Abstract Background The long-term effects of COVID-19, which can vary significantly in type and timing, are considered relevant and impacting on the well-being of individuals. The present study aims to assess the incidence of outpatient care in the post-acute phase of SARS-CoV-2 infection in two Italian regions. Methods The study has a multicentre, population-based, pre-post, repeated measures design to compare the incidence rate of access to outpatient visits and diagnostics before and after SARS-CoV-2 infection, considering a follow-up of 24 months. The study made use of previously recorded large-scale healthcare data available in the administrative databases of the Emilia-Romagna (E-R) and Veneto regions. Analyses were carried out separately in the two regions and results were pooled using random effects meta-analysis. Results There were 27,140 subjects in E-R and 22,876 in Veneto who were included in the analysis. The pooled outputs showed an increase in rates of outpatient visits and diagnostics starting from month 2 after SARS-CoV-2 infection (IRR = 1.68, 95% CI = 1.56–1.81) with a peak at month 4 (IRR = 2.05, 95% CI = 1.95–2.15); the increase continued with reduced intensity up to month 15. Stratified analysis revealed that subjects with severe acute COVID-19 had a higher increase in rates (up to IRR = 3.96, 95% CI = 2.89–5.44), as well as patients with no comorbidities (up to IRR = 2.71, 95% CI = 2.60–2.83). Conclusion Long-term effects of COVID-19 include an increase in the healthcare burden especially in the first months after the acute infection. The increased demand for resources can last up to two years after infection in particular subgroups of patients such as subjects admitted to hospital during the acute phase due to the severe presentation of the disease.

Summary: Background: Each high-risk HPV genotype has different oncogenic potential, and the risk of CIN3+ varies according to genotype. We evaluated the performance of different strategies of HPV-positivity triage combining cytology, p16/ki67 dual staining (DS), and extended genotyping. Methods: Samples from 3180 consecutive women from the NTCC2 study (NCT01837693) positive for HPV DNA at primary screening, were retrospectively analyzed by the BD Onclarity HPV Assay, which allows extended genotyping. Genotypes were divided into three groups based on the risk of CIN3+. HPV DNA-positive women were followed up for 24 months or to clearance. Findings: Combining the three groups of genotypes with cytology or DS results we identify a group of women who need immediate colposcopy (PPV for CIN3+ from 7.8 to 20.1%), a group that can be referred to 1-year HPV retesting (PPV in those HPV-positive at retesting from 2.2 to 3.8), and a group with a very low 24-month CIN3+ risk, i.e. 0.4%, composed by women cytology or DS negative and positive for HPV 56/59/66 or 35/39/68 or negative with the Onclarity test, who can be referred to 3-year retesting. Interpretation: Among the baseline HPV DNA positive/cytology or DS negative women, the extended genotyping allows to stratify for risk of CIN3+, and to identify a group of women with a risk of CIN3+ so low in the next 24 months that they could be referred to a new screening round after 3 years. Funding: Italian Ministry of Health (grant number RF-2009-1536040). Hologic-Genprobe, Roche Diagnostics, and Becton & Dickinson provided financial and non-financial support.

ObjectivesWe study the introduction of a web portal allowing women to manage their appointments in the public cervical cancer screening program of an Italian Local Health Unit (LHU). We investigate how this intervention affects program participation and the ability of the LHU to collect information on women's screening outside the program.MethodsWe use administrative data from the LHU and a difference-in-differences design to compare outcomes of women in the treated group (n=870), who could reschedule appointments either through phone calls or through the portal, and the control group (n=768), who could only reschedule by phone.ResultsThe portal reduces the number of appointments rescheduled by phone (b = −0.176, 95% CI = −0.228 to −0.114, p < 0.001). It also makes women more likely to report both screenings outside the program (b = 0.049, 95% CI = 0.006–0.912, p < 0.05) and the various reasons for canceling their appointments. However, the portal also decreases the probability of screening (b = −0.156, 95% CI = −0.216–0.096, p < 0.001). Two-thirds of this reduction is due to increased unjustified no-shows (b = 0.099, 95% CI = 0.043–0.155, p < 0.001).ConclusionsDigital innovations increase efficiency of screening programs. However, they may discourage screening, by triggering behavioral biases such as limited attention and procrastination. Pairing portals with frequent reminders may help to boost participation.

Background: In Italy, a recent national project has expanded local collaboration between colorectal (CRC) screening programmes and pharmacies to the national level. Objective: The objective of this study is to provide an overview of the existing agreements between regional authorities and pharmacy owners in Italy regarding CRC screening programmes, to make internationally available the most qualifying elements of the collaboration.Methods: We analyzed the agreements, in force on 01/08/2021, arranged between the Regions and their respective pharmacy owners, describing the process phases addressed such as the faecal occult blood test pathway and supplementary activities provided by the pharmacies together with the CRC screening kit delivery. Results: Agreements were received from 18 Regions (86% of the total). The amount of money paid for each kit varies a lot, with a range from 0 to 18 EUR. The number of process phases covered by the agreements ranged from a maximum of 16 (out of 18) to a minimum of 0. The processes most frequently covered were the supply/ delivery of kits and education/awareness of CRC screening (68.8%). Less covered processes were warehouse management and awareness of other healthcare initiatives (12.5%), and delivery of preparation for intestinal cleansing (6.3%).Conclusions: Arrangements between pharmacies and CRC screening programmes in Italy vary widely and lack a unified model. Collaboration quality standards should be set at the national/international level.

HPV is the most common cause of sexually-transmitted infections the world over. The aim of this study was to assess the impact of a healthcare quality improvement strategy designed to increase the rate of vaccination against HPV in women diagnosed with cervical lesions graded as CIN2 or higher (CIN2+) during routine screening. The Veneto Regional Health Service developed a 22-item questionnaire to measure the gap between ideal procedure and real practice regarding the offer of vaccination against HPV for women undergoing routine cervical screening. The questionnaire was administered to nine expert doctors, one at each of the region's Local Health Units (LHUs). An additional specific assessment concerned the quality of the related web pages available on the LHU websites. Strategies to close the gap between ideal procedure and real practice were decided collegially, and a checklist to support good practices was developed and shared with operators at the LHUs. Changes in practice were measured using data relating to women diagnosed with CIN2+ lesions extracted from the regional oncological screening database before and after the publication of a Regional Procedure on the topic. The LHUs differed considerably in how they managed each step, in terms of training for healthcare personnel, organization and assessment of the pathway from cervical screening to HPV vaccination, and in dedicated website communication. After implementing the quality improvement strategy, the proportion of women given a first dose of HPV vaccine within 3 months of being diagnosed with CIN2+ lesions at 1st-level screening rose to 50% (compared with 30.85% beforehand), and the median time elapsing between a diagnosis of CIN2+ lesion and a first dose of HPV vaccine dropped from 158 to 90 days. These findings underscore the importance of providing training to promote vaccination for general practitioners and other clinicians. The study also confirms the need for more efforts in communication to ensure that any citizen has the opportunity to access preventive healthcare.

BackgroundKnowledge about the dynamics of transmission of SARS-CoV-2 and the clinical aspects of COVID-19 has steadily increased over time, although evidence of the determinants of disease severity and duration is still limited and mainly focused on older adult and fragile populations.MethodsThe present study was conceived and carried out in the Emilia-Romagna (E-R) and Veneto Regions, Italy, within the context of the EU’s Horizon 2020 research project called ORCHESTRA (Connecting European Cohorts to increase common and effective response to SARS-CoV-2 pandemic) (www.orchestra-cohort.eu). The study has a multicenter retrospective population-based cohort design and aimed to investigate the incidence and risk factors of access to specific healthcare services (outpatient visits and diagnostics, drug prescriptions) during the post-acute phase from day-31 to day-365 after SARS-CoV-2 infection, in a healthy population at low risk of severe acute COVID-19. The study made use of previously recorded large-scale healthcare data available in the administrative databases of the two Italian Regions. The statistical analysis made use of methods for competing risks. Risk factors were assessed separately in the two Regions and results were pooled using random effects meta-analysis.ResultsThere were 35,128 subjects in E-R and 88,881 in Veneto who were included in the data analysis. The outcome (access to selected health services) occurred in a high percentage of subjects in the post-acute phase (25% in E-R and 21% in Veneto). Outpatient care was observed more frequently than drug prescriptions (18% vs. 12% in E-R and 15% vs. 10% in Veneto). Risk factors associated with the outcome were female sex, age greater than 40 years, baseline risk of hospitalization and death, moderate to severe acute COVID-19, and acute extrapulmonary complications.ConclusionThe outcome of interest may be considered as a proxy for long-term effects of COVID-19 needing clinical attention. Our data suggest that this outcome occurs in a substantial percentage of cases, even among a previously healthy population with low or mild severity of acute COVID-19. The study results provide useful insights into planning COVID-19-related services.

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.

An Italian region introduced a web portal allowing women to manage online their appointment in the public cervical cancer screening program, besides the standard possibility of doing it via phone. We report quasi-experimental evidence on how access to the portal changes screening behaviour. We find that eligible women do manage their appointment online. The introduction of the portal also reduces attendance of the screening program. Two factors contribute to explain this finding. First, by encouraging women not to take a screening test if they performed an analogous one in the previous three years, the portal reduces overly-frequent screening. Second, the portal induces procrastination in rescheduling the appointment. We also find that, when they cancel their appointment online, women are more likely to share information about their screening episodes in the private health sector, that is useful to schedule future screening appointments.

Background and aim: Anti-thrombotic agents (ATs) are risk factors of acute upper gastrointestinal bleeding (AUGIB), but their impact on clinical outcomes is uncertain.Primary aim of the study was to determine if patients with AUGIB while on specific ATs are at higher risk for mortality.Secondary aims were to compare risk of rebleeding, need for blood transfusions and salvage surgical or radiological procedures and length of hospital stay among patients treated and untreated with ATs. Materials and methods: Patients with AUGIB (non-variceal, NV-AUGIB or variceal, V-AUGIB) in 50 Italian hospitals were prospectively enrolled from 1st January 2014 to 31st December 2015.Clinical data, laboratory tests, comorbidities, prognostic scores, received therapies and outcomes (death, rebleeding, surgery/radiology, transfusions, length of hospitalization) were analyzed and compared among ATs users and non-users.To evaluate the independent role of the AT therapy we conducted a multivariate logistic regression considering comorbidities.A sensitivity analysis was conducted for NV-and V-AUGIB.Results: 3324 patients (2764 NV-AUGIB, 83.2% and 560 V-AUGIB, 16.8%) were enrolled, 1399 (42.1%) on ATs.Patients taking ATs were older (75.4 vs 62.8 years, p<0.001), had higher ASA, Rockall and Glasgow-Blatchford scores (p<0.001).At multivariate analysis considering comorbidities, ATs use resulted an independent protective factor against death (OR 0.63, 95% CI 0.45-0.87,p=0.006).Rebleeding (5.5% vs 5.8%, p=0.71) and need for salvage surgery/ radiology (4.2% vs 4.8%, p=0.41) were similar in the two groups.Considering specific ATs, low-dose aspirin was the most powerful factor lowering the death risk (OR 0.51, 95% CI 0.33-0.81,p=0.004).While the generic use of AT therapy did not emerge as a statistically significant independent protective factor considering separately NV-AUGIB (OR 0.80, 95% CI 0.56-1.13,p=0.21) and V-AUGIB (OR 0.40, 95% CI 0.15-1.07,p=0.068), the protective effect of low-dose aspirin was confirmed for NV-AUGIB (OR 0.62, 95% CI 0.41-0.94,p=0.025).Conclusions: ATs use is an independent protective factor against death in patients with AUGIB.The protective effect is mainly derived from low-dose aspirin.

Background: Veneto was one of the Italian regions hit hardest by the early phase of the coronavirus disease (COVID-19) pandemic. Aim: This paper describes the public health response and epidemiology of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections in the Veneto Region from 21 February to 2 April 2020. Methods: Information on the public health response was collected from regional health authorities' official sources. Epidemiological data were extracted from a web-based regional surveillance system. The epidemic curve was represented by date of testing. Characteristics of hospitalised COVID-19 cases were described and compared to those never admitted to hospital. Age- and sex-stratified case fatality ratios (CFRs) were calculated. Results: Key elements of the regional public health response were thorough case-finding and contact tracing, home care for non-severe cases, creation of dedicated COVID-19 healthcare facilities and activation of sub-intensive care units for non-invasive ventilation. As at 2 April 2020, 91,345 individuals were tested for SARS-CoV-2 and 10,457 (11.4%) were positive. Testing and attack rates were 18.6 per 1,000 and 213.2 per 100,000 population, respectively. The epidemic peaked around 20 to 24 March, with case numbers declining thereafter. Hospitalised cases (n=3,623; 34.6%) were older and more frequently male compared with never-hospitalised cases. The CFR was 5.6% overall, and was higher among males and people > 60 years of age. Conclusion: In the Veneto Region, the strict social distancing measures imposed by the Italian government were supported by thorough case finding and contact tracing, as well as well-defined roles for different levels of care.

After the appearance of COVID-19 in China last December 2019, Italy was the first European country to be severely affected by the outbreak. The first diagnosis in Italy was on February 20, 2020, followed by the establishment of a light and a tight lockdown on February 23 and on March 8, 2020, respectively. The virus spread rapidly, particularly in the North of the country in the 'Padan Plain' area, known as one of the most polluted regions in Europe. Air pollution has been recently hypothesized to enhance the clinical severity of SARS-CoV-2 infection, acting through adverse effects on immunity, induction of respiratory and other chronic disease, upregulation of viral receptor ACE-2, and possible pathogen transportation as a virus carrier. We investigated the association between air pollution and subsequent COVID-19 mortality rates within two Italian regions (Veneto and Emilia-Romagna). We estimated ground-level nitrogen dioxide through its tropospheric levels using data available from the Sentinel-5P satellites of the European Space Agency Copernicus Earth Observation Programme before the lockdown. We then examined COVID-19 mortality rates in relation to the nitrogen dioxide levels at three 14-day lag points after the lockdown, namely March 8, 22 and April 5, 2020. Using a multivariable negative binomial regression model, we found an association between nitrogen dioxide and COVID-19 mortality. Although ecological data provide only weak evidence, these findings indicate an association between air pollution levels and COVID-19 severity.

Objective To assess faecal immunochemical test sensitivity for cancer in a very large population-based cohort followed up for six rounds with biennial faecal immunochemical test repetition. Methods This study is based on interval colorectal cancers diagnosed in a cohort of subjects aged 50–69 undergoing repeated faecal immunochemical test screening (six rounds) from 2002 to 2015. Test sensitivity was calculated using both the Proportional Interval Cancer Rate and the Interval Cancer Proportion method. Results Among 441,647 faecal immunochemical tests (123,347 individuals), 150 interval colorectal cancers were detected after a negative faecal immunochemical test. Interval colorectal cancer incidence rate was 1.87 per 10,000 person-years (95%CI: 1.60–2.20), and it was higher during the second interval year (rate ratio: 1.78; 95%CI: 1.28–2.47), for proximal locations (rate ratio: 3.00; 95%CI: 1.92–4.68), and among 60–71 year old subjects (rate ratio: 2.37; 95%CI: 1.61–3.50). The Proportional Interval Cancer Rate was 13.1%, with an overall faecal immunochemical test sensitivity of 86.9% (95%CI: 84.7–89.0). Sensitivity was lowest at the first round (81.5%; 95%CI: 75.6–86.2), and increased to 91.9% (95%CI: 83.9–96.5) for subsequent rounds. Applying the Interval Cancer Proportion method, sensitivity was 83.9% (95%CI: 81.3–86.2), and it was highest at the first round (89.0%; 95%CI: 85.7–91.6), ranging between 73% and 83.1% at subsequent rounds. Conclusions A faecal immunochemical test sensitivity for cancer higher than 80% resulted in a low incidence of interval colorectal cancers, representing an accurate estimate of one of the major limits of screening programmes. Due to intrinsic biases, the Proportional Interval Cancer Rate and the Interval Cancer Proportion methods generated different trends in faecal immunochemical test sensitivity by screening round.

Background Although the adenoma detection rate (ADR) cut-off for colonoscopies after positive fecal immunochemical tests (FIT) continues to be a debated issue, the ADR is one of the most accepted benchmarks for colonoscopy quality. There is some evidence that the quality of colonscopy screening can be improved by educational interventions. This study aimed to analyze the effect of endoscopist-related characteristics on colonoscopy quality indicators and to evaluate the factors affecting ADR patterns registered in the colorectal (CRC) screening program in the Veneto Region between 201–017. Methods the following data about endoscopists in screening programs between 201–017 were collected: age, sex, years as physician, specialization, annual colonoscopy volume. During 201–014, younger endoscopists (<40 yr) underwent four meetings with a senior endoscopist (Cristopher Williams), to improve general endoscopic ability and, in particular, the sensibility to detect adenomatous lesions. ADR was calculated for each operator. Data were analyzed with SPSS program. Results During the three year period, 191 endoscopists performed a total of 42,706 first colonoscopies after FIT positivity. One hundred forty with at least 20 colonoscopies after FIT positivity/yr, (mean age 48.2yr ± 10.8yr (M±SD), Male 53.9%) were selected. Three hundred eight-two ADRs were collected during the observation period. Overall ADR was 43.7±9.5%. Ninety-six of the endoscopists were specialized in gastroenterology, 35 in general surgery, and 8 in other specialities. ADR was 44.1± 9.7% for the gastroenterologists, 42.7 ±9.6% for the surgeons (p=ns) and 39.5 ±7% for those with other specialities (p=0.033). ADR was significantly higher for the younger endoscopists (3–9yr 47.5%; 4–9yr 44.6%; >50yr 41.4%, with p<0.001). The ADRs over the three year period were similar (44.2% vs 42.9% vs 43.3%, p= ns). No significant association between ADR and number of screening colonoscopies performed weew found. When the ADR in 2017 of 81 endoscopists was analyzed depending on the cumulative number of total colonoscopies/yr, it was found that the those with > 300 colonoscopies/yr had higher ADRs ( 35.5 ±21.4% vs 43.5±11.5%, p=0.04) in colonoscopies after FIT positivity/yr . Conclusions Study findings demonstrated that junior endoscopists and those specialized in gastroenterology were more effective in identifying adenomas during screening colonscopy procedures. High annual colonoscopy volumes and working exclusively as endoscopists but not years of experience or being older were associated with higher ADRs. Educational interventions seemed to be effective in improving sensitivity and performance.

To evaluate if time to colonoscopy after a positive fecal blood test is associated with the risk of colorectal cancer or adenoma and to identify a safety-threshold.

Background Although the adenoma detection rate (ADR) cut-off for colonoscopies after positive fecal immunochemical tests (FIT) continues to be a debated issue, the ADR is one of the most accepted benchmarks for colonoscopy quality. There is some evidence that the quality of colonscopy screening can be improved by educational interventions. This study aimed to analyze the effect of endoscopist-related characteristics on colonoscopy quality indicators and to evaluate the factors affecting ADR patterns registered in the colorectal (CRC) screening program in the Veneto Region between 201–017. Methods the following data about endoscopists in screening programs between 201–017 were collected: age, sex, years as physician, specialization, annual colonoscopy volume. During 201–014, younger endoscopists (<40 yr) underwent four meetings with a senior endoscopist (Cristopher Williams), to improve general endoscopic ability and, in particular, the sensibility to detect adenomatous lesions. ADR was calculated for each operator. Data were analyzed with SPSS program. Results During the three year period, 191 endoscopists performed a total of 42,706 first colonoscopies after FIT positivity. One hundred forty with at least 20 colonoscopies after FIT positivity/yr, (mean age 48.2yr ± 10.8yr (M±SD), Male 53.9%) were selected. Three hundred eight-two ADRs were collected during the observation period. Overall ADR was 43.7±9.5%. Ninety-six of the endoscopists were specialized in gastroenterology, 35 in general surgery, and 8 in other specialities. ADR was 44.1± 9.7% for the gastroenterologists, 42.7 ±9.6% for the surgeons (p=ns) and 39.5 ±7% for those with other specialities (p=0.033). ADR was significantly higher for the younger endoscopists (3–9yr 47.5%; 4–9yr 44.6%; >50yr 41.4%, with p<0.001). The ADRs over the three year period were similar (44.2% vs 42.9% vs 43.3%, p= ns). No significant association between ADR and number of screening colonoscopies performed weew found. When the ADR in 2017 of 81 endoscopists was analyzed depending on the cumulative number of total colonoscopies/yr, it was found that the those with > 300 colonoscopies/yr had higher ADRs ( 35.5 ±21.4% vs 43.5±11.5%, p=0.04) in colonoscopies after FIT positivity/yr . Conclusions Study findings demonstrated that junior endoscopists and those specialized in gastroenterology were more effective in identifying adenomas during screening colonscopy procedures. High annual colonoscopy volumes and working exclusively as endoscopists but not years of experience or being older were associated with higher ADRs. Educational interventions seemed to be effective in improving sensitivity and performance.

Background Although the adenoma detection rate (ADR) cut-off for colonoscopies after positive fecal immunochemical tests (FIT) continues to be a debated issue, the ADR is one of the most accepted benchmarks for colonoscopy quality. There is some evidence that the quality of colonscopy screening can be improved by educational interventions. This study aimed to analyze the effect of endoscopist-related characteristics on colonoscopy quality indicators and to evaluate the factors affecting ADR patterns registered in the colorectal (CRC) screening program in the Veneto Region between 201–017. Methods the following data about endoscopists in screening programs between 201–017 were collected: age, sex, years as physician, specialization, annual colonoscopy volume. During 201–014, younger endoscopists (<40 yr) underwent four meetings with a senior endoscopist (Cristopher Williams), to improve general endoscopic ability and, in particular, the sensibility to detect adenomatous lesions. ADR was calculated for each operator. Data were analyzed with SPSS program. Results During the three year period, 191 endoscopists performed a total of 42,706 first colonoscopies after FIT positivity. One hundred forty with at least 20 colonoscopies after FIT positivity/yr, (mean age 48.2yr ± 10.8yr (M±SD), Male 53.9%) were selected. Three hundred eight-two ADRs were collected during the observation period. Overall ADR was 43.7±9.5%. Ninety-six of the endoscopists were specialized in gastroenterology, 35 in general surgery, and 8 in other specialities. ADR was 44.1± 9.7% for the gastroenterologists, 42.7 ±9.6% for the surgeons (p=ns) and 39.5 ±7% for those with other specialities (p=0.033). ADR was significantly higher for the younger endoscopists (3–9yr 47.5%; 4–9yr 44.6%; >50yr 41.4%, with p<0.001). The ADRs over the three year period were similar (44.2% vs 42.9% vs 43.3%, p= ns). No significant association between ADR and number of screening colonoscopies performed weew found. When the ADR in 2017 of 81 endoscopists was analyzed depending on the cumulative number of total colonoscopies/yr, it was found that the those with > 300 colonoscopies/yr had higher ADRs ( 35.5 ±21.4% vs 43.5±11.5%, p=0.04) in colonoscopies after FIT positivity/yr . Conclusions Study findings demonstrated that junior endoscopists and those specialized in gastroenterology were more effective in identifying adenomas during screening colonscopy procedures. High annual colonoscopy volumes and working exclusively as endoscopists but not years of experience or being older were associated with higher ADRs. Educational interventions seemed to be effective in improving sensitivity and performance.