Diversity, integration, and variability of intergenerational relationships in old age: New insights from personal network research

Relationships between family members from different generations have long been described as a source of solidarity and support in aging populations and, more recently, as a potential risk factor for COVID-19 contagion. Personal or egocentric network research offers a powerful kit of conceptual and methodological tools to study these relationships, but this has not yet been employed to its full potential in the literature. We investigate the heterogeneity, social integration, and individual correlates of intergenerational relationships in old age analyzing highly granular data on the personal networks of 230 older adults (2747 social ties) from a local survey in one of the areas of the world at the forefront of global aging trends (northern Italy). Using information on different layers in broad egocentric networks and on the structure of connectivity among the social contacts of aging people, we propose multiple conceptualizations and measures of intergenerational connectedness. Results show that intergenerational relationships are strongly integrated, but also highly diverse and variable, in older adults' social networks. Different types of intergenerational ties exist in different network layers, with various relational roles, degrees of tie strength, and patterns of association with individual and tie characteristics. We discuss how new and existing personal network data can be leveraged to consider novel questions and hypotheses about intergenerational relationships in contemporary aging families.

Proximal hip fractures in 71,920 elderly patients: incidence, epidemiology, mortality and costs from a retrospective observational study

BACKGROUND

The risk of proximal femoral fractures increases with aging, causing significant morbidity, disability, mortality and socioeconomic pressure. The aims of the present work are (1) to investigate the epidemiology and incidence of these fractures among the elderly in the Region of Lombardy; (2) to identify the factors influencing survival; (3) to identify the factors influencing hospitalization and post-operative costs.

METHODS

The Region of Lombardy provided anonymized datasets on hospitalized patients with a femoral neck fracture between 2011 and 2016, and anonymized datasets on extra-hospital treatments to track the patient history between 2008 and 2019. Statistical evaluations included descriptive statistics, survival analysis, Cox regression and multiple linear models.

RESULTS

71,920 older adults suffered a femoral fracture in Lombardy between 2011 and 2016. 76.3% of patients were females and the median age was 84. The raw incidence of fractures was stable from year 2011 to year 2016, while the age-adjusted incidence diminished. Pertrochanteric fractures were more spread than transcervical fractures. In patients treated with surgery, receiving treatment within 48 h reduced the hazard of death within the next 24 months. Combined surgical procedures led to increased hazard in comparison with arthroplasty alone, while no differences were observed between different arthroplasties and reduction or fixation. In patients treated conservatively, age and male gender were associated with higher hazard of death. All patients considered, the type of surgery was the main factor determining primary hospitalization costs. A higher number of surgeries performed by the index hospital in the previous year was associated with financial savings. The early intervention significantly correlated with minor costs.

CONCLUSIONS

The number of proximal femoral fractures is increasing even if the age-adjusted incidence is decreasing. This is possibly due to prevention policies focused on the oldest cohort of the population. Two policies proved to be significantly beneficial in clinical and financial terms: the centralization of patients in high-volume hospitals and a time limit of 48 h from fracture to surgery.

TRIAL REGISTRATION

Non applicable.

A regional scale flux-based O3 risk assessment for winter wheat in northern Italy, and effects of different spatio-temporal resolutions

Tropospheric ozone (O3) is a secondary atmospheric pollutant known to cause negative effects on vegetation in terms of physiological oxidative stress, growth rate reductions and yield losses. In recent years, dose-response relationships based on the O3 stomatal flux and effects on the biomass growth have been defined for several crop species. This study was aimed at developing a dual-sink big-leaf model for winter wheat (Triticum aestivum L.) to map the seasonal Phytotoxic Ozone Dose above a threshold of 6nmolm-2s-1 (POD6) in a domain centered on the Lombardy region (Italy). The model runs on local measured data of air temperature, relative humidity, precipitation, wind speed, global radiation and background O3 concentration provided by regional monitoring networks, and includes parameterizations for the crop's geometry and phenology, the light penetration within the canopy, the stomatal conductance, the atmospheric turbulence, and the soil water availability for the plants. For the 2017 an average POD6 of 2.03mmolm-2PLA (Projected Leaf Area) was found for the Lombardy regional domain, corresponding to an average relative yield loss of 7.5%, using the finest spatio-temporal resolution (1×1km2 and 1-h). An analysis of the model's response to different spatio-temporal resolutions (from 2×2 to 50×50km2 and from 1 to 6 h) suggests that coarser resolution maps underestimated the average POD6 regional value from 8to16%, and were unable to detect O3 hotspots. Nevertheless, resolutions of 5×5km2 1-h, and 1×1km2 3-h, can still be considered reliable for the estimation of the O3 risk at the regional level since they presented relatively low root mean squared error. Furthermore, although temperature was the main limiting factor for the wheat stomatal conductance in most of the domain, soil water availability emerged as the key factor for determining the spatial patterns of the POD6.

Comparison of ammonia air concentration before and during the spread of COVID-19 in Lombardy (Italy) using ground-based and satellite data

Several anthropogenic activities have undergone major changes following the spread of the COVID-19 pandemic, which in turn has had consequences on the environment. The effect on air pollution has been studied in detail in the literature, although some pollutants, such as ammonia (NH₃), have received comparatively less attention to date. Focusing on the case of Lombardy in Northern Italy, this study aimed to evaluate changes in NH₃ atmospheric concentration on a temporal scale (the years from 2013 to 2019 compared to 2020) and on a spatial scale (countryside, city, and mountain areas). For this purpose, ground-based (from public air quality control units scattered throughout the region) and satellite observations (from IASI sensors on board MetOp-A and MetOp-B) were collected and analyzed. For ground-based measurements, a marked spatial variability is observed between the different areas while, as regards the comparison between periods, statistically significant differences were observed only for the countryside areas (+31% in 2020 compared to previous years). The satellite data show similar patterns but do not present statistically significant differences neither between different areas, nor between the two periods. In general, there have been no reduction effects of atmospheric NH₃ as a consequence of COVID-19. This calls into question the role of the agricultural sector, which is known to be the largest responsible for NH₃ emissions. Even if the direct comparison between the two datasets shows little correlation, their contextual consideration allows making more robust considerations regarding air pollutants.

Is administered competition suitable for dealing with a public health emergency? Lessons from the local healthcare system at the centre of early COVID-19 outbreak in Italy

OBJECTIVES

The Lombardy Region, Italy, was the most severely affected by the COVID-19 outbreak. In absence of effective treatments and with basic hygiene measures made mandatory, Lombardy response to COVID-19 relied on its healthcare system characteristics, the administered competition or "quasi-market" model. The aim of the study was to review the strengths and weaknesses of Lombardy's response during the first wave of the COVID-19 epidemic, to explore whether the healthcare model influenced crisis management and describe which policies could help to contain future outbreaks. The results are expected to provide similar healthcare systems with lessons to avoid mistakes and learn from best practice.

METHODS

Data for quantitative analyses on the performance of the Lombardy and Veneto Regions healthcare systems were derived from existing government sources including the Italian Civil Protection Agency and the Ministry of Health.

RESULTS

Lombardian quasi-market model, traditionally characterized by a strong hospital network, was held responsible for many suboptimal outcomes. According to critics, years of disinvestments in community care resulted in a hospital overload. However, the same model was responsible for other positive outcomes which have been substantially neglected, such as the opportunity to test for effective containment treatments in a safe environment and rapidly extend the number of beds.

CONCLUSIONS

The performance of a quasi-market model against public health emergencies largely depends on integration between policy-makers and balance between healthcare providers, which require clear regulation. Reducing institutional fragmentation between levels of governance, improving the coordination of healthcare facilities and adopting telemedicine technologies are means by which healthcare networks could strengthen their resilience against future outbreaks.

How Did COVID-19 Affect Suicidality? Data from a Multicentric Study in Lombardy

The aim of the study was to describe the characteristics of subjects accessing the emergency rooms for suicidal behavior during the first epidemic wave of COVID-19 in three Emergency Departments (EDs) in Lombardy (Italy). A retrospective chart review was conducted for the period 8 March–3 June 2020, and during the same time frame in 2019. For all subjects accessing for suicidality, socio-demographic and clinical data were collected and compared between the two years. The proportion of subjects accessing for suicidality was significantly higher in 2020 than in 2019 (13.0 vs. 17.2%, p = 0.03). No differences between the two years were found for sex, triage priority level, history of substance abuse, factor triggering suicidality and discharge diagnosis. During 2020 a greater proportion of subjects did not show any mental disorders and were psychotropic drug-free. Women were more likely than men to receive inpatient psychiatric treatment, while men were more likely to be discharged with a diagnosis of acute alcohol/drug intoxication. Our study provides hints for managing suicidal behaviors during the still ongoing emergency and may be primary ground for further studies on suicidality in the course of or after massive infectious outbreaks.

Almost one year of COVID-19 pandemic: how radiotherapy centers have counteracted its impact on cancer treatment in Lombardy, Italy. CODRAL/AIRO-L study

Lombardy has represented the Italian and European epicenter of the coronavirus disease 2019 (COVID-19) pandemic. Although most clinical efforts within hospitals were diverted towards the care of virally infected patients, therapies for patients with cancer, including radiotherapy (RT), have continued. During both the first and second pandemic waves, several national and regional organizations provided Italian and Lombardian RT departments with detailed guidelines aimed at ensuring safe treatments during the pandemic. The spread of infection among patients and personnel was limited by adopting strict measures, including triage procedures, interpersonal distance, and adequate implementation of personal protective equipment (PPE). Screening procedures addressed to both the healthcare workforce and patients, such as periodic nasopharyngeal swabs, have allowed the early identification of asymptomatic or pauci-symptomatic COVID-19 cases, thus reducing the spread of the infection. Prevention of infection was deemed of paramount importance to protect both patients and personnel and to ensure the availability of a minimum number of staff members to maintain clinical activity. The choice of treating COVID-19-positive patients has represented a matter of debate, and the risk of oncologic progression has been weighted against the risk of infection of personnel and other patients. Such risk was minimized by creating dedicated paths, reserving time slots, applying intensified cleaning procedures, and supplying personnel and staff with appropriate PPE. Remote working of research staff, medical physicists, and, in some cases, radiation oncologists has prevented overcrowding of shared spaces, reducing infection spread.

Dangerous liaisons: an online experiment on the role of scientific experts and politicians in ensuring public support for anti-COVID measures

The effectiveness of public health measures to prevent COVID-19 contagion has required less vulnerable citizens to pay an individual cost in terms of personal liberty infringement to protect more vulnerable groups. However, the close relationship between scientific experts and politicians in providing information on COVID-19 measures makes it difficult to understand which communication source was more effective in increasing pro-social behaviour. Here, we present an online experiment performed in May 2020, during the first wave of the pandemic on 1131 adult residents in Lombardy, Italy, one of the world's hardest hit regions. Results showed that when scientific experts recommended anti-contagion measures, participants were more sensitive to pro-social motivations, unlike whenever these measures were recommended by politicians and scientific experts together. Our findings suggest the importance of trusted sources in public communication during a pandemic.

Vascular Surgery During COVID-19 Emergency in Hub Hospitals of Lombardy: Experience on 305 Patients

Objective

During the most aggressive phase of the COVID-19 outbreak in Italy, the Regional Authority of Lombardy identified a number of hospitals, named Hubs, chosen to serve the whole region for highly specialised cases, including vascular surgery. This study reports the experience of the four Hubs for Vascular Surgery in Lombardy and provides a comparison of in hospital mortality and major adverse events (MAEs) according to COVID-19 testing.

Methods

Data from all patients who were referred to the Vascular Surgery Department of Hubs from 9 March to 28 April 2020 were collected prospectively and analysed. A positive COVID-19 polymerase chain reaction swab test, or symptoms (fever > 37.5 °C, upper respiratory tract symptoms, chest pain, and contact/travel history) associated with interstitial pneumonia on chest computed tomography scan were considered diagnostic of COVID-19 disease. Patient characteristics, operative variables, and in hospital outcomes were compared according to COVID-19 testing. A multivariable model was used to identify independent predictors of in hospital death and MAEs.

Results

Among 305 included patients, 64 (21%) tested positive for COVID-19 (COVID group) and 241 (79%) did not (non-COVID group). COVID patients presented more frequently with acute limb ischaemia than non-COVID patients (64% vs. 23%; p < .001) and had a significantly higher in hospital mortality (25% vs. 6%; p < .001). Clinical success, MAEs, re-interventions, and pulmonary and renal complications were significantly worse in COVID patients. Independent risk factors for in hospital death were COVID (OR 4.1), medical treatment (OR 7.2), and emergency setting (OR 13.6). COVID (OR 3.4), obesity class V (OR 13.5), and emergency setting (OR 4.0) were independent risk factors for development of MAEs.

Conclusion

During the COVID-19 pandemic in Lombardy, acute limb ischaemia was the most frequent vascular disease requiring surgical treatment. COVID-19 was associated with a fourfold increased risk of death and a threefold increased risk of major adverse events.

Back to (new) normality-A CODRAL/AIRO-L survey on cancer radiotherapy in Lombardy during Italian COVID-19 phase 2

Background

Italy experienced one of the world’s severest COVID-19 outbreak, with Lombardy being the most afflicted region. However, the imposed safety measures allowed to flatten the epidemic curve and hence to ease the restrictions and inaugurate, on the 4th of May 2020, the Italian phase (P) 2 of the pandemic. The present survey study, endorsed by CODRAL and AIRO-L, aimed to assess how radiotherapy (RT) departments in Lombardy have dealt with the recovery.

Materials and methods

A questionnaire dealing with the management of pandemic was developed online and sent to all CODRAL Directors on the 10th of June 2020. Answers were collected in full anonymity one week after.

Results

All the 33 contacted RT facilities (100%) responded to the survey. Despite the scale of the pandemic, during P1 14 (42.4%) centres managed to safely continue the activity (≤ 10% reduction). During P2, 10 (30.3%) centres fully recovered and 14 (42.4%) reported an increase. Nonetheless, 6 (18.2%) declared no changes and, interestingly, 3 (9.1%) reduced activities. Overall, 21 centres (63.6%) reported suspected or positive cases within healthcare workforce since the beginning of the pandemic. Staff units were quarantined in 19 (57.6%) and 6 (18.2%) centres throughout P1 and P2, respectively. In the two phases, about two thirds centres registered positive or suspected cases amongst patients.

Conclusion

The study revealed a particular attention to anti-contagion measures and a return to normal or even higher clinical workload in most RT centres in Lombardy, necessary to carry out current and previously deferred treatments.

Electronic supplementary material

The online version of this article (10.1007/s12032-020-01434-1) contains supplementary material, which is available to authorized users.

The Lombardy Emergency Medical System Faced with COVID-19: The Impact of Out-of-Hospital Outbreak

OBJECTIVE

The Lombardy region was among the areas most affected by COVID-19 infection worldwide; the Lombardy Emergency Medical System (EMS) responded immediately to this emergency. We analyzed several critical aspects to understand what occurred in that region.

METHODS

This retrospective study compares the events managed by the dispatch center and the characteristics of the patients transported to the hospital -age, sex, SpO₂, deaths- managed by the EMS in Brescia and Bergamo provinces between March-April 2020 and March-April 2019. Ambulances' waiting time at the hospitals before discharging patients and the patients' severity at emergency department admission were also analyzed.

RESULTS

EMS managed 37,340 events in March-April 2020, +51.5% versus 2019. "Breathing" or "Infective" events reported to the dispatch center increased more than ten-fold (OR 25.1, p < 0.0001) in March 2020 and two-fold in April 2020 compared to 2019 (OR 3, p < 0.0001). Deaths increased +246% (OR 1.7, p < 0.0001), and patients not transported to hospital +481% (OR 2.9, p < 0.0001) in March 2020 compared to 2019. In some hospitals, ambulances waited more than one hour before discharging the patients, and the emergency departments doubled the admission of critically ill patients. Transported patients for "Breathing" or "Infective" events were primarily males (OR 1.5, p < 0.0001). The patients had lower SpO₂ in 2020 than in 2019 and they were younger.

CONCLUSIONS

The Lombardy region experienced an unexpected outbreak in an extremely short timeframe and in a limited area. The EMS coped with this pandemic, covering an extremely higher number of requests, with a ten-fold increase in the number of events managed.

Preliminary Analysis of Relationships between COVID19 and Climate, Morphology, and Urbanization in the Lombardy Region (Northern Italy)

The coronavirus disease 2019 (COVID-19) pandemic is the most severe global health and socioeconomic crisis of our time, and represents the greatest challenge faced by the world since the end of the Second World War. The academic literature indicates that climatic features, specifically temperature and absolute humidity, are very important factors affecting infectious pulmonary disease epidemics - such as severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS); however, the influence of climatic parameters on COVID-19 remains extremely controversial. The goal of this study is to individuate relationships between several climate parameters (temperature, relative humidity, accumulated precipitation, solar radiation, evaporation, and wind direction and intensity), local morphological parameters, and new daily positive swabs for COVID-19, which represents the only parameter that can be statistically used to quantify the pandemic. The daily deaths parameter was not considered, because it is not reliable, due to frequent administrative errors. Daily data on meteorological conditions and new cases of COVID-19 were collected for the Lombardy Region (Northern Italy) from 1 March, 2020 to 20 April, 2020. This region exhibited the largest rate of official deaths in the world, with a value of approximately 1700 per million on 30 June 2020. Moreover, the apparent lethality was approximately 17% in this area, mainly due to the considerable housing density and the extensive presence of industrial and craft areas. Both the Mann–Kendall test and multivariate statistical analysis showed that none of the considered climatic variables exhibited statistically significant relationships with the epidemiological evolution of COVID-19, at least during spring months in temperate subcontinental climate areas, with the exception of solar radiation, which was directly related and showed an otherwise low explained variability of approximately 20%. Furthermore, the average temperatures of two highly representative meteorological stations of Molise and Lucania (Southern Italy), the most weakly affected by the pandemic, were approximately 1.5 °C lower than those in Bergamo and Brescia (Lombardy), again confirming that a significant relationship between the increase in temperature and decrease in virulence from COVID-19 is not evident, at least in Italy.

The importance of patients' case-mix for the correct interpretation of the hospital fatality rate in COVID-19 disease

OBJECTIVE

We aimed to document data on the epidemiology and factors associated with clinical course leading to death of patients hospitalised with COVID-19.

METHODS

Prospective observational cohort study on patients hospitalised with COVID-19 disease in February-24th/May-17th 2020 in Milan, Italy. Uni-multivariable Cox regression analyses were performed. Death's percentage by two-weeks' intervals according to age and disease severity was analysed.

RESULTS

A total of 174/539 (32.3%) patients died in hospital over 8228 person-day follow-up; the 14-day Kaplan-Meier probability of death was 29.5% (95%CI: 25.5-34.0). Older age, burden of comorbidities, COVID-19 disease severity, inflammatory markers at admission were independent predictors of increased risk, while several drug-combinations were predictors of reduced risk of in-hospital death. The highest fatality rate, 36.5%, occurred during the 2nd-3rd week of March, when 55.4% of patients presented with severe disease, while a second peak, by the end of April, was related to the admission of older patients (55% ≥80 years) with less severe disease, 30% coming from long-term care facilities.

CONCLUSIONS

The unusual fatality rate in our setting is likely to be related to age and the clinical conditions of our patients. These findings may be useful to better allocate resources of the national healthcare system, in case of re-intensification of COVID-19 epidemics.

The Spread of SARS-CoV-2 Infection Among the Medical Oncology Staff of ASST Spedali Civili of Brescia: Efficacy of Preventive Measures

Patients with cancer are at a higher risk of developing serious disease-related complications in case of contracting SARS-CoV-2. Oncology units should implement all possible preventive measures to reduce the risk of viral transmission by healthcare professionals (HCPs) to patients. We conducted a surveillance for SARS-CoV-2 infection among the staff members of the Medical Oncology Unit of ASST Spedali Civili in Brescia, one of the Italian areas most affected by the SARS-CoV-2 pandemic. The aim of this study was to demonstrate whether the recommended preventive measures, promptly implemented by the unit, have been effective in reducing the spread of the virus among the HCPs. Between February 24 and May 19, 2020, SARS-CoV-2 infection was detected in 10 out of 76 healthy HCPs (13%). Six of them developed a symptomatic disease, leading to home quarantine, and four remained asymptomatic. The infection was revealed when a serology test was performed on all staff members of the unit. In seven HCPs, in which it was possible to trace the person-to-person infection, the contagion occurred as a result of unprotected contacts or partially protected with surgical masks. In particular, four asymptomatic HCPs did not stop working, but a widespread outbreak in the unit was avoided. Adherence to the recommended preventive strategies, in particular, wearing of surgical masks by both the HCPs and the patients, is effective in reducing and preventing the viral spread.

First data analysis about possible COVID-19 virus airborne diffusion due to air particulate matter (PM): The case of Lombardy (Italy)

The severe cases of COVID-19 infections in Italy, and notably in Lombardy (mainly in Brescia and Bergamo areas), registered at the beginning of March 2020, occurred after a period of PM10 pollution, that exceeded the concentration of 50 μg/m3 (the attention limit) for several days. The two events were supposed to be correlated, also based on the limited information available about the new virus. Despite that clear indications about the role of particulate matter (PM) in the virus mechanism dispersion cannot be found in literature, some researchers supposed that PM can act as virus carrier, promoting its diffusion through the air. This paper, for the first time, analyses the PM10 situation in Lombardy (from 10th February to March 27, 2020), several days before the sanitary emergency explosion. The data of the detected infection cases are reported and discussed parallelly. As a comparison, the situation of Piedmont, located near to the Lombardy is also presented. Data are reported for Brescia, Bergamo, Cremona, Lodi, Milano, Monza-Brianza, Pavia (Lombardy), Alessandria, Vercelli, Novara, Biella, Asti, and Torino (Piedmont). The results show that it is not possible to conclude that COVID-19 diffusion mechanism also occurs through the air, by using PM10 as a carrier. In particular, it is shown that Piedmont cities, presenting lower detected infections cases in comparison to Brescia and Bergamo in the investigated period, had most sever PM10 pollution events in comparison to Lombardy cities. This first study may serve as a reference to better understand and predict the factors affecting the COVID-19 diffusion and transmission routes, focusing on the role of air particulate matter in the atmosphere.

Mental Health Services in Lombardy during COVID-19 outbreak

Lombardy is the Region in Italy the most heavily affected by coronavirus disease (COVID-19) contagion. The Regional Health Authority mandates that mental health services should be guaranteed, identifying mental health as a priority for their citizens. Recommendations for occupational and health safety have been provided to patients and hospital staff, including support for telemedicine activities and remote psychosocial interventions. Services of the Mental Health Departments of Milano "Niguarda" and Brescia "Spedali Civili" Hospitals are providing continued care at a community, residential and hospital level, and to positive COVID-19 psychiatric patients in need of hospitalization.

Radiotherapy for oligometastatic cancer: a survey among radiation oncologists of Lombardy (AIRO-Lombardy), Italy

AIMS

To evaluate the use of radiotherapy (RT) for oligometastatic cancer (OMC) among radiation oncologists in Lombardy, Italy.

METHODS AND STUDY DESIGN

A survey with 12 items regarding data of 2016 was sent to all 34 Lombardy RT centers. The survey included six general items and six specific items regarding patient/disease/treatment characteristics.

RESULTS

Thirteen centers answered the survey (38%). All centers responded to general items and 12 centers submitted patient/disease/treatment data. General items The majority of centers (8/13) consider OMC if metastases number is less than 5. The most commonly prescribed dose/fraction is 5-10 Gy (8/13) using schedules of 3-5 fractions (11/13). Patient data items A total of 15.681 patients were treated in 2016 with external beam RT in 12 responding centers, and 1.087 patients were treated for OMC (7%). Primary tumor included lung, prostate, breast, colorectal and other malignancies in 33%, 21%, 12%, 9% and 25% of all OMC patients, respectively. Brain, lymph node, lung, bone, liver and others were the most common treated sites (24%, 24%, 22%, 17%, 8% and 5%, respectively). One and more than one metastasis were treated in 75 and 25% of patients, respectively. The vast majority of patients (95%) were treated with image-guided intensity-modulated RT or stereotactic RT.

CONCLUSIONS

Seven percent of all RT patients in Lombardy are treated for OMC. Extreme hypofractionation and high-precision RT are commonly employed. The initiative of multicenter and multidisciplinary collaboration has been undertaken in order to prepare the platform for prospective and/or observational studies in OMC.

The redistributive effects of copayment in outpatient prescriptions: evidence from Lombardy

Background

In Italy, copayment has changed its nature and it can no longer be simply considered a system to curb inappropriate expenditure. It has become an important form of revenue for public health care provision, but it might also become a source of distortions in income and health benefits redistribution.

Methods

We use a rich administrative dataset gathering information on patients demand (whose records have been matched to income declared for tax purposes) to study the effects of an additional copayment (the so called “superticket” introduced by the Italian government in 2012) in Lombardy, the biggest Italian Region whose socio-economic dimension is comparable to that of many European countries (e.g., the Netherlands, Switzerland, etc.).

Results

Our analysis shows that at the aggregate level the non-uniform superticket schedule adopted in Lombardy is slightly pro-poor, but this result coexists with evidences pointing towards possible cases of restriction to access caused by the additional copayment.

Conclusions

The introduction of the superticket and the ensuing increase in the out-of pocket payment for health care raises questions about the distribution of the burden among patients, and the sustainability of the extra revenue through time. This issue needs to be further investigated by combining health status data with the information in this dataset.

Cost-effectiveness evaluation of escitalopram in major depressive disorder in Italy

Background

Depression has a lifetime prevalence of 10%–25% among women and 5%–12% among men. Selective serotonin reuptake inhibitors (SSRIs) are the most used and the most cost-effective treatment for long-term major depressive disorder. Since the introduction of generic SSRIs, the costs of branded drugs have been questioned. The objective of this study was to assess the cost-effectiveness (€ per quality-adjusted life year [QALY]) of escitalopram (which is still covered by a patent) compared with paroxetine, sertraline, and citalopram, the patents for which have expired.

Methods

A decision analytic model was adapted from the Swedish Dental and Pharmaceutical benefits agency model to reflect current clinical practice in the treatment of depression in Italy in collaboration with an expert panel of Italian psychiatrists and health economists. The population comprised patients with a first diagnosis of major depressive disorder and receiving for the first time one of the following SSRIs: escitalopram, sertraline, paroxetine, and citalopram. The time frame used was 12 months. Efficacy and utility data for the original model were validated by our expert panel. Local data were considered for resource utilization and for treatment costs based on the Lombardy region health service perspective. Several scenario simulations, oneway sensitivity analyses, and Monte Carlo simulations were performed to test the robustness of the model.

Results

The base case scenario showed that escitalopram had an incremental cost-effectiveness ratio (ICER) of €4395 and €1080 per QALY compared with sertraline and paroxetine, respectively. Escitalopram was dominant over citalopram, which was confirmed by most one-way sensitivity analyses. The escitalopram strategy gained 0.011 QALYs more than citalopram, 0.008 more than paroxetine, and around 0.007 more than sertraline. Monte Carlo simulations indicated that ICER values for escitalopram were centered around €1100 and €4400 per QALY compared with paroxetine and sertraline, respectively. Although there is no official cost-effectiveness threshold in Italy, the value of €25,000 per QALY could be acceptable. All ICER values retrieved in all analyses were lower than this threshold.

Conclusion

The findings from this cost-effectiveness analysis indicate that escitalopram could be accepted as a cost-effective strategy for the Lombardy region health service compared with the other SSRIs studied. The present assessment is based on ICER values resulting from this analysis, which are lower than the thresholds proposed by health care authorities in other European Union countries. These benefits are driven by the effectiveness of escitalopram, which result in an improved health-related quality of life, a higher probability of sustained remission, and better utilization of health care resources. The study results are robust and in line with other pharmacoeconomic analyses comparing escitalopram with other SSRIs.