Effectiveness of interventions for an appropriate use of resources in Milan:

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 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 GP’s 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!