Progetto
"Toward a
sustainable and
wise Medicine”
R. Nardi
AUSL di Bologna-Ospedale
Maggiore
Congresso Regionale FADOI-ANIMO Veneto
NH Laguna Palace
Mestre 25 ottobre 2013
Ore 11:35 11:55
III SESSIONE CONGIUNTA ANIMO:MEDICINA
SOSTENIBILE (Moderatori: Gianluigi Scannapieco, Paola Pauletti
1.Technological advances
2.Aging of population
3.Increase in chronic disease
4. Inefficiency and redundancy
5. Profiteering by investor-owned companies
6.Consumer demand
7.Defensive medicine
Drivers Of Health Care Costs
Carradori T, 19 settembre 2013, Bologna
APPROPRIATEZZA DEI SERVIZI SANITARI
Lipitz-Snyderman A, Bach PB, JAMA Internal Medicine 2013, 173/14: 1277-1278
Interventions for Which “More” Has Been Shown to Be Associated With Worse Outcome
Kox M, Pickkers P, “Less IsMore” in Critically Ill Patients Not Too Intensive, JAMA Intern Med. 2013;173(14):1369-1372.
Interventions for Which “More” Has Been Shown to Be Associated With Worse Outcome
Kox M, Pickkers P, “Less IsMore” in Critically Ill Patients Not Too Intensive, JAMA Intern Med. 2013;173(14):1369-1372.
Interventions for Which “More” Has Been Shown to Be Associated With Worse Outcome
Kox M, Pickkers P, “Less IsMore” in Critically Ill Patients Not Too Intensive, JAMA Intern Med. 2013;173(14):1369-1372.
JAMA Internal Medicine July 22, 2013 Volume 173, Number 14
Defensive medicine is widely practiced • In a Gallup poll, physicians attributed 34% of overall
healthcare costs to defensive.
• Specifically interventions were performed to avoid lawsuits in these domains:
– 35% of diagnostic
– 29% of laboratory tests
– 19% of hospitalizations
– 14% of prescriptions
– 8% of surgical
• This survey estimated that defensive medicine practices cost the US 650-850 billion dollars each year Hettrich CM, Mather RC 3rd, Sethi MK, et al. The costs of defensive medicine. AAOS Now, Dec 2010.
Available from: http://www.aaos.org/news/aaosnow/ dec10/advocacy2.asp
The “Top 5 Lists”
• Funded by an ABIM Foundation grant, the National Physicians Alliance piloted the concept through its Good Stewardship Working Group
• Developed lists of top five activities in family medicine, internal medicine, and pediatrics where the quality of care could be improved
• Published in Archives of Internal Medicine
• Subsequent research published in Archives found a cost savings of more than $5 billion could be realized if the recommendations were put in to practice.
Top 5 List in Internal Medicine
The Good Stewardship Working Group, Arch Intern Med. 2011;171(15):1385-1390.
Choosing Wisely Partners Societies Released Lists in April 2012 • American Academy of Allergy Asthma & Immunology • American Academy of Family Physicians • American College of Cardiology • American College of Physicians • American College of Radiology • American Gastroenterological Association • American Society of Nephrology • American Society of Nuclear Cardiology • American Society of Clinical Oncology Consumer Groups Through Partnership with Consumer Reports • AARP • Alliance Health Networks • Leapfrog Group • Midwest Business Group on Health • Minnesota Health Action Network • National Business Coalition on Health • National Business Group on Health • National Center for Farmworker Health • National Hospice and Palliative Care Organization • National Partnership for Women & Families • Pacific Business Group on Health • SEIU • Union Plus
• Wikipedia
Societies Releasing Lists in Feb 2013 • American Academy of Hospice and Palliative
Medicine
• American Academy of Neurology
• American Academy of Ophthalmology
• American Academy of Otolaryngology-Head and Neck Surgery
• American Academy of Pediatrics
• American College of Obstetricians and Gynecologists
• American College of Rheumatology
• American Geriatrics Society
• American Society for Clinical Pathology
• American Society of Echocardiography
• American Urological Association
• Society of Hospital Medicine
• Society of Nuclear Medicine and Molecular Imaging
• Society of Thoracic Surgeons
• Society of Vascular Medicine
Societies Releasing Lists later in 2013 • American College of Surgeons • American Headache Society
The Ten Points of the Federation of Associations of Hospital Doctors on Internal Medicine for a Slow Medicine.
Italian Journal of Medicine 2013; volume 7:135-137
1. In the Internal Medicine complex patient with multi-morbidities you have
to exercise a proactive selection of priorities, putting the various
problems in order of importance with respect to their actual clinical significance
Italian Journal of Medicine 2013; 7:e22
Some of the bed-side implications related to the complexity of the hospitalized patient in internal medicine practice
• Exercising a comprehensive global assessment in patients admitted in IM wards
• Searching for comorbidities (both as overt and/or underlying iceberg diseases)
• Identifying frail patients and those with functional deficits
• Selecting the treatments really necessary, by constructing the hierarchy of priorities
• Tailoring a targeted treatment, by defining clinical endpoints upon a multidimensional comprehensive assessment of the patient
• Avoiding, if possible, a hospital discharge delay, by planning the tailored program management for the difficult patient
• Managing the risk of errors and of the higher risk of iatrogenic damage (polypharmacy, drug interactions, ADR, incompatibilities, contraindications)
Nardi R et al, Italian Journal of Medicine 2013; 7:e24
2. You must not request unnecessary specialist consultations: consultations
should be limited to those that are really needed according to the
expected results of the individual case
Italian Journal of Medicine 2013; 7:e22
3. Before requesting new tests and examinations you should check:
a) if they have already been carried out
previously and, if so, when;
b) what additional useful information can they give you concerning patient management;
c) what are the risks involved
Italian Journal of Medicine 2013; 7:e22
un test “mal richiesto”
genera una serie di altri
esami inappropriati se il
risultato è appena al di
fuori dei valori di
normalità
Irrelevant ‘abnormals’ • Virtually all quantitative laboratory test ‘normal ranges’ are
based on the mean +/- 2 SD (95% confidence interval) for a subject population
• 5% of normal patients will have values that lie outside this range (magnified for ill patients)
2.5% 2.5%
• If a patient has 10 tests
ordered, each with a 5%
chance that the test may
have a result outside the
normal range.
• Then there is a 50% chance
that at least one test will have
an ‘abnormal’ result
• This is especially true with
ordering chemistry ‘panels’
Risparmi in ospedale se i medici sono
informati sui costi degli esami Feldman LS et al. Impact of providing fee data on laboratory test ordering. JAMA Intern Med Published online April 15,
2013.
se vengono evidenziati i costi degli esami, i medici ordinatori di spesa si
rendono conto in maniera più chiara del loro valore e tendono a ridurre gli
eventuali sprechi. • 61 esami di laboratorio prescelti sono stati assegnati in modo
random ad un braccio attivo (comunicazione dei costi) e ad un
braccio di controllo (costi non comunicati).
• Sono stati valutati il totale degli esami richiesti e la frequenza di
richieste per paziente al giorno.
– Nel braccio attivo (comunicazione del costo degli esami) la richiesta di esami
in numero assoluto è diminuita del 9.1% (da 458.297 al baseline a 416.805
nel periodo di intervento) ed è passata da 3.72 test/paziente al giorno (nel
periodo baseline) a 3.40 nel periodo di intervento (riduzione pari all'8.59%;
95% CI - 8.99%/- 8.19%).
– Nel braccio di controllo (costi non comunicati) la richiesta di esami tra il
periodo baseline e quello di intervento attivo è aumentata in numero assoluto
del 5 .1% (da 142.196 a 149.155 esami) e per quanto attiene il numero di
esami/paziente/giorno del 5.64% (95% CI 4.90%/6.39%; p < 0.01).
una politica di trasparenza e condivisione dei costi degli esami di laboratorio
può incidere in modo soddisfacente sul loro utilizzo complessivo (arrivando ad
una riduzione dei costi fino a quasi il 9%).
4. You have to inform and involve the patient and his caregivers about the choices concerning care;
you have to tailor the management and
treatment of the patient according to his real needs, values, and preferences, as well as considering
potential risks;
according to the best available knowledge, you have to explain what clinical goals can berealistically
pursued and which potential improper requests could be made by the patient and his family
Italian Journal of Medicine 2013; 7:e22
5. In the terminal patient at the end of life, please refrain from sophisticated
and/or invasive procedures.
Treatment choice should ensure adequate Quality of Life and effective pain control
Italian Journal of Medicine 2013; 7:e22
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D. Valenti et al, 2011
6. At hospital admission, at discharge and at each check up/outpatient visit you have to exercise the
concept of medication reconciliation.
Reconciliation is the process that starts with comparing the list of drugs taken by the patient (recognition) with those that
should be administered to the patient in the particular circumstances at that time.
This allows you to decide the correct medication to be prescribed
Italian Journal of Medicine 2013; 7:e22
7. For any new treatment and for treatment-naïve patients you have to use equivalent
drugs according to:
- patients’ characteristics, - the disease
- the active ingredients of the drug concerned Italian Journal of Medicine 2013; 7:e22
Furher goals to increase rates of prescribing generic have to be a part of efforts to improve the quality and
efficacy for a more sustainable medicine.
Reasons for supporting the use of generics
a. they are already used for a long time, thus substantially well known in terms of quality, efficacy and safety;
b. the price reduction defined by law at least 20% (but currently the price reduction also comes more than 60% of the retail price) allows to allocate resources to innovative medicines without renouncing to long-established treatments;
c. they are an opportunity for saving money not only for the NHS but also for the citizen
Nardi R et al, "Generic"- equivalent drugs use in general-internal medicine patients: distrust, confusion, lack of certainties or of knowledges?
Part 3. Clinical issues, Ital J Med 2014, in press
for a more sustainable medicine, all doctors should facilitate as far as possible an extensive use of generic drugs
• in any new treatment, equivalent drugs use has to be implemented as much as possible;
• a strategy aimed to increase a systematic diffusion of generics is to prescribe generic drugs at any hospital discharge;
• in naive patients starting treatment (initial monotherapy or additional prescription) generic drugs may be, after informing the patients, a good, if not the best, choice, sometimes offering cost-sensitive benefits;
• it may be advisable to prescribe generics whenever the outcome sought is clinically easily measurable, ie: drugs for pain, blood pressure, etc.
Nardi R et al, "Generic"- equivalent drugs use in general-internal medicine patients: distrust, confusion, lack of certainties or of knowledges?
Part 3. Clinical issues, Ital J Med 2014, in press
8. On discharge from the hospital, reduce the number of prescribed drugs as much as possible, preferably to less
than those already being taken before admission
Italian Journal of Medicine 2013; 7:e22
9. Plan the patient’s discharge.
On admission to the hospital, a comprehensive patient assessment (clinical, functional, psychological-
cognitive, economic, social and familial) can help identify difficult to discharge
cases, taking into consideration the community health resources
available for the continuity of care
Italian Journal of Medicine 2013; 7:e22
Discharge planning…
•Should be initiated within 24-48 hours after hospital admission.
10. On hospital discharge, when possible, provide your patients, their families and caregivers with all the
information they need for the self management of the disease:
medicines and the equipment or facilities needed, the
symptoms and signs to be monitored to maintain patient well-being, the people to contact if help is
needed, a list of the procedures and appointments for the post-discharge period, and any home care services that have been activated or that need to be activated.
Italian Journal of Medicine 2013; 7:e22
• We firmly believe that reinforcing a common agenda between medicine and public health, and sharing a common vision among professionals and decision makers in the planning of care, may be the greatest opportunity for any every health care reform.
• The future of the health care system cannot be restricted to mere cost reduction, but should aim to deliver better health care in relation to the money spent.
• Even in this period of austerity, new opportunities can still be found and doctors must lead efforts to meet this challenge.
CONCLUSIONS
Nardi R et Al, Italian Journal of Medicine 2013; 7:e1
• We have to learn (or relearn) to practice a medicine that is not so dependent on technology.
• Our medical healthcare has to be tailored to the real needs of the person.
• In this way, it will be easier for us to remember that the diagnosis is based, in most cases, on history and physical examination, and that the last drug used is not necessarily the best.
Nardi R et Al, Italian Journal of Medicine 2013; 7:e1
CONCLUSIONS
