Slow Medicine: the Italian approach to appropriateness cannot be through a law

Transcription

1 Slow Medicine: the Italian approach to appropriateness cannot be through a law M. Congedo, S. Vernero, A. Bonaldi, M. Bobbio, A. Gardini

2 The reasons of a new Italian law Overuse of medical tests is common in Italy, in particular CT scans and magnetic resonance imaging, though published data are uncommon due to the lack of use of clinical databases in research. In a prospective analysis of requests for radiological tests only 55.5% were appropriate (1); a lower result than those observed in international surveys (2). 1. Cristofaro M, Busi Rizzi E, Schininà V, Chiappetta D, Angeletti C, Bibbolino C. Appropriateness: analysis of outpatientsradiologyrequests. RadiolMed 2012,117: Levinson W, Kallewaard M, Bhatia RS, Wolfson D, Shortt S, Kerr EA. 'Choosing Wisely': a growing international campaign. BMJ QualSaf 2015;24(2):

3 Physicians health illiteracy (3), defensive medicine with pervasive fear of litigation, conflict of interests, consumer access to information on the web, the request by patients for more examinations (4) and local recommendations hierarchically established drive to excesses. Is a law a way to change the present trend? 3. Malhotra A, Maughan D, Ansell J, Lehman R, Henderson A, Gray M, Stephenson T, Bailey S. Choosing Wisely in the UK: the Academy of Medical Royal Colleges' initiative to reduce the harms of too much medicine. BMJ 2015;350:h Hoffman JR, Kanzaria HK. Intolerance of error and culture of blame drive medical excess BMJ 2014;349:g5702.

4 LORENZIN-ACT The Italian legislative act, named Lorenzin- Act from the name of the Health Minister, was enacted on December 9th 2015 and came into force on January 21st 2016.

5 It sets the requirements for the provision of some diagnostics for out patients, in a list of 208 exams whose official appropriateness criteria are listed in the same law.

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7 The act makes reference to article 9 of the legislative act 78/2015, which states that the compliance with the above mentioned criteria is mandatory for physicians, and that non-compliance can be sanctioned by local and regional authorities.

8 Contents of Slow Medicine open letter published on February 8th The Lorenzin-Act has been produced without any contribution of health professionals, who at present are involved in implementing it. The government decision that some diagnostics must be rationed can t be confused with appropriateness (as establishing in odontology that care is in charge of National Health Service for children but not for adults). Diagnostic use can t be established by law: it must be considered in the specific patient context. Overdiagnose and overtreatment are a main issue but underuse of diagnostics and treatments must be considered (as in long-term diseases, for patients in domiciliary care) as a direct effect of the reduction of government financing to the National Health Service.

9 Doing more does not mean doing better Slow Medicine, a movement founded in 2011 to promote a measured, respectful and equitable medicine, launched the campaign: Doing more does not mean doing better in Italy in The campaign is part of Choosing Wisely International and is promoted by the Federazione Nazionale dei Medici Chirurghi e degli Odontoiatri, FNOMCeO - equivalent in the UK to the General Medical Council, GMC - by the Italian Nurses Colleges, IPASVI, and by other associations of health professionals, patients and citizens.

10 Health spending review? Slow Medicine is contrary to the reduction of government financing to the National Health Service, as Italy ranks below the OECD (Organization of Economic Cooperation and Development) average in terms of health spending per capita: what Italy needs is to spend better for healthcare, through the reduction of overuse and underuse, not to spend less.

11 Slow Medicine/Choosing Wisely Italy proposes a different way to reduce overuse Instead of a top-down approach charging patients or penalizing doctors for overuse of diagnostic tests, drugs and other treatments, Slow Medicine underlines the cultural aspects, concerning physicians and other health professionals, as patients and citizens.

12 Looking for clinical appropriateness Lorenzin-Act aims to reduce public charge in health confounds public charge and appropriateness in a normative and administrative context with a top-down approach nor for relationship between patient and doctor Slow Medicine aims to diffuse health care, clinical appropriateness and related fair use of public resources favouring professionals involvement considering balance between advantages and harms centred on relationship between patient and doctor.

13 Other entities are involved in Lorenzin-Act debate Federazione Nazionale Ordini dei Medici Chirurghi e degli Odontoiatri (equivalent to Britsh General Medical Council) A network of Italian associations for sustainability and health A foundation whose mission is to align the conveniences of professionals and of their organizations to the health needs of the community

14 Instead of a law 1. Identification of good practices locally implemented and diffused as a way to involved heath professionals directly.

15 Instead of a law 2. Choosing Wisely Top Five Lists diffusion as a tool to discuss inappropriateness among citizens and professionals.

16 Instead of a law 3. EBM teaching in order to recognize evidence based use of exams and treatments, as well as uncertainty in medical behaviour.

17 Instead of a law 4. Awareness of conflict of interest in medical societies guidelines that, also for this reason, can t be normative.

18 Instead of a law 5. Change of payment model for health professionals rewarding with financial and career incentives comprehensive health results (first of all the progression to a healthy longevity), the opposite of fee-forservice.

19 CONCLUSION Without a shared effort to identify the cultural and structural roots of inappropriateness, the present law encourages private clinical activity and increases inequalities, giving Italian citizens fewer opportunities to have an efficacious, effective and equitable National Health Service.

20 THANK YOU FOR YOUR ATTENTION!