Pneumonia has traditionally been classified into two subtypes: community-acquired pneumonia (CAP) and nosocomial pneumonia (NP). Recently, a new entity has been defined, called healthcare-associated pneumonia (HCAP). Few studies have investigated the potential of population-based, electronic, healthcare databases to identify the incidences of these three subtypes of pneumonia. The aim of this study was to estimate the burden of the three subtypes of pneumonia in elderly patients (aged 65+ years) in a large region of central Italy.

Background. COPD is the fourth leading cause of death in the world. In the case of exacerbations or persistent symptoms, regular treatment with long-acting bronchodilators is recommended to control the symptoms, reduce exacerbations and improve health status. Objectives. To describe patterns of drug utilization among patients diagnosed with COPD, to measure continuity with long-acting bronchodilators, to identify determinants of not receiving long-acting therapy continuously. Methods. We identified a cohort of patients discharged from hospital with diagnosis of COPD between 2006 and 2008. Patients were observed for a two-year follow-up period, starting from the day of discharge. Follow-up was segmented in six-month periods, in order to dynamically evaluate prescription patterns of Long-Acting Beta-Agonists (LABA), tiotropium, and inhaled corticosteroids. Patients with prescriptions for LABA and/or tiotropium in each of the six-month periods were defined as “continuously treated with long-acting bronchodilators.” The degree of drug treatment coverage was measured through the Medication Possession Ratio (MPR). Logistic regression was performed to identify determinants of not receiving long-acting bronchodilators continuously. Results. A total of 11,452 patients diagnosed with COPD were enrolled. Only 34.8% received long-acting bronchodilators continuously. The MPR was greater than 75% in 19.6% of cases. Among the determinants of not receiving long-acting bronchodilators continuously, older age and co-morbidities played an important role. Conclusions. In clinical practice, the COPD pharmacotherapy is not consistent with clinical guidelines. Medical education is needed to disseminate evidence-based prescribing patterns for COPD, and to raise awareness among physicians and patients on the health benefits of an appropriate pharmacological treatment.

Purpose. Chronic therapy with long-acting bronchodilators (LB) is recommended to treat moderate-to-severe COPD. Although the benefits of adding inhaled corticosteroid (ICS) to LB are still unclear, patients who experience repeated exacerbations are suggested to add ICS to their LB treatment. The objective of this study is to analyze whether adding ICS to LB therapy reduces mortality. Methods. We identified a cohort of patients discharged from hospital with COPD diagnosis between 2006 and 2009. The first prescription for LB or ICS following discharge was defined as the index prescription. Only new users were included (no use of any study drug in the 6 months before treatment). A 4-day time window was used to classify patients into “LB alone” or “LB plus ICS” initiators. We used propensity score to balance the study groups. Sensitivity analyses were performed in patients with recent out-of-hospital exacerbations. Results. Among the 18615 adults enrolled, 12207 initiated “LB plus ICS” therapy and 6408 “LB alone.” Crude mortality rates were 110 and 143 cases per 1000 person-years in the “LB plus ICS” and “LB alone” groups, respectively. The adjusted hazard ratio (HR) was 0.83 (95% CI: 0.72–0.97; p-value: 0.024). When analyzing patients with recent out-of-hospital exacerbations, the benefit of the combination therapy was more pronounced, HR = 0.63 (95% CI: 0.44–0.90; p-value: 0.012). Discussion. Our findings showed a beneficial effect on mortality of adding inhaled corticosteroids to long-acting bronchodilators. The advantage was much more pronounced in patients with frequent exacerbations.

Introduction: Despite recommendations from associations of geriatric and psychiatry societies and warnings from drug agencies, antipsychotic (AP) drugs are frequently used to control behavioral and psychological symptoms of dementia. APs are associated with a range of potential adverse events, including increased risk of cerebrovascular events and mortality. Evidence suggests limited efficacy of APs for aggression and psychosis. Our objectives were to investigate patterns and predictors for prescription of APs among older adults with dementia residing in a large region of central Italy, and to identify patient characteristics related to typical or atypical APs prescribing. Methods: This is a retrospective population-based cohort study using data from regional health information systems (HIS). We included dementia patients aged ≥65 years residing in the Lazio region. The exposure was defined as new use vs non-use of APs. Dementia patients with incident use of APs during 2015 were followed-up from the date of first prescription to the earliest among discontinuation of use, death, or end of study (December 31, 2016). Results: We enrolled 24,735 dementia patients, 1727 (6.7%) new users and 23,008 non-users of APs. Forty-four percent of AP users were treated for more than 3 months, and among these about 60% received APs continuously for at least 12 months. Individuals using antidepressant or anti-dementia drugs had higher odds of being prescribed with APs (OR: 1.67 and OR: 1.86, respectively). Patients exposed to polypharmacy were less likely to receive APs (OR: 0.82). Cardiovascular risk factors and comorbidities were not associated with APs use. Low socio-economic position was associated with lower odds of atypical AP prescribing (OR: 0.57). Conclusion: The study showed that a not negligible proportion of patients had a period of AP use longer than recommended by guidelines. We identified socio-demographic and clinical factors associated with first use of APs, providing insight into prescribing practices in a community setting and useful information to address areas of potential inappropriateness.

Inhaled corticosteroid (ICS) use in chronic obstructive pulmonary disease (COPD) patients is associated with a reduction of exacerbations and a potential risk of pneumonia. The objective was to determine if ICS use, with or without long-acting β₂-agonist, increases pneumonia risk in COPD patients. A cohort study was performed using linked hospital and drug prescription databases in the Lazio region. Patients (45+) discharged with COPD in 2006–2009 were enrolled and followed from cohort entry until first admission for pneumonia, death or study end, 31 December, 2012. A nested case-control approach was used to estimate the rate ratio (RR) associated with current or past use of ICS adjusted for age, gender, number of exacerbations in the previous year and co-morbidities. Current users were defined as patients with their last ICS prescribed in the 60 days prior to the event. Past users were those with the last prescription between 61 and 365 days before the event. Current use was classified into three levels (high, medium, low) according to the medication possession ratio. Among the cohort of 19288 patients, 3141 had an event of pneumonia (incidence rate for current use 87/1000py, past use 32/1000py). After adjustment, patients with current use were 2.29 (95% confidence interval [CI]: 1.99–2.63) times more likely to be hospitalised for pneumonia with respect to no use; for past use RR was 1.23 (95% CI: 1.07–1.42). For older patients (80+), the rate was higher than that for younger patients. ICS use was associated with an excess risk of pneumonia. The effect was greatest for higher doses and in the very elderly.

Identifying chronic obstructive disease (COPD) cases is required to estimate COPD prevalence, to enroll COPD cohorts and to estimate air pollution health effects. Administrative health data are frequently used to identify COPD cases, though their validity has not been satisfactorily assessed. This paper aims to assess the contribution of pharmaceutical data in detecting COPD cases and to estimate the reliability of hospital/mortality databases in detecting COPD cases. Prevalent COPD cases among 35-plus-year-olds were estimated in four Italian areas in 2006 from hospital/mortality registries and adding pharmaceutical data. Age-specific and age-standardized prevalence rates were calculated in each area. Internal validity of COPD diagnoses from hospital and mortality databases was assessed. Pharmaceutical database was used to confirm the hospital/mortality COPD cases and to examine the selection and misclassification of hospitalized cases. Possible misclassification between COPD and asthma cases was estimated using hospital data. Prevalent COPD cases were 77,098 from hospital/mortality registries, 172,357 when respiratory prescriptions were added. Prevalence ranged from 4.0%–6.7%. Only 22.7% of pharmaceutical COPD cases were hospitalized or died and only 37.2% of hospital/mortality cases consumed respiratory medicines; this last proportion increased to 64.5% among the older cases with a principal diagnosis. COPD cases with a contemporary asthma diagnosis were 3.1%. We found that pharmaceutical data increases COPD prevalence estimates 2.2–2.5 times. Hospitalization does not necessarily indicate COPD severity, COPD as a principal diagnosis confirmed with medicine prescription more likely represented true cases. Misclassification affects asthma cases to greater extent than COPD cases.