Overordering of tumor marker for outpatients revealed by performance indicators and the impact of a health policy intervention: An observational study using administrative records.

PURPOSE: The overuse of laboratory tests contributes to impair health systems effectiveness, tumor markers (TMs) being a paradigmatic example. In the present study we applied indicators of TMs appropriateness developed from administrative datasets to appraise regionwide overordering in the clinical practice. PATIENTS AND METHODS: TMs ordered to outpatients in the Veneto Region over 6 years were obtained from the eletronic Outpatients' Records of Diagnostic and Therapeutic Procedures. TMs orders were examined as aggregated data or stratified according to disease codes, gender, age, and requests per patient. TMs recommended only for specific malignancies were examined using epidemiological data obtained from Veneto Tumor Registry. RESULTS: A total of 5,821,251 TMs were ordered in 4,382,159 patients over 6 years. Overall, 3,252,389 (55.9%) TMs were ordered without appropriate disease codes (ranging from 77.0% for PSA to 17.5% for CA15.3). TM orders declined over 6 years (-13.4%), with a noticeable reduction of orders without appropriate disease codes (-21.3%). Orders decreased sharply from 2015 to 2016, after the enactment of a national Decree-Law aimed at improving appropriateness, and remained stable thereafter. However, the rate of inappropriate TMs requests still remained elevated (44.4%) in the last year of observation, with orders of TMs being much higher than expected on the basis of prevalence and incidence figures of specific malignancies. CONCLUSIONS: Indicators developed from administrative datasets were effective in assessing the overordering of TMs and the impact of interventions to improve appropriateness. The developed indicators could be considered for other diagnostic tests.

Are Gyms a Feasible Setting for Exercise Training Interventions in Patients with Cardiovascular Risk Factors? An Italian 10-Years Cross-Sectional Survey Comparison.

BACKGROUND: Exercise training is a known important prevention and treatment modality in patients with cardiovascular (CV) diseases. However, the CV risk factors in gym users have been poorly studied. The aim of this study was to monitor CV risk factors of gym users over 10 years in order to investigate whether gyms are used settings for secondary disease prevention. METHODS: In 2007 and 2017, a cross-sectional research survey was adopted to determine CV risk factors and habits in gym users (18-69 years) of the Veneto region. These data were analyzed and compared with those of PASSI, a national surveillance system of the Italian population. RESULTS: During the last decade, there has been an increase in gym users over 50 years of age and in people with arterial hypertension and hypercholesterolemia. People attending the gym on medical referral are increasing, but they are still few (<10%). When comparing the collected data with PASSI surveillance, most of the CV risk factors are strongly underrepresented in gym users. CONCLUSION: The prevalence of gym users with CV risk factors is rather low, regardless of age. Physicians still need to encourage and prescribe physical exercise for secondary prevention and treatment of chronic diseases.

Impact of breast cancer screening in a population with high spontaneous coverage with mammography.

OBJECTIVE: The impact of organized screening programs on breast cancer (BC) mortality is unclear in an era of high spontaneous referral of women to mammography. The aim of this study was to analyze if the introduction of mammographic screening programs reduced BC mortality in the Veneto region, Italy, despite already widespread spontaneous access to mammography. METHODS: In Veneto, screening was introduced in different years between 1999 and 2009 across 21 local health units (LHUs), inviting asymptomatic women aged 50-69 years to undergo mammography biennially. We compared BC mortality for the 1995-2014 period of women aged 40-49 and 50-74 years who were resident in LHUs where screening programs started in 2003 (early LHUs) with women resident in LHUs where screening was introduced later (late LHUs). Poisson regression models were applied to incidence-based mortality (IBM), including only deaths from BC arising within the screening period. RESULTS: In the prescreening period and until 2010, BC mortality rates in early and late LHUs were similar in both age groups. In the last study period (2010-2014), we observed a 10% decrease in overall BC mortality in early compared to late LHU, limited to women aged 50-74 years. IBM was reduced by 8% (95% CI 1%-16%) in the overall study period and by 16% (6%-25%) in 2010-2014. CONCLUSIONS: In the Veneto region, screening programs were associated with a significant impact on BC-specific mortality; such effect appeared at least 8 years after screening implementation.

[Observed smoking in car: results of a study of the Regional Health Prevention Service of Veneto, Northern Italy]. / La prevalenza dell'abitudine a fumare in automobile: i risultati dello studio osservazionale in Veneto.

OBJECTIVE: to estimate the prevalence of smokers inside cars or duty vehicles and the presence of children exposed to second hand smoke on board, in the NHS districts of Veneto Region. DESIGN: an observational study was carried out by the technicians of the Prevention department from October 1st to October 17th 2008. The observers had to record sex of the driver and of the passengers, their presumed ages, verify if drivers or passengers were smoking, and if there were any children on board. SETTING AND PARTICIPANTS: 19 Local Health Authorities (90,5%) out of 21 in the Veneto region. MAIN OUTCOMES MEASURES: percentage of crossings monitored out of the total scheduled. RESULTS: a total of 5,928 cars were examined at the crossings, males accounted for 61,4% of the drivers. Smoking overall by at least one person in the car was reported in 409 cases (6.9%, 12% among commercial vehicles), the driver alone was smoking in 87.3% of the cases, whereas only the passenger smoking represented 8.3% of the cases. Both the driver and passenger smoking were 4.4% of the observations. Children were present as passengers in 762 cars (12.9%); there were people smoking with children on board in 7 cars (0.9%). CONCLUSION: in spite of the efforts to limit the dangers of second hand smoke, smoking in car is still a common behaviour, and represents a serious risk both for both, adults and children. Focusing in research projects could help the Department of Prevention of the Local Health Authorities to increase their activities and involvement in the research field.

[Smoking in car: monitoring pollution of particulate matter, of organic volatile compounds and of carbon monoxide. The effect of opening the driver's window]. / Fumare in macchina: l'inquinamento da polveri, da composti organici volatili e da monossido di carbonio. L'effetto dell'apertura del finestrino.

OBJECTIVE: to identify the most suitable marker for monitoring ETS inside a moving car, and to verify the efficacy of window opening to reduce ETS pollution inside the car. DESIGN: experimental pilot study. SSETTING AND PARTICIPANTS: monitoring of ETS markers in a moving car. MAIN OUTCOMES MEASURES: we used real time analyzers to measure: n particulate matter as mass (mug/m3, PM1, PM2.5, PM10); n suspended particle number (total number of particles sized >0.3 e >0.4 mum; n the number of particles with aerodynamic size between 0.3-0.4 mum in diameter; n total volatile organic compounds (TVOC); n carbon monoxide (CO). The recordings were carried out inside a car moving on the road at the speed of 50 km/h, with controlled conditions of temperature and relative humidity. RESULTS: after lighting a cigarette, with driver's window closed, the levels of all the pollutants increased dramatically, with peaks of 700 mug/m3 for PM2.5 and PM10, and of over 600,000 particles/ liter, while TVOC reached values up to 6,000 mug/m3 and CO up to 6 ppm. When a cigarette was lit with the window 1/4 open, excess pollution was promptly recorded, although with less intensity. With the window completely open, PM, TVOC and CO concentrations were hardly measurable as compared to background levels. On the contrary, particle number increased dramatically up to over 300,000/liter, mostly due to the submicrometric particle fraction in the range 0.3-0.4 mum. CONCLUSION: smoking just a cigarette inside a car represents an extremely high exposure to ETS. Partially opening the window is useless to prevent the accumulation of pollutants. Complete window opening is helpful to remove coarse PM and volatile pollutants, but is ineffective against submicrometer particles. Measuring particle number seems to be the best way to assess ETS pollution inside a car.

Cognitive impairment, chronic disease burden, and functional disability: a population study of older Italians.

OBJECTIVE: To evaluate associations of cognitive impairment and disease burden with disability in an elderly population. METHODS: The Mini-Cog was used as a cognitive screen in a population-based survey of health and functional status of 2,192 randomly selected older adults (age 65+ years) in 11 regions of Italy. Associations of cognitive and disease measures with functional outcomes were calculated using hierarchical logistic regressions including age, Mini-Cog score, disease burden, age, education, and geographic region. Statistical significance was assigned at p <0.01. RESULTS: Mini-Cog scores were related to all functional indicators (activities of daily living [ADLs], social activities, exercise, telephone and face-to-face conversation, urinary control, and ability to read the newspaper) as well as stroke, falls, and dementia diagnoses. In univariate analyses, low education was associated with Mini-Cog scores, disease burden, and disability. However, in logistic regressions, Mini-Cog score and disease burden, but not education, remained significant predictors of all basic ADLs and most higher-order functions. Functional disability was best predicted by a Mini-Cog cutoff score of 1 out of 5. Overall, although both are significant, the impact of cognitive impairment on basic ADL impairment was over four times greater than that of disease burden (accounting for 14% versus 3% of variance). CONCLUSION: Cognitive impairment assessed by the Mini-Cog is a more powerful predictor of impaired ADLs than disease burden in older adults. The association of education with Mini-Cog score did not bias its ability to predict functional status. Results suggest that the Mini-Cog could be useful in assessing older population assistance needs.

[Use of the Mini-Cog test as a screening method for dementia in the Italian population: the Argento Study results]. / Utilizzo del test Mini-Cog come metodo di screening per la demenza nella popolazione italiana: l'esperienza dello Studio Argento.

INTRODUCTION: This article describes the use of the Mini Cog test in a sample of elderly subjects participating in a multicentre Italian study on the healthcare needs of older adults. The Mini Cog is a simple screening test for cognitive impairment. It combines a brief memory test and a simply scored clock-drawing test and allows rapid screening for short term memory defects, learning and different cognitive abilities that are impaired in dementia patients. Various studies have shown that the Mini-Cog, which can be administered in as little as 3 minutes, is as effective in detecting dementia as longer screening tests. In addition, it can be easily administered by personnel that is unfamiliar with cognitive testing. METHODS: The Mini-Cog test was administered to 2,186 elderly subjects participating in the Argento study, a study conducted in 11 Italian regions. Clocks were rated as abnormal (0 points) or normal (1 point) and 1 point was given for each recalled word in the memory test. A total score of 0-2 was considered positive for dementia. Two training courses were organized for the 11 regional coordinators who were responsible for rating the clock drawing test. In order to validate the study results, 300 clocks were rated by expert raters who had developed the test. RESULTS: The test was acceptable to study subjects and less than 1% refused to perform the clock drawing test. Ratings by expert and local raters were found to be 90% concordant. The estimated prevalence of persons with a score >or=2 was 23.1% and double in persons over 75 years of age (65-74: 16,4%; >or=75: 31,2%). No gender differences were observed. On the other hand large differences were observed between persons with different educational levels; in fact while 63.1% of illiterate subjects scored positive for dementia, only 8.9% of university educated persons had positive tests. CONCLUSIONS: The Mini-Cog test was found to be easy to administer by Italian Local Health Unit personnel in the context of evaluating healthcare needs of older persons. Study results were consistent with other population studies that evaluated cognitive impairment in elderly subjects in developed countries. In view of its high acceptability and reliability the Mini-Cog can be a valid screening tool for use in outpatient services and by general practitioners and in the planning and management of healthcare services.

[Epidemiology of falls among the elderly]. / Indagine sulle cadute nella popolazione anziana di undici regioni italiane: Studio Argento 2001-2002.

INTRODUCTION: Falls among the elderly have important physical and psychological consequences. Interventions of proven effectiveness exist at individual and population level for their prevention. Studies conducted in other countries have estimated the prevalence and identified the health and environmental risk factors associated with falls, while in Italy, the information available is limited to elderly living in protected residences. To estimate therefore the prevalence of falls and to estimate the association between these events and different risk factors, a series of questions on falls and their possible determinants were included in Studio Argento, a cross-sectional survey of the state of health of the non-institutionalized population > or = 65 years of age that was conducted in 2002 in 11 Italian Regions. METHODS: In each region, two-stage cluster sampling was used to sample 210 individuals. In the first phase, 30 communes were selected, with the probability of selection proportionate to their population; in the second phase, simple random sampling using the communal population register to select the persons to be interviewed. Interviews were conducted in the homes of the study subjects using a standardized questionnaire. Data from the 11 regions were merged for purposes of the analysis, and the C-sample routine of Epi-Info version 2002 was used to conduct the analysis, taking into account of the survey design and the size of the total population > or = 65 years in the various Regions. SUDAAN, an application of SAS was used for the calculation of the rate ratios (R.R.) and 95% confidence intervals (95% CI) and the population-attributable fractions, taking into account potentially confounding variables. RESULTS: A total of 2,273 persons were included in the study. During the previous 12 months, 651 (28.6%; 95% CI = 26.4%-30.7%) had fallen; of these 43.1% (95% IC = 38.6%-47.7%) had fallen 2 or more times. Sixty percent (95% CI = 55,6%-64,2%) of those who had fallen reported having fallen at home. Risk factors for falls included stroke (adjusted RR = 1.4 (95% CI = 1.03-1.8)). diabetes (adjusted RR = 1.7 (95% CI = 1.2-2.1)). visual difficulties (adjusted RR = 1.3 (95% CI = 1.02-1.6)). urinary incontinence (adjusted RR = 1.3 (95%CI= 1.1-1.5) and physical inactivity (adjusted RR = 1.3 (95% CI = 1.03-1.5)). In addition, the consumption of anti-anxiety drugs was also associated with a greater risk of falls. The highest population-attributable fractions were seen for urinary incontinence (9.4%) and lack of physical activity (10.0%). CONCLUSIONS: Falls are common in Italian elderly and are linked with the fragility of aging. To prevent falls, it is necessary to intervene on factors associated with fragility. Methods include encouraging regular physical activity to improve equilibrium and muscle strength and the continuous monitoring of health status to prevent further deterioration. Moreover studies carried out in other countries have demonstrated that the multidisciplinary interventions targeted at persons who have already experienced a fall reduces their risk of further falls. These interventions consist of evaluations of visual acuity, balance, and gait and a review of clinical history with eventual modifications of drug therapy and the environmental risks in the home.

[Statistical approaches to test for spatial heterogeneity of relative risks of cause-specific mortality in Alto Vicentino Municipalities (years 1991-2000)]. / Valutazione dell'eterogeneità nei rischi relativi di mortalità per causa: un'applicazione ai Comuni dell'ULSS Alto Vicentino (decessi 1991-2000).

OBJECTIVE: To review the statistical approaches to test for spatial heterogeneity of relative risks. Three different statistical tests (Gail, Martuzzi-Hills and Potthoff-Whittinghill) are reviewed and applied--as motivating example--to the analysis of cause-specific mortality records (years: 1991-2000) of the Municipalities belonging to the Local Health Unit Alto Vicentino. METHODS: Spatial heterogeneity was found in 17 (Martuzzi-Hills) and 18 (Gail, Potthoff-Whittinghill) among 70 selected causes of death. Cohens Kappa test was chosen to assess the agreement among the tests (k = 0.596; p < or = 0.001). CONCLUSION: Spatial heterogeneity must be interpreted with great caution, taking into account the available evidence about risk factors for specific causes of death and carefully evaluating available exposure data.

Estimating the cumulative number of human immunodeficiency virus diagnoses by cross-linking from four different sources.

BACKGROUND: We estimated the cumulative number of people diagnosed with human immunodeficiency virus (HIV) infection in a region of Italy by cross-linking data from four surveillance systems and applying capture-recapture methods. METHODS: The study was conducted using data referring to residents of the Veneto Region (population 4.4 million). We cross-linked data from the AIDS Registry (data 1983-2000), the HIV Registry (1988-2000), the Death Registry (1992-1999), and the Hospital-Discharge Registry (1997-2000), using a code based on name, birth date, and sex. A specific software for capture-recapture models (CARE-1) was used to estimate the size of the target population with two different statistical approaches (sample coverage and log-linear models). RESULTS: A total of 2801 people were reported to the AIDS Registry, 6415 to the HIV Registry, 1598 to the Death Registry as HIV/AIDS-related deaths, and 3330 to the Hospital-Discharge Registry with a diagnosis of HIV infection. Overall, 8723 people were present in at least one registry: 4896 people were present in only one registry, 2387 in two registries, 1286 in three registries, and 154 in all four registries. Using the sample coverage approach, we estimated that, since the beginning of the epidemic in Veneto, an estimated 11 281 people (95% CI: 10 981, 11 621) should have been reported to at least one registry; thus the estimated coverage of the four registries was 77.3% (i.e. 8723/11 281). Results obtained applying the log-linear approach were similar, although the fitting of this model was not adequate. CONCLUSIONS: Cross-linking data from four different sources and applying the capture-recapture method can improve the accuracy of the estimates of the dimensions of the HIV epidemic.