• Chiara Marinacci1

  1. Ministero della Salute, Dipartimento della programmazione e dell'ordinamento del Servizio sanitario nazionale, Direzione Generale della Programmazione Sanitaria.

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Stringa: ("socioeconomic factors"[MeSH Terms] OR "social class"[MeSH Terms]) OR "educational status"[MeSH Terms]) OR inequalities[Title/Abstract]) OR inequities[Title/Abstract]) OR socioeconomic[Title/Abstract]) OR socio-economic[Title/Abstract]) OR disparities[Title/Abstract]) AND ("italy"[MeSH Terms] OR "italy"[All Fields]) AND ("2013/04/01"[PDAT] : "2013/06/15"[PDAT])
1. Barsanti S, Nuti S. The equity lens in the health care performance evaluation system. Int J Health Plann Manage. 2013 May 30. doi: 10.1002/hpm.2195. [Epub ahead of print]
Istituto di Management, Laboratorio Management e Sanità, Scuola Superiore Sant'Anna Pisa, Pisa, Italy.

Abstract The main objective of this paper is to describe how indicators of the equity of access to health care according to socioeconomic conditions may be included in a performance evaluation system (PES) in the regional context level and in the planning and strategic control system of healthcare organisations. In particular, the paper investigates how the PES adopted, in the experience of the Tuscany region in Italy, indicators of vertical equity over time. Studies that testify inequality of access to health services often remain just a research output and are not used as targets and measurements in planning and control systems. After a brief introduction to the concept of horizontal and vertical equity in health care systems and equity measures in PES, the paper describes the 'equity process' by which selected health indicators declined by socioeconomic conditions were shared and used in the evaluation of health care institutions and in the CEOs' rewarding system, and subsequently analyses the initial results. Results on the maternal and child path and the chronicity care path not only show improvements in addressing health care inequalities, but also verify whether the health system responds appropriately to different population groups.

2. Bajaj JS, Riggio O, Allampati S, Prakash R, Gioia S, Onori E, Piazza N, Noble NA, White MB, Mullen KD. Cognitive Dysfunction Is Associated With Poor Socioeconomic Status in Patients With Cirrhosis: An International Multicenter Study. Clin Gastroenterol Hepatol. 2013 May 22. pii: S1542-3565(13)00689-7. doi: 10.1016/j.cgh.2013.05.010. [Epub ahead of print]
Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia. Electronic address:

Abstract BACKGROUND & AIMS: In patients with cirrhosis, cognitive dysfunction most often results from covert hepatic encephalopathy (HE). These patients are not tested routinely for cognitive dysfunction despite single-center evidence that it could be associated with poor socioeconomic status (SES). We investigated the association between SES and cognition in a multicenter study of cirrhosis. METHODS: In a cross-sectional study, 236 cirrhotic patients from 3 centers (84 subjects from Virginia, 102 from Ohio, and 50 from Rome, Italy; age 57.7 ± 8.6 y; 14% with prior overt HE) were given recommended cognitive tests and a validated SES questionnaire that included questions about employment, personal and family income, and overall financial security. Comparisons were made among centers and between subjects who were employed or not. Regression analysis was performed using employment and personal income as outcomes. RESULTS: Only 37% of subjects had been employed in the past year. Subjects had substantial financial insecurity-their yearly personal income ranged from $16,000 to $24,999, and their family income ranged from $25,000 to $49,999. They would be able to maintain a residence for only 3 to 6 months if their income stopped, and their current liquid assets were $500 to $4999 (<$500 if debt was subtracted). Cognition and SES were worst in Ohio and best in Virginia. Cognition correlated with personal and family income, within and between centers. On regression analysis, cognitive performance (digit symbol, lures, and line tracing) was associated with personal yearly income, after controlling for demographics, country, employment, and overt HE. Unemployed subjects had a higher rate of overt HE, worse cognition, and lower personal income than employed subjects. On regression analysis, performance on digit symbol, line tracing, inhibitory control test lures, and serial dotting tests remained associated with income, similar to employment. CONCLUSIONS: In an international multicenter study of patients with cirrhosis, socioeconomic condition, based on employment and personal income, was associated strongly with cognitive performance, independent of age, education, and country.

3. Buja A, Gini R, Visca M, Damiani G, Federico B, Francesconi P, Donato D, Marini A, Donatini A, Brugaletta S, Baldo V, Bellentani M; Valore Project. Prevalence of chronic diseases by immigrant status and disparities in chronic disease management in immigrants: a population-based cohort study, Valore Project. BMC Public Health. 2013 May 24;13:504. doi: 10.1186/1471-2458-13-504.
Department of Molecular Medicine, Laboratory for Public Health and Population Studies, University of Padova, Via Loredan 18, Padova 35128, Italy.

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

Breve commento a cura di Chiara Marinacci
Uno dei pochi studi che hanno analizzato le differenze nella qualità dell’assistenza a pazienti cronici, in relazione alla cittadinanza. Barriere linguistiche, differenze culturali nell’attitudine ad investire sulla propria salute, ma anche difficoltà nell’utilizzo ottimale del servizio sanitario e nelle capacità di orientarsi all’interno delle sue complessità organizzative: queste le probabili spiegazioni dei peggiori indici di qualità assistenziale sistematicamente riscontrati, in tutti e tre i gruppi di pazienti cronici considerati, tra i cittadini provenienti da aree a forte pressione migratoria.

4. Minelli G, Conti S, Manno V, Olivieri A, Ascoli V. The geographical pattern of thyroid cancer mortality between 1980 and 2009 in Italy. Thyroid. 2013 May 13. [Epub ahead of print]
Istituto Superiore di Sanità, Ufficio di Statistica, Rome, Italy ;

Abstract Background: Mortality for thyroid cancer (TC) is low and has been decreasing worldwide; yet few population studies based on mortality have been conducted. Several non-radiation risk factors have been associated with TC, including residence in goiter-endemic areas (as an indicator of iodine deficiency). We used mortality data to perform a spatial-temporal analysis regarding TC in Italy, and investigated the association between mortality and socioeconomic status and geographical features (residing in a mountainous area is a proxy for iodine deficiency). Methods: We analyzed data from Italy's National Mortality Database (1980-2009). To evaluate temporal trends in mortality the age-standardized death rate (ASR) were used; to identify geographic areas with excess deaths due to TC standardized mortality rates (SMR) were calculated. We also calculated the rate ratios (RR) of the ASR and the 95% CI by gender. We performed a cluster analysis to identify municipalities with major departures from expected mortality, both in the entire study period and into two periods to evaluate the spatial-temporal variability. Finally, we evaluated the association between mortality and index of deprivation and altitude. Results: There were 16,473 deaths due to TC (10,690 females, 5783 males. The mean ASR was unsurprisingly low (0.58/100.000). There was a trend of decrease in mortality throughout Italy (-42% for 2007-2009 vs. 1980-1984), more pronounced among women. The decrease was greater in the north. Four geographic clusters were identified when considering the entire study period: two in the north and two in the south; however, the clusters in northern Italy refer to the earlier period (1980-1994) and those in southern Italy to the later period (1995-2009). Mortality was associated with residing in a mountainous area. A slight association with high socioeconomic status was found.

5. Bonaccio M, Di Castelnuovo A, Costanzo S, De Lucia F, Olivieri M, Donati MB, de Gaetano G, Iacoviello L, Bonanni A; Moli-sani Project Investigators. Nutrition knowledge is associated with higher adherence to Mediterranean diet and lower prevalence of obesity. Results from the Moli-sani study. Appetite. 2013 Sep;68:139-46. doi: 10.1016/j.appet.2013.04.026. Epub 2013 May 7.
Laboratory of Genetic and Environmental Epidemiology, Research Laboratories, Fondazione di Ricerca e Cura "Giovanni Paolo II", Largo Gemelli 1, 86100 Campobasso, Italy.

Abstract A Mediterranean dietary pattern has been associated with reducing the risk of cardiovascular and chronic disease. The aim of this study was to evaluate the role of nutrition knowledge in determining possible differences among dietary patterns in a general population from a Mediterranean region. We conducted a cross-sectional study on a subsample of 744 subjects enrolled in the population-based cohort of the Moli-sani Project. A 92-item questionnaire on nutrition knowledge was elaborated, validated and administered. Dietary information were obtained from the EPIC food frequency questionnaire and adherence to a Mediterranean dietary pattern was evaluated both by the a priori Greek Mediterranean diet score and the a posteriori approach obtained by principal component analysis. Nutrition knowledge was significantly associated with higher adherence to a Mediterranean dietary pattern. The odds of having higher adherence to a Mediterranean dietary pattern increased with greater nutrition knowledge. The odds ratio of being obese significantly decreased with increasing nutrition knowledge levels. The results showed that nutrition knowledge was significantly associated with higher adherence to a Mediterranean dietary pattern and with lower prevalence of obesity in a Southern Italian region with Mediterranean diet tradition independently from education and other socioeconomic factors.

6. Cavalieri M. Geographical variation of unmet medical needs in Italy: a multivariate logistic regression analysis. Int J Health Geogr. 2013 May 12;12:27. doi: 10.1186/1476-072X-12-27.
Department of Economic and Business, University of Catania, Corso Italia 55, Catania 95129, Italy.

Abstract BACKGROUND: Unmet health needs should be, in theory, a minor issue in Italy where a publicly funded and universally accessible health system exists. This, however, does not seem to be the case. Moreover, in the last two decades responsibilities for health care have been progressively decentralized to regional governments, which have differently organized health service delivery within their territories. Regional decision-making has affected the use of health care services, further increasing the existing geographical disparities in the access to care across the country. This study aims at comparing self-perceived unmet needs across Italian regions and assessing how the reported reasons - grouped into the categories of availability, accessibility and acceptability - vary geographically. METHODS: Data from the 2006 Italian component of the European Union Statistics on Income and Living Conditions are employed to explore reasons and predictors of self-reported unmet medical needs among 45,175 Italian respondents aged 18 and over. Multivariate logistic regression models are used to determine adjusted rates for overall unmet medical needs and for each of the three categories of reasons. RESULTS: Results show that, overall, 6.9% of the Italian population stated having experienced at least one unmet medical need during the last 12 months. The unadjusted rates vary markedly across regions, thus resulting in a clear-cut north-south divide (4.6% in the North-East vs. 10.6% in the South). Among those reporting unmet medical needs, the leading reason was problems of accessibility related to cost or transportation (45.5%), followed by acceptability (26.4%) and availability due to the presence of too long waiting lists (21.4%). In the South, more than one out of two individuals with an unmet need refrained from seeing a physician due to economic reasons. In the northern regions, working and family responsibilities contribute relatively more to the underutilization of medical services. Logistic regression results suggest that some population groups are more vulnerable than others to experiencing unmet health needs and to reporting some categories of reasons. Adjusting for the predictors resulted in very few changes in the rank order of macro-area rates. CONCLUSIONS: Policies to address unmet health care needs should adopt a multidimensional approach and be tailored so as to consider such geographical heterogeneities.

7. Gorini G, Carreras G, Allara E, Faggiano F. Decennial trends of social differences in smoking habits in Italy: a 30-year update. Cancer Causes Control. 2013 Jul;24(7):1385-91. doi: 10.1007/s10552-013-0218-9. Epub 2013 May 3.
Environmental and Occupational Epidemiology Unit, Cancer Prevention and Research Institute (ISPO), Via delle Oblate 2, 50141, Florence, Italy,

Abstract PURPOSE: To update educational inequalities in smoking in Italy up to 2009, with an in-depth analysis of female prevalence. METHODS: Data from 15 national health surveys (1980, 1983, 1986-1987, 1990, 1994, 1999-2003, 2005-2009) were analyzed. The overall sample size was representative of the population older than 25 years of age (3,300,000 men and 3,620,000 women). Main measures smoking prevalence rates standardized to the 2,000 European population, prevalence ratios by educational level (high: university degree or high school diploma; low: primary or middle school diploma), area (north, center, south and islands), and age-group (25-44, 45-59, >=60 years). Trends in tobacco prevalence were also analyzed with a multivariate approach using the negative binomial distribution. RESULTS: Although male prevalence steadily declined of about 2 % annually from 56.1 % in 1980 to 30.2 % in 2009, educational inequalities slightly widened, recording in 2009 a 53 % higher prevalence in men with low educational level compared to graduates. Even though female prevalence stalled around 18 % in the last three decades, this was the result of opposite trends by educational group. In fact, highly educated women, with the highest prevalence during 1980s, decreased their tobacco use, determining a reversal similar to men in educational inequalities in smoking. This reversal occurred from the 1980s onwards with a time gradient starting from north to south and from younger to older women. CONCLUSION: To achieve a fairer reduction in smoking habits, tobacco control policies focusing on lower social groups are needed.

Breve commento a cura di Chiara Marinacci
Lo studio aggiorna il paper di Faggiano et al. del 2001, con i dati dalle multiscopo Istat fino al 2009; l’aumento delle diseguaglianze nell’abitudine al fumo tra gli uomini e, tra le donne, la transizione del gradiente verso quello maschile (con un ritardo di 2-3 decadi rispetto ai paesi nord-europei) consolidano quanto segnalato in altri recenti studi.

8. Penno G, Solini A, Bonora E, Fondelli C, Orsi E, Zerbini G, Trevisan R, Vedovato M, Gruden G, Laviola L, Nicolucci A, Pugliese G; the Renal Insufficiency And Cardiovascular Events (RIACE) study, group. Gender differences in cardiovascular disease risk factors, treatments and complications in patients with type 2 diabetes: the RIACE Italian multicentre study. J Intern Med. 2013 Apr 9. doi: 10.1111/joim.12073. [Epub ahead of print]
Department of Endocrinology and Metabolism, University of Pisa, Pisa, Italy.

Abstract OBJECTIVES: Poorer control of risk factors for cardiovascular disease (CVD) has been reported in diabetic women, as compared with diabetic men. It has been proposed that this finding is due to gender disparities in treatment intensity. We investigated this hypothesis in a large contemporary cohort of subjects with type 2 diabetes. DESIGN: Observational, cross-sectional study. SUBJECTS AND SETTING: Consecutive patients with type 2 diabetes from the Renal Insufficiency And Cardiovascular Events (RIACE) Italian multicentre study (n = 15 773), attending 19 hospital-based diabetes clinics in 2007-2008. MAIN OUTCOME MEASURES: Traditional CVD risk factors, macro- and microvascular complications and current glucose-, lipid- and blood pressure (BP)-lowering treatments were assessed. RESULTS: Although CVD was more prevalent in men, women showed a less favourable CVD risk profile and worse performance in achieving treatment targets for haemoglobin A1c , LDL, HDL and non-HDL cholesterol, systolic blood pressure (BP) and in particular obesity [body mass index (BMI) and waist circumference], but not for triglycerides and diastolic BP. However, women were more frequently receiving pharmacological treatment for hypertension and to a lesser extent hyperglycaemia and dyslipidaemia than men, and female gender remained an independent predictor of unmet therapeutic targets after adjustment for confounders such as treatments, BMI, duration of diabetes and, except for the systolic BP goal, age. CONCLUSIONS: In women with type 2 diabetes from the RIACE cohort, a more adverse CVD risk profile and a higher likelihood of failing treatment targets, compared with men, were not associated with treatment differences. This suggests that factors other than gender disparities in treatment intensity are responsible.

9. Piovani D, Clavenna A, Bonati M; Interregional Italian Drug Utilisation Group. Collaborators: Bortolotti A, Fortino I, Merlino L, Davoli M, Kirchmayer U, Aquilino A, Bux F, D'Ettorre A, Lepore V. Drug use profile in outpatient children and adolescents in different Italian regions. BMC Pediatr. 2013 Apr 4;13:46. doi: 10.1186/1471-2431-13-46.
Department of Public Health, Laboratory for Mother and Child Health, IRCCS-Istituto di Ricerche Farmacologiche Mario Negri, Milan, 20156, Italy.

Abstract BACKGROUND: Large differences exist in the prevalence rate of drugs prescribed to children and adolescents between and within countries. The aim of this study was to evaluate child and adolescent drug prescription patterns in Italy in an extra-hospital setting at the regional and Local Health Unit (LHU) levels. METHODS: Data sources were three regional prescription databases. Data concerning the year 2008 were evaluated. A total of 3.3 million children and adolescents were included. Drug prevalence and prescription rates were evaluated at the regional and LHU levels. The correlation between mean latitude, average annual income, hospitalisation rate, number of paediatricians per 1,000 resident children, and prevalence rate was evaluated by LHU using a linear multiple regression analysis. RESULTS: Large differences were found across Italian regions and LHUs. The mean prevalence rate was 56.4% (95% CI 56.3-56.5%; 51.2-65.4% among regions) and, at the LHU level, ranged from 43.1% to 70.0% (higher in the South). A total of 878 drugs were prescribed, 175 of which were shared by all LHUs. Amoxicillin clavulanate was the most used drug in all regions and in 31 of 33 LHUs. Amoxicillin was the drug with the highest variability in use between LHUs (9.1-52.1% of treated children). An inverse correlation was found between prevalence rate and both latitude (p < 0.0001) and average annual income (p = 0.0002). CONCLUSIONS: The use of drugs in children and adolescents is higher in southern Italy and is inversely related to latitude and average annual income. More efforts should be devoted to informing physicians, patients and policy makers in order to plan effective initiatives to improve the situation.

10. Federico B, Mackenbach JP, Eikemo TA, Sebastiani G, Marinacci C, Costa G, Kunst AE. Educational inequalities in mortality in northern, mid and southern Italy and the contribution of smoking. J Epidemiol Community Health. 2013 Jul;67(7):603-9. doi: 10.1136/jech-2012-201716. Epub 2013 Apr 17.
Department of Human Sciences, Society and Health, University of Cassino and Southern Lazio, via Sant'Angelo snc, Cassino 03043, Italy;

Abstract BACKGROUND: Previous studies have shown that mortality inequalities are smaller in Italy than in most European countries. This may be due to the weak association between socioeconomic status and smoking in Italy. However, most published studies were based on data from a single city in northern Italy (Turin). In this study, we aimed to assess the size of mortality inequalities in Italy as a whole, their geographical pattern of variation within Italy, and the contribution of smoking to these inequalities. METHODS: Participants in the National Health Interview Survey 1999-2000 were followed up for mortality until 31 December 2007. Using Cox regression, we computed the age-adjusted relative index of inequality (RII) for all-cause mortality with and without controlling for smoking status and intensity. Education was used as an indicator of socioeconomic status. RESULTS: Among 72 762 individuals aged 30-74 years at baseline, 4092 died during the follow-up. The age-adjusted RII of mortality was 1.69 (95% CI 1.44 to 2.00) among men and 1.43 (95% CI 1.13 to 1.82) among women. Among men, inequalities were larger in both northern and southern regions than in the middle of the country, whereas among women they were larger in the south. After controlling for smoking RII decreased to 1.63 (95% CI 1.38 to 1.92) among men and increased to 1.54 (95% CI 1.21 to 1.96) among women. The geographical variation in mortality inequalities was not affected by smoking adjustment. CONCLUSIONS: Mortality inequalities in Italy are smaller than in most European countries. This is due, among other factors, to the weak socioeconomic pattern of smoking over the past decades in Italy.

11. Lenzi M, Vieno A, Santinello M, Perkins DD. How neighborhood structural and institutional features can shape neighborhood social connectedness: a multilevel study of adolescent perceptions. Am J Community Psychol. 2013 Jun;51(3-4):451-67. doi: 10.1007/s10464-012-9563-1.
Department of Developmental and Social Psychology, University of Padova, via Belzoni, 80, 35131 Padua, Italy.

Abstract According to the norms and collective efficacy model, the levels of social connectedness within a local community are a function of neighborhood structural characteristics, such as socioeconomic status and ethnic composition. The current work aims to determine whether neighborhood structural and institutional features (neighborhood wealth, percentage of immigrants, population density, opportunities for activities and meeting places) have an impact on different components of neighborhood social connectedness (intergenerational closure, trust and reciprocity, neighborhood-based friendship and personal relationships with neighbors). The study involved a representative sample of 389 early and middle adolescents aged 11-15 years old, coming from 31 Italian neighborhoods. Using hierarchical linear modeling, our findings showed that high population density, ethnic diversity, and physical and social disorder might represent obstacles for the creation of social ties within the neighborhood. On the contrary, the presence of opportunities for activities and meeting places in the neighborhood was associated with higher levels of social connectedness among residents.

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