Strategies for delivery of faecal occult blood test kits and participation to colorectal cancer screening in the Emilia-Romagna Region of Italy.

There is a lack of agreement about which routine invitation strategy should be adopted in colorectal cancer screening. We conducted an observational study to assess the impact of three invitation strategies on participation. Invitation records for the years 2005-2009 were evaluated. There were 2,234,276 invitations from 1,230,683 individuals. Among first invitations, participation associated with direct mailing of the faecal occult blood test kits was slightly lower (relative risk, RR 0.985; 95% confidence interval 0.979-0.990) than that of the reference invitation strategy, that is, the distribution of the test kits by pharmacies. In repeated invitations/previous non-responders, the participation associated with the direct mailing of the test kits was even lower (RR 0.914; 95% confidence interval 0.895-0.933) and this was also the case for the distribution of the test kits by primary care centres (RR 0.983; 95% confidence interval 0.971-0.995). In contrast, in repeated invitations/previous responders, the impact of primary care centres and direct mailing of the test kits was greater than the use of pharmacies, showing only modest RRs: 1.021 (95% confidence interval 1.019-1.023) and 1.029 (95% confidence interval 1.025-1.033) respectively. The faecal occult blood test mailing strategy modestly increased participation in previous responders.

A comparison between self-reported and GIS-based proxies of residential exposure to environmental pollution in a case-control study on lung cancer.

In epidemiological studies both questionnaire results and GIS modeling have been used to assess exposure to environmental risk factors. Nevertheless, few studies have used both these techniques to evaluate the degree of agreement between different exposure assessment methodologies. As part of a case-control study on lung cancer, we present a comparison between self-reported and GIS-derived proxies of residential exposure to environmental pollution. 649 subjects were asked to fill out a questionnaire and give information about residential history and perceived exposure. Using GIS, for each residence we evaluated land use patterns, proximity to major roads and exposure to industrial pollution. We then compared the GIS exposure-index values among groups created on the basis of questionnaire responses. Our results showed a relatively high agreement between the two methods. Although none of these methods is the "exposure gold standard", understanding similarities, weaknesses and strengths of each method is essential to strengthen epidemiological evidence.

The Italian register of cardiovascular diseases: attack rates and case fatality for cerebrovascular events.

BACKGROUND: The Italian register of cardiovascular diseases is a surveillance system of fatal and nonfatal cardiovascular events in the general population aged 35-74 years. It was launched in Italy at the end of the 1990 s with the aim of estimating periodically the occurrence and case fatality rate of coronary and cerebrovascular events in the different geographical areas of the country. This paper presents data for cerebrovascular events. METHODS: Current events were assessed through record linkage between two sources of information: death certificates and hospital discharge diagnosis records. Events were identified through the ICD codes and duration. To calculate the number of estimated events, current events were multiplied by the positive predictive value of each specific mortality or discharge code derived from the validation of a sample of suspected events. Attack rates were calculated by dividing estimated events by resident population, and case fatality rate at 28 days was determined from the ratio of estimated fatal to total events. RESULTS: Attack rates were found to be higher in men than in women: mean age-standardized attack rate was 21.9/10,000 in men and 12.5/10,000 in women; age-standardized 28-day case fatality rate was higher in women (17.1%) than in men (14.5%). Significant geographical differences were found in attack rates of both men and women. Case fatality was significantly heterogeneous in both men and women. CONCLUSIONS: Differences still exist in the geographical distribution of attack and case fatality rates of cerebrovascular events, regardless of the north-south gradient. These data show the feasibility of implementing a population-based register using a validated routine database, necessary for monitoring cardiovascular diseases.

Multidimensional evaluation of home-dwelling elderly: the impact of medical and social factors on health status indices.

Since 1980 the WHO has proposed at least tree indices to characterize health status (impairment, disease, disability). Their relationships have been examined in some chronic diseases, but little is known about elderly at risk of frailty. We studied the influence of gender, age and living conditions on these indices and on their relationships. A sample of 100 home-dwelling elderly subjects underwent a multidimensional assessment at home to collect biological, symptomatic and functional measures. The sample consists of 48 males and 47 females, their mean age was 80.2 years, the mean schooling was 4.7 years. Living at home alone 14%, with spouse 60%, other 26%. Applying a MANOVA that considered the above mentioned items as factors and the biological, symptomatic and functional measures as dependent variables, no significant difference was found in biological measures, whereas the interaction of (i) gender and living conditions, (ii) gender and age classes showed differences in affective symptoms. Moreover, gender alone resulted a significant source of differences in instrumental activities of daily living (IADL). To assay the impact of biological, symptomatic scores on disability, a backward linear regression was applied. The principal index of postural control, Tinetti scale score, alone explained 50% of variance in activities of daily living (ADL), this index together with the measures, respectively, of cognitive functioning (Camcog score) and behavioral profile neuro-psychological inventory (NPI) score resulted to be the main sources of the IADL variance. These preliminary data allow us to identify both medical and social factors able to enhance the risk of frailty; is worth wile to stress that prevention programs could be targeted on possible modification of these factors.

Survival among elderly Italian patients with dementia treated with atypical antipsychotics: observational study.

The objective was to compare survival in a population-based cohort of elderly demented patients with behavioural and psychological symptoms (BPSD) dispensed an atypical antipsychotic (AA) with that of a sample of demented patients not treated with AAs. An observational cohort study was carried out in the province of Modena, Italy (644,000 inhabitants) on a cohort of 294 patients with BPSD diagnosed by a dementia specialist and treated with an AA, and a cohort of 2020 demented adults not dispensed AAs. All patients were 65 years of age or older. Measured outcomes were death by any cause and death by cerebrovascular accident at the end of the study. After a median follow-up of one year, survival was not significantly different between patients treated and not treated with AAs (overall mortality rates: 0.52 vs. 0.55/1000 years/person, respectively; relative risk reduction 0.047, 95% confidence interval -0.251 to 0.286). Multivariate survival analysis showed that older age at entry, male gender, severe dementia and functional impairment were associated with a higher risk of death. Although our sample size does not allow the exclusion of small differences in the short term, age, gender and dementia severity but not treatment with AAs seem to influence survival among elderly demented patients.

Audit of a shared-care program for persons with diabetes: baseline and 3 annual follow-ups.

In Italy, data on shared-care programs for diabetes are lacking. We described the characteristics of type 2 diabetic population assisted in general practice and evaluated 3 years of follow-up outcomes and performance indicators in a shared-care program in Modena, Italy (1998-2001); only well-controlled diabetic patients were considered. Forty-nine percent of territorial GPs adhered to the project (257 out of 521) and 77% of them sent 6409 paired baseline and follow-up datasheets. Altogether, 97.8% patients had type 2 diabetes, mean age 68.6+/-11.7 years, disease duration 9.6+/-7.5 years, BMI 28.6+/-4.8 kg/m2, HbA(1c) 7.6%+/-1.6%, 16.1% of them were disabled. Among the non-disabled patients, 23.6% had optimal glycemic control (HbA(1c) < or =6.5%); at baseline the prevalence of micro- and macrovascular diabetic complications was: 8.2% microalbuminuria and 2.4% macroalbuminuria plus nephropathy, 11.0% nonproliferative and 3.0% preproliferative retinopathy, 7.0% neuropathy, 1.8% diabetic foot; 8.5% angina, 6.9% TIA or stroke, 6.3% infarction, 5.2% intermittent claudication, 4.1% heart failure. Among the disabled patients 27.9% had optimal glycemic control, but they had more diabetic complications. The performance indicators significantly improved over the 3-year study period: glycemic control indicators increased from 66%-75% to 83%-90% and micro- and macrovascular indicators from 59%-65% to 75%-81%. The outcome indicators also improved: mean HbA(1c) value changed from 7.6%+/-1.6% to 7.3%+/-1.3% and the percentage of people with HbA(1c)< or =6.5% significantly improved over time. Similar trends were observed in both disabled and non-disabled diabetic patients.

Changes in long-term glycemic control and performance indicators in a cohort of type 2 diabetic patients cared for by general practitioners: findings from the "Modena Diabetes Project".

BACKGROUND AND AIM: General practitioners (GPs) are being increasingly asked to play a key role in the shared care of people with diabetes mellitus, but data concerning the effects of this in Italy are still scarce. We therefore evaluated the 4-year follow-up changes in outcomes and performance indicators in type 2 diabetic patients cared for by GPs in the framework of the "Modena Diabetes Project". METHODS AND RESULTS: Seventy-four percent of the local GPs participating in the project (387 out of 521) sent 5260 paired baseline and follow-up datasheets. The baseline characteristics of the type 2 diabetic patients (49.6% male) were a mean age of 67.3+/-11.2 years, a mean disease duration of 10.9+/-7.4 years, a mean BMI of 28.7+/-4.8 kg/m2, and a mean HbA1c level 7.56+/-1.52%. After four years follow-up, the individual before/after match-paired outcomes revealed an improvement in glycemic control: HbA1c levels significantly decreased to 7.39+/-1.31%, and the percentage of patients with HbA1c level of <6.5% significantly increased from 15.7% to 22.1%. There was also a significant decrease in body weight (from 78.3+/-14.8 to 77.6+/-14.6 kg) and BMI (from 28.8+/-4.8 to 28.5+/-4.9 kg/m2). The time trends of glycemic control significantly improved during the 4-year follow up, but those of the body weight and BMI values did not. Furthermore, the percentages of performance indicators matching the expected rate of recurrence per each year of follow-up significantly improved during the study period. CONCLUSIONS: Long-term glycemic control and the performance indicators relating to the type 2 diabetic patients participating in our shared care programme progressively improved.

[Case-control study in an area of the province of Ferrara having a high mortality rate for lung tumors]. / Studio caso-controllo in un'area della provincia di Ferrara a elevata mortalità per tumore del polmone.

The province of Ferrara represents one of the areas with the highest mortality rate for lung cancer in Italy. The aim of the study is to evaluate the relative importance of the main known risk factors for lung cancer in that area. It is a case control study based on the population where the cases under study (249) are selected from subjects deceased over the period 1988-1993 in the territory of the ex USL 33 (Local Health Authority) of Comacchio, while the controls (500) lived in the same area. The statistical analysis showed the same information that can be found in other medical literature regarding the known risk factors: smoking (OR = 3.7-44.9 per n. cigarettes/die), spouse passive smoking (OR = 1.1), passive smoking due to social setting (pubs) (OR = 1.9), vegetable diet (OR = 0.4). A important role was played by the factors linked to socio-economic differences. There was a significant increase in risk for those who had lived in "casazze" in the area, which are typical homes of the poorer social classes. There was also a significant increase in risk for subjects with a lower level of education. To obtain these results the analysis method known as "classification trees" was also used in order to verify its possible use in the public health sector.

[Observations, comments and proposals on a survey carried out in the Emilia-Romagna region in 1987, on various sentinel events]. / Osservazioni, commenti e proposti su un'indagine condotta nella Regione Emilia-Romagna nel 1987, su alcuni eventi sentinella.

The investigation intends to estimate the frequency of some Sentinel health events (SHE) in order to evaluate, preliminarily in methodological terms, the applicability of the survey on some probable SHE, which derive from the death certificates sent to Public health board. The work load has been estimated in relation to the different demographic economic and social realities existing in Emilia Romagna Region. Moreover, the suitability (applicability), in operative terms, of the list suggested by the National group for the SHE (CISM), has been examined. In the end, some questions have been raised and some organizational suggestions have been proposed, in order to guarantee the constancy and validity of the survey and above all the knowable acceptance of the insiders.