Health care costs and functional outcomes of road traffic injuries in the Lazio region of Italy.

The economic consequences of road traffic injuries (RTIs) are very important in terms of health care costs. The aim of this study is to provide estimates of health care costs of non-fatal RTIs and to estimate functional outcomes using in-hospital rehabilitation data. We identified all emergency department (ED) visits related to RTI during 2008 and then linked them with hospital discharges and rehabilitation admissions, health care costs following RTI were estimated from the integrated database. We performed an epidemiological evaluation of RTI with a comprehensive description of functional outcomes at 6 months. Health care costs have been estimated at about €80 million with a per person cost of €522. About 18% of the total cost was due to rehabilitation treatments. In multivariate analysis the variables that correlated better with higher total health care costs were: older age, injury severity, presence of spinal lesion. Patients requiring rehabilitation were: the elderly, patients suffering from a spinal cord injury and leg injuries. This study provides consistent health care cost estimates of RTI using administrative databases and it shows a picture of functional outcomes after RTI. Further research is needed for the estimation of other components of the total cost of RTI.

Methods to increase participation in organised screening programs: a systematic review.

BACKGROUND: The European Community recommends the implementation of population-based screening programmes for cervical, breast, and colorectal cancers. This recommendation is supported by many observational studies showing that organised programmes effectively reduce mortality and control the inappropriate use of screening tests. We conducted a systematic review of studies assessing the efficacy of interventions to increase participation in organised population-based screening programs. METHODS: We included all studies on interventions aimed at increasing screening participation published between 1/1999 and 7/2012. For those published before 1999, we considered the Jepson et al. (2000) review (Health Technol Assess 4:1-133, 2000). RESULTS: Including studies from the Jepson review, we found 69 with quantitative information on interventions in organised screening: 19 for cervical, 26 for breast, 20 colorectal cancers, and 4 for cervical and breast cancer together.Effective interventions were: postal (breast RR = 1,37 95% Confidence Interval (95% CI): 1.25-1.51; cervical RR = 1.71 95% CI: 1.60-1.83; colorectal RR = 1.33 95% CI: 1.17-1.51) and telephone reminders (with heterogeneous methods for implementation); GP's signature on invitation letter (breast RR = 1.13 95% CI: 1.11-1.16; cervical RR = 1.20 95% CI: 1.10-1.30; colorectal RR = 1.15 95% CI: 1.07-1.24); scheduled appointment instead of open appointment (breast RR = 1.26 95% CI: 1.02-1.55; cervical RR = 1.49 95% CI: 1.27-1.75; colorectal RR = 1.79 95% CI: 1.65-1.93). Mailing a kit for self-sampling cervical specimens increased participation in non-responders (RR = 2.37 95% CI: 1.44-3.90). CONCLUSION: Although some interventions did prove to be effective, some specific variables may influence their effectiveness in and applicability to organised population-based screening programs.

How socioeconomic status influences road traffic injuries and home injuries in Rome.

Road traffic injuries (RTI) and home injuries (HI) are a relevant public health problem, especially among people living in deprived areas. The objective of this study was to explore the relationship between morbidity, hospitalisation, mortality from RTI and HI, and socioeconomic status (SES) of the area of residence. RTI and HI surveillance based on the Emergency Information System, the Hospital Information System and the Mortality Registry of Lazio region are the three sources of this study to create a unique surveillance system. For each subject, the SES index (5 levels) of its census tract of residence was obtained. The study population included emergency department admissions (year 2005) of residents in Rome, Italy. Incidence Rate Ratios (IRRs) have been estimated using Poisson Regression. The rates of RTI and HI emergency department visits were higher among the most deprived level of SES (IRR = 1.27, 95% CI: 1.24-1.30; IRR = 1.33, 95% CI: 1.29-1.37, respectively) compared to the most privileged ones; a similar result was found for hospitalisation (IRR = 1.19, 95% CI: 1.08-1.32; IRR = 1.11, 95% CI: 1.01-1.22). A strong relation was found between RTI mortality rates and poor level of SES. The study concluded that RTI and HI incidence were associated to sociodemographic factors.

[Methods to increase participation in cancer screening programmes]. / Metodi per aumentare la partecipazione ai programmi di screening oncologici.

OBJECTIVE: to synthesize scientific evidences about methods to increase cervical, breast and colorectal cancer screening participation. METHODS: a multidisciplinary working group has been set up to define the scope of the report and to conduct the evaluation. The scope and the final evaluation have been submitted to a stakeholder committee, including the Ministry of Health, the National Screening Observatory, regional screening program coordinators, scientific societies, and Lega Italiana Lotta ai Tumori, for comments and integrations. A systematic review of the principal biomedical and social literature databases was conducted to identify experimental and observational studies, updating the existing review by Jepson and coll. (Health Technol Assess. 2000;4(14):i-vii, 1-133). RESULTS: 5900 have been identified, 900 relevant for the topic.Among those, 148 reported quantitative information on intervention efficacy, other 90 came from the previous review. Organised screening programmes, based on invitation letter or on GP involvement,were consistently effective in increasing participation compared to spontaneous screening. Interventions are classified according to their target: individual, community, test simplification, health operators, health service organization. The report presents meta-analyses on efficacy, analyses of cost-effectiveness, impact on organisation and social inequality, and ethical and legal issues, of all the intervention reported in the literature. CONCLUSIONS: there are several interventions consistently effective in any context, some of them have minimal impact on costs and health service resources.

Direct mailing of faecal occult blood tests for colorectal cancer screening: a randomized population study from Central Italy.

BACKGROUND: Sending faecal occult blood tests (FOBT) by mail has been proposed both as a method to increase participation and a way to reduce staff costs in colorectal cancer screening. METHODS: Two multicentre randomized controlled trials (ISRCTN10351276) were performed: one randomly assigned 3196 individuals who had previously participated in colorectal screening to receive a FOBT kit at home or a standard invitation; in the second, 4219 people aged 50-69 years who did not respond to a screening invitation were either sent a FOBT or a standard recall letter. The cost per returned kit was calculated in each arm. RESULTS: Participation was higher with direct FOBT mailing in both trials: relative risk 1.11 (95% CI 1.06-1.17) and 1.36 (95% CI 1.16-1.60) for previous responders and non-responders, respectively. The cost per returned kit for previous responders ranged from 4.24€ to 16.10€, and from 3.29€ to 7.36€ with FOBT mailing and standard invitation, respectively, not including staff costs; for non-responders it ranged from 17.13€ to 46.80€, and from 7.36€ to 18.30€ with FOBT mailing and standard recall, respectively. CONCLUSIONS: The FOBT mailing strategy modestly increased participation. This method can be used on a population of previous responders to reduce personnel costs and workload. When used as a reminder to non-responders, this method increases costs.

A case-control study on risk factors of domestic accidents in an elderly population.

The aim of this study was to evaluate the combined influence of several lifestyle, health and housing factors in the occurrence of home injuries (HIs) among the elderly. The subjects were recruited from 10 hospitals in Rome, Italy. This study is a paired case-control study. Cases included subjects, aged 65-85 years, who visited the Emergency Department for an HI and were subsequently hospitalised (15 September 2004-30 June 2005). Controls were the subjects of the same gender, age (±3 years) and area of residence of cases. A conditional logistic regression model was used for analysing the variables obtained. In this study, we enrolled 107 hospitalised cases. It was found that the living room was the place where 33% of the accidents occurred. Eighty-seven per cent of the accidents were falls, and 33% of the accidents were the immediate consequence of sudden malaise. One-half of the cases reported one or more leg fractures. The variables that were independently associated with HI were poor household illumination, poor emotional status, regular physical activities and housekeeping activities. We conclude that this study shows the areas of intervention to target HI prevention activities.

Triage and Injury Severity Scores as predictors of mortality and hospital admission for injuries: a validation study.

BACKGROUND: Many emergency departments use a rating system to establish priority based on urgency: "triage". The aim of this study was to evaluate the validity of triage in predicting hospitalization and mortality compared to that of the ICD-9-CM based Injury Severity Score (ISS). SOURCES: The Emergency Information System 2000, the Hospital Information System 2000-2001 and the Mortality Register 2000-2001, of the Lazio Region. Case selection: Emergency department visits for traumas that occurred on the road or at home. OUTCOMES: Hospitalization and 30-day mortality. For each case, trauma diagnoses from the ICD-9-CM were given a corresponding ISS value. We performed logistic models, including age, sex and, alternatively, triage or ISS. We compared discrimination measures and calibration of the models. RESULTS: Out of 264,709 emergency department visits, 22,249 (8.4%) were followed by a hospitalization and 655 (0.2%) died within 30 days. ISS scores were calculated for 72,179 (27%) cases. Of the most urgent triage (840 patients), 78.3% (658) were hospitalized and 9% (76) died, while among patients with ISS > or = 16 value (1276) 36.4% (464) of were hospitalized and 1.8% (23) died. Measures of discrimination and calibration showed similar results. The triage model had a better fitness in predicting hospitalization probability for home accidents (Hosmer-Lemeshow statistic: chi(2)(triage)=5.5 vs chi(2)(ISS)=34.3) and had a better performance for road accidents (ROC(triage)=0.71 vs ROC(ISS)=0.66). There were no differences between the models in predicting the probability of death. CONCLUSIONS: The agreement between the two scales confirms the validity of triage as a clinical management tool in the emergency department, and as a proxy of trauma severity.

An integrated surveillance system of road traffic injuries in the Lazio region of Italy: results of a 5-year study (2001-2005).

Road traffic injuries represent a relevant public-health problem. In the Lazio region of Italy, a surveillance system was activated. The aim of this work is to describe the surveillance system and report the health information in terms of temporal trends for the 5-year period 2001-2005. We identified all emergency department (ED) visits in the emergency database and then linked them with hospital discharges and mortality registry. From the integrated database, we calculated the rates of emergency room visits, of hospital admissions, and of mortality, reporting the temporal trends. Between 2001 and 2005 the rate of ED visits was 3151 per 100,000 inhabitants. Hospitalisation rates showed a significant decreasing trend. The surveillance identified 22% more deaths in the study period than reported by the official statistics. The surveillance revealed a decreasing trend for hospital admissions and a decline in deaths in 2003 concurrent to the introduction of the driver's licence point system.

Road traffic injuries in one local health unit in the Lazio region: results of a surveillance system integrating police and health data.

OBJECTIVE: Different sources are available for the surveillance of Road Traffic injuries (RTI), but studied individually they present several limits. In this paper we present the results of a surveillance integrating healthcare data with the data gathered by the municipal police in the southeastern area of Rome (630,000 inhabitants) during the year 2003. METHODS: The Municipal police RTI reports, which list the exact location, circumstances and some risk factor of the crash, were searched in the emergency visit, hospitalization and mortality databases, to integrate them with the information on health consequences. A multivariate analysis was conducted to evaluate risk factors (crash circumstances, age ad gender of the casualty) associated with hospital admission following a RTI. Mapping of RTI locations was created. The locations with higher risk of accidents with severe health consequences and at higher risk for pedestrians were identified. RESULTS: According to police records 4571 RTI occurred in 2003, 75% of which led to emergency department admissions. Sixteen percent of these emergency visits ended in hospitalization, and 44 deaths were reported within 30 days of the event, most of which occurred in young men. The people with the highest risk of hospitalization after an RTI were the cyclists, pedestrians and followed by people on two-wheeled vehicles. The type of crash with the highest risk of hospitalization was head-on collision. Geographical analyses showed four clusters with higher severity of RTI. Specific attention was paid to pedestrian injuries. Analyzing the locations of RTIs involving pedestrians permitted us to rank the most dangerous streets. The roads at high risk for pedestrians identified problems in the bus stop constructions and in the placement of the zebra pedestrian crossings. CONCLUSION: This study proves the feasibility of an integrated surveillance system of RTI by using routinely collected local data. The high-risk locations identified with the geographic analyses method in this study highlighted infrastructural problems, suggesting immediate preventive interventions.

Mortality in elderly injured patients: the role of comorbidities.

Home injuries in older people are an important cause of morbidity, disability and death. In addition, the presence of a pre-existing disease has generally been shown to be associated with higher mortality in this population. The objective of the study was to evaluate the association between pre-existing chronic conditions and risk of death among older trauma patients. A retrospective study was conducted in the Lazio Region, including the city of Rome. The study included all the people aged 65 years or older who were admitted to emergency departments in the year 2000 for home or road injuries, which was followed by hospitalisation within 24 hours. Comorbidities are quantified according to the Charlson Comorbidity Index (CCI). The outcome of interest was 30-day mortality. To measure the association between comorbidities and the probability of death, logistic regression was used, adjusting for triage code, sex, age and place of injury. An analysis stratified by triage was also performed. It was found that 17.9% of the injured subjects (8145) were affected by one or more chronic conditions. The probability of death was higher among males, older people, more severe patients and in cases of home accident. Risk of death for non-urgent and urgent patients increased with the increasing of the CCI score. Mortality among very urgent injured elderly was not affected by the presence of chronic conditions. It was concluded that chronic conditions are strong determinants of mortality, particularly for mild injuries.

Breast cancer diagnostic methods: screen-detected and clinical cases. An Italian survey of women's experiences.

AIMS AND BACKGROUND: The real practice of breast cancer diagnosis and treatment is often very different from guideline recommendations. Screening programs should minimize deviations from "best practice". The aim of the study was to compare cases detected by screening programs with cases that were not part of the public screening program, analyzing the diagnostic pathways from the first suspected breast problem to therapeutic intervention for breast cancer. METHODS: We interviewed a random sample of 268 women aged 49-70 years in three Italian regions (Lazio, Tuscany, Basilicata) who were treated for breast cancer, stratified by screening participation. RESULTS: In the nonscreened group, 48% of women were symptomatic and 50% were diagnosed by preventive tests. The proportion of women treated within 30 days of diagnosis was significantly lower in the screened group, 21.3% vs 35.8% (P = 0.0003). The mean number of tests (mammography, ultrasonography, cytology and histology) performed in the screened group was significantly higher than in the nonscreened group, 3.7 vs 2.8 (P = 0.001). The percentage of women treated without a preoperative histological or cytological diagnosis was lower in the screened group than in the nonscreened group, 14% vs 25% (P = 0.024). CONCLUSION: Participation in screening programs seems to lead to more appropriate disease management even for breast cancer cases treated at the same hospital.

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.

Evaluation of the health effects of the new driving penalty point system in the Lazio Region, Italy, 2001-4.

OBJECTIVE: The penalty point system was introduced in Italy in June 2003. The aim of this study was to evaluate the health effects of this legislation in the Lazio region. METHODS: Poisson models were used to compare emergency department visits, hospitalizations and death between the pre-law and post-law periods (July 2001-June 2003; July 2003-June 2004). RESULTS: The emergency department visit rate ratio (RR) of the two periods was 0.87 (95% confidence interval (CI) 0.86 to 0.88); the corresponding hospital admission RR was 0.87 (95% CI 0.84 to 0.9). The death RR was 0.93 (95% CI 0.82 to 1.05). CONCLUSION: After the legislation was introduced, there were fewer visits to the emergency department, hospitalizations and death from road traffic injuries. However, the effect was lower than expected, and it decreased over time.

Home injuries mortality: sensitivity and specificity analysis of different data sources and operative definitions.

UNLABELLED: The aim of this longitudinal study was to test different operational definitions of home accident mortality. METHODS: The sources of data were the Emergency Information System, hospital discharge reports and the mortality registry of the Lazio Region, 2000-2001. We selected all emergency room visits for unintentional traumas that occurred at home. A 9-month follow-up was performed to calculate mortality rates. A sensitivity analysis of in-hospital mortality, deaths within 30 days and deaths from home accident E-codes was performed. A gold standard definition of home accident-related deaths was proposed. RESULTS: We observed 598 home accident-related fatalities (29.1% of all the deaths found in the follow-up study). In-hospital mortality, deaths within 30 days and deaths for home accident E-codes had sensitivity values of 63.4%, 63.4% and 59.4%, respectively; positive predictive values were 78.1%, 67.1% and 100%, respectively. CONCLUSIONS: The best operational definition of home injury was based on in-hospital mortality, while mortality based on E-codes reported on death certificates was lacking. In order to measure the real burden of home injuries, hospital and mortality data must be integrated.

[Road and home-accident injuries of infants and adolescents in the Lazio region. Results of an integrated surveillance system]. / Incidenti stradali e domestici nei bambini e adolescenti della Regione Lazio. Risultati della sorveglianza integrata.

OBJECTIVE: road traffic and home accidents are one of the leading causes of death for infants and adolescents between 0-18 years of age. This study aimed to describe the injuries of children in the Lazio Region, in the year 2000. DESIGN: retrospective cohort study. SETTING: road traffic and home accident injury visits to all Emergency Departments (ED) in the Lazio region during 2000, Hospital discharges in the region during 2000-2001, integrated through deterministic linkage strategy PARTICIPANTS: all children aged 0-18 who visited one of the ED for home or road traffic injuries. MAIN OUTCOME MEASURES: we computed ED visits and hospitalisation rates and stratified them by sex, age and place of residence. Cases were classified by body region and type of lesion. IRR and 95% confidence intervals have been estimated using Poisson Regression. RESULTS: the rate of home accident visits was particularly high among children aged 1-5 years (55.2/1000), while the highest rate for road traffic injuries was in 14-18 year old children (53.8/1000). Girls had a lower hospitalisation rate than boys. Higher hospitalisation rates were found for children living outside of Rome. The body region most frequently injured in road traffic accidents was the lower extremities (28.4%), while most frequently injured in home accidents was the head and neck (34.8%). CONCLUSION: this study shows how integrating different systems of surveillance can provide a more complete picture of injuries from road and home accidents, that is difficult to obtain using other sources. The youngest children are at high risk of home accidents while teen-agers are at risk for road traffic injuries.

Unintentional home injuries reported by an emergency-based surveillance system: incidence, hospitalisation rate and mortality.

OBJECTIVE: The aim of this study is to quantify the incidence of home injuries using an integrated surveillance system. It aims to estimate home accident mortality. MATERIAL AND METHODS: The sources of data for this epidemiological descriptive study were the emergency information system, the hospital information system and the mortality registry of Lazio Region, 2000-2001. We selected all emergency department (ED) visits for unintentional traumas that occurred at home. We calculated incidence of ED visits, hospitalisation and mortality rates by sex and age. RESULTS: In the year 2000, 145101 persons visited the ED (2700/100000), 8.1% of whom were then admitted to the hospital. Incidence was higher among children and older people. We observed 620 fatalities, a rate of 0.43%. The mortality registry reported 1042 deceased, a home accident-related mortality rate of 31.1/100000. CONCLUSIONS: Unintentional injuries in the home are a relevant public health problem. Since none of the databases used in the study give a complete measure of the burden of home injuries, we combined the data from all of them to estimate the mortality and the burden of home injuries. Interventions for prevention must identify the specific accidents/injuries they are trying to reduce in order to focus their intervention on the appropriate population.

Road traffic injuries in Lazio, Italy: a descriptive analysis from an emergency department-based surveillance system.

STUDY OBJECTIVE: Road crashes are the leading cause of death for young adults in industrialized countries. In most countries, the only data available are the police-based statistics, which report the number of deaths and injuries, without any information about severity or diagnosis. We describe the results of an emergency department (ED)--based integrated surveillance system of road-crash health consequences in the Lazio region (5.3 million inhabitants) for 2000. METHODS: We identified all ED visits in the emergency database and then linked them with hospital discharges and mortality registry. Deaths that occurred at the site of the crash were identified in the mortality registry. Cases are classified according to body region affected, nature of the injury, and severity. RESULTS: We found 146,600 cases, for an overall incidence of 2,700 per 100,000 and a peak of 8,000 per 100,000 in 20- to 24-year-old men. There were 597 fatalities for men and 205 female fatalities, with an overall mortality of 15.9 per 100.000 and a hospitalization rate of 224 per 100,000. CONCLUSION: Our surveillance system reported a 6-times-higher incidence of road-traffic injuries, with 139 more fatalities than the national statistics of the same year. The underreporting in police reports and the absence of diagnostic information reveal the need for health-based surveillance systems of road-traffic injuries.