Francesco Zambon

Evidence-based Policy on Road Safety: The Effect of the Demerit Points System on Seat Belt Use and Health Outcomes

Objective: To assess the effect of a demerit points system, introduced in Italy in July 2003, on the prevalence of seat belt use (intermediate outcome) and the number of road traffic deaths and injuries (health outcomes). Design: Pre- and post-intervention regional observational study for seat belt investigation (April 2003, October 2004); national time-series analysis of road traffic deaths and injuries between 1999 and 2004 for health outcomes. Setting: Veneto region, Italy. Participants: 19 551 drivers, 19 057 front passengers and 8123 rear passengers estimated to be aged over 11 years were included in the investigation into seat belt use. 38 154 fatalities and 1 938 550 injured subjects were examined for the time-series analysis. Interventions: Demerit points system. Main outcome measures: The proportions of drivers and front and rear passengers observed to be using seat belts before and after the intervention; estimates of lives and injuries saved through the implementation of a penalty points system. Results: The demerit points system was followed by an increase in observed seat belt use of 51.8% (95% confidence interval 48.7% to 54.9%) among drivers, of 42.3% (95% confidence interval 39.2% to 45.5%) among front passengers and of 120.7% (95% confidence interval 99.4% to 144.3%) among rear passengers. It is estimated that 1545 (95% confidence interval 1387 to 1703; p<0.0001) deaths and 91 772 (95% confidence interval 67 762 to 115 783; p<0.0001) injuries were prevented in the 18 months after the introduction of the legislation, i.e. an 18% reduction (1545/8570) in fatalities and a 19% reduction (91 772/473 048) in injuries. Conclusions: The demerit points system is effective both in encouraging drivers and passengers to adhere to the law and in terms of health outcomes, substantially contributing to road safety.

Obstetric hospitalizations among Italian women, regular and irregular immigrants in North-Eastern Italy

Objective. Italy has become an important host country for economic immigrants. The study is aimed at providing a descriptive analysis of obstetric hospitalizations among Italian and immigrant women in North‐Eastern Italy. Design. Population‐based registry descriptive study. Setting. Veneto Region, Italy. Methods. All obstetric hospitalizations in 2006–2007 were extracted from the regional archive of hospital discharge records (n = 144,698). Discharges for vaginal delivery, cesarean section, threatened abortion and other antepartum diagnoses, miscarriages, and induced abortions were identified among residents with Italian or foreign citizenship, and irregular immigrants. Hospitalization rates for the above diagnostic categories were computed for Italian and foreign Veneto residents. Main outcome measures. Delivery rates, proportion of cesarean sections, hospitalization rates for antepartum hospitalizations, miscarriage, induced abortion, and hospitalization rate ratios of immigrants versus Italian women. Results. Among Italian women, regular and irregular immigrants, the percentages of teenage deliveries were 0.7, 2.9, and 8.4%; the ratios of miscarriages to deliveries were 0.16, 0.15 and 0.35; the ratios of induced abortions to deliveries were 0.13, 0.24 and 0.81, respectively. Regular immigrants accounted for 10% of population aged 15–49 and for 20% of deliveries. The age‐related increase in miscarriage risk was steeper among regular immigrants. The induced abortions to deliveries ratio peaked among Italians aged <25 and regular immigrants aged ≥35 years. 40% of Italians and 30% of regular immigrants sought care outside nearest hospitals. Conclusions. Wide differences in reproductive behavior, health status, and patterns in the access to health services exist between Italians, regular and irregular immigrants even though they represent three connected populations.

Seat Belt and Child Seat Use in Lipetskaya Oblast, Russia: Frequencies, Attitudes, and Perceptions

Objective: Despite the importance of understanding seat belt use patterns among drivers and passengers for the purpose of direct interventions or monitoring improvements, no study has described wearing rates for all seat positions in Russia. This study describes observed seat belt use and knowledge, attitudes, and perceptions of seat belt use in Lipetskaya Oblast, Russia. Methods: An observational study on the use of seat belts and child restraints in the Lipetskaya region conducted during October 2010 collected data in 6 districts and on 3 different road types. A roadside survey gathered information on knowledge, attitudes, and perceptions toward the use of seat belts from randomly selected drivers. Frequencies of seat belt use by seat position, gender, and road type were calculated. A multivariable logit model disclosed the associations between seat belt use and sociodemographic factors. The study design permitted comparison of observed seat belt use to self-reported seat belt use. Results: A total of 25,795 vehicles and 39,833 drivers and passengers contributed observations. Overall, 55 percent of drivers were observed to be using seat belts. More than half (58%) of front seat passengers wore seat belts and only 9 percent of back seat passengers were observed to be wearing seat belts; 11 percent of cars with children had any type of child safety measure. Drivers on urban roads were less likely to wear seat belts compared to those on main highways and rural roads. Nearly 60 percent of survey respondents mentioned “seat belts save lives,” and more than half mentioned law requirements and fines. Conclusions: Although the observed seat belt use in Lipetskaya Oblast is much higher than previous estimates in Russia, overall wearing rates remain far from universal. Rear seat passengers and children are particularly at risk. Because combined education and enforcement has proven to be effective elsewhere, such interventions are needed to improve seat belt use.

Sustainability of the effects of the demerit points system on seat belt use: a region-wide before-and-after observational study in Italy.

To assess the short and long term effects of the demerit points system on seat belt use, we set a region-wide cross-sectional observational study 3 months before, and 3 and 15 months after the introduction of the scheme (July 2003) in the Veneto Region, Italy. We analysed differences in seat belt use by year of observation, gender and position in the vehicle, and obtained adjusted prevalence ratio (APR) through Poisson regression. A total of 29,303 drivers, 28,778 front and 12,186 rear passengers were observed. Prevalence levels of 54% for drivers and 53% for front passengers in 2003 switched to 83 and 76%, respectively, 3 months after the new legislation, with further slight increases 15 months thereafter. Seventy-four percent rear passengers were still not compliant with the legislation in 2005. The probability of being belted was 25% lower in males than females (APR=0.75, 95% CI 0.73-0.77) at the beginning of the study period. However, the effect of the new legislation was 19% greater among males (APR=1.19, 95% CI 1.16-1.23). A substantial increase in seat belt use was reached and sustained with the demerit points system. Specific efforts should target rear passengers whose seat belt use still remains worryingly low.

Variability of adenoidectomy/tonsillectomy rates among children of the Veneto Region, Italy.

BackgroundDespite national guidelines in 2003 aimed at limiting the recourse to tonsillectomy and/or adenoidectomy (A/T), the latter are among the most frequent pediatric surgeries performed in Italy. Aim of the study is to investigate variability of A/T rates among children of the Veneto Region, Italy.MethodsAll discharges of Veneto residents with Diagnosis-Related Groups 57–60 and ICD9-CM intervention codes 28.2 (tonsillectomy), 28.3 (adenotonsillectomy), 28.6 (adenoidectomy) were selected in the period 2000–2006 for a descriptive analysis. A multilevel Poisson regression model was applied to estimate Incidence Rate Ratios (IRR) with 95% Confidence Intervals (CI) for A/T surgery among children aged 2–9 years in 2004–2006, while taking into account clustering of interventions within the 21 Local Health Units.ResultsThrough 2000–2006, the overall number of A/T surgeries decreased (-8%); there was a decline of adenoidectomies (-20%) and tonsillectomies (-8%), whereas adenotonsillectomies raised (+18%). Analyses on children aged 2–9 resulted in an overall rate of 14.4 surgeries per 1000 person-years (16.1 among males and 12.5 among females), with a wide heterogeneity across Local Health Units (range 8.1–27.6). At random intercept Poisson regression, while adjusting for sex and age, intervention rates were markedly lower among foreign than among Italian children (IRR = 0.57, CI 0.53–0.61). A/T rates in the 10–40 age group (mainly tonsillectomies) computed for each Local Health Unit and introduced in the regression model accounted for 40% of the variance at Local Health Unit level of pediatric rates (mainly adenoidectomies and adenotonsillectomies).ConclusionA/T rates in the Veneto Region, especially adenoidectomies among children aged 2–9 years, remain high notwithstanding a decrease through 2000–2006. A wide heterogeneity according to nationality and Local Health Units is evident. The propensity to A/T surgery of each Local Health Unit is similar in different age groups and for different surgical indications.

Seat belt use among rear passengers: validity of self-reported versus observational measures

BackgroundThe effects of seat belt laws and public education campaigns on seat belt use are assessed on the basis of observational or self-reported data on seat belt use.Previous studies focusing on front seat occupants have shown that self-reports indicate a greater seat belt usage than observational findings.Whether this over-reporting in self reports applies to rear seat belt usage, and to what extent, have yet to be investigated.We aimed to evaluate the over-reporting factor for rear seat passengers and whether this varies by gender and under different compulsory seat belt use conditions.MethodsThe study was conducted in the Veneto Region, an area in the North-East of Italy with a population of 4.7 million.The prevalence of seat belt use among rear seat passengers was determined by means of a cross-sectional self-report survey and an observational study.Both investigations were performed in two time periods: in 2003, when rear seat belt use was not enforced by primary legislation, and in 2005, after rear seat belt use had become compulsory (June 2003).Overall, 8138 observations and 7902 interviews were recorded.Gender differences in the prevalence of rear seat belt use were examined using the chi-square test. The over-reporting factor, defined as the ratio of the self-reported to the observed prevalence of rear seat belt use, was calculated by gender before and after the rear seat belt legislation came into effect.ResultsAmong rear seat passengers, self-reported rates were always higher than the observational findings, with an overall over-reporting factor of 1.4.We registered no statistically significant changes over time in the over-reporting factor, nor any major differences between genders.ConclusionSelf-reported seat belt usage by rear passengers represents an efficient alternative to observational studies for tracking changes in actual behavior, although the reported figures need to be adjusted using an appropriate over-reporting factor in order to gain an idea of genuine seat belt use.

Youth suicide: an insight into previous hospitalisation for injury and sociodemographic conditions from a nationwide cohort study

Background This study investigates the degree to which a previous hospitalisation for injury of any intent is a risk of subsequent youth suicide and whether this association is influenced by family socioeconomic status or economic stress. Methods A nationwide register-based cohort study was conducted covering all Swedish subjects born between January 1977 and December 1991 (N=1 616 342, male/female ratio=1.05). The cohort subjects were followed-up from January 1998 to December 2003, when aged 7–26 years. Poisson regression and the likelihood ratio test (95% CI) were used to assess the age-adjusted effect of hospitalisation for injuries of various intent on youth suicide and its effect once adjusted for family sociodemographic and social circumstances. Results Each set of exposures was associated independently and significantly with suicide mortality. Being hospitalised for self-inflicted injuries or injuries of undetermined intent was associated with a risk of suicide 36 to 47 times, respectively, that of subjects never hospitalised in the period under study (95% CI 28.36 to 45.58 and 26.67 to 83.87 for self-inflicted injuries and for events of undetermined intent, respectively; overall p<0.01). Similarly, previous events of unintentional injury markedly increased the risk of suicide (RR 3.08; 95% CI 2.26 to 4.19). These effects were solid and not substantially altered after adjustment for family demographic and socioeconomic circumstances. Conclusion A strong association exists between previous hospitalisation for injury of any intent and youth suicide. The association is robust and unaltered by family socioeconomic circumstances.

Quality of care in congestive heart failure in the elderly: epidemiological evidence of a gap between guidelines and clinical practice

Background and aims: This study aimed at evaluating the quality of care in elderly patients hospitalized for heart failure, compared with that received by subjects of younger age. Methods: A cross-sectional retrospective study was performed on hospitalized subjects for heart failure in the Veneto Region (4.5 million inhabitants), located in North-East Italy, for the year 2004. Through consultation of clinical charts, performance of echocardiography, and prescription of ACE-inhibitors and β-blockers were evaluated in each patient. Multivariate statistical analysis was used to test the association between age and the end-points of interest: prescription of ACE-inhibitors or β-blockers and performance of echocardiography. Results: The percentage of patients with prescriptions for ACE-inhibitors decreased with age, from 75% for patients under 65 years, to 62% for subjects over 84 years (p=0.02). A similar, but more marked, finding was observed for prescriptions of β-blockers (56% in subjects aged <65 yrs vs 16% in those aged >84 yrs) (p<0.001). Evaluation of echocardiography was performed in 61 % of subjects under 65 and in 22% in those over 84 (p<0.001). After statistical adjustment, age remained a significant predictor of prescription for β-blockers and performance of echocardiography, but no longer for prescription of ACE-inhibitors. Conclusions: Among the elderly, age was a negative predictor of β-blocker prescription and echocardiographic evaluation, but did not affect prescriptions for ACE-inhibitors.

Education level and chronic liver disease by aetiology: A proportional mortality study.

BACKGROUND Data are lacking on mortality from chronic liver diseases of different aetiology by education level. AIMS To investigate the association between education level and mortality from alcoholic, viral, and non-viral/non-alcoholic chronic liver disease. METHODS Proportional mortality was investigated in 2011-2013 in the Veneto Region (Italy). Odds ratios were estimated by conditional logistic regression with deaths from liver cirrhosis, liver cancer, and viral hepatitis as cases, and all other deaths as controls. Disease aetiology was determined from all conditions mentioned in the death certificate. RESULTS Overall chronic liver disease proportional mortality was higher in males (OR 1.37, 95% CI 1.18-1.60) and females (OR 1.72, 95% CI 1.29-2.30) with primary education than in subjects with higher educational level. The risk for alcohol-related and non-viral/non-alcohol-related disease significantly increased with lower education in both genders. CONCLUSIONS Proportional mortality analysis of multiple causes of death records showed an association between education and chronic liver diseases with alcoholic and non-viral/non-alcoholic aetiology.

Hospitalisation for surgical procedures is lower among immigrants than among non-immigrant preschool children: results from a region-wide study in Italy

Background Whether immigrant children receive unnecessary treatments and surgical procedures to a greater extent than non-immigrants remains controversial. Objective To investigate whether hospitalisation rates differ between immigrant and non-immigrant preschool children and the extent to which such differences relate to specific pathological conditions. Methods All discharges occurring to children aged 1–5 years between 2005 and 2007 in the Italian Region of Veneto (4.8 million inhabitants) were analysed by diagnosis related groups (DRGs). Crude and age-standardised hospitalisation RRs of immigrant versus Italian children were computed. Results Hospitalisation rates for medical conditions were similar between immigrant and Italian children. However, hospitalisation rates among immigrant children were significantly lower than those among Italians for all the most frequent surgical DRGs. RRs (95% CI) of immigrant versus Italian children were 0.46 (0.41 to 0.51) for tonsillectomy/adenoidectomy and 0.46 (0.38 to 0.57) for testes procedures in boys; 0.44 (0.38 to 0.49) for tonsillectomy/adenoidectomy and 0.47 (0.34 to 0.65) for extraocular procedures in girls. Only circumcision procedures were more frequent (fourfold excess) among immigrants. Conclusion Hospitalisation rates for the most frequent surgical procedures are significantly lower among immigrants compared to non-immigrant preschool children. Reduced surgery rates among immigrants might result from a complex interplay between parental attitudes and knowledge of paediatric conditions, language barriers and access to primary care.