Transcript Diapositiva 1

Effectiveness of interventions for an appropriate use of resources in Milan:
independent Medical Education for GPs and Health Education for patients.
D.Sghedoni, A. Donzelli, G. Lacaita, P. Moser, P.Gini, W. Locatelli
ASL of Milan (Lombardy) – Italy
PURPOSE
To verify if a targeted half-day course, organized by the ASL and not sponsored,
could reduce overprescribed specific tests. Many specialists of the main city
hospitals were also involved receiving the course conclusions and collaborating in
writing appropriate Diagnostic Clinical and Therapeutic Pathways (PDTAs).
A more comprehensive monitoring was also aimed retrospectively to verify
whether independent specific Health Information for GPs and Education material
for patients (Pillole di Buona Pratica Clinica per medici e Pillole di Educazione
Sanitaria per cittadini-consumatori), sent regularly by the ASL to all its GPs’ and
integrated with other initiatives, can lower the Health Service (HS) drug
expenditure.
CONTEXT
Unnecessary diagnostic tests and inappropriate choice of drugs are a waste for health budgets. Many diagnostic tests are overvalued
because based mainly on specialist–led education, focused often to very detailed diagnoses, with no impact on the therapeutic
decisions. The drug choice is oriented by pharmaceutical firms’ biased “information” and often many specialist opinion leaders have
undisclosed conflicts of interests: generic drugs are still underused in Italy, where independent information is scarce.
Three diagnostics tests were selected by the ASL of Milan because performed in excess and with possible iatrogenic risks when overprescribed:
•MNR for uncomplicated low back pain; PSA for prostate cancer screening; fT3 for first-line thyroid work-up
Their inappropriate use; the limits and costs of Medical Imaging, screening, laboratory; the meaning of overdiagnosis and Number
Needed to Test, as well as risk communication strategies, were addressed in a half-day course, taught by GPs, ASL specialists and
community specialists. The course was held in 4 editions reaching 795 GPs ( 70% of the total) and was rather appreciated .
The numbers of the tests prescribed by GPs and specialists were compared before and after the course.
For a few years the ASL of Milan have also been issuing Health Information and Education material, with a special focus in promoting
EB life-styles in patients before or coupled with drugs. Doctors and patients are informed about cost-effective and non-branded
selected drugs (antihypertensives, statins, antidepressant, proton pump inhibitors etc.), to facilitate a personalized and rational
prescriptive choice.
The expenditure in 2009 for these selected drugs was then compared with that of other Lombardy ASLs (Local Health Units).
STATE OF THE ART
The number of all three tests prescribed by GPs after the course, from July to December 2009, in comparison with the same six
months of 2008, decreased by :
5% (MNR),  17.5% (PSA),  23.7% (fT3),
while those prescribed by the specialists somewhat increased.
Multiple interventions (CME courses, PDTAs, written information tools for GPs and patients) on targeted drugs are accompanied by an
age-weighted lower expense in comparison with the other Regional ASLs.
In other countries independent written information have been already been shown (Dormuth, CMAJ 2004) to be effective in orienting
new prescriptions and the experience of the ASL of Milan is now part of an AIFA (the Italian National Agency for Drugs)-funded
project and is shared by other ASLs of Lombardy and other Regions.
Antihypertensives: age-weighted expenditure
in Lombardy ASLs, Italy, Region and Milan
Statins: age-weighted expenditure in
Lombardy ASLs, Italy, Region and Milan
Antipertensivi spesa netta pesata SSN x 1000 ab ASL, RL, Ita. 2009
Statine spesa netta pesata SSN x 1000 ab ASL RL 2009
50.000
18.000
45.507
45.000
16.000
14.677
39.755
14.000
40.000
13.285
36.643
12.520
12.000
35.000
Italia
Lombardia
Italia
Milano
Lombardia
Milano
STATEMENTS FOR DEBATE
1)Important roles of the ASLs are providing independent information (to GPs and public) and monitoring the appropriateness of
services and drugs paid by the HS. The former may be achieved by CME and Health Education, the latter by electronic data-bases.
2)Quaternary Prevention (defined by Jamoulle M and WONCA as “the prevention of overmedicalization” is a fundamental GP’s task.
3)CME by the ASL, coupled with informative material for patients, may be effective at least in the short run in reducing the GPs’
overprescription of selected diagnostic tests and drugs. Optimally also specialists’ CME should be independent and integrated with
GPs’.
POSSIBLE IMPROVEMENTS
Health Information should be targeted also to people with low health literacy and special needs (e.g. recent immigrants – disabilities –
age …… )
Samples of ASL Information for GPs
“Pillole di Buona Pratica Clinica”
Please,
take one!
Samples of ASL Information for Patients
“Pillole di Educazione Sanitaria”