Morbidity experience in populations residentially exposed to 50 hz magnetic fields: methodology and preliminary findings of a cohort study.

A morbidity study of the population of a district of Rome built in part under a 60 kV electric distribution line, included 345 subjects resident in the study area in any period between 1954 and 2003, excluding those deceased before 1998. Residential magnetic field levels were estimated based on current load, line characteristics, and distance of the dwellings from the power line, and the study area was divided into sub-areas with differing magnetic field levels. Standardized morbidity ratios were computed from hospital discharge records dated 1998-2003. Non statistically significant increases were observed for all and primary cancers; primary cancers were significantly increased among subjects with > 30 years' residence and latency. A significant increase for all, primary, and secondary cancers, and a two-fold increase for ischaemic diseases, was observed in subjects in the sub-area with the highest exposure. No increase was seen in neoplastic haematological diseases.

[Objectives, tools and methods for an epidemiological use of electronic health archives in various areas of Italy]. / Obiettivi, strumenti e metodi per un utilizzo epidemiologico di archivi sanitari elettronici correnti in diverse aree italiane.

The availability of Electronic Health Archives (EHA) has increased remarkably over the last twenty years. As part of a joint project of the Italian Association of Epidemiology (AIE) and the Italian Association of Medical Statistics and Clinical Epidemiology (SISMEC), a workgroup of experts was set up in 2005 with the aim of comparing various experiences and of standardizing the procedures by which electronic sources can be integrated. In particular, the workgroup's aim was to estimate the frequency of certain major diseases using standard algorithms applied to EHA. This volume is published with the purpose of making available in a common publication the methods and the results obtained. The results from a multicentre study using a standard approach to probabilistic record-linkage procedures are also included in a specific chapter. Eleven Italian centres from five Italian regions with an overall population of 11,932,026 collected and treated more than 21,374,426 records (year 2003) from five electronic information sources: death certificates, hospital discharge records (including outpatient discharges), drug prescriptions, tax- exemptions, and pathology records in order to estimate the frequency of the following diseases: diabetes, ischemic heart diseases, acute myocardial infarction, stroke, asthma, chronic obstructive pulmonary disease, obstructive lung diseases. For each pathology a specific algorithm was developed and used by all centres for the identification of the prevalent/incident cases of the selected diseases. Standardized methods were used to estimate the rates. The results confirm the need for a common standard approach to produce estimates based on EHA, considering the variability of the quality and of the completeness of the archives, and the difficulties of standardizing record-linkage operations in the various centres. The main achievement of this work was the elimination of the variability due to the use of different algorithms to identify cases using EHA.

[Acute stroke incidence estimated using a standard algorithm based on electronic health data in various areas of Italy]. / Stima dell'incidenza di ictus acuto basata su dati sanitari correnti mediante un algoritmo comune in differenti aree italiane.

AIM: to define an algorithm and implement it in various areas of Italy, in order to evaluate acute stroke incidence through current databases. SETTING: Lazio, Tuscana , Venezia AULSS 12, Torino ASL 5. PARTICIPANTS: resident-based population in the above mentioned 4 areas during 2002-2004. MAIN OUTCOME: Annual and triennal incidence rate (crude and standardized per 100,000 inhabitants with 95% CI) by sex and age classes (0-14, 15-34, 35-54, 55-64, 65-74, 75-84, 85+), standardized rate of mortality by sex and areas. METHODS: acute stroke incident cases during 2002-2004 in the 4 Italian areas were identified through hospitalization databases (SDO) and death causes (CM). The selection was made including hospitalization cases (no outpatients) and deceased people with a discharge or death code ICD9-CM 430*, 431*, 434*, 436* with no hospitalization for stroke diagnosis in the previous 60 months. Moreover, patients with 438* codes in secondary diagnoses and patients with hospital discharge from rehabilitation or long-hospital units were excluded. RESULTS: men have a higher crude incidence rate than women (+30%). The age-specific rates show a large variability among the areas for elderly people (65+ for men and 75+ for women), with higher rates in Toscana in both genders (cases per 100,000 inhabitants: 260.1 men; 193.1 women). Intermediate values were found in Torino and in Lazio; the lowest values are reported in Venezia (men: 182.5; women: 1368). Standardized mortality rates also present higher mortality levels in the two regional areas (Lazio and Toscana) and lower levels in the two urban areas (Torino and Venezia). CONCLUSIONS: It is not easy to evaluate the algorithm. Results seem compatible enough with other studies and show a certain consistency with current mortality data. Different socio-economical characteristics could account for differences in the estimated incidence among areas. However, diferences in the quality indicators suggest that a validation study with standardized diagnostic criteria will make quality evaluation of the algorithm possible.

[Record-linkage procedures in epidemiology: an Italian multicentre study]. / Procedure di record linkage in epidemiologia: uno studio multicentrico italiano.

OBJECTIVE: To compare record linkage (RL) procedures adopted in several Italian settings and a standard probabilistic RL procedure for matching data from electronic health care databases. DESIGN: Two health care archives are matched: the hospital discharges (HD) archive and the population registry of four Italian areas. Exact deterministic, stepwise deterministic techniques and a standard probabilistic RL procedure are applied to match HD for acute myocardial infarction (AMI) and diabetes mellitus. Sensitivity and specificity for RL procedures are estimated after manual review. Age and gender standardized annual hospitalization rates for AMI and diabetes are computed using different RL procedures and compared. SETTING: Municipalities of Pisa and Roma, and Regions of Puglia and Piemonte. PARTICIPANTS: Residents in the considered areas on 31 December 2003 and corresponding episodes of hospitalization in the same areas during 2004. MAIN OUTCOME MEASURES: Measures of accuracy of RL procedures to match health care administrative databases. RESULTS: Data quality varies among archives and affects the decision rule of the probabilistic procedure. A unique decision rule was therefore adopted by means of choosing a positive predictive value of at least 98% for all the considered areas. The number of matched pairs identified with the probabilistic procedure is on average more then 11% greater than the number identified with the deterministic procedure. Sensitivity of probabilistic RL is similar or greater than that of other procedures. Differences between annual standardized hospitalization rates computed with stepwise deterministic RL and the standard probabilistic RL procedure vary among areas. CONCLUSION: Exact deterministic RL works well when unique identifiers and high quality data are available. The probabilistic procedure here proposed works as well as semi-deterministic RL when the latter implements a quality control of data or a manual review of final results. Otherwise, deterministic or semi-deterministic procedures imply classification errors of unknown size and direction.

Agreement between emergency room and discharge diagnoses in a population of injured inpatients: determinants and mortality.

BACKGROUND: Various factors contribute to the quality of care of an injured patient at the emergency room (ER), and a correct diagnosis can improve and accelerate care. The aim of this study was to evaluate the agreement between diagnoses assigned in the ER and those assigned after hospital admission to patients with unintentional injuries. We also tried to determine the factors that influenced the disagreement, and to evaluate if discordant diagnoses were associated with higher mortality risk. METHODS: All ER visits for unintentional injuries that were followed by hospital admission at the 60 emergency departments in the Lazio Region in 2000. Concordant diagnoses (ER/discharge) were established based on the Barell matrix cells. Logistic regression was used to assess the role of individual and ER care factors on the probability of concordance. A logistic regression was performed, where death within 30 days was the outcome and concordance was the determinant. RESULTS: We considered 22,892 ER visits for injury that were followed by hospital admission. In 62.2% of cases, the ER and discharge diagnoses were concordant. Higher concordance was found for older patients and less urgent cases. Factors influencing concordance were the hour of the visit, ER specialization degree, initial outcome, and length of hospital stay. Patients who had disconcordant diagnoses had a 30% higher probability of death. CONCLUSIONS: A correct diagnosis (i.e. confirmed at hospital discharge) at first contact with the emergency room is associated with lower mortality. Comparing administrative ER and hospital discharge data can be useful in emergency department management studies.

[Mortality and hospital admissions in the industrial area of Civitavecchia, 1997-2004]. / Mortalità e ricoveri ospedalieri nell'area industriale di Civitavecchia, anni 1997-2004.

OBJECTIVE: the industrial area of Civitavecchia (central Italy) has been object of concern because of several sources of environmental contamination potentially affecting the residential communities: a harbor, a cement factory and several power plans are present in the area. A coal power plant is currently under construction. The aim of the study is to evaluate the health of residents in the area, through the analysis of the mortality registry and the hospital discharge records. DESIGN: cause and gender specific indirect Standardized Mortality (1997-2001) and Hospitalization (1997-2000 and 2001-2004) Ratios were computed, with 95% Confidence Intervals, using regional population as reference. RESULTS: mortality and morbidity excesses for cancer were observed, in particular an increased mortality for lung cancer (observed 134, SMR= 120) and for malignant neoplasm of pleura (observed 8, SMR= 516) were detected among men. An increased frequency of hospital admissions for asthma was observed among children aged 0-14 (period 1997-2000: males, observed 73, SHR= 177; females, observed 40, SHR= 157). Finally an significantly increased incidence of renal diseases was recorded by the Lazio Dialysis Registry in the period 2001-2004 (observed 28, SHR= 156). CONCLUSION: in view of the environmental changes of the area, the excesses observed in this study suggest the need for epidemiologic monitoring found in excess (lung and pleural cancer, respiratory diseases among children, renal diseases) in the area.

Determinants of hospitalization in a cohort of chronic dialysis patients in central Italy.

BACKGROUND: Few studies linking hospital discharge records with the population register of chronic dialysis (CD) patients are available. This study aimed to evaluate the frequency and the determinants of hospitalization, taking into account the demographic, clinical and biochemical data. METHODS: We conducted a retrospective cohort study in 3411 patients starting dialysis from 1996-2000, reported to the Lazio Dialysis Registry (RDL) (Italy). These patients were linked with the hospital information system from 1996-2002. Hospital admission probability was calculated using the Kaplan-Meier method. To evaluate the determinants of hospitalization risk we used Cox's proportional hazards for the first admission and a marginal model considering competitive effect of mortality, the Wei-Lin-Weissfeld model, for any admission. RESULTS: We found 7530 hospital admissions, referring to 1711 patients (50.7%), with a rate of 63/100 person-years. The most prevalent diagnoses were "diseases of the genitourinary system", (37.4%), and "diseases of the circulatory system", among secondary diagnoses (46.6%). Hospitalization probability was 34.4% at 1 yr after starting dialysis. The risk of first and any hospital admission was higher (p<0.05) for patients having more than one comorbid disease, hematocrit (Hct) level <30%, serum albumin level <3.5 g/dL, and a low degree of self-sufficiency. CONCLUSIONS: Hospitalization frequency, mainly during the first months of dialysis, suggests the need to improve the early management of chronic renal failure and indicates the importance of preventing complications and maximizing functional status among the dialysis population.

Differences in access to coronary care unit among patients with acute myocardial infarction in Rome: old, ill, and poor people hold the burden of inefficiency.

BACKGROUND: Direct admission to Coronary Care Unit (CCU) on hospital arrival can be considered as a good proxy for adequate management in patients with acute myocardial infarction (AMI), as it has been associated with better prognosis. We analyzed a cohort of patients with AMI hospitalized in Rome (Italy) in 1997-2000 to assess the proportion directly admitted to CCU and to investigate the effect of patient characteristics such as gender, age, illness severity on admission, and socio-economic status (SES) on CCU admission practices. METHODS: Using discharge data, we analyzed a cohort of 9127 AMI patients. Illness severity on admission was determined using the Deyo's adaptation of the Charlson's comorbidity index, and each patient was assigned to one to four SES groups (level I referring to the highest SES) defined by a socioeconomic index, derived by the characteristics of the census tract of residence. The effect of gender, age, illness severity and SES, on risk of non-admission to CCU was investigated using a logistic regression model (OR, CI 95%). RESULTS: Only 53.9% of patients were directly admitted to CCU, and access to optimal care was more frequently offered to younger patients (OR = 0.35; 95%CI = 0.25-0.48 when comparing 85+ to >=50 years), those with less severe illness (OR = 0.48; 95%CI = 0.37-0.61 when comparing Charlson index 3+ to 0) and the socially advantaged (OR = 0.81; 95%CI = 0.66-0.99 when comparing low to high SES). CONCLUSION: In Rome, Italy, standard optimal coronary care is underprovided. It seems to be granted preferentially to the better off, even after controversial clinical criteria, such as age and severity of illness, are taken into account.

Contrast-enhanced voiding US for grading of reflux in adult patients prior to antireflux ureteral implantation.

PURPOSE: To prospectively assess contrast material-enhanced voiding ultrasonography (US) for grading of vesicoureteral reflux (VUR) and to compare results with those of voiding cystourethrography (VCUG) in adult patients undergoing antireflux ureteral implantation. MATERIALS AND METHODS: Thirty-seven consecutive adult patients who had undergone renal transplantation with Politano-Leadbetter (18 patients) or Lich-Gregoire (19 patients) technique were included on the basis of previous urinary tract infections (UTIs) and time elapsed after renal transplantation. Exclusion criterion was current UTI. US was performed by one of two sonologists with injection of saline and microbubble suspension and was recorded on videotape. Sonologists assigned VUR diagnosis in consensus after videotape review. VCUG was performed by one of two radiologists immediately after US. Radiologists were blinded to US findings and assigned VCUG diagnoses in consensus. Contingency table was used to compare US and VCUG. Agreement between US and VCUG was determined with kappa statistics. RESULTS: With VCUG, VUR was diagnosed in 15 patients and not diagnosed in 22 patients. US and VCUG results were in agreement in 14 patients with VUR and 21 patients without VUR. US sensitivity and specificity for detection of VUR were 93% (14 true-positive results in 15 abnormal cases) and 95% (21 true-negative results in 22 normal cases), respectively. Agreement between US and VCUG was 95% (kappa = 0.89, P <.001). In 11 of 14 patients, VUR grades were in agreement for US and VCUG. In three of 14 patients, US indicated a higher grade than did VCUG. VUR was diagnosed in seven of 18 Politano-Leadbetter cases and eight of 19 Lich-Gregoire cases. CONCLUSION: A high rate of agreement was seen between voiding US and VCUG.

[Hospitalization for pneumonia in adults. Lazio, 1997-1999]. / Ricoveri ospedalieri per polmonite negli adulti. Lazio 1997-1999.

The aim of this study is to define the burden of pneumonia requiring hospitalization among adults in Lazio region from 1997 to 1999 and to describe the characteristic of community acquired (CAP), suspected nosocomial (NP) and in AIDS pneumonia. The data source is the hospital discharge register. 30517 incident episodes of pneumonia hospitalization occurred in the three years period, 20497 CAP, 9760 NP and 964 in AIDS of which 704 supposed to be acquired in hospital; the mean age is 65, 69 and 38 years respectively. Standardized hospitalization rates for CAP do not show a clear geographical pattern, while for NPs and in AIDS they are higher in the city of Rome than in the rest of the region. There are peaks of incidence during the winter for CAPs and NPs but not for AIDS. Only 20% of pneumonias have etiological diagnosis. The proportional analysis of aetiological agents shows: pneumococcus, pseudomonas, staphylococci and influenza; the most frequent comorbidities are: circulatory diseases, chronic obstructive pulmonary disease (COPD), malignancies and diabetes. 3.9% of individuals in the study with CAP or NP had more than one episode of pneumonia during the study period, for those with pneumonia in AIDS this percentage was 14.8. In-hospital lethality is 9.4%, 29.3% and 11.2% for CAP, NP and in AIDS, respectively. Data from the hospital discharge registers can be used to give a cheap and rapid glimpse to the epidemiology of pathologies frequently requiring hospitalisation neglected from more analytical surveillance systems or registries.