Coverage of HPV vaccination programme in Friuli Venezia Giulia Region (Northern Italy).

OBJECTIVES: to assess the completeness and timeliness of Human papillomavirus (HPV) vaccination programme in Friuli Venezia Giulia (FVG) Region (Northern Italy), notably by monitoring 2-dose coverage among girls before they turn 15 years old (referred to as "at 15") in each year between 2009 and 2018 and making a preliminary evaluation of coverage among boys at 13 years in 2016-2018. DESIGN: retrospective study. SETTING AND PARTICIPANTS: for each vaccine recipient, demographic information and history of HPV vaccine uptake from the digital FVG Vaccination Registry updated as of 31.12.2018 were extracted. Numerator data comprised all doses allocated to FVG residents. Age-specific denominators were derived from the FVG census in each examined year. Coverage estimates for the year 2018 were also provided by number of doses. MAIN OUTCOME MEASURES: coverage for a full course of HPV vaccine, defined as 2 doses in girls and boys younger than age 15 years but 3 doses in less young women. RESULTS: In FVG 52,217 females had received >=1 dose since 2008 and 12,152 males since 2015. >=2-dose coverage in girls at 15 increased from 42% in 2009 to 76% in 2015 and slightly declined afterwards (69% in 2018). In 2008, 3-dose coverage was 65%, 74%, and 59% in females aged 16-17, 18-19, and 20-26 years, respectively. In the same year, 2-dose coverage in boys at 13 years was 54%, similar to the coverage in girls at 13 years (57%). CONCLUSIONS: this paper shows the achievements of routine and catch-up HPV vaccination in FVG. While coverage in girls at 15 years of age peaked in 2015 and slightly diminished in subsequent years, the coverage in boys at 13 in 2018 had already approached the coverage in same-age girls (57%). On account of the signs of weakening in girls' coverage, campaigns in support to HPV vaccination must be repeated, especially in favour of the most cost-effective group, i.e., girls before 15 years of age. The heavy burden posed by the COVID-19 emergency on other prevention-related activities makes a better targeted use of HPV vaccination even more necessary.

[Early effects of attendance to the Friuli Venezia Giulia (Northern Italy) mammography screening programme on the incidence of advanced-stage breast cancer: a cohort study]. / Effetti precoci dell'adesione al programma di screening mammografico della Regione Friuli Venezia Giulia sull'incidenza del cancro della mammella in stadio avanzato: uno studio di coorte.

OBJECTIVES: to evaluate the incidence of advanced-stage breast cancer (BC) - an early surrogate indicator of effectiveness of mammography screening - among women who attended the Friuli Venezia Giulia (FVG) Region (Northern Italy) screening programme compared to women who did not attend. DESIGN: retrospective cohort study. Women invited to the first screening round (2006-2007) were identified from the database of the programme. The cohort was record-linked to the archive of women invited to the second round (2008-2009). The definition of attendance to screening was based on attendance to at least one of the two rounds. The incidence of BC was assessed through record linkage with the FVG cancer registry using an anonymous univocal identifier (end of follow-up: 31st December 2013). Three distinct definitions of advanced stage were used: pT2 or greater (pT2+), positive lymph nodes (pN+), and TNM stage II or greater (stage II+). SETTING AND PARTICIPANTS: organized mammography screening programme for women aged 50-69 years in the five regional healthcare districts. MAIN OUTCOME MEASURES: incidence rate ratio (IRR) between attenders and non-attenders, adjusted for age and deprivation index, with 95% confidence interval (95%CI). RESULTS: the cohort included 104,488 attenders and 49,839 non-attenders. During follow-up (median duration 84 months), 2,717 invasive BCs were diagnosed among attenders and 1,149 among non-attenders. Total incidence rate was 13% higher among attenders (IRR 1.13; 95%CI 1.05-1.21). These, conversely, had a 36% lower rate of pT2+ BC (IRR 0.64; 95%CI 0.56-0.72), a 13% lower rate of pN+ BC (IRR 0.87; 95%CI 0.78-0.98), a 22% lower rate of stage II+ BC (IRR 0.78; 95%CI 0.70-0.87), and a 32% lower rate of mastectomy (IRR 0.68; 95%CI 0.60-0.78). CONCLUSIONS: attenders had lower incidence rates of advanced-stage BC. This early effect is suggestive of a future impact of the screening programme on BC mortality.

Changes in cervical cancer incidence following the introduction of organized screening in Italy.

OBJECTIVE: To quantify the impact of organized cervical screening programs (OCSPs) on the incidence of invasive cervical cancer (ICC), comparing rates before and after activation of OCSPs. METHODS: This population-based investigation, using individual data from cancer registries and OCSPs, included 3557 women diagnosed with ICC at age 25-74years in 1995-2008. The year of full-activation of each OCSP was defined as the year when at least 40% of target women had been invited. Incidence rate ratios (IRRs) with 95% confidence intervals (95% CIs) were calculated as the ratios between age-standardized incidence rates observed in periods after full-activation of OCSPs vs those observed in the preceding quinquennium. RESULTS: ICC incidence rates diminished with time since OCSPs full-activation: after 6-8years, the IRR was 0.75 (95% CI: 0.67-0.85). The reduction was higher for stages IB-IV (IRR=0.68, 95% CI: 0.58-0.80), squamous cell ICCs (IRR=0.74, 95% CI: 0.64-0.84), and particularly evident among women aged 45-74years. Conversely, incidence rates of micro-invasive (stage IA) ICCs increased, though not significantly, among women aged 25-44years (IRR=1.34, 95% CI: 0.91-1.96). Following full-activation of OCSPs, micro-invasive ICCs were mainly and increasingly diagnosed within OCSPs (up to 72%). CONCLUSION(S): Within few years from activation, organized screening positively impacted the already low ICC incidence in Italy and favored down-staging.

Screening patterns within organized programs and survival of Italian women with invasive cervical cancer.

OBJECTIVES: To evaluate screening patterns within organized cervical screening programs (OCSPs) and survival of women with invasive cervical cancer (ICC). METHODS: A population-based study was conducted in Italian areas covered by cancer registries and OCSPs. The study included all women aged 25-65 years diagnosed with ICC between 1995 and 2008, and their screening histories within OCSPs were retrieved. Hazard ratios (HR) of death and 95% confidence intervals (CI) were computed according to screening pattern, using Cox models adjusted for age, ICC stage, and major confounders. RESULTS: Among 3268 women with ICC, 20% were never-invited to OCSP, 36% were never-compliant with OCSP's invitation, 33% were compliant and had a screen-detected ICC within OCSP (i.e., after a positive cytology), and 11% were compliant but had a non-screen-detected ICC. Screen-detected ICCs were more frequently micro-invasive (42%) compared to non-screen-detected ones (14%). Compared to women with screen-detected ICC, the adjusted HRs of death were 1.9 (95% CI 1.5-2.4) for those never-invited, 2.0 (95% CI 1.6-2.5) for never-compliant, and 1.7 (95% CI 1.3-2.4) for compliant women having non-screen-detected ICC. CONCLUSION: Prolonged survival, beyond down-staging, of women with ICC detected within OCSPs in Italy, further calls for improvements of OCSPs' invitational coverage and participation.

Early and late mortality in elderly patients after hip fracture: a cohort study using administrative health databases in the Lazio region, Italy.

BACKGROUND: Hip fractures represent one of the most important causes of morbidity and mortality in elderly people. We evaluated the risk and the potential determinants of early, mid and long term mortality, in a population-based cohort of subjects aged ≥ 65 years old. METHODS: Using hospital discharge database we identified all hospitalized hip fracture cases of 2006, among residents in Lazio Region aged ≥ 65 years old. The mortality follow-up was performed through a deterministic record-linkage between the cohort and the death registry for the years 2006 and 2007. Kaplan-Meier method was used to calculate cumulative survival probability after admission. Shared frailties Cox regression model was used to estimate adjusted hazard ratios (HRs) for early (within 1 month), mid (1-6 months) and long term (6-24 months) mortality. As possible cofactors we considered age, gender, marital status, education degree, comorbidities, surgical intervention, and hospital volume of surgical treatment for hip fracture. RESULTS: We identified 6,896 patients; 78% were females, median age was 83 and 9% had two or more comorbidities. Five percent died during hospital stay; the cumulative probability of dying at 30, 180 days, and at 2 years was 7%, 18% and 30%. In the first month following admission, we found a significantly increased HR with older age, male sex, not married status, history of hearth disease, chronic pulmonary and renal disease; for those who had surgery there was a significantly increased HR within two days after surgical intervention and a significantly decreased HR thereafter compared to those who received a conservative management. Between 1 and 6 months significantly increased HRs were for older age, male sex and higher hospital volume of surgical treatment. After six months, significantly increased HRs were for older age, male sex, presence of dementia and other low prevalence diseases. CONCLUSION: In Lazio region the risk of dying after hip fracture is similar to that found in high-income countries. Both clinical and organizational factors of acute care are associated with the risk of early mortality. As time passes, some of these factors tend to become less important while older age, male gender, the presence of cognitive problems and the presence of other comorbidities remain significant.

The influence of patients' complexity and general practitioners' characteristics on referrals to outpatient health services in an Italian region.

BACKGROUND: Patient referrals to outpatient health services may affect both health outcomes and health expenditures. General practitioners (GP) have a crucial role in driving the use of outpatient services and recognizing factors which affect referrals is important for health managers and planners. OBJECTIVES: We investigated patient- and physician-related determinants of patient referrals in an Italian region. METHODS: This was cross-sectional study based on the individual linkage of administrative databases from the health information system of the Friuli Venezia Giulia region. For each GP of the region, the association of the number of patient referrals to different types of outpatient services with the proportion of patients with chronic conditions, with the number of hospital admissions and drug prescriptions in 2012, and with GP's characteristics was investigated through multilevel multivariable Poisson regression models. RESULTS: Some chronic conditions (e.g., cancer, autoimmune diseases, endocrine diseases, digestive system diseases) were positively associated with the number of referrals, as were hospital admissions and drug prescriptions. Time since GP's graduation was inversely related with referrals. CONCLUSION: Patient complexity and GP's experience affect referral rates. These factors should be considered in case of a reorganization of the general practice structure in Friuli Venezia Giulia.

[The effects of implementation of heart failure guidelines in the Pordenone province: analysis of the results following databases of the regional health guide system]. / Gli effetti dell'implementazione delle linee guida sullo scompenso cardiaco nella provincia di pordenone: valutazione dei risultati mediante utilizzo delle banche dati del sistema informativo sanitario regionale.

BACKGROUND: The aim of this study was to evaluate the effects of heart failure guideline implementation in the Pordenone province area, by using the regional health system databases. METHODS: We created the provincial registry of hospitalization for heart failure and we defined a set of indicators to assess the adequate use of the hospital facility, the correct use of diagnostic instruments, the appropriate use of medications, the in-hospital, 6-month and 1-year mortality rates. RESULTS: Up to December 31, 2002, 2977 subjects, living in the Pordenone province area, were hospitalized for heart failure (10.4 for 1000 inhabitants). Repeated hospitalizations in the years have percentage values oscillating at around 20%. The average length of hospitalization appeared declining, ranging from 11.1 days in 2000 to 10.3 days in 2002. The in-hospital death rate varied between 16-17%. The cumulative death rate within 6 months (33.2%) and 1 year (41.0%) of hospitalization resulted rather high, also considering the patients' advanced mean age (79 years). The percentage of patients who underwent an echocardiogram as outpatients in the previous year increased from 5.7% in 2000 to 13.1% in 2002. As for therapy, an increase in the percentage of patients treated with ACE-inhibitors (from 44.6 to 50.2%), sartans (from 8.2 to 11.7%), beta-blockers (from 11.7 to 16.7%) and diuretics (from 66.4 to 68.5%) was evident from 2000 to 2001. A mild reduction in the percentage of patients treated with digitalis (from 35.0 to 33.8%) and with calcium antagonists (from 22.4 to 20.9%) was also noted. CONCLUSIONS: The results of this study show that it is possible to use some indicators in evaluating the effects of guideline implementation in heart failure, by using the regional health system data. The final goal is to gradually involve all the professionals in the different phases of the natural course of heart failure patients, particularly the general practitioners.

Screening history of women with invasive cervical cancer in north-east Italy.

OBJECTIVES: To describe screening histories of women with invasive cervical cancer (ICC) in Friuli Venezia Giulia, after the introduction of organized screening, in order to identify possible reasons undermining prevention of ICC. To investigate associations between screening histories in relation to women's survival and tumor characteristics, with a focus on organized and opportunistic screenings. STUDY DESIGN: 438 women, diagnosed with ICC between 1999 and 2005, were identified using the regional Cancer Registry. Cytological and histopathological information were obtained through regional health databases. Associations between different screening histories and characteristics of women and their tumors were evaluated by means of odds ratios (OR) and corresponding 95% confidence intervals (CI), through multinomial logistic regression models adjusted for age; death risks were estimated by computing hazard ratios (HR) with 95% CI, using Cox models adjusted for age, tumor stage, and histology. RESULTS: 165 (38%) women with ICC had no Pap smears: 71 (16%) never attended the organized screening despite invitation; 69 (16%) were never invited because they were above 64 years of age; and 25 (6%) were yet to be invited. Conversely, 273 (62%) women underwent screening: 141 women (32%) had opportunistic screening; 132 (30%) women attended the organized program. A total of 193 (44%) women had ICC detected at screening. Compared to women with ICC who had never been screened, those screened within the organized program were more often at stage IA (46%), were seldom at stage II or higher (OR=0.3, 95% CI: 0.1-0.6, vs. IB), and showed a lower risk of death (HR=0.6, 95% CI: 0.3-1.0). CONCLUSIONS: In Friuli Venezia Giulia, the lack of screening among older women and of compliance with organized programs among women in the target population are the main limitations in cervical cancer secondary prevention. Our findings indicate that participation in organized screening has a beneficial effect in terms of down-staging and improved survival as compared to both absence of screening and opportunistic screening.

Risk factors correlated with post-operative mortality for hip fracture surgery in the elderly: a population-based approach.

OBJECTIVES: To estimate the effect of waiting time for surgery and volume of surgical activity on mortality in patients with hip fracture and to compare risk-adjusted outcomes between hospitals providing surgery for such patients. DESIGN: Retrospective cohort study. SETTING: Friuli Venezia Giulia, Italy. PARTICIPANTS: A total of 6,629 elderly people who underwent surgery for hip fracture between 1st January 1996 and 31th December 2000. MAIN OUTCOME MEASURES: In-hospital, 6-month and 1-year mortality rate. RESULTS: In-hospital mortality rate was 5.4%. At six months, the mortality rate was 20.0%, and at 1 year 25.3%. Age, male sex, and comorbidity were significant predictors of mortality. Logistic regression analysis indicated that, after controlling for main patients risk factors and taking into account the hospital level variability, there was no significant association between increase in mortality rate and more than 1 day of waiting time for surgery (OR 0.90; 95% CI 0.58-1.40 for in-hospital mortality). One hospital had a significantly higher mortality rate than the others; high hospital volume for hip fracture surgery was associated with worse outcomes (OR 1.57; 95% CI 1.38-1.78 for in-hospital mortality). Mortality after hip fracture decreased significantly from 1996 to 2000 (OR 0.85; 95% CI 0.80-0.90). CONCLUSIONS: Longer waiting time for surgery was not associated with mortality after adjusting for patient risk factors, and taking into account hospital level variability. Hospital level variability was statistically significant, and was partially explained by the total volume of hospital surgical activity. The decrease in mortality between 1996 and 2000 was confirmed by multivariate models.