Long-term effectiveness evaluation of an action-research intervention to improve hand hygiene in an intensive care unit.

OBJECTIVES: To evaluate the long-term effectiveness of an action research intervention aimed at improving hand hygiene in an intensive care unit of a public hospital in Italy. METHODS: An observational, prospective before-after study was carried out.Compliance with hand hygiene was estimated by measuring the utilization of hand hygiene products before the intervention and four years after the end of the project. Products used were the following: detergent liquid soap, antiseptic liquid soap and alcohol-based hand gel. Endpoints were quantity consumed (in grams) for each product category. Quantitative consumptions per workshift were compared. RESULTS: In 2017 the median consumption of antiseptic liquid soap and alcohol-based hand gel per workshift was significantly higher than in 2012 (111.5 g vs 72.5 g, p = 0.014, and 18.0 g vs 5.0 g, p < 0.001). Odds in favour of a higher value in 2017 were 1.99:1 (CI95%: 1.19:1 to 3.73:1) for antiseptic solution, and 5.39:1 (CI95%: 3.09:1 to 13.61:1) for antiseptic gel. Covariates were not associated with consumption of products, and this made it possible to compare the measurements in the two data collections. CONCLUSIONS: Results of this study support the long-term effectiveness of the action research intervention to improve practices of hand hygiene in an intensive care setting.

Desimplification to multi-tablet antiretroviral regimens in human immunodeficiency virus-type 1 infected adults: A cohort study.

BACKGROUND: Highly active antiretroviral therapy (HAART) is provided free of charge to all human immunodeficiency virus (HIV) positive residents in Italy. As fixed dose coformulations (FDCs) are often more expensive in comparison to the same drugs administered separately in a multi-tablet regimen (MTR), we considered a cost-effective strategy involving patients in the switch from their FDCs to corresponding MTRs including generic antiretrovirals. AIM: To verify if this would affect the virological and immunological response in comparison to maintaining the FDC regimens. METHODS: From January 2012 to December 2013, we assessed the eligibility of all the HIV-1 positive adults on stable HAART being treated at our hospital-based outpatient clinic in Treviso, Italy. Participants who accepted to switch from their FDC regimen to the corresponding MTR joined the MTR group, while those who maintained a FDC regimen joined the FDC group. Clinical data, including changes in HAART regimens, respective reasons why and adverse effects, were recorded at baseline and at follow-up visits occurring at weeks 24, 48 and 96. All participants were assessed for virological and immunological responses at baseline and at weeks 24, 48 and 96. RESULTS: Two hundred and forty-three eligible HIV-1 adults on HAART were enrolled: 163 (67%) accepted to switch to a MTR, joining the MTR group, while 80 (33%) maintained their FDCs, joining the FDC group. In a parallel analysis, there were no significant differences in linear trend of distribution of HIV-RNA levels between the two groups and there were no significant odds in favour of a higher level of HIV-RNA in either group at any follow-up and on the overall three strata analysis. In a before-after analysis, both FDC and MTR groups presented no significant differences in distribution of HIV-RNA levels at either weeks 48 vs 24 and weeks 96 vs 24 cross tabulations. A steady increase of mean CD4 count was observed in the MTR group only, while in the FDC group we observed a slight decrease (-23 cells per mmc) between weeks 24 and 48. CONCLUSION: Involving patients in the switch from their FDC regimens to the corresponding MTRs for economic reasons did not affect the effectiveness of antiretroviral therapy in terms of virological response and immunological recovery.

Evaluation of allograft decontamination with two different antibiotic cocktails at the Treviso Tissue Bank Foundation.

Microbiological contamination of retrieved tissues is a critical aspect of allograft safety and tissue banks must continuously implement decontamination procedures to minimize tissue contamination. In this study we compared the decontamination efficacy of a new antibiotic cocktail (cocktail B: BASE medium with Gentamicin, Meropenem and Vancomycin) with the cocktail previously adopted at Treviso Tissue Bank Foundation (FBTV) (cocktail A: RPMI medium with Ceftazidime, Lincomycin, Polymyxin B and Vancomycin). Two decontamination steps were carried out, the first immediately after retrieval, the second after processing. The contamination rate was calculated before processing (Time 1) and cryopreservation (Time 2) for total tissues, musculoskeletal tissues and cardiovascular tissues, and the bacterial species involved were analyzed. Cocktail A was used to decontaminate 3548 tissues, of which 266 were cardiovascular and 3282 musculoskeletal tissues. For cocktail A, total tissue contamination was 18.6% at Time 1 and 0.9% at Time 2, with 15.7% contaminated musculoskeletal tissues at Time 1 and 0.4% at Time 2, respectively, while cardiovascular tissues were 50% contaminated at Time 1 and 6.4% at Time 2. Cocktail B was used to decontaminate 3634 tissues of which 318 were cardiovascular and 3316 musculoskeletal tissues. For cocktail B, total tissue contamination was 8.6% at Time 1 and 0.2% at Time 2, with 7.6% contaminated musculoskeletal tissues at Time 1 and 0.03% at Time 2, respectively. Contamination of cardiovascular tissues was 20.4% at Time 1 and 1.9% at Time 2. Intergroup and intragroup contamination rates decreased statistically significantly (p<0.05). Our results have shown that cocktail B was more effective than cocktail A in killing bacteria in both cardiovascular and musculoskeletal tissues during the two decontamination cycles.

Neuropsychological tools to predict conversion from amnestic mild cognitive impairment to dementia. The TREDEM Registry.

Most of the studies about conversion from Mild cognitive impairment (MCI) to dementia have focused on amnestic MCI (aMCI) which is considered a preclinical phase of Alzheimer's disease. The aim of the present study was to identify neuropsychological tools that would best predict conversion from aMCI to dementia. Fifty-five aMCI subjects on the Treviso Dementia Registry were investigated. They underwent a neuropsychological evaluation during their first assessment and again at follow-up. Cox proportional-hazard regression models were created to measure the association between the dependent variable (dementia diagnosis or MCI status maintenance) and the neuropsychological test scores at baseline. The sample (28 women and 27 men; mean age 76.82 ± 5.88 years; education 7.62 ± 3.99 years) was observed for an average time of 2.17 ± 1.25 years. A Cox backward stepwise regression showed that the Rey Auditory Verbal Learning Test, Delayed Recall (p = .041) and Semantic Verbal Fluency tests (p = .031) appear to be useful in predicting conversion to dementia.

Blood transfusions and steatohepatitis are independent risk factors for complications following liver resection for colorectal cancer liver metastases.

The aim of the present study was to evaluate the risk factors for postoperative complications following liver resection for colorectal cancer liver metastases. Patients who underwent hepatic resection for colorectal cancer liver metastases were stratified according to chemotherapy administration and body mass index (BMI) to eliminate potential confounding factors. A univariate analysis was conducted to identify potential risk factors for postoperative complications following liver resection. Variables that exhibited a potential association were evaluated by multivariable logistic regression analysis to identify those independently associated with postoperative morbidity. Between January 2012 and March 2012, 100 patients underwent hepatic resection for liver metastases from colorectal carcinoma at the Treviso Regional Hospital (Treviso, Italy) and at the Regina Elena National Cancer Institute (Rome, Italy). Of the 100 patients, 61 received preoperative oxaliplatin- or irinotecan-based chemotherapy. A total of 25 the patients had a BMI of ≥28 kg/m2. On univariate analysis, BMI ≥28 kg/m2 was found to be positively correlated with the presence of steatosis (P<0.01) and steatohepatitis (P<0.01). The administration of preoperative chemotherapy was correlated with the development of steatosis (P<0.01), steatohepatitis (P=0.02) and postoperative complications (P=0.03). Even following stratification for the use of preoperative chemotherapy, BMI ≥28 kg/m2 maintained its positive association with steatohepatitis. On multivariate analysis, steatohepatitis (P=0.005, HR=0.118, 95% CI: 0.027-0.518) and blood transfusions (P=0.001, HR=0.131, 95% CI: 0.038-0.452) were independently associated with postoperative complications. BMI ≥28 kg/m2 (P=0.004, HR=8.30, 95% CI: 2.39-28.7) and irinotecan treatment (P=0.016, HR=0.16, 95% CI: 0.037-0.711) were independent risk factors for steatohepatitis. In conclusion, steatohepatitis and perioperative blood transfusions were found to be the main determinant of postoperative complications following liver resection for colorectal liver metastases. Overweight patients may be more prone to the cytotoxic effects of irinotecan, harboring a higher risk of developing steatohepatitis.

Developing professional habits of hand hygiene in intensive care settings: An action-research intervention.

OBJECTIVES: To explore perceptions and unconscious psychological processes underlying handwashing behaviours of intensive care nurses, to implement organisational innovations for improving hand hygiene in clinical practice. RESEARCH METHODOLOGY: An action-research intervention was performed in 2012 and 2013 in the intensive care unit of a public hospital in Italy, consisting of: structured interviews, semantic analysis, development and validation of a questionnaire, team discussion, project design and implementation. Five general workers, 16 staff nurses and 53 nurse students participated in the various stages. RESULTS: Social handwashing emerged as a structured and efficient habit, which follows automatically the pattern "cue/behaviour/gratification" when hands are perceived as "dirty". The perception of "dirt" starts unconsciously the process of social washing also in professional settings. Professional handwashing is perceived as goal-directed. The main concern identified is the fact that washing hands requires too much time to be performed in a setting of urgency. These findings addressed participants to develop a professional "habit-directed" hand hygiene procedure, to be implemented at beginning of workshifts. CONCLUSIONS: Handwashing is a ritualistic behaviour driven by deep and unconscious patterns, and social habits affect professional practice. Creating professional habits of hand hygiene could be a key solution to improve compliance in intensive care settings.

Clinical and radiological results after coracoclavicular ligament reconstruction for type III acromioclavicular joint dislocation using three different techniques. A retrospective study.

PURPOSE: the purpose of this retrospective study was to present the outcomes of three different techniques for the treatment of type III acromioclavicular joint dislocations: arthroscopic TightRope (TR), arthroscopic GraftRope (GR), and open reconstruction of the coracoclavicular (CC) ligament using the Ligament Augmentation and Reconstruction System (LARS). METHODS: eighteen patients underwent clinical and radiological evaluations after a mean follow-up time of 43 months. The following clinical outcome measures were considered: the Disability of the Arm, Shoulder and Hand outcome measure (DASH), the Nottingham Clavicle Score (NCS), and the Constant score (CS). On X-rays, the CC distance was measured. RESULTS: the median DASH score at follow-up was 12.5 in the TR group, 5 in the GR group, and 4.2 in the LARS group. The median NCS value was 88 in the TR group, 88 in the GR group, and 91 in the LARS group. The median CS was 100 in the TR group, 95 in the GR group, and 94.5 in the LARS group. The mean CC distance was 10.3 mm in the TR group, 13.8 in the GR group, and 16.6 in the LARS group. CONCLUSIONS: all three techniques proved to be reliable in providing good clinical outcomes, although none of the studied techniques demonstrated reliability in maintaining anatomical reduction after surgery. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Reliability of a self-report Italian version of the AUDIT-C questionnaire, used to estimate alcohol consumption by pregnant women in an obstetric setting.

AIM: Alcohol consumption during pregnancy can result in a range of harmful effects on the developing foetus and newborn, called Fetal Alcohol Spectrum Disorders (FASD). The identification of pregnant women who use alcohol enables to provide information, support and treatment for women and the surveillance of their children. The AUDIT-C (the shortened consumption version of the Alcohol Use Disorders Identification Test) is used for investigating risky drinking with different populations, and has been applied to estimate alcohol use and risky drinking also in antenatal clinics. The aim of the study was to investigate the reliability of a self-report Italian version of the AUDIT-C questionnaire to detect alcohol consumption during pregnancy, regardless of its use as a screening tool. METHODS: The questionnaire was filled in by two independent consecutive series of pregnant women at the 38th gestation week visit in the two birth locations of the Local Health Authority of Treviso (Italy), during the years 2010 and 2011 (n=220 and n=239). Reliability analysis was performed using internal consistency, item-total score correlations, and inter-item correlations. The "discriminatory power" of the test was also evaluated. Results. Overall, about one third of women recalled alcohol consumption at least once during the current pregnancy. The questionnaire had an internal consistency of 0.565 for the group of the year 2010, of 0.516 for the year 2011, and of 0.542 for the overall group. The highest item total correlations' coefficient was 0.687 and the highest inter-item correlations' coefficient was 0.675. As for the discriminatory power of the questionnaire, the highest Ferguson's delta coefficient was 0.623. CONCLUSIONS: These findings suggest that the Italian self-report version of the AUDIT-C possesses unsatisfactory reliability to estimate alcohol consumption during pregnancy when used as self-report questionnaire in an obstetric setting.

Evaluation of a Multilevel and Integrated Program to Raise Awareness of the Harmful Effects of Prenatal Alcohol Exposure in a Local Community.

AIMS: To evaluate a multilevel program to raise awareness of the risks of prenatal exposure to alcohol in the area of Treviso (Italy). The program started in 2008 and consists of an action-research experience involving health professionals of maternal-child services, and in the campaign 'Mamma Beve Bimbo Beve', targeted to the childbearing-aged population. METHODS: A comparative study was carried out in 2013. Surveys using semi-structured self-report questionnaires were carried out among professionals and pregnant women in Treviso, and among control groups belonging to another local area of Italy (Verona). The questionnaires investigated awareness and opinions about alcohol and pregnancy, as well as sources and kind of information provided and received. RESULTS: Health professionals in Treviso, who had been exposed both to the action-research experience and to the campaign, showed a more rational approach to alcohol than colleagues in the control group, and were more aware and sensitized about the risks of alcohol consumption during pregnancy. Physicians and midwives had a higher probability of having advised pregnant women to abstain from alcohol in Treviso. Pregnant women in Treviso, who had received information through the campaign and from professionals, had a higher probability of having received only correct advice about the issue of alcohol and pregnancy, but did not hold perceptions different to women in Verona. CONCLUSIONS: The multilevel program carried out in the Treviso area was effective in increasing awareness and improving attitudes towards the risks of alcohol use during pregnancy among local healthcare professionals, compared with the control group.

Multidimensional prognostic index in a cognitive impairment outpatient setting: mortality and hospitalizations. The Treviso Dementia (TREDEM) study.

BACKGROUND: The Multidimensional Prognostic Index (MPI) based on a comprehensive geriatric assessment has been developed to predict mortality in hospitalized elderly patients. The Treviso Dementia (TREDEM) Study is an observational prospective cohort study of 1,364 outpatients evaluated at the Cognitive Impairment Center in Treviso, Italy from 2000 to January 2010. OBJECTIVE: To use the MPI in the TREDEM outpatient setting to assess the correlation of MPI with mortality and hospitalizations for acute cases that occurred after the date of assessment. METHODS: MPI was consecutively applied to the last 340 of 1,364 outpatients who were evaluated at the Center from 2008 to January 2010, after the first publication of MPI index in 2008. Participants' mortality was verified by linking the cohort with Registries of Municipalities, National Register of Revenue Authorities, and Nominal Register of Causes of Death. Data about hospitalizations for acute cases that occurred within 12 months after the date of assessment were obtained from all Italian hospitals. A Cox regression method was used to investigate the effect of MPI upon mortality and hospitalizations, also considering confounder factors such as age and gender. RESULTS: 114 men and 226 women, aged 52.1-99 years (mean age 80.4 years), were studied and had an MPI mean of 0.41. On 15 February 2013, 100 were deceased, and average hospitalizations for acute cases were 0.3, days 3.8. For MPI scores between 0 and 1, the increase in the probability of death was more than nine times (odds: 9.53 p = 0.0002) and of hospitalization was more than six times (odds: 6.50, p = 0.0079). CONCLUSION: MPI discloses the risk of death and of hospitalizations for acute cases in outpatients affected by cognitive impairment.

Sacral nerve stimulation for fecal incontinence related to external sphincter atrophy.

BACKGROUND: Atrophy of the external anal sphincter, a pathologic muscle volume anomaly associated with fecal incontinence, has been shown to be a negative predictor of the outcome of surgery for defects of the external anal sphincter. It is unclear whether external anal sphincter atrophy also affects the outcome of sacral nerve stimulation for fecal incontinence. OBJECTIVE: Our aim was to assess the effectiveness of sacral nerve stimulation in patients with fecal incontinence and external anal sphincter atrophy and to determine whether severity of atrophy and concomitant presence of a sphincter defect are negative predictors of outcome. DESIGN: This was a prospective observational study of treatment outcome. SETTING: The study was conducted from November 2004 through November 2010 at a regional hospital in Italy. PATIENTS: Consecutive patients with fecal incontinence and external anal sphincter atrophy were included. By means of MRI, patients were determined to have either moderate (<50%) or severe (≥ 50%) thinning of and/or replacement of sphincter muscle by fat. The concomitant presence of defects of the external anal sphincter was also detected by MRI. INTERVENTION: All patients underwent sacral nerve stimulation through a staged implantation procedure. MAIN OUTCOME MEASURES: The main outcome measures were improvement in the Cleveland Clinic Florida Fecal Incontinence Scale (Wexner score), number of episodes of incontinence per week, and the Fecal Incontinence Quality of Life Scale. RESULTS: A total of 28 patients underwent definitive implantation of the sacral nerve stimulation device. Wexner scores decreased from a median of 16 (range, 10-20) at baseline to 3 (range, 0-8) at 6-month follow-up (p < 0.001). Weekly incontinence episodes decreased from a mean (SD) of 14.7 (12.5) to 0.40 (0.82); p < 0.001. Improvement was significantly related to severity of fecal incontinence (r = 0.86; p < 0.001). Overall quality-of-life scores improved from a mean of 1.8 (0.6) to 3.8 (0.4);p < 0.001. Sacral nerve stimulation was effective in both moderate (n = 16) and severe (n = 12) atrophy and in patients with (n = 8) or without (n = 20) external anal sphincter defects. LIMITATIONS: The study was limited by its observational nature and relatively small sample size. CONCLUSIONS: Sacral nerve stimulation can be effective in restoring continence and improving quality of life in patients with fecal incontinence related to atrophy of the external anal sphincter, regardless of the severity of atrophy. Moreover, the presence of EAS atrophy does not influence the success of the outcome of SNS in patients with a sphincter defect. These findings are consistent with the hypothesis that the effects of SNS are not achieved solely by its action on the anal sphincter complex.

Evaluation of the impact of the image used in a communication campaign to raise awareness about the effects of alcohol use during pregnancy.

AIMS: To assess the impact of the advertising image used in the health communication campaign 'Mummy Drinks Baby Drinks', aimed to raise awareness about the effects of drinking alcohol during pregnancy in the childbearing-aged population of the Local Health Authority of Treviso (Italy). The image depicted a foetus inside a glass of a local alcoholic drink. METHODS: A survey using a semi-structured self-reported questionnaire was carried out. The questionnaire was administered to a consecutive series of 690 parents or caregivers who accompanied children aged 0-2 years in the vaccination clinics of the Local Health Unit, during a 30-day period 1 year after the start of the campaign. The questionnaire measured the level of exposure to the image, emotional reactions and awareness of the health messages conveyed by the image. RESULTS: Overall, 84% of the respondents said that they remembered the image. Almost all (93%) recalled the warning message and 53% recalled the health behaviours suggested by the campaign. The image generally seemed to arouse a high emotive impact: 38% indicated distress and 40% liking as a general opinion, while ∼50% expressed distress emotions and 13% were pleasantly affected when reflecting on the feelings evoked. We did not find unequivocal relationships between the level and kind of emotional reactions and the recalling of the health behaviours. CONCLUSION: The image obtained a high level of visibility. It was effective in spreading the health message conveyed by the campaign, regardless of the level and kind of emotive impact evoked.

Pump flow changes do not impair sublingual microcirculation during cardiopulmonary bypass.

OBJECTIVE: The flow rate of the cardiopulmonary bypass (CPB) pump used in cardiac surgery often undergoes inherent fluctuations ranging from 10% to 20% of its theoretic value. However, the effects of such alterations remain unknown. In the present study, the authors investigated whether such variations could induce changes in the microvascular flow, which is considered a primary indicator of poor perfusion. DESIGN: A prospective, observational, clinical study. SETTING: A university-affiliated teaching hospital. PARTICIPANTS: Thirty adult patients undergoing elective cardiac surgery with CPB. INTERVENTIONS: Analysis of the sublingual microcirculation during CPB using a pump flow rate of 80% or 100% of the theoretic value. MEASUREMENTS AND MAIN RESULTS: Sidestream dark field (SDF) imaging was used to record 2 video clips of the sublingual microcirculation in each patient. The videos were recorded at the same site at 80% and 100% of the theoretic flow rate. Microvascular analysis displaying the De Backer score, the microvascular flow index, the total vessel density, the perfused vessel density, and the proportion of perfused vessels was performed. Moreover, the mean arterial pressure (MAP), SvO(2), and PaCO(2) were evaluated. No significant changes in the measured parameters were noted at the 2 different flow rates. CONCLUSIONS: Changes in the CPB pump flow rate within 20% (80%-100%) of its theoretic value do not alter the sublingual microcirculation. Thereafter, it is conceivable that during perioperative adjustments of the CPB pump rate, blood flow autoregulation mechanisms are activated so that limited changes in the pump flow can be considered safe not only at the sublingual site but also for the entire microcirculation.

Interobserver and interdisciplinary reproducibility of 3D endovaginal ultrasound assessment of pelvic floor anatomy.

INTRODUCTION AND HYPOTHESIS: the study aims were to evaluate (1) the interobserver and (2) the interdisciplinary repeatability of levator hiatus, urethral thickness, and anorectal angle measurements using three-dimensional endovaginal ultrasound (3D-EVUS). METHODS: twenty-seven nulliparous asymptomatic females were imaged with 3D-EVUS. Analyses were conducted off-line from stored 3D volumes by six readers (two radiologists, two urogynecologists, and two colorectal surgeons) using a standardized technique. Reproducibility was determined using the interclass correlation coefficients (ICC). RESULTS: the overall interobserver repeatability for levator hiatus dimensions was good to excellent (ICC, 0.655-0.889), for urethral thickness was good (ICC, 0.624), and for anorectal angle was moderate (ICC, 0472). The interdisciplinary repeatability for levator hiatus indices was good to excellent (ICC, 0.639-0.915), for urethral thickness was moderate to good (ICC, 0.565-0.671), and for anorectal angle was fair to moderate (ICC, 0.204-0.434). CONCLUSIONS: 3D-EVUS yields reproducible measurements of levator hiatus dimensions and urethral thickness in asymptomatic nulliparous women.

The value of high-resolution three-dimensional endorectal ultrasonography in the management of submucosal invasive rectal tumors.

PURPOSE: The aims of this prospective study were 1) to evaluate the accuracy of high-resolution three-dimensional endorectal ultrasonography in distinguishing slight from massive submucosal invasion of early rectal tumors, and 2) to determine the technology's role in treatment selection. METHODS: A total of 142 consecutive patients with clinically possible pT1 rectal cancers underwent three-dimensional endorectal ultrasonography. Slight or massive irregularity of the hyperechoic submucosal layer was considered to characterize uT1-slight or uT1-massive tumors. Treatment was selected on the basis of ultrasonographic findings: endoscopic resection or full-thickness transanal local excision was selected for uT1-slight lesions, and radical resection was selected for uT1-massive tumors. Ultrasonographic staging was compared with histopathologic staging. RESULTS: One hundred twenty-six patients were included in the final analyses. Three-dimensional endorectal ultrasonography staged 77 lesions as uT0, 25 as uT1-slight, 20 as uT1-massive, and 4 as uT2. Histologically, adenomas were found in 75 patients and tumor invasion was found in 44 lesions (24 pT1-slight, 16 pT1-massive, 4 pT2). The overall kappa for the concordance between ultrasonographic and histopathologic stagings was 0.81 (95% confidence interval, 0.72-0.89). No invasive carcinomas remained undetected. The depth of invasion was correctly determined in 87.2% of both pT1-slight and pT1-massive lesions. Considering the complete series of 126 patients, the accuracy of this modality in selecting appropriate management was 95.2% (kappa, 0.84; 95% confidence interval, 0.71-0.96). Adequate surgery was performed in 87.5% of pT1 tumors. CONCLUSION: Three-dimensional endorectal ultrasonography is useful for assessing the depth of submucosal invasion in early rectal cancer and for selecting therapeutic options.

[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.

[Ischemic heart disease prevalence estimated using a standard algorithm based on electronic health data in various areas of Italy]. / Stima della prevalenza della cardiopatia ischemica basata su dati sanitari correnti mediante un algoritmo comune in differenti aree italiane.

AIM: to define an algorithm to estimate prevalence of ischemic heart disease from health administrative datasets. SETTING: four Italian areas: Venezia, Treviso, Torino, Firenze. PARTICIPANTS: resident population in the four areas in the period 2002-2004 (only 2003 for Firenze) for a total of 2,350,000 inhabitants in 2003. MAIN OUTCOMES: annual crude and standardized prevalence rate (x100 inhabitants), 95% confidence intervals by area. Quality (comparability and coherence) indicators are also reported METHODS: the algorithm is based on record linkage of hospital discharges (SDO), pharmacological prescriptions (PF), exemptions from health-tax exemptions (ET) and causes of mortality (CM). From SDO we extracted discharges for ICD9-CM codes 410*-414* in all diagnoses in the estimation year and during the four years immediately preceding. We selected from PF subjects with at least two prescriptions of organic nitrates (ATC = C01DA*) in the estimation year. From ET subjects with a new exemption for ischemic heart disease (002.414) or who obtained exemption in the three years preceding, were selected. We also considered all deaths in the year for ischemic heart disease (ICD9 CM 410-414). Cases were defined as ischemic heart disease prevalent cases if they were extracted at least once from one of the datasets and if they were alive on January 1 of the estimation year. RESULTS: estimated crude prevalence ranges from 2.5 to 4%. The standardized prevalence led to a narrower range of values (2.8-3.3%). Venezia and Firenze show a higher standardized prevalence in both sexes (men 4.7% and 4.4%; women 2.3% and 2.2% respectively); Treviso and Torino present a lower standardized prevalence (men: 3.9%; women: 1.9%). The hospital discharges are the main source to identify prevalent subjects (34-48% of subjects are solely identified by SDO), pharmacological prescriptions are a relevant source in Firenze and Torino (27-28%), while they are less relevant in Venezia and Treviso (13-15%). ET shows a different contribution to prevalent case identification in the four areas: Venezia (8%), Treviso (3.2%), Firenze (1.3%), whereas in Torino this source was not available at all. Subjects classified as prevalent cases only through causes of death are less than 2%. The percentage of subjects simultaneously identified by multiple sources is high in Venezia (43%) and low in Torino (30%). CONCLUSIONS: patterns in use of pharmaceuticals and exemptions from prescription charges appear to be heterogeneous in the different areas under study. These two aspects make a proper comparison between areas difficult. The algorithm could be applied only in areas with a similar use of organic nitrates and with a good comparability of the exemptions dataset.