Fibrosis-4 score for screening of metabolic dysfunction-associated steatotic liver disease (MASLD): Data from a population-based sample in Tuscany.

BACKGROUND AND AIM: To verify the prevalence of positive Fibrosis-4 (FIB-4) score, a screening test for metabolic-associated liver disease, in a large population-based sample in the Tuscany Italian Region, and to identify sub-populations at higher risk which could be targeted by specific screening programs. METHODS AND RESULTS: Population-based survey performed in the Italian region of Tuscany, with Tuscany health informative system's administrative data. We included 594,923 subjects, of which 32% had available data for the FIB-4 calculation. The overall proportion of subjects with an FIB-4 value > 1.3, was 41.6% of those with available exams, and 12,8% of the whole population, whereas 5.4% and 1.7% had FIB-4 >2.67. In those younger than 80 years, FIB >1.3 had a 33.1% and 9.4%. People with diabetes mellitus had higher figures (52.8.% and 28.9% for FIB>1.3). Among subjects aged 70 years or over, 74.9% of those with available data and 38.4% of the general population had a FIB-4>1.3, whereas 32% and 16% had a FIB-4 > 2. CONCLUSIONS: The relevant proportion of FIB-4 positivity in the general population poses a significant burden for further screening with liver elastography. Targeting people with diabetes, excluding people older than 80 years and/or adopting a FIB-4 threshold of 2 in those aged more than 70 years could increase the cost-effectiveness of the screening procedures.

Prevalence and features of SARS-CoV-2 infection in prisons in Tuscany.

BACKGROUND: Prisons can be a reservoir for infectious diseases, including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), due to the very intimate nature of the living spaces and the large number of people forced to share them. AIM: To investigate the SARS-CoV-2 epidemiology in prisons, this study evaluated the infection incidence rate in prisoners who underwent nasopharyngeal swabs. METHODS: This is an observational cohort study. Data collection included information on prisoners who underwent nasopharyngeal swab testing for SARS-CoV-2 and the results. Nasopharyngeal swab tests for SARS-CoV-2 were performed between 15 February 2021 and 31 May 2021 for prisoners with symptoms and all new arrivals to the facility. Another section included information on the diagnosis of the disease according to the International Classification of Diseases, Ninth Revision, and Clinical Modification. RESULTS: Up until the 31 May 2021, 79.2% of the prisoner cohort (n = 1744) agreed to a nasopharyngeal swab test (n = 1381). Of these, 1288 were negative (93.3%) and 85 were positive (6.2%). A significant association [relative risk (RR)] was found only for the risk of SARS-CoV-2 infection among foreigners compared to Italians [RR = 2.4, 95% confidence interval (CI): 1.2-4.8]. A positive association with SARS-CoV-2 infection was also found for inmates with at least one nervous system disorder (RR = 4, 95%CI: 1.8-9.1). The SARS-CoV-2 incidence rate among prisoners is significantly lower than in the general population in Tuscany (standardized incidence ratio 0.7, 95%CI: 0.6-0.9). CONCLUSION: In the prisoner cohort, screening and rapid access to health care for the immigrant population were critical to limiting virus transmission and subsequent morbidity and mortality in this vulnerable population.

Examining potential Long COVID effects through utilization of healthcare resources: a retrospective, population-based, matched cohort study comparing individuals with and without prior SARS-CoV-2 infection.

BACKGROUND: A significant proportion of individuals reports persistent clinical manifestations following SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) acute infection. Nevertheless, knowledge of the burden of this condition-often referred to as 'Long COVID'-on the health care system remains limited. This study aimed to evaluate healthcare utilization potentially related to Long COVID. METHODS: Population-based, retrospective, multi-center cohort study that analyzed hospital admissions and utilization of outpatient visits and diagnostic tests between adults aged 40 years and older recovered from SARS-CoV-2 infection occurred between February 2020 and December 2021 and matched unexposed individuals during a 6-month observation period. Healthcare utilization was analyzed by considering the setting of care for acute SARS-CoV-2 infection [non-hospitalized, hospitalized and intensive care unit (ICU)-admitted] as a proxy for the severity of acute infection and epidemic phases characterized by different SARS-CoV-2 variants. Data were retrieved from regional health administrative databases of three Italian Regions. RESULTS: The final cohort consisted of 307 994 previously SARS-CoV-2 infected matched with 307 994 uninfected individuals. Among exposed individuals, 92.2% were not hospitalized during the acute infection, 7.3% were hospitalized in a non-ICU ward and 0.5% were admitted to ICU. Individuals previously infected with SARS-CoV-2 (vs. unexposed), especially those hospitalized or admitted to ICU, reported higher utilization of outpatient visits (range of pooled Incidence Rate Ratios across phases; non-hospitalized: 1.11-1.33, hospitalized: 1.93-2.19, ICU-admitted: 3.01-3.40), diagnostic tests (non-hospitalized: 1.35-1.84, hospitalized: 2.86-3.43, ICU-admitted: 4.72-7.03) and hospitalizations (non-hospitalized: 1.00-1.52, hospitalized: 1.87-2.36, ICU-admitted: 4.69-5.38). CONCLUSIONS: This study found that SARS-CoV-2 infection was associated with increased use of health care in the 6 months following infection, and association was mainly driven by acute infection severity.

LDL-cholesterol target levels achievement in high-risk patients: An (un)expected gender bias.

BACKGROUND AND AIMS: Lowering low-density lipoprotein cholesterol (LDL-C) is the cornerstone of cardiovascular disease prevention. Collection of epidemiological data is crucial for monitoring healthcare appropriateness. This analysis aimed to evaluate the proportion of high-risk patients who achieved guidelines recommended LDL-C goal, and explore the predictors of therapeutic failure, with a focus on the role of gender. METHODS AND RESULTS: Health administrative and laboratory data from seven Local Health Districts in Tuscany were collected for residents aged ≥45 years with a history of major adverse cardiac or cerebrovascular event (MACCE) and/or type 2 diabetes mellitus (T2DM) from January 1, 2019, to January 1, 2021. The study aimed to assess the number of patients with optimal levels of LDL-C (<55 mg/dl for patients with MACCE and <70 mg/dl for patients with T2DM without MACCE). A cohort of 174 200 individuals (55% males) was analyzed and it was found that 11.6% of them achieved the target LDL-C levels. Female gender was identified as an independent predictor of LDL-C target underattainment in patients with MACCE with or without T2DM, after adjusting for age, cardiovascular risk factors, comorbidities, and district area (adjusted-IRR 0.58 ± 0.01; p < 0.001). This result was consistent in subjects without lipid-lowering therapies (adjusted-IRR 0.56 ± 0.01; p < 0.001). CONCLUSION: In an unselected cohort of high-risk individuals, females have a significantly lower probability of reaching LDL-C recommended targets. These results emphasize the need for action to implement education for clinicians and patients and to establish clinical care pathways for high-risk patients, with a special focus on women.

Access to SARS-CoV-2 vaccination in immigrants in Italy, by geographical area of origin.

OBJECTIVE: Immigrants are commonly considered disadvantaged and at high risk of not receiving appropriate care, including vaccination. This study aimed to evaluate the access to SARS-CoV-2 vaccination in immigrants, by geographical area of origin, compared with Italian citizens. We also evaluated sex differences in vaccine's coverage by geographical area of origin. METHODS: We performed a retrospective observational study in four Italian regions, including all resident subjects aged 5-69 years, and undergoing first dose SARS-CoV-2 vaccination in the period 28th December 2020- 3rd April 2022. We estimated cumulative coverage percentages, by age class and geographical area. To compare first-dose vaccine coverage by geographical area of origin, we estimated, through a Poisson analysis, Vaccine Coverage Ratios (VCR) with 95 % confidence intervals (95 %CI), adjusting for age and sex. RESULTS: We included 16,294,785 Italian citizens and 2,534,351 immigrants aged 5-69 years and resident in the four regions considered. Regarding the geographical area of origin, 40.7 % of immigrants came from Eastern Europe, 13.5 % from North Africa and 13.1 % from Western Asia. A great variability in the first dose vaccine coverage emerged. We documented substantial heterogeneity in the first-dose vaccine coverage within immigrant's population, expressed with Italy as a reference, ranging from 0,768 (95 %CI: 0,766-0,769) in Eastern Europe countries to 1,013 (95 %CI: 1,009 - 1,018) in Eastern Asia. The chance of being vaccinated was found higher in males compared with females for African countries (VCR 1.07, 95 %CI 1.06-1.08) and Western Asian countries (VCR 1.08, 95 %CI 1.07-1.09). CONCLUSION: We observed substantial heterogeneity in first-dose SARS-CoV-2 vaccination coverage in immigrants, suggesting a different propensity to vaccines according to the geographical area of origin. These data can help define appropriate and tailored strategies in order to improve vaccine coverage in some specific immigrant groups at the local health district level.

Foreigners living in Tuscany at the time of coronavirus outbreak.

Background: During the coronavirus outbreak, a worldwide state of emergency and lockdown significantly affected the volunteer services for foreigners. The SARS-CoV-2 surveillance program was strengthened among migrants arriving in Italy. However, few screening measures for SARS-CoV2 infection have been conducted on the foreign population already present in Italy. In Tuscany, a great effort was made to know the epidemiological features of coronavirus outbreaks in the foreigners. Based on these premises, this study describes the prevalence and characteristics of SARS-CoV-2 infection in foreigners present in the Tuscan territory during the months of the highest incidence of this pandemic. Methods: Ministry of Health established the COVID-19 surveillance and predisposed the methods for reporting cases of SARS-CoV-2 infection in agreement with the Department of Infectious Diseases of the Istituto Superiore di Sanità. Data on SARS-CoV-2, updated daily, were collected based on the platform of the Istituto Superiore di Sanità.For each patient were available data on diagnosis, gender, age, nationality, exposure place, hospitalization and symptoms severity. Symptoms severity was classified using a 6-level scale (asymptomatic, paucisymptomatic, mild symptoms, severe symptoms, critic, and died). Results: By July 14, 2020, 10,090 SARS-CoV-2 cases were recorded. Out of 10,090 cases, 8,947 were Italians (88.7%), 608 foreigners (6%); in 535 patients (5.3%) citizenship was missing. The average age of foreigners was 44.1 years (range: 42.9-45.4), compared to 61.1 years (range: 60.7-61.5) of Italians. Chronic pathologies affected 16.8% of foreigners (14.0% -20.0%) and 36.4% of Italians (35.4% -37.4%). Foreigners with asymptomatic or mild symptoms of COVID-19 were 81.7% (78.4% -84.6%), while the Italians were 67% (66.6% -68.5%). Foreigners with severe COVID-19 were 15.2% (12.6% -18.4%) and Italians were 17.6% (16.8% -18.4%). Foreigners in critical conditions were 1.0% (0.5% -2.2%) and Italians were 2.6% (2.3% -3.0%). 38.6% (33.7% -43.7%) of foreigners were infected at the workplace as a health or social-health worker, compared to 24.2% (23.1% -25.4%) of Italians. Conclusion: The time between the onset of symptoms and the execution of the laboratory tests was similar between foreigners and Italians. The foreigners infected by SARS-COV-2 were younger compared to the Italians. Foreigners showed few comorbidities, and asymptomatic or mild symptomatic COVID-19, and consequently, a low lethality index. National and Tuscany policy decisions are needed to create equity in the access to the health care system for immigrants and their families, regardless of their immigration status.

Access to SARS-CoV-2 diagnostic tests: are there barriers for the immigrants in Italy?

OBJECTIVES: to describe the epidemiology of SARS-CoV-2 infection in relation with the use of nasal swabs in the immigrant population in Italy, using data from the COVID-19 national surveillance system and to verify if a difference is present comparing natives and immigrant. DESIGN: descriptive study based on longitudinal health-administrative data. SETTING AND PARTICIPANTS: general population of six Italian Regions (Piedmont, Lombardy, Veneto, Emilia-Romagna, Tuscany, Lazio) covering about 55% of the resident population and 72% of foreigners' population. MAIN OUTCOME MEASURES: regional rates of access to at least a nasal swab, separately by country of origin. RESULTS: across all the periods, a lower rate in the foreigners' group was observed, with the only exception of the period May-June 2021. Considering separately High Migratory Pressure Countries (HMPCs) and Highly Developed Countries (HDCs), a higher proportion of nasal swabs performed in people coming from HDC with respect to HMPCs and natives was noticed. This observation is consistent in males and females. CONCLUSIONS: during the first wave of the pandemic, Italians have had a higher proportion of nasal swabs compared to migrants across all Regions. This difference disappeared in the following periods, probably due to a major availability of diagnostic tests.

[SARS-CoV-2 epidemic among Italians e resident immigrant population: differential incidence from an interregional multicentre study]. / L'epidemia di SARS-CoV-2 nella popolazione italiana e straniera: differenze di incidenza che emergono da uno studio multicentrico interregionale.

OBJECTIVES: to describe differences in the incidence of SARS-CoV-2 infections between Italians and foreigners residing in seven Italian Regions during the different phases of the pandemic and by gender. DESIGN: retrospective observational study. SETTING AND PARTICIPANTS: all confirmed SARS-CoV-2 infections from 02.02. 2020 to 16.07.2021 in the seven Regions under study were included. Italian resident population calculated by the National Institute of Statistics as of 01.01.2020 was used to calculate the rates. The considered period is divided into 5 sub-periods (phases). MAIN OUTCOME MEASURES: number of confirmed SARS-CoV-2 infections in the five phases of the pandemic and crude rates by citizenship (Italian vs foreign). Distribution of infections by age group and by week. Crude and age-adjusted incidence rates ratios (IRR) were calculated, by Region, gender, and phase of the pandemic. RESULTS: an epidemic curve delay was observed in foreigners in the first phase of the epidemic, in particular in the northern Regions, the most affected in that phase. The first phase of the epidemic was characterized by a greater proportion of cases occurred in people aged over 60 years than the other phases, both in Italians and in foreigners. The incidence among foreigners is higher during the summer of 2020 (intermediate period: June-September 2020) and during the last period (May-July 2021) in all Regions. The overall figure shows a lower incidence among foreigners than Italians, except for males in Tuscany. CONCLUSIONS: the lower incidence rates among foreigners should be interpreted with caution as the available data suggest that it is at least partly attributable to less access to diagnostic tests. Regional differences found in the study deserve further research together with the effect of gender and country of origin.

[Hospital assistance for COVID-19: a comparison between non-Italian and Italian resident population in five Italian Regions since the beginning of the pandemic until June 2021]. / Un confronto tra italiani e stranieri residenti nell'assistenza ospedaliera per COVID-19 in cinque Regioni italiane da inizio pandemia a giugno 2021.

OBJECTIVES: to describe trends of overall and intensive care hospitalization for COVID-19 since the beginning of the pandemic in Italy until June 2021, and to compare the results between foreign and Italian population. DESIGN: retrospective observational study. SETTING AND PARTICIPANTS: hospital discharges of 28 million people living in Lombardy, Piedmont, Emilia-Romagna (Northern Italy), Toscana and Lazio (Central Italy) occurred between 22.02.2020 and 02.07.2021 in the hospitals located in each considered Region. MAIN OUTCOME MEASURES: two weekly outcomes were examined: 1. the overall number of COVID-19 hospitalizations; 2. the number of COVID-19 hospitalizations in intensive care units. RESULTS: a higher COVID-19 overall and intensive care unit hospitalization was found among the foreign population compared to Italians. The association emerged only after the adjustment for age, and it was consistent among all Regions, though less marked in Lombardy. The association varied across epidemic phases. CONCLUSIONS: the issue of vulnerability of migrants to the risk of severe COVID-19 calls for a diversity-sensitive approach in prevention. The specific country of origin and the prevalence of preventable co-morbidities that are often underestimated in the migrant populations, and related to COVID-19 complications, should be taken into consideration in future analyses.

[Mortality and impact of COVID-19 by citizenship in seven Italian Regions from the beginning of the pandemic to mid-July 2021]. / Mortalità per COVID-19 nella popolazione immigrata in sette Regioni italiane da inizio pandemia a metà luglio 2021.

OBJECTIVES: to quantify the variability of COVID-19 mortality from the beginning of the pandemic to mid-July 2021, in relation to the immigrant status and by Region and period. DESIGN: observational incidence study. SETTING AND PARTICIPANTS: the study population consists of the residents at the beginning of 2020 in seven Regions (Piedmont, Lombardy, Veneto, Emilia-Romagna, Tuscany, Lazio, Sicily) aged <=74 years. MAIN OUTCOME MEASURES: absolute frequency of deaths occurred in subjects who tested positive for SARS-CoV-2, crude and standardized rates (standard: Italian population at the beginning of 2020), and mortality rates ratios (obtained using Poisson models), by immigrant status and stratified by gender, Region of residence, and period. The study period was divided into 5 subperiods: 22.02.2020-25.05.2020, 26.05.2020-02.10.2020, 03.10.2020-26.02.2021, 27.02.2021-16.07.2021. RESULTS: the study includes more than one half of the Italian population and most of the immigrants residing in the country, who are younger than Italians and experienced fewer COVID-19 deaths. Deaths among those who tested positive varied greatly between Regions and periods; standardized rates showed considerable increases over time among immigrants. In terms of rate ratios, there were excesses among immigrant males in the third period (MRR: 1.46; 95%CI 1.30-1.65) and in the fourth period (MRR: 1.55; 95%CI 1, 34-1.81). Among immigrant females, there is an indication of lower risk in the third period (MRR: 0.79; 95%CI 0.65-0.97) and of greater risk in the fourth period (MRR: 1. 46; 95%CI 1.21-1.77). Finally, the effect is modified by the Region of residence, both in the third and in the fourth period for males and only in the fourth period for females. CONCLUSIONS: the risk of premature mortality due to COVID-19 is linked to immigrant status and with an intensity that varies by gender, Region, and period. More accessible tools for prevention, diagnosis and early healthcare can support immigrant communities in managing the risk factors linked to the spread of infections and, in particular, counteract their evolution into more severe disease outcomes.

[The impact of the COVID-19 pandemic on the Italian and foreign population in the various phases: the results of an interregional multicentre project]. / L'impatto della pandemia di COVID-19 nella popolazione italiana e straniera residente nelle diverse fasi: i risultati di un progetto multicentrico inter-regionale.

OBJECTIVES: to analyze the difference of the SARS-CoV-2 infection impact between Italian and foreigner subjects, evaluating the trend of infections and access to diagnostic tests (molecular or antigenic swabs for the detection of SARS- CoV-2) in the two different populations, inducing the detection of new positive cases in the population. DESIGN: retrospective population study for the period February 2020-June 2021. SETTING AND PARTICIPANTS: Italian and foreign resident population on 1st January of the years 2020 and 2021 in the Regions participating to the project: Piedmont, Lombardy, Veneto, Emilia-Romagna (Northern Italy), Tuscany, Lazio (Central Italy), and Sicily (Southern Italy). MAIN OUTCOME MEASURES: in the two populations, for every week and aggregated by macropandemic period were calculated: • the test rate (people tested on the population); • the swab positivity rate (positive subjects on those who are tested); • the new positives (positive subjects on study population); • the percentage of foreigners among the new positive cases. The ratio of the value of the indicators in the foreign and Italian populations (with 95% confidence interval) was calculated to evaluate the association between nationality (Italian vs not Italian) and outcome. The analyses were conducted at the regional level and at pool level. RESULTS: the trend of new positives by nationality (Italian vs not Italian) has a similar tendency in the different pandemic waves. However, the incidence of new positives during pandemic waves among foreigners is lower than in Italians, while it tends to increase during intermediate periods. Except for the summer periods, foreigners are less tested than Italians, but the percentage of new positives out of the total of new ones tested is higher among foreigners compared to Italians. The relative weight of new positives among foreigners tends to increase in periods with the greatest risk of inflow of SARS-CoV-2 for foreigners. CONCLUSIONS: the epidemic trends in the two populations are similar, although foreigners tend to show lower incidence values, probably in part because they are tested less frequently. Furthermore, in foreigners compared to Italians, there is a greater risk of contracting SARS-CoV-2 infection, especially in periods of relaxation of containment Coronavirus measures, reopening of national borders, production and commercial activities.

Effect of diabetes on short-term mortality and incidence of first hospitalizations for cardiovascular events after recovery from SARS-CoV-2 infection.

AIM: To evaluate the impact of diabetes and COVID-19 on all-cause-mortality and first hospitalizations for cardiovascular events (CVE): myocardial infarction or stroke, within six months after being tested positive and having recovered from SARS-CoV-2 infection. METHODS: Resident population in Tuscany, Italy of age 45-94 yr without prior hospitalization for CVE, tested positive for SARS-CoV-2 by March 1st, 2020 and afterwards recovering from COVID-19 was compared with age, gender and diabetes matched controls without infection, for incidence rate ratio (IRR) of all-cause-deaths or first CVE at six months follow up. RESULTS: 46,152 subjects of whom 4,597 with diabetes, tested positive and recovered from SARS-CoV-2 were compared with 1:1 age, gender and diabetes matched controls without infection. COVID-19 was associated with higher all-cause-mortality: IRR:1.92(95 %CI:1.63-2.25) while diabetes with increased risk of first CVE hospitalizations: IRR:2.24(2.18-4.25). Co-presence of COVID-19 and diabetes didn't add any additional excess risk. Being women and statins' use significantly reduced death risk. CONCLUSIONS: After recovery from COVID-19, independently of diabetes, all-cause-mortality risk at six months was twofold increased, while risk of first CVE hospitalization remained unmodified. Diabetes, independently of prior COVID-19, resulted in higher six-months risk of first CVE not of death. Female gender and statins' use reduced both excess risks.

Trends in cardiovascular diseases burden and vascular risk factors in Italy: The Global Burden of Disease study 1990-2017.

AIMS: An exhaustive and updated estimation of cardiovascular disease burden and vascular risk factors is still lacking in European countries. This study aims to fill this gap assessing the global Italian cardiovascular disease burden and its changes from 1990 to 2017 and comparing the Italian situation with European countries. METHODS: All accessible data sources from the 2017 Global Burden of Disease study were used to estimate the cardiovascular disease prevalence, mortality and disability-adjusted life years and cardiovascular disease attributable risk factors burden in Italy from 1990 to 2017. Furthermore, we compared the cardiovascular disease burden within the 28 European Union countries. RESULTS: Since 1990, we observed a significant decrease of cardiovascular disease burden, particularly in the age-standardised prevalence (-12.7%), mortality rate (-53.8%), and disability-adjusted life years rate (-55.5%). Similar improvements were observed in the majority of European countries. However, we found an increase in all-ages prevalence of cardiovascular diseases from 5.75 m to 7.49 m Italian residents. Cardiovascular diseases still remain the first cause of death (34.8% of total mortality). More than 80% of the cardiovascular disease burden could be attributed to known modifiable risk factors such as high systolic blood pressure, dietary risks, high low density lipoprotein cholesterol, and impaired kidney function. CONCLUSIONS: Our study shows a decline in cardiovascular mortality and disability-adjusted life years, which reflects the success in reducing disability, premature death and early incidence of cardiovascular diseases. However, the burden of cardiovascular diseases is still high. An approach that includes the cooperation and coordination of all stakeholders of the Italian National Health System is required to further reduce this burden.

Chronic polytherapy after myocardial infarction: the trade-off between hospital and community-based providers in determining adherence to medication.

BACKGROUND: The benefits of chronic polytherapy in reducing readmissions and death after myocardial infarction (MI) have been clearly shown. However, real-world evidence shows poor medication adherence and large geographic variation, suggesting critical issues in access to optimal care. Our objectives were to measure adherence to polytherapy, to compare the amount of variation attributable to hospitals of discharge and to community-based providers, and to identify determinants of adherence to medications. METHODS: This is a population-based study. Data were obtained from the information systems of the Lazio and Tuscany Regions, Italy (9.5 million inhabitants). Patients hospitalized with incident MI in 2010-2014 were analyzed. The outcome measure was medication adherence, defined as a Medication Possession Ratio (MPR) ≥ 0.75 for at least 3 of the following drugs: antiplatelets, ß-blockers, ACEI/ARBs, statins. A 2-year cohort-study was performed. Cross-classified multilevel models were applied to analyze geographic variation. The variance components attributable to hospitals of discharge and community-based providers were expressed as Median Odds Ratio (MOR). RESULTS: A total of 32,962 patients were enrolled. About 63% of patients in the Lazio cohort and 59% of the Tuscan cohort were adherent to chronic polytherapy. Women and patients aged 85 years and over were most at risk of non-adherence. In both regions, adherence was higher for patients discharged from cardiology wards (Lazio: OR = 1.58, p < 0.001, Tuscany: OR = 1.59, p < 0.001) and for patients with a percutaneous coronary intervention during the index admission. Relevant variation between community-based providers was observed, though when the hospital of discharge was included as a cross-classified level, in both Lazio and Tuscany regions the variation attributable to hospitals of discharge was the only significant component (Lazio: MOR = 1.30, p = 0.001; Tuscany: MOR = 1.31, p = 0.001). CONCLUSION: Adherence to best practice treatments after MI is not consistent with clinical guidelines, and varies between patient groups as well as within and between regions. The variation attributable to providers is affected by the hospital of discharge, up to two years from the acute episode. This variation is likely to be attributable to hospital discharge processes, and could be reduced through appropriate policy levers.

Obesity as a risk factor for hospitalization in COronaVirus Disease-19 (COVID-19) patients: Analysis of the Tuscany regional database.

BACKGROUND AND AIMS: Aim of the present study is to determine the role of obesity as a risk factor for COronaVirus Disease-19 (COVID-19) hospitalization. METHODS AND RESULTS: This observational study was performed using Istituto Superiore di Sanità (ISS) Tuscany COVID-19 database by the Agenzia Regionale Sanità (ARS), including all COVID-19 cases registered until April 30th, 2020, with reported information on chronic diseases. The principal outcome was hospitalization. An age and gender-adjusted logistic regression model was used to assess the association of clinical and demographic characteristics with hospitalization. Further multivariate models were applied. Of 4481 included subjects (36.9% aged over 70 years), 1907 (42.6%) were admitted to hospital. Obesity was associated with hospitalization after adjusting for age and gender. The association of obesity with hospitalization retained statistical significance in a fully adjusted model, including possible confounders (OR: 2.99 [IC 95% 2.04-4.37]). The effect of obesity was more evident in younger (<70 years) than in older (≥70 years) subjects. CONCLUSIONS: The present data confirm that obesity is associated with an increased risk of hospitalization in patients with COVID-19. Interestingly, the association of obesity with hospitalization was greater in younger (<70 years) patients.

Prevalence and clustering of chronic diseases in Tuscany (Central Italy): evidence from a large administrative data warehouse.

BACKGROUND: chronic diseases and multimorbidity are on the rise and have a great impact on health and services. OBJECTIVES: to assess the prevalence and patterns of chronic diseases. DESIGN: cross-sectional population-based study on administrative data. SETTING AND PARTICIPANTS: the study includes 3,234,276 Tuscany (Central Italy) inhabitants aged over 15, observed as at 01.01.2019. MAIN OUTCOME MEASURES: subjects were classified as affected or not affected by one of the 17 chronic diseases considered, according to administrative data algorithms. Population prevalence was estimated overall and stratified by gender, age range, and socioeconomic level. A factor analysis was performed in order to evaluate multimorbidity. RESULTS: in Tuscany, 444.8 per 1,000 inhabitants aged over 15 have a chronic disease. The prevalence is 463.5 per 1,000 among females and 424.5 per 1,000 among males, but the two age-adjusted prevalences are equal. The prevalence of chronic patients increases with the level of socioeconomic disadvantage. The most frequent disease is hypertension (308.7 per 1,000), followed by dyslipidaemia (251 per 1,000) and diabetes (75.7 per 1,000). Inflammatory rheumatic diseases and neurological diseases are more prevalent among females than males. The prevalence identified among males almost doubles in comparison to females for all other diseases, in particular for circulatory system diseases. Chronic patients suffer from at least two pathologies in 53.2% of cases. On average, males have more diseases than females. The cardiovascular factor (circulatory system diseases and related) and the neurological factor (neurological diseases and mental disorders) emerged from the factor analysis. CONCLUSIONS: this study quantifies the burden of chronic diseases in the population, which is useful information in epidemiology, in clinical practice, and in services management.

[Chronic diseases and risk of symptomatic COVID-19: results of a case-population study on a sample of patients in the Local Health Unit 'Toscana Centro' (Tuscany Region, Central Italy)]. / Malattie croniche e rischio di ammalarsi di COVID-19 sintomatica: risultati di uno studio case-population su un campione di casi in AUSL Toscana Centro.

BACKGROUND: the COVID-19 pandemic represents a challenge for health systems around the world, with just under 10,000 cases in Tuscany Region (Central Italy) and about 4,500 in the Local Health Unit (LHU) 'Toscana Centro', updated on 11 May 2020. The risk factors reported are several, including age, being male, and some chronic diseases such as hypertension, diabetes, respiratory and cardiovascular diseases. However, the relative importance of chronic diseases is still to be explored. OBJECTIVES: to evaluate the role of chronic diseases on the risk to develop clinically evident (at least mild symptomatic) forms of SARS-CoV-2 infection in the population of the LHU Toscana Centro. DESIGN: case-population study. SETTING AND PARTICIPANTS: 'case' is a subject with SARS-CoV-2 positive swab with at least mild clinical status, who lives in the LHU Toscana Centro area; 'controls' are all people residing in the LHU Toscana Centro area at 1 January 2020. People aged under 30 and patients living in nursing care homes are excluded from the analysis. MAIN OUTCOME MEASURES: the analysis assesses the effect of gender, age, neoplasm, and the main chronic diseases on the onset of an infection with at least mild symptoms by calculating odds ratios (OR) by multivariate logistic regression models (to produce adjusted OR by potential confounders). RESULTS: among the 1,840 cases, compared to the general population, the presence of males and over-60-year-old people is greater. Almost all the considered chronic diseases are more frequent among the cases, compared to the general population. A chronic patient has a 68% greater risk to be positive with at least mild symptoms. Many of the considered diseases show an effect on the risk of getting COVID-19 in a symptomatic form, which remains even adjusting by other comorbidities. The main ones include heart failure, psychiatric disorders, Parkinson's disease, and rheumatic diseases. CONCLUSIONS: these results confirm evidence already shown in other studies on COVID-19 patients and add information on the chronic diseases attributable risk in the population, referred to the symptomatic forms and adjusted by age, gender or the possible copresence of more diseases. These risk estimates should guide prevention interventions by health services in order to protect the chronic patients affected by the pathologies most at risk.

Chronic Care Model for the Management of Patients with Heart Failure in Primary Care.

We recently investigated the prognostic impact of a Chronic Care Model (CCM)-based healthcare program applied in primary care in Tuscany Region mainly run by multidisciplinary teams composed of general practitioners (GPs) and nurses. The project included proactively planned follow-up visits for each patient, individualized counselling to optimize lifestyle modifications and adherence to appropriate diagnostic and therapeutic pathways. 1761 patients with Chronic heart failure (CHF) directly enrolled by the GPs were matched with 3522 CHF controls not involved in the project. Over a 4-year follow-up in the CCM group a higher CHF hospitalization rate was found (12.1 vs 10.3 events/100 patient-years; incidence rate ratio [IRR] 1.15, p=0.0030), whereas mortality was lower (10.8 vs 12.6 events/100 patient-years; IRR 0.82, p<0.0001). The CCM status was independently associated with a 34% increase in the risk of CHF hospitalization and a 18% reduction in the risk of death (p<0.0001 for both). The CCM status was associated with a 50% increase in the rate of planned Heart failure (HF) hospitalizations whereas the rate of 1-month CHF readmissions showed no differences. Such a divergent trend could be explained by the direct involvement of GPs in the CCM program, leading them to a better awareness of patients' clinical status, and then to a more frequent use of clinical pathways and facilities, including hospitalization. It is reasonable to argue that not all hospitalizations must necessarily be considered as a poor outcome, as they often provide additional opportunities to improve therapies, optimize patient education, or define follow-up strategies. The evidence of a divergent trend between mortality and hospitalization in our population might support the clinical importance of a multidisciplinary approach for the management of patients with HF.

Factors Associated With Hospitalization Before the Start of Long-Term Care Among Elderly Disabled People.

The growing number of elderly people with functional limitations, cognitive impairment, and disability is an organizational challenge for the health care sector. This study investigated the factors associated with hospitalization in the period between evaluation and the start of a long-term care (LTC) program for patients on the waiting list. A population-based historical cohort study was performed using data extracted from different administrative databases. The cohort included disabled individuals 65 years and older who were evaluated for entrance into an LTC program between January 1, 2012, and December 31, 2013, in Tuscany, Italy. The sample consisted of 11,429 subjects. The characteristics positively associated with hospital admission were residence zone {urban incidence rate ratio (IRR) = 0.83 (95% confidence interval [CI] 0.74-0.94)}, number of prescribed drugs IRR = 1.01 (95% CI 1.00-1.02), a Charlson Comorbidity Index of 2 IRR = 1.44 (95% CI 1.26-1.64), and lower social conditions IRR = 0.99 (95% CI 0.98-1.00). The rate of hospitalization for patients with heart failure, chronic obstructive pulmonary disease, and dementia was higher than for patients without these diseases. Our results indicate that it may be possible to predict factors that can lead to hospitalization before the start of an LTC program.