AbstractAimsA set of indicators to assess the quality of care for patients hospitalized for heart failure was developed by an expert working group of the Italian Health Ministry. Because a better performance profile measured using these indicators does not necessarily translate to better outcomes, a study to validate these indicators through their relationship with measurable clinical outcomes and healthcare costs supported by the Italian National Health System was carried out.Methods and resultsResidents of four Italian regions (Lombardy, Marche, Lazio, and Sicily) who were newly hospitalized for heart failure (irrespective of stage and New York Heart Association class) during 2014–2015 entered in the cohort and followed up until 2019. Adherence to evidence‐based recommendations [i.e. renin–angiotensin–aldosterone system (RAS) inhibitors, beta‐blockers, mineralocorticoid receptor antagonists (MRAs), and echocardiograms (ECCs)] experienced during the first year after index discharge was assessed. Composite clinical outcomes (cardiovascular hospital admissions and all‐cause mortality) and healthcare costs (hospitalizations, drugs, and outpatient services) were assessed during the follow‐up. The restricted mean survival time at 5 years (denoted as the number of months free from clinical outcomes), the hazard of clinical outcomes (according to the Cox model), and average annual healthcare cost (expressed in euros per person‐year) were compared between adherent and non‐adherent patients. A non‐parametric bootstrap method based on 1000 resamples was used to account for uncertainty in cost‐effectiveness estimates. A total of 41 406 patients were included in this study (46.3% males, mean age 76.9 ± 9.4 years). Adherence to RAS inhibitors, beta‐blockers, MRAs, and ECCs were 64%, 57%, 62%, and 20% among the cohort members, respectively. Compared with non‐adherent patients, those who adhered to ECCs, RAS inhibitors, beta‐blockers, and MRAs experienced (i) a delay in the composite outcome of 1.6, 1.9, 1.6, and 0.6 months and reduced risks of 9% (95% confidence interval, 2–14%), 11% (7–14%), 8% (5–11%), and 4% (−1–8%), respectively; and (ii) lower (€262, €92, and €571 per year for RAS inhibitors, beta‐blockers, and MRAs, respectively) and higher costs (€511 per year for ECC). Adherence to RAS inhibitors, beta‐blockers, and MRAs showed a delay in the composite outcome and a saving of costs in 98%, 84%, and 93% of the 1000 bootstrap replications, respectively.ConclusionsStrict monitoring of patients with heart failure through regular clinical examinations and drug therapies should be considered the cornerstone of national guidelines and audits.

Introduzione. Una rappresentazione sintetica dei molteplici indicatori che misurano la qualità dell’assistenza territoriale può essere molto utile per comprendere rapidamente i dati e definire le strategie di azione in maniera appropriata. L’obiettivo dello studio è implementare una rappresentazione grafica basata sul TreeMap, uno strumento in grado di sintetizzare i risultati di indicatori eterogenei, con scale di misurazione e riferimenti differenti, e utilizzarne le potenzialità per misurare l’impatto indiretto dell’epidemia da Sars-CoV-2 sulla qualità delle cure erogate. Metodi. Sono state considerate 7 aree assistenziali ciascuna definita da un set di indicatori rappresentativi dell’attività valutata. Al valore di ogni indicatore è stato attribuito un punteggio discreto variabile da 1 (standard di qualità molto alto) a 5 (standard di qualità molto basso), in base al livello di aderenza alle raccomandazioni evidence-based. Infine, il punteggio di ogni area assistenziale viene ottenuto come media ponderata dei punteggi degli indicatori rappresentativi dell’area. Il TreeMap territoriale viene calcolato per ciascuna Asl della Regione Lazio. Per valutare l’impatto dell’epidemia è stato effettuato un confronto tra i risultati del 2019 e quelli del 2020. Risultati. Sono stati riportati, a titolo di esempio, i risultati di una delle 10 Asl della Regione Lazio. Rispetto al 2019, nel 2020 si nota un miglioramento dell’assistenza territoriale in tutte le aree considerate, a eccezione dell’area metabolica che rimane stabile. Sono diminuite le ospedalizzazioni “evitabili” come quelle per scompenso cardiaco, Bpco e complicanze del diabete. È diminuita l’incidenza di eventi cardio-cerebrovascolari dopo un evento acuto, come l’infarto o l’ictus ischemico, e si sono ridotti gli accessi inappropriati in pronto soccorso. Inoltre, dopo decenni di sovraprescrizione, l’utilizzo di farmaci ad alto rischio di inappropriatezza, come gli antibiotici e i cortisonici inalatori, ha subìto una repentina battuta d’arresto. Discussione. Il TreeMap si è dimostrato un valido strumento per valutare la qualità delle cure territoriali, sintetizzando i risultati di numerosi indicatori “elementari”, per loro natura eterogenei. I miglioramenti nei livelli di qualità osservati nel 2020 rispetto al 2019 vanno interpretati con estrema cautela perché potrebbero costituire un paradosso generato dagli effetti indiretti dell’epidemia da Sars-CoV-2. Se, nel caso dell’epidemia, i fattori di distorsione possono essere facilmente identificati, in contesti valutativi differenti e più ordinari la “ricerca delle cause” potrebbe essere molto più complessa.

Abstract Background In Italy, inhaled corticosteroids (ICSs) are inappropriately prescribed to provide relief in URTI symptoms. Extreme variation in ICS prescribing has been described at regional and sub-regional level. During 2020, extraordinary containment measures were implemented in attempt to halt Coronavirus, such as social distancing, lockdown, and the use of mask. Our objectives were to evaluate the indirect impact of the SARS-CoV-2 pandemic on prescribing patterns of ICSs in preschool children and to estimate the prescribing variability among pediatricians before and during the pandemic. Methods In this real-world study, we enrolled all children residing in the Lazio region (Italy), aged 5 years or less during the period 2017–2020. The main outcome measures were the annual ICS prescription prevalence, and the variability in ICS prescribing, for each study year. Variability was expressed as Median Odds Ratios (MORs). If the MOR is 1.00, there is no variation between clusters (e.g., pediatricians). If there is considerable between-cluster variation, the MOR will be large. Results The study population consisted of 210,996 children, cared by 738 pediatricians located in the 46 local health districts (LHDs). Before the pandemic, the percentage of children exposed to ICS was almost stable, ranging from 27.3 to 29.1%. During the SARS-CoV-2 pandemic, the ICS prescription prevalence dropped to 17.0% (p < 0.001). In each study year, a relevant (p < 0.001) variability was detected among both LHDs and pediatricians working in the same LHD. However, the variability among individual pediatricians was always higher. In 2020, the MOR among pediatricians was 1.77 (95% CI: 1.71–1.83) whereas the MOR among LHDs was 1.29 (1.21–1.40). Furthermore, MORs remained stable over time, and no differences were detected in ICS prescription variability before and after pandemic outbreak. Conclusions If on one hand the SARS-CoV-2 pandemic indirectly caused the reduction in ICS prescriptions, on the other the variability in ICS prescribing habits among both LHDs and pediatricians remained stable over the whole study time span (2017–2020), showing no differences between pre- pandemic and pandemic periods. The intra-regional drug prescribing variability underlines the lack of shared guidelines for appropriate ICS therapy in preschool children, and raises equity issues in access to optimal care.

INTRODUCTION:A concise representation of different primary and ambulatory care quality indicators can be very useful for quickly understanding the data and defining appropriate intervention strategies. The objectives of this study are to implement a graphical representation based on the TreeMap, a tool capable of summarizing results from heterogeneous indicators, with different measurement scales and thresholds, and take advantage of TreeMap's potential to measure the indirect impact of the Sars-CoV-2 epidemic on primary and ambulatory care processes.METHODS:Seven healthcare areas were considered each defined by a set of different indicators representative of the area. A discrete score ranging from 1 (very high quality) to 5 (very low quality) was assigned to the value of each indicator, based on the level of adherence to evidence-based recommendations. Finally, the score of each healthcare area is obtained as the weighted average of the scores of the representative indicators. The TreeMap is calculated for each Local health authority (Lha) of the Lazio Region. In order to assess the impact of the epidemic, a comparison was made between the results observed in 2019 and those observed in 2020.RESULTS:As an example, the results of one of the 10 Lhas of the Lazio Region have been reported. Compared to 2019, in 2020 there was an improvement in primary and ambulatory healthcare regarding all of the evaluated areas, with the exception of the metabolic area which remained stable. "Avoidable" hospitalizations have decreased, such as those for heart failure, Copd and diabetes. The incidence of cardio-cerebrovascular events following myocardial infarction or ischemic stroke has decreased, and inappropriate visits to emergency room have reduced. Furthermore, after decades of overprescribing, the use of drugs with a high risk of inappropriateness, such as antibiotics and aerosolized corticosteroids, has significantly decreased.DISCUSSION:The TreeMap has proven to be a valid tool for evaluating the quality of primary care, summarizing evidence from different and heterogeneous indicators. The improvements in quality levels observed in 2020, compared to 2019, should be interpreted with extreme caution because they could represent a paradox generated by the indirect effects of the Sars-CoV-2 epidemic. If, in the case of the epidemic, the distorting factors can be easily identified, in different and more ordinary evaluative analyses the "research for the causes" could be much more complex.

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 benefits of chronic polytherapy in reducing readmissions and death after myocardial infarction (MI) have been clearly shown. However, real-world evidence shows poor medication adherence and large geographic variation, suggesting critical issues in access to optimal care. Our objectives were to measure adherence to polytherapy, to compare the amount of variation attributable to hospitals of discharge and to community-based providers, and to identify determinants of adherence to medications. Methods This is a population-based study. Data were obtained from the information systems of the Lazio and Tuscany Regions, Italy (9.5 million inhabitants). Patients hospitalized with incident MI in 2010–2014 were analyzed. The outcome measure was medication adherence, defined as a Medication Possession Ratio (MPR) ≥ 0.75 for at least 3 of the following drugs: antiplatelets, β-blockers, ACEI/ARBs, statins. A 2-year cohort-study was performed. Cross-classified multilevel models were applied to analyze geographic variation. The variance components attributable to hospitals of discharge and community-based providers were expressed as Median Odds Ratio (MOR). Results A total of 32,962 patients were enrolled. About 63% of patients in the Lazio cohort and 59% of the Tuscan cohort were adherent to chronic polytherapy. Women and patients aged 85 years and over were most at risk of non-adherence. In both regions, adherence was higher for patients discharged from cardiology wards (Lazio: OR = 1.58, p < 0.001, Tuscany: OR = 1.59, p < 0.001) and for patients with a percutaneous coronary intervention during the index admission. Relevant variation between community-based providers was observed, though when the hospital of discharge was included as a cross-classified level, in both Lazio and Tuscany regions the variation attributable to hospitals of discharge was the only significant component (Lazio: MOR = 1.30, p = 0.001; Tuscany: MOR = 1.31, p = 0.001). Conclusion Adherence to best practice treatments after MI is not consistent with clinical guidelines, and varies between patient groups as well as within and between regions. The variation attributable to providers is affected by the hospital of discharge, up to two years from the acute episode. This variation is likely to be attributable to hospital discharge processes, and could be reduced through appropriate policy levers.

Background:In Italy, direct oral anticoagulant drugs (DOACs) were authorized for stroke prevention in patients with non-valvular atrial fibrillation (NVAF) in 2013. There is conflicting evidence on their benefit-risk profile under real world conditions. Methods:The Italian Medicines Agency funded this study to investigate effectiveness and safety of DOACs compared to vitamin K antagonists (VKAs) in three Italian regions. An observational study was conducted with a sequential propensity-score-matched new user parallel-cohort design in the period July 2013-December 2015 using administrative health data. DOAC users with NVAF diagnosis were 1:1 matched to VKA users based on a PS which accounted for over 90 potential confounders at baseline. Applying an as-treated approach with a 90-day renewal grace time, patients were followed from the day after the first prescription of the study drug until occurrence of the outcome, death, discontinuation, switch, end of health plan enrolment, or study end. Outcomes were total and cardiovascular mortality, acute myocardial infarction, ischemic and haemorrhagic stroke, and gastrointestinal bleeding. Analyses were performed, using Cox proportional hazard models stratified by matched set. The results of the regional analyses were combined through a random-effects meta-analysis. Results:During the first 30 months of authorisation for NVAF, DOACs were increasingly prescribed. Overall, 72,434 new anticoagulant users were enrolled, 34% of whom received a DOAC. After PS matching, 37,266 patients contributed to the analysis. No differences between the study groups were found for total and cardiovascular mortality, myocardial infarction and ischemic stroke. DOAC users were at higher risk of gastrointestinal bleeding (HR 1.41, 95%CI 1.07-1.86) and at a not significant lower risk of haemorrhagic stroke (HR 0.36, 95%CI 0.10-1.33). Conclusions:The present study confirms findings from previous research regarding bleeding events, whereas we did not find a reduced risk of mortality in DOAC users. Further research on single active agents and specific populations is warranted.

Objective: To validate a set of indicators for quality of diabetes care through their relationship with measurable clinical outcomes. Design: A retrospective cohort study was carried out from 2010 to 2015. Setting: Population-based study. Data were retrieved from healthcare utilization databases of three Italian regions (Lombardy, Emilia Romagna and Lazio) on the whole covering 20 million citizens. Participants: The 77 285 individuals who were newly taken in care for diabetes during 2010 entered into the cohort. Interventions: Exposure to selected clinical recommendations (i.e. periodic controls for glycated hemoglobin, lipid profile, urine albumin excretion, serum creatinine and dilated eye exams) was recorded. Main outcomes measures: A composite outcome was employed taking into account hospitalizations for brief-term diabetes complications, uncontrolled diabetes, long-term vascular outcomes and no traumatic lower limb amputation. A multivariable proportional hazards model was fitted to estimate hazard ratio, and 95% confidence intervals (CI), for the exposure-outcome association. Results: Among the newly taken in care patients with diabetes, those who adhered to almost none (0 or 1), just some (2 or 3) or almost all (4 or 5) recommendations during the first year after diagnosis were 44%, 36% and 20%, respectively. Compared patients who adhered to almost none recommendation, significant risk reductions of 16% (95% CI, 6-24%) and 20% (7-28%) were observed for those who adhered to just some and almost all recommendations, respectively. Conclusions: Tight control of patients with diabetes through regular clinical examinations must to be considered the cornerstone of national guidance, national audits and quality improvement incentives schemes.

Patients who have had an acute myocardial infarction (MI) are at increased risk of mortality and morbidity. International guidelines agree on the use of combination of the following drugs: platelet antiplatelets, β-blockers, ACEI⁄ARBs and statins. The benefits of chronic polytherapy in reducing cardiovascular disease have been clearly shown. However, observational studies reported poor adherence to chronic polytherapy. We identified about 52,000 patients discharged from hospital with a first MI diagnosis from three Italian regions: Lazio, Toscana and Sicilia. Adherence to chronic poly-therapy in the two years after hospital discharge ranged from 63% in the Lazio region to 27% in the Sicilia region. More than 75 percent of MI patients had chronic concomitant diseases. Chronic diseases played a major role among barriers to adherence. MI patients with multimorbidity have complex health needs but, due to the current traditional disease-oriented approach, they face a highly fragmented form of care that leads to incomplete, inefficient, ineffective and possibly harmful clinical interventions, and are likely to receive complex drug regimens, which increase the risk of inappropriate prescribing, drug-drug interactions, and poor adherence. In order to address patient-specific needs, a network of multidisciplinary teams should be implemented, avoiding fragmentation and ensuring continuity of care.

L’infarto miocardico acuto aumenta notevolmente il rischio di morbilità e mortalità. Le linee-guida raccomandano il trattamento combinato e continuativo con quattro farmaci evidence-based: antiaggreganti, betabloccanti, ACE-inibitori/sartani e statine. Queste raccomandazioni sono supportate da solide evidenze scientifiche. Tuttavia, studi osservazionali hanno documentato una ridotta aderenza alla politerapia cronica. In questo studio, condotto in tre regioni italiane, Lazio, Toscana e Sicilia, sono stati analizzati circa 52.000 pazienti al primo episodio di infarto. L’aderenza alla politerapia cronica variava dal 63% nella regione Lazio al 27% nella regione Sicilia. Più del 75% dei pazienti presentava almeno una patologia cronica concomitante. La presenza di patologie croniche rappresentava una delle principali barriere all’aderenza al trattamento. I pazienti multicronici con pregresso infarto presentano un’elevata complessità assistenziale. Tuttavia, ricevono ancora un’assistenza frammentata, fornita da molteplici provider che non interagiscono tra loro. Quando il paziente viene “de-strutturato” nelle singole patologie da cui è affetto, aumenta il rischio che venga esposto a un numero eccessivo di trattamenti farmacologici. Questo fenomeno, da un lato, riduce l’aderenza ai trattamenti e, dall’altro, può generare interazioni nocive tra i diversi farmaci. Sarebbe auspicabile istituire sul territorio una rete di team multidisciplinari, volti alla valutazione globale del paziente e alla sua continuità assistenziale.

OBJECTIVES:to test the validity of algorithms to identify diabetes, chronic obstructive pulmonary disease (COPD), hypertension, and hypothyroidism from routinely collected health data using information from self-reported diagnosis and laboratory or functional test.SETTING AND PARTICIPANTS:clinical or self-reported diagnosis from three surveys conducted in Lazio Region (Central Italy) between year 2010 and 2014 were assumed as gold standard and compared to the results of the algorithms application to administrative data.MAIN OUTCOME MEASURES:prevalence resulted from administrative data and from information available in the surveys were compared. Sensitivity, specificity, positive predictive value, and positive likelihood ratio of algorithms with respect to self-reported diagnosis, laboratory or functional test, assumed as gold standards, were calculated.RESULTS:we analyzed data of 7,318 subjects (1,545 for diabetes, 1,783 for COPD, 2,448 for hypertension, and 1,542 for hypothyroidism). For hypertension and hypothyroidism, we observed a higher prevalence from laboratory or functional test compared to self-reported diagnosis (54.5% vs. 44.9% and 7.5% vs. 1.5%). Sensitivity of administrative data with respect to self-reported diagnosis resulted 90.9%, 38.5%, 88.3%, and 47.8%, respectively, for diabetes, COPD, hypertension, and hypothyroidism. Respectively, specificity was 97.4%, 91.7%, 84.8% and 91.8%; positive predictive value was 70,9%, 38.1%, 82.6% and 8.1%. All values of positive likelihood ratio resulted moderate (about 5), with exception of the diabetes algorithm and the disease-specific payment exemptions register for hypertension (respectively 35.5 and 17.4).CONCLUSION:hypertension and hypothyroidism resulted markedly underdiagnosed from self-reported data. Case identification algorithms are highly specific, allowing their utilization for selection of cohort of subject affected by chronic diseases. The sub-optimal sensitivity observed for COPD and hypothyroidism could limit the utilization of the algorithms for prevalence estimation.

According to scientific literature, antibacterials are prescribed for common pediatric conditions that do not benefit from antibiotic therapy. The link between antibiotic use and bacterial resistance is well known. Antibiotic overprescribing generates high social costs and severe consequences for children. Our objectives were to analyze antibiotic prescription patterns in pediatric outpatients residing in the Lazio region (Italy), to identify physicians’ characteristics associated with increased propensity for prescription, to identify the priority axes for action to improve the rational use of antibiotics.

In moderate-severe chronic obstructive pulmonary disease (COPD), long-acting bronchodilators (LBs) are recommended to improve the quality of life. The aims of this study were to measure adherence to LBs after discharge for COPD, identify determinants of adherence, and compare amounts of variation attributable to hospitals of discharge and primary care providers, i.e. local health districts (LHDs) and general practitioners (GPs). This cohort study was based on the Lazio region population, Italy. Patients discharged in 2007-2011 for COPD were followed up for 2 years. Adherence was defined as a medication possession ratio >80%. Cross-classified models were performed to analyse variation. Variances were expressed as median odds ratios (MORs). An MOR of 1.00 stands for no variation, a large MOR indicates considerable variation. We enrolled 13,178 patients. About 29% of patients were adherent to LBs. Adherence was higher for patients discharged from pneumology wards and for patients with GPs working in group practice. A relevant variation between LHDs (MOR = 1.21, p = 0.001) and GPs (MOR = 1.28, p = 0.035) was detected. When introducing the hospital of discharge in the model, the MOR related to LHDs decreased to 1.05 (p = 0.345), MOR related to GPs dropped to 1.22 (p = 0.086), whereas MOR associated with hospitals of discharge was 1.38 (p < 0.001). Treatments with proven benefit for COPD were underused. Moreover, a relevant geographic variation was observed. This heterogeneity raises equity concerns in access to optimal care. The reduction of variability among LHDs and GPs after entering the hospital level proved that differences we observe in primary care partially 'reflect' the clinical approach of hospitals of discharge.

Objective To develop and validate a novel comorbidity score (multisource comorbidity score (MCS)) predictive of mortality, hospital admissions and healthcare costs using multiple source information from the administrative Italian National Health System (NHS) databases. Methods An index of 34 variables (measured from inpatient diagnoses and outpatient drug prescriptions within 2 years before baseline) independently predicting 1-year mortality in a sample of 500 000 individuals aged 50 years or older randomly selected from the NHS beneficiaries of the Italian region of Lombardy (training set) was developed. The corresponding weights were assigned from the regression coefficients of a Weibull survival model. MCS performance was evaluated by using an internal (ie, another sample of 500 000 NHS beneficiaries from Lombardy) and three external (each consisting of 500 000 NHS beneficiaries from Emilia-Romagna, Lazio and Sicily) validation sets. Discriminant power and net reclassification improvement were used to compare MCS performance with that of other comorbidity scores. MCS ability to predict secondary health outcomes (ie, hospital admissions and costs) was also investigated. Results Primary and secondary outcomes progressively increased with increasing MCS value. MCS improved the net 1-year mortality reclassification from 27% (with respect to the Chronic Disease Score) to 69% (with respect to the Elixhauser Index). MCS discrimination performance was similar in the four regions of Italy we tested, the area under the receiver operating characteristic curves (95% CI) being 0.78 (0.77 to 0.79) in Lombardy, 0.78 (0.77 to 0.79) in Emilia-Romagna, 0.77 (0.76 to 0.78) in Lazio and 0.78 (0.77 to 0.79) in Sicily. Conclusion MCS seems better than conventional scores for predicting health outcomes, at least in the general population from Italy. This may offer an improved tool for risk adjustment, policy planning and identifying patients in need of a focused treatment approach in the everyday medical practice.

ObjectivesTo measure the adherence to polytherapy after myocardial infarction (MI), to compare the proportions of variation attributable to hospitals of discharge and to primary care providers, and to identify determinants of adherence to medications.SettingThis is a population-based study. Data were obtained from the Information Systems of the Lazio Region, Italy (5 million inhabitants).ParticipantsPatients hospitalised with incident MI in 2007–2010.Outcome measureThe outcome was chronic polytherapy after MI. Adherence was defined as a medication possession ratio ≥0.75 for at least three of the following drugs: antiplatelets, β-blockers, ACEI angiotensin receptor blockers, statins.Design and analysisA 2-year cohort study was performed. Cross-classified multilevel models were applied to analyse geographic variation and compare proportions of variability attributable to hospitals of discharge and primary care providers. The variance components were expressed as median ORs MORs. If the MOR is 1.00, there is no variation between clusters. If there is considerable between-cluster variation, the MOR will be large.ResultsA total of 9606 patients were enrolled. About 63% were adherent to chronic polytherapy. Adherence was higher for patients discharged from cardiology wards (OR=1.56 vs other wards, p<0.001) and for patients with general practitioners working in group practice (OR=1.14 vs single-handed, p=0.042). A relevant variation in adherence was detected between local health districts (MOR=1.24, p<0.001). When introducing the hospital of discharge as a cross-classified level, the variation between local health districts decreased (MOR=1.13, p=0.020) and the variability attributable to hospitals of discharge was significantly higher (MOR=1.37, p<0.001).ConclusionsSecondary prevention pharmacotherapy after MI is not consistent with clinical guidelines. The relevant geographic variation raises equity issues in access to optimal care. Adherence was influenced more by the hospital that discharged the patient than by the primary care providers. Cross-classified models proved to be a useful tool for defining priority areas for more targeted interventions.

BACKGROUND:Climate change is projected to increase the number and intensity of extreme weather events, for example heat waves. Heat waves have adverse health effects, especially for the elderly, since chronic diseases are more frequent in that group than in the population overall. The aim of the study was to investigate mortality during heat waves in an adult population aged 50 years or over, as well as in susceptible subgroups of that population in Rome and Stockholm during the summer periods from 2000 to 2008.METHODS:We collected daily number of deaths occurring between 15th May and 15th September each year for the population above 50 as well as the susceptible subgroups. Heat wave days were defined as two or more days exceeding the city specific 95th percentile of maximum apparent temperature (MAT). The relationship between heat waves and all-cause non-accidental mortality was investigated through time series modelling, adjusting for time trends.RESULTS:The percent increase in daily mortality during heat waves as compared to normal summer days was, in the 50+ population, 22% (95% Confidence Interval (CI): 18-26%) in Rome and 8% (95% CI: 3-12%) in Stockholm. Subgroup specific increase in mortality in Rome ranged from 7% (95% CI:-17-39%) among survivors of myocardial infarction to 25% in the COPD (95% CI:9-43%) and diabetes (95% CI:14-37%) subgroups. In Stockholm the range was from 10% (95% CI: 2-19%) for congestive heart failure to 33% (95% CI: 10-61%) for the psychiatric subgroup.CONCLUSIONS:Mortality during heat waves increased in both Rome and Stockholm for the 50+ population as well as in the considered subgroups. It should be evaluated if protective measures should be directed towards susceptible groups, rather than the population as a whole.

Background Preterm births represent about 10% of total births and the first cause of perinatal mortality and morbidity in developed countries. Aims To evaluate the effect of short term exposure to high and low temperatures and air pollution on preterm delivery. Moreover to identify maternal risk factors enhancing individual susceptibility. Methods All singleton live-births in Rome between 2001-2010 were analyzed. Preterms were defined as births between the 22nd and the 36th week of gestational age. Cold (Nov to Mar) and warm (Apr to Oct) season were studied using daily minimum temperature (MT) in the first and maximum apparent temperature (MAT) and heat waves (HW) in the second. PM10, O3 and NO2 were also analyzed by season. Shape and lag dimension of the temperature-preterm relationship was tested. A Poisson GAM model was used for effect estimation, controlling for seasonal and long-term trends, day of the week, holidays. Socio-demographic and clinical risk factors were analyzed. Results Study population was of 132,691 total births, 5.5% of which preterm. A linear relationship with lag 0-2 was observed with MAT in summer, while no effect of MT was observed in winter at any lag. An increase of 1,7% (IC 95%: 0.67 -2.64) in daily preterm births per 1°C increase in MAT was estimated. Older women, with higher education level and those with obstetric or chronic pathologies reported during delivery had a lower risk while women with a chronic disease in the two years before delivery and mothers <20yrs showed a higher risk (%change 7.09; IC95% 1.42-13.08; and 2.99; IC95% 0.11-5.95 respectively). We observed a 17% increase in preterm births during HW days. Air pollutants showed no effect on preterm births, and didn’t act as confounders and effect modifiers of temperature-preterm relationship. Conclusion Prevention measures targeted to pregnant women during high temperatures should be introduced, to reduce the risk of preterm birth and the consequent adverse health conditions among preterm children.

Background: The on-going climate change is projected to increase the number, as well as the intensity, of extreme weather events. Heat waves are well known to cause significant adverse health consequences with the elderly and chronically ill among the most susceptible groups. Aim: We aim to investigate mortality during heat waves among the population above 50 as well as certain cohorts of persons with chronic disease according to health care registers in Rome, Italy and Stockholm, Sweden during the period summer period 2000-2008. We investigated the following diseases; Chronic Obstructive Pulmonary Disease (COPD); Congestive Heart Failure (CHF); Survival to Myocardial Infarction (MI); Diabetes and Psychiatric disease. Methods: For the 50+ population and our cohorts we collected daily information on the deaths occurring between 15th May and 15th September each year. We defined a heat wave as two, or more, consecutive days with temperatures exceeding the 98th percentile of daily maximum temperature. The relationship between heat waves and all-cause mortality was investigated through time series modelling, adjusting for time trends. Results: The per cent increase in mortality during heat waves as compared to normal summer days was, in the 50+ population, estimated to be 13.5% (95% CI: 7.1-20.2%) and 11.7% (95% CI: 3.8-20.1%) in Rome and Stockholm respectively. Cohort specific increase in mortality in Rome ranged from 15.3% (95% CI: -11.6-50.4%) in the Psychiatric disease cohort to 70.8% (95% CI: 16.7-149.8%) for the MI cohort. In Stockholm the range of mortality increase was from 6.0% (95% CI:-8.2-23.0%) for the CHF cohort to 25.7% (95% CI: -2.5-62.2%) for the COPD cohort. Conclusions: Mortality during heat waves increased in both Rome and Stockholm for the 50+ population as well as for our vulnerable groups. With an expected increase of elderly and other potentially vulnerable groups in society it is of importance to identify these groups in order to optimize future heat warning systems.

Introduction: Although the prevalence of preterm births ranges from 5 to 13% and represents the leading cause of perinatal mortality and morbidity in developed countries, the etiology of preterm birth remains uncertain. We aimed to evaluate the effect of short-term exposure to high and low temperatures and air pollution on preterm delivery and to identify socio-demographic and clinical maternal risk factors enhancing individual susceptibility.Methods: We analyzed all singleton live births by natural delivery that occurred in Rome in 2001-2010. A time-series approach was used to estimate the effect of exposure to minimum temperature, maximum apparent temperature, heat waves, particulate matter with an aerodynamic diameter of 10 mu m or less (PM10), ozone, and nitrogen dioxide in the month preceding delivery; the analysis was conducted separately for cold and warm seasons. Socio-demographic and clinical risk factors were included as interaction terms.Results: Preterm births comprised nearly 6% of our cohort. An increase of 1.9% (95% confidence interval (CI) 0.86-2.87) in daily preterm births per 1 degrees C increase in maximum apparent temperature in the 2 days preceding delivery was estimated for the warm season. Older women, women with higher education levels, and women with obstetric or chronic pathologies reported during delivery had a lower effect of temperature on the risk of preterm birth, while women with a chronic disease in the two years before delivery and mothers < 20 years showed a higher effect. A + 19% (95% CI 7.91-31.69) increase in preterm births was observed during heat waves. Temperature had no effect during the cold season. We detected a significant effect of PM10 on preterm-birth risk at a lag period of 12-22 days during the warm season ( + 0.69%; 95% CI 0.23-1.15, for 1 mu g/m(3) increase of pollutant); women with obstetric pathologies and with a higher education level showed a higher risk.Conclusions: Our results suggest a possible short-term effect of heat and a more delayed and prolonged effect of PM10 exposure on preterm-bitth risk, as well as the existence of more susceptible subgroups of women. Our observations support the few reported investigations, and may help to increase awareness among public-health stakeholders and clinicians regarding the role of these environmental exposures as risk factors for premature birth and health consequences for children later in life. (C) 2013 Elsevier Ltd. All rights reserved.