Diapositiva 1

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 specialistled 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 over-prescribed
• 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

• STATEMENTS FOR DEBATE
• 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.
• Quaternary Prevention (defined by Jamoulle M and
  WONCA as the prevention of overmedicalization
  is a fundamental GPs task.
• 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 Patients Pillole
di Educazione Sanitaria
Samples of ASL Information for GPs Pillole di
Buona Pratica Clinica
Please, take one!