Elisa Stivanello

Ethnic variation in the prevalence of depression and anxiety in primary care: A systematic review and meta-analysis

Primary care plays a key role in the detection and management of depression and anxiety. At present it is not clear if the prevalence of depression and anxiety in primary care differs between migrants and ethnic minorities (MI) and natives and ethnic majorities (MA). A systematic review and a meta-analysis of studies comparing the prevalence of depression and anxiety in MI and MA in primary care were performed. Studies were identified by searching MEDLINE, PsychINFO, EMBASE and through hand-search. We included 25 studies, most of which had a relatively small sample size. Significant variations were found in the prevalence of anxiety and depression across studies. Pooled analyses were carried out for 23 studies, based on random-effects models. Pooled RR of depression and anxiety in MI were 1.21 (95% CI 1.04-1.40, p=0.012) and 1.01 (95% CI 0.76-1.32, p=0.971), with high heterogeneity (I²=87.2% and I²=73%). Differences in prevalence rates among studies can be accounted for by inclusion criteria, sampling methods, diagnostic instruments and study design. Further research on larger samples and with culturally adapted instruments is needed to estimate the prevalence of depression and anxiety in MI seeking help for these disorders.

Peripartum hysterectomy and cesarean delivery: a population-based study.

Objective. To estimate the incidence of peripartum hysterectomy in an Italian Region (Emilia‐Romagna) and investigate its association with cesarean delivery. Design. Population‐based retrospective study using hospital discharge records. Setting. All public and private hospitals in Emilia‐Romagna region, Italy. Population. A total of 151,494 women delivering between 2003 and 2006, 131 of whom had a peripartum hysterectomy. Methods. Peripartum hysterectomy was defined as a hysterectomy performed at the time of delivery or afterwards during the same hospitalization. Incidence rates were calculated by type of delivery. Odds ratios (ORs) with 95% confidence intervals (CIs) were estimated with logistic regression to evaluate the association between peripartum hysterectomy and delivery type. Main outcome measures. Incidence rates of peripartum hysterectomy by type of delivery; odds of peripartum hysterectomy after primary or repeat cesarean compared with vaginal delivery without previous cesarean. Results. A total of 131 peripartum hysterectomies were performed among 151,494 deliveries (0.86/1,000 deliveries; 95% CI 0.72–1.03) with 20.7% primary and 9.6% repeat cesarean deliveries. Women undergoing a primary caesarean delivery were more likely to have a peripartum hysterectomy than women having a vaginal delivery who had never had a cesarean delivery (OR 6.48; 95% CI 4.16–10.07). Women undergoing a repeat caesarean delivery were also at increased risk (OR 3.69; 95% CI 2.11–6.46). Conclusions. In this population, primary and repeat cesarean deliveries are associated with an increased risk of peripartum hysterectomy. These results are of particular concern given the steady increase in the cesarean delivery rate in many countries. The pathological mechanism of this association requires further investigation.

Migrant pathways to community mental health centres in Italy

Background: Many studies indicate that migrants in western countries have limited access to and low utilization of community mental health centres (CMHCs) despite the high prevalence of mental disorders. Aims: We aimed to compare migrant pathways to care across four CMHCs located in different Italian provinces and to identify pathway to care predictors. Methods: Migrants attending the four CMHCs between 1 July 1999 and 31 December 2007 were included in the study. Data were gathered retrospectively from clinical data sets and chart review. Results: Five hundred and eleven (511) migrants attended the four CMHCs, 61% were referred by GPs or other health services and 39% followed non-medical pathways to care (self-referral or through social and voluntary organizations), with important site variations. Younger age and being married were predictors of medical pathways to care; lacking a residence permit and having a diagnosis of substance abuse were related to non-medical pathways. Conclusions: Pathways to CMHCs are complex and influenced by many factors. Non-medical pathways to care seem to be frequent among migrants in Italy. More attention should be paid to developing psychiatric consultation liaison models that also encompass the social services and voluntary organizations.

Acupuncture As an Integrative Approach for the Treatment of Hot Flashes in Women With Breast Cancer: A Prospective Multicenter Randomized Controlled Trial (AcCliMaT)

PURPOSE To determine the effectiveness of acupuncture for the management of hot flashes in women with breast cancer. PATIENTS AND METHODS We conducted a pragmatic, randomized controlled trial comparing acupuncture plus enhanced self-care versus enhanced self-care alone. A total of 190 women with breast cancer were randomly assigned. Random assignment was performed with stratification for hormonal therapy; the allocation ratio was 1:1. Both groups received a booklet with information about climacteric syndrome and its management to be followed for at least 12 weeks. In addition, the acupuncture group received 10 traditional acupuncture treatment sessions involving needling of predefined acupoints. The primary outcome was hot flash score at the end of treatment (week 12), calculated as the frequency multiplied by the average severity of hot flashes. The secondary outcomes were climacteric symptoms and quality of life, measured by the Greene Climacteric and Menopause Quality of Life scales. Health outcomes were measured for up to 6 months after treatment. Expectation and satisfaction of treatment effect and safety were also evaluated. We used intention-to-treat analyses. RESULTS Of the participants, 105 were randomly assigned to enhanced self-care and 85 to acupuncture plus enhanced self-care. Acupuncture plus enhanced self-care was associated with a significantly lower hot flash score than enhanced self-care at the end of treatment (P < .001) and at 3- and 6-month post-treatment follow-up visits (P = .0028 and .001, respectively). Acupuncture was also associated with fewer climacteric symptoms and higher quality of life in the vasomotor, physical, and psychosocial dimensions (P < .05). CONCLUSION Acupuncture in association with enhanced self-care is an effective integrative intervention for managing hot flashes and improving quality of life in women with breast cancer.

Risk adjustment models for interhospital comparison of CS rates using Robson’s ten group classification system and other socio-demographic and clinical variables

BackgroundCaesarean section (CS) rate is a quality of health care indicator frequently used at national and international level. The aim of this study was to assess whether adjustment for Robson’s Ten Group Classification System (TGCS), and clinical and socio-demographic variables of the mother and the fetus is necessary for inter-hospital comparisons of CS rates.MethodsThe study population includes 64,423 deliveries in Emilia-Romagna between January 1, 2003 and December 31, 2004, classified according to theTGCS. Poisson regression was used to estimate crude and adjusted hospital relative risks of CS compared to a reference category. Analyses were carried out in the overall population and separately according to the Robson groups (groups I, II, III, IV and V–X combined). Adjusted relative risks (RR) of CS were estimated using two risk-adjustment models; the first (M1) including the TGCS group as the only adjustment factor; the second (M2) including in addition demographic and clinical confounders identified using a stepwise selection procedure. Percentage variations between crude and adjusted RRs by hospital were calculated to evaluate the confounding effect of covariates.ResultsThe percentage variations from crude to adjusted RR proved to be similar in M1 and M2 model. However, stratified analyses by Robson’s classification groups showed that residual confounding for clinical and demographic variables was present in groups I (nulliparous, single, cephalic, ≥37 weeks, spontaneous labour) and III (multiparous, excluding previous CS, single, cephalic, ≥37 weeks, spontaneous labour) and IV (multiparous, excluding previous CS, single, cephalic, ≥37 weeks, induced or CS before labour) and to a minor extent in groups II (nulliparous, single, cephalic, ≥37 weeks, induced or CS before labour) and IV (multiparous, excluding previous CS, single, cephalic, ≥37 weeks, induced or CS before labour).ConclusionsThe TGCS classification is useful for inter-hospital comparison of CS section rates, but residual confounding is present in the TGCS strata.

Migrants referring to the Bologna Transcultural Psychiatric Team: Reasons for drop-out

Background: Recent immigrants face various difficulties in adjusting to western countries and show a high prevalence of mental disorders. Access to a culturally appropriate community mental health centre (CMHC) is crucial for immigrants (Bhui et al., 2007). The Bologna West Transcultural Psychiatric Team (BoTPT, Tarricone et al., 2009) is one of the first projects in Italy that prioritizes cultural competence care. This paper aims to evaluate the effectiveness of this service and to describe what characteristics of patient and psychiatric intervention are related to ‘drop-out’. Method: All migrants who consecutively attended the BoTPT between 1 July 1999 and 30 June 2008 were included and evaluated at first contact and again six months later. Results: After six months we followed up 162 patients; 32 (17.9%) of these had interrupted treatment. Non-Asian origin, a recent history of migration and not receiving social intervention were the strongest predictors of drop-out cases. Conclusion: Psychiatric consultation services to migrants could be made more effective by enhancing: (a) cultural competence, through cultural mediator involvement; and (b) social support from the first psychiatric contact. These two characteristics of psychiatric consultation could be developed from resources ordinarily present in the context of a CMHC and could then become a cost-effective strategy for addressing mental health needs among first-generation immigrants.

Does breast cancer screening level health inequalities out? A population-based study in an Italian region.

BACKGROUND Although population-based screening has the potential to reduce inequalities in breast cancer survival, evidence on this topic is controversial. The objective of this study was to evaluate whether the full implementation of a mammography screening programme in Emilia-Romagna in Italy had an impact on variations in breast cancer survival by educational level. METHODS A cohort study was performed, including all women <70 years and residing in Emilia-Romagna who had infiltrating breast cancer registered in 1997-2000 (transitional screening period) or 2001-03 (consolidation screening period). Cancer cases were retrieved from the regional Breast Cancer Registry and followed up for 5 years. Educational level was determined from census data and allocated to cancer cases by individual record linkage. Age at diagnosis was classified into two groups (30-49, 50-69: screening target population). RESULTS A total of 9639 cases were analyzed. In the 1997-2000 period, low-educated women had significantly lower survival compared with high-educated women, both in the younger and in the older age-groups. After the full implementation of the screening programme, these differences decreased in both age-groups, until disappearing completely among women in the age-group invited to screening. CONCLUSIONS Our findings suggest that a fee-free population-based organized mammography screening programme with active invitation of the whole target population could be effective in reducing differences in survival in the population targeted by the screening.

Risk adjustment for cesarean delivery rates: how many variables do we need? An observational study using administrative databases

BackgroundVarious studies indicate that inter-hospital comparisons have to take case mix into account and that risk adjustment procedures are necessary to control for potential predictors of cesarean delivery (CD). Different data sources have been used to retrieve information on potential predictors of CD. The aim of this study was to compare the discrimination capacity and fit of predictive models of CD created using different sources and to assess whether more complex models improve inter-hospital comparisons.MethodsWe created 4 predictive models of CD. One model included only variables from Hospital Discharge Records of the index hospitalization, one included also information from previous hospitalizations, one also clinical variables from birth certificates (BC) and one also socio-demographic variables. We compared the four models using the Receiver Operator Curve and the Akaike and Bayesian Information Criteria.ResultsInformation from Birth Certificates improved the discrimination and model fit. Adding socio-demographic variables or past comorbidities did not improve the discrimination capacity or the model fit. Hospital-specific CD resulting from the models were highly correlated.ConclusionsRecord linkage improves the performance of the models but does not affect inter-hospital comparisons.

Risk adjustment for inter-hospital comparison of caesarean delivery rates in low-risk deliveries.

Background Caesarean delivery (CD) rates have been frequently used as quality measures for maternity service comparisons. More recently, primary CD rates (CD in women without previous CD) or CD rates within selected categories such as nulliparous, term, cephalic singleton deliveries (NTCS) have been used. The objective of this study is to determine the extent to which risk adjustment for clinical and socio-demographic variables is needed for inter-hospital comparisons of CD rates in women without previous CD and in NTCS deliveries. Methods Hospital discharge records of women who delivered in Emilia-Romagna Region (Italy) from January, 2007 to June 2009 and in Tuscany Region for year 2009 were linked with birth certificates. Adjusted RRs of CD in women without a previous Caesarean and NTCS were estimated using Poisson regression. Percentage differences in RR before and after adjustment were calculated and hospital rankings, based on crude and adjusted RRs, were examined. Results Adjusted RR differed substantially from crude RR in women without a previous Caesarean and only marginally in NTCS group. Hospital ranking was markedly affected by adjustment in women without a previous CD, but less in NTCS. Conclusion Risk adjustment is warranted for inter-hospital comparisons of primary CD rates but not for NTCS CD rates. Crude NTCS CD rates are a reliable estimate of adjusted NTCS CD.

Determinants of cesarean delivery: a classification tree analysis

BackgroundCesarean delivery (CD) rates are rising in many parts of the world. To define strategies to reduce them, it is important to identify their clinical and organizational determinants. The objective of this cross-sectional study is to identify sub-types of women at higher risk of CD using demographic, clinical and organizational variables.MethodsAll hospital discharge records of women who delivered between 2005 and mid-2010 in the Emilia-Romagna Region of Italy were retrieved and linked with birth certificates. Sociodemographic and clinical information was retrieved from the two data sources. Organizational variables included activity volume (number of births per year), hospital type, and hour and day of delivery. A classification tree analysis was used to identify the variables and the combinations of variables that best discriminated cesarean from vaginal delivery.ResultsThe classification tree analysis indicated that the most important variables discriminating the sub-groups of women at different risk of cesarean section were: previous cesarean, mal-position/mal-presentation, fetal distress, and abruptio placentae or placenta previa or ante-partum hemorrhage. These variables account for more than 60% of all cesarean deliveries. A sensitivity analysis identified multiparity and fetal weight as additional discriminatory variables.ConclusionsClinical variables are important predictors of CD. To reduce the CD rate, audit activities should examine in more detail the clinical conditions for which the need of CD is questionable or inappropriate.