Youth suicide: an insight into previous hospitalisation for injury and sociodemographic conditions from a nationwide cohort study.

BACKGROUND: This study investigates the degree to which a previous hospitalisation for injury of any intent is a risk of subsequent youth suicide and whether this association is influenced by family socioeconomic status or economic stress. METHODS: A nationwide register-based cohort study was conducted covering all Swedish subjects born between January 1977 and December 1991 (N=1,616,342, male/female ratio=1.05). The cohort subjects were followed-up from January 1998 to December 2003, when aged 7-26 years. Poisson regression and the likelihood ratio test (95% CI) were used to assess the age-adjusted effect of hospitalisation for injuries of various intent on youth suicide and its effect once adjusted for family sociodemographic and social circumstances. RESULTS: Each set of exposures was associated independently and significantly with suicide mortality. Being hospitalised for self-inflicted injuries or injuries of undetermined intent was associated with a risk of suicide 36 to 47 times, respectively, that of subjects never hospitalised in the period under study (95% CI 28.36 to 45.58 and 26.67 to 83.87 for self-inflicted injuries and for events of undetermined intent, respectively; overall p<0.01). Similarly, previous events of unintentional injury markedly increased the risk of suicide (RR 3.08; 95% CI 2.26 to 4.19). These effects were solid and not substantially altered after adjustment for family demographic and socioeconomic circumstances. CONCLUSION: A strong association exists between previous hospitalisation for injury of any intent and youth suicide. The association is robust and unaltered by family socioeconomic circumstances.

Diffusion of good practices of care and decline of the association with case volume: the example of breast conserving surgery.

BACKGROUND: Several previous studies conducted on cancer registry data and hospital discharge records (HDR) have found an association between hospital volume and the recourse to breast conserving surgery (BCS) for breast cancer. The aim of the current study is to depict concurrent time trends in the recourse to BCS and its association with hospital volume. METHODS: Admissions of breast cancer patients for BCS or mastectomy in the period 2000-2004 were identified from the discharge database of the Veneto Region (Italy). The role of procedural volume (low < 50, medium 50-100, high > 100 breast cancer surgeries/year), and of individual risk factors obtainable from HDR was assessed through a hierarchical log-binomial regression. RESULTS: Overall, the recourse to BCS was higher in medium (risk ratio = 1.12, 95% confidence interval 1.07-1.18) and high-volume (1.09, 1.03-1.14) compared to low-volume hospitals. The proportion of patients treated in low-volume hospitals dropped from 22% to 12%, with a concurrent increase in the activity of medium-volume providers. The increase over time in breast conservation (globally from 56% to 67%) was steeper in the categories of low- and medium-volume hospitals with respect to high caseload. CONCLUSION: The growth in the recourse to BCS was accompanied by a decline of the association with hospital volume; larger centers probably acted as early adopters of breast conservation strategies that subsequently spread to smaller providers.

Evidence-based policy on road safety: the effect of the demerit points system on seat belt use and health outcomes.

OBJECTIVE: To assess the effect of a demerit points system, introduced in Italy in July 2003, on the prevalence of seat belt use (intermediate outcome) and the number of road traffic deaths and injuries (health outcomes). DESIGN: Pre- and post-intervention regional observational study for seat belt investigation (April 2003, October 2004); national time-series analysis of road traffic deaths and injuries between 1999 and 2004 for health outcomes. SETTING: Veneto region, Italy. PARTICIPANTS: 19,551 drivers, 19,057 front passengers and 8,123 rear passengers estimated to be aged over 11 years were included in the investigation into seat belt use. 38,154 fatalities and 1,938,550 injured subjects were examined for the time-series analysis. INTERVENTIONS: Demerit points system. MAIN OUTCOME MEASURES: The proportions of drivers and front and rear passengers observed to be using seat belts before and after the intervention; estimates of lives and injuries saved through the implementation of a penalty points system. RESULTS: The demerit points system was followed by an increase in observed seat belt use of 51.8% (95% confidence interval 48.7% to 54.9%) among drivers, of 42.3% (95% confidence interval 39.2% to 45.5%) among front passengers and of 120.7% (95% confidence interval 99.4% to 144.3%) among rear passengers. It is estimated that 1,545 (95% confidence interval 1387 to 1703; p<0.0001) deaths and 91,772 (95% confidence interval 67,762 to 115,783; p<0.0001) injuries were prevented in the 18 months after the introduction of the legislation, i.e. an 18% reduction (1545/8570) in fatalities and a 19% reduction (91,772/473,048) in injuries. CONCLUSIONS: The demerit points system is effective both in encouraging drivers and passengers to adhere to the law and in terms of health outcomes, substantially contributing to road safety.

Pattern and determinants of hospitalization during heat waves: an ecologic study.

BACKGROUND: Numerous studies have investigated mortality during a heatwave, while few have quantified heat associated morbidity. Our aim was to investigate the relationship between hospital admissions and intensity, duration and timing of heatwave across the summer months. METHODS: The study area (Veneto Region, Italy) holds 4577408 inhabitants (on January 1st, 2003), and is subdivided in seven provinces with 60 hospitals and about 20000 beds for acute care. Five consecutive heatwaves (three or more consecutive days with Humidex above 40 degrees C) occurred during summer 2002 and 2003 in the region. From the regional computerized archive of hospital discharge records, we extracted the daily count of hospital admissions for people aged >or=75, from June 1 through August 31 in 2002 and 2003. Among people aged over 74 years, daily hospital admissions for disorders of fluid and electrolyte balance, acute renal failure, and heat stroke (grouped in a single nosologic entity, heat diseases, HD), respiratory diseases (RD), circulatory diseases (CD), and a reference category chosen a priori (fractures of the femur, FF) were independently analyzed by Generalized Estimating Equations. RESULTS: Heatwave duration, not intensity, increased the risk of hospital admissions for HD and RD by, respectively, 16% (p < .0001) and 5% (p < .0001) with each additional day of heatwave duration. At least four consecutive hot humid days were required to observe a major increase in hospital admissions, the excesses being more than twofold for HD (p < .0001) and about 50% for RD (p < .0001). Hospital admissions for HD peaked equally at the first heatwave (early June) and last heatwave (August) in 2004 as did RD. No correlation was found for FF or CD admissions. CONCLUSION: The first four days of an heatwave had only minor effects, thus supporting heat health systems where alerts are based on duration of hot humid days. Although the finding is based on a single late summer heatwave, adaptations to extreme temperature in late summer seem to be unlikely.

Monitoring the occurrence of diabetes mellitus and its major complications: the combined use of different administrative databases.

OBJECTIVE: Diabetes mellitus is a growing public health problem, for which efficient and timely surveillance is a key policy. Administrative databases offer relevant opportunities for this purpose. We aim to monitor the incidence of diabetes and its major complications using administrative data. STUDY DESIGN AND METHODS: We study a population of about 850,000 inhabitants in the Veneto Region (Italy) from the end of year 2001 to the end of year 2004. We use four administrative databases with record linkage. Databases of drug prescriptions and of exemptions from medical charge were linked to identify diabetic subjects; hospital discharge records and mortality data were used for the assessment of macrovascular and renal complications and vital status. RESULTS: We identified 30,230 and 34,620 diabetic subjects at the start and at the end of the study respectively. The row prevalence increased from 38.3/1000 (95% CI 37.2-39.5) to 43.2/1000 (95% CI 42.3-44) for males and from 34.7/1000 (95% CI 33.9-35.5) to 38.1/1000 (95% CI 37.4-39) for females. The mean row incidence is 5.3/1000 (95% CI 5-5.6) person years for males and 4.8/1000 (95% CI 4.4-5.2) person years for females. The rate of hospitalisations for cardiovascular or kidney diseases is greatly increased in diabetic people with respect to non diabetics for both genders. The mortality relative risk is particularly important in younger age classes: diabetic males and females aged 45-64 years present relative risk for death of 1.7 (95% CI 1.58-1.88) and 2.6 (95% CI 2.29-2.97) respectively. CONCLUSION: This study provides a feasible and efficient method to determine and monitor the incidence and prevalence of diabetes and the occurrence of its complications along with indexes of morbidity and mortality.

Effect of the new diagnostic criteria for ST-elevation and non-ST-elevation acute myocardial infarction on 4-year hospitalization: an analysis of hospital discharge records in the Veneto Region.

OBJECTIVE: To assess the burden of hospitalization for acute coronary syndrome (ACS) and the impact of the new diagnostic criteria for acute myocardial infarction on epidemiology of ACSs. METHODS: We analysed the hospital discharge record archives of the Veneto Region in the period 2000-2003, including admissions of regional residents outside the study area. We defined a list of ICD-9-CM codes for the identification of different types of ACS. We examined trends in standardized hospitalization rates as well as patient characteristics (age, sex) and pattern of care (setting, invasive revascularization, length of hospital stay, in-hospital mortality). RESULTS: The hospitalization rate for non-ST-elevation myocardial infarction increased by about 70%, with a parallel decrease in hospitalizations for unstable angina, whereas the hospitalization rate for ST-elevation myocardial infarction remained unchanged. These trends are likely influenced by the new diagnostic criteria for acute myocardial infarction. At the end of the study period, although the main patient characteristics did not vary substantially, the pattern of care turned out to be more aggressive. CONCLUSIONS: Despite some limitations, our results indicate that the new diagnostic criteria for acute myocardial infarction have a major impact on epidemiological evaluation. These data may be relevant when comparing epidemiological data of different periods and planning healthcare policies. Further studies are needed in order to evaluate the accuracy of ICD-9-CM codes in the diagnosis of ACSs.

Measuring accuracy of discharge diagnoses for a region-wide surveillance of hospitalized strokes.

BACKGROUND AND PURPOSE: Measuring the impact of stroke through population-based stroke registers is complex and costly. The aim of the present study is to assess the validity of hospital discharge diagnoses (all ages) and to estimate the total number of hospitalized stroke events in the Veneto region (Northeastern Italy, 4,500,000 inhabitants). METHODS: All discharges covering a 1-year period (1999) from Veneto hospitals with International Classification of Diseases, 9th Revision codes 342, 430 to 434, and 436 to 438 were identified. A stratified sample was extracted and submitted to retrospective clinical record review according to the World Health Organization MONItoring trends and determinants in CArdiovascular disease stroke project. Using the positive predictive value (PPV) for validated acute stroke of each code to adjust for inaccuracy of discharge diagnoses, an estimate of hospital strokes was obtained. RESULTS: 4015 admissions were reviewed. Codes 430, 431, 434, and 436 as primary diagnoses had the highest PPV, which sharply decreased in the other diagnostic levels. Code 342 also showed a high PPV. The probability of suspected events meeting the stroke definition increased with age and was highest for patients admitted to neurological wards and for fatal events. Overall 9400 strokes (first-ever and recurrent) were estimated to be hospitalized in 1999, with an attack rate of 208 per 100,000. CONCLUSIONS: Our data indicate that once validation studies are undertaken on a sample of all hospitalized events, hospital discharge records can provide a valuable source of information on the actual burden of strokes on hospital services.

Pleurectomy/decortication plus chemotherapy: outcomes of 40 cases of malignant pleural mesothelioma.

Malignant pleural mesothelioma still has a dismal prognosis. Despite good patient selection and a multimodality approach, local disease control remains a problem. Whether submitted to pleurectomy/decortication or to extrapleural pneumonectomy, disease progression occurred in all 40 patients in this study. The role of radio-chemotherapy remains uncertain. Between 1985 and 2002, 40 patients underwent pleurectomy/decortication in combination with intracavitary chemotherapy. Pleurectomy was performed to remove all gross tumour, or to achieve significant debulking. Partial or total pleurectomy of the visceral pleura depended on the extent of the tumour. Systemic chemotherapy was administered when disease progression occurred. All 40 patients had disease progression, due in all cases to local recurrence. The Kaplan-Meyer method was used for statistical evaluation. Treatment was relatively well tolerated and quality of life satisfactory. Until disease progression, no important chest pain, pleural effusion, or dyspnoea occurred. Overall survival was 28% at 2 years and 17% at 3 years. Histological sub-type is the only significant prognostic factor for survival. Low morbidity and mortality and good quality of life after treatment make pleurectomy/decortication with intracavitary and systemic chemotherapy not only a radical approach in early stages, but also a good palliative treatment in advanced malignant pleural mesothelioma, especially in patients who are unsuitable for extrapleural pneumonectomy.