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Background: The combination of atezolizumab-bevacizumab has been proven to be superior to sorafenib for the treatment of unresectable hepatocellular carcinoma not amenable to locoregional treatments, be-coming the standard of care of systemic therapy.Aim: This study aimed at assessing real-world feasibility of atezolizumab-bevacizumab in patients treated with tyrosine-kinase inhibitors.Methods: Among 1447 patients treated with tyrosine-kinase inhibitors from January 2010 to December 2020, we assessed the percentage of those potentially eligible to atezolizumab-bevacizumab (according to IMbrave-150 trial criteria), and the overall survival of eligible and non-eligible patients.Results: 422 (29%) patients were qualified for atezolizumab-bevacizumab therapy. The main exclusion causes were Child-Pugh class and Performance Status. Adopting the more permissive inclusion criteria of SHARP trial, 535 patients became eligible. The median overall survival of tyrosine-kinase inhibitors patients was 14.9 months, longer in eligible patients than in their counterpart due to better baseline liver function and oncological features.Conclusion: Real-world data indicate that less than one-third of hepatocellular carcinoma patients treated with tyrosine-kinase inhibitors are potentially eligible to atezolizumab-bevacizumab according to the reg-istration trial criteria. These patients have a longer survival than the non-eligible ones. If the selection criteria of atezolizumab-bevacizumab trial are maintained in clinical practice, tyrosine-kinase inhibitors will remain the most used systemic therapy for hepatocellular carcinoma patients.(c) 2022 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.

Background: Whether the etiology of underlying liver disease represents a prognostic factor in patients with hepatocellular carcinoma (HCC) treated with lenvatinib is still a matter of debate. This study investigates whether the viral etiology of HCC plays a prognostic role in overall survival (OS). Methods: Data derived from a multicenter series of 313 HCC patients treated with lenvatinib between 2019 and 2022 were analyzed. Actuarial survival estimates were computed using the Kaplan–Meier method and compared with the log-rank test. We performed an event-based counterfactual mediation analysis to estimate direct (chronic inflammation and immunosuppression), indirect (tobacco smoking, alcohol use, illicit drug abuse with injections), and the total effect of viral etiology on OS. Results were expressed as hazard ratio (HR) and 95% CI. Results: Median OS was 21 months (95% CI: 20–23) in the group with other etiologies and 15 months (14–16) in the group with viral etiology (p < 0.0001). The total effect of viral etiology was associated with OS (HR 2.76, 1.32–5.21), and it was mainly explained by the pure direct effect of viral etiology (HR 2.74, 1.15–4.45). By contrast, its total indirect effect was not associated with poorer survival (HR 1.05, 0.82–2.13). These results were confirmed when considering tobacco, alcohol consumption, or injection drug abuse as potential mediators. Median progression-free survival was 9 months (8–10) in patients with other etiologies and 6 months (5–7) in patients with viral etiology (p < 0.0001). No difference in terms of adverse event rate was observed between the two groups. Conclusions: Patients affected by HCC with nonviral etiology treated with lenvatinib exhibit longer survival than those with viral etiology. This finding may have relevance in the treatment decision-making process.

Background: Comprehensive and contemporary data pertaining large populations of patients with Primary Biliary Cholangitis (PBC) and hepatocellular carcinoma (HCC) are missing. Aim: To describe main characteristics and outcome of PBC patients with HCC diagnosed in the new millennium. Methods: Analysing the Italian Liver Cancer registry we identified 80 PBC patients with HCC diagnosed after the year 2000, and described their clinical characteristics, access to treatment and survival. Results: Median age of patients was 71 years and 50.0% were males. Cirrhosis was present in 86.3% of patients, being well-compensated in 58.0%. Median HCC diameter was smaller in patients under surveillance (2.6vs 4.0cm, P=0.007). Curative treatment, feasible in 50.0% of patients, was associated with improved survival compared to palliative and supportive care (42vs 33vs 6 months, P

Introduction: Community hospitals (CHs) could address the emerging complex care needs of patients. We investigated which characteristics of patients’ and CHs affect patient outcomes, in order to identify who could benefit the most from CH care and the best skill mix to deliver this care. Methods: We analysed all elderly patients discharged from the CHs of Emilia-Romagna, Italy. CH skill mix and care processes were collected with an ad hoc survey. The primary outcome was improvement in the Barthel index (BI) on discharge. Hierarchical regression analysis was performed to test the associations under study. Results: 53% of the patients had a BI improvement ≥10. After adjusting for the diverse case mix of the patients, no significant association was found between CH characteristics and BI improvement. Patient characteristics explained only a portion of the variability in CH performance. Discussion: Heterogeneity in case mix reflects the nature of CHs, which play context-specific roles as integrators between primary care services and hospitals. Residual variability in BI improvement rates across CHs might be attributed to aspects of care not detected in our survey. Conclusions: More research is needed to study the impact of CH skill mix and care processes on patient outcomes.

Obeticholic acid (OCA) improves cholestasis and is generally well tolerated in patients with primary biliary cholangitis (PBC) not responding, or intolerant, to ursodeoxycholic acid (UDCA). As PBC is mainly a cholestatic disorder, less attention is paid to aminotransferase behavior in the course of treatment. In this study we evaluated, in clinical practice, the efficacy of OCA treatment on both alkaline phosphatase (ALP) and alanine aminotransferase (ALT) using updated healthy ranges for aminotransferases. Fifteen PBC patients, non-responders to UDCA, were evaluated at baseline and during OCA treatment with serial measurement of cholestasis indexes and ALT, that were also assessed using updated normal ranges (

BackgroundNew organizational models to face the unmet needs of frail patients are needed. Community hospitals (CHs) could foster integration between acute and primary care. The aim of this study was to investigate which patients’ characteristics and which care processes affect clinical outcomes, in order to identify who could benefit the most from CH care.MethodsThis study included all patients aged ≥65 and discharged in 2017 from the 16 CHs of Emilia-Romagna, Italy. Data sources were the regional CH informative system and hospital discharge records. CH skill mix and processes of care were collected with a survey. The study outcome was variation of the Barthel index (BI). We performed a 2-level random-intercept logistic regression analysis, and used the variance partition coefficient (VPC) to quantify the proportion of BI improvement that lay at CH level.ResultsOf the 13 CHs, 8 had a general practitioner medical support model, and 6 had >12 nurses’ working hours/week/bed. Overall, 53% of the patients had a BI improvement ≥10. The patient case mix explained a portion of variability across CHs. Skill mix and processes of care were not associated with BI change.ConclusionsPatients’ characteristics explained part of between-CH variation in BI improvement. Professional skill mix and processes of care, albeit fundamental to achieve appropriate care and respond to the unmet needs of the frail elderly, did not account for differences in CH-specific outcomes.

Si stanno sviluppando a livello internazionale modelli di organizzazione dei servizi cosiddetti di "cure intermedie", per rispondere ai bisogni emergenti rappresentati da invecchiamento, aumento di patologie croniche, multimorbosita e fragilita, per evitare ospedalizzazioni inappropriate e ritardare l’istituzionalizzazione di lungo periodo. Obiettivo dello studio e esaminare il caso di studio della Regione Emilia- Romagna (RER) per meglio definire il ruolo di questi servizi "intermedi" nella filiera della long term care per gli anziani. Sono quindi valutate le dotazioni infrastrutturali e l’utilizzo dei servizi nelle diverse aziende della RER per evidenziare variabilita infra-regionali, principali spill over tra setting assistenziali, aree potenziali di inappropriatezza e gap di servizi. A partire dalle evidenze emerse, vengono proposte suggestioni per un nuovo framework di rappresentazione e pianificazione delle cure intermedie e della filiera in cui collocarle.

Prothrombotic haematological disorders, in particular myeloproliferative disorders, are identified in a significant proportion of patients with Budd-Chiari syndrome and portal vein thrombosis (PVT). Multiple prothrombotic disorders may coexist. PVT is diagnosed in one fourth of patients with cirrhosis and is more common with advanced liver disease and hepatocellular carcinoma. PVT in cirrhosis can precipitate decompensation. Intrahepatic microthrombosis may play a role in the pathogenesis of hepatic fibrosis. Sinusoidal obstruction syndrome is usually a complication of myeloablative treatment before haematopoietic stem cell transplantation. Post-transplant lymphoproliferative disorders can complicate liver transplantation and are related to Epstein-Barr virus infection. Hepatitis B reactivation in patients receiving chemotherapy for haematological malignancies is very common without pre-emptive treatment, and can lead to liver failure. Liver involvement is common in primary haematological diseases, such as haemolytic anaemias, lymphomas and leukaemia.

The serum levels of soluble HLA class I antigens (sHLA-A, -B, -C and sHLA-G) were determined in 40 HCV genotype 1-infected patients before (T 0), after 3, 6, and 12 months (T 3, T 6, and T 12) of pegylated-IFN-α plus ribavirin therapy and 6 months (T 18) after the end of treatment. Twenty patients were sustained virological responders (SVR), and 20 were non-responders (NR). sHLA-A, -B, -C levels at T 0 were significantly higher in both SVR (mean 10.48 μg/ml) and NR (mean 11.87 μg/ml) patients as compared to healthy controls (mean 0.34 μg/ml, p

Summary Background & aims Different neuromuscular functional domains in types I and II Spinal Muscular Atrophy (SMAI and SMAII) could lead to differences in body composition (BC) and resting energy expenditure (REE). Their identification could provide the key to defining appropriate strategies in clinical dietary management, but data comparing SMAI and SMAII in terms of BC and REE are not yet available. We measured total and regional fat (FM), lean (LBM), mineral (BMC) masses, body water (total, intra- and extra-cellular, TBW, ICW, ECW) and REE in a sample of SMAI and II children, matched for age and sex, and also adjusting for body size to compare these features of the two SMA phenotypes. Methods 15 SMAI and 15 SMAII children, (M/F = 9/6 vs 9/6, age 3.6 ± 1.9 vs 3.5 ± 1.8 years, p = 0.99), confirmed genetically, were measured as follows: Anthropometric measurements [Body Weight (BW), Supine Length (SL), Arm Length (AL), Femur Length (FL), Tibia Length (TL)], Dual x-ray Energy Absorptiometry (DEXA) [total and segmental FM, LBM, FFM, and BMC], Bioelectrical impedance (BIA) [TBW, ICW, ECW] and Indirect Calorimetry (REE, respiratory quotients) were collected by the same trained dietician. BW, SL and Body Mass Index (BMI) Z-scores were calculated according to CDC Growth Charts (2000). Results SMA children had high percentages of FM and a lower percentage of TBW and ECW compared to the respective reference values for sex and age, whereas the BMC percentages did not differ, even splitting the two phenotypes. SMA I children had a lower BW and BMI-Z score compared to children with SMA II, but similar total and segmental FM. On the contrary, total FFM and LBM were significantly lower in SMAI (7290.0 ± 1729.1 g vs 8410.1 ± 1508.4 g; 6971.8 ± 1637.1 g vs 8041.7 ± 1427.7 g, p = 0.039, p = 0.037, respectively), particularly at the trunk level. Arm BMC also resulted significantly lower in SMAI. The measured REE values were similar (684 ± 143 kcal/day vs 703 ± 122 Kcal/day p = 0.707) whereas REE per FFM unit was higher in SMA I children than in SMA II (95 ± 12 kcal/FFMkg vs 84 ± 11 kcal/FFMkg p = 0.017). Conclusions This study has shown that BW and BMI Z-score measurements alone can be misleading in assessing nutritional status, particularly in SMAI. The differences between SMAI and II in total and regional BC are related only to FFM, LBM and BMC, and seem to be more linked to the magnitude of neurofunctional impairment rather than to the nutritional status derangement. SMA I and SMA II children can have different energy requirements in relation to their specific BC and hypermetabolism of FFM. Based on these results, our recommendation is to use direct BC and REE measurements in the nutritional care process until SMA-specific predictive equations become available.

Objectives Many studies have investigated multimorbidity, whose prevalence varies according to settings and data sources. However, few studies on this topic have been conducted in Italy, a country with universal healthcare and one of the most aged populations in the world. The aim of this study was to estimate the prevalence of multimorbidity in a Northern Italian region, to investigate its distribution by age, gender and citizenship and to analyse the correlations of diseases. Design Cross-sectional study based on administrative data. Setting Emilia-Romagna, an Italian region with ∼4.4 million inhabitants, of which almost one-fourth are aged ≥65 years. Participants All adults residing in Emilia-Romagna on 31 December 2012. Hospitalisations, drug prescriptions and contacts with community mental health services from 2003 to 2012 were traced to identify the presence of 17 physical and 9 mental health disorders. Primary and secondary outcome measures Descriptive analysis of differences in the prevalence of multimorbidity in relation to age, gender and citizenship. The correlations of diseases were analysed using exploratory factor analysis. Results The study population included 622 026 men and 751 011women, with a mean age of 66.4 years. Patients with multimorbidity were 33.5% in 75 years and >60% among patients aged ≥90 years; among patients aged ≥65 years, the proportion of multimorbidity was 39.9%. After standardisation by age and gender, multimorbidity was significantly more frequent among Italian citizens than among immigrants. Factor analysis identified 5 multimorbidity patterns: (1) psychiatric disorders, (2) cardiovascular, renal, pulmonary and cerebrovascular diseases, (3) neurological diseases, (4) liver diseases, AIDS/HIV and substance abuse and (5) tumours. Conclusions Multimorbidity was highly prevalent in Emilia-Romagna and strongly associated with age. This finding highlights the need for healthcare providers to adopt individualised care plans and ensure continuity of care.

Background To explore parents’ experiences and perceptions on informational, management and relational continuity of care for children with special health care needs from hospitalization to the first months after discharge to the home. Methods Semi-structured interviews and a focus group were carried out to capture parents’ experiences and perceptions. Transcripts were analyzed using a directed approach to the qualitative content analysis. Results 16 families participated to this study: 13 were involved in interviews (10 face-to-face and 3 by phone) and 3 in a focus group, within 1–6 months after discharge from the University Hospital of Bologna (S.Orsola/Malpighi) and from hospitals of Bologna Province. To parents of children with special health care needs, the three domains of continuity of care were relevant in a whole but with different key elements during hospitalization, at discharge and after discharge. Moreover, empowerment emerged from parents’ narratives as essential to help parents cope with the transition from the hospital setting to the new responsibilities connected with the home care of their child. Parent’s perceptions about the family pediatrician concerned his/her centrality in the activation and coordination of the healthcare network. Moreover, parents exhibited different attitudes towards involvement in decision making: some wished and expected to be involved, others preferred not to be involved. Conclusions Care coordination for children with special care needs is a complex process that need to be attended to during the hospitalization phase and after discharge to the community. The findings of this study may contribute to elucidating the perceptions and experiences of parents with children with special health care needs about the continuity of care from hospital to community care. Electronic supplementary material The online version of this article (doi:10.1186/s13052-015-0114-x) contains supplementary material, which is available to authorized users.

Pharmacokinetics and dose-finding studies on sorafenib were conducted on heterogeneous groups of patients with solid tumors. Portal hypertension, gut motility impairment and altered bile enterohepatic circulation may explain different sorafenib toxicological profile in cirrhotic patients. This study evaluated sorafenib plasma concentration in a homogeneous group of cirrhotic patients with hepatocellular carcinoma (HCC). Sorafenib concentrations were determined by liquid chromatography in 12 consecutive patients. Data have been evaluated by the generalized estimating equations method (p value statistical level was set at α = 0.05). (1) There were not significant differences between sorafenib concentrations in patients who tolerate the full dose versus patients with reduced dose due to toxicity; (2) the average sorafenib concentrations measured 3 h after the morning dosing were lower than those measured 12 h after the evening dosing (p = 0.005); (3) sorafenib concentrations decrease overtime (p 10(-4)); (4) it has been found an association between the development of severe adverse reactions and sorafenib concentrations (p 10(-5)). The relationship between dose and concentration of sorafenib in HCC patients is poor and not clinically predictable, confirming the variability both in the maximum tolerated dose and in plasma concentrations. Several factors may influence the pharmacokinetics in patients with liver disease. This may explain the inter-patient variability of concentrations and the lack of differences in concentration at different dosages. It could be interesting to extend the series of HCC patients to enhance information on the kinetics of the drug; furthermore, to establish a threshold of plasma sorafenib concentrations to predict severe adverse reactions would be clinically useful.

In a complex, global, multicultural and post-modern society such as the contemporary one, the concepts of "democracy", citizenship "and" training” are undergoing a more urgent and necessary rethinking, which is tracing more and more constant new variations, contaminations and interconnections. On the one hand citizenship has become today active and participatory, as today it can be exercised. On the other hand, volunteering can be a response to the need for participation claimed by contemporary societies: the donation of blood, a particular declination of the traditional concept of gift, is seen as an opportunity to participate in community life and to exercise active and responsible citizenship. From this point of view, the subject is the main actor and protagonist of contemporary processes, and must be trained in understanding the complexity of the notion of citizenship.In una societa complessa, globale, multiculturale e postmoderna come quella contemporanea, i concetti di “democrazia”, cittadinanza” e “formazione” stanno andando incontro ad un ripensamento quanto piu urgente e necessario, che ne sta tracciando declinazioni nuove e soprattutto intrecci ed interconnessioni sempre piu costanti. Se da una parte la cittadinanza si fa, oggi, cittadinanza attiva, partecipata e tale solo in virtu della possibilita di essere esercitata, dall’altra il volontariato puo costituire una risposta al bisogno di partecipazione reclamato dalle societa contemporanee: la donazione del sangue, particolare declinazione del concetto tradizionale di dono, viene vista come occasione di partecipazione alla vita della comunita e di esercizio di cittadinanza attiva e responsabile. In questo panorama il soggetto, attore principale e protagonista dei processi contemporanei, deve essere formato alla comprensione della complessita della nozione di cittadinanza.

Background The rising prevalence of chronic diseases and management of multimorbidity represent a main challenge for health care systems worldwide, as it correlates with high use of health services resources over time. Prevalence estimates of multimorbidity vary widely among countries, as neither a widely accepted definition has been stated nor standard approach for measuring the phenomenon has been established so far. The aim of this study was to describe the prevalence of multimorbidity in Emilia-Romagna region (Northern Italy). Methods Multimorbidity was defined as the presence of two or more chronic conditions. To assess multimorbidity, patients (aged ≥ 18 years) were classified according to Charlson's algorithm, integrated with some categories retrieved from Elixhauser's list. The prevalence of multimorbidity was calculated using information on hospitalizations and drug therapies retrieved from administrative databases between 2008 and 2012. Results From 2008 to 2012, 905707 persons living in Emilia-Romagna region had one chronic condition (prevalence of 24.4%), whereas 604856 had multimorbidity (prevalence of 16.3%). The prevalence of multimorbidity was higher in men and increased with age: by age 60 years, half of the population had at least one chronic disease, and by the age 70 years 30% had multimorbidity. The most prevalent chronic condition was hypertension (35.6%), followed by diabetes (7.6%), cancer (4.9%), stroke (4.0%) and heart failure (3.4%). The prevalence of one chronic disease and that of multimorbidity was lower in immigrants than in Italian citizens, probably due to a “healthy immigrant effect”. However, in immigrants the age-standardized prevalence of multimorbidity was higher than the prevalence of one chronic disease. Conclusions Multimorbidity occurred in a high percentage of Emilia-Romagna population, especially in the elderly. The analysis also revealed a different prevalence of multimorbidity by citizenship, implying a different burden of health care by citizenship and suggesting that more efforts are needed to guarantee migrant-sensitive health care. Future perspectives include retrieving information on mental health, to provide a strong evidence base for the care and management of patients with multimorbidity.

Background Various studies indicate that inter-hospital comparisons have to take case mix into account and that risk adjustment procedures are necessary to control for potential predictors of cesarean delivery (CD). Different data sources have been used to retrieve information on potential predictors of CD. The aim of this study was to compare the discrimination capacity and fit of predictive models of CD created using different sources and to assess whether more complex models improve inter-hospital comparisons. Methods We created 4 predictive models of CD. One model included only variables from Hospital Discharge Records of the index hospitalization, one included also information from previous hospitalizations, one also clinical variables from birth certificates (BC) and one also socio-demographic variables. We compared the four models using the Receiver Operator Curve and the Akaike and Bayesian Information Criteria. Results Information from Birth Certificates improved the discrimination and model fit. Adding socio-demographic variables or past comorbidities did not improve the discrimination capacity or the model fit. Hospital-specific CD resulting from the models were highly correlated. Conclusions Record linkage improves the performance of the models but does not affect inter-hospital comparisons.

OBJECTIVES: Prognosis for patients with cirrhosis admitted to intensive care unit (ICU) is poor. ICU prognostic models are more accurate than liver-specific models. We identified predictors of mortality, developed a novel prognostic score (Royal Free Hospital (RFH) score), and tested it against established prognostic models and the yet unvalidated Chronic Liver Failure-Sequential Organ Failure Assessment (CLIF-SOFA) model. METHODS: Predictors of mortality were defined by logistic regression in a cohort of 635 consecutive patients with cirrhosis admitted to ICU (1989–2012). The RFH score was derived using a 75% training and 25% validation set. Predictive accuracy and calibration were evaluated using area under the receiver operating characteristic (AUROC) and goodness-of-fit χ2 for the RFH score, as well as for SOFA, Model for End-Stage Liver Disease (MELD), Acute Physiology and Chronic Health Evaluation (APACHE II), and Child-Pugh. CLIF-SOFA was applied to a recent subset (2005–2012) of patients. RESULTS: In-hospital mortality was 52.3%. Mortality improved over time but with a corresponding reduction in acuity of illness on admission. Predictors of mortality in training set, which constituted the RFH score, were the following: bilirubin, international normalized ratio, lactate, alveolar arterial partial pressure oxygen gradient, urea, while variceal bleeding as indication for admission conferred lesser risk. Classification accuracy was 73.4% in training and 76.7% in validation sample and did not change significantly across different eras of admission. The AUROC for the derived model was 0.83 and the goodness-of-fit χ2 was 3.74 (P=0.88). AUROC for SOFA was 0.81, MELD was 0.79, APACHE II was 0.78, and Child-Pugh was 0.67. In 2005–2012 cohort, AUROC was: SOFA: 0.74, CLIF-SOFA: 0.75, and RFH: 0.78. Goodness-of-fit χ2 was: SOFA: 6.21 (P=0.63), CLIF-SOFA: 9.18 (P=0.33), and RFH: 2.91 (P=0.94). CONCLUSIONS: RFH score demonstrated good discriminative ability and calibration. Internal validation supports its generalizability. CLIF-SOFA did not perform better than RFH and the original SOFA. External validation of our model should be undertaken to confirm its clinical utility.

Background In patients with chronic hepatitis C virus (HCV) infection, the presence of peripheral blood cytopaenia may represent an obstacle to pegylated interferon and ribavirin treatment. Aims To evaluate the prevalence of anaemia, neutropaenia and thrombocytopaenia potentially limiting initiation of pegylated interferon and ribavirin treatment in patients with chronic HCV infection who were otherwise eligible for antiviral therapy. Methods We studied 3059 consecutive anti-HCV and HCV-RNA positive patients referred to our centre to be evaluated for antiviral therapy from June 2002 to May 2011. The European Association for the Study of Liver HCV guidelines were applied to assess eligibility for antiviral therapy. Results In the study cohort, 1,521 patients (49.7%) were not eligible for treatment because of reasons different from haematological abnormalities. In the remaining 1,538 patients the overall prevalence of any peripheral blood cytopaenia potentially preventing patients from being treated with antiviral therapy was 15.1%. In particular, anaemia (haemoglobin level

to compare trends in infant, neonatal and post-neonatal mortality in Italy from 1991 to 2005 both at the national level and among the three Italian large geographical macro-areas (North, Center, South-Islands).observational study based on routine data.the analysis was performed on the cohort of newborns (up to the first age of life) in Italy from 1991 to 2005.infant, neonatal and post-neonatal mortality rate calculated for 3-year and 5-year periods, relative risks, attributable fraction.during the study period infant mortality rates significantly decreased from 7.72 to 3.91 per 1,000 births, neonatal mortality rates from 5.87 to 2.84 per 1,000 births, and postneonatal mortality rates from 1.85 to 1.08. Despite these significant reductions, important disparities persist in different geographical areas within Italy. In particular, rates appears to be much higher in the southern regions of the country: during the period 2001-2005 the excess of mortality in the South comparing with the North was 37%. Since 1998, following a change in legislation, individual matching of Certificates of Delivery Care (CedAP) and Death Certificates during the first year of life, at a national level, is not possible.during the period 1991-2005 Italy experienced significant infant mortality reduction, but important geographical disparities still remain. In order to investigate these disparities and the determinants of infant mortality in Italy, the lack of routine data could represent an important limit to conduct update epidemiologic studies.

BACKGROUND: Caesarean delivery (CD) rates have been frequently used as quality measures for maternity service comparisons. More recently, primary CD rates (CD in women without previous CD) or CD rates within selected categories such as nulliparous, term, cephalic singleton deliveries (NTCS) have been used. The objective of this study is to determine the extent to which risk adjustment for clinical and socio-demographic variables is needed for inter-hospital comparisons of CD rates in women without previous CD and in NTCS deliveries. METHODS: Hospital discharge records of women who delivered in Emilia-Romagna Region (Italy) from January, 2007 to June 2009 and in Tuscany Region for year 2009 were linked with birth certificates. Adjusted RRs of CD in women without a previous Caesarean and NTCS were estimated using Poisson regression. Percentage differences in RR before and after adjustment were calculated and hospital rankings, based on crude and adjusted RRs, were examined. RESULTS: Adjusted RR differed substantially from crude RR in women without a previous Caesarean and only marginally in NTCS group. Hospital ranking was markedly affected by adjustment in women without a previous CD, but less in NTCS. CONCLUSION: Risk adjustment is warranted for inter-hospital comparisons of primary CD rates but not for NTCS CD rates. Crude NTCS CD rates are a reliable estimate of adjusted NTCS CD.

BACKGROUND: Caesarean section (CS) rate is a quality of health care indicator frequently used at national and international level . The aim of this study was to assess whether adjustment for Robson's Ten Group Classification System (TGCS), and clinical and socio-demographic of the mother and the fetus is necessary for inter-hospital comparisons of CS rates. METHODS: The study population includes 64,423 deliveries in Emilia-Romagna between January 1, 2003 and December 31, 2004, classified according to theTGCS. Poisson regression was used to estimate crude and adjusted hospital relative risks of CS compared to a reference category. Analyses were carried out in the overall population and separately according to the Robson groups (groups I, II, III, IV and V-X combined). Adjusted relative risks (RR) of CS were estimated using two risk-adjustment models; the first (M1) including the TGCS group as the only adjustment factor; the second (M2) including in addition demographic and clinical confounders identified using a stepwise selection procedure. Percentage variations between crude and adjusted RRs by hospital were calculated to evaluate the confounding effect of covariates. RESULTS: The percentage variations from crude to adjusted RR proved to be similar in M1 and M2 model. However, stratified analyses by Robson's classification groups showed that residual confounding for clinical and demographic variables was present in groups I (nulliparous, single, cephalic, [greater than or equal to]37 weeks, spontaneous labour) and III (multiparous, excluding previous CS, single, cephalic, [greater than or equal to]37 weeks, spontaneous labour) and IV (multiparous, excluding previous CS, single, cephalic, [greater than or equal to]37 weeks, induced or CS before labour) and to a minor extent in groups II (nulliparous, single, cephalic, [greater than or equal to]37 weeks, induced or CS before labour) and IV (multiparous, excluding previous CS, single, cephalic, [greater than or equal to]37 weeks, induced or CS before labour). CONCLUSIONS: The TGCS classification is useful for inter-hospital comparison of CS section rates, but residual confounding is present in the TGCS strata.

Background Improving health care for chronic health conditions is a major goal of contemporary health service delivery systems. To date, the main research focus has been on adults and elderly, while fewer attention has been focused on newborns and children with chronic health conditions. To address the challenges related to the provision of integrated care to children with special health care needs, the Special Needs Kids (SpeNK) project was carried out in Emilia-Romagna Region. The specific aims of this study were: to review the ongoing sheltered discharge procedures, to develop and test instruments to assess the families’ perspective on the continuity of care and to estimate the time devoted by the family pediatrician to care coordination activities. Materials and methods The SpeNK project is still ongoing. After reviewing the procedures implemented in the Local Health Authorities of the study area, 10 face-to-face, 3 telephone semi-structured interviews and a focus group with the families at 1-6 months from discharge were conducted by a psychologist. A 20-item questionnaire on continuity of care was then developed, based on the contents of the interview and on Haggerty’s constructs of informational, management and relational continuity. The questionnaire was validated on 102 parents of preterm newborns and then administered by phone to the families of children enrolled in the SpeNK study after 9 months from discharge. Results A qualitative analysis of the contents of the semi-structured interviews revealed that families underscored the importance of informational continuity among hospital clinicians and across health care services, set a high value on the information/training received during the hospital stay of children and at discharge, and exhibited a mixed attitude towards involvement in the health care decisions. Examination of the structure of the questionnaire using factor analysis with oblique rotation identified 5 factors accounting for 61.1% of the variance of items. The factors identified can be interpretable as ‘management continuity’ , ‘informational continuity’ ‘trustful relation with the family pediatrician’, ‘information provided to families’ and ‘family empowerment’. Conclusions The preliminary results of the qualitative analysis of the semi-structured interviews suggest the relevance to the families of the hospital experience and some criticalities in the informational continuity among professionals. The questionnaire on continuity of care has a well-defined structure and can be a useful tool to capture problems related to informational continuity and to the interaction of families with the professionals involved in the care of children with special care needs.

Il numero di parti effettuati con taglio cesareo (TC) è un fenomeno sanitario in continuo aumento in molti paesi del mondo, nonostante questo incremento non sia associato a miglioramenti nella mortalità e morbidità materna e perinatale. In Italia il ricorso alla pratica del TC ha raggiunto livelli allarmanti, sia per il numero di interventi effettuati sia per la variabilità rilevata tra le diverse regioni e aziende sanitarie. Sulla base di queste considerazioni, il Sistema Nazionale per le Linee Guida dell’Istituto Superiore di Sanità (SNLG-ISS) ha sviluppato raccomandazioni per la pratica clinica relativamente al ricorso al TC. La Linea Guida è stata pubblicata nel Gennaio 2010. La riduzione del numero di TC rimane tra gli obiettivi individuati dal Documento preliminare informativo sui contenuti del nuovo Piano sanitario nazionale 2010-2012. L’indicatore più frequentemente utilizzato per la valutazione dei servizi ostetrici è la proporzione totale di parti cesarei. Nel 2008 la proporzione italiana di TC totali è pari al 39.19%, mostrando una certa tendenza alla stabilizzazione o alla riduzione nella maggior parte delle regioni. Tale tendenza è legata ad una riduzione della proporzione di TC primari, accompagnata però da un aumento della proporzione di TC ripetuti. Poiché ad un TC primario seguirà, con una probabilità molto elevata, un TC ripetuto, nonostante dal 2007 al 2008 si osservi una riduzione nel numero di TC primari, la proporzione di TC ripetuti è ancora in aumento, mentre il numero complessivo di TC è in via di stabilizzazione. Continua ad essere importante, pertanto, tenere distinti i due indicatori (TC primari e TC ripetuti) nei confronti tra regioni e concentrarsi sull’individuazione dei determinanti, clinici e non clinici, dei TC primari.