Analysis of users and reasons for use of a physician-on-call service in an Italian local health unit.

BACKGROUND: In recent years, several countries have proposed changes to primary care organisation. OBJECTIVE: Our study investigated the characteristics of 'physician-on-call' usage in a local health unit of Lombardy (ASL MI1). METHODS: We analysed the incoming calls to the Operative Medical Central Station and collected the user characteristics, the call reasons and the outcomes from 1 October to 31 December 2012. Then, we randomly extracted 10% of the call sample from this period. We focused on two outputs: telephone advice (TA) and emergency department referral. We fit a logistic regression model to identify potential predictors of these outputs. RESULTS: In total, we evaluated 2146 calls. Women made most of the calls. Older age was associated with the referral to emergency care [adjusted odds ratio (aOR) 3.1], while paediatric calls were associated with TA (aOR 1.9). Information requests were related to TA (aOR 2.3), while cardiovascular symptoms (aOR 3.5), pain (aOR 2.6) and traumas (aOR 4.7) were linked to emergency care. CONCLUSIONS: Our study outlined the increasing use of TA, particularly for calls regarding paediatric patients. In contrast, calls for elderly patients were more frequently referred to emergency care. These findings led to the implementation of an age-targeted educational programme. Overall, our observations highlighted that women used the physician-on-call service more frequently than men. Furthermore, some reasons for calling were significantly associated with emergency care.

[The diffusion of screening programmes in Italy, year 2010]. / La diffusione dei programmi di screening in Italia, anno 2010.

The national meeting of the National Centre for Screening Monitoring (ONS) was given the title "The screening during the crisis" as we realize that the severe economical crisis of our country influences all the health policies and, as a consequence, screening programs. Within this global scenario, the results of 2010 concerning screening programs can be considered as still positive even if the gap between the North and the Central Regions as compared to the South remains. In short, in 2010 almost 9.5 millions people were invited to undergo a screening examination (3,450,000; 2,496,000 and 3,464,000 for cervical, mammographic and colorectal cancer respectively). As compared to the previous year, a large increase was observed for colorectal screening.Whereas a slight decrease was observed both for cervical and for mammographic screening. The latter trend was partially due to the overload consequent to the extension of the programme to women younger than fifty in a couple of regions (Emilia-Romagna and Piemonte). More than 4.3 millions of subjects actually complied to the invitation (1,375,000; 1,382,000 and 1,582,000 for cervical, mammographic and colorectal cancer, respectively). As a consequence of these activities were identified 6,015 breast cancers (31% of annual occurring breast cancers in Italy in the age group 50-69 years according to the most update estimates of breast cancer occurrence), 4,597 CIN2 or more severe cervical lesions, 2,916 colorectal cancers (15% of annual occurring CRC cancer in Italy in the age group 50-69 years) and 15,049 advanced adenomas.

The diffusion of screening programmes in Italy, year 2009.

In 2009, screening programmes in Italy continued to have positive results, as well as retaining some of the issues encountered in previous years. Overall, in 2009 over 9,000,000 people were invited to undergo a screening examination (3,547,000, 2,522,000 and 2,994,000, for cervical, breast, and colorectal cancer, respectively). More than 4 million people actually took up the invitation (1,393,000, 1,363,000, and 1,423,000 for cervical, breast, and colorectal cancer, respectively). The screening activities led to the finding of 5,973 breast cancers (36% of annual occurring breast cancers in Italy in the 50-69 year age group), 4 454 CIN2 or more severe cervical lesions, 2,556 colorectal cancers (16% of annual occurring CRC cancer in Italy in the 50-69 year age group), and 13,554 advanced adenomas.

Multicentric GISCoR Study "intensive clinical follow-up versus surgical radicalization after complete endoscopic polypectomy of a malignant adenoma" (SEC-GISCoR).

Colorectal cancer screening programs result in an early diagnosis of the disease. In 2007, 250 malignant polyps were identified in Lombardy, out of 1,329 screen-detected colorectal carcinomas. The Italian Group for Colorectal Cancer (GISCoR) promoted the multicentric study "Endoscopic Follow-up versus Surgical Radicalization of Malignant Polyps after Complete Endoscopic Polypectomy" (SEC-GISCoR). The protocol was a multicentric, prospective, observational, non-randomized study. It included patients diagnosed a colorectal malignant adenoma, after complete endoscopic removal. From November 2005 to September 2009, three participating centers enrolled 120 patients with malignant polyps after "complete" endoscopic polypectomy; malignant polyps were classified as "low risk" or "high risk". The study had two arms: "Intensive follow-up" (42 patients: 32 with low-risk and 10 with high-risk polyps) and "Surgical radicalization" (78 patients: 5 with low-risk and 73 with high-risk polyps). Data were collected using an online CRF. Overall, 37/120 polyps (30.8%) were low risk and 83/120 (69.2%) were high risk. 42 out of 120 patients (35%) were enrolled in the "clinical follow-up" arm, while 78/120 (65%) entered the surgery arm. In 15 cases, patients were not enrolled in the correct arm, according to the criteria agreed upon before starting the study. There still is a high incidence (11.5%) of pathological mismatches. No clinical event was reported in 2.9 years of follow-up. In conclusion, some differences emerged in the management of patients with malignant polyps among participating centers (p < 0.001), mismatches can be explained by high surgical risk or patient's choice. Only in 5 cases (4.2%), did data analysis not allow to exactly determine the reason for a choice different from protocol criteria. The availability of new risk factors and the evidence of pathological mismatches confirmed the need for future studies on this issue.

Impact of a population-based colorectal cancer screening program on local health services demand in Italy: a 7-year survey in a northern province.

OBJECTIVES: In 2005, the National Health Service recommended a population-based colorectal cancer (CRC) screening program using biennial fecal occult blood testing (FOBT), followed by total colonoscopy in positive patients. So far, no studies have been performed to evaluate the impact of a mass-screening CRC campaign on the health system services at the community level in Italy. We have therefore assessed the workload generated by the first two biennial rounds of screening program on the activity of hospital services involved in CRC diagnosis in the Lecco province. METHODS: Routine data from all hospital services of our province were collected on activity levels related to CRC diagnosis from January 2003 to December 2009. This time span covered the 2 years prior to, as well as the two biennial rounds of the CRC screening program. In particular, we focused on the volume of outpatient FOBTs and colonoscopies (both diagnostic and interventional) performed among subjects outside the screening program. Joinpoint models were used to test whether an apparent change in trend of examination over time was statistically significant in different age cohorts of the population (<50 years, 50-69 years, and ≥70 years). RESULTS: The volume of "extra-screening" per-patient/FOBTs and colonoscopies increased significantly over the evaluated periods in all ages, until year 2008, when a steady trend was beginning; the AAPCs (average of the annual percent changes) values were 5.7, 3.1, and 8.4 for FOBT and 14.6, 13.4, and 16.7 for colonoscopy in the three age cohorts, respectively. However, the increase in both FOBT and colonoscopy demand was maximal in the cohort ≥70 years, where three statistically significant annual percent changes (APCs) were identified (in 2003-2005, 2005-2006, and 2006-2007 APCs were 12.3, 14.9, and 15.9 for FOBT, and 18.7, 36.8, and 25.4 for colonoscopy, respectively). CONCLUSIONS: After the implementation of a FOBT-based mass-screening program for CRC, careful consideration must be given to the significant increase in the workload of hospital services involved in CRC diagnosis, outside the screening campaign. The extra-work mainly involves gastroenterologists performing colonoscopy, whose activity increased over the 5-year period by 118%, as well as laboratory services, where the demand of FOBTs rose by 40%. This phenomenon, mainly attributable to a profound change in the attitude toward CRC screening by those age cohorts outside the program, covers a time span of two full rounds of screening, whereupon a steady trend for colonoscopy is apparent.

[Workplace health promotion: evaluation of evidence of efficacy and methodological recommendations]. / La promozione della salute nei luoghi di lavoro: valutazione di evidenze di efficacia e raccomandazioni metodologiche.

BACKGROUND: During the period 2004-2007 five Italian regions in cooperation with the Universities of Pavia and Perugia and the Italian Cochrane Centre carried out a research project on health promotion programmes. OBJECTIVES: Evaluation of efficacy of health education programmes developed by the Local Health Units from 2000 to 2004. RESULTS: Analysis of 69 of health promotion programmes and 23 Cochrane reviews led to establishing recommendations for health operators; at the workplace the efficacious actions were: to encourage consumption of healthy food (also via automatic distributors of fruit and vegetable snacks) and physical activity, guarantee observance of the smoking ban and/or offer assistance to quit smoking. CONCLUSION: Health promotion projects involve the use of public resources so it is necessary that the potential impact and efficacy be evaluated in the planning process. In particular, it is advisable to examine the data in the literature and assign preference to projects that have proved efficacious.

Quality assessment of the mammographic screening programme in the Azienda Sanitaria locale Provincia Milano 1 -- analysis of interval cancers and discussion of possible causes of diagnostic error.

PURPOSE: To evaluate the sensitivity of the mammographic screening programme and the causes of diagnostic fault in cases surfacing as interval cancers. MATERIALS AND METHODS: Interval cancers (CI) were identified by linkage of the screening database for the years 2000-2002 to the database of hospital discharge records (HDR) for breast cancer during 2000-2002. Linkage between screening attenders during 2000-2001 and HDR (biennial follow-up for year 2000, one year follow-up for year 2001) was used to calculate the proportional rate of observed/expected IC. The observed/ expected rate was compared with international standards and literature data. Screening mammograms followed by IC, randomly admixtured with negative controls, underwent blind review by an independent radiologist, using the recommended classification criteria to evaluate causes of error (occult, minimal signs, screening error). RESULTS: The analysis of HDR during 2000-2002 allowed us to identify 31 out of 89 expected IC. Proportional observed/expected IC rate in the first or second year of screening interval was 26 or 67%, respectively. Screening mammograms for radiological review were available in 38 of 61 total IC: 20 cases (52.6%) were classified as occult, whereas minimal signs or screening errors were 2 (5.2%) or 16 (42.1%), respectively. Diagnostic suspicion had been reported at screening in 7 of 16 cases classified as screening error, but were not diagnosed at the subsequent diagnostic assessment. CONCLUSIONS: Proportional IC rate was higher than reported in the literature or currently recommended (<30% in the 1st, <50% in the 2nd year). The analysis of error causes shows an excess of screening errors with respect to current recommendations (<20% of IC should be classified as screening error at review), but also an excess of IC suspected at screening but misdiagnosed at assessment (7/38=18.4 %). Overall the analysis revealed a reduced sensitivity of the screening programme, as often observed in service screening as compared to excellence centres, and suggests proper action to improve diagnostic accuracy. Analysis and critical review of IC is an early indicator of screening efficacy which is not currently used in Italian screening programmes. Using HDR for this purpose may have limited drawbacks, but gives the advantage of earlier identification of IC as compared to cancer registries and is the most reliable source of information in areas lacking a cancer registry. The present study methodology might be currently applied in screening programmes.