to analyze incidence and outcomes of IE in the Veneto Region (North-Eastern Italy). METHODS: Residents with a first hospitalization for IE in 2000-2008 were extracted from discharge data and linked to mortality records to estimate 365-days survival. Etiology was retrieved in subsets of this cohort by discharge codes and by linkage to a microbiological database. Risk factors for mortality were assessed through logistic regression. RESULTS: 1,863 subjects were hospitalized for IE, with a corresponding crude rate of 4.4 per 100,000 person-years, increasing from 4.1 in 2000-2002 to 4.9 in 2006-2008 (p = 0.003). Median age was 68 years; 39% of subjects were hospitalized in the three preceding months. 23% of patients underwent a cardiac valve procedure in the index admission or in the following year. Inhospital mortality was 14% (19% including hospital transfers); 90-days and 365-days mortality rose through the study years. Mortality increased with age and the Charlson comorbidity index, in subjects with previous hospitalizations for heart failure, and (in the subcohort with microbiological data) in IE due to Staphylococci (40% of IE). CONCLUSIONS: The study demonstrates an increasing incidence and mortality for IE over the last decade. Analyses of electronic archives provide a region-wide picture of IE, overcoming referral biases affecting single clinic or multicentric studies, and therefore represent a first fundamental step to detect critical issues related to IE.

Population-based analyses of radical cystectomy and urinary diversion for bladder cancer in northern Italy.

OBJECTIVE: •To provide updated figures on urinary diversion, length of stay and mortality after cystectomy in two regions of northern Italy. PATIENTS AND METHODS: •Discharge records of patients undergoing cystectomy for bladder cancer in 2000-2008 were extracted from the regional archives of hospital discharges. •Data on partial vs radical cystectomy and type of urinary diversion were obtained from intervention codes. •The influence of demographic characteristics, year of intervention, presence of comorbidities and hospital cystectomy volume on the adoption of a continent diversion and on in-hospital mortality was assessed through multilevel models. RESULTS: •The crude cystectomy rate was close to 10 per 100,000. •The share of partial cystectomies declined from 5.5% in 2000-2002 to 3.0% in 2006-2008. •A continent diversion was adopted in 35% of radical cystectomies, with higher rates in young male patients treated in high-volume hospitals. •Median length of stay declined from 20 days in 2000-2002 to 18 in 2006-2008; in-hospital mortality decreased from 3.2% to 2.2%. CONCLUSION: •This first population-based report on cystectomies for bladder cancer from continental Europe evidences a limited role of partial cystectomy, a high proportion of continent diversion and a decreasing trend of length of stay and in-hospital mortality.

Hospitalisation for surgical procedures is lower among immigrants than among non-immigrant preschool children: results from a region-wide study in Italy.

BACKGROUND: Whether immigrant children receive unnecessary treatments and surgical procedures to a greater extent than non-immigrants remains controversial. OBJECTIVE: To investigate whether hospitalisation rates differ between immigrant and non-immigrant preschool children and the extent to which such differences relate to specific pathological conditions. METHODS: All discharges occurring to children aged 1-5 years between 2005 and 2007 in the Italian Region of Veneto (4.8 million inhabitants) were analysed by diagnosis related groups (DRGs). Crude and age-standardised hospitalisation RRs of immigrant versus Italian children were computed. Results Hospitalisation rates for medical conditions were similar between immigrant and Italian children. However, hospitalisation rates among immigrant children were significantly lower than those among Italians for all the most frequent surgical DRGs. RRs (95% CI) of immigrant versus Italian children were 0.46 (0.41 to 0.51) for tonsillectomy/adenoidectomy and 0.46 (0.38 to 0.57) for testes procedures in boys; 0.44 (0.38 to 0.49) for tonsillectomy/adenoidectomy and 0.47 (0.34 to 0.65) for extraocular procedures in girls. Only circumcision procedures were more frequent (fourfold excess) among immigrants. CONCLUSION: Hospitalisation rates for the most frequent surgical procedures are significantly lower among immigrants compared to non-immigrant preschool children. Reduced surgery rates among immigrants might result from a complex interplay between parental attitudes and knowledge of paediatric conditions, language barriers and access to primary care.

Youth suicide: an insight into previous hospitalisation for injury and sociodemographic conditions from a nationwide cohort study.

BACKGROUND: This study investigates the degree to which a previous hospitalisation for injury of any intent is a risk of subsequent youth suicide and whether this association is influenced by family socioeconomic status or economic stress. METHODS: A nationwide register-based cohort study was conducted covering all Swedish subjects born between January 1977 and December 1991 (N=1,616,342, male/female ratio=1.05). The cohort subjects were followed-up from January 1998 to December 2003, when aged 7-26 years. Poisson regression and the likelihood ratio test (95% CI) were used to assess the age-adjusted effect of hospitalisation for injuries of various intent on youth suicide and its effect once adjusted for family sociodemographic and social circumstances. RESULTS: Each set of exposures was associated independently and significantly with suicide mortality. Being hospitalised for self-inflicted injuries or injuries of undetermined intent was associated with a risk of suicide 36 to 47 times, respectively, that of subjects never hospitalised in the period under study (95% CI 28.36 to 45.58 and 26.67 to 83.87 for self-inflicted injuries and for events of undetermined intent, respectively; overall p<0.01). Similarly, previous events of unintentional injury markedly increased the risk of suicide (RR 3.08; 95% CI 2.26 to 4.19). These effects were solid and not substantially altered after adjustment for family demographic and socioeconomic circumstances. CONCLUSION: A strong association exists between previous hospitalisation for injury of any intent and youth suicide. The association is robust and unaltered by family socioeconomic circumstances.

Obstetric hospitalizations among Italian women, regular and irregular immigrants in North-Eastern Italy.

OBJECTIVE: Italy has become an important host country for economic immigrants. The study is aimed at providing a descriptive analysis of obstetric hospitalizations among Italian and immigrant women in North-Eastern Italy. DESIGN: Population-based registry descriptive study. SETTING: Veneto Region, Italy. METHODS: All obstetric hospitalizations in 2006-2007 were extracted from the regional archive of hospital discharge records (n = 144,698). Discharges for vaginal delivery, cesarean section, threatened abortion and other antepartum diagnoses, miscarriages, and induced abortions were identified among residents with Italian or foreign citizenship, and irregular immigrants. Hospitalization rates for the above diagnostic categories were computed for Italian and foreign Veneto residents. MAIN OUTCOME MEASURES: Delivery rates, proportion of cesarean sections, hospitalization rates for antepartum hospitalizations, miscarriage, induced abortion, and hospitalization rate ratios of immigrants versus Italian women. RESULTS: Among Italian women, regular and irregular immigrants, the percentages of teenage deliveries were 0.7, 2.9, and 8.4%; the ratios of miscarriages to deliveries were 0.16, 0.15 and 0.35; the ratios of induced abortions to deliveries were 0.13, 0.24 and 0.81, respectively. Regular immigrants accounted for 10% of population aged 15-49 and for 20% of deliveries. The age-related increase in miscarriage risk was steeper among regular immigrants. The induced abortions to deliveries ratio peaked among Italians aged <25 and regular immigrants aged ≥35 years. 40% of Italians and 30% of regular immigrants sought care outside nearest hospitals. CONCLUSIONS: Wide differences in reproductive behavior, health status, and patterns in the access to health services exist between Italians, regular and irregular immigrants even though they represent three connected populations.

Quality of care in congestive heart failure in the elderly: epidemiological evidence of a gap between guidelines and clinical practice.

BACKGROUND AND AIMS: This study aimed at evaluating the quality of care in elderly patients hospitalized for heart failure, compared with that received by subjects of younger age. METHODS: A cross-sectional retrospective study was performed on hospitalized subjects for heart failure in the Veneto Region (4.5 million inhabitants), located in North-East Italy, for the year 2004. Through consultation of clinical charts, performance of echocardiography, and prescription of ACE-inhibitors and beta-blockers were evaluated in each patient. Multivariate statistical analysis was used to test the association between age and the end-points of interest: prescription of ACE-inhibitors or beta- blockers and performance of echocardiography. RESULTS: The percentage of patients with prescriptions for ACE-inhibitors decreased with age, from 75% for patients under 65 years, to 62% for subjects over 84 years (p=0.02). A similar, but more marked, finding was observed for prescriptions of beta- blockers (56% in subjects aged <65 yrs vs 16% in those aged >84 yrs) (p<0.001). Evaluation of echocardiography was performed in 61% of subjects under 65 and in 22% in those over 84 (p<0.001). After statistical adjustment, age remained a significant predictor of prescription for beta-blockers and performance of echocardiography, but no longer for prescription of ACE-inhibitors. CONCLUSIONS: Among the elderly, age was a negative predictor of beta-blocker prescription and echocardiographic evaluation, but did not affect prescriptions for ACE-inhibitors.

A European project on incidence, treatment, and outcome of sarcoma.

BACKGROUND: Sarcomas are rare tumors (1-2% of all cancers) of mesenchymal origin that may develop in soft tissues and viscera. Since the International Classification of Disease (ICD) attributes visceral sarcomas (VS) to the organ of origin, the incidence of sarcoma is grossly underestimated. The rarity of the disease and the variety of histological types (more than 70) or locations account for the difficulty in acquiring sufficient personal experience. In view of the above the European Commission funded the project called Connective Tissues Cancers Network (CONTICANET), to improve the prognosis of sarcoma patients by increasing the level of standardization of diagnostic and therapeutic procedures through a multicentre collaboration. METHODS/DESIGN: Two protocols of epidemiological researches are here presented. The first investigation aims to build the population-based incidence of sarcoma in a two-year period, using the new 2002 WHO classification and the "second opinion" given by an expert regional pathologist on the initial diagnosis by a local pathologist. A three to five year survival rate will also be determined. Pathology reports and clinical records will be the sources of information.The second study aims to compare the effects on survival or relapse-free period - allowing for histological subtypes, clinical stage, primary site, age and gender - when the disease was treated or not according to the clinical practice guidelines (CPGs). DISCUSSION: Within CONTICANET, each group was asked to design a particular study on a specific objective, the partners of the network being free to accept or not the proposed protocol. The first protocol was accepted by the other researchers, therefore the incidence of sarcoma will be assessed in three European regions, Rhone-Alpes and Aquitaine (France) and Veneto (Italy), where the geographic distribution of sarcoma will be compared after taking into account age and gender. The conformity of the clinical practice with the recommended guidelines will be investigated in a French (Rhone Alps) and Italian (Veneto) region since the CPGs were similar in both areas.

Trends from 1999 to 2007 in the surgical treatments of kidney cancer in Europe: data from the Veneto Region, Italy.

OBJECTIVE: To investigate trends in the incidence of overall renal oncological surgery, and the trends and determinants of nephron-sparing (NSS) and minimally invasive surgery, in the Veneto region of North-eastern Italy. PATIENTS AND METHODS: The regional archive of hospital discharge records (HDRs) in the Veneto region of North-eastern Italy was assessed to identify discharged patients with a diagnosis of neoplasm of the kidney and intervention codes for partial nephrectomy (PN) or radical nephrectomy (RN) in 1999-2007. An indirect method for identifying minimally invasive surgery was also adopted. Demographic characteristics, year of intervention, presence of comorbidities, and hospital nephrectomy volume were retrieved from HDRs. The influence of patient and hospital variables on the adoption of nephron-sparing surgery (NSS) was assessed through multivariate models. RESULTS: The crude rate of surgery for kidney cancer increased from 11.5 to 17.0 per 100 000 population and overall 7221 procedures were included in the evaluated period. The use of PN increased through the study period, reaching 31% of kidney cancer operations in 2007. Younger age, male sex and being hospitalized in facilities with a higher procedural volume were strongly associated with NSS. Laparoscopic nephrectomies, uncommon in 1999, increased to approximately 18% of all procedures by the end of the study period, irrespective of hospital volume. CONCLUSIONS: The proportion of open RNs declined to about half of all kidney cancer surgery by 2007; this was the result of an increase in NSS and an even greater increase in laparoscopic RN.

Variability of adenoidectomy/tonsillectomy rates among children of the Veneto Region, Italy.

BACKGROUND: Despite national guidelines in 2003 aimed at limiting the recourse to tonsillectomy and/or adenoidectomy (A/T), the latter are among the most frequent pediatric surgeries performed in Italy. Aim of the study is to investigate variability of A/T rates among children of the Veneto Region, Italy. METHODS: All discharges of Veneto residents with Diagnosis-Related Groups 57-60 and ICD9-CM intervention codes 28.2 (tonsillectomy), 28.3 (adenotonsillectomy), 28.6 (adenoidectomy) were selected in the period 2000-2006 for a descriptive analysis. A multilevel Poisson regression model was applied to estimate Incidence Rate Ratios (IRR) with 95% Confidence Intervals (CI) for A/T surgery among children aged 2-9 years in 2004-2006, while taking into account clustering of interventions within the 21 Local Health Units. RESULTS: Through 2000-2006, the overall number of A/T surgeries decreased (-8%); there was a decline of adenoidectomies (-20%) and tonsillectomies (-8%), whereas adenotonsillectomies raised (+18%). Analyses on children aged 2-9 resulted in an overall rate of 14.4 surgeries per 1000 person-years (16.1 among males and 12.5 among females), with a wide heterogeneity across Local Health Units (range 8.1-27.6). At random intercept Poisson regression, while adjusting for sex and age, intervention rates were markedly lower among foreign than among Italian children (IRR = 0.57, CI 0.53-0.61). A/T rates in the 10-40 age group (mainly tonsillectomies) computed for each Local Health Unit and introduced in the regression model accounted for 40% of the variance at Local Health Unit level of pediatric rates (mainly adenoidectomies and adenotonsillectomies). CONCLUSION: A/T rates in the Veneto Region, especially adenoidectomies among children aged 2-9 years, remain high notwithstanding a decrease through 2000-2006. A wide heterogeneity according to nationality and Local Health Units is evident. The propensity to A/T surgery of each Local Health Unit is similar in different age groups and for different surgical indications.

Seat belt use among rear passengers: validity of self-reported versus observational measures.

BACKGROUND: The effects of seat belt laws and public education campaigns on seat belt use are assessed on the basis of observational or self-reported data on seat belt use. Previous studies focusing on front seat occupants have shown that self-reports indicate a greater seat belt usage than observational findings. Whether this over-reporting in self reports applies to rear seat belt usage, and to what extent, have yet to be investigated. We aimed to evaluate the over-reporting factor for rear seat passengers and whether this varies by gender and under different compulsory seat belt use conditions. METHODS: The study was conducted in the Veneto Region, an area in the North-East of Italy with a population of 4.7 million. The prevalence of seat belt use among rear seat passengers was determined by means of a cross-sectional self-report survey and an observational study. Both investigations were performed in two time periods: in 2003, when rear seat belt use was not enforced by primary legislation, and in 2005, after rear seat belt use had become compulsory (June 2003). Overall, 8138 observations and 7902 interviews were recorded. Gender differences in the prevalence of rear seat belt use were examined using the chi-square test. The over-reporting factor, defined as the ratio of the self-reported to the observed prevalence of rear seat belt use, was calculated by gender before and after the rear seat belt legislation came into effect. RESULTS: Among rear seat passengers, self-reported rates were always higher than the observational findings, with an overall over-reporting factor of 1.4. We registered no statistically significant changes over time in the over-reporting factor, nor any major differences between genders. CONCLUSION: Self-reported seat belt usage by rear passengers represents an efficient alternative to observational studies for tracking changes in actual behavior, although the reported figures need to be adjusted using an appropriate over-reporting factor in order to gain an idea of genuine seat belt use.

Feasibility of a screening programme for lung cancer in former asbestos workers.

BACKGROUND: Low-dose computed tomography (CT) has been found to detect more Stage IA lung cancer than chest x-ray. AIMS: To investigate whether lung cancer screening with CT was effective and acceptable in former asbestos workers. METHODS: CT scanning was carried out following the protocol previously described in the literature. A questionnaire was used to assess cumulative asbestos exposure. An economic analysis was also performed. Informed consent was obtained from all patients. RESULTS: A total of 1119 male asbestos workers (58% of invited) were examined, of whom 65% were smokers or ex-smokers. Mean age was 57.1 years with mean cumulative exposure to asbestos of 123 fibres/ml x years. Pleural plaques were found in 375 workers (32%), while 338 workers (29%) were included in the radiological follow-up, which led to 25 biopsies (13 of lung, 9 of pleura, 3 of both) and five screen-detected lung cancers (0.4%), one in Stage I. Incidence rate was 149 per 10(5), equal to that in the male general population of similar age. The expenses for diagnosis were 1014 and 244962 Euro per screened subject and screen-detected lung cancer case, respectively. CONCLUSIONS: Screening adherence and frequency of detection were low, while costs and radiation dose were high. In spite of a high cumulative asbestos exposure, lung cancer risk was not increased relative to the general population. The screening programme was not felt to be cost-effective from the perspective of the government as a third-party funding agency.

Sustainability of the effects of the demerit points system on seat belt use: a region-wide before-and-after observational study in Italy.

To assess the short and long term effects of the demerit points system on seat belt use, we set a region-wide cross-sectional observational study 3 months before, and 3 and 15 months after the introduction of the scheme (July 2003) in the Veneto Region, Italy. We analysed differences in seat belt use by year of observation, gender and position in the vehicle, and obtained adjusted prevalence ratio (APR) through Poisson regression. A total of 29,303 drivers, 28,778 front and 12,186 rear passengers were observed. Prevalence levels of 54% for drivers and 53% for front passengers in 2003 switched to 83 and 76%, respectively, 3 months after the new legislation, with further slight increases 15 months thereafter. Seventy-four percent rear passengers were still not compliant with the legislation in 2005. The probability of being belted was 25% lower in males than females (APR=0.75, 95% CI 0.73-0.77) at the beginning of the study period. However, the effect of the new legislation was 19% greater among males (APR=1.19, 95% CI 1.16-1.23). A substantial increase in seat belt use was reached and sustained with the demerit points system. Specific efforts should target rear passengers whose seat belt use still remains worryingly low.

Diffusion of good practices of care and decline of the association with case volume: the example of breast conserving surgery.

BACKGROUND: Several previous studies conducted on cancer registry data and hospital discharge records (HDR) have found an association between hospital volume and the recourse to breast conserving surgery (BCS) for breast cancer. The aim of the current study is to depict concurrent time trends in the recourse to BCS and its association with hospital volume. METHODS: Admissions of breast cancer patients for BCS or mastectomy in the period 2000-2004 were identified from the discharge database of the Veneto Region (Italy). The role of procedural volume (low < 50, medium 50-100, high > 100 breast cancer surgeries/year), and of individual risk factors obtainable from HDR was assessed through a hierarchical log-binomial regression. RESULTS: Overall, the recourse to BCS was higher in medium (risk ratio = 1.12, 95% confidence interval 1.07-1.18) and high-volume (1.09, 1.03-1.14) compared to low-volume hospitals. The proportion of patients treated in low-volume hospitals dropped from 22% to 12%, with a concurrent increase in the activity of medium-volume providers. The increase over time in breast conservation (globally from 56% to 67%) was steeper in the categories of low- and medium-volume hospitals with respect to high caseload. CONCLUSION: The growth in the recourse to BCS was accompanied by a decline of the association with hospital volume; larger centers probably acted as early adopters of breast conservation strategies that subsequently spread to smaller providers.

Evidence-based policy on road safety: the effect of the demerit points system on seat belt use and health outcomes.

OBJECTIVE: To assess the effect of a demerit points system, introduced in Italy in July 2003, on the prevalence of seat belt use (intermediate outcome) and the number of road traffic deaths and injuries (health outcomes). DESIGN: Pre- and post-intervention regional observational study for seat belt investigation (April 2003, October 2004); national time-series analysis of road traffic deaths and injuries between 1999 and 2004 for health outcomes. SETTING: Veneto region, Italy. PARTICIPANTS: 19,551 drivers, 19,057 front passengers and 8,123 rear passengers estimated to be aged over 11 years were included in the investigation into seat belt use. 38,154 fatalities and 1,938,550 injured subjects were examined for the time-series analysis. INTERVENTIONS: Demerit points system. MAIN OUTCOME MEASURES: The proportions of drivers and front and rear passengers observed to be using seat belts before and after the intervention; estimates of lives and injuries saved through the implementation of a penalty points system. RESULTS: The demerit points system was followed by an increase in observed seat belt use of 51.8% (95% confidence interval 48.7% to 54.9%) among drivers, of 42.3% (95% confidence interval 39.2% to 45.5%) among front passengers and of 120.7% (95% confidence interval 99.4% to 144.3%) among rear passengers. It is estimated that 1,545 (95% confidence interval 1387 to 1703; p<0.0001) deaths and 91,772 (95% confidence interval 67,762 to 115,783; p<0.0001) injuries were prevented in the 18 months after the introduction of the legislation, i.e. an 18% reduction (1545/8570) in fatalities and a 19% reduction (91,772/473,048) in injuries. CONCLUSIONS: The demerit points system is effective both in encouraging drivers and passengers to adhere to the law and in terms of health outcomes, substantially contributing to road safety.

Pattern and determinants of hospitalization during heat waves: an ecologic study.

BACKGROUND: Numerous studies have investigated mortality during a heatwave, while few have quantified heat associated morbidity. Our aim was to investigate the relationship between hospital admissions and intensity, duration and timing of heatwave across the summer months. METHODS: The study area (Veneto Region, Italy) holds 4577408 inhabitants (on January 1st, 2003), and is subdivided in seven provinces with 60 hospitals and about 20000 beds for acute care. Five consecutive heatwaves (three or more consecutive days with Humidex above 40 degrees C) occurred during summer 2002 and 2003 in the region. From the regional computerized archive of hospital discharge records, we extracted the daily count of hospital admissions for people aged >or=75, from June 1 through August 31 in 2002 and 2003. Among people aged over 74 years, daily hospital admissions for disorders of fluid and electrolyte balance, acute renal failure, and heat stroke (grouped in a single nosologic entity, heat diseases, HD), respiratory diseases (RD), circulatory diseases (CD), and a reference category chosen a priori (fractures of the femur, FF) were independently analyzed by Generalized Estimating Equations. RESULTS: Heatwave duration, not intensity, increased the risk of hospital admissions for HD and RD by, respectively, 16% (p < .0001) and 5% (p < .0001) with each additional day of heatwave duration. At least four consecutive hot humid days were required to observe a major increase in hospital admissions, the excesses being more than twofold for HD (p < .0001) and about 50% for RD (p < .0001). Hospital admissions for HD peaked equally at the first heatwave (early June) and last heatwave (August) in 2004 as did RD. No correlation was found for FF or CD admissions. CONCLUSION: The first four days of an heatwave had only minor effects, thus supporting heat health systems where alerts are based on duration of hot humid days. Although the finding is based on a single late summer heatwave, adaptations to extreme temperature in late summer seem to be unlikely.