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Background and aims To validate a set of indicators for monitoring the quality of care of patients with diabetes in ‘real-life’ practice through its relationship with measurable clinical outcomes and healthcare costs. Methods and results A population-based cohort study was carried out by including the 20,635 patients, residents in the Lombardy Region (Italy), who in the year 2012 were newly taken-in-care for diabetes. Adherence with clinical recommendations (i.e., controls for glycated haemoglobin, lipid profile, urine albumin excretion and serum creatinine) was recorded during the first year after the patient was taken-in-care, and categorized according whether he/she complied with none or almost none (0 or 1), just some (2) or all or almost all (3 or 4) the recommendations, respectively denoted as poor, intermediate and high adherence. Short- and long-term complications of diabetes, and healthcare cost incurred by the National Health Service, were assessed during follow-up. Compared with patients with poor adherence, those with intermediate and high adherence respectively showed (i) a delay in outcome occurrence of 13 days (95% CI, -2 to 27) and 23 days (9 to 38), and (ii) a lower healthcare cost of 54 € and 77 €. In average, a gain of 18 Euros and 15 Euros for each day free from diabetic complication by increasing adherence respectively from poor to intermediate and from poor to high were observed. Conclusion Close control of patients with diabetes through regular clinical examinations must be considered the cornerstone of national guidance, national audits, and quality improvement incentive schemes.

We are presenting here the findings of the reaction to the COVID-19 epidemic during the period March to June 2020 of those centres participating in the research EASY-NET which is on-going in Italy, funded by the Ministry of Health and co-founded by the Regional Health Authorities. The objective of EASY-NET is to evaluate the effectiveness of the audit and feedback (AF) strategies in different clinical and organizational settings in seven regions. As a negative consequence of the COVID-19 epidemic, the activities of the project have suddenly slowed down; nevertheless, the COVID-19 epidemic represented an opportunity to apply the AF methodology and support the healthcare within the regional authorities in order to manage and monitor the impact of this new disease. The reaction to the crisis on behalf of EASY-NET was inconsistent across the participating regions for various reasons. Factors which influenced the reaction levels in relation to the rapidity and efficiency of the implementation of the AF strategies were as follows: the varying epidemiological impact of the COVID-19 epidemic in the various territories, the different clinical and organizational context and availability of expert research teams together with AF procedures which had already been tested before the start of the epidemic.

Background Multimorbidity is a growing concern for healthcare systems, with many countries experiencing demographic transition to older population profiles. A simple multisource comorbidity score (MCS) has been recently developed and validated. A very large real-world investigation was conducted with the aim of measuring inequalities in the MCS distribution across Italy. Methods Beneficiaries of the Italian National Health Service aged 50–85 years who in 2018 were resident in one of the 10 participant regions formed the study population (15.7 million of the 24.9 million overall resident in Italy). MCS was assigned to each beneficiary by categorizing the individual sum of the comorbid values (i.e. the weights corresponding to the comorbid conditions of which the individual suffered) into one of the six categories denoting a progressive worsening comorbidity status. MCS distributions in women and men across geographic partitions were compared. Results Compared with beneficiaries from northern Italy, those from centre and south showed worse comorbidity profile for both women and men. MCS median age (i.e. the age above which half of the beneficiaries suffered at least one comorbidity) ranged from 60 (centre and south) to 68 years (north) in women and from 63 (centre and south) to 68 years (north) in men. The percentage of comorbid population was lower than 50% for northern population, whereas it was around 60% for central and southern ones. Conclusion MCS allowed of capturing geographic variability of multimorbidity prevalence, thus showing up its value for addressing health policy in order to guide national health planning.

Graphical abstract, The aim of MED HISS methodology was to test the effectiveness of a low-cost approach to study long-term effects of air pollution, applicable in all European countries. This approach is potentially exportable to other environmental issues where a cohort representative of the country population is needed. The cohort is derived from the National Health Interview Survey, compulsory in European countries, which has information on individual lifestyle factors. In Life Med Hiss approach, subjects recruited have been linked at individual level with health data and have been then followed-up for mortality and hospital admissions outcomes. Exposure values of air pollution (PM2.5 and NO2) have been assigned using national dispersion models, enhanced by the information derived from monitoring station with data fusion techniques, and then upscaled at municipality level (highest level of detail achievable for the Italian Survey). Results for mortality have been used to test the effectiveness of this methodology and are encouraging if compared with European ones. The advantages of this technique are summarized below: • It uses a cohort already available and compulsory in European countries • It uses air quality modelling data, available for most of the countries • It permits to implement versatile environmental surveillance systems

The mantra that inspires healthcare systems is: “If you can’t measure it, you can’t manage it.” The measuring process is closely related to the epistemological ideal of modern science. This has been developed through a world simplification, which is considered useful to disclose principles that work under surrounding reality. The search for natural laws carries a distinctive component: phenomena are not accepted as they are, but they are instead transformed through abstraction and experimentation. What is considered as real is the result of abstraction and experimentation. This attitude, however, entails that some reality aspects are sacrificed in their variety and entirety. In economics, especially in the rational choice theory, the world, where we make decisions and judgments, is not real, but outward and accidental. In its stead, we find abstract constructions of expected utility maximization and pursuit of self-interest.

Several studies have recognized the health disadvantage of residents in socioeconomically deprived neighborhoods, independent of the influence of individual socioeconomic conditions. The effect of neighborhood socioeconomic deprivation on general mortality has appeared heterogeneous among the cities analyzed: the underlying mechanisms have been less empirically explored, and explanations for this heterogeneous health effect remain unclear. The present study aimed to: (1) analyze the distribution of socioeconomically disadvantaged persons in neighborhoods of 4 European cities—Turin, Barcelona, Stockholm and Helsinki—trying to measure segregation of residents according to their socioeconomic conditions. Two measuring approaches were used, respectively, through dissimilarity index and clustering estimated from Bayesian models. (2) Analyze the distribution of mortality in the above mentioned cities, trying to disentangle the independent effects of both neighborhood socioeconomic deprivation and neighborhood segregation of residents according to their socioeconomic conditions, using multilevel models. A significantly higher risk of death was observed among residents in more deprived neighborhoods in all 4 cities considered, slightly heterogeneous across them. Poverty segregation appeared to be slightly associated with increasing mortality in Turin and, among females and only according to dissimilarity, in Barcelona. Few studies have explored the health effects of social clustering, and results could inform urban policy design with regard to social mix.

This longitudinal study evaluates the role of individual and contextual socioeconomic determinants in the socioeconomic inequalities in incidence and mortality for coronary events in Turin, Italy, using hierarchical models. All residents aged 35–74 at the start of 1997 were included in the study population. We considered as outcomes all incident cases and deaths that occurred in the study population in the period 1997–2002. The socioeconomic indicators were educational level, job status and median income per census tract. A neighbourhood deprivation index was also used, which combines, in an aggregated measure, a series of poor individual socioeconomic conditions. The analyses were performed using hierarchical Poisson models, with individuals ( n = 523 , 755 ) considered as level I units and neighbourhoods ( n = 23 ) as level II units. Among men, we observed an inverse gradient in incidence by educational level and an excess risk for persons who were not actively employed. More marked excesses were found for mortality (RR: 1.63; 95% CI: 1.05–2.55, for unemployed persons compared to employed persons). Among women, greater socioeconomic differences were observed for both incidence and mortality; all of the individual indicators contributed to these differences. The differentials in mortality were particularly great for the retired and for housewives (RR: 1.98; 95% CI: 1.40–2.81). Slight excesses in incidence were observed among men for the most deprived areas. The results of this study reveal that job status is the most important individual factor explaining socioeconomic inequalities for coronary events, whereas context seems to play a marginal role.

Rationale The phenomenon of repeat work-related accidents has not been sufficiently studied. Objectives To evaluate the role of work-related factors in the occurrence of repeat accidents in Italy, using economic activity and the size of the enterprise as proxies and basing the analysis on available administrative data. Methods The data, provided by the Italian Workers’ Compensation Authority (INAIL), refer to accidents in the industry and artisan sectors and in the service industry between 1994 and 1999. We selected the data on accidents among 633,735 persons 25–55 years of age with a first accident in 1996–1997, and we determined the occurrence of further accidents within two years in the same economic activity, taking into account job mobility and factors associated with underreporting (geographic area, age, and size of the enterprise). The gender-specific relative risk was computed for each economic activity, given by the ratio between the risk of repeat accidents in a given economic activity and the risk in all of the other activities. Results Individuals with a single accident differed from those with a repeat accident in terms of the distribution by gender, age-class, and severity of injury. The economic activities with the highest relative risk were generally those known to represent a risk of accidents in general: metal ore and coal mining, shipbuilding, the manufacturing of railroad equipment, building construction, road and railway construction, the primary iron and steel industry, foundry work, logging/wood manufacturing, slaughtering, and agriculture. However, certain activities not generally considered as hazardous showed a high risk of repeat accidents (e.g., public hygiene, and the manufacturing of bricks, pottery, and glass). Conclusions The epidemiological pattern of repeat accidents by economic activity reflects that of accidents in general, though with exceptions. Results suggest that factors associated with specific technical aspects and production processes are important determinants of safety. The differences between single accidents and repeat accidents by gender, age class, and severity of injury suggest that studying repeat accidents separately from first accidents is quite useful.

Background : The efficacy of colorectal cancer screening has been proved, and three different screening tests are recommended by international guidelines: the faecal occult blood test, flexible sigmoidoscopy and colonoscopy. While the effectiveness of a screening program depends on the compliance obtained, the role of the type of test on compliance has not yet been sufficiently studied. Aims : To measure the effect of the type of screening test used, i.e. faecal occult blood test or flexible sigmoidoscopy, on the compliance to colorectal cancer screening programs. Subjects and methods : A cluster-randomized two-arm trial was conducted. We randomly assigned 20 GP's practices that had an average of 150 patients between 50 and 74 years old. Results: 1449 individuals were referred to faecal occult blood test and 1538 to flexible sigmoidoscopy. The faecal occult blood test obtained higher compliance: 17.2% (95%CI 12.5–25.7) versus 7.0% (95%CI 5.7–9.0). The socio-economic status was an effect modifier of the test type: the effect of the type of test was smaller in low socioeconomic classes. Conclusions : The type of screening test used for colorectal cancer is a determinant of participation. In a low compliance area, better compliance will result from offering the faecal occult blood test than from the flexible sigmoidoscopy.

STUDY OBJECTIVE: Studies have shown that living in more deprived neighbourhoods is related to higher mortality rates, independent of individual socioeconomic characteristics. One approach that contributes to understanding the processes underlying this association is to examine whether the relation is modified by the country context. In this study, the size of the association between neighbourhood unemployment rates and all cause mortality was compared across samples from six countries (United States, Netherlands, England, Finland, Italy, and Spain). DESIGN: Data from three prospective cohort studies (ARIC (US), GLOBE (Netherlands), and Whitehall II (England)) and three population based register studies (Helsinki, Turin, Madrid) were analysed. In each study, neighbourhood unemployment rates were derived from census, register based data. Cox proportional hazard models, taking into account the possible correlation of outcomes among people of the same neighbourhood, were used to assess the associations between neighbourhood unemployment and all cause mortality, adjusted for education and occupation at the individual level. RESULTS: In men, after adjustment for age, education, and occupation, living in the quartile of neighbourhoods with the highest compared with the lowest unemployment rates was associated with increased hazards of mortality (14%-46%), although for the Whitehall II study associations were not statistically significant. Similar patterns were found in women, but associations were not statistically significant in two of the five studies that included women. CONCLUSIONS: Living in more deprived neighbourhoods is associated with increased all cause mortality in the US and five European countries, independent of individual socioeconomic characteristics. There is no evidence that country substantially modified this association.

Cluster randomization is often used in intervention trials, yet when individuals nested within clusters are considered as the units of analysis for outcome evaluation, it cannot be assumed that the observations are statistically independent. Observations that are not statistically independent also result when repeated measures are taken over time for the same individual. Ignoring clustered observations when performing data analysis can lead to the erroneous conclusion that the intervention under study had a statistically significant effect. Moreover, individual responses are often collected on ordinal scales; thus models for continuous or categorical data are usually not appropriate. We applied a random effect ordinal regression model to data sets from two randomized controlled intervention trials that measured graded scale non-independent responses. The first trial compared two school programmes for AIDS prevention in terms of impact (i.e., changes in the frequency of condom use). The second trial used the MOS-HIV questionnaire to measure the quality of life of new AIDS cases four times over a one-year follow-up period (only results of the role-functioning scale are reported). Regarding the first data set, the effect of the intervention was not significant, and the post-intervention frequency of condom use was mainly attributable to the pre-intervention frequency (p < 0.01), with no differences among schools. Regarding the second data set, a borderline significant increase in the role-functioning scale scores was observed over the follow-up period; the results differed only slightly by intervention group; a significant (p < 0.01) intra-individual correlation of 0.4 was found.

Data provided by nine registries based in European and Latin America countries were analyzed to assess whether there is an excess of malformations in twins compared to singletons. Specific congenital malformations were coded according to the ninth revision of the International Classification of Diseases (ICD). Malformation rates and rate ratios (RR) for twins compared to singletons were calculated for each registry, and the homogeneity of the RRs was tested using the test of Breslow and Day. If departure from homogeneity in the different registries was not significant, registry-adjusted RRs with 95% confidence intervals were calculated. Overall, among 260,865 twins, 5,572 malformations were reported. A total of 101 different types of malformations or groups of defects was identified, and a homogeneous estimate of the RRs among registries was found for 91.1% of the malformations. Thirty-nine of the 92 malformations with homogeneous estimates of RRs were more common in twins than in singletons. For the remaining nine malformations, heterogeneous estimates of RRs were obtained. This study confirms the majority of already known associations and further identifies previously unreported malformations associated with twins. In conclusion, there is an excess of malformations in twins compared with singletons, and all anatomical sites are involved. The number of specific malformations associated with twins is higher than that previously reported in smaller studies.

Aims: To explore inequalities in total mortality between small areas of 16 European cities for men and women, as well as to analyse the relationship between these geographical inequalities and their socioeconomic indicators. Methods: A cross-sectional ecological design was used to analyse small areas in 16 European cities (26,229,104 inhabitants). Most cities had mortality data for a period between 2000 and 2008 and population size data for the same period. Socioeconomic indicators included an index of socioeconomic deprivation, unemployment, and educational level. We estimated standardised mortality ratios and controlled for their variability using Bayesian models. We estimated relative risk of mortality and excess number of deaths according to socioeconomic indicators. Results: We observed a consistent pattern of inequality in mortality in almost all cities, with mortality increasing in parallel with socioeconomic deprivation. Socioeconomic inequalities in mortality were more pronounced for men than women, and relative inequalities were greater in Eastern and Northern European cities, and lower in some Western (men) and Southern (women) European cities. The pattern of excess number of deaths was slightly different, with greater inequality in some Western and Northern European cities and also in Budapest, and lower among women in Madrid and Barcelona. Conclusions: In this study, we report a consistent pattern of socioeconomic inequalities in mortality in 16 European cities. Future studies should further explore specific causes of death, in order to determine whether the general pattern observed is consistent for each cause of death.

Objectives: Neglecting the presence of unobserved heterogeneity in survival analysis models has been showed to potentially lead to underestimating the effect of the covariates included in the analysis. This study aimed to investigate the role of unobserved heterogeneity of frailty on the estimation of mortality differentials from age 50 on by education level. Design: Longitudinal mortality follow-up of the census-based Turin population linked with the city registry office. Setting: Italian North-Western city of Turin, observation window 1971-2007. Population: 391 170 men and 456 216 women followed from age 50. Primary outcome measures: Mortality rate ratios obtained from survival analysis regression. Models were estimated with and without the component of unobserved heterogeneity of frailty and controlling for mortality improvement over time from both cohort and period perspectives. Results: In the majority of cases, the models without frailty estimated a smaller educational gradient than the models with frailty. Conclusions: The results draw the attention of the potential underestimation of the mortality inequalities by socioeconomic levels in survival analysis models when not controlling for unobserved heterogeneity of frailty.

This study analysed socioeconomic inequalities in mortality due to injuries in small areas of 15 European cities, by sex, at the beginning of this century. A cross-sectional ecological study with units of analysis being small areas within 15 European cities was conducted. Relative risks of injury mortality associated with the socioeconomic deprivation index were estimated using hierarchical Bayesian model. The number of small areas varies from 17 in Bratislava to 2666 in Turin. The median population per small area varies by city (e.g. Turin had 274 inhabitants per area while Budapest had 76,970). Socioeconomic inequalities in all injury mortality are observed in the majority of cities and are more pronounced in men. In the cities of northern and western Europe, socioeconomic inequalities in injury mortality are found for most types of injuries. These inequalities are not significant in the majority of cities in southern Europe among women and in the majority of central eastern European cities for both sexes. The results confirm the existence of socioeconomic inequalities in injury related mortality and reveal variations in their magnitude between different European cities. This paper has been partially funded by the project INEQ-CITIES, “Socioeconomic inequalities in mortality: evidence and policies of cities of Europe”; project funded by the Executive Agency for Health and Consumers (Commission of the European Union), project no. 2008 12 13.

Background: There is extensive documentation on social inequalities in mortality across Europe, showing heterogeneity among countries. Italy contributed to this comparative research, through longitudinal systems from northern or central cities of the country. This study aims to analyse educational inequalities in general and cause-specific mortality in a sample of the Italian population. Methods: Study population was selected within a cohort of 123 056 individuals, followed up for mortality through record linkage with national archive of death certificates for the period 1999–2007. People aged between 25 and 74 years were selected (n = 81 763); relative risks of death by education were estimated through Poisson models, stratified according to sex and adjusted for age and geographic area of residence. Heterogeneity of risks by area of residence was evaluated. Results: Men and women with primary education or less show 79% and 63% higher mortality risks, respectively, compared with graduates. Mortality risks seem to frequently increase with decreasing education, with a significant linear trend among men. For men, social inequalities appear related to mortality due to diseases of the circulatory system and to all neoplasms, whereas for women, they are related to inequalities in cancer mortality. Conclusions: Results from the first follow-up of a national sample highlight that Italy presents significant differences in mortality according to the socio-economic conditions of both men and women. These results not only challenge policies aimed at redistributing resources to individuals and groups, but also those policies that direct programmes and resources for treatment and prevention according to the different health needs.

Background Previous studies have shown that mortality inequalities are smaller in Italy than in most European countries. This may be due to the weak association between socioeconomic status and smoking in Italy. However, most published studies were based on data from a single city in northern Italy (Turin). In this study, we aimed to assess the size of mortality inequalities in Italy as a whole, their geographical pattern of variation within Italy, and the contribution of smoking to these inequalities. Methods Participants in the National Health Interview Survey 1999–2000 were followed up for mortality until 31 December 2007. Using Cox regression, we computed the age-adjusted relative index of inequality (RII) for all-cause mortality with and without controlling for smoking status and intensity. Education was used as an indicator of socioeconomic status. Results Among 72 762 individuals aged 30–74 years at baseline, 4092 died during the follow-up. The age-adjusted RII of mortality was 1.69 (95% CI 1.44 to 2.00) among men and 1.43 (95% CI 1.13 to 1.82) among women. Among men, inequalities were larger in both northern and southern regions than in the middle of the country, whereas among women they were larger in the south. After controlling for smoking RII decreased to 1.63 (95% CI 1.38 to 1.92) among men and increased to 1.54 (95% CI 1.21 to 1.96) among women. The geographical variation in mortality inequalities was not affected by smoking adjustment. Conclusions Mortality inequalities in Italy are smaller than in most European countries. This is due, among other factors, to the weak socioeconomic pattern of smoking over the past decades in Italy.

This paper examines the association between lifetime income and old age mortality risk, referred to as the income–mortality gradient, in Italy during the 1980s and 1990s.We find that the shape of the income–mortality gradient is characterized by two discontinuities (knots) for males and one discontinuity for females. For both genders, the estimated associations between income and mortality risk are negative and stronger at higher income levels. Results for the change in the income–mortality gradient between the 1980s and 1990s are sensitive to inclusion in the model of controls for regions. Without controlling for regional differences, the income-mortality gradient widens between the 1980s and the 1990s due to a rather surprising positive gradient for males whose income is below the 66th percentile in the 1980s. One possible explanation for this result could be the presence of manual workers with relatively high salary and high mortality during the 1980s in the industrialized Northwest. After controlling for regional differences, we find no empirical evidence of a change in the income–mortality gradient, including the position of the knots, over time.

The main aim of this study was to examine prospectively the relationship between antidepressant prescriptions (ADP), as a proxy of depressive symptoms, and work-related stress, measured according to the demand-control model.A cohort of 2,046 union workers who participated in a survey on working conditions and health in 1999-2000 was followed up to 2005, through the Regional Drug Prescription Register, for an ADP. The relative risks associated with demand, control and job strain were estimated using Poisson regression, adjusting for age, sex and other workplace factors (shift work, overtime, loud noise and psychological violence).In final multivariable models, high demand significantly increased the risk of depressive symptoms among blue collars (RR = 1.82), whereas among white collars, it was significantly protective (RR = 0.38). No significant relationship was found for job control or strain in either occupational class.The direct association observed elsewhere among blue collars between depressive symptoms and demand was confirmed, but not for job control or job strain. It cannot be ruled out that the association with demand was at least in part determined by reverse causation, due to exposure over-reporting among subjects with subclinical depressive symptoms at baseline. The protective effect of demand among white collars is not consistent with the literature and may be attributable to the particular characteristics of this sample, which included mainly workers employed in public administrative positions.

to evaluate the impact of a programme based on soft home care services and an offer of social caretaking, compared to one based only on soft home care, for the prevention of heat-related health events among clinically and/or functionally frail elderly.cluster randomised controlled trial.the study population included 2,612 persons over 75 years of age living alone in the city of Turin, North-West Italy, who were classified as clinically (hospitalization with specific diagnoses before summer 2004) and/or functionally (were receiving a disability pension) frail.a programme' s impact was evaluated on the basis of the hospitalizations and deaths that occurred during summer 2004, using gender-specific multilevel logistic regression models, controlling first for age and then also for education and income.among males, a weak protection against emergency hospitalization was observed within the group randomised to soft home care services and offer of social caretaking, compared to the only soft home care group (OR=0.33, 95% CI=0.11; 0.96). Among females, the programme including social caretaking seemed to lower the overall risk of hospitalization (OR=0.96, 95% CI=0.93; 0.98).this study has two important public health implications: first, it highlights the potential impact of programmes based on both soft home care and offer of social caretaking; second, it helps to raise awareness, both among health/social work and in the community, of the need for protection during summer periods for the elderly.

Background A relationship between quality of primary health care and preventable hospitalizations has been described in the US, especially among the elderly. In Europe, there has been a recent increase in the evaluation of Ambulatory Care Sensitive Conditions (ACSC) as an indicator of health care quality, but evidence is still limited. The aim of this study was to determine whether income level is associated with higher hospitalization rates for ACSC in adults in a country with universal health care coverage. Methods From the hospital registries in four Italian cities (Turin, Milan, Bologna, Rome), we identified 9384 hospital admissions for six chronic conditions (diabetes, hypertension, congestive heart failure, angina pectoris, chronic obstructive pulmonary disease, and asthma) among 20-64 year-olds in 2000. Case definition was based on the ICD-9-CM coding algorithm suggested by the Agency for Health Research and Quality - Prevention Quality Indicators. An area-based (census block) income index was used for each individual. All hospitalization rates were directly standardised for gender and age using the Italian population. Poisson regression analysis was performed to assess the relationship between income level (quintiles) and hospitalization rates (RR, 95% CI) separately for the selected conditions controlling for age, gender and city of residence. Results Overall, the ACSC age-standardized rate was 26.1 per 10.000 inhabitants. All conditions showed a statistically significant socioeconomic gradient, with low income people being more likely to be hospitalized than their well off counterparts. The association was particularly strong for chronic obstructive pulmonary disease (level V low income vs. level I high income RR = 4.23 95%CI 3.37-5.31) and for congestive heart failure (RR = 3.78, 95% CI = 3.09-4.62). With the exception of asthma, males were more vulnerable to ACSC hospitalizations than females. The risks were higher among 45-64 year olds than in younger people. Conclusions The socioeconomic gradient in ACSC hospitalization rates confirms the gap in health status between social groups in our country. Insufficient or ineffective primary care is suggested as a plausible additional factor aggravating inequality. This finding highlights the need for improving outpatient care programmes to reduce the excess of unnecessary hospitalizations among poor people.

The quality of care received by terminally ill cancer patients depends heavily on socio-economic conditions and family resources, especially because of the current increase in home care assistance.To validate the demographic information on educational level which is recorded in the registries of residents in Italian towns; to compare simple indicators of socio-economic status and family profiles with composite indicators in their ability to predict the economic and social impact of the disease.A two-level probabilistic sample of cancer deaths from the Italian Survey on Dying Of Cancer.2000 deaths were sampled; caregivers were identified and interviewed between 4 and 12 months after the patient's death.We calculated Cohens kappa for educational level as reported in the registry, and in the questionnaire. We constructed a composite indicator of socio-economic status and family profile using a cluster analysis; its association with the impact on finances and quality of daily life was compared with that from the educational level reported in the questionnaire and with a previously derived indicator of family profile.The weighted kappa of the two sources used for educational level was 0.60 (CI 95% 0.55-0.64). Of the two indicators, educational level and socio-economic status (6 groups), only the later showed a significant association with the outcomes "difficulties" in sustaining the costs of treatment" and "use of entire savings for the illness". The composite indicator of family profile (7 groups) was significantly associated with all outcomes considered. Log-likelihood was significantly better with model using the composite and the prior indicators of family profile than in models without them. Models that included educational level and prior indicator of family profile (7 groups) were more adaptable than models with the composite indicators.The good level of agreement between the two sources regarding educational level suggests that the registry is an adequate data source, when other information is lacking. Our study did not reveal which of the indicators we used is the best, at least with regard to the outcomes we considered.

The efficacy of colorectal cancer screening has been proved, and three different screening tests are recommended by international guidelines: the faecal occult blood test, flexible sigmoidoscopy and colonoscopy. While the effectiveness of a screening program depends on the compliance obtained, the role of the type of test on compliance has not yet been sufficiently studied.To measure the effect of the type of screening test used, i.e. faecal occult blood test or flexible sigmoidoscopy, on the compliance to colorectal cancer screening programs.A cluster-randomized two-arm trial was conducted. We randomly assigned 20 GP's practices that had an average of 150 patients between 50 and 74 years old.1449 individuals were referred to faecal occult blood test and 1538 to flexible sigmoidoscopy. The faecal occult blood test obtained higher compliance: 17.2% (95%CI 12.5-25.7) versus 7.0% (95%CI 5.7-9.0). The socio-economic status was an effect modifier of the test type: the effect of the type of test was smaller in low socioeconomic classes.The type of screening test used for colorectal cancer is a determinant of participation. In a low compliance area, better compliance will result from offering the faecal occult blood test than from the flexible sigmoidoscopy.

The indicators of healthy life expectancy measure differences in health among various population subgroups more sensitively than do indicators of mortality.The aim of the study was to analyze some of the above indicators to evaluate the differences among occupational categories in Turin.Mortality tables by occupation were calculated on Turin residents, aged 18-64 years in 1991, using the Turin Longitudinal Study which combines personal, census, and health information for the residents of the city. Longitudinal assessments of health expectancy were obtained by means of record-linkage with the Cancer Registry, the Diabetes Registry, and hospital discharge records. In addition, prevalence estimates of good health, disability, and chronic illness, obtained from ISTAT (Central Statistics Institute) investigations in 1999-2000 were combined with mortality data using Sullivan's algorithm.Among men there was a systematic disadvantage in almost all indicators of health expectancy for some manual occupations, while jobs requiring more qualifications were more advantaged. The health profile for women was more controversial, with an overall disadvantage among women who were professional consultants, although this group showed substantial variability: the legal professions had the lowest life and health expectancies, with approximately 3 years of life less than the health professions, which were among the most advantaged.The various indicators gave results which were at times conflicting, especially because the information obtained from the available sources had major limitations. The development of indicators needs to aim for greater homogeneity between mortality and health data to ensure maximum comparability.

Few studies have been aimed at describing organizational and psychosocial conditions of the Italian workforce by occupational group, and they have been mainly conducted within specific occupations.The present study aimed at identifying specific groups of occupations which have unfavourable profiles from the point of view of exposure to specific organizational factors and psychosocial risks, and to physical, chemical and ergonomic risks, and analyzing their distribution by worker age.The analysis was conducted on a sample of 4,195 workers in the Piedmont Region who were members of the CGIL Trade Union (Italian General Confederation of Labour), who answered a self-administered questionnaire in 2000, aimed at assessing chemical, physical, and ergonomic risks, accidents, and psychosocial factors connected with work organization and work tasks. Psychosocial risks were assessed via three scales aimed at measuring the degree of control, psychophysical demands, and worker satisfaction. The proportion of workers exposed to the above mentioned risks was analysed according to occupational group. This group was then compared with all other groups taken together, according to prevalence of high strain condition (combination of high demand and low control) and HSUR condition (High Strain Unfairly Rewarded; combination of high strain and low satisfaction).Among males aged 25-44 years, restricted to the occupation groups with more than ten workers in high strain condition, significantly higher proportions of stress were observed in leather workers and shoemakers, paper factory workers, rubber workers, crane and bridge crane operators, plastic workers, painters, transport drivers and carpenters. For many of these groups, excesses were confirmed for the HSUR condition. Among subjects aged over 44 years, a higher risk for high strain was confirmed in rubber workers, transport drivers and carpenters. In addition, machine tool operators, assembly line and mechanical workers in this age group were exposed to higher risk of stress. In younger women there was a significantly higher risk of both high strain and HSUR conditions in workers employed in the rubber, plastic and the food industries, and in machine tool workers. Such excess risk was confirmed in the latter three categories also among older women. In general, the proportion of male workers classified as working in high strain conditions decreased as age increased, while in women it remained stable.The study allowed evaluation of the differential impact of exposure to physical, chemical, and psychosocial risk factors among occupational groups, thus contributing to the identification and classification of exhausting jobs. The results further showed, particularly among men, a smaller proportion of older workers, compared to younger ones, exposed to harmful physical, chemical, ergonomic and psychosocial conditions, indicating a possible propensity of companies to adapt workplace conditions, organization and internal mobility to worker age.

Repetitive work injuries are a phenomenon that has not been sufficiently studied. Using data gathered by INAIL (National Institute for Insurance against Occupational Accidents and Diseases), it is possible to study the propensity of having a further injuries at the workplace after the first one.To identify the risk of experiencing multiple injuries according to occupation, with discussion of how useful the available information systems are.The data base includes workplace injuries, as classified by INAIL in Italy between 1994 and 2000 in the industrial and artisan sectors (2,162,702 subjects, ages 25-55). Selecting data on accidents occurring among 107,082 subjects who had experienced the first accident in 1996-99, in this cohort we assessed the occurrence of further accidents within two years in the same occupation, taking into account job mobility and factors eventually influencing underreporting (geographic area, age, severity of first accident and size of the enterprise). The risk for each occupation was computed stratifying by gender.There were significant differences between the first and successive accidents when examined by type, age group, severity of physical consequences and company size. Among men, the occupations showing higher risk were those already known to be at high risk for accidents: cleaning staff and refuse workers, foundry workers, masons, pilots, woodworkers, carpenters, transport workers, sailors, farmers, and miners. Among women the occupations most at risk were postwomen and messengers, cleaning staff and refuse workers, waitresses, cooks, bartenders, machine tool operators, woodworkers, and weavers in the textile industry.Among men, the risk of recurrent workplace accidents by occupation tends to reflect the frequency of the total accidents in each occupation. The results indicate that the study model employed is efficient and useful in providing risk profiles which allow identification of where to direct future studies, investigations, and preventive measures for each sex.

To evaluate differences in mortality by social class and to determine the impacts of socioeconomic factors on health inequalities in Italy, mortality data from 1981-2001 were analyzed as a function of social class in Turin, controlling for occupational risks, housing conditions, and education. For general and cause-specific mortality, the weight of each socioeconomic indicator was evaluated on population-attributable fraction to social class. Among men, mortality risk was significantly higher in unskilled blue-collar workers (RR = 1.45). Among women, the differences by social class were slighter. Education and economic status mostly explain the mortality differences by social class in men, while economic status showed the highest contribution in women.

Background: Studies of socioeconomic disparities in patterns of cause of death have been limited to single countries, middle-aged people, men, or broad cause of death groups. We assessed contribution of specific causes of death to disparities in mortality between groups with different levels of education, in men and women, middle-aged and old, in eight western European populations. Methods: We analysed data from longitudinal mortality studies by cause of death, between Jan 1, 1990, and Dec 31, 1997. Data were included for more than 1 million deaths in 51 million person years of observation. Findings: Absolute educational inequalities in total mortality peaked at 2127 deaths per 100 000 person years in men, and at 1588 deaths per 100 000 person years in women aged 75 years and older. In this age-group, rate ratios were greater than 1.00 for total mortality and all specific causes of death, apart form prostate cancer in men and lung cancer in women, showing increased mortality in low versus high eductational groups. In men, cardiovascular diseases accounted for 39% of the difference between low and high eductational groups in total mortality, cancer for 24%, other diseases for 32%, and external causes for 5%. Among women, contributions were 60%, 11%, 30%, and 0%, respectively. The contributions of cerebrovascular disease, other cardiovascular diseases, pneumonia, and COPD strongly increased by age, whereas those of cancer and external causes declined. Although relative inequalities in total mortality were closely similar in all populations, we noted striking differences in the contribution of specific causes to these inequalities. Interpretation: Research needs to be broadened to include older populations, other diseases, and populations from different parts of Europe. Effective interventions should be developed and implemented to reduce exposure to cardiovascular risk factors in low-educational groups.

Socioeconomic inequality and its impact on health is a growing concern in the European public health debate. In many countries, the issue is moving away from description towards the identification of the determinants of inequalities and the development of policies explicitly aimed at reducing inequalities in health. In Italy, ten years after the publication of the first report on inequalities in health, this topic is seldom present on the agenda of public policy makers. The purpose of this report is to update the Italian profile of social variation in health and health care in order to stimulate the debate on ways to tackle inequalities in health that are preventable. In the first section of this book, the threefold objective is to describe the principal mechanisms involved in the generation of social inequalities in health (Introduction); to report Italian data on the distribution and magnitude of this phenomenon in the last decade; and to evaluate policies and interventions in both the social (chapter 1.9, Section I) and the health sector (chapter 2.3, Section I), which are potentially useful to reduce health inequalities. It is intended for anyone who is in a position to contribute t o decision-making that will benefit the health of communities. For this reason, chapters are organized by specific determinants of inequalities on which interentions may have an impact. The methodological approach in the second section focuses on the best methods to monitor social inequalities including recommendations on social indicators, sources of information and study models, based on European guidelines revised for the Italian situation. According to data from national and local studies, mortality increases linearly with social disadvantage for a wide range of indicators at both the individual (education, social class, income, quality of housing) and the geographical level (deprivation indexes computed at different levels of aggregation). This positive correlation is evident for both sexes, with the steepest gradient observed among adults of working age, although differences persist also among the elderly. The causes of death found to be most highly correlated with social inequality, and largely responsible for the increasing inequality over the last decade, are those associated with addiction and exclusion (drug, alcohol and violence related deaths), with smoking (lung cancer) and with safety in the workplace and on the roads (accidents). Similar gradients and trends have been observed with different outcomes, such as self-reported morbidity, disability and cancer incidence (chapter 1.1, Section I). Reproductive outcomes confiirm this picture: compared to women belonging to the upper classes, those women in low conditions experience more spontaneous abortions and their children suffer from higher infant mortality and low birth weight. This is a critical issue since poor infant health, particularly for metabolic and respiratory pathologies, affects health in adult life. There is now substantive evidence showing that also socioeconomic circumstances at birth or during adolescence may have a strong impact on adult health (chapter 1.2, Section I). Differences in harmful lifestyles, such as smoking, heavy drinking, drug use, unhealthy diet, obesity and physical inactivity, have a similar effect. The only exception is smoking among women, which is positively correlated with socioeconomic status; however, since women in the upper classes have a greater tendency to quit smoking, the gradient will soon be reversed (chapter 1.7, Section I). On the other hand, most of these behaviours do not follow from free and conscious individual choice; they are a form of adaptation to chronic stress originating in the work-place (chapter 1.4, Section I), or to particularly unfavourable events and conditions, such as unemployment (chapter 1.5, Section I) or lack of family and social support (chapter 1.6, Section I). Poor socioeconomic circumstances are the threshold of absolute poverty and may lead to social exclusion, a condition with a heavy impact on health, which in Italy includes marginal groups of the native population and broader classes of immigrants (chapter 1.3, Section I). Finally, there is recent and consistent evidence on the existence of a "contextual" effect on health, as opposed to the "compositional" effect given solely by the aggregation of individual processes. According to this hypothesis, characteristics of the infrastructure, and the physical and socioeconomic environment of an area would have an impact on individual health independent from the cultural and economic resources personally available to people living in that area (chapter 1.8, Section I). With respect to the health care system, various studies are in agreement in demonstrating that poor and less educated people have inadequate access both to primary prevention and early diagnosis (chapter 2.1, Section I), and to early and appropriate care (chapter 2.2, Section I). They also experience higher rates of hospitalization, particularly in emergencies and with advanced levels of severity.

The geographic distribution of health status across Italian regions shows a North-South gradient, with better conditions in the North for both males and females. Using data from the 2000 National Health Interview Survey, the authors first analyze the geographic variation in subjective health and presence of chronic conditions, with specific attention to the effects of individual and area-based socioeconomic conditions and their heterogeneity across regions. The results suggest the North-South gradient in health is mainly affected, at least for subjective health, by the different composition of macro-areas with respect to individual education, and is slightly influenced by contextual circumstances. Moreover, being less educated results in poorer health in some regions (mainly South and Isles) than in others (mainly Northeast). The authors next analyze the circumstances affecting the presence of more disadvantaged people in the South, to highlight features of the Southern context that might exacerbate social inequalities in health and features of Northern areas that might allay them. Indicators of inequalities, welfare, labor, and power resources were analyzed. The results confirm the disadvantage of the South in terms of social, economic, and cultural features, mainly revealing the compositional effects found in the first part of the study. However, the contextual predictive value of income inequalities, quality of care, and social cohesion can have a supplementary effect on health outcomes of disadvantaged persons.

Purpose To evaluate the effectiveness of peer education when compared to teacher-led curricula in AIDS prevention programs conducted in schools in Rome, Italy. Methods Eighteen high schools were randomly assigned to one of two prevention programs: one led by teachers and the other by peer leaders. A sample of students attending the last 2 years (n = 1295) completed pre and post-intervention questionnaires. Changes in sexual behaviors, knowledge, prevention skills, risk perception and attitudes were first evaluated within each intervention group. Afterwards, changes in knowledge, prevention skills, risk perception, and attitudes total scale scores (post-test scores minus pre-test scores) were compared between the two groups, through linear regression models, in order to control for confounders, taking into account the within-school correlation in score changes. As for sexual behaviors, number of sexual partners and frequency of condom use in the 3 months before post-test were compared by intervention group through ordinal regression models, also taking into account behaviors reported before pre-test. Results For both groups, we observed significant improvements in skills, knowledge, attitudes and risk perception. The peer-led group showed a 6.7% (95% C.I. 1.9–11.5) scores greater improvement in knowledge, compared to the teacher-led group. In neither group were improvements observed in condom use or number of sexual partners. Conclusions The only apparent benefit of the peer-led intervention, compared to that led by teachers, was a greater improvement in knowledge of HIV. Neither of the interventions induced changes in sexual behavior. However, the role of possible biases and methodological problems must be considered when interpreting these results.

Objective . The aim of this study was to improve the definition of birth weight discordancy based on its distribution in the population after a correction in the unlike sex pairs. Study Design . The analysis was conducted on 849 Italian twin pairs. Male's birth weight in the unlike sex pairs was corrected by the physiological birth weight difference estimated on 21.595 Italian twins data. Birth weight discordancy was computed as a percentage of the larger twin's birth weight and it was compared by sex pairs and by gestational ages (Kruskal–Wallis test). Kolmogorov–Smirnov test was used to fit a normal distribution to the square-root transformed birth weight discordancy. Results . The estimated physiological birth weight difference between males and females was 4.39%, without any difference among gestational ages. The 90th centile of birth weight discordancy was 23.9% and the 95th centile was 29.2%. Conclusions . Ninetieth and 95th centiles of the fitted distribution are proposed as cut-off values for the definition of mild and severe birth weight discordancy.

European studies highlight a widening of relative inequalities in general mortality by socioeconomic status from the 1970s to the 1990s. Few studies are available for Southern European countries; they show that these countries represent an exception to these trends. Available evidence on this for Italy is for a specific city only and nationwide evidence does not exist yet. This paper examines the association between lifetime income and old age mortality risk, referred to as the income–mortality gradient, in Italy during the 1980s and 1990s. We investigate the shape of the gradient. Most importantly, we analyze the evolution of the gradient between these two decades. We use data drawn from an administrative pension archive held by the main Italian social security institution and proxy individual lifetime income with pension income. We use non-standard Cox proportional hazard models, where the positions and number of the knots in the spline function for income are determined by the data. The shape of the income–mortality gradient shows two discontinuities for males and one for females; these kink points are situated almost at the same percentiles of the income distribution during the 1980s and the 1990s. The estimated associations are negative and stronger at higher income levels. The income–mortality gradient widens over time for males and remains unchanged for females. Accounting for regional effects explains most of the widening in the gradient over time for males. Our findings show for both males and females that mortality risk decreases with income. Once controlled for regional differences, and in contrast with the trends observed in many other European countries, the relative difference in mortality risk between high and low-income individuals is rather stable over time in Italy.

Background The inverse association between socioeconomic position (SEP) and health has been extensively explored in Italy; however few studies have been carried out on the relationship between income inequalities and health status or health services utilisation, particularly at a local level. The objective of this study is to test the association between the demand for hospital care and a small area indicator based on income in four Italian cities, over a four-year period (1997-2000), in the adult population. Methods Census Block (median 260 residents) Median per capita Income (CBMI) was computed through record linkage between 1998 national tax and local population registries in the cities of Rome, Turin, Milan and Bologna (total population approximately 5.5 million). CBMI was linked to acute hospital discharges among residents, based on patient's residence. Age-standardized gender-specific hospitalisation rates were computed by CBMI quintiles (first quintile indicating lowest income), overall, and by city and year. Heterogeneity of the association between income level and hospitalisation was analysed through a Poisson model. Results We found an inverse association between small area income level and hospitalisation rates, which decreased continuously from 153 per 1000 inhabitants in the first quintile to 107 per 1000 inhabitants in the fifth quintile. Income differences in hospitalisation were confirmed in each city and year. However, the magnitude of the association and the absolute level of hospitalisation rates were quite different in each city and tended to slightly decrease over time in all cities considered, except Bologna. Conclusion Our study confirms an inverse association between income level and the use of hospitalization in four Italian cities, using a small area economic indicator, based on population tax data. Further analysis of the association between income and cause-specific hospitalization rates will allow to better understand the capability of the Italian National Health System to compel with socio-economic inequalities in health needs. Furthermore the SEP indicator we propose can represent a contribution to the improvement of tools for monitoring inequalities in health and in health services utilization.