[How to optimize Audit&Feedback: experience from the EASY-NET programme]. / Come rendere più efficace l'Audit&Feedback: riflessioni dal programma di rete EASY-NET.

This is the second of a series of papers dedicated to the EASY-NET research programme (NET-2016-02364191). The rationale, structure and methodologies are described in the previous contribution. Scientific literature demonstrated that Audit & Feedback (A&F) is an effective strategy for continuous quality improvement and its effectiveness varies considerably according to factors that are currently little known. Some recent publication pointed out, with the contribution of an international group of experts, 15 suggestions to optimize A&F and developed a tool to evaluate their application. This tool, called REFLECT-52, includes 52 items related to the 15 suggestions and organized into four categories relating to the "Nature of the desired action", to the "Nature of the data available for feedback", to the "Feedback Display" and to the "Intervention delivery". Then, the aim of this work was to evaluate the level of adherence of A&F interventions tested in EASY-NET to suggestions from the literature by using a slightly adapted version of the REFLECT-52 tool, in its original language. In EASY-NET, 14 A&F interventions with different characteristics and in different clinical and organizational contexts were tested in seven Italian regions, each of these was evaluated by the respective research groups. Overall, the level of adherence was high in three of the four categories analysed, with some difficulties reported regarding the nature of the data available for feedback. In fact, contrary to what the literature suggests, it was not possible to send repeated feedback for some interventions and, in some cases, the data available for feedback presented a delay longer than one year. In summary, this analysis has confirmed a high level of compliance of the interventions tested with the suggestions from the literature, but it has also allowed researchers to identify critical aspects that need to be addressed for the future development of these strategies.

[Mortality inequalities in Rome: the role of individual education and neighbourhood real estate market]. / Differenziali di mortalità a Roma: il ruolo dell'istruzione e dei prezzi immobiliari del quartiere di residenza.

OBJECTIVES: to investigate the association between real estate prices, education, and mortality. DESIGN: cohort study. SETTING AND PARTICIPANTS: residents in Rome at the 2011 Italian Census, not living in institutions, and living in the address reported in the Census survey. People aged 18-99 years were followed from 2011 to 2016 using anonymous record linkage procedures with administrative databases. The Census includes several individual information, such as gender, age, education, residential neighbourhood. Data and cause of death were collected from mortality register. Real estate prices (euros/m2) were available for each neighbourhood. MAIN OUTCOME MEASURES: adjusted Cox regression models (hazard ratios - HRs and 95%CIs) were used to estimate the association among individual education, real estate price in the neighbourhood, and mortality. RESULTS: the subjects selected were 2,051,376 (54% women, 22.5% with high education level). During the follow-up, 127,352 subjects died. Taking into account gender, age, marital status, and real estate prices, education level was strongly associated with all-cause mortality; compared to highly educated the higher mortality, risk was 35% (95%CI 32%-37%) for low education level and 16% (95%CI 14%-19%) for medium education level. Taking into account the same factors and education level, each increase of 1,000 euros in price/m2 was inversely associated with mortality (HR 0.96, 95%CI 0.96-0.97). CONCLUSIONS: there is an independent association between the two indicators and mortality in Rome. A simple indicator such as real estate prices can be used to tackle inequalities.

[Urban health and inequalities in highly socially marginalised settings in Rome]. / Salute urbana e disuguaglianze a Roma in contesti a elevata marginalità sociale.

OBJECTIVES: to describe hospitalisation, access to emergency care, and mortality of people living in marginalized urban areas which include public housing buildings in the North-West suburb of Rome, and to compare the results with those observed among people living in the neighbouring area. DESIGN: cross sectional study. SETTING AND PARTICIPANTS: resident population in the XIII and XIV Municipality of Rome, subdivided into five urban areas, in 2011-2018. MAIN OUTCOME MEASURES: hospitalisation, access to emergency care, and mortality rates and rates ratios based on hospital discharges and emergency department visits derived from the Health Information Systems and from the Mortality Registry of Lazio Region (Central Italy), stratified by urban areas. RESULTS: the results show a higher use of hospital assistance and emergency care services as well a higher mortality among residents of urban areas characterized by marginalization and social disadvantage in the North-West suburb in Rome, compared to the surrounding area. The association is stronger for the residents of ex-Bastogi, a compound particularly marginalised and socially disadvantaged, where excesses in hospitalisation, emergency care admission, and mortality of +60%, +150%, and +140%, respectively, occurred. CONCLUSIONS: the excesses of hospital use, emergency care visits, and mortality observed among the residents of marginalized urban areas suggest the need to reorganize the preventive and primary care services considering the socioeconomic disadvantage in such housing contexts. The use of both qualitative and quantitative approaches allows to understand the complexity of such contexts.

[Covid-19 and clinical-epidemiological research in Italy: proposal of a research agenda on priority topics by the Italian association of epidemiology]. / Covid-19 e ricerca clinico-epidemiologica in Italia: proposta di un'agenda di ricerca su temi prioritari da parte dell'Associazione italiana di epidemiologia.

BACKGROUND: the Covid-19 pandemic has provoked a huge of clinical and epidemiological research initiatives, especially in the most involved countries. However, this very large effort was characterized by several methodological weaknesses, both in the field of discovering effective treatments (with too many small and uncontrolled trials) and in the field of identifying preventable risks and prognostic factors (with too few large, representative and well-designed cohorts or case-control studies). OBJECTIVES: in response to the fragmented and uncoordinated research production on Covid-19, the   italian Association of Epidemiology (AIE) stimulated the formation of a working group (WG) with the aims of identifying the most important gaps in knowledge and to propose a structured research agenda of clinical and epidemiological studies considered at high priority on Covid-19, including recommendations on the preferable methodology. METHODS: the WG was composed by 25 subjects, mainly epidemiologists, statisticians, and other experts in specific fields, who have voluntarily agreed to the proposal. The agreement on a list of main research questions and on the structure of the specific documents to be produced were defined through few meetings and cycles of document exchanges. RESULTS: twelve main research questions on Covid-19 were identified, covering aetiology, prognosis, interventions, follow-up and impact on general and specific populations (children, pregnant women). For each of them, a two-page form was developed, structured in: background, main topics, methods (with recommendations on preferred study design and warnings for bias prevention) and an essential bibliography. CONCLUSIONS: this research agenda represents an initial contribution to direct clinical and epidemiological research efforts on high priority topics with a focus on methodological aspects. Further development and refinements of this agenda by Public Health Authorities are encouraged.

Estimating dementia cases in the immigrant population living in Italy.

INTRODUCTION: The phenomenon of dementia among immigrants and ethnic minorities represents an emerging challenge for Western countries. The aim of the present study was to estimate the number of dementia cases among immigrant subjects residing in Italy and in each Italian region to provide pivotal information on the magnitude of such public health issue. METHOD: The number of immigrant individuals, aged 65 years or older, living in Italy and in the 20 Italian regions was derived by the 2017 data of the National Institute for Statistics. The dementia prevalence rates were taken from the European data provided by the Neurologic Diseases in the Elderly Research Group. The estimated dementia cases were calculated by multiplying the number of immigrants with the age- and sex-specific prevalence rates. RESULTS:  Overall, 186,373 older immigrant subjects lived in Italy in January 2017. Nearly 7700 dementia cases were estimated in this population (5022 among women, 2725 among men). When considering each specific Italian region, the number of estimated cases ranged from 19 (Basilicata) to 1500 (Lombardia) with a marked inter-regional variability. DISCUSSION: Our findings indicate that the occurrence of dementia among immigrants and ethnic minorities constitutes a novel but already relevant issue for our healthcare systems. A non-negligible number of immigrant individuals is probably already seeking or might seek help for cognitive disturbances, thus potentially referring to general practitioners and/or to the Italian dementia services. The forecasted increasing magnitude of this phenomenon reinforces the need for tailored and locally oriented initiatives and policies.

Respiratory symptoms/diseases and environmental tobacco smoke (ETS) in never smoker Italian women.

AIM: To study the relationship between respiratory/allergic disorders and chronic environmental tobacco smoke (ETS) exposure to husband or at workplace among non-smoking women of a general population in Italy. METHODS: Analyses regard 2195 married or employed women. Information was collected through a self-administered questionnaire. ETS exposure was validated by salivary cotinine. RESULTS: Exposure both to husband and at work resulted a significant risk factor for current dyspnoea (odds ratio (OR) 1.61, 95% confidence interval (CI) 1.20-2.16), any shortness of breath at rest (OR 2.81, 95% CI 1.83-4.30), recent wheeze (OR 1.71, 95% CI 1.04-2.82), recent attacks of shortness of breath with wheeze (OR 1.85, 95% CI 1.05-3.26), asthma diagnosis/symptoms (OR 1.50, 95% CI 1.09-2.08), diagnosis of asthma or bronchitis/emphysema (obstructive lung diseases (OLD)) (OR 2.24, 95% CI 1.40-3.58), current cough/phlegm (OR 1.52, 95% CI 1.07-2.15), and rhino-conjunctivitis (OR 1.48, 95% CI 1.13-1.94). Exposure only at work yielded higher adjusted odds ratios for all health conditions, except for rhino-conjunctivitis. Overall, about 24% of shortness of breath at rest, 16% of dyspnoea, 17% of rhino-conjunctivitis, 12% of OLD, and 10% of asthma diagnosis/symptoms are attributable to the effect of exposures to both husband and at work. Twelve percent of shortness of breath at rest and 10% of rhino-conjunctivitis cases might be avoided by eliminating exposure only at work and only to husband, respectively. CONCLUSIONS: Lifetime ETS exposure, especially at work, is associated with respiratory symptoms/diseases, and it accounts for a sizeable proportion of such disorders. The combined effect of both exposures is higher than the separate effects.

[Respiratory and allergic disorders in children: differences in socio-economic status]. / Differenze sociali nella frequenza di disturbi respiratori e allergici nell'infanzia.

The association between socio-economic status (SES) and respiratory and allergic disorders is controversial, and conflicting results are reported in literature. We examined this association using as indicators of SES parental education and occupation. Persistent cough resulted inversely associated with SES, while current wheezing and atopic dermatitis were directly associated with SES. The role of SES on frequency of respiratory and allergic conditions in Italy needs to be further investigated, although our results confirm a higher frequency of allergic dermatitis and a lower frequency of persistent cough in more advantaged families.

Epidemiology of idiopathic pulmonary fibrosis in Europe--an update.

Idiopathic pulmonary fibrosis (IPF) is a non-neoplastic pulmonary disease that is characterised by the formation of scar tissue within the lungs in the absence of any known cause. IPF is the most common of the idiopathic interstitial pneumonias and is an important cause of respiratory mortality. IPF is a relatively rare disease with an estimated prevalence ranging from two to 29 cases per 100,000 and slightly higher in men (20.2/100,000) than in women (13.2/100,000). The mean age at presentation is 66 years. Little recent epidemiological data on the prevalence, incidence, risk factors, and mortality related to the disease are available or are limited by methodological weaknesses. Outstanding questions remain, including the causes of IPF, why the incidence is on the rise, and how best to manage this disease. New comparable epidemiological data on IPF are needed.

Walking four times weekly for at least 15 min is associated with longevity in a cohort of very elderly people.

OBJECTIVES: This study investigated the role of walking outdoors on longevity, controlling for individual and other life-style factors as possible confounders. METHODS: A 10-year cohort study was conducted with 152 self-caring and mobile, mean age 80 years, were enrolled in the study. Information on socio-demographic characteristics, clinical and biochemical data, diet, physical activity, smoking, depression status, cognitive status and anthropometrics measurements, were obtained for all participants. Cox proportional-hazards models were used to determine independent predictors of longevity. RESULTS: During the 10-years of follow-up, 96 (63%) died. Old age, chronic diseases, smoking, depression, CD4/CD8 ratio and coffee consumption were significantly predictors of mortality. Over-all survival was highest for subjects walking at open air for 4 times weekly for at least 15 min in comparison to subjects walking less than 4 times weekly (40% versus 22%). After adjusting for sex, age, education, chronic diseases, smoking, Body Mass Index and CD4/CD8 ratio, elderly people walking at open air for four times weekly had 40% decreased risk of mortality that individuals who walked less than four times weekly [relative risk (RR)=0.53; 95% confidence interval (CI)=0.32-0.88, p=0.01]. CONCLUSIONS: Findings suggest an independent and protective effect of walking on mortality and supports the encouragement of physical activity in advanced age for increasing longevity.

Socioeconomic status, particulate air pollution, and daily mortality: differential exposure or differential susceptibility.

BACKGROUND: Short-term increases in particulate air pollution are linked with increased daily mortality and morbidity. Socioeconomic status (SES) is a determinant of overall health. We investigated whether social class is an effect modifier of the PM(10) (particulate matter with diameter <10 micron)-daily mortality association, and possible mechanisms for this effect modification. METHODS: Area-based traffic emissions, income, and SES were available for each resident in Rome. All natural deaths (83,253 subjects) occurring in Rome among city residents (aged 35+ years) during the period 1998-2001 were identified. For each deceased individual, all the previous hospitalizations within 2 years before death were available via a record linkage procedure. PM(10) daily data were available from two urban monitoring sites. A case-crossover analysis was utilized in which control days were selected according to the time stratified approach (same day of the week during the same month). Conditional logistic regression was used. RESULTS: Due to the social class distribution in the city, exposure to traffic emissions was higher among those with higher area-based income and SES. Meanwhile, people of lower social class had suffered to a larger extent from chronic diseases before death than more affluent residents, especially diabetes mellitus, hypertension, heart failure, and chronic obstructive pulmonary diseases. Overall, PM(10) (lag 0-1) was strongly associated with mortality (1.1% increase, 95%CI = 0.7-1.6%, per 10 microg/m(3)). The effect was more pronounced among persons with lower income and SES (1.9% and 1.4% per 10 microg/m(3), respectively) compared to those in the upper income and SES levels (0.0% and 0.1%, respectively). CONCLUSIONS: The results confirm previous suggestions of a stronger effect of particulate air pollution among people in low social class. Given the uneven geographical distributions of social deprivation and traffic emissions in Rome, the most likely explanation is a differential burden of chronic health conditions conferring a greater susceptibility to less advantaged people.

Plasma, salivary and urinary cotinine in non-smoker Italian women exposed and unexposed to environmental tobacco smoking (SEASD study).

BACKGROUND: The aim of this study was to compare cotinine determinations in three biological fluids for assessing environmental tobacco smoke (ETS) exposure in female non-smokers (n=1605) in Italy. METHODS: Information about ETS exposure at home, in the workplace, and in other places within the previous week was collected via questionnaire. Plasma, salivary and urinary cotinine levels were measured. Cotinine levels of > or =0.1 ng/mL for plasma, > or =0.2 ng/mL for saliva, and > or =0.5 ng/mL for urine were used to determine biochemical exposure. RESULTS: Median cotinine levels were significantly higher in exposed than in unexposed women (0.21 vs. 0.05 ng/mL in plasma, 0.80 vs. 0.41 ng/mL in saliva, and 9.74 vs. 5.30 ng/mL in urine). Self-reported ETS exposure was significantly related to biochemical exposure [odds ratio 2.99, (95% CI 2.40-3.72) for plasma; 1.90 (1.51-2.39) for saliva; and 2.67 (2.14-3.34) for urine]. Cotinine significantly increased with increasing exposure level, regardless of the exposure source. Among self-reported exposed subjects, higher percentages of cotinine level above the cut-off, i.e., indicating exposure, were found in saliva (76%) and urine (75%) than in plasma (52%). CONCLUSIONS: In general, women correctly reported their ETS exposure status. Both non-invasive salivary and urinary cotinine determinations seem preferable in epidemiological studies, in view of their higher sensitivity, when compared to plasma cotinine.