Policy choices and compliance behavior in pandemic times

In this paper, we model an evolutionary noncooperative game between politicians and citizens that, given the level of infection, describes the observed variety of mitigation policies and citizens' compliance during the COVID-19 pandemic period. Our results show that different stable equilibria exist and that different ways/paths exist to reach these equilibria may be present, depending on the choice of parameters. When the parameters are chosen opportunistically, in the short run, our model generates transitions between hard and soft policy measures to deal with the pandemic. In the long-run, convergence is achieved toward one of the possible stable steady states (obey or not obey lockdown rules) as functions of politicians' and citizens' incentives.

Gender Differences in the Risk of Adverse Outcomes After Incident Diabetic Foot Hospitalization: A Population Cohort Study

BACKGROUND

Diabetic Foot Disease (DFD) is more prevalent among males and is associated with an excess risk of cardiovascular events or mortality.

AIMS

This study aimed at exploring the risk of cardiovascular events, renal failure, and all-cause mortality after incident DFD hospitalizations, separately in males and females, to detect any gender difference in a cohort of 322,140 people with diabetes retrospectively followed up through administrative data sources in Tuscany, Italy, over the years 2011-2018.

METHODS

The Hazard Ratio (HR) for incident adverse outcomes after first hospitalizations for DFD, categorized as major/minor amputations (No.=449;3.89%), lower limbs' revascularizations (LLR: No.=2854;24.75%), and lower-extremity-arterial-disease (LEAD) with no procedures (LEAD-no proc: No.=6282;54.49%), was compared to the risk of patients having a background of DFD (ulcers, infections, Charcot-neuroarthropathy: No.=1,944;16.86%).

RESULTS

DFD incidence rate was higher among males compared to females (1.57(95% CI:1.54-1.61) vs. 0.97(0.94-1.00)/100,000p-years]. After DFD, the overall risk of coronary artery disease was significantly associated with the male gender and of stroke with the female gender. LEAD-no proc and LLR were associated with the risk of stroke only in females, whereas they were found to be associated with the risk of coronary artery disease among females to a significantly greater extent compared to males. The incident of renal failure was not associated with any DFD category. Amputations and LEAD-no proc significantly predicted high mortality risk only in females, while LLR showed reduced risk in both genders. Moreover, females had a greater risk of composite outcomes (death or cardiovascular events). Compared to the background of DFD, the risk was found to be 34% higher after amputations (HR: 1.34(1.04-1.72)) and 10% higher after LEAD-no proc (HR:1.10(1.03-1.18)), confirming that after incident DFD associated with vascular pathogenesis, females are at an increased risk of adverse events.

CONCLUSION

After incident DFD hospitalizations, females with DFD associated with amputations or arterial disease are at a greater risk of subsequent adverse cardiovascular events than those with a DFD background.

Gender Difference in the Risk of Adverse Outcomes After Diabetic Foot Disease: A Mini-Review

Diabetic foot disease (DFD) is a complication of diabetes mellitus, characterized by multiple pathogenetic factors, bearing a very high burden of disability as well as of direct and indirect costs for individuals or healthcare systems. A further characteristic of DFD is that it is associated with a marked risk of subsequent hospitalizations for incident cardiovascular events, chronic renal failure or of allcause mortality. Additionally, DFD is strongly linked to the male sex, being much more prevalent among men. However, even if DFD mainly affects males, several past reports suggest that females are disadvantaged as regards the risk of subsequent adverse outcomes. This review aims to clarify this point, attempting to provide an explanation for this apparent oddity: being DFD a typically male complication of diabetes but, seemingly, with a greater load of subsequent consequences for females.

Chronic Care Model for the Management of Patients with Heart Failure in Primary Care

We recently investigated the prognostic impact of a Chronic Care Model (CCM)-based healthcare program applied in primary care in Tuscany Region mainly run by multidisciplinary teams composed of general practitioners (GPs) and nurses. The project included proactively planned follow-up visits for each patient, individualized counselling to optimize lifestyle modifications and adherence to appropriate diagnostic and therapeutic pathways. 1761 patients with Chronic heart failure (CHF) directly enrolled by the GPs were matched with 3522 CHF controls not involved in the project. Over a 4-year follow-up in the CCM group a higher CHF hospitalization rate was found (12.1 vs 10.3 events/100 patient-years; incidence rate ratio [IRR] 1.15, p=0.0030), whereas mortality was lower (10.8 vs 12.6 events/100 patient-years; IRR 0.82, p<0.0001). The CCM status was independently associated with a 34% increase in the risk of CHF hospitalization and a 18% reduction in the risk of death (p<0.0001 for both). The CCM status was associated with a 50% increase in the rate of planned Heart failure (HF) hospitalizations whereas the rate of 1-month CHF readmissions showed no differences. Such a divergent trend could be explained by the direct involvement of GPs in the CCM program, leading them to a better awareness of patients’ clinical status, and then to a more frequent use of clinical pathways and facilities, including hospitalization. It is reasonable to argue that not all hospitalizations must necessarily be considered as a poor outcome, as they often provide additional opportunities to improve therapies, optimize patient education, or define follow-up strategies. The evidence of a divergent trend between mortality and hospitalization in our population might support the clinical importance of a multidisciplinary approach for the management of patients with HF.

Gender difference in the risk for cardiovascular events or mortality of patients with diabetic foot syndrome

AIMS

Diabetic foot syndrome (DFS) increases the risk for atherosclerotic cardiovascular disease (ASCVD), chronic kidney disease (CKD), or mortality. The present study aims at ascertaining whether such DFS-related excess risk differs between genders, retrospectively investigating a population with diabetes from Tuscany, Italy, followed-up for 6 years (2011-2016).

METHODS

People with diabetes living in Tuscany on January 1st 2011 identified by administrative databases, were divided by baseline history of prior DFS hospitalizations, stratified by presence/absence of peripheral vascular disease and evaluating, by Cox regression analysis, whether adjusted DFS-related excess risk of incident ASCVD, CKD or mortality differed between genders.

RESULTS

In an overall population of 165,650 subjects with diabetes (81,829M/83,821F), basal prevalence of DFS was twice higher among males, who were moreover at a significantly greater risk of all considered outcomes along the 6-year period. On the contrary, baseline DFS significantly increased the hospitalization risk for ASCVD, CKD and mortality equally or at a slightly greater extent in females, while the risk for stroke was significantly associated with DFS only among females (HR: 1.622 (1.314-1.980); p = 0.0001 vs. HR: 1.132 (0.955-1.332); p = NS). This finding was even reinforced in non-vascular DFS, which was associated with a significant raised risk for stroke, heart failure or mortality exclusively in females.

CONCLUSIONS

In this population, DFS prevalence and overall risk for ASCVD, CKD or mortality were significantly higher among males. Baseline co-presence of DFS, however, conferred a similar adjusted risk for all these outcomes between genders, and in case of non-vascular DFS the risk was significantly increased only among females.

Frequency of drug combinations between enzyme-inducing first-generation antiepileptic drugs and inducible drugs in patients with epilepsy

OBJECTIVE

The objective of the study was to systematically assess, through the analysis of administrative data, the frequency of combinations of first-generation enzyme-inducing (EI) antiepileptic drugs (AEDs) with drugs frequently prescribed in patients with epilepsy whose metabolism is induced by EIAEDs.

METHODS

From the population of Tuscany (a region in Italy of about 3,750,000 habitants), patients who had been treated with at least one first-generation EIAEDs (carbamazepine, phenytoin, phenobarbital, and primidone) and had received prescriptions of an inducible non-AED (NON-AED) included in a prespecified list of 103 inducible drugs were identified.

RESULTS

At the index date, 9221 patients with epilepsy were treated with at least one traditional EIAED, and there were 2538 drug combinations between EIAEDs and NON-AEDs, which may result in potentially serious clinical consequences, and 3317 combinations with NON-AEDs that have their metabolism consistently increased.

CONCLUSIONS

Patients with epilepsy treated with traditional EIAEDs are at a very high risk of drug interactions.

Opposite trends in hospitalization and mortality after implementation of a chronic care model-based regional program for the management of patients with heart failure in primary care

BACKGROUND

The chronic care model (CCM) is an established framework for the management of patients with chronic illness at the individual and population level. Its application has been previously shown to improve clinical outcome in several conditions, but the prognostic impact of CCM-based programs for the management of patients with chronic heart failure (HF) in primary care is still to be elucidated.

METHODS

We assessed the prognostic impact of a primary-care, CCM-based project applied in Tuscany, Italy, in 1761 patients with chronic HF enrolled in a retrospective matched cohort study. The project was based on predefined working teams including general practitioners and nurses, proactively scheduled regular follow-up visitations for each patient, counseling for therapy adherence and lifestyle modifications, appropriate diagnostic and therapeutic pathways according to international guidelines, and a key supporting role of the nurses, who were responsible for the practical coordination of the follow-up. A matched group of 3522 HF subjects assisted by general practitioners not involved in the project was considered as control group. The endpoints of this study were HF hospitalization and all-cause mortality.

RESULTS

Over a 4-year follow-up period, HF hospitalization rate was higher in the CCM group than the controls (12.1 vs 10.3 events/100 patient-years; incidence rate ratio 1.15[1.05-1.27], p = 0.0030). Mortality was lower in the CCM group than the controls (10.8 vs 12.6 events/100 patient-years; incidence rate ratio 0.82[0.75-0.91], p < 0.0001). In multivariable analysis, the CCM status was associated with a 34% higher risk of HF hospitalization and 18% lower risk of death (p < 0.0001 for both). The effect on HF hospitalization was mostly driven by a 50% higher rate of planned HF hospitalization.

CONCLUSIONS

Implementation of a CCM-based program for the management of HF patients in primary care led to reduced mortality and increased HF hospitalization. These findings support the hypothesis that the beneficial effects of CCM on survival might be extended to patients with chronic HF followed in primary care, but also support the need for further strategies aimed at improving the management of these patients in terms of hospitalizations.

Effect of statins in preventing hospitalizations for infections: A population study

PURPOSE

To investigate whether the hospitalization rate for bacterial infections was modified by statin therapy in a population retrospectively followed up, over years 2011 to 2015.

METHODS

By using administrative databases, the 5-year hospitalization rate due to bacterial infections in population living in Tuscany, Italy exposed to statin therapy (n = 52,049) was stratified by 5 prescribed daily doses classes (0%-20%, 20%-50%, 50%-80%, 80%-100%, ≥100% of DDD) and subsequently compared with that of a population of untreated individuals (n = 3 300 ,675), matched through a propensity score accounting for all available covariates potentially able to modulate risk of infections such as age, gender, previous hospitalizations for infections, cardiovascular events, previous co-morbidities, diabetes, as well as general practitioners' proactive behaviour of care delivery according to current guidelines.

RESULTS

Unmatched individuals of each treatment-class had significantly more hospitalizations than controls, while matched treated people, apart from those in class 0% to 20%, had a decrease of hospitalizations, as large as the increase in prescribed drug. Statin effect in reducing hospitalizations translated into a number needed to treat (NNT) ranging across treatment strata from 102 to 54.

CONCLUSIONS

Compliance to statin prescribed daily doses above the threshold 20% of DDD, along a 5-year follow-up, prevented hospitalizations due to infectious diseases in a large unselected population, after adjusting for covariates able to modulate baseline risk of infections. The NNTs to avoid 1 hospitalization for infections resulted on average not too dissimilar from a value lying between the 95% CI of NNTs previously found for primary prevention of 1 incident coronary ischemic event (72 to 119).

Hospitalization for Charcot neuroarthropathy in diabetes: A population study in Italy

AIMS

To provide data on hospitalization and incidence rates of Charcot neuroarthropathy (CN) and its relation to lower limbs' amputations/revascularizations in population with diabetes of Italy as well as of one of its regions (Tuscany).

METHODS

Hospitalizations with CN diagnosis (codes ICD-9-CM: 7130, 7135, 7138) have been recorded in people with diabetes over years 2003-2013 in Italy and 2008-2015 in Tuscany. Amputations, peripheral vascular disease, revascularizations and infections were likewise evaluated.

RESULTS

Between 2003 and 2013 CN hospitalizations were very infrequent in Italy ranging between 14×100,000 and 11×100,000 patients with diabetes. In Tuscany they declined to a minimum of 7×100,000 patients in 2015, after a previous increase to a maximum of 22×100,000 (p=NS for both). Yearly CN incidence remained constant in Italy, declining in Tuscany to a minimum of 3.4×100,000 diabetic patients in 2015 (p=0.047). CN patients were younger and with longer length of hospital stay than those with non-Charcot diabetic foot (p<0.05 for both). Amputation and infection rates were manifold higher in CN patients than in those with non-Charcot diabetic foot, while the revascularization rate was similar in both.

CONCLUSIONS

Over last decade, in Italy and Tuscany yearly CN incidence and hospitalization rates concerned only a small percentage of patients, remaining constant over years and declining in Tuscany in the last couple of years. CN was significantly associated to younger age, longer hospital stay and greater risk of amputations and infections while the need of revascularization was similar to that of non-Charcot diabetic foot.

Effect of statins on hospitalization risk of bacterial infections in patients with or without diabetes

AIMS

To investigate whether statins reduce the risk to first hospitalization of bacterial infections, in patients with or without diabetes taking into account prior or incident comorbidities.

METHODS

By using administrative databases, the effect of current statin use was measured on the risk of first hospitalizations due to bacterial infections in people living in Tuscany, Italy, in the period January 1, 2011-December 31, 2015, after excluding those with previous statins use. Population was stratified as with (n = 128,207) or without diabetes (n = 3,304,906), and the hospitalization risk was analyzed by a Cox proportional hazards regression analysis after adjusting for age, gender, previous comorbidities, chronic renal failure, and prior or incident cardiovascular diseases.

RESULTS

During the 5-year follow-up, 31,543 hospitalizations for bacterial infections were observed: 2.08(2.06-2.10) per 1000 person-year in non-diabetic and 5679: 9.13(8.94-9.32) per 1000 person-year in diabetic population. Diabetes conferred a greater risk of hospitalizations, independently from confounders [adjusted HR (95% CI) 2.04 (1.97-2.10); P < 0.0001]. Statin use decreased the risk by about 2.5% for each one month of therapy, at the same extent in subjects with or without diabetes, after adjusting for all covariates.

CONCLUSIONS

In this population, diabetes was associated by a twofold increase in the 5-year risk of hospitalizations for bacterial infections. Statin use decreased this risk to a same extent in subjects without or with diabetes, after adjusting for main confounders including comorbidities, and previous or incident cardiovascular events.

Gender difference in diabetes related excess risk of cardiovascular events: When does the 'risk window' open?

OBJECTIVE

Women with diabetes have a greater excess risk for cardiovascular diseases (CVD) than men. This study was aimed at clarifying whether this effect is lifelong or more evident in some life-periods.

METHODS

The effect of diabetes and gender on the risk of first ever hospitalization for acute myocardial infarction (AMI), ischemic stroke (IS), congestive heart failure (CHF), lower extremity amputations (LEA) or any of these major cardiovascular events (MACE) have been evaluated by a Cox-hazard model, over years 2008-2012 querying administrative databases of a cohort living in Tuscany, Italy.

RESULTS

Comparing subjects with diabetes to those without it the overall age-adjusted excess risk was higher in women than in men for AMI and MACE and higher in men for LEA, with no difference for IS or CHF. In women the excess risk for AMI and MACE started earlier (46yr) and lasted until age of more than 85yr, while 'risk-windows' opened later and had a shorter duration for CHF (56-65yr) and IS (66-75yr).

CONCLUSION

Diabetic women have a significant diabetes-associated excess of CVD risk, except for LEA, with a 'risk window' opening earlier and lasting longer for AMI and MACE, later and with a shorter duration for IS and CHF.

The Effect of Sex and Gender on Diabetic Complications

While in non-diabetic people the risk for cardiovascular disease is higher in men, diabetes completely reverts this sex-gender difference conferring to women a greater burden of cardiovascular complications. Additionally, all risk factors associated with cardiovascular disease appear to be more active in diabetic females than in their male counterparts. The reasons of this different impact of diabetes between genders are not completely clear. The aim of this review is trying to clarify these issues in a sex and gender perspective. Both genetic and hormonal factors are at the basis of sex-gender differences in diabetes, even do not explain the totality of data. Possibly women arrive later and in worse conditions to the diagnosis of diabetes, receive both diagnostic and therapeutic supports in a lesser measure and, finally, reach therapeutic goals as recommended by guidelines in a lesser extent. Further aspects of sex-gender differences in diabetic complications are represented by a more frequent prevalence of drug side effects in women, as well as by increased resistance to the action of drugs used in prevention or in the therapy of cardiovascular diseases. As to microvascular complications, the issue of sex-gender differences is even more complex, with some important differences emerging in experimental models 'in vitro', as well as in human pathology 'in vivo'. The main problem, however, also in this case, is that it is difficult to differentiate how common pathogenetic mechanisms acting in diabetes may differently impact between genders. In conclusion what is evident is that diabetes represents a 'risk magnifier' for the damage of both micro and macrovessels differently in men and in women. This issue deserves, therefore, a more careful approach from people involved in both clinical aspects and research regarding diabetes and its complications, in a sex-gender oriented perspective.

Does the hospitalization after a cancer diagnosis modify adherence to process indicators of diabetes care quality?

AIMS

This study was designed to answer the question whether surgery due to newly diagnosed cancer may modify quality of diabetes' management, as suggested by current guidelines.

METHODS

Adherence to guideline composite indicator (GCI), a process indicator including one annual assessment of HbA1c and at least two among eye examination, serum lipids measurement and microalbuminuria, was evaluated between years 2011-2012 and 2014-2015 in 158,069 diabetic patients living in Tuscany, Italy, on 1 January 2011 and surviving on 31 December 2015, of whom 661 were hospitalized in index year 2013 for a surgery procedure due to a newly incident cancer. Difference in GCI modification (DELTA_GCI) of these patients was compared with that of diabetic people without cancer, strictly matched for main confounders by means of a propensity score.

RESULTS

In diabetic patients with cancer, GCI adherence increased by about 8 % between years 2011-2012 and 2014-2015. When compared with controls, DELTA_GCI increased by 6 % in cancer group compared with controls (p < 0.05), but any significance was lost after matching the groups by propensity score (3 %; p = NS).

CONCLUSIONS

Our study suggests that a hospitalization for a surgical procedure due to a newly diagnosed cancer does not influence the compliance to a quality process indicator of diabetes care such as GCI.

Hospital incidental diagnosis of diabetes: A population study

AIMS

To identify incidental previously unrecognized diabetes (IPUD) among hospitalized patients and corresponding mortality risk in comparison with individuals with known diabetes (KDM).

METHODS

Out of 214,991 individuals discharged in year 2011 from all hospitals of Tuscany, Italy we retrospectively identified IPUD as individuals with no known diabetes and/or previous antidiabetic medication, receiving at least two prescriptions of glucose-lowering-drugs over the next 6months after discharge. Two-year (2012-2013) adjusted mortality risk was tested by a Cox-regression-analysis, comparing IPUD and KDM patients with at least one hospital admission in 2011.

RESULTS

974 patients with IPUD (375.6×100,000 hospitalized people) have been identified. IPUD risk was associated with aging, male gender and greater burden of co-morbidities, was higher in migrants of non-Italian ancestry and was reduced among patients of family physicians adhering to guidelines resulting in a proactive model of care delivery. In IPUD patients alive at 1st January 2012, (n=865) the adjusted risk of two-year mortality was similar to that of KDM subjects (HR=1.08; 95% CI: 0.92-1.26; p=NS).

CONCLUSIONS

IPUD occurs more commonly in older male subjects, migrants of non-Italian ancestry, and among patients of physicians non-adhering to a shared diabetes care model. People with IPUD have similar two-year-mortality risk compared with KDM individuals.

Prevalence of Multiple Sclerosis in Tuscany (Central Italy): A Study Based on Validated Administrative Data

BACKGROUND

Multiple Sclerosis (MS) epidemiology in Italy is mainly based on population-based prevalence studies. Administrative data are an additional source of information, when available, in prevalence studies of chronic diseases such as MS. The aim of our study is to update the prevalence rate of MS in Tuscany (central Italy) as at 2011 using a validated case-finding algorithm based on administrative data.

METHODS

The prevalence was calculated using an algorithm based on the following administrative data: hospital discharge records, drug-dispensing records, disease-specific exemptions from copayment to health care, home and residential long-term care and inhabitant registry. To test algorithm sensitivity, we used a true-positive reference cohort of MS patients from the Tuscan MS register. To test algorithm specificity, we used another cohort of individuals who were presumably not affected by MS.

RESULTS

As at December 31, 2011, we identified 6,890 cases (4,738 females and 2,152 males) with a prevalence of 187.9 per 100,000. The sensitivity of algorithm was 98% and the specificity was 99.99%.

CONCLUSIONS

We found a prevalence higher than the rates present in literature. Our algorithm, based on administrative data, can accurately identify MS patients; moreover, the resulting cohort is suitable to monitor disease care pathways.

Should low birth-weight be considered a relevant risk factor for rise in pulse pressure among adult overweight-obese subjects?

Low birth-weight (BW) is related to rise in blood pressure (BP) later in life. Aim of this study is investigating whether presence of overweight-obesity modifies this relationship, independently from any additional correlate of metabolic syndrome. We studied 535 (216 M/319 F) otherwise healthy overweight-obese people (body mass index≥25 kg/m²), recording systolic, diastolic and pulse BP as well as plasma glucose and lipids, additionally interviewing them about BW and weight-change after age of 18 years. The reciprocal of BW was related only to pulse pressure (PP, r=0.14; P=0.04), uniquely in men and individuals with BW≤2500 g had a higher relative risk of having PP above upper quartile (&gt;60 mmHg), independently of sex. After adjusting for confounders each 1 kg rise in BW was associated with 2.84±0.88 (standard error) mmHg decrease in PP; P=0.0042. Moreover, again only among males, the lower BW the higher was the risk of a PP&gt;60 mmHg [odds ratio (95% confidence interval): 2.43 (1.39-4.24); P=0.0018]. In conclusion BW was inversely related only with PP in overweight-obese subjects, uniquely in men, being such effect independent from other correlates of metabolic syndrome. Since elevated PP can be considered a proxy of vascular damage, these findings further stress the importance of inquiring about BW to better stratify the risk of vascular damage, in adult overweight-obese individuals.

Gender difference in diabetes-associated risk of first-ever and recurrent ischemic stroke

OBJECTIVE

To evaluate the effect of diabetes by gender on the peak-risk of first-ever-ischemic stroke and its recurrence.

METHODS

Administrative datasets including all hospital discharges for ischemic stroke (N = 43,332) in the diabetic (N = 207,568) and non-diabetic (N = 2,808,554) population of the Tuscany region, Italy were used to calculate Hazard ratios (HR) after Cox-regression, of first-ever and recurrent ischemic strokes, between 2005 and 2011.

RESULTS

Overall, diabetes increased the HR of first-ever ischemic stroke by about 50% in both genders. However, this risk significantly declined with age and was higher in women aged 55-74 yr than in men of the same age (HR; 95% CI: 1.392; 1.228-1.579 in age-class 55-64 yr and 1.203; 1.110-1.304 in age class 65-74 yr; p < 0.001). Diabetes also increased the adjusted risk of three-year-stroke recurrence (N = 5,998) in women, independently of age, whereas this was the case in men < 70 yr.

CONCLUSIONS

Diabetes is associated with increased risk of ischemic stroke although it declines with age though at lower rate among women than men. Moreover, diabetic women have greater risk of recurrence than in men > 70 yrs old, supporting a high-risk "time-window" in postmenopausal-elderly diabetic women.

Effect of diabetes on hospitalization for ischemic stroke and related in-hospital mortality: a study in Tuscany, Italy, over years 2004-2011

BACKGROUND

Incidence of ischemic stroke and associated in-hospital mortality is decreasing in Western populations, while the prevalence of diabetes, a well-known risk factor for ischemic stroke, is progressively rising. This study was aimed at evaluating the effect of diabetes on ischemic stroke hospitalization and in-hospital mortality after ischemic stroke.

METHODS

Discharges with diagnosis of ischemic stroke were identified in a database containing all hospitalizations of resident population of Tuscany, Italy, over years 2004-2011. Cases with diabetes were identified through specific drug prescriptions, official certifications or previous hospital diagnosis. Rates of annual ischemic stroke incidence and related in-hospital mortality were separately calculated for gender and age class, in subjects with and without diabetes.

RESULTS

Sixty-five thousand one hundred sixty-five hospital discharges with ischemic stroke diagnosis were identified. Diabetes was associated with increased risk of stroke odds ratio(95% confidence interval):1.31(1.28-1.34) in men and 1.24(1.21-1.37) in women. Diabetic women, compared with men, had a higher in-hospital mortality risk after ischemic stroke (odds ratio:1.32; 1.06-1.64), whereas in non-diabetic subjects, there was no difference between genders. Incidence of ischemic stroke has declined in non-diabetic subjects, except for women aged ≤70 years; a similar reduction was observed for in-hospital mortality. Among diabetic patients, conversely, annual incidence of ischemic stroke rose by 3% in the elderly people (>70 years), and annual mortality trend remained unchanged.

CONCLUSIONS

In the last decade, the incidence of ischemic stroke and of related in-hospital mortality declined in persons without diabetes, while increasing among diabetic patients of advanced age. Women with diabetes, compared with men, had a higher in-hospital mortality risk.