Bollettino epidemiologico nazionale

The Practice of Epidemiology in the Italian National Health

Sabrina Ferri, Armando Muzzi

Department of Public Health, University of Tor Vergata, Rome

Italy has a strong tradition of analytic epidemiology and has made landmark contributions in a number of fields. Increasingly, however, there has been a transition in emphasis on the part of health institutions from “classical” epidemiology based on the analysis of the health status of the population through the study of risk factors and disease incidence (1) to the epidemiology of health services. This latter type, which involves both quantitative as well as qualitative methods, studies the functioning of health systems and health services. The goal is to improve the health of the population through the provision of quality health services.

The development of regional health services agencies, followed by the creation in various regions of regional health agencies can be viewed as signs of the changes under way in Italy. This process is also apparent from the transformation and/or integration of some regional epidemiologic observatories, regional epidemiologic systems (as in the Veneto region), and multizonal epidemiologic services (Piedmont) into regional health agencies.

These transformations are not solely semantic but also indicate a change in the function and activities of these structures, often added to their existing functions. To study this transition, we analyzed the functions undertaken by these various types of structures to document whether indeed there has been a real change in the epidemiologic reality of the country, stimulated not only by scientific interests but also by the need to respond to problems limiting the appropriate functioning of the health system.

To analyze the functions of the various structure, information was obtained from the internet site http://camera.mac.ancitel.it combined with a bibliographic search and a search for pertinent legislation, and, where necessary, interviews with regional officials. Nine regions, which had instituted regional health agencies, were considered (Campania, Emilia - Romagna, Friuli-Venezia-Giulia, Lazio, Marche, Piemont, Puglia, Tuscany, and Veneto). This choice was dictated by the need to compare the function of these agencies with those of the regional epidemiologic observatories, which was the main purpose of our analysis.

After analyzing the activities conducted by both types of structures, the functions were classified as “classical epidemiology” and “epidemiology of health services” based on the following definitions:

• Classical epidemiology was considered the branch of public health which studies the frequency and distribution of diseases in the population, their causes, and their associated risk factors, with the objective of improving disease control (2)

• The epidemiology of health services was considered “a multidisciplinary approach, both basic and applied, that concerns the use, costs, quality, accessibility, access, organization, functioning, and outcomes of health services to improve the knowledge and understanding of these services, of the processes and effects of health services on the health of individuals and the population” (3).

The table shows the functions of the two types of epidemiologic structures in the nine regions considered. Only Piedmont, Veneto, and Tuscany had given their regional epidemiology observatories functions related to health services in addition to classical epidemiologic functions; these regions were those who had most recently organized regional observatories, respectively in 1998, 1999, and 2000. Of note, the Friuli-Venezia-Giulia region also had given their observatory some health services functions, even though it had been created in 1986. It can also be seen in the table that the regional health agency of Friuli-Venezia-Giulia and Lazio also carry out functions in “classical” epidemiology since their observatories were suppressed, while the Campania, Emilia-Romagna, Tuscany e Puglia regions, where regional health agencies and observatories were both active, the two types of functions were kept distinct. Overall, these data suggest that the epidemiology of health services has become increasingly important, as demonstrated by the transformation and integration of the regional observatories in the regional health agencies.

These agencies were designed to provide methodologic and support and knowledge to the local health agencies and regional political bodies so that decisions, be they operative or governmental, could be increasingly evidence-based (4). Without abandoning classical epidemiology, which is more used for planning purposes, the study of health services has been added, with the main purpose of conducting evaluations. The institutional changes in the National Health Service can be better realized and obstacles overcome with the assistance of persons skilled in health services research.

Editorial Note

Donato Greco, Laboratory of Epidemiology and Biostatistics, Istituto Superiore di Sanità, Rome

With the recognition of the discipline of “epidemiology” among the professions of the regional health services, an additional step has been made to further affirm the importance of this discipline in our National Health Service. For some time, many local and regional health services have understood the importance of the epidemiologic methods and in a number of different settings, organized epidemiologic structures have been functioning.

The work of Ferri and Muzzi adds to our knowledge of the Italian epidemiolgic network based on its investigation of epidemiologic practices in 9 regions. This work is descriptive, methodologically appropriate, and involved the active collection of data from various sources. The resulting table gives a relatively optimistic view of the functioning of the regional health agencies, with relatively few functional areas left uncovered.

This is a worthwhile study, albeit limited by the number of regions included (ed. note—Italy has 20 regions) and the emphasis only on regional health agencies; in several regions, there are regional epidemiologic observatories integrated in health care structures (Sicily, Calabria, Basilicata, Campania, Umbria), while in others, contracts have been let with (Liguria, Puglia), although some regions (Sardinia, Abruzzo, Molise) remain without specific structures.

Bibliography

1. Fara G M: La programmazione sanitaria nazionale e regionale ed il ruolo dell'U.S.L.. Aspetti epidemiologici e sanitari, l'USL come azienda: processi programmatori e gestionali, SIPIS, 21-22, 1987

2. Weed DL: Theory and Practice in Epidemiology. Ann. NY Acad. Sciences 2001, 954, 52-62.

3. Field MJ, Tranquada RE, and Feasley JF, eds. Health Services Research: Work Force and Educational Issues. National Academy Press: Washington, D.C., 1995.

4. Di Stanislao F, Marcobelli A, Gardini A, Noto G: L'Agenzia regionale sanitaria: strumento di innovazione del sistema sanitario. Tendenze nuove, gennaio/febbraio, 55-58, 2000.