2. What business we are
On January 19, 2012, after 131 years of operation, the Eastman Kodak
Company filed in U.S. bankruptcy court.
Central among them was that Kodak was late to
recognize that it was not in the film and camera
business: it was in the imaging business.
With the advent of digital imaging, Kodak was outpaced by other companies that could
better achieve consumer goals
3. Altri fallimenti
• Successo
• Whats app
• Facebook
• Google
IBM
Nokia
Olivetti
M246310
Business immateriale basato
su servizi e soddisfazione
utente
5. OECD Health Data 2013 Dove si colloca l’Italia
In Italia, la spesa sanitaria rappresentava il 9.2% del PIL nel 2011, una percentuale leggermente inferiore alla media dei paesi
dell’OCSE (9.3%.). La quota della spesa sanitaria nel PIL in Italia rimane tuttavia assai inferiore a quella degli Stati Uniti (17.7%)
come pure a quella di alcuni altri paesi europei come i Paesi Bassi (11.9%), la Francia (11.6%) e la Germania (11.3%).
L’Italia si colloca al di sotto della media OCSE in termini di spesa sanitaria pro-capite, con una spesa di 3012 USD (corretta per il
potere d’acquisto), rispetto ad una media di 3339 USD nei paesi dell’OCSE
Circa 120 miliardi complessivamente
6. L’Aumento della Spesa Sanitaria:
Quali le Cause?
• Nuove tecnologie e nuovi farmaci,
solitamente costosi
• Rinnovate aspettative dei pazienti (reali ed
indotte)
• Pressioni (spesso non giustificate) della
Industria Farmaceutica
Mongan JJ et al. N Engl J Med 358:1509, 2008
• Invecchiamento della popolazione e stili di
vita (sedentarietà, fumo) che favoriscono
malattie croniche
8. I Tagli in Sanità Non Sono una
Scelta Eticamente Accettabile
(razionalizzare vs razionare)
9. Come Razionalizzare la Spesa
Sanitaria: Evitare gli Sprechi
Brody H. New Engl J Med, 366:1949, 2012
10. Sono necessarie scelte sanitarie
razionali, non razionate!
.. le risorse devono essere indirizzate
verso prestazioni la cui efficacia è
riconosciuta in base alle evidenze
scientifiche e verso i soggetti che
maggiormente ne possono trarre
beneficio ...
Ministero della Salute, Piano Sanitario Nazionale 2012
11. The “Stabilization Triangle” and
Reduction in Health Expenditure
6 tipi di sprechi
Berwick DM & Hackbarth AD, JAMA 307:1513, 2012
12. Gimbe Bologna 2014 link
• Sovra utilizzo interventi sanitari 26%
• Frodi abusi 21%
• Tecnologie sanitarie acquistate a costi eccessivi 19%
• Sottoutilizzo interventi sanitari efficaci/appropriati 12%
• Complessita’ amministrative 12%
• Inadeguato coordinamento assistenza 10%
Categorie sprechi Euro
Oltre il 20% della spesa sanitaria totale (circa 22 miliardi . . . )
18. Main Drivers of Overdiagnosis
• Technological changes detecting ever smaller
“abnormalities”
• Legal incentives that punish underdiagnosis but
not overdiagnosis (defensive medicine)
• Health system incentives favouring more tests
and treatments
• Commercial and professional vested interests
• Conflicted panels producing expanded disease
definitions and writing guidelines
• Cultural beliefs that “more is better”
Moynihan R et al, BMJ, 344:19, 2012
19. Fare quanto piu’ e’ possibile PER il paziente,
fare il meno possibile AL paziente
20. La vera “spending review” o i veri tagli:
Togliere quello che non serve o non è provato
21. The Main Pathways Leading to
Overdiagnosis
• Screening detected “diseases” in people
without symptoms
• Use of increasingly sensitive tests in those with
symptoms
• Incidentally discovered abnormalities
(incidentalomas)
• Overdiagnosis resulting from excessively
widened disease definition
Moynihan R et al, BMJ, 344:19, 2012
27. The ERPSC Study: Main Results
• After a median follow-up of 11 years, the relative
reduction in the risk of death from prostate cancer
in the screening group was 21% (RR: 0.79; 95%
CI: 0.68 to 0.91; P=0.001).
• The absolute reduction in mortality in the screening
group was 0.10 deaths per 1000 person-years or
1.07 deaths per 1000 men who underwent
randomization.
• There was no significant between-group difference
in all-cause mortality.
• To prevent one death from prostate cancer at 11
years of follow-up, 1055 men would need to be
invited for screening and 37 cancers would need
to be detected.
Schroeder FH et al., New Engl J Med, 366:981, 2012
28. Rate of new diagnoses and death in four
cancers in the SEaER data (1975-2005)
Welch GH and Black WC, JNCI, 102:605, 2010
29.
30. • The introduction of screening mammography in the United
States has been associated with a doubling in the number of
cases of early-stage breast cancer that are detected each year,
from 112 to 234 cases per 100,000 women — an absolute
increase of 122 cases per 100,000 women.
• Only 8 of the 122 additional early-stage cancers diagnosed were
expected to progress to advanced disease.
• We estimated that in 2008, breast cancer was overdiagnosed
(i.e., tumors were detected on screening that would never have
led to clinical symptoms) in more than 70,000 women; this
accounted for 31% of all breast cancers diagnosed.
overdiagnosed) and in 1.3 million U.S. women in the past 30
years. suggestsing that there is substantial overdiagnosis,
accounting for nearly a third of all newly diagnosed breast
cancers
Bleyer A and Welch GH, New Engl J Med , 367:1998, 2012
31.
32.
33.
34. 1990 2006
Increase the Median
Survival by 1.7-4.7 mo
Cost/year Therapy
$ 161,00-240,000
I Costi: l’esempio del Tumore del Colon
Metastatico
Schrag D, New Engl J Med 351:317, 2004
35. Tol J et al. N Engl J Med 2009;360:563-572
Kaplan-Meier Estimates of Progression-free and Overall Survival
Panel B shows overall survival; the median was 19.4
months in the CBC group and 20.3 months in the CB
group (P=0.16; hazard ratio, 1.15).
36.
37. The Main Pathways Leading to
Overdiagnosis
• Screening detected “diseases” in people
without symptoms
• Overdiagnosis resulting from excessively
widened disease definition
• Use of increasingly sensitive tests in those with
symptoms
• Incidentally discovered abnormalities
(incidentalomas)
Moynihan R et al, BMJ, 344:19, 2012
38.
39. • The new ACC–AHA guidelines for the management of
cholesterol would increase the number of adults who would
be eligible for statin therapy by 12.8 million, with the
increase seen mostly among older adults without
cardiovascular disease.
40. DistribuzioneDei pazienti trattati con ipolipemizzanti e
della spesa per farmaci ipolipemizzanti per aderenza e
raggiungimento del target terapeutico
fonte: Degli Esposti Fabbisogno assistenziale e allocazione delle risorse nel
trattamento dell'ipercolesterolemia; risultati dello studio STAR politiche sanitarie 2012
Pazienti 7.276 (24%)
Spesa 2.329.086 (33%)
Pazienti 9,967 (33%)
Spesa 1,950,087 (28%)
Pazienti 4.0336 (13%)
Spesa 1.290.396 (18%)
Pazienti 8,705 (29%)
Spesa 1.477.722 (21%)
NOSI
NO
SI
Target
Aderenza
Meno del 60% dei pazienti e' a target quasi il 60% dei pazienti NON e' compliante
41. Livelli di PA
Quasi 6 milioni di persone non
dovrebbero piu’ assumere terapia
42. • Deploy pre-clinical curricula that emphasize value-based medical decision-making.
• Include cost-conscious ordering and prescribing in our board examinations.
• Reward trainee restraint.
• Give trainees some sense of the cost and price of tests and treatments.
• Get leadership buy-in at academic centers.
47. • Conclusions
• In patients with advanced CKD, timing of dialysis
therapy initiation was not associated with mortality
when accounting for lead time bias and survivor bias.
48. Dati di 9/17 regioni RIDT, 2000-2008, 35.000 soggetti
2011
49. • Newswise — ROCHESTER, Minn. — New research from
Mayo Clinic finds that half of elderly patients who start
dialysis after age 75 will die within one year. The findings
are being presented this week at the American Society of
Nephrology’s Kidney Week 2013 in Atlanta.
50. Treatment effects of convective dialysis are unreliable due to limitations in
trial methods and reporting. Convective dialysis may reduce cardiovascular
but not all-cause mortality, and effects on nonfatal cardiovascular events and
hospitalization are inconclusive.
The potential benefits of convective modalities over standard HD for cardiovascular outcomes and mortality remain unproved.
Since the meeting in Paris, new evidence has
become available regarding the clinical
benefits of HDF.
53. Published on Line, October 2013
ACP does not recommend
screening for CKD in
asymptomatic adults with risk
factors (diabetes, Hypertension and
CV disease).
Standard Detection of
CKD is considered a
sufficient approach, at
least for now.
New studies needed.
54. • Screening for CKD is suggested to be cost- effective in
patients with diabetes and hypertension. CKD screening
may be cost-effective in populations with higher incidences of
CKD, rapid rates of progression, and more effective drug
56. Percentuali di pazienti a cui è stata segnata una
creatininemia e’ 49%
Audit pazienti diabetici ed ipertesi
Totale pazienti circa 30.000
Oltre 100 medici
Pazienti
5261
2535
8056
Creat si prescritte
Creat si registrate
Creat no
7796 =
49%
51 %
16%
33%
59. • Tens of thousands of patients are needlessly dying in our hospitals
every year from kidney failure linked to dehydration, according to the
healthcare regulator.
• Between 12,000 and 42,000 deaths could be prevented every year if
patients received the best possible care.
• The condition, which kills more people every year than common cancers, can develop
very quickly and occurs in people ill with conditions such as heart failure, diabetes and
those suffering infections.
• A new guideline from the National Institute for Health and Care Excellence (Nice) says
acute kidney injury costs the NHS between £434 million and £620 million a year - more
than it spends on breast, lung and skin cancer combined.
• Between 262,000 and one million people admitted to hospital as an emergency will have
the kidney condition, of which just under a quarter will die.
60.
61. • La mortalità acuta (entro 48h da una iperpotassiemia) era
piu’ alta nel gruppo dei NON nefrologi
62. • Health care leaders and policy makers have tried countless incremental fixes—attacking
fraud, reducing errors, enforcing practice guidelines, making patients better “consumers,”
implementing electronic medical records—but none have had much impact.
• It’s time for a fundamentally new strategy.
• At its core is maximizing value for patients: that is,
achieving the best outcomes at the lowest cost.
63. • “E’ necessario un nuovo modello qualitativo per consentire a medici,
fornitori e autorità regolatorie di assicurare ai pazienti una vita migliore
grazie alle terapie tecnicamente complesse e costose che essi stanno
ricevendo.
• Con solide fondamenta, è giunto il momento di concentrarsi sugli outcome
clinici intermedi più complessi quali, la gestione dei fluidi, il controllo delle
infezioni, la gestione del diabete, la gestione dei farmaci e le cure terminali.
Ed anche negli outcome primari: una migliore sopravvivenza, un minor
numero di ospedalizzazioni, un migliore approccio del paziente al
trattamento e, in definitiva, una migliore qualità della vita.
65. missioni in capo alla specialità.
•a) “il nefrologo è un internista con una specializzazione rispetto
all’organo”;
•b) “in condizioni di ridotta funzionalità del rene, c’è bisogno di uno
specialista nefrologo”;
•c) “il nefrologo è lo specialista degli squilibri idroelettrolitici” con massima
espressione clinica nell’insufficienza renale a diuresi assente;
•d) “il nefrologo è colui che ha competenze precipue della dell’insufficienza
renale acuta”;
•e) “il nefrologo è colui che ha competenze precipue per il trattamento delle
complicanze multiorgano derivate dall’insufficienza renale cronica”;
•f) “la nefrologia è la specialità di malattie poco note (glomerulonefriti)” che
possono essere alla base di ipertensione secondaria o di insufficienza renale
cronica, se non diagnosticate tempestivamente.
CUSAS
66.
67. Progress toward the “Patient-
Centered Medicine”
Bardes CL. New Engl J Med. 366:782, 2012
68. Non Dimenticare l’Ennalogo di
Richard Smith
.. l’azione più urgente ed efficace è quella di
intervenire onestamente sulle aspettative dei
cittadini nei confronti di una “medicina
mitica” che tutto risolve …..
3. la maggior parte delle malattie gravi non può
essere guarita
4. tutti i farmaci hanno anche effetti collaterali
5. buona parte delle procedure diagnostiche e
degli interventi sanitari producono solo benefici
marginali (e talvolta non li producono affatto!)
Smith R. British Medical Journal, 1999
73. • Thirty-day in-hospital mortality correlated with time in clinical practice;
decreasing from 8.9% and 9.1% with <15 and 15–20years to 7.7% for
each of the categories of >20≤25years and >25years.
Certified specialists appear to continue with experiential learning with
evidence of improved outcome after 20years in clinical practice.
74.
75. • I risparmi obbligati di oggi rischiano di
moltiplicare la spesa nel giro dei prossimi
anni” (W. Ricciardi)
76.
77. • The 2011—12 increased mortality in people older than 55 years (about 2200 excess deaths)
probably constitutes the first evident short-term consequence of austerity on mortality in
Greece. This trend is probably related to barriers to access health care for chronically ill
patients because of the drastic restrictions in health policies and the increase in uninsured
individuals
The 2008—12 rise in the number of deaths is attributed to
the increase in the number of deaths in the oldest
individuals, with 12·5% and 24·3% increases in people aged
80—84 years and older than 85 years, respectively
78. ”Non pretendiamo che le cose cambino se
continuiamo a farle nello stesso modo.
La crisi è la miglior cosa che possa accadere a persone e interi
paesi perché è proprio la crisi a portare il progresso
http://www.slideshare.net/slideshow/embed_code/34292948
http://www.slideshare.net/pqr9ap/