Epidemiolgia (Basel, Switzerland)最新文献

{"title":"Infodemiology of West Nile Virus in Greece, 2024-2025, with Descriptive One Health Preparedness Evidence from Crete.","authors":"Antonios Papadakis, Eleftherios Koufakis, Sandra Gewehr, Spiros Mourelatos, Elias Ath Chaidoutis, George Pitsoulis, Apostolos Kamekis, Areti Lagiou","doi":"10.3390/epidemiologia7040102","DOIUrl":"10.3390/epidemiologia7040102","url":null,"abstract":"<p><strong>Background/objectives: </strong>West Nile virus (WNV) is a persistent mosquito-borne threat in Greece. This study examined whether online information-seeking patterns reflected official WNV surveillance during 2024-2025, with Crete providing descriptive field-level One Health preparedness context.</p><p><strong>Methods: </strong>Official national surveillance data were compared with country-level Google Trends relative search volume and Greek-language Wikipedia pageviews, focusing on weekly locally acquired West Nile neuroinvasive disease/central nervous system (WNND/CNS) cases. The Crete component separately summarized regional One Health preparedness.</p><p><strong>Results: </strong>Greece reported 220 locally acquired WNV cases (157 WNND/CNS) in 2024 and 96 (76 WNND/CNS) in 2025. Wikipedia pageviews showed the strongest full-year associations with WNND/CNS activity when pageviews followed cases by one week (2024: Spearman rho = 0.802; 2025: rho = 0.763; both <i>p</i> < 0.001). Google Trends showed weaker associations at the same lag (2024: rho = 0.402, <i>p</i> = 0.003; 2025: rho = 0.452, <i>p</i> < 0.001). Transmission-period sensitivity analyses attenuated several associations: the 2025 Wikipedia associations and the Google Trends associations in both years were not statistically significant. The first-difference lag analysis identified no leading digital signal.</p><p><strong>Conclusions: </strong>Wikipedia showed more stable language-specific temporal concordance with national surveillance than Google Trends. However, the digital indicators reflected concurrent or lagging public attention and did not demonstrate predictive capacity. The Crete component separately illustrates how regional One Health preparedness complements national surveillance and risk communication.</p>","PeriodicalId":72944,"journal":{"name":"Epidemiolgia (Basel, Switzerland)","volume":"7 4","pages":""},"PeriodicalIF":2.2,"publicationDate":"2026-07-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13397845/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148581401","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Unrecognized Dengue Transmission in Socially Vulnerable Peri-Urban Neighborhoods of a Temperate Argentine City: Integrating Serology with Knowledge, Attitudes, and Practices.","authors":"Diego A Mendicino, Tamara Ricardo, Maximiliano A Cristaldi, Mariana Maglianese, Gastón Guzmán, Sebastián Claussen, Romina Chiaraviglio, Federico Costa, Christian A Avalos, M Andrea Previtali","doi":"10.3390/epidemiologia7040099","DOIUrl":"10.3390/epidemiologia7040099","url":null,"abstract":"<p><p><b>Background/Objectives:</b> Dengue is an emerging arboviral disease in temperate South America, where urban expansion, climate variability, and social vulnerability favor transmission. In Argentina, the endemic circulation of dengue was established in the late 1990s and outbreaks are reported every three or four years. <b>Methods:</b> This cross-sectional study assessed dengue virus (DENV) seropositivity and associated sociodemographic, environmental, and knowledge-attitudes-practices (KAPs) factors in three socioeconomically vulnerable peripheral neighborhoods of Santa Fe, Argentina, between December 2019 and March 2020. <b>Results:</b> A total of 188 adults were surveyed and tested for anti-DENV IgG using ELISA. KAPs questionnaires and direct peridomiciliary observations were used to characterize exposure contexts. Apparent seropositivity was 16.5%, with an adjusted estimate of 10.7% after accounting for test performance, indicating substantial unrecognized DENV circulation. Most seropositive individuals had no previous dengue diagnosis, highlighting underdetection likely related to asymptomatic infections, limited healthcare access, or surveillance gaps. Although dengue awareness was high (98.4%), knowledge was often incomplete and was weakly correlated with preventive practices, suggesting that awareness alone does not translate into effective risk reduction under structural constraints. In multivariate analysis, living farther from vacant lots was associated with higher odds of seropositivity, consistent with transmission concentrated in denser urban settings. <b>Conclusions:</b> Integrating serology with KAPs surveys provides critical insights into hidden transmission and supports targeted surveillance and public health interventions in vulnerable urban settings.</p>","PeriodicalId":72944,"journal":{"name":"Epidemiolgia (Basel, Switzerland)","volume":"7 4","pages":""},"PeriodicalIF":2.2,"publicationDate":"2026-07-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13397892/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148581350","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Combustible Cigarette Smoking, Electronic Cigarette Use, and Metabolic Syndrome in a Working Population.","authors":"Astrid Lorena Urbano Cano, Rosa Elvira Alvarez Rosero, Nelson Esteban Portuguez Jaramillo, Jose Luis Piñeros-Alvarez","doi":"10.3390/epidemiologia7040100","DOIUrl":"10.3390/epidemiologia7040100","url":null,"abstract":"<p><strong>Background: </strong>Metabolic syndrome is a major public health concern because of its association with cardiovascular disease and type 2 diabetes. Tobacco exposure, including combustible cigarette smoking and electronic cigarette use, has increasingly been linked to cardiometabolic dysfunction; however, evidence in occupational populations remains limited.</p><p><strong>Objectives: </strong>This study evaluated the association of combustible cigarette smoking, electronic cigarette use, and dual use with metabolic syndrome in a working population from southwestern Colombia.</p><p><strong>Methods: </strong>We conducted a cross-sectional study of 822 workers from formal companies. Tobacco exposure was self-reported and categorized as exclusive electronic cigarette use, exclusive combustible cigarette smoking, dual use, or non-use. Sociodemographic, anthropometric, and metabolic variables were collected using standardized procedures. Logistic regression models were fitted to estimate crude and adjusted odds ratios with 95% confidence intervals.</p><p><strong>Results: </strong>Metabolic syndrome was identified in 39.8% of participants. It was more frequent in men, who also exhibited a greater accumulation of metabolic abnormalities. Hypertriglyceridemia and low high-density lipoprotein cholesterol were the components most strongly associated with metabolic syndrome. Compared with non-use, the odds of metabolic syndrome were higher across all tobacco-exposed groups, with odds ratios of 3.02 for exclusive electronic cigarette use, 7.29 for exclusive combustible cigarette smoking, and 4.75 for dual use. The strongest association was observed for exclusive combustible cigarette smoking.</p><p><strong>Conclusions: </strong>Metabolic syndrome was prevalent in this occupational population, and tobacco-related exposures were associated with a less favorable cardiometabolic profile. These findings support integrated workplace prevention strategies that combine smoking control with early detection of metabolic risk.</p>","PeriodicalId":72944,"journal":{"name":"Epidemiolgia (Basel, Switzerland)","volume":"7 4","pages":""},"PeriodicalIF":2.2,"publicationDate":"2026-07-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13398340/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148581297","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Determinants of Oral Health System Effectiveness for Preschool Children in Decentralized Child Development Centres: A Cross-Sectional Study in Northeastern Thailand.","authors":"Somporn Keawtong, Chanwit Maneenin, Adisorn Wongkongdech, Niruwan Turnbull","doi":"10.3390/epidemiologia7040098","DOIUrl":"10.3390/epidemiologia7040098","url":null,"abstract":"<p><strong>Background: </strong>Early childhood oral health remains a major public health concern in Thailand despite the implementation of preventive oral health programs. Understanding the factors influencing oral health care system effectiveness is essential for improving oral health outcomes among preschool children. This study aimed to assess oral health care system factors and identify determinants associated with the effectiveness of oral health care services for preschool children in child development centres under local administrative organizations in Ubon Ratchathani Province, Thailand.</p><p><strong>Methods: </strong>A cross-sectional analytical study was conducted among 270 stakeholders involved in the preschool oral health care system, including administrators, teachers, health professionals, village health volunteers, and parent representatives. Data were collected using a structured questionnaire developed based on the Input-Process-Output framework. Oral health outcome data were obtained from routine dental examination records of 498 preschool children. Descriptive statistics, Pearson's correlation analysis, and multiple linear regression were used to analyse the data.</p><p><strong>Results: </strong>Overall oral health care system effectiveness was rated at a high level (mean = 4.01, SD = 0.44). Service delivery processes showed the highest mean score (mean = 4.19, SD = 0.39), while monitoring and evaluation activities demonstrated the lowest performance. The prevalence of dental caries among preschool children was 57.83%. Multiple linear regression analysis identified service delivery processes (β = 0.239, <i>p</i> < 0.001) and home visits by public health and dental personnel (β = 0.165, <i>p</i> = 0.006) as significant predictors of oral health care system effectiveness. The final model explained 11.1% of the variance in system effectiveness (R² = 0.111, <i>p</i> < 0.001).</p><p><strong>Conclusions: </strong>The effectiveness of oral health care systems for preschool children was primarily influenced by the quality of service delivery processes and community-based outreach activities. These findings indicate that strengthening service implementation and home-visit programs may enhance oral health system effectiveness in child development centres operating within decentralized local government settings.</p>","PeriodicalId":72944,"journal":{"name":"Epidemiolgia (Basel, Switzerland)","volume":"7 4","pages":""},"PeriodicalIF":2.2,"publicationDate":"2026-07-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13398169/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148581272","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Ambient Air Pollution and Asthma-Coded Hospital Admission Rates in Children Aged 0-3 Years in Spain: A Municipality-Year Urban-Rural Ecological Study.","authors":"Laura Sánchez de Prada, Daniel Vélez-Serrano, Alejandro Alvaro-Meca","doi":"10.3390/epidemiologia7040097","DOIUrl":"10.3390/epidemiologia7040097","url":null,"abstract":"<p><p><b>Background/Objectives:</b> Asthma-coded hospital admissions in very young children represent a clinically relevant but diagnostically complex marker of severe wheezing/asthma-like morbidity. <b>Methods:</b> We conducted a nationwide ecological municipality-year study of children aged 0-3 years in Spain during 2020-2022 using hospital discharge records from the Spanish Minimum Basic Data Set (MBDS/RAE-CMBD). Exposure and outcome were analyzed at the municipality-year level: the exposure metric was the contemporaneous annual mean municipality-level concentration of PM_2.5, PM₁₀, NO₂, SO₂, O₃, and CO, and the outcome was the annual number of asthma-coded admissions, with the population aged 0-3 years as offset. <b>Results:</b> The regression panel comprised 20,746 municipality-year observations, 7251 municipalities, and 3231 admissions; 93.7% of municipality-years had zero admissions. In unipollutant Poisson models adjusted for calendar year, rural-urban status, temperature, and relative humidity, incidence rate ratios per interquartile-range increase were 1.54 (95% CI 1.28-1.85) for PM_2.5 and 1.89 (95% CI 1.59-2.26) for PM₁₀. Negative-binomial and province-fixed-effect sensitivity models attenuated but did not remove the particulate-matter signal. The multipollutant model was unstable because of strong collinearity between particulate fractions and was interpreted only as an exploratory sensitivity analysis. <b>Conclusions:</b> These findings should be interpreted as ecological, population-level associations between annual ambient particulate pollution and pediatric respiratory hospital burden, not as individual-level causal risk estimates.</p>","PeriodicalId":72944,"journal":{"name":"Epidemiolgia (Basel, Switzerland)","volume":"7 4","pages":""},"PeriodicalIF":2.2,"publicationDate":"2026-07-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13397977/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148581335","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Short Sickness Absenteeism Rate in a Large Tertiary Hospital: The Role of Fitness for Work and Influenza Vaccination.","authors":"Alberto Lontano, Luca Inguaggiato, Daniele Ceriotti, Riccardo Rescinito, Enrico Oddone, Stefano M Candura, Matteo Ratti","doi":"10.3390/epidemiologia7040096","DOIUrl":"10.3390/epidemiologia7040096","url":null,"abstract":"<p><p><b>Background:</b> Sickness absenteeism has long been an organizational problem due to the consequent loss of productivity (1-2% of gross domestic product in European Union countries) and job overload for workers. We designed and conducted an observational cohort study to describe and analyze the short sickness events and their derived absence days in a large university tertiary hospital, also incorporating the fit for work assessment and the anti-influenza vaccination coverage. <b>Materials and Methods:</b> The anonymous data of workers with at least one day of certified presence during the period 1 January-31 August 2025 were extracted from the hospital information system. Crude and job-specific absence rates were calculated. The incidence rate ratios (IRRs) along with their 99% confidence intervals for the covariates were obtained by a negative binomial model fit. <b>Results:</b> The overall sickness event rate was 0.54 per 100 person-workdays, ranging from 0.22 (physicians) to 0.92 (technical/administrative staff), while the overall sickness day rate was 0.88 per 100 person-workdays, spanning from 0.31 (physicians) to 1.41 (health and social care assistants). The multi-variable model fit of sickness days returned significant IRRs for being vaccinated (0.74; 99% CI: 0.58-0.93), for male gender (0.77; 99% CI: 0.63-0.95) and for limitations regarding the fitness for work assessment (2.14; 99% CI: 1.51-3.05). <b>Conclusions:</b> Our findings indicate that, in a large tertiary university hospital, an anti-influenza vaccination campaign may effectively protect workers from sickness absences, even accounting for gender, age and regardless of job typology and fit for work assessment. Furthermore, the health risk of the technical/administrative job category might be underestimated. Finally, our results seem to suggest that workers with limitations might be \"fragile\", or more vulnerable, than expected in a broader sense of the term, both from nosological and temporal points of view. Further research with a higher level of evidence is needed to verify and confirm these findings.</p>","PeriodicalId":72944,"journal":{"name":"Epidemiolgia (Basel, Switzerland)","volume":"7 4","pages":""},"PeriodicalIF":2.2,"publicationDate":"2026-07-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13397925/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148581404","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Beyond 42 Days: A National Cohort Study of Maternal and Late Maternal Deaths in Brazil from 2010 to 2023.","authors":"Gustavo Gonçalves Dos Santos, Elizabeth Mollard, Rita Pace Parascandalo, Sithokozile Maposa, Andrew Muriuki, Ricardo José Oliveira Mouta, Karina Franco Zihlmann, Carolliny Rossi de Faria Ichikawa, Cindy Ferreira Lima, Cesar Henrique Rodrigues Reis, Maria João Jacinto Guerra, Júlia Maria das Neves Carvalho, Ana Cristina Ribeiro da Fonseca Dias, Maria Luísa Santos Bettencourt, Cely de Oliveira, Bruna Feichas Renó, Eneida Tramontina Cerqueira, Katucha Rocha de Almeida Farias","doi":"10.3390/epidemiologia7040094","DOIUrl":"10.3390/epidemiologia7040094","url":null,"abstract":"<p><p>Maternal mortality is a serious public health problem and reflects social, ethnic, racial, and regional inequalities in access to and quality of obstetric care. Despite advances in the surveillance and investigation of maternal deaths in Brazil, late maternal deaths (occurring between 43 days and 1 year after birth) are still underestimated and underexplored. Therefore, the objective of this study was to analyze the distribution and factors associated with maternal deaths and late maternal deaths in Brazil between 2010 and 2023. This was a population-based, retrospective cohort study with a quantitative approach, using secondary data from the Mortality Information System. All maternal deaths (Chapter XV of ICD-10) and late deaths recorded during the period were included. Sociodemographic, clinical, and administrative variables were analyzed. Statistical tests of association (chi-square, test of proportions, and 95% CI) were used, with a significance level of 5%. A total of 26,953 deaths were identified, of which 24,387 were maternal and 2566 were late deaths. Most deaths occurred among single, mixed-race women with 8 to 11 years of schooling, and residing in the Southeast region. Late deaths were more frequent in the South and among women aged 40 to 49. The main causes were direct obstetric conditions. A statistically significant association was observed between the type of death and sociodemographic variables. The results highlight structural inequalities in maternal mortality in Brazil and reinforce the importance of expanding postpartum surveillance beyond 42 days, with a focus on equity and continuity of care.</p>","PeriodicalId":72944,"journal":{"name":"Epidemiolgia (Basel, Switzerland)","volume":"7 4","pages":""},"PeriodicalIF":2.2,"publicationDate":"2026-07-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13398290/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148581285","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Mumps Vaccination Policies and Epidemiological Consequences: A Comparative Review of the United States and Japan.","authors":"Naruhito Otani, Masaki Ohmuraya, Toshiomi Okuno","doi":"10.3390/epidemiologia7040095","DOIUrl":"10.3390/epidemiologia7040095","url":null,"abstract":"<p><p>Mumps remains a public health challenge worldwide despite being a vaccine-preventable disease. This review outlines the historical development and contrasting mumps vaccination policies in the United States and Japan and their epidemiological consequences. In the United States, where the two-dose measles, mumps, and rubella (MMR) vaccine is routinely administered, the incidence of mumps has markedly decreased. Recently, however, sporadic outbreaks have emerged, driven by breakthrough infections among vaccinated individuals. These resurgences are driven largely by waning immunity, coupled with antigenic divergence between the vaccine strain and circulating wild-type viruses. In contrast, Japan vaccination the MMR vaccine was licensed in 2026 after being suspended in 1993 owing to concerns over aseptic meningitis as an adverse event following immunization but mumps vaccination remains voluntary. This has resulted in low vaccination coverage, a lack of herd immunity, and recurrent epidemics. This review also highlights the disease-modifying effect of mumps vaccination, including a reduced risk of complications such as meningitis and orchitis, even in cases of breakthrough infection. In Japan, irreversible sensorineural hearing loss (mumps deafness), continues to occur even following subclinical infection. To prevent these complications, continuous molecular surveillance, improved vaccine safety, and reintroduction of routine two-dose mumps vaccination in Japan are essential.</p>","PeriodicalId":72944,"journal":{"name":"Epidemiolgia (Basel, Switzerland)","volume":"7 4","pages":""},"PeriodicalIF":2.2,"publicationDate":"2026-07-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13398083/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148581381","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Epidemiological Determinants of Urolithiasis Recurrence: A Retrospective Cohort Study Integrating Stone Composition and Behavioral Factors.","authors":"Marius Ivănuță, Dragoș Puia, Mihaela Corlade-Andrei, Ana-Maria Ivănuță, Bogdan Doroftei, Octavia Petrila, Mihaela Nikolic, Cătălin Pricop","doi":"10.3390/epidemiologia7040093","DOIUrl":"10.3390/epidemiologia7040093","url":null,"abstract":"<p><p><b>Background</b>: Urolithiasis is a common condition characterized by a high risk of recurrence, although this risk varies substantially between patients. The present study aimed to quantify incidence, identify determinants, and model recurrence risk between stone composition and recurrence, and to assess the role of selected clinical and behavioral factors in a cohort of patients with confirmed stone clearance. <b>Methods</b>: This retrospective cohort study included adult patients with urolithiasis managed between 2017 and 2021 in a specialized referral center. Only patients with confirmed stone-free status and available follow-up were included. Stone composition was determined using morpho-spectroscopic analysis. Clinical and behavioral variables were collected from medical records. Recurrence was defined as a new stone event during follow-up. Time-to-event analysis was performed using Kaplan-Meier estimates and Cox proportional hazards models. <b>Results</b>: A total of 962 patients were included, with a median follow-up of over three years. During this period, recurrence occurred in approximately one-third of patients. Uric acid stones were associated with a higher risk of recurrence compared with calcium oxalate monohydrate stones, while the effect size was moderate. Previous stone history and low fluid intake were also independently associated with recurrence. Other dietary variables did not retain statistical significance after adjustment. <b>Conclusions</b>: Recurrence in urolithiasis appears to reflect the combined effect of compositional, clinical, and behavioral factors. While certain variables are associated with increased risk, no single determinant fully explains recurrence patterns. These findings support a more individualized approach to risk assessment and follow-up.</p>","PeriodicalId":72944,"journal":{"name":"Epidemiolgia (Basel, Switzerland)","volume":"7 4","pages":""},"PeriodicalIF":2.2,"publicationDate":"2026-07-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13398209/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148581368","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Healthcare Expenditure and Health System Efficiency in 25 European Countries: A Multidimensional Data Envelopment Analysis with Bootstrap Correction and Second-Stage Regression.","authors":"Antonio Pinto, Flavia Pennisi, Carlo Signorelli","doi":"10.3390/epidemiologia7040092","DOIUrl":"10.3390/epidemiologia7040092","url":null,"abstract":"&lt;p&gt;&lt;strong&gt;Background: &lt;/strong&gt;European health systems face growing pressure from population ageing, post-pandemic service backlogs, and fiscal constraints. Yet substantial cross-country differences in health outcomes persist despite comparable levels of healthcare expenditure. This study evaluated the relative efficiency of European health systems using a multidimensional framework that integrates expenditure, prevention, and population health outcomes.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Methods: &lt;/strong&gt;A cross-sectional analysis was conducted on 25 European countries using 2022 data or the nearest available year. An output-oriented constant returns to scale Data Envelopment Analysis (DEA) model was estimated with two inputs, public and private healthcare expenditure per capita, and five outputs, life expectancy at birth, inverse infant mortality, healthy life years at birth, breast cancer screening coverage, and poliomyelitis vaccination coverage. A robustness specification added physician density as an additional input. Bootstrap bias correction with 1000 replications was applied to the baseline model. A second-stage Simar-Wilson truncated regression with 2000 bootstrap replications examined the association between inefficiency and selected contextual variables, including GDP per capita, population ageing, obesity prevalence, and tobacco use prevalence.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Results: &lt;/strong&gt;In the baseline DEA model, 8 of 25 countries were located on the technical efficiency frontier (Croatia, Czechia, Estonia, Greece, Hungary, Latvia, Lithuania, and Poland; output-oriented DEA inefficiency score = 1.000 for each country), while inefficiency scores among the remaining countries ranged from 1.042 to 2.617. The highest inefficiency scores were observed for Germany (2.617), Austria (2.283), Belgium (2.230), Ireland (2.219), and France (2.167). When physician density was added as an additional input, 12 countries were located on the estimated frontier. Bootstrap correction of the baseline model increased the estimated output-oriented inefficiency scores, with bias-corrected values ranging from 1.100 to 2.941. In the second-stage analysis, higher log GDP per capita was positively associated with bias-corrected inefficiency (coefficient 1.993; 95% bootstrap CI 0.219 to 4.197), whereas population ageing, adult obesity prevalence, and tobacco use prevalence were not statistically associated with bias-corrected inefficiency.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions: &lt;/strong&gt;In this cross-sectional sample of 25 European countries, higher healthcare expenditure was not consistently associated with frontier performance when health outcomes and preventive coverage were considered jointly. The results were sensitive to the inclusion of physician density and to bootstrap correction, supporting the interpretation of Data Envelopment Analysis as an exploratory benchmarking tool rather than a definitive ranking of health systems. These findings highlight the importance of assessing how financial an","PeriodicalId":72944,"journal":{"name":"Epidemiolgia (Basel, Switzerland)","volume":"7 4","pages":""},"PeriodicalIF":2.2,"publicationDate":"2026-07-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13398304/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148581428","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}