Background/Objectives: Inappropriate use of emergency department (ED) services is widely acknowledged to have a negative impact on health systems as a whole. A minor portion of Frequent User (FU) patients are often responsible for the disproportionate use of ED services. Methods: A retrospective population study was conducted on the attendances of pediatric EDs from 1 January 2022 to 31 December 2022 at the Roma 1 Local Health Authority in Rome, a territory served by more than 13 EDs. Nested logistic regression analysis was used to investigate patient characteristics in predicting inappropriate use of EDs. Results: In 2022, 35,691 pediatric ED attendances were recorded, with 24,824 patients distributed among 904 PCP/GPs in the six districts. A total of 71.8% of patients had only one attendance in 2022. A total of 3.5% of the patients were FUs, who were responsible for more than 10% of the attendances. However, most of the attendances were not appropriate. FUs, younger age (<2 yo), and more severe clinical presentations were more likely to be associated with appropriate ED attendance. PCPs/GPs and districts do not have a role in determining a higher number of ED attendances. The single patient’s characteristics have a greater influence on this phenomenon. Conclusions: Frequent use of the ED is not associated with inappropriate use among children, mainly due to the characteristics and needs of specific patients. However, parents’ education for a more rational use of health system resources and the provision of local solutions to children’s health needs may allow for a more appropriate use of health service resources.

INTRODUCTION:Onsite school-based intervention represents a key strategy to increase influenza vaccination uptake and improve knowledge of children, parents and school staff. This study aims to quantitatively describe an intervention in Local Health Authority Roma 1. METHODS:Vaccination was offered to children aged 2-6 years. A quantitative descriptive analysis of vaccination coverage and population variables was performed. RESULTS:29 schools were included. Out of 2,424 eligible children, 405 were vaccinated (16.7%). Of these, 218 (53.8%) were male and 187 (46.2%) female, mean age 4.4 years old. 177 (43.7%) received one dose, while 228 (56.3%) were vaccinated for the first time. Of these, 150 students (65.8%) also received the second dose. 148 other people (parents, teachers and older children) decided to join the campaign, thus being vaccinated. CONCLUSIONS:Community-based interventions in school settings increase adherence to health promotion campaigns. It is necessary to continue researching and investing in such activities.

Objective The natural infection with SARS-CoV-2, or vaccination against it, has been postulated to directly contribute to an increase in the incidence of autoimmune inflammatory rheumatic diseases (AIIRDs). Conversely, preventive measures limiting access to healthcare services could have resulted in missed or delayed AIIRD diagnoses or have reduced the infection rate of any triggering infections. We aimed to define real-life trends in AIIRD diagnoses from the prepandemic period through 2023 in a large and geographically circumscribed population of 6.5 million inhabitants.Methods AIIRDs’ annual diagnosis rates from 2017 to 2023 were derived from the registration of disease-specific exemption codes of the resident population of Lazio, a highly populated region in central Italy. Incidence rate ratios (IRRs) were calculated to compare pandemic and average prepandemic rates (2017–2019). Poisson regression was used to define statistically significant changes.Results A total of 16 254 AIIRD diagnoses were registered over the 7-year period. The average prepandemic incidence of AIIRDs was 4.81 per 10 000 inhabitants (95% CI 4.69 to 4.92). Compared with the prepandemic period, the diagnosis rate decreased in 2020 (IRR 0.68, 95% CI 0.64 to 0.72) but remained above prepandemic levels in 2021, 2022 and 2023. In 2023, there was a 22% increase in AIIRD incidence compared with prepandemic levels (IRR 1.22, 95% CI 1.17 to 1.28, p<0.001). This excess incidence was primarily driven by increases in both primary arthritides and systemic rheumatic diseases.Conclusions We observed a temporary decline in diagnosis in 2020, followed by a substantial increase from 2021 to 2023. This trend (decline and increase) may be linked to COVID-19 infection or to the reduction and subsequently potential increase of other infectious triggers following the use of preventive measures, such as facial masks and social distancing.

Background/Objectives: Frequent users (FUs) are patients who repeatedly attend Emergency Departments (EDs). This study aims to identify the clinical and social characteristics of FUs in a Local Health Authority in Rome and to quantify and compare the variation in the probability of being FU attributable to General Practitioners (GPs) and Local Health Districts (LHDs). Methods: The Healthcare Emergency Information System and an automated database of Lazio Region residents were used for the collection of data on the patients’ socioeconomic status, GP, LHD and chronic diseases. Different FU thresholds (attendances ≥4, 5, 7 or 10) were used for descriptive analyses. Univariate logistic analysis and a multilevel logistic model were performed for inferential analyses. Results: A total of 89,036 individuals attended at least one of the 13 EDs included in the study. Mental illness was present in 2.6% of non-FUs compared with 7.6% of FUs with ≥4 attendances. The OR of being FU increased with higher clinical complexity. GP appeared to play an important role in determining FU behavior, while no significant effect was found on the LHD level. Conclusions: This study identified potential risk factors predictive of disproportionate ED use and may help policymakers address the FU phenomenon.

Abstract Background Recent studies have reported the increasing utilisation of the Emergency Departments (EDs) for non-urgent attendances by people aged <18 years. The aim of this study is to describe the characteristic of the paediatric frequent user (FU) population, highlighting the differences between FUs and non-FUs, and to identify factors linked to appropriate ED attendance, comparing the level of variability attributed to the geographical and family physician components. Methods A retrospective cohort study was carried out of the ED attendances in 2022 in the 8 EDs of the Local Health Authority Roma 1 geographical area, in Rome. The cohort was enrolled from the regional Healthcare Emergency Information System. Records included information on number of attendance, age and gender, usage of emergency medical service (EMS), triage code, appropriateness of attendance. Multivariable nested logistic regression was performed to identify the characteristics of FU and non-FU attendances and the predictors for appropriateness of attendances. Results In 2022, the total number of children with at least 1 ED attendance is 24.824 and a total of 35.691 attendances were recorded. The regression analysis highlights that the appropriateness of attendances is associated to the female gender (OR male: 0.84), age <1 year (OR: 2.06), the usage of EMS (OR: 2.00), high triage code and being a FU (OR FU: 1.53). The family physician group have a greater influence of District group but lower influence of single patient characteristics group to determine the appropriateness of paediatric ED attendances (MOR District: 1.73; MOR PCP: 1.84; MOR single patient characteristics: 2.75). Conclusions Frequent use of the ED is partially associated with an inappropriate use of EDs, mostly due to the specific patients’ characteristics. It is therefore necessary to adopt strategies to improve the appropriate use of health service resources in order to provide quality health solutions to real health needs. Key messages • This is the first study that defines an ED paediatric FU profile in Italy. • It compares the level of variability attributed to the geographical component and family physician components.

Population Medicine considers the following types of articles:• Research Papers -reports of data from original research or secondary dataset analyses.• Review Papers -comprehensive, authoritative, reviews within the journal's scope.These include both systematic reviews and narrative reviews.• Short Reports -brief reports of data from original research.• Policy Case Studies -brief articles on policy development at a regional or national level.• Study Protocols -articles describing a research protocol of a study.• Methodology Papers -papers that present different methodological approaches that can be used to investigate problems in a relevant scientific field and to encourage innovation.• Methodology Papers -papers that present different methodological approaches that can be used to investigate problems in a relevant scientific field and to encourage innovation.

Background The Russian invasion of Ukraine caused millions of Ukrainian refugees to flee to other nations. To provide the most appropriate assistance, host nations necessitate up-to-date information regarding Ukrainian refugee's demographic and epidemiological conditions. We aim to investigate the demographic composition, the COVID-19 vaccinations performed, specialist care provided and the prevalence of non-communicable diseases (NCDs) in refugees assisted by an Italian Local Health Authority (LHA). Methods We conducted a retrospective cross-sectional analysis from March to June 2022, analyzing the demographic and epidemiological status of Ukrainians. Statistical analyses were carried out to assess possible associations between NCDs distribution, age and gender. Results LHA Roma 1 assisted 9349 Ukrainian refugees. Of these, 2784 (29.8%) were males and 6565 (70.2%) were females, with a median age of 25 years. Two thousand four hundred and eighty-five Ukrainian refugees were vaccinated against COVID-19. Among them, 401 (16.1%) had at least one NCD. The most frequent groups of diseases were related to the circulatory system (50.6%), the endocrine system (24.9%), and mental and behavioral disorders (6.5%). Conclusion Refugees need healthcare services targeted mainly towards minors and females. It is essential to analyze and monitor the demographic and epidemiological conditions to provide evidence about patient management and the best care integrated into the health service of host countries.

Abstract COVID-19 pandemic represented a disruptive event for all sectors, especially the healthcare one. It revealed weakness of healthcare systems, often organised in silos, and called for a great coordination among several stakeholders. Different healthcare organizational solutions were implemented in order to address this extraordinary situation. This study investigates the impact of an organizational innovation, District Operation Centres (DOCs), of a Local Health Authority (LHA) in Rome aimed at responding overall to primary care and public health (PH) needs during the first phases of pandemic. In the DOCs health districts professionals supported general physicians (GPs) and family paediatricians (FPs), acting as a bridge with the PH Department, in order to better manage COVID-19 patients and close contacts. To understand the utility and the areas of support to GPs and FPs a survey (21 open questions or on a Likert scale), realised according the Delphi method, was admnistered to them. The sample was calculated using Epi Info, randomization was performed through Excel. A descriptive analysis of the sample and of the answers was carried out. When appropriate, statistical tests were used to understand differences among districts. 215 doctors were interviewed between Dec 2020 and Jan 2021. More than 50% declared to have found DOCs useful, above all for guiding to legislation and to activate medical equipes to deliver swabs at home. The support was evaluated not good regarding COVID-19 cases/contacts and cluster(s) management. Further needs as support in frail patients’ management, involvement of specialists, delivery of telemedicine, more involvement of GPs/FPs in district activities were identified. DOCs were an attempt to support GPs/FPs in improving care to COVID-19 patients/contacts. To provide this new service in the pandemic emergency denotes great leadership in the LHA to yield collaboration among several stakeholeders and vision about patient-centered healthcare. Key messages • Although several limits like need of more integration, DOCs represent an experience aimed at overcoming duality between primary care and public health systems and the fragmentation of the system. • DOCs could be considered an organizational innovation to make the system more resilient and patient-centered.

Background and Aims: Patients’ nutritional intake is a crucial issue in modern hospitals, where the high prevalence of disease-related malnutrition may worsen clinical outcomes. On the other hand, food waste raises concerns in terms of sustainability and environmental burden. We conducted a systematic review to ascertain which hospital services could overcome both issues. Methods: A systematic literature search following PRISMA guidelines was conducted across MEDLINE, Web of Science, and Scopus for randomised controlled trials (RCTs) and observational studies comparing the effect of hospital strategies on energy intake, protein intake, and plate/food waste. The quality of included studies was assessed using the Newcastle-Ottawa Scale for cohort studies and the Cochrane Risk of Bias tool from the Cochrane Handbook for Systematic Reviews of Interventions for RCTs. Results: Nineteen studies were included, assessing as many hospital strategies such as food service systems—including catering and room service—(n = 9), protected mealtimes and volunteer feeding assistance (n = 4), food presentation strategies (n = 3), nutritional counseling and education (n = 2), plant-based proteins meal (n = 1). Given the heterogeneity of the included studies, the results were narratively analysed. Conclusions: Although the results should be confirmed by prospective and large sample-size studies, the personalisation of the meal and efficient room service may improve nutritional intake while decreasing food waste. Clinical nutritionist staff—especially dietitians—may increase food intake reducing food waste through active monitoring of the patients’ nutritional needs.

Population Medicine considers the following types of articles:• Research Papers -reports of data from original research or secondary dataset analyses.• Review Papers -comprehensive, authoritative, reviews within the journal's scope.These include both systematic reviews and narrative reviews.• Short Reports -brief reports of data from original research.• Policy Case Studies -brief articles on policy development at a regional or national level.• Study Protocols -articles describing a research protocol of a study.• Methodology Papers -papers that present different methodological approaches that can be used to investigate problems in a relevant scientific field and to encourage innovation.• Methodology Papers -papers that present different methodological approaches that can be used to investigate problems in a relevant scientific field and to encourage innovation.

BackgroundTelemedical approaches represent a valuable tool for the management of coronavirus disease 2019 patients, allowing daily clinical assessment, monitoring of vital parameters, remote visits, and prescription of treatment or hospitalization in case of clinical worsening. This cross-sectional study aims to evaluate the use, barriers and facilitators of the "Lazio ADVICE" telemedical platform, a regional system for remote assistance for coronavirus disease 2019 patients at home, according to General Practitioners and Family Pediatricians of the Local Health Authority Roma 1, during the coronavirus disease 2019 pandemic. MethodsAn interview-based survey was performed between December 2020 and January 2021. The survey investigated the demographic information of General Practitioner and Family Pediatricians, the knowledge of the platform, frequency of utilization, usefulness, strengths and weaknesses, and hypothesis of future implementation proposed. ResultsWe interviewed 214 physicians and 89 (41.6%) were classified as users and 125 (58.4%) as non-users. Older age and working in District 1, 14 and 15 (vs. District 13) significantly reduced the probability of using the platform physician. Among the 89 users, 19 (21.3%) used the platform every day or even several times a day, 40 (44.9%) several times a week but less than one access per day, 30 (33.7%) used the platform several times a month up to one entry per week. Most of them (92.3%) consider the platform useful. Barriers were poor integration with software and work routine (76.4%), and usability issues (53.9%). Among the 125 non-users, 14 (11.2%) didn't know the existence of the platform, 60 (48.0%) never tried it and 51 (40.8%) tried to use it. Reported reasons for the interruption of use were not very user-friendly (45.1%), perceived useless (37.3%), non-optimal functioning (23.5%), and lack of time (19.6%). ConclusionThe pandemic accelerated the implementation of telemedicine services around Lazio Region, starting a positive and continuous exchange of experiences, activities and best practices among physicians.

Population Medicine considers the following types of articles:• Research Papers -reports of data from original research or secondary dataset analyses.• Review Papers -comprehensive, authoritative, reviews within the journal's scope.These include both systematic reviews and narrative reviews.• Short Reports -brief reports of data from original research.• Policy Case Studies -brief articles on policy development at a regional or national level.• Study Protocols -articles describing a research protocol of a study.• Methodology Papers -papers that present different methodological approaches that can be used to investigate problems in a relevant scientific field and to encourage innovation.• Methodology Papers -papers that present different methodological approaches that can be used to investigate problems in a relevant scientific field and to encourage innovation.

BACKGROUND:COVID-19 pandemic represented a shock for healthcare systems. Italy was one of the first country to deal with a huge number of patients to be diagnosed, isolated, and treated with scarce evidence-based guidelines and resources. Several organizational and structural changes were needed to face the pandemic at local level. The article aims at studying the perceived impact of the newly implemented District Operation Centres (DOCs) of Local Health Authority (LHA) Roma 1 in managing active surveillance and home care of COVID-19 patients and their close contacts in cooperation with general practitioners (GPs). METHODS:A questionnaire, developed according to Delphi methodology, was validated by 7 experts and administered to a randomized sample of GPs and family paediatricians (FPs). All medical doctors selected received a phone interview between December 2020 and January 2021. The questionnaire investigated general characteristics of the sample, relations with DOC and its usefulness, and potential developments. A descriptive analysis was performed and inferential statistical tests were used to assess differences. RESULTS:In April 2020 the LHA Roma 1 implemented one DOCs in each local health district. 215 medical doctors were interviewed, reaching the sample target for health districts (80% CL and 10% MOE) and the whole LHA (90% CL and 5% MOE). Several aspects in the management of COVID-19 cases and close contacts of COVID-19 cases, and of the support of DOCs to GPs/FPs were investigated. More than 55% of the GPs and FPs interviewed found the DOCs useful and more than 78% would recommend a service DOC-like to other LHAs. The medical professionals interviewed would use DOCs in the future as support in treating vulnerable patients, utilizing digital health tools, enlisting specialist doctors, establishing networks, and facilitating professional counselling by nurses. CONCLUSIONS:This study is an attempt to evaluate an organizational change happened during COVID-19 pandemic. DOCs were created to support GPs and FPs as a link between primary healthcare and public health. Although several difficulties were disclosed, DOCs' experience can help to overcome the fragmentation of the systems and the duality between primary care and public health and make the system more resilient.

Population Medicine considers the following types of articles:• Research Papers -reports of data from original research or secondary dataset analyses.• Review Papers -comprehensive, authoritative, reviews within the journal's scope.These include both systematic reviews and narrative reviews.• Short Reports -brief reports of data from original research.• Policy Case Studies -brief articles on policy development at a regional or national level.• Study Protocols -articles describing a research protocol of a study.• Methodology Papers -papers that present different methodological approaches that can be used to investigate problems in a relevant scientific field and to encourage innovation.• Methodology Papers -papers that present different methodological approaches that can be used to investigate problems in a relevant scientific field and to encourage innovation.

BACKGROUND:The conflict between Russia and Ukraine has strained the health systems of countries that welcome war refugees on all levels, from national to local. Despite the Public Health guidelines regarding assistance being published on the topic, the scientific literature currently lacks evidence on the experience of applying theory in practice. This study aims to describe evidence-based practices that were implemented and to provide a detailed description of emerging problems and solutions pertaining Ukrainian refugee assistance in the context of one of the biggest Local Health Authorities in Italy (LHA Roma 1).METHODS:LHA Roma 1 developed a strategic plan based on local expertise, national and international guidelines to ensure infectious disease prevention and control, as well as continuity of care for non-communicable diseases and mental health.RESULTS:The insertion of Ukrainian refugees in the National Health System through an identification code assignment and other services such as COVID-19 swab and vaccination were provided either in one of the three major assistance hubs or in local district level ambulatories spread throughout the LHA. Many challenges were faced during the implementation phase of the outlined practice guidelines, which required sensible and timely solutions. These challenges include the necessity of rapid resource provision, overcoming linguistic and cultural barriers, guaranteeing a standard of care across multiple sites and coordination of interventions. Public Private Partnerships, the creation of a centralized multicultural and multidisciplinary team and the mutually beneficial collaboration with the local Ukrainian community were essential to guarantee the success of all operations.CONCLUSIONS:The experience of LHA Roma 1 helps shed light on the importance of leadership in emergency settings and how a dynamic relationship between policy and practice would allow each intervention to be modulated according to the local environment, to better realize the potential of local realities to provide appropriate health interventions to all those in need.

Abstract Background: The impact of the severe acute respiratory syndrome Coronavirus 2 disease (COVID-19) pandemic on people with systemic autoimmune rheumatic diseases (SARDs) is not fully established. It is unclear whether SARDs are an independent risk factor for infection and poor outcomes. Methods: Incidence and 30-day outcomes of COVID-19 infection were retrospectively evaluated in 40,490 SARD patients in the Lazio Italian Region and compared to the general population as incidence rate ratio adjusted for demographics and comorbidities (adjIRR). SARD diagnosis and comorbidities were derived from medical administrative records using the Chronic Related Group classification system. Data on COVID-19 infection were derived from a dedicated regional digital network. Results: The COVID-19 infection risk was increased in patients with Psoriatic Arthritis (adjIRR=1.21, 95% CI 1.10-1.33) and Undifferentiated Connective Tissue Disease (adjIRR=1.26, 95% CI 1.03-1.54). The hospitalization risk was higher in patients with Axial Spondylarthritis (adjIRR=2.16, 95% CI 1.45-3.22), and Systemic Vasculitis (adjIRR=1.81, 95% CI 1.07-3.06) while intensive care unit admission risk was higher in Systemic Erythematosus Lupus (adjIRR=3.67, 95% CI 1.52-8.83) and primary Sjögren Syndrome (adjIRR=4.13, 95% CI 1.71-9.96) patients. Increased mortality was reported in patients with Rheumatoid Arthritis (adjIRR=1.50, 95% CI 1.04-2.17), Systemic Erythematosus Lupus (adjIRR=2.67, 95% CI 1.10-6.44), primary Sjögren Syndrome (adjIRR=2.51, 95% CI 1.12-5.62), and Scleroderma (adjIRR=4.60, 95% CI 2.06-10.29). Conclusions: Each SARDs presents a peculiar pattern in terms of increased risk of COVID-19 incidence, hospitalization, intensive care unit admission, and death, that is not linked to the immunosuppressive behaviour of the disease.

Background: Healthcare workers' attitudes toward vaccination have been widely described in the literature, but a restricted amount of studies assessed healthcare students' knowledge, attitudes, and opinions on this issue. This study aimed to estimate the influence of a degree course on knowledge and immunization behavior among healthcare students and to compare medical students with students from other health profession degree programs to identify possible differences. Methods: A multicenter, cross-sectional study was performed in 2018 in 14 Italian Universities (3,131 students were interviewed). A validated questionnaire was used to assess knowledge, attitudes, and opinions toward vaccinations, with a specific focus on influenza vaccine and attitudes toward mandatory vaccination policies. Statistical software STATA (R) 14 was used. Results: Significant differences were recorded between medical students and other healthcare students. The intention to get vaccinated against influenza during the next season and having been vaccinated in the previous season was higher in the medical group (p < 0.001). In the group of students of other health professions, we registered a lower probability of identifying themselves as a high-risk group for contracting infectious diseases as a consequence of their profession and health status (aOR 0.49; CI95%: 0.40-0.60) and an increased likelihood of defining their level of knowledge on vaccine-preventable diseases and related vaccinations as "insufficient/sufficient/fair" (aOR 1.31; CI95%: 1.11-1.56). Conclusions: Results show several differences between medical students and students of other health professions when it comes to vaccination knowledge, attitudes, and perceptions, as well as a general low tendency to be vaccinated against influenza.(c) 2021 Occupational Safety and Health Research Institute, Published by Elsevier Korea LLC. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

In this paper, we start from a contextualization about the measures used to contain the COVID-19 diffusion and the need to promote geotechnological proposals, data sharing and homogenous centralised systems for data collection and analysis. Successively, we present the "Dynamic Space-Time Diffusion Simulator in a GIS Environment to Tackle the COVID-19 Emergency" that we have elaborated on the basis of the data provided by the UOC Hygiene and Public Health Service - Local Health Unit Rome 1. Particularly, after describing the main technical process able to predispose the dynamic simulator, we underline the possible added value that it can provide in terms of infection surveillance and monitoring, precision preparedness, support to decision making and territorial screening. For this demonstrative application, we have extracted from the simulator some groups of four digital screenshots which are able to show synoptic photographs in temporal perspective concerning the total number of cases of COVID-19 in Rome (Italy) for the period February 25th - September 26th. Specifically we have selected: - four screenshots for the period February 25th - June 11th, to provide significant evidence about the first three months and a half; - four screenshots for the period March 1st - March 29th, to add an insight into the geographically and statistically meaningful month of March; - four screenshots for the period June - 12th September 26th, to supply an efficacious geovisualisation of the last three months and a half available; - four screenshots for the period February 25th - September 26th, to show a cumulative elaboration aimed at geolocating all the cases recorded in the seven months examined; - four screenshots for the period March 26th - September 26th, with a distinction about the first and second data sets, for a detailed (cumulative) zoom. This simulator, elaborated for the COVID-19 emergency, can be replicated in any circumstance for which specific data and information are available for the scientific community, shared and progressively updated in order to provide a productive contribution to the identification of serious infectious disease clusters, patterns and trends, and quickly respond to specific needs.

Background Patient portals are becoming increasingly popular worldwide even though their impact on individual health and health system efficiency is still unclear. Objective The aim of this systematic review was to summarize evidence on the impact of patient portals on health outcomes and health care efficiency, and to examine user characteristics, attitudes, and satisfaction. Methods We searched the PubMed and Web of Science databases for articles published from January 1, 2013, to October 31, 2019. Eligible studies were primary studies reporting on the impact of patient portal adoption in relation to health outcomes, health care efficiency, and patient attitudes and satisfaction. We excluded studies where portals were not accessible for patients and pilot studies, with the exception of articles evaluating patient attitudes. Results Overall, 3456 records were screened, and 47 articles were included. Among them, 11 studies addressed health outcomes reporting positive results, such as better monitoring of health status, improved patient-doctor interaction, and improved quality of care. Fifteen studies evaluated the impact of digital patient portals on the utilization of health services with mixed results. Patient characteristics were described in 32 studies, and it was reported that the utilization rate usually increases with age and female gender. Finally, 30 studies described attitudes and defined the main barriers (concerns about privacy and data security, and lack of time) and facilitators (access to clinical data and laboratory results) to the use of a portal. Conclusions Evidence regarding health outcomes is generally favorable, and patient portals have the potential to enhance the doctor-patient relationship, improve health status awareness, and increase adherence to therapy. It is still unclear whether the use of patient portals improves health service utilization and efficiency.