Publications by authors named "Roberto Gnavi"

57 Publications

Validation of an Algorithm to Detect Multiple Sclerosis Cases in Administrative Health Databases in Piedmont (Italy): An Application to the Estimate of Prevalence by Age and Urbanization Level.

Neuroepidemiology 2021 10;55(2):119-125. Epub 2021 Mar 10.

Epidemiology Unit, ASL TO3 Regione Piemonte, Grugliasco, Italy.

Introduction: Italy is considered a high-risk country for multiple sclerosis (MS). Exploiting electronic health archives (EHAs) is highly useful to continuously monitoring the prevalence of the disease, as well as the care delivered to patients and its outcomes. The aim of this study was to validate an EHA-based algorithm to identify MS patients, suitable for epidemiological purposes, and to estimate MS prevalence in Piedmont (North Italy).

Methods: MS cases were identified, in the period between January 1, 2012 and December 31, 2017, linking data from 4 different sources: hospital discharges, drug prescriptions, exemptions from co-payment to health care, and long-term care facilities. Sensitivity of the algorithm was tested through record linkage with a cohort of 656 neurologist-confirmed MS cases; specificity was tested with a cohort of 2,966,293 residents presumably not affected by MS. Undercount was estimated by a capture-recapture method. We calculated crude, and age- and gender-specific prevalence. We also calculated age-adjusted prevalence by level of urbanization of the municipality of residence.

Results: On December 31, 2017, the algorithm identified 8,850 MS cases. Sensitivity was 95.9%, specificity was 99.97%, and the estimated completeness of ascertainment was 91.9%. The overall prevalence, adjusted for undercount, was 152 per 100,000 among men and 286 among women; it increased with increasing age and reached its peak value in the 45- to 54-year class, followed by a progressive reduction. The age-adjusted prevalence of residents in cities was 15% higher than in those living in the countryside.

Discussion/conclusion: We validated an algorithm based on EHAs to identify cases of MS for epidemiological use. The prevalence of MS, adjusted for undercount, was among the highest in Italy. We also found that the prevalence was higher in highly urbanized areas.
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http://dx.doi.org/10.1159/000513763DOI Listing
March 2021

[Epidemiology in support of intervention priorities: the case of diabetes in Turin (Piedmont Region, Northern Italy)].

Epidemiol Prev 2020 Sep-Dec;44(5-6 Suppl 1):172-178

Servizio sovrazonale di epidemiologia, ASL TO3, Grugliasco (TO).

Objectives: to describe the epidemiology of diabetes within the city of Turin (Piedmont Region, Northern Italy) and to present the process initiated by the city network of diabetes care for the improvement of prevention and treatment of the disease.

Design: ecological study based on administrative database.

Setting And Participants: residents in Turin from 2016 to 2018.

Main Outcome Measures: incidence and prevalence of diabetes, percentage of glycosylated haemoglobin testing, and case-fatality.

Results: in the considered three-year period (2016-2018), the cumulative incidence of diabetes was 11.5 x1,000; as of 31.12.2018 the prevalence was 5.9%. 77% had performed at least one measurement of glycated haemoglobin during the previous year, and the case-fatality was 12.6% in the three-year period. The standardized prevalence per statistical zone varied from a minimum of 2% (95%CI 1.2-3.3) to a maximum of 10.2% (95%CI 9.1-11.4). The highest values were recorded in the most deprived city areas. The geographical distribution of incidence, varying between 5.1 x1,000 (95%CI 2.7-10.0) e 19.4 x1,000 (95%CI 15.8-24.0), reproduces the geography of prevalence, as well as the percentage of measurement of glycated haemoglobin, while the variability of the fatality rate is more modest without an obvious geographic pattern.

Conclusions: diabetes occurs most frequently in the most deprived areas of the city, but the response of the health care system is adequate and equitable. Sharing of these results with the city health authorities and the diabetologists has led to identify as a priority interventions for the reduction of unhealthy behaviours, and for the improvements of patient care pathway, starting form the most disadvantaged areas of the city. A process of listening and involvement of all actors potentially interested in the prevention and treatment of diabetes has been started.
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http://dx.doi.org/10.19191/EP20.5-6.S1.P172.087DOI Listing
January 2021

Educational inequalities in the prevalence and outcomes of diabetes in the Emilian Longitudinal Study.

Nutr Metab Cardiovasc Dis 2020 08 19;30(9):1525-1534. Epub 2020 May 19.

Health and Social Care Agency, Emilia-Romagna Region, Bologna, Italy. Electronic address:

Background And Aim: Studies carried out in Italy in the last decades reported an effect modification in the association between socioeconomic position and diabetes outcomes, and the disease integrated care approach has been suggested as an explanatory factor. Whether this is true in Emilia-Romagna region in recent years is unknown and the aim of this study is to describe the role of educational level both on diabetes prevalence and health outcomes among the adult population with and without diabetes enrolled in the Emilian Longitudinal Study.

Methods And Results: Inequalities in diabetes prevalence were evaluated through standardised estimates and prevalence ratios by educational level and inequalities in outcomes through standardised hospitalisation and mortality ratios and rate ratios by educational level. The lower the education the greater the diabetes prevalence; such differences were larger among women and younger age groups. Diabetes conferred a higher risk of hospitalisation and mortality; those outcomes also presented a social gradient with the less educated bearing the higher risk. However, educational differences were slightly stronger among the disease-free subjects, especially in the case of mortality. In both genders, inequalities tended to disappear with age.

Conclusion: This study confirms that diabetes increases the risk of unfavourable outcomes, but does not increase social inequalities in outcomes as might be expected. Similarly to what has been previously shown, it is likely that the protective effect of diabetes on the negative health effects of the low social position is attributable to the disease integrated care approach.
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http://dx.doi.org/10.1016/j.numecd.2020.04.032DOI Listing
August 2020

Therapy With Agents Acting on the Renin-Angiotensin System and Risk of Severe Acute Respiratory Syndrome Coronavirus 2 Infection.

Clin Infect Dis 2020 11;71(16):2291-2293

Epidemiology Unit, Azienda Sanitaria Locale TO3  , Regione Piemonte, Grugliasco, Italy.

Exposure to agents acting on the renin-angiotensin system was not associated with a risk increase of COVID-19 infection in 2 Italian matched case-control studies, 1 nested in hypertensive patients and the other in patients with cardiovascular diseases or diabetes.
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http://dx.doi.org/10.1093/cid/ciaa634DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7543878PMC
November 2020

Socioeconomic and citizenship inequalities in hospitalisation of the adult population in Italy.

PLoS One 2020 23;15(4):e0231564. Epub 2020 Apr 23.

Italian National Institute of Statistics (Istat), Rome, Italy.

Background: Higher levels of hospital admissions among people with lower socioeconomic level, including immigrants, have been observed in developed countries. In Europe, immigrants present a more frequent use of emergency services compared to the native population. The aim of our study was to evaluate the socioeconomic and citizenship differences in the hospitalisation of the adult population in Italy.

Methods: The study was conducted using the database created by the record linkage between the National Health Interview Survey (2005) with the National Hospital Discharge Database (2005-2014). 79,341 individuals aged 18-64 years were included. The outcomes were acute hospital admissions, urgent admissions and length of stay (1-7 days, > = 8 days). Education level, occupational status, self-perceived economic resources and migratory status were considered as socioeconomic determinants. A multivariate proportional hazards model for recurrent events was used to estimate the risk of total hospital admissions. Logistic models were used to estimate the risk of urgent hospitalisation as well as of length of stay.

Results: Low education level, the lack of employment and negative self-perceived economic resources were conditions associated with the risk of hospitalisation, a longer hospital stay and greater recourse to urgent hospitalisation. Foreigners had a lower risk of hospitalisation (HR = 0.75; 95% CI:0.68-0.83) but a higher risk of urgent hospitalisation (OR = 1.36; 95% CI:1.18-1.55) and more frequent hospitalisations with a length of stay of at least eight days (OR = 1.19; 95% CI:1.02-1.40).

Conclusions: To improve equity in access, effective primary, secondary and tertiary prevention strategies must be strengthened, as should access to appropriate levels of care.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0231564PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7179888PMC
July 2020

Opportunistic screening for type 2 diabetes in community pharmacies. Results from a region-wide experience in Italy.

PLoS One 2020 18;15(3):e0229842. Epub 2020 Mar 18.

Department of Drug Science and Technology, University of Torino, Torino TO, Italy.

Background And Aims: Given the paucity of symptoms in the early stages of type 2 diabetes, its diagnosis is often made when complications have already arisen. Although systematic population-based screening is not recommended, there is room to experience new strategies for improving early diagnosis of the disease in high risk subjects. We report the results of an opportunistic screening for diabetes, implemented in the setting of community pharmacies.

Methods And Results: To identify people at high risk to develop diabetes, pharmacists were trained to administer FINDRISC questionnaire to overweight, diabetes-free customers aged 45 or more. Each interviewee was followed for 365 days, searching in the administrative database whether he/she had a glycaemic or HbA1c test, or a diabetologists consultation, and to detect any new diagnosis of diabetes defined by either a prescription of any anti-hyperglycaemic drug, or the enrolment in the register of patients, or a hospital discharge with a diagnosis of diabetes. Out of 5977 interviewees, 53% were at risk of developing diabetes. An elevated FINDRISC score was associated with higher age, lower education, and living alone. Excluding the number of cases expected, based on the incidence rate of diabetes in the population, 51 new cases were identified, one every 117 interviews. FINDRISC score, being a male and living alone were significantly associated with the diagnosis.

Conclusions: The implementation of a community pharmacy-based screening programme can contribute to reduce the burden of the disease, particularly focusing on people at higher risk, such as the elderly and the socially vulnerable.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0229842PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7080237PMC
July 2020

Assessment of Non-Adherence to Oral Metformin and Atorvastatin Therapies: A Cross-Sectional Survey in Piedmont (Italy).

Patient Prefer Adherence 2020 14;14:261-266. Epub 2020 Feb 14.

Department of Drug Science and Technology, University of Turin, Turin, Italy.

Introduction: It is not possible to recover from chronic diseases; however, a healthy lifestyle and correct adherence to therapy can avoid complications and co-morbidities. The aim of this study was the cross-sectional evaluation, by means of a questionnaire, of real-world data on the prevalence of non-adherence to metformin and atorvastatin oral therapies in a sample of patients that attend community pharmacies in the Piedmont Region. The secondary aim was to evaluate the presence of correlations between non-adherence and a number of variables detected by the questionnaire.

Materials And Methods: Data were gathered from face-to-face interviews in six community pharmacies in Piedmont. The questionnaire was divided into two sections: the first included the Morisky, Green and Levine Medication Adherence Questionnaire (MAQ) (to assess therapy adherence); the second included questions on gender, age, level of education and the pharmacy in which the questionnaire was administered. Comparisons between proportions and mean values were performed using the χ2 test. Modified Poisson regression with robust standard errors was used for multivariate analysis. The level of significance was fixed at 0.05, CI at 95%.

Results: The sample analysed was composed of 408 subjects (receiving either metformin or atorvastatin). According to MAQ, 62 patients were non-adherent (15% of the total cohort). Crude and multivariate analysis did not show any statistically significant correlation between gender, age, level of education and non-adherence. It emerged that there was a correlation between non-adherence and being a customer of two of the pharmacies involved [PR = 3.31 (p=0.028) and PR = 3.11 (p=0.027)].

Conclusions: Community pharmacies can be an appropriate setting to identify non-adherent patients. Therefore, healthcare professionals could realize an integrated and structured intervention to improve adherence. However, MAQ could underestimate the number of non-adherent patients. Further studies to test the association between non-adherence prevalence and being the customer of a specific pharmacy should be performed.
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http://dx.doi.org/10.2147/PPA.S226206DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7028384PMC
February 2020

Incretin-based therapy and risk of cholangiocarcinoma: a nested case-control study in a population of subjects with type 2 diabetes.

Acta Diabetol 2020 Apr 5;57(4):401-408. Epub 2019 Nov 5.

Epidemiology Unit, ASL TO3, Regione Piemonte, Grugliasco, Italy.

Background And Aims: One cohort and several basic science studies have raised suspicion about an association between incretin therapies and cholangiocarcinoma. Our aim was to verify the occurrence of CC in relation to incretin-based medication use versus any antidiabetic treatment in an unselected population of diabetic patients.

Methods: A population-based matched case-control study was conducted using administrative data from the Region of Piedmont (4,400,000 inhabitants), Italy. From a database of 312,323 patients treated with antidiabetic drugs, we identified 744 cases hospitalized for cholangiocarcinoma from 2010 to 2016 and 2976 controls matched for gender, age and initiation of antidiabetic therapy; cases and controls were compared for exposure to incretin-based medications. All analyses were adjusted for risk factors for CC, as ascertained by hospital discharge records. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated by fitting a conditional logistic model.

Results: The mean age of the sampled population (cases and controls, 75 years) was very high, with no gender prevalence. Five per cent was treated with incretin-based medications. After adjusting for possible confounders, we found no increased risk of cholangiocarcinoma associated with the use of either DPP4i (OR 0.98, 95% CI 0.75-1.29: p = 0.89) or GLP-1-RA (OR 1.09, 95% CI 0.63-1.89; p = 0.76) in the 24 months before hospital admission. Neither the duration of the therapy nor the dose modified the risk of cholangiocarcinoma.

Conclusions: Our findings suggest that, in an unselected population, the use of both classes of incretin-based medications is not associated with an increased risk of cholangiocarcinoma.
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http://dx.doi.org/10.1007/s00592-019-01444-0DOI Listing
April 2020

A Systematic Review of Case-Identification Algorithms Based on Italian Healthcare Administrative Databases for Two Relevant Diseases of the Endocrine System: Diabetes Mellitus and Thyroid Disorders.

Epidemiol Prev 2019 Jul-Aug;43(4 Suppl 2):17-36

Epidemiology Unit, ASL TO3, Piedmont Region, Grugliasco, Turin (Italy).

Background: diabetes mellitus (DM) and thyroid disorders (TDs) are two of the most prevalent and relevant endocrine disorders worldwide, and determining their occurrence and their follow-up pathways is essential. In Italy, due to the presence of a universal health care system, administrative data can be effectively used to determine these measurements. DM is an ideal model for surveillance with administrative data, due to its specific pharmacologic treatment, high rate of hospitalization, and specific care units. The identification of TDs, conversely, is more challenging: they are less frequently managed in a hospital setting, and even if the treatment is highly specific, subclinical forms often do not need any pharmacological treatment.

Objectives: to identify and to describe all DM and TD caseidentification algorithms by means of Italian Healthcare Administrative Databases (HADs), through the review of papers published in the past 10 years.

Methods: this study is part of a project that systematically reviewed case-identification algorithms for 18 acute and chronic conditions by means of HADs in Italy. PubMed was searched for original articles, published between 2007 and 2017, in Italian or English. The search string consisted of a combination of free text and MeSH terms with a common part that focused on HADs and a disease-specific part. All identified papers were screened by two independent reviewers. Pertinent papers were classified according to the objective for which the algorithm had been used, and only articles that used algorithms for "primary objectives" (I disease occurrence; II population/cohort selection; III outcome identification) were considered for algorithm extraction. The HADs used (hospital discharge records, drug prescriptions, etc.), ICD-9 and ICD-10 codes, ATC classification of drugs, follow-back periods, and age ranges applied by the algorithms have been reported. Further information on specific objective(s), accuracy measures, sensitivity analyses and the contribution of each HAD, have also been recorded. Algorithms were divided between those identifying type 2/not specified DM and type 1 DM, and those created to identify hypo- and hyperthyroidism.

Results: of the 780 articles identified for DM, 77 were included and a further 14 papers were added by screening the references. For TD, 65 articles were identified through the search string and 5 of them were included. Of the selected articles, 64% and 80% were published after 2014 for DM and TD, respectively, and 33% (for DM) and 20% (for TD) used multicentric national or international data. Forty original algorithms for DM (29 for type 2 DM/not-specified DM, and 11 for type 1 DM) and 9 for TD (6 for hypo- and 3 for hyperthyroidism) were extracted. In 6 algorithms, specific selections were made so as not to include gestational diabetes. With regard to type 2 DM, the most commonly used sources were the drug prescription database (DPD, 27 cases), hospital discharge record database (HDD, 23 cases), and exemption from healthcare co-payment database (ECD, 19 cases). Other sources were the ambulatory care services database (ACD), birth register, and mortality record database (MRD). Among the 11 algorithms to identify type 1 DM, 9 used DPD, 7 ECD, and 6 HDD; in one case ACD codes were added, and all 11 algorithms but one was applied to a population of young people (always <35 years old). With regard to TDs, 2 algorithms from one paper for hypo and hyperthyroidism relied on DPD as the only source, the other 7 original algorithms combined DPD with HDD (5 cases), ECD (3 cases), and ACD (1 case). One paper identified autoimmune/iodine deficiency hypothyroidism by subtracting iatrogenic hypothyroidism cases (identified through records of previous procedures from HDD and ACD) from the whole hypothyroid population (identified through DPD). External validation was performed for two algorithms for DM and none for TD. The first algorithm for DM was obtained through HDD only and its sensitivity ranged from 61% to 70%, the second had a sensitivity of 71%.

Conclusion: Italian literature on the use of administrative healthcare data for case identification of diabetes is vast; the proposed algorithms are quite similar to one another, and the differences between them are rarely accompanied by clinical justification. On the contrary, the literature concerning thyroid disorders is relatively poor. Further validations of the proposed algorithms, as well as their further implementation, are needed.
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http://dx.doi.org/10.19191/EP19.4.S2.P008.089DOI Listing
April 2020

A Systematic Review of Case-Identification Algorithms for 18 Conditions Based on Italian Healthcare Administrative Databases: A Study Protocol.

Epidemiol Prev 2019 Jul-Aug;43(4 Suppl 2):8-16

Department of Epidemiology, Lazio Regional Health Service, ASL Roma 1, Rome (Italy).

Background: there has been a long-standing, consistent use worldwide of Healthcare Administrative Databases (HADs) for epidemiological purposes, especially to identify acute and chronic health conditions. These databases are able to reflect health-related conditions at a population level through disease-specific case-identification algorithms that combine information coded in multiple HADs. In Italy, in the past 10 years, HAD-based case-identification algorithms have experienced a constant increase, with a significant extension of the spectrum of identifiable diseases. Besides estimating incidence and/or prevalence of diseases, these algorithms have been used to enroll cohorts, monitor quality of care, assess the effect of environmental exposure, and identify health outcomes in analytic studies. Despite the rapid increase in the use of case-identification algorithms, information on their accuracy and misclassification rate is currently unavailable for most conditions.

Objectives: to define a protocol to systematically review algorithms used in Italy in the past 10 years for the identification of several chronic and acute diseases, providing an accessible overview to future users in the Italian and international context.

Methods: PubMed will be searched for original research articles, published between 2007 and 2017, in Italian or English. The search string consists of a combination of free text and MeSH terms with a common part on HADs and a disease-specific part. All identified papers will be screened for eligibility by two independent reviewers. All articles that used/defined an algorithm for the identification of each disease of interest using Italian HADs will be included. Algorithms with exclusive use of death certificates, pathology register, general practitioner or pediatrician data will be excluded. Pertinent papers will be classified according to the objective for which the algorithm was used, and only articles that used algorithms with "primary objectives" (I disease occurrence; II population/cohort selection; III outcome identification) will be considered for algorithm extraction. The HADs used (hospital discharge records, drug prescriptions, etc.), ICD-9 and ICD-10 codes, ATC classification of drugs, follow-back periods, and age ranges applied by the algorithms will be collected. Further information on specific accuracy measures from external validations, sensitivity analyses, and the contribution of each source will be recorded. This protocol will be applied for 16 different systematic reviews concerning eighteen diseases (Hypothyroidism, Hyperthyroidism, Diabetes mellitus, Type 1 diabetes mellitus, Acute myocardial infarction, Ischemic heart disease, Stroke, Hypertension, Heart failure, Congenital heart anomalies, Parkinson's disease, Multiple sclerosis, Epilepsy, Chronic obstructive pulmonary disease, Asthma, Inflammatory bowel disease, Celiac disease, Chronic kidney failure).

Conclusion: this protocol defines a standardized approach to extensively examine and compare all experiences of case identification algorithms in Italy, on the 18 abovementioned diseases. The methodology proposed may be applied to other systematic reviews concerning diseases not included in this project, as well as other settings, including international ones. Considering the increasing availability of healthcare data, developing standard criteria to describe and update characteristics of published algorithms would be of great use to enhance awareness in the choice of algorithms and provide a greater comparability of results.
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http://dx.doi.org/10.19191/EP19.4.S2.P008.089DOI Listing
April 2020

Incidence of hospitalization and mortality in patients with diabetic foot regardless of amputation: a population study.

Acta Diabetol 2020 Feb 29;57(2):221-228. Epub 2019 Aug 29.

Diabetes Unit, ASL TO5, Chieri, TO, Italy.

Aims: The aim of our study was to estimate the overall rate of first hospitalizations for diabetic foot (DF) regardless of the outcome in amputations, as well as the mortality rate with their determinants in the period 2012-2016 in Piedmont Region in Italy.

Methods: The study included all the subjects registered in the Regional Diabetes Registry and alive as at January 1, 2012. DF cases were identified by record linkage with the regional hospital discharge database. Incident cases of diabetic foot were followed up for mortality.

Results: The 5-year rates were 1762, 324, and 343 × 100,000 patients for first hospitalization without amputations, with major amputations, and with minor amputations, respectively. Patients not undergoing amputations were more than 70% of the cohort. Patients with the more severe stages of diabetes and those with low education were at higher risk of each type of hospitalization. The risk of death during a mean follow-up of 2.5 years was about 16, 18, and 30% among patients without amputations, with major amputations, and with minor amputations, respectively. Males, insulin-treated patients, those affected with severe diabetes complications, particularly on dialysis, and those with lower levels of education were at higher risk.

Conclusions: The heavier burden of DF on hospitalizations is due to cases without amputation, a condition that is seldom considered in the diabetes literature. The severity of diabetes, preexisting complications, and low educational levels are associated with both first hospitalization and subsequent survival at any level of severity of DF.
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http://dx.doi.org/10.1007/s00592-019-01412-8DOI Listing
February 2020

Prevention, education and counselling: the worldwide role of the community pharmacist as an epidemiological sentinel of headaches.

Neurol Sci 2019 May;40(Suppl 1):15-21

Department of Drug Science and Technology, University of Turin, Via Pietro Giuria 9, 10125, Turin, Italy.

Headache disorders are the third among the worldwide causes of disability, measured in years of life lost to disability. Given the pharmacies' importance in general in headache patient and, in particular in migraine patient management, various studies have been carried out in recent years dealing with this issue. Indeed, in 2014, our research group first analysed publications on a number of studies conducted worldwide. As five years have passed since our first analysis of the literature and having carried out a number of specific studies in Italy since 2014, we wish to analyse once again the studies carried out globally on this topic to evaluate how the situation has evolved in the meantime. The key words used for the bibliographic search were "community pharmacy" and "headache"; we considered articles published between 2014 and 2018. The selected studies regarded Sweden USA, Belgium, Ireland, Jordan and Ethiopia. From the analysis of the international research papers, it is evident that, despite the time that has passed since the previous analyses and the general agreement that pharmacists find themselves in an ideal position to offer adequate levels of counselling to headache patients, the knowledge of pharmacists is not yet sufficient. Clearly, there is a strong need to develop training programmes specifically focused on this subject. Regarding Italy, a national study, commenced in 2016, was designed as a cross-sectional survey employing face-to-face interviews between pharmacist and patient using a questionnaire drawn up by experts in compliance with best practice from scientific literature. Six hundred ten pharmacists followed a specific training course; 4425 questionnaires were correctly completed. The use of pharmacies as epidemiological sentinels, given their capillarity and daily contact with the local population in Italy, enabled us to obtain an epidemiological snapshot closer to the real-life situation compared to specialist headache centres. Over the course of this study, data on headaches were gathered in Italian pharmacies with the highest levels of numerosity in the world.
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http://dx.doi.org/10.1007/s10072-019-03794-7DOI Listing
May 2019

Self-medication for migraine: A nationwide cross-sectional study in Italy.

PLoS One 2019 23;14(1):e0211191. Epub 2019 Jan 23.

FI.CEF Onlus, Italian Headache Foundation, Milan, Italy.

Headache disorders are considered the second leading cause of years lived with disability worldwide, and 90% of people have a headache episode at least once a year, thus representing a relevant public health priority. As the pharmacist is often the first and only point of reference for people complaining of headache, we carried out a survey in a nationwide sample of Italian pharmacies, in order to describe the distribution of migraine or non-migraine type headaches and medicines overuse among people entering pharmacies seeking for self-medication; and to evaluate the association, in particular of migraine, with socio-demographic and clinical characteristics, and with the pathway of care followed by the patients. A 14-item questionnaire, including socio-demographic and clinical factors, was administered by trained pharmacists to subjects who entered a pharmacy requesting self-medication for a headache attack. The ID Migraine™ Screener was used to classify headache sufferers in four classes. From June 2016 to January 2017, 4424 people have been interviewed. The prevalence of definite migraines was 40%, significantly higher among women and less educated people. About half of all headache sufferers and a third of migraineurs do not consider their condition as a disease and are not cared by any doctor. Among people seeking self-medication in pharmacies for acute headache attacks, the rate of definite or probable migraine is high, and a large percentage of them is not correctly diagnosed and treated. The pharmacy can be a valuable observatory for the study of headaches, and the first important step to improve the quality of care delivered to these patients.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0211191PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6343913PMC
October 2019

Ten-year comparative analysis of incidence, prognosis, and associated factors for dialysis and renal transplantation in type 1 and type 2 diabetes versus non-diabetes.

Acta Diabetol 2018 Jul 20;55(7):733-740. Epub 2018 Apr 20.

Epidemiology Unit, ASL TO3, Regione Piemonte, Grugliasco, TO, Italy.

Aims: To study the incidence of and the factors associated with renal dialysis and transplantation in type 1 (T1DM) and type 2 diabetes (T2DM).

Methods: Data on individuals who had received dialysis treatment or renal transplant between 1 January 2004 and 31 December 2013 were extracted from the regional administrative database (Piedmont, Italy), and the crude (cumulative) incidence of dialysis was calculated. Overall cumulative survival was estimated using the Kaplan-Meier method and compared using the log-rank test. Poisson regression was used to estimate adjusted rate ratios for potential predictors of renal transplant or death.

Results: A total of 7401 persons started dialysis treatment during the decade, with a 10-year cumulative crude incidence of 16.8/100,000. Incidence was stable and consistently eightfold higher in persons with T2DM (tenfold higher in T1DM) compared to those without diabetes. The risk of dialysis in T1DM was about double that of T2DM. The mortality rate was significantly higher in diabetics than in non-diabetes (241.4/1000 vs. 153.99/1000 person-years). During the decade 2004-2013, 893 patients underwent a kidney transplant. Transplantation rates were significantly lower for diabetics than non-diabetics (16.5/1000 vs. 42.9/1000 person-years).

Conclusions: In the past decade, the incidence of dialysis has stabilized in both the general population and in diabetics in whom it remains far higher by comparison. Also mortality rates are higher, with a worse prognosis for T1DM. Diabetes poses a barrier to allotransplantation, and efforts should be made to overcome this limitation.
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http://dx.doi.org/10.1007/s00592-018-1142-yDOI Listing
July 2018

Effect of Socioeconomic Status on Surgery Waiting Times and Mortality After Hip Fractures in Italy.

J Healthc Qual 2018 Jul/Aug;40(4):209-216

Background: Reducing inequities is a main goal of the Italian healthcare system. We evaluated socioeconomic differences in delayed surgery and postoperative mortality after a hip replacement after a fracture in Piedmont Region (Italy).

Methods: Cohort study including all people aged ≥65 years hospitalized for a hip fracture in 2007-2010 (n = 21,432). Study outcomes were the following: (1) surgery waiting times >2 days; (2) 30-day, 90-day, and 1-year mortality from admission. Log-binomial models were used to evaluate the effect of socioeconomic status on waiting time, adjusting for age, sex, comorbidities, biennium, and Local Health Unit. Logistic models were fitted for mortality, adjusting also for the type of intervention (prosthesis/reduction) and waiting time.

Results: Seventy percent of surgeries were performed beyond 2 days from admission; 30-day mortality was 4.1%, 90-day was 10.8%, and 1-year was 21.9%. Lower socioeconomic levels were associated with higher risk of waiting >2 days (Adjusted Relative Risk: 1.14) and higher odds for 90-day (Adjusted Odds Ratio: 1.18) and 1-year (Adjusted OR: 1.27) mortality.

Conclusions: We found socioeconomic inequities in access to hip replacement and postoperative outcomes. Strengthening the connection between hospital, primary care and rehabilitation services, improving regional monitoring systems and taking into account quality of care in funding health system, may contribute to guarantee uniform levels of healthcare quality in Italy.
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http://dx.doi.org/10.1097/JHQ.0000000000000091DOI Listing
September 2019

[Assessment of an algorithm to identify paediatric-onset celiac disease cases through administrative healthcare databases].

Epidemiol Prev 2017 Mar-Apr;41(2):102-108

Dipartimento di medicina molecolare, Università degli studi di Padova.

Objectives: to assess the role of four administrative healthcare databases (pathology reports, copayment exemptions, hospital discharge records, gluten-free food prescriptions) for the identification of possible paediatric cases of celiac disease.

Design: population-based observational study with record linkage of administrative healthcare databases. SETTING AND PARTICIPANT S: children born alive in the Friuli Venezia Giulia Region (Northern Italy) to resident mothers in the years 1989-2012, identified using the regional Medical Birth Register.

Main Outcome Measures: we defined possible celiac disease as having at least one of the following, from 2002 onward: 1. a pathology report of intestinal villous atrophy; 2. a copayment exemption for celiac disease; 3. a hospital discharge record with ICD-9-CM code of celiac disease; 4. a gluten-free food prescription. We evaluated the proportion of subjects identified by each archive and by combinations of archives, and examined the temporal relationship of the different sources in cases identified by more than one source. RESULT S: out of 962 possible cases of celiac disease, 660 (68.6%) had a pathology report, 714 (74.2%) a copayment exemption, 667 (69.3%) a hospital discharge record, and 636 (66.1%) a gluten-free food prescription. The four sources coexisted in 42.2% of subjects, whereas 30.2% were identified by two or three sources and 27.6% by a single source (16.9% by pathology reports, 4.2% by hospital discharge records, 3.9% by copayment exemptions, and 2.6% by gluten-free food prescriptions). Excluding pathology reports, 70.6% of cases were identified by at least two sources. A definition based on copayment exemptions and discharge records traced 80.5% of the 962 possible cases of celiac disease; whereas a definition based on copayment exemptions, discharge records, and gluten-free food prescriptions traced 83.1% of those cases. The temporal relationship of the different sources was compatible with the typical diagnostic pathway of subjects with celiac disease.

Conclusions: the four sources were only partially consistent. A relevant proportion of all possible cases of paediatric celiac disease were identified exclusively by pathology reports.
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http://dx.doi.org/10.19191/EP17.2.P102.029DOI Listing
May 2018

Community pharmacies as epidemiological sentinels of headache: first experience in Italy.

Neurol Sci 2017 May;38(Suppl 1):15-20

FI.CEF Onlus, Milan, Italy.

Migraine is a disabling neurovascular syndrome which affects 12-15% of the global population and it represents the third cause in years lived with disability in both males and females aged 15-49 years. Among migraineurs, the symptomatic drug abuse may be a risk factor in the development of medication overuse headache (MOH). Detecting cases of MOH is not straightforward; community pharmacists may, therefore, be in a strategic position to identify individuals who self-medicate, particularly with respect to prevent the development of MOH. In 2014, our group published the results of a survey conducted in Piedmont, Italy, on the patterns of use and dispensing of drugs in patients requesting assistance from pharmacists for relief of a migraine attack. We decided, now, to expand the scope of the model to a national level. The study is based on cross-sectional face-to-face interviews using questionnaires, presented in this paper, consisting of a first part regarding the socio-economic situation and a second part which aimed to classify the disease and any excessive use of drugs. Of the 610 pharmacists trained with an online course, 446 gathered a total of 4425 correctly compiled questionnaires. The participation of community pharmacies has highlighted various criticalities especially of an organisational nature; however, it also revealed the power of this method as a means of gathering epidemiological data with a capillarity which few other methods can match. The objective was also to identify each territory's requirements and facilitate the decision-making process in terms of understanding what patients/citizens actually require.
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http://dx.doi.org/10.1007/s10072-017-2908-7DOI Listing
May 2017

[Community pharmacy; towards a new model.]

Recenti Prog Med 2017 Apr;108(4):168-171

Dipartimento di Scienze Cliniche e Biologiche, Università di Torino.

In recent years, even in Italy, a new model of "Community pharmacy" is being developed, which identifies the pharmacist as the most accessible health care professional for citizens, and recognizes his role in preventing chronic diseases. A project started in Piedmont (Italy) in 2012 has aimed at applying and evaluating this model of pharmacy in the prevention of diabetes, through the early detection of individuals with undiagnosed diabetes or at high risk of developing the disease, or with counselling to diabetic patients not adhering to the optimal therapeutic pathway. The results suggest that the pharmacy might be able to implement an effective preventive action, particularly among socio-economically disadvantaged people, thereby helping to reduce inequalities in care. The cost/effectiveness evaluation of long-term outcomes, based on the use of existing health information systems, will provide more accurate information on the value of the model.
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http://dx.doi.org/10.1701/2681.27451DOI Listing
April 2017

Prevalence, incidence and associated comorbidities of treated hypothyroidism: an update from a European population.

Eur J Endocrinol 2017 May 8;176(5):533-542. Epub 2017 Feb 8.

Epidemiology UnitRegione Piemonte, Grugliasco, Italy.

Objective: Estimates of the prevalence of hypothyroidism in unselected populations date from the late 1990s. We present an update on the prevalence and incidence of overt hypothyroidism in Piedmont, northwest Italy and examine the association between hypothyroidism and multiple chronic comorbidities.

Design And Methods: Data were obtained from drug prescription and hospital discharge databases. Individuals who had received at least two levothyroxine prescriptions in 2012 were defined as having hypothyroidism; those who had undergone thyroidectomy or I irradiation in the previous 5 years were defined as having iatrogenic hypothyroidism and those who had either obtained exemption from treatment co-payment or had been discharged from hospital with a chronic comorbidity (diabetes and connective tissue diseases) were identified as having one of these conditions.

Results: The overall crude prevalence was 31.1/1000 (2.3/1000 for iatrogenic hypothyroidism) and the overall crude incidence was 7/1000. The average daily dose of thyroxine (122 µg) roughly corresponded to 1.7 µg/kg. There was a strong association between hypothyroidism and diabetes (type 1, type 2 or gestational) and with autoimmune diseases, with the odds ratio ranging from 1.43 (1.02-1.99) for psoriatic arthritis to 4.99 (3.06-8.15) for lupus erythematosus.

Conclusions: As compared with previous estimates, the prevalence of hypothyroidism rose by about 35%, driven mainly by non-iatrogenic forms. The increase may be due to either population aging or improved diagnostic capability or both. The frequent co-occurrence of hypothyroidism with other multiple chronic conditions characterizes it more as a comorbidity rather than an isolated chronic disease.
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http://dx.doi.org/10.1530/EJE-16-0559DOI Listing
May 2017

[Contribution of amenable mortality to the decrease of overall mortality in Piedmont Region (Northern Italy), 1980-2011].

Epidemiol Prev 2016 Nov-Dec;40(6):418-426

Servizio sovrazonale di epidemiologia, Azienda sanitaria locale Torino 3, Regione Piemonte.

Objectives: to describe overall and amenable mortality trends over the last 30 years in the Local Health Authorities (LHAs) of Piedmont Region (Northern Italy). By comparing these trends, it is possible to analyse intraregional variability in the performance of the healthcare system.

Design: descriptive study.

Setting And Participants: mortality data from the Italian National Institute of Statistics (Istat) for the population between 0 and 74 years resident in Piedmont Region for the period 1980-2011.

Main Outcome Measures: overall and amenable age-standardised death rates, by gender and health unit; ratio of the differences in amenable and in all-cause mortality (standardised rate difference - SRD: SRDamenable/SRDall-cause) over the observation period.

Results: between 1980 and 2011, overall mortality in Piedmont has decreased from 425.8 x100,000 to 205.5 x100.000 among women, and from 891.6 x100,000 to 390.7 x100,000 among men. The rate of amenable mortality on overall mortality decreased from 40% to 32% among women, and from 33% to 21% among men. Furthermore, amenable mortality contributed to 48% of the overall mortality reduction among women and to 35% among men. Regional results show heterogeneity between health units. This heterogeneity decreased over the three decades and was higher in men than in women.

Conclusion: although Piedmont is one of the Italian Regions with the highest amenable mortality rate, a considerable decrease of its contribution to the overall mortality was seen in the last three decades. This improvement was not equally among LHAs, and substantial intraregional differences are still present, probably due to different timing and way of introduction of healthcare innovations for prevention and care for amenable to healthcare diseases. The proportion of amenable mortality on overall mortality is much higher among women than men, and it probably depends on the diseases considered in the definition itself.
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http://dx.doi.org/10.19191/EP16.6.P418.122DOI Listing
January 2018

Geographic and socioeconomic differences in access to revascularization following acute myocardial infarction.

Eur J Public Health 2016 10 23;26(5):760-765. Epub 2016 May 23.

Epidemiology Unit, ASL TO3, Piedmont Region, Grugliasco, Italy.

Background: Geographic and socioeconomic barriers may hinder fair access to healthcare. This study assesses geographic and socioeconomic disparities in access to reperfusion procedures in acute myocardial infarction (AMI) patients residing in Piedmont (Italy).

Methods: Coronary Care Units (CCUs) were geocoded with a geographic information system (GIS) and the shortest drive time from CCUs to patients' residence was computed and categorized as 0 to <20, 20 to <40 and ≥40 min. Using data on AMI emergency hospitalizations in 2004-2012, we employed a log-binomial regression model to evaluate the relation between drive time and use of Percutaneous Transluminal Coronary Angioplasty (PTCA) occurring within 2 days after a hospitalization for an episode of AMI, and whether this relation varied depending on the period of hospitalization.

Results: A total of 29% of all cases with a diagnosis of AMI (n = 66 097), were revascularized within 2 days from the index admission. The further AMI patients lived from CCUs, the less likely they were to receive revascularization: compared with distance <20 min, RRs were respectively 0.84 [95% CI 0.80-0.88] and 0.78 [95% CI 0.71-0.86]. Findings also showed that less educated people had a lower relative risk of being revascularized compared to more educated people (RR = 0.78; 95% CI = 0.74-0.82). Both inequalities have reduced in recent years.

Conclusion: This study provides evidence of reduced geographical and socioeconomic differences in revascularization use over time. Geography and socioeconomic status should not determine the type of treatment received for life-threatening conditions such as AMI.
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http://dx.doi.org/10.1093/eurpub/ckw062DOI Listing
October 2016

Is the choice of the statistical model relevant in the cost estimation of patients with chronic diseases? An empirical approach by the Piedmont Diabetes Registry.

BMC Health Serv Res 2015 Dec 30;15:582. Epub 2015 Dec 30.

Department of Medical Sciences, University of Turin, corso Dogliotti 14, 10126, Turin, Italy.

Background: Chronic diseases impose large economic burdens. Cost analysis is not straightforward, particularly when the goal is to relate costs to specific patterns of covariates, and to compare costs between diseased and healthy populations. Using different statistical methods this study describes the impact on results and conclusions of analyzing health care costs in a population with diabetes.

Methods: Direct health care costs of people living in Turin were estimated from administrative databases of the Regional Health System. Patients with diabetes were identified through the Piedmont Diabetes Registry. The effect of diabetes on mean annual expenditure was analyzed using the following multivariable models: 1) an ordinary least squares regression (OLS); 2) a lognormal linear regression model; 3) a generalized linear model (GLM) with gamma distribution. Presence of zero cost observation was handled by means of a two part model.

Results: The OLS provides the effect of covariates in terms of absolute additive costs due to the presence of diabetes (€ 1,832). Lognormal and GLM provide relative estimates of the effect: the cost for diabetes would be six fold that for non diabetes patients calculated with the lognormal. The same data give a 2.6-fold increase if calculated with the GLM. Different methods provide quite different estimated costs for patients with and without diabetes, and different costs ratios between them, ranging from 3.2 to 5.6.

Conclusions: Costs estimates of a chronic disease vary considerably depending on the statistical method employed; therefore a careful choice of methods to analyze data is required before inferring results.
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http://dx.doi.org/10.1186/s12913-015-1241-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4696194PMC
December 2015

Hospitalisation for heart failure and mortality associated with dipeptidyl peptidase 4 (DPP-4) inhibitor use in an unselected population of subjects with type 2 diabetes: a nested case-control study.

BMJ Open 2015 Jun 5;5(6):e007959. Epub 2015 Jun 5.

Epidemiology Unit, ASL TO3, Regione Piemonte, Grugliasco, Italy.

Objective: The SAVOR TIMI-53 study reported a significant increase in the risk of hospitalisation for heart failure (HF) in patients treated with a DPP-4 inhibitor (DPP-4i) in comparison with placebo. A recent case-control study in part confirmed this risk signal. Our aim was to compare the occurrence of HF in relation to DPP-4i use versus any antidiabetic treatment.

Design: Population-based matched case-control study conducted using administrative data.

Setting: The Italian Region of Piedmont (4.4 million inhabitants).

Participants: From a database of 282,000 patients treated with antidiabetic drugs, we identified 14,613 hospitalisations for HF, 7212 incident cases, and 1727 hospital re-admissions between 2008 and 2012; each case was matched for gender, age and antidiabetic therapy with 10 controls; cases and controls were compared for exposure to DPP-4i.

Outcome Measures: ORs and 95% CIs were calculated by fitting a conditional logistic model. All analyses were adjusted for available risk factors for HF.

Results: We found no increased risk of hospitalisation for HF associated with the use of DPP-4i (OR for admission for HF 1.00 (0.94 to 1.07), incident HF1.01 (0.92 to 1.11), recurrent HF 1.02 (0.84 to 1.22)). All-cause mortality was 6% lower in DPP-4i users (p<0.001), whereas insulin users showed an excess of risk for any type of hospital admission (19%) and death (20%) (p<0.001).

Conclusions: Our findings suggest that, in an unselected population of diabetic patients, the use of DPP-4i is not associated with an increased risk of HF. The favourable impact on all-cause mortality should be viewed with caution and also other explanations investigated.
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http://dx.doi.org/10.1136/bmjopen-2015-007959DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4458680PMC
June 2015

Educational inequalities in diabetes mortality across Europe in the 2000s: the interaction with gender.

Int J Public Health 2015 May 7;60(4):401-10. Epub 2015 Mar 7.

Interface Demography, Department of Sociology, Vrije Universiteit Brussel, 5 Pleinlaan, 1050, Brussels, Belgium,

Objectives: To evaluate educational inequalities in diabetes mortality in Europe in the 2000s, and to assess whether these inequalities differ between genders.

Methods: Data were obtained from mortality registries covering 14 European countries. To determine educational inequalities in diabetes mortality, age-standardised mortality rates, mortality rate ratios, and slope and relative indices of inequality were calculated. To assess whether the association between education and diabetes mortality differs between genders, diabetes mortality was regressed on gender, educational rank and 'gender × educational rank'.

Results: An inverse association between education and diabetes mortality exists in both genders across Europe. Absolute educational inequalities are generally larger among men than women; relative inequalities are generally more pronounced among women, the relative index of inequality being 2.8 (95 % CI 2.0-3.9) in men versus 4.8 (95 % CI 3.2-7.2) in women. Gender inequalities in diabetes mortality are more marked in the highest than the lowest educated.

Conclusions: Education and diabetes mortality are inversely related in Europe in the 2000s. This association differs by gender, indicating the need to take the socioeconomic and gender dimension into account when developing public health policies.
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http://dx.doi.org/10.1007/s00038-015-0669-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4555194PMC
May 2015

Gender, socioeconomic position, revascularization procedures and mortality in patients presenting with STEMI and NSTEMI in the era of primary PCI. Differences or inequities?

Int J Cardiol 2014 Oct 4;176(3):724-30. Epub 2014 Aug 4.

Epidemiology Unit, Regione Piemonte, Grugliasco (TO) ASL TO3, Italy.

Background: Several studies have reported gender and socioeconomic differences in the use of revascularization procedures in patients with acute myocardial infarction. However, it is not clear whether these differences influence patients' survival. Moreover, most of the studies neither considered STEMI and NSTEMI separately, nor included primary PCI, which nowadays is the treatment of choice in case of AMI. In an unselected population of patients admitted to hospital with a first episode of STEMI and NSTEMI we examined gender and socioeconomic differences in the use of cardiac invasive procedures and in one-year mortality.

Methods: Subjects hospitalized with a first episode of STEMI (n=3506) or NSTEMI (n=2286) were selected from the Piedmont (Italy) hospital discharge database. We considered the percentage of patients undergoing PCI, primary PCI and CABG, and in-hospital mortality. Out of hospital mortality was calculated through record linkage with the regional register. The relation between outcomes and gender or educational level was investigated using appropriate multivariate regression models adjusting for available confounders.

Results: After adjustment for age, comorbidity and hospital characteristics, women and low educated patients had a lower probability of undergoing revascularization procedures. However, neither in-hospital, nor 30-day, nor 1-year mortality showed gender or social disparities.

Conclusions: Despite gender and socioeconomic differences in the use of revascularization, no differences emerged in in-hospital and 1-year mortality. These findings could suggest that patients are differently, but equitably, treated; differences are more likely due to an inability to fully adjust for clinical conditions rather than to a selection process at admission.
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http://dx.doi.org/10.1016/j.ijcard.2014.07.107DOI Listing
October 2014

Incretin-based therapies and acute pancreatitis risk: a systematic review and meta-analysis of observational studies.

Endocrine 2015 Mar 22;48(2):461-71. Epub 2014 Aug 22.

Metabolism and Diabetes Unit, ASL TO5, Regione Piemonte, Chieri, Italy,

Concerns raised by several animal studies, case reports, and pharmacovigilance warnings over incretin-based therapy potentially exposing type two diabetes patients to an elevated risk of pancreatitis have cast a shadow on the overall safety of this class of drugs. This systematic review evaluates the data from observational studies that compared treatment with or without incretins and the risk of pancreatitis. We searched PubMed for publications with the key terms incretins or GLP-1 receptor agonists or DPP-4 inhibitors or sitagliptin or vildagliptin or saxagliptin or linagliptin or alogliptin or exenatide or liraglutide AND pancreatitis in the title or abstract. Studies were evaluated against the following criteria: design (either cohort or case-control); outcome definition (incidence of pancreatitis); exposure definition (new or current or past incretins users); and comparison between patients receiving incretins or not for type 2 diabetes. Two authors independently selected the studies and extracted the data. Six studies meeting the inclusion criteria were reviewed. No difference was found in the overall risk of pancreatitis between incretin users and non-users (odds ratio 1.08; 95 % CI [0.84-1.40]). A risk increase lower than 35 % cannot be excluded according to the power calculation. This systematic review and meta-analysis suggests that type 2 diabetes patients receiving incretin-based therapy are not exposed to an elevated risk of pancreatitis. Limitations of this analysis are the low prevalence of incretin users and the lack of a clear distinction by the studies between therapy with DPP-4 inhibitors or with GLP-1 receptor agonists.
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http://dx.doi.org/10.1007/s12020-014-0386-8DOI Listing
March 2015

Incretin therapies and risk of hospital admission for acute pancreatitis in an unselected population of European patients with type 2 diabetes: a case-control study.

Lancet Diabetes Endocrinol 2014 Feb 12;2(2):111-5. Epub 2013 Nov 12.

Epidemiology Unit, ASL TO3, Regione Piemonte, Grugliasco, Italy.

Background: Previous studies have yielded conflicting results about the association between incretin therapies and acute pancreatitis. We aimed to compare the occurrence of acute pancreatitis in a population of patients with type 2 diabetes who received incretins compared with those who received other antidiabetic treatment.

Methods: In our population-based matched case-control study, we extracted information from an administrative database from Piedmont, Italy (containing data for 4·4 million inhabitants). From a dataset of 282,429 patients receiving treatment with antidiabetic drugs for type 2 diabetes, we identified 1003 cases older than 41 years who had been admitted to hospital for acute pancreatitis between Jan 1, 2008, and Dec 31, 2012, and 4012 controls who were matched for sex, age, and time of start of antidiabetic therapy. We compared incretin exposure in cases and controls with a conditional logistic regression model, expressed as odds ratios (ORs [95% CI]). We adjusted all analyses for risk factors of acute pancreatitis, as ascertained by hospital discharge records, and concomitant use of metformin or glibenclamide.

Findings: The mean age of cases and controls (72·2 years [SD 11·1]) was high, as expected in an unselected diabetic population in Europe. After adjustment for available confounders, use of incretins in the 6 months before hospital admission was not associated with increased risk of acute pancreatitis (OR 0·98, 95% CI 0·69-1·38; p=0·8958).

Interpretation: Our findings suggest that, in an unselected population, use of incretins is not associated with an increased risk of acute pancreatitis. Larger studies are needed to clarify whether age or type of incretin therapy could affect the risk of acute pancreatitis in patients with type 2 diabetes.

Funding: Chaira Medica Association, Chieri, Italy.
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http://dx.doi.org/10.1016/S2213-8587(13)70147-5DOI Listing
February 2014

Resource consumption and healthcare costs of acute coronary syndrome: a retrospective observational administrative database analysis.

Crit Pathw Cardiol 2013 Dec;12(4):204-9

From the *ProCure Solutions sas, Bergamo, Italy; †Servizio Sovrazonale di Epidemiologia, ASL TO3, Regione Piemonte, Italy; ‡Ospedale Maria Vittoria, Divisione di Cardiologia, ASL TO2, Torino, Italy; and §Ospedale Giovanni Bosco, Divisione di Cardiologia, ASL TO2, Torino, Italy.

The objective of this study was to estimate resource consumption and direct healthcare costs of patients with a first hospitalization for acute coronary syndrome (ACS) in 2008 in the Piedmont Region, Italy. Subjects hospitalized with a first episode of ACS in 2008 were selected from the regional hospital discharge database. All hospitalizations, drug prescriptions, and outpatient episodes of care in the 12 months following discharge were considered to estimate resource consumption and direct healthcare costs from the Piedmont Regional Health Service perspective. The analysis was carried out separately for ST-elevation myocardial infarction (STEMI), non-ST-elevation myocardial infarction (NSTEMI), and unstable angina (UA) populations. In the accrual period, 7765 subjects (1.75‰ of the total population) were hospitalized for ACS (64.2% men). The average age was 66.5 for men and 75.4 for women. The average in-hospital mortality was 6.5% (n = 508). The total ACS population was classified as: STEMI 45.2%, NSTEMI 29.4%, and UA 25.4%. The average yearly costs per patient alive at the end of follow-up (n = 6851) were 14,160.8&OV0556; (18,678.7 USD): 83.9% for inpatient admissions [11,881.2&OV0556; (15,671.8 USD)], 9.3% for drugs [1311.6&OV0556; (1730.1 USD)], 5.0% for diagnostic and therapeutic procedures and outpatient visits [708.2&OV0556; (934.1 USD)], and 1.8% for 1-day hospital stays [259.8&OV0556; (342.7 USD)]. The average yearly direct healthcare costs by ACS event were 14,984.5&OV0556; (19,765.2 USD) for STEMI, 14,554.1&OV0556; (19,197.4 USD) for NSTEMI, and 12,481.5&OV0556; (16,463.6 USD) for UA. In each subpopulation, costs were significantly higher for men than for women. ACS imposes a significant burden in terms of morbidity and mortality and generates major public health service costs.
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http://dx.doi.org/10.1097/HPC.0b013e3182a78c06DOI Listing
December 2013

Care of acute myocardial infarction in the coronary care units of Piedmont in 2007: results from the 'PRIMA_sweet' region-wide survey.

J Cardiovasc Med (Hagerstown) 2013 May;14(5):354-63

SSD Emodinamica, Dipartimento Cardiovascolare AO S. Croce, Via Coppino 26, 12100 Cuneo, Italy.

Background: The treatment of acute myocardial infarction (AMI), both with ST-segment elevation [ST-elevation myocardial infarction (STEMI)] and non-ST-segment elevation [non-ST-elevation myocardial infarction (NSTEMI)], is evolving in Piedmont, with an increase in interventional procedures and hub-and-spoke networks. This new region-wide survey provides updated assessment of the management of STEMI and unprecedented data on NSTEMI.

Methods: In 30 coronary care units in Piedmont, all patients with AMI symptoms of duration less than 48 h, between January and March 2007, were included.

Results: Of 921 patients, 447 had STEMI and 474 NSTEMI. Diabetes was present in 35% and chronic kidney disease in 38%. Hospital mortality was 4.7% [95% confidence interval (CI) 3.3-6.1]: age 75 years or older, Killip class higher than 1 and known diabetes or abnormal blood glucose on admission were multivariate predictors. Thrombolysis and primary percutaneous transluminal coronary angioplasty (pPTCA) were performed in 17.6 and 53.1% of 391 patients, respectively, with STEMI of 12 h or less, and 29.3% had no reperfusion therapy, notably 52% of patients aged 75 years or older and 51% of those reaching non-24/24 h interventional centres. Mortality after pPTCA was 2.5% and onsite door-to-balloon time was less than 90 min in 67.5%. Overall mortality after STEMI was 5.4% (95% CI 3.2-7.6). In NSTEMI, use of antithrombotic treatments was extensive, but invasive treatment within 72 h was limited to 8% of patients in centres without interventional facilities and independent of patient's risk profile. Mortality after NSTEMI was 4.0% (95% CI 2.2-5.8) and was predicted by both the Global Registry of Acute Coronary Events risk score and diabetes.

Conclusion: There is room for improvement in the treatment of AMI in our region, with more extensive use of reperfusion therapy in STEMI, especially in the elderly, and early revascularization and optimal medical treatment in higher-risk NSTEMI.
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http://dx.doi.org/10.2459/JCM.0b013e32835422f8DOI Listing
May 2013