Progetto "Toward a sustainable and wise Medicine

Transcription

1 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

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3 Drivers Of Health Care Costs 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

4 Carradori T, 19 settembre 2013, Bologna

5 APPROPRIATEZZA DEI SERVIZI SANITARI

6 Lipitz-Snyderman A, Bach PB, JAMA Internal Medicine 2013, 173/14:

7 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):

8 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):

9 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):

10 JAMA Internal Medicine July 22, 2013 Volume 173, Number 14

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13 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 billion dollars each year Hettrich CM, Mather RC 3rd, Sethi MK, et al. The costs of defensive medicine. AAOS Now, Dec Available from: dec10/advocacy2.asp

14 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.

15 Top 5 List in Internal Medicine The Good Stewardship Working Group, Arch Intern Med. 2011;171(15):

16 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

17 Italian Journal of Medicine 2013; volume 7: The Ten Points of the Federation of Associations of Hospital Doctors on Internal Medicine for a Slow Medicine.

18 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

19 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

20 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

21 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

22 un test mal richiesto genera una serie di altri esami inappropriati se il risultato è appena al di fuori dei valori di normalità

23 Irrelevant abnormals Virtually all quantitative laboratory test normal ranges are based on the mean +/- 2 SD (95% confidence interval) for a subject population If a patient has 10 tests ordered, each with a 5% chance that the test may have a result outside the normal range. 2.5% 2.5% Then there is a 50% chance that at least one test will have an abnormal result This is especially true with ordering chemistry panels 5% of normal patients will have values that lie outside this range (magnified for ill patients)

24 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, 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 al baseline a 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 %/- 8.19%). 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 a 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%).

25 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

26 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

27 Esami strumentali- Ultimo ricovero- media di giorni ECG Ecogr. Altri Rx TAC Rx T Eco CD EGDS RMN Scint. BroncoSC ColonSC Rx clis.op. Altro D. Valenti et al, 2011 danila valenti

28 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

29 7. For any new treatment and for treatmentnaïve 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.

30 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

31 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 costsensitive 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

32 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

33 9. Plan the patient s discharge. On admission to the hospital, a comprehensive patient assessment (clinical, functional, psychologicalcognitive, 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

34 Discharge planning Should be initiated within hours after hospital admission.

35 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

36 CONCLUSIONS 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. Nardi R et Al, Italian Journal of Medicine 2013; 7:e1

37 CONCLUSIONS 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