Burden of multimorbidity in relation to age, gender and immigrant status: A cross-sectional study based on administrative data

Objectives Many studies have investigated multimorbidity, whose prevalence varies according to settings and data sources. However, few studies on this topic have been conducted in Italy, a country with universal healthcare and one of the most aged populations in the world. The aim of this study was to estimate the prevalence of multimorbidity in a Northern Italian region, to investigate its distribution by age, gender and citizenship and to analyse the correlations of diseases. Design Cross-sectional study based on administrative data. Setting Emilia-Romagna, an Italian region with-1/44.4 million inhabitants, of which almost one-fourth are aged 6565 years. Participants All adults residing in Emilia-Romagna on 31 December 2012. Hospitalisations, drug prescriptions and contacts with community mental health services from 2003 to 2012 were traced to identify the presence of 17 physical and 9 mental health disorders. Primary and secondary outcome measures Descriptive analysis of differences in the prevalence of multimorbidity in relation to age, gender and citizenship. The correlations of diseases were analysed using exploratory factor analysis. Results The study population included 622 026 men and 751 011women, with a mean age of 66.4 years. Patients with multimorbidity were 33.5% in 75 years and >60% among patients aged 6590 years; among patients aged 6565 years, the proportion of multimorbidity was 39.9%. After standardisation by age and gender, multimorbidity was significantly more frequent among Italian citizens than among immigrants. Factor analysis identified 5 multimorbidity patterns: (1) psychiatric disorders, (2) cardiovascular, renal, pulmonary and cerebrovascular diseases, (3) neurological diseases, (4) liver diseases, AIDS/HIV and substance abuse and (5) tumours. Conclusions Multimorbidity was highly prevalent in Emilia-Romagna and strongly associated with age. This finding highlights the need for healthcare providers to adopt individualised care plans and ensure continuity of care

Medical Costs of Patients with Type 2 Diabetes in a Single Payer System: A Classification and Regression Tree Analysis

Background and objectives Many studies and systematic reviews have estimated the healthcare costs of diabetes using a cost-of-illness approach. However, in the studies based on this approach patients\u2019 heterogeneity is rarely taken into account. The aim of this study is to stratify patients with type-2 diabetes into homogeneous cost groups based on demographic and clinical characteristics. Methods We conducted a retrospective cost of illness study by linking individual data on health services utilization retrieved from the administrative databases of Emilia-Romagna Region (Italy). Direct medical costs (either all-cause or diabetes-related) were calculated from the perspective of regional health service, using tariffs for hospitalizations and outpatient services and the unit costs of prescriptions for drugs. The determinants of costs identified in a generalized linear regression model were used to characterize subgroups of patients with homogeneous costs in a classification and regression tree analysis. Results The study population consists of a cohort of 101,334 patients with type 2 diabetes, followed up for 1 year, with a mean age of 70.9 years. Age, gender, complications, comorbidities and living area accounted significantly for cost variability. The classification tree identified 10 patient subgroups with different costs, ranging from a median of \u20ac 483 to \u20ac 39,578. The 2 subgroups with highest costs comprised dialysis patients and the largest subgroup (57.9%) comprised patients aged 6565 years without renal, cardiovascular and cerebrovascular complications. Conclusions Patients\u2019 classification into homogeneous cost subgroups can be used to improve the management and budget allocation for patients with type 2 diabetes

Costi diretti annuali per la gestione dei pazienti con diabete mellito di tipo 2 nelle Aziende Usl di Parma, Modena e Bologna

Introduzione. L’impatto economico del diabete mellito è in costante crescita e numerosi studi hanno calcolato i costi dei pazienti con diabete con risultati difficilmente confrontabili perché ottenuti con metodologie e prospettive differenti. Una valutazione delle prestazioni assistenziali erogate e della spesa correlata per la cura del diabete che sia specifica per il contesto regionale e nazionale è essenziale per sviluppare e migliorare programmi volti ad ottenere cure efficaci, garantendo la sostenibilità economica. Obiettivo. Valutare l’impatto economico dei pazienti con diabete mellito di tipo 2 nelle Aziende Usl di Parma, Modena e Bologna. Metodi. Studio cost-of-illness condotto secondo un’ottica di prevalenza e con un approccio comprensivo globale. Sono stati calcolati i costi diretti sanitari annuali dei pazienti con diabete mellito di tipo 2, nel 2015, relativi a ricoveri, farmaci e prestazioni specialistiche, attraverso il linkage di banche dati da flussi amministrativi correnti. I costi sono stati stimati secondo la prospettiva del Servizio sanitario nazionale e con un approccio bottom-up. Risultati. La popolazione in studio è composta da 101.334 soggetti con un’età media di 70,9 anni e una leggera predominanza di soggetti di genere maschile (54,1%). Nel 2015, il costo mediano per paziente diabetico è stato di 1012,6 euro. È stato possibile individuare due distinti gruppi di pazienti: a ‘basso costo’ e ad ‘alto costo’ che differiscono principalmente per età, durata di malattia e complicanze. I determinanti dei costi più rilevanti sono stati le complicanze, le comorbidità e l’età avanzata. Conclusioni. I nostri risultati mettono in evidenza l’eterogeneità dei pazienti diabetici per caratteristiche cliniche e consumo di risorse e forniscono indicazioni per programmare misure di controllo e contenimento dei costi attraverso l’organizzazione di interventi di prevenzione e una presa in carico appropriata rispetto ai bisogni assistenziali

Costi diretti annuali per la gestione dei pazienti con diabete mellito di tipo 2 nelle Aziende Usl di Parma, Modena e Bologna

Introduzione. L’impatto economico del diabete mellito è in costante crescita e numerosi studi hanno calcolato i costi dei pazienti con diabete con risultati difficilmente confrontabili perché ottenuti con metodologie e prospettive differenti. Una valutazione delle prestazioni assistenziali erogate e della spesa correlata per la cura del diabete che sia specifica per il contesto regionale e nazionale è essenziale per sviluppare e migliorare programmi volti ad ottenere cure efficaci, garantendo la sostenibilità economica. Obiettivo. Valutare l’impatto economico dei pazienti con diabete mellito di tipo 2 nelle Aziende Usl di Parma, Modena e Bologna. Metodi. Studio cost-of-illness condotto secondo un’ottica di prevalenza e con un approccio comprensivo globale. Sono stati calcolati i costi diretti sanitari annuali dei pazienti con diabete mellito di tipo 2, nel 2015, relativi a ricoveri, farmaci e prestazioni specialistiche, attraverso il linkage di banche dati da flussi amministrativi correnti. I costi sono stati stimati secondo la prospettiva del Servizio sanitario nazionale e con un approccio bottom-up. Risultati. La popolazione in studio è composta da 101.334 soggetti con un’età media di 70,9 anni e una leggera predominanza di soggetti di genere maschile (54,1%). Nel 2015, il costo mediano per paziente diabetico è stato di 1012,6 euro. È stato possibile individuare due distinti gruppi di pazienti: a ‘basso costo’ e ad ‘alto costo’ che differiscono principalmente per età, durata di malattia e complicanze. I determinanti dei costi più rilevanti sono stati le complicanze, le comorbidità e l’età avanzata. Conclusioni. I nostri risultati mettono in evidenza l’eterogeneità dei pazienti diabetici per caratteristiche cliniche e consumo di risorse e forniscono indicazioni per programmare misure di controllo e contenimento dei costi attraverso l’organizzazione di interventi di prevenzione e una presa in carico appropriata rispetto ai bisogni assistenziali

Are degree of urbanisation and travel times to healthcare services associated with the processes of care and outcomes of heart failure? A retrospective cohort study based on administrative data.

A few studies have found that patients with heart failure (HF) living in less densely populated areas have reduced use of services and poorer outcomes. However, there is a lack of evidence regarding transport accessibility measured as the actual distance between the patient's home and the healthcare facility. The aim of this study was to investigate if different urbanisation levels and travel times to healthcare services are associated with the processes of care and the outcomes of HF. This retrospective cohort study included patients residing in the Local Healthcare Authority of Bologna (2915 square kilometres) who were discharged from hospital with a diagnosis of HF between 1 January and 31 December 2017. Six-month study outcomes included both process (cardiology follow-up visits) and outcome measures (all-cause readmissions, emergency room visits, all-cause mortality). Of the 2022 study patients, 963 (47.6%) lived in urban areas, 639 (31.6%) in intermediate density areas, and 420 (20.8%) in rural communities. Most patients lived ≤30 minutes away from the nearest healthcare facility, either inpatient or outpatient. After controlling for a number of individual factors, no significant association between travel times and outcomes was present. However, rural patients as opposed to urban patients were more likely to see a cardiologist during follow-up (OR 1.42, 99% CI 1.03-1.96). These follow-up visits were associated with reduced mortality within 6 months of discharge (OR 0.53, 99% CI 0.32-0.87). We also found that multidisciplinary interventions for HF were more common in rural than in urban settings (18.8% vs. 4.0%). In conclusion, travel times had no impact on the quality of care for patients with HF. Differences between urban and rural patients were possibly mediated by more proximal factors, some of which are potential targets for intervention such as the availability and utilisation of follow-up cardiology services and multidisciplinary models of care

Caratteristiche ed esiti della sindrome coronarica acuta nella popolazione italiana e migrante: uno studio osservazionale basato su dati amministrativi sanitari nella Regione Emilia-Romagna

RAZIONALE. Lo scopo dello studio \ue8 analizzare le caratteristiche e gli esiti dei pazienti con sindrome coronarica acuta (SCA) in relazione al paese di origine. MATERIALI E METODI. La popolazione in studio comprende i residenti in Emilia-Romagna con un ricovero per infarto miocardico acuto (con [STEMI] e senza sopraslivellamento del tratto ST) tra il 2012 e il 2014. Sono stati indagati cinque esiti: procedura coronarica percutanea (PCI) entro 2 giorni dallo STEMI, mortalit\ue0 a 30 giorni, mortalit\ue0 a 1 anno, eventi cardio-cerebrovascolari avversi maggiori a 1 anno (MACCE) e aderenza alla terapia post-infarto. Gli esiti sono stati valutati in funzione della cittadinanza, al netto di potenziali confondenti (rilevati al ricovero indice e nelle ospedalizzazioni dei 2 anni precedenti) con modelli di regressione multipla. RISULTATI. Dei 23 884 soggetti in studio, 647 (2.7%) sono migranti. L\u2019et\ue0 media di insorgenza della SCA \ue8 pi\uf9 bassa tra i migranti (56 anni) rispetto agli italiani (73 anni). La mortalit\ue0 a 30 giorni dal ricovero per SCA \ue8 pari al 9.6% mentre le percentuali di mortalit\ue0 e MACCE a 1 anno sono rispettivamente del 19.8% e 20.8%. Il 63.2% dei soggetti con STEMI viene sottoposto a PCI e i pazienti aderenti alla terapia post-infarto sono il 31.0%. Rispetto agli italiani, gli africani e gli asiatici hanno una probabilit\ue0 inferiore di essere sottoposti a PCI e sono significativamente meno aderenti alla terapia. Non si rilevano differenze significative nei tassi di mortalit\ue0, mentre gli asiatici hanno un rischio pi\uf9 alto del 62% di incorrere in un MACCE. CONCLUSIONI. I cittadini migranti con SCA sono molto pi\uf9 giovani, vengono sottoposti meno frequentemente a procedure invasive e sono meno aderenti alle terapie farmacologiche rispetto agli italiani. Sono necessari ulteriori studi per valutare i determinanti di tali differenze e sviluppare modelli organizzativi che tengano conto delle esigenze specifiche di questi pazienti.Background. The aim of this study was to analyze the characteristics and outcomes of patients with acute coronary syndrome (ACS) in relation to country of origin. Methods. The study population included patients living in the Emilia-Romagna Region and discharged from 2012 to 2014 with a diagnosis of acute myocardial infarction (with [STEMI] and without ST-elevation). The study outcomes were: percutaneous coronary intervention (PCI) within 48 hours of admission for STEMI, 30-day all-cause mortality, 1-year all-cause mortality, 1-year major adverse cardiac and cerebrovascular events (MACCE), and adherence to post-infarction medications. The relationship between outcomes and citizenship was investigated using multiple regression analysis. Potential confounders were identified among diagnoses recorded in the index hospitalization and in all hospitalizations occurring 2 years prior to the index hospitalization. Results. Of the 23 884 study patients, 647 (2.7%) were non-Italians. The mean age of onset of ACS was lower among immigrants (56 years) than among Italians (73 years). Thirty-day mortality was 9.6% while 1-year mortality and MACCE were 19.8% and 20.8%, respectively. The proportion of PCI within 48 hours was 63.2%, while patients adherent to medications were 31.0%. Compared with Italians, patients from Africa and Asia had a reduced probability of undergoing PCI and were less adherent to medications. Adjusted mortality rates were similar between Italians and immigrants, while patients from Asia had a 62% increased probability of experiencing a MACCE during follow-up. Conclusions. Compared with Italians, immigrant citizens with ACS were younger, less likely to undergo PCI, and less adherent to drug treatment after discharge. Further studies are warranted to identify the determinants of these disparities and to develop organizational models tailored to the specific needs of immigrant patients

Are degree of urbanisation and travel times to healthcare services associated with the processes of care and outcomes of heart failure? A retrospective cohort study based on administrative data

A few studies have found that patients with heart failure (HF) living in less densely populated areas have reduced use of services and poorer outcomes. However, there is a lack of evidence regarding transport accessibility measured as the actual distance between the patient's home and the healthcare facility. The aim of this study was to investigate if different urbanisation levels and travel times to healthcare services are associated with the processes of care and the outcomes of HF. This retrospective cohort study included patients residing in the Local Healthcare Authority of Bologna (2915 square kilometres) who were discharged from hospital with a diagnosis of HF between 1 January and 31 December 2017. Six-month study outcomes included both process (cardiology follow-up visits) and outcome measures (all-cause readmissions, emergency room visits, all-cause mortality). Of the 2022 study patients, 963 (47.6%) lived in urban areas, 639 (31.6%) in intermediate density areas, and 420 (20.8%) in rural communities. Most patients lived 6430 minutes away from the nearest healthcare facility, either inpatient or outpatient. After controlling for a number of individual factors, no significant association between travel times and outcomes was present. However, rural patients as opposed to urban patients were more likely to see a cardiologist during follow-up (OR 1.42, 99% CI 1.03-1.96). These follow-up visits were associated with reduced mortality within 6 months of discharge (OR 0.53, 99% CI 0.32-0.87). We also found that multidisciplinary interventions for HF were more common in rural than in urban settings (18.8% vs. 4.0%). In conclusion, travel times had no impact on the quality of care for patients with HF. Differences between urban and rural patients were possibly mediated by more proximal factors, some of which are potential targets for intervention such as the availability and utilisation of follow-up cardiology services and multidisciplinary models of care

Organisational determinants of adherence to secondary prevention medications after acute myocardial infarction

OBJECTIVES: to identify organisational determinants of adherence to evidence-based drug treatments after acute myocardial infarction (AMI), under the hypothesis that low adherence is associated with higher mortality and risk of reinfarction. In particular, we investigated the effect of group vs. single handed practice and multi-professional practice characteristics on patients' adherence to polytherapy after AMI. DESIGN: retrospective cohort study. SETTING AND PARTICIPANTS: residents in the Local Health Authority of Bologna (Italy) who were discharged from any Italian hospital between 2008 and 2011 with a diagnosis of AMI, and followed-up for a year. MAIN OUTCOME MEASURES: adherence to at least three out of the four drug therapies recommended for secondary prevention of AMI (angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, \u3b2-blockers, antiplatelet agents, statins). Patients who had at least 80% of days of follow-up covered by drug doses were considered adherent. RESULTS: of the 4,828 post-AMI patients, 31.6% were adherent to polytherapy. General practice characteristics were unrelated to adherence, whereas discharge from cardiology hospital wards was significantly associated with higher patients' adherence (OR 1.97; 95%CI 1.56-2.48). CONCLUSION: general practice organisational models are not associated with higher adherence to evidence-based medications after AMI, whereas cardiologists seem to play a key role in improving patient adherence to polytherapy. Healthcare delivery models should be designed; in them, general practitioners are responsible for the provision of patient-centred care pathways and for care co-ordination with other primary care professionals and specialists, and take an advocacy role for the patient when needed

Effect of cardiologist care on 6-month outcomes in patients discharged with heart failure: Results from an observational study based on administrative data

Objectives To evaluate the effect of cardiologist care on adherence to evidence-based secondary prevention medications, mortality and readmission within 6 months of discharge in patients with heart failure (HF). Design Retrospective observational study based on administrative data. Setting Local Healthcare Authority (LHA) of Bologna, one of the largest LHAs of Italy with ~870 000 inhabitants. Participants All patients residing in the LHA of Bologna discharged from hospital with a diagnosis of HF between 1 January 2015 and 31 December 2015. Primary and secondary outcome measures Multivariable regression analysis was used to assess the association of inpatient and outpatient cardiologist care with adherence to evidence-based medications, all-cause mortality and hospital readmission (including emergency room visits) within 6 months of discharge. Results The study population included 2650 patients (mean age 82.3 years). 340 (12.8%) patients were discharged from cardiology wards, while 635 (24.0%) were seen by a cardiologist during follow-up. Inpatient and outpatient cardiologist care was associated with an increased likelihood of adherence to ACE inhibitors/ angiotensin receptor blockers (ACEIs/ARBs), \uce\ub2-blockers and aldosterone antagonists after discharge. The risk of mortality was significantly lower among patients adherent to ACEIs/ARBs and/or \uce\ub2-blockers (\ue2\u80\u9353% and \ue2\u80\u9328%, respectively); the risk of hospital readmission was significantly lower among patients adherent to ACEIs/ARBs (\ue2\u80\u9328%). Conclusions Compared with non-specialist care, cardiologist care improves patient adherence to evidence-based medications and might thus favourably affect mortality and readmission following HF