Gianfranco Damiani

The effectiveness of computerized clinical guidelines in the process of care: a systematic review

BackgroundClinical practice guidelines have been developed aiming to improve the quality of care. The implementation of the computerized clinical guidelines (CCG) has been supported by the development of computerized clinical decision support systems.This systematic review assesses the impact of CCG on the process of care compared with non-computerized clinical guidelines.MethodsSpecific features of CCG were studied through an extensive search of scientific literature, querying electronic databases: Pubmed/Medline, Embase and Cochrane Controlled Trials Register. A multivariable logistic regression was carried out to evaluate the association of CCGs features with positive effect on the process of care.ResultsForty-five articles were selected. The logistic model showed that Automatic provision of recommendation in electronic version as part of clinician workflow (Odds Ratio [OR]= 17.5; 95% confidence interval [CI]: 1.6-193.7) and Publication Year (OR = 6.7; 95%CI: 1.3-34.3) were statistically significant predictors.ConclusionsFrom the research that has been carried out, we can conclude that after implementation of CCG significant improvements in process of care are shown. Our findings also suggest clinicians, managers and other health care decision makers which features of CCG might improve the structure of computerized system.

Socioeconomic disparities in the uptake of breast and cervical cancer screening in Italy: a cross sectional study

BackgroundBreast and cervical cancer screening are widely recognized as effective preventive procedures in reducing cancer mortality. The aim of this study was to evaluate the impact of socioeconomic disparities in the uptake of female screening in Italy, with a specific focus on different types of screening programs.MethodsA cross-sectional study was conducted using data from the 2004-2005 national health interview survey. A sample of 15, 486 women aged 50-69 years for mammography and one of 35, 349 women aged 25-64 years for Pap smear were analysed. Logistic regression models were used to estimate the association between socioeconomic factors and female screening utilization.ResultsEducation and occupation were positively associated with attendance to both screening. Women with higher levels of education were more likely to have a mammogram than those with a lower level (OR = 1.28; 95% CI = 1.10-1.49). Women of intermediate and high occupational classes were more likely to use breast cancer screening (OR = 1.77; 95% CI = 1.55-2.03, OR = 1.63; 95% CI = 1.40-1.91) compared to unemployed women. Women in the highest occupational class had a higher likelihood of cervical cancer screening compared to those in the lowest class (OR = 1.81; 95% CI = 1.63-2.01). Among women who attended screening, those with lower levels of education and lower occupational classes were more likely than more advantaged women to attend organized screening programs rather than being screened on the basis of their own initiative.ConclusionsInequalities in the uptake of female screening widely exist in Italy. Organized screening programs may have an important role in increasing screening attendance and tackling inequalities.

Chronic disease prevalence from Italian administrative databases in the VALORE project: A validation through comparison of population estimates with general practice databases and national survey

BackgroundAdministrative databases are widely available and have been extensively used to provide estimates of chronic disease prevalence for the purpose of surveillance of both geographical and temporal trends. There are, however, other sources of data available, such as medical records from primary care and national surveys. In this paper we compare disease prevalence estimates obtained from these three different data sources.MethodsData from general practitioners (GP) and administrative transactions for health services were collected from five Italian regions (Veneto, Emilia Romagna, Tuscany, Marche and Sicily) belonging to all the three macroareas of the country (North, Center, South). Crude prevalence estimates were calculated by data source and region for diabetes, ischaemic heart disease, heart failure and chronic obstructive pulmonary disease (COPD). For diabetes and COPD, prevalence estimates were also obtained from a national health survey. When necessary, estimates were adjusted for completeness of data ascertainment.ResultsCrude prevalence estimates of diabetes in administrative databases (range: from 4.8% to 7.1%) were lower than corresponding GP (6.2%-8.5%) and survey-based estimates (5.1%-7.5%). Geographical trends were similar in the three sources and estimates based on treatment were the same, while estimates adjusted for completeness of ascertainment (6.1%-8.8%) were slightly higher. For ischaemic heart disease administrative and GP data sources were fairly consistent, with prevalence ranging from 3.7% to 4.7% and from 3.3% to 4.9%, respectively. In the case of heart failure administrative estimates were consistently higher than GPs’ estimates in all five regions, the highest difference being 1.4% vs 1.1%. For COPD the estimates from administrative data, ranging from 3.1% to 5.2%, fell into the confidence interval of the Survey estimates in four regions, but failed to detect the higher prevalence in the most Southern region (4.0% in administrative data vs 6.8% in survey data). The prevalence estimates for COPD from GP data were consistently higher than the corresponding estimates from the other two sources.ConclusionThis study supports the use of data from Italian administrative databases to estimate geographic differences in population prevalence of ischaemic heart disease, treated diabetes, diabetes mellitus and heart failure. The algorithm for COPD used in this study requires further refinement.

Vacuum-assisted closure therapy for patients with infected sternal wounds: A meta-analysis of current evidence

Acute and chronic wound infections are the main reasons for the observed increase in mortality rate and represent a significant risk factor in hospitalisation. From the patients perspective, wound therapy is an uncomfortable, painful and long-term treatment. Modern sternal-wound-treatment systems would be expected to shorten wound healing and hospital stay periods. Vacuum-assisted closure (VAC) therapy is a system that promotes wound healing through the application of negative pressure by controlled suction to the wound surface. The application of controlled levels of negative pressure accelerates healing in many types of wounds. There are a number of scientific publications that have used meta-analysis to compare VAC and traditional therapy, considering changes in wound size. This article surveys the research literature focussing on the management of wound infections. The objective of this study is to assess the impact of VAC compared with conventional therapy on length of stay (LOS) and mortality. Six articles were selected that included a total of 321 patients (169 for VAC therapy and 152 for conventional therapy). The meta-analysis showed that VAC therapy resulted in a decrease of 7.18 days in hospital LOS (confidence interval (CI) 95%: 10.82, 3.54), with no significant impact on mortality. Our data provide robust evidence of the effectiveness of VAC therapy.

Factors associated with health-related quality of life: the role of social relationships among the elderly in an Italian region

OBJECTIVES This study examines the association between social relationships and health-related quality of life (HRQL) in the elderly in Lazio Region, Italy, a Mediterranean country where the shape and role of social links has dramatically changed. METHODS Data were extracted from a national cross-sectional survey in Italy, representative of the non-institutionalised population aged 60 years and over resident in Lazio Region during 1999--2000. HRQL was measured with the Short Health Survey Questionnaire (SF-12). Data analysis was performed using multiple linear regression models using adjustment for the main confounders. RESULTS Among the sample, 40.4% of the elderly were not married and 27.1 % were living alone. While being married and not living alone were associated with higher scores in the physical and mental quality-of-life components (P-value<0.001), more frequent visiting/seeing friends was likely to be associated with higher scores in both the physical and the mental health components (P-value<0.05). Multiple logistic regression analysis demonstrated that low physical health scores were associated with a low frequency of meeting with relatives and with living far from relatives. CONCLUSIONS In a region covering 9.2% of the whole Italian population, only a small proportion of the elderly lack frequent social ties, yet low frequency of relationships with friends is associated with a decline in quality of life measured through mental and physical scores. Our findings will be useful for drawing up welfare strategies both at the national and at the Mediterranean level, in countries, like Italy, where the primacy of family support of the elderly has been decreasing in recent years.

Influence of socioeconomic factors on hospital readmissions for heart failure and acute myocardial infarction in patients 65 years and older: evidence from a systematic review

Purpose Cardiovascular diseases are the leading cause of death and disability worldwide. Among these diseases, heart failure (HF) and acute myocardial infarction (AMI) are the most common causes of hospitalization. Therefore, readmission for HF and AMI is receiving increasing attention. Several socioeconomic factors could affect readmissions in this target group, and thus, a systematic review was conducted to identify the effect of socioeconomic factors on the risk for readmission in people aged 65 years and older with HF or AMI. Methods The search was carried out by querying an electronic database and hand searching. Studies with an association between the risk for readmission and at least one socioeconomic factor in patients aged 65 years or older who are affected by HF or AMI were included. A quality assessment was conducted independently by two reviewers. The agreement was quantified by Cohen’s Kappa statistic. The outcomes of studies were categorized in the short-term and the long-term, according to the follow-up period of readmission. A positive association was reported if an increase in the risk for readmission among disadvantaged patients was found. A cumulative effect of socioeconomic factors was computed by considering the association for each study and the number of available studies. Results A total of eleven articles were included in the review. They were mainly published in the United States. All the articles analyzed patients who were hospitalized for HF, and four of them also analyzed patients with AMI. Seven studies (63.6%) were found for the short-term outcome, and four studies (36.4%) were found for the long-term outcome. For the short-term outcome, race/ethnicity and marital status showed a positive cumulative effect on the risk for readmission. Regarding the educational level of a patient, no effect was found. Conclusion Among the socioeconomic factors, mainly race/ethnicity and marital status affect the risk for readmission in elderly people with HF or AMI. Multidisciplinary hospital-based quality initiatives, disease management, and care transition programs are a priority for health care systems to achieve better coordination.

Patterns of Long Term Care in 29 European countries: evidence from an exploratory study

BackgroundThe challenges posed by the rapidly ageing population, and the increased preponderance of disabled people in this group, coupled with the rising level of public expenditure required to service the complex organization of long term care (LTC) delivery are causing increased pressure on LTC systems in Europe. A pan-European survey was carried out to evaluate whether patterns of LTC can be identified across Europe and what are the trends of the countries along them.MethodsAn ecological study was conducted on the 27 EU Member States plus Norway and Iceland, referring to the period 2003-2007. Several variables related to organizational features, elderly needs and expenditure were drawn from OECD Health Data and the Eurostat Statistics database and combined using Multiple Factor Analysis (MFA).ResultsTwo global Principal Components were taken into consideration given that their expressed total variance was greater than 60%. They were interpreted according to the higher (more than 0.5) positive or negative correlation coefficients between them and the original variables; thus patterns of LTC were identified. High alignment between old age related expenditure and elderly needs characterizes Nordic and Western European countries, the former also having a higher level of formal care than the latter. Mediterranean as well as Central and South Eastern European countries show lower alignment between old age related expenditure and elderly needs, coupled with a level of provision of formal care that is around or slightly above the average European level. In the dynamic comparison, linear, stable or unclear trends were shown for the studied countries.ConclusionsThe analysis carried out is an explorative and descriptive study, which is an attempt to reveal patterns and trends of LTC in Europe, allowing comparisons between countries. It also stimulates further researches with lower aggregated data useful to gain meaningful policy-making evidence.Please see related article: http://www.biomedcentral.com/1741-7015/9/124

Postoperative pulmonary function in open versus laparoscopic cholecystectomy: a meta-analysis of the Tiffenau index

Background: Available scientific literature about open cholecystectomy (OC) and laparoscopic cholecystectomy (LC) does not show univocal results in terms of postoperative pulmonary function. A meta-analysis was carried out to evaluate the postoperative pulmonary function after OC and LC focusing on the Tiffenau index. Methods: Electronic databases were consulted (Cochrane Library, Embase and Pubmed). Standardized mean difference (SMD) with 95% CI was calculated for the Tiffenau Index. The kappa test was performed to evaluate agreement between the reviewers regarding the quality of the selected studies. A sensitivity analysis was carried out to assess the robustness of our study. Heterogeneity among studies was tested by using a χ2 test at 0.05 significance level. A random effects model meta-analysis was performed. Results: Meta-analysis of the 13 articles included, resulted in a SMD of 53% (95% CI 0.04, 1.02) for the Tiffenau Index in favor of laparoscopic cholecystectomy. The χ2 test analysis showed the presence of heterogeneity among studies (Tiffenau index χ2 = 99.97, p = 0.03). The sensitivity analysis confirms the validity of our results. Conclusions: Postoperative pulmonary function is better preserved after laparoscopic cholecystectomy than open cholecystectomy.

The impact of level of education on adherence to breast and cervical cancer screening: Evidence from a systematic review and meta-analysis

OBJECTIVE To assess the inequalities in adherence to breast and cervical cancer screening according to educational level. METHODS A systematic review was carried out between 2000 and 2013 by querying an electronic database using specific keywords. Studies published in English reporting an estimation of the association between level of education and adherence to breast and/or cervical cancer screening were included in the study. Two different meta-analyses were carried out for adherence to breast and cervical cancer screening, respectively: women with the highest level of education and women with the lowest level of education were compared. The level of heterogeneity was investigated and subgroup analyses were carried out. RESULTS Of 1231 identified articles, 10 cross-sectional studies were included in the analysis. The meta-analyses showed that women with the highest level of education were more likely to have both screenings with an overall OR=1.61 (95% CI 1.36-1.91; I(2)=71%) for mammography and OR=1.96 (95% CI 1.79-2.16; I(2)=0%) for Pap test, respectively. Stratified meta-analysis for breast cancer screening included only studies that reported guidelines with target age of population ≥50 years and showed a reduction in the level of heterogeneity and an increase of 36% in the adherence (95% CI 1.19-1.55; I(2)=0%). CONCLUSIONS This study confirms and reinforces evidence of inequalities in breast and cervical cancer screening adherence according to educational level.

Prevalence of chronic diseases by immigrant status and disparities in chronic disease management in immigrants: a population-based cohort study, Valore Project

BackgroundFor chronic conditions, disparities can take effect cumulatively at various times as the disease progresses, even when care is provided. The aim of this study was to quantify the prevalence of diabetes, congestive heart failure (CHF) and coronary heart disease (CHD) in adults by citizenship, and to compare the performance of primary care services in managing these chronic conditions, again by citizenship.MethodsThis is a population-based retrospective cohort study on 1,948,622 people aged 16 years or more residing in Italy. A multilevel regression model was applied to analyze adherence to care processes using explanatory variables at both patient and district level.ResultsThe age-adjusted prevalence of diabetes was found higher among immigrants from high migratory pressure countries (HMPC) than among Italians, while the age-adjusted prevalence of CHD and CHF was higher for Italians than for HMPC immigrants or those from highly-developed countries (HDC). Our results indicate lower levels in all quality management indicators for citizens from HMPC than for Italians, for all the chronic conditions considered. Patients from HDC did not differ from Italian in their adherence to disease management schemes.ConclusionThis study revealed a different prevalence of chronic diseases by citizenship, implying a different burden of primary care by citizenship. Our findings show that more effort is needed to guarantee migrant-sensitive primary health care.