“doing more does not mean doing better”
TRANSCRIPT
Sandra Vernero MD
Co-founder and Vice-Chair of Italy’s Slow Medicine
Coordinator of the campaign “Doing more does not mean doing better“
Italy’s SLOW MEDICINE and the campaign
“Doing more
does not mean doing better”
Slow MedicineMeasured Doing more does not mean doing better
Respectful People’s values, expectations and desires are different and inviolable
Equitable Appropriate and good quality care for all
“I have little doubt that Slow Medicine – like
Slow Food and slow lovemaking – is the best
kind of medicine for the 21st century”
Bologna, December 14 2012
Health at a Glance 2013: OECD Indicators
Health at a Glance: Europe 2012
Antibiotics consumption, 2000 and 2010 (or nearest year)
Source: OECD Health Data 2012; European Surveillance of Antimicrobial
Consumption (ESAC) project, 2011
Rapid evolution and spread of carbapenemases among Enterobacteriaceae in Europe Canton R et al, Clin Microbiol Infect 2012; 18: 413–431
Health at a Glance 2013: OECD Indicators
Italy’s campaign “Doing more does not mean doing better”
Each Italian specialty society engaged in the project develops a list of top 5 tests
and treatments whose necessity should be questioned and discussed as :
• they are commonly used in Italy
• they have been shown by the currently available evidence not to provide
any meaningful benefit to at least some major categories of patients
for whom they are commonly ordered
• they may cause patient harm
Physician and patient should have conversations and discuss the use of these
tests and treatments, in view of wise and shared choices.
PARTNERSHIP between physicians and other health professionals & patients
and citizens.
December 2012
OVERUSE of TESTS and TREATMENTS
• WASTE of RESOURCES
• CLINICAL ERROR
- direct damage from inappropriate tests and treatments (Xrays and
contrast media, side effects of drugs, interactions among drugs…)
- damage by false positives and overdiagnosis from inappropriate tests >>
anxiety and stress, further tests also invasive, inappropriate interventional
and surgical treatments (overtreatment)
Slow Medicine launched the campaign
“Doing more does not mean doing better” in December 2012. Other promoters :
• The Italian Federation of Medical Doctors’ and Dentists’ Colleges (FNOMCeO)
• The Italian Federation of Nurses’ Colleges (IPASVI)
• The Academy of Nurses (ASI)
• The Italian Society for Quality in Healthcare (SIQuAS VRQ)
• The Union of Radiologists (SNR)
• Change Institut in Turin
• Partecipa Salute, established by IRCCS-Mario Negri, Italian Cochrane Centre and Zadig srl.
• Inversa Onlus, patients’ association
• Altroconsumo, a consumers’ association
• The Federation of Social and Health Care of the Autonomous Province of Bolzano
• Slow Food Italy
1. The Italian Association of Dietetics and Clinical Nutrition – ADI
2. The Italian Association of Hospital Cardiologists– ANMCO
3. The Italian Association of Radiation Oncology – AIRO
4. The Italian Board of Medical Oncology Directors – CIPOMO
5. The Cochrane Neurological Field in Italy – CNF (list 1, reviewed in 2015)
6. The Italian Society of Allergy, Asthma and Clinical Immunology – SIAAIC
7. The Italian Society of Pediatric Allergy and Immunology – SIAIP
8. The Italian Society of General Practitioners – SIMG
9. The Italian Society of Medical Radiology – SIRM
10. Italian Specialty Societies of Nurses of: Operating Theater, Stomacare, Skin
Ulcers, Hospital Medicine, Hospital Urology– AICO, AIOSS, AIUC, AIURO, ANIMO
The top 5 recommendations released in 2014
The Italian Society of General Practitioners - SIMG
2014
1. Don’t recommend routine imaging of the spine in patients with low back pain in the absence
of warning signs or symptoms (red flags).
2. Don’t routinely prescribe antibiotics for acute infections of the upper airways. Evaluate their
opportunity for patients at risk of lower respiratory tract infections or in the presence of
clinical worsening after some days.
3. Don’t routinely prescribe proton pump inhibitors to patients not at risk for peptic ulcer. For
pharmacological treatment of patients with gastroesophageal reflux disease (GERD), they
should be titrated to the lowest effective dose needed to achieve therapeutic goals, educating
the patient to desirable periods of suspension.
4. Don’t prescribe non steroidal anti-inflammatory drugs (NSAIDS) without initially assessing,
and periodically reassessing, the true clinical indication and the risk of side effects in that
moment and for that patient.
5. Don’t routinely prescribe benzodiazepines or Z-drugs in older adults as first choice for
insomnia. Recommend to use them intermittently and to periodically reassess the clinical
indication as well as any side effects.
1. The Cultural Association of Pediatricians - ACP
2. The Italian Association of Nuclear Medicine - AIMN
3. The Italian Association of Medical Diabetologists – AMD
4. The Italian Association of Medical Endocrinologists - AME
5. The Italian Association for the Promotion of appropriate care in Obstetrics, Ginecology
and Perinatal Medicine – ANDRIA
6. The Cochrane Neurological Field in Italy – CNF (II list)
7. The Italian Federation of Associations of Hospital Internal Medicine – FADOI (I list)
8. The Italian Federation of Associations of Hospital Internal Medicine – FADOI (II list)
9. The Italian section of the International Society of Doctors for the Environment - ISDE
10. The Italian Society of Palliative Care - SICP
11. The Italian Society of Human Genetics – SIGU
12. The Italian Society for Medical Education (SIPeM)
The top 5 recommendations released in 2015
More than 10 Italian specialty societies and associations of physicians and other health
professionals joined the project too and are creating their lists:
• The Italian College of Vascular Surgery Directors
• The Italian Federation of Pediatricians – FIMP
• The Italian Association of Doctors of the Hospital Directions – ANMDO
• The Italian Society of Laboratory Medicine - SIMeL
• The Coordination of Doctors of Legal Medicine in Healthcare Organisations – COMLAS
• The Italian Society of Nephrology – SIN
• The Italian Association of Physiotherapists – AIFI
• The Italian Group of Cardiac Rehabilitation –GICR
• The Italian Private Dentistry- OPI
• The Italian Association of Outpatient Territorial Neurologists – AINAT
• The Italian Society of Biochemistry and Clinical Molecular Biology – SIBIOC
• Other Italian Specialty Societies of Nurses
The International Society of Doctors for the Environment – ISDE
Italian section
2015
1. Air: don’t consume energy derived from fossil fuels (coal, petrol, gas). Use renewable energy sources
(those which can be provided by solar energy, photovoltaic systems, wind power, geothermic sources
and buildings constructed using materials which save energy), when possible
The use of private cars should be reduced preferring instead the use of bicycles, public transport,
car pooling and walking.
2. Water: don’t drink bottled water but choose, where possible, water from the tap, which has often
better organoleptic characteristics and is subject to rigorous quality control.
3. Biodiversity: use antibiotics only when absolutely necessary and only under medical supervision.
4. Ionized Radiation: X-rays should not be carried out unless there is a specific clinical indication.
5. Nutrition: don’t purchase or consume foods which are mass produced by industry or come from a
distant geographical location but prefer instead fresh foods (fruit, vegetables, whole wheat cereals
and milk) from your local area.
3
21.5
4
14.5
927
22
4 5
Primary prevention
Imaging
Cardiological tests
Laboratory tests
Other tests
Drugs
Other treatments
Other procedures
(healthcare)
Other procedures
(medical education)
The first 110 recommendations in Italy
www.slowmedicine.it/pratiche.htm
Primary prevention 3
Tests (imaging, laboratory, cardiological, other) 49
Treatments (drugs, other) 49
Other procedures (healthcare) 4
Other procedures (medical education) 5
110
The first 110 recommendations in Italy
www.slowmedicine.it/pratiche.htm
24
30
21
35
0
5
10
15
20
25
30
35
40
2014 2015
Recommendations equal/similar to CW USA
YES
NO
YES NO %YES
2014 24 21 45 53,3%
2015 30 35 65 46,2%
54 56 110 49,1%
Information and dissemination
• Information of health Professionals and their education about EBM, Medical
Humanities and their relationship with patients
• Development of patient-friendly material by both physicians and citizens
(Altroconsumo)
• The lists will be disseminated widely, as well as the concept that
“Doing more does not mean doing better”
Brochures for citizens created by Altroconsumo
www.altroconsumo.it
- imaging in low back pain – SIMG and SIRM
- antibiotics for infections of upper airway - SIMG
- proton pump inhibitors– SIMG and FADOI
- Non Steroid Anti-inflammatory Drugs – SIMG and FADOI
- benzodiazepines in the elderly – SIMG and FADOI
- preoperatory chest xrays – SIRM
- MRI of the knee – SIRM
- allergy tests for drugs or food – SIAAIC
- food intolerance tests – ADI/SIAAIC
First implementations
A first practical application of the project just started in Piedmont, named “Scegliamo con cura”
with the collaboration of the local section of the Italian Society of General Practitioners – SIMG.
Moving from the 5 recommendations chosen by the General Practitioners, other actions
will follow, namely:
• a specific training of physicians focusing on the acquisition of communication and of counseling
skills
• the development of patient-friendly material about the overused tests and treatments
identified
• a specific communication campaign to patients and citizens
• a quantitative and qualitative measurement of the impact of the initiative.
Some hospitals too started to identify tests and
treatments whose necessity should be questioned
and discussed.
The first was the hospitals in Cuneo (Piedmont).
A network of SLOW HOSPITALS will be created
soon.
2nd International Roundtable on Choosing Wisely
Thursday, May 28 – Friday, May 29, 2015
London, UKAustralia
Austria
Brazil
Canada
Denmark
England
France
Germany
Italy
Japan
New Zealand
South Corea
Switzerland
The Netherlands
UK
US
Wales
MAIN STRENGHTS
- Bottom up campaign : enhancement of professionalism of physicians and of nurses –
responsibility for the health of their patients – do not harm (not a rationing campaign)
- Systemic view and complexity theory: shared vision – leverage effect – network –
collaboration and co-creation
- Partnership between HC professionals and patients/citizens
- part of Slow Medicine: change of culture and of paradygm
MAIN CHALLENGES
- many physicians prescribe unnecessary tests and treatments as they are concerned about
complaints and litigations (defensive medicine)
- lack of training on communication with patients and families and on decision sharing both
in medical schools and in subsequent education of physicians
- financial rewards more focused on quantitative and financial results than on health
outcomes – conflicting interests between public and private sector
- the common message from the media to citizens is that new is always better as well as
doing more
www.slowmedicine.it
Facebook: Group (closed) of
more than 4.000 members
Slow Medicine Italia
Twitter: @Slow Medicine
THANK YOU