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1 Cardiovascular Prevention in Milan, Lombardy Dr. Walter Locatelli General Director Heart Friends around the World San Pellegrino May 17-23 2010

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2 Cardiovascular Prevention in Milan, Lombardy presented by dr. Donatella Sghedoni, M.D. , Specialist in Public Health on behalf of Dr. Walter Locatelli , General Director of ASL of Milan Dr. Walter Locatelli General Director Heart Friends around the World San Pellegrino May 17-23 2010

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3 Contents Heart Friends around the World San Pellegrino May 17-23 2010 Italian National Health System and roles of regions and ASLa Features of ASL of Milan and CV epidemiology GP’s features and involvement in CV prevention Projects for CV Prevention in Milan CME and Health Education Research in Primary Care

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4 Roles of the Regions and ASLs The 19 Italian Regions and 2 Autonomous Provinces have a large autonomy in terms of laws and regulations for health care planning and financing. Heart Friends around the World San Pellegrino May 17-23 2010

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5 Roles of the Regions and ASLs The health services (hospitals and ambulatories) are administered at local level. In addition to health care, the Local Health Units (ASLs in Lombardy, USSLs in other Regions ) are concerned with protecting and promoting public health and are responsible for achieving the health objectives and targets established by national and regional plans. Heart Friends around the World San Pellegrino May 17-23 2010

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6 Italian National Health Service NHS features Universal coverage Strong integration with social services No co-payment for hospital stays Patients with chronic diseases are exempted from co-payments No payment to GPs, also for home visits Heart Friends around the World San Pellegrino May 17-23 2010

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7 NHS features in Lombardy Excellence hospitals with patients coming from other Regions (in Milan Accreditation of public and private hospitals Small co-payment (max 4 € for prescription) for drugs Co-payment for specialist consultations and diagnostic tests (max 30 €) Short waiting lists Balanced Budget Heart Friends around the World San Pellegrino May 17-23 2010

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8 Tasks and Mission of ASL of Milan Heart Friends around the World San Pellegrino May 17-23 2010 Purchase and control of cost-effective health services from accreditated public and private hospitals through clinical governance (peculiar to Lombardy Region) Direct supply of some health and social services (e.g. vaccinations, safety of workplaces, medical aids, veterinary services) Coordination, education and management of General Practitoners and out-of-hours doctors in order to guarantee the health of all its population, including appropriate prevention, diagnosis, cure , rehabilitation … respecting the individual’s choices

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9 ASL of Milan: the largest single ASL in Italy Heart Friends around the World San Pellegrino May 17-23 2010 Caring for 1.626.213 people and covering an area of 225.49 sq. Kms, including both the city and six municipalities at North,organized in 7 Health Districts with a staff of 2.095 people, including 277 Medical and Veterinary Doctors and Pharmacists and with a General Director (dr. G. Walter Locatelli) nominated by Lombardy Region the 1 August 2009 31 hospitals (including 10 university and large hospitals) with a total of 12.000 beds and 6 Dpts of Cardiosurgery

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10 All Cardiovascular Disease Deaths in the world Territories are sized in proportion to the absolute number of people who died from diagnosed cardiovascular disease in one year. (source: www.worldmapper.org) Heart Friends around the World San Pellegrino May 17-23 2010 Cardiovascular diseases caused 29% of all deaths worldwide in 2002, an average of 2688 deaths per million people per year. In Italy they are the first cause of death

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11 Dr. Walter Locatelli General Director Cardiovascular Prevention Heart Friends around the World San Pellegrino May 17-23 2010 From the Atlas of Hospitalization and Mortality in Milan and from the Regional Health Data Bank (BDA) Standardized and Weighted Hospitalization rate for Cardiovascular diseases ICD-IX 390-459                                                                                                                                                        Women

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12 Heart Friends around the World San Pellegrino May 17-23 2010 CV Mortality and Inequality (Source : A.Russo e L:Bisanti, Atlas of Hospitalization and Mortality in Milan, 2005) Women Relative Risk for Income Income Quintiles

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13 Heart Friends around the World San Pellegrino May 17-23 2010 CV diseases in Milan Cardiovascular diseases, often combined with diabetes, are the most frequent cause of death in Milan, as well as in Italy and in all the developed countries, even if with a decreasing trend in the last 15 years, probably both because of a growing awareness of risky life-styles (smoking) and of therapeutical progress (e.g. thrombolityc treatment of AMI….) In Milan the people with new diagnosed cardiovascular diseases each year are around 14,000, but those living with them reach 400,000 and their health expenses are therefore one of the main issues of the ASL health budget, that we would like to tackle and optimize. There is an inverse linear relationship among mortality and income, with those living in the richest area having a 40% risk reduction As in other CV diseases, women die more often but all hospitalization and pharmaceutical data show instead more men being treated, so gender seems to affect unfavourably the access to care.

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14 Heart Friends around the World San Pellegrino May 17-23 2010 Primary Health Care in Milan 1286 General Practitioners (GPs) including 170 Family Pediatricians 95 out-of-hours doctors organized in Group and network practices (142) with all-day access and nurses, covering more than half of the population and also Solo-practices All web-connected to the ASL and to the hospitals (in Lombardy)

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15 Italian GPs ‘ features favouring prevention of CV diseases Heart Friends around the World San Pellegrino May 17-23 2010 Self-employed but with national, regional and ASL agreements Capitation payment with incentives for special projects and services with a list of patients Gatekeeping and health education role High accessibility : free of charge consultations both by appointment and by free access Knowledge of the patients’ personal, familiar and social circumstances The most appreciated and trusted actors of NHS according to surveys

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16 European GPs’ desidered features Heart Friends around the World San Pellegrino May 17-23 2010

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17 Heart Friends around the World San Pellegrino May 17-23 2010 Cardiovascolar Prevention in Milan and Lombardy Health “Dowry” Project with GPs 1 GPs receive a list of his/her pts with DM type 2 and Hypertension , as from Regional Health Data Base GPs integrate the list with their own knowledge of pts (CV Risk chart) and select those to be followed mostly in Primary Care GPs writes a personalised “Health care plan” for each selected pt, including needed lifestyle changes, tests and drugs

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18 Heart Friends around the World San Pellegrino May 17-23 2010 Cardiovascolar Prevention in Milan and Lombardy Health “Dowry” Project with GPs 2 The GP discusses the Plan with the Pt. and she/he chooses wheter to commit her/himself formally or not to follow it , included its “10 rules for CV Prevention” and other specific Health Education material GPs perform selected EB CV monitoring at set intervals (BP, Hb A1c, BMI…) and drug therapy following Clinical Pathways agreed with Specialists GPs report to ASL their data monitoring

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19 Heart Friends around the World San Pellegrino May 17-23 2010 Health “Dowry” Project with GPs 3 Project agreed with GPs’ Unions representatives Voluntary Participation of GPs (participating 346 out of 1116) GPs will receive a bonus according to the n° of patients successfully followed for one year The ultimate goal of the Project is to extend the EBM best practices to the community.

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20 Heart Friends around the World San Pellegrino May 17-23 2010 Health “Dowry” Project with GPs : Indicators Diabetes Process Indicators : All enrolled pts must have at least two Hb A1c dosages in the year and an eye fundus in the last two years Outcome Indicators 70% of enrolled pts must have Hb A1c < 7 for diabetics recently diagnosed and < 8 for others and received metformin as first choice, if not otherwise contraindicated Hypertension Process Indicators : All enrolled pts must have at least two BP measures and follow the PDTA recommended therapy Outcome Indicators 70% of enrolled pts must have their BP values within the normal range

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21 Heart Friends around the World San Pellegrino May 17-23 2010 The 10 Golden Rules to prevent CV risk 1 (source: Il Progetto Cuore Istituto Superiore di Sanità) 1 Avoid smoking, both actively and passively 2 Increase your daily intake of seasonal fruit and vegetables (at least 3 vegetable servings + 2 fruit servings) 3 Increase your daily intake of fish, legumes and whole cereals 4 Limit your intake of fats, cheeses and sweets (do not eat fried food and favour raw olive oil for dressing) 5 Limit your intake of salt and moderate your intake of alcohol (use spices and do not add salt to cooked food, keeping it under 6 g/day)

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22 Heart Friends around the World San Pellegrino May 17-23 2010 The 10 Golden Rules to prevent CV risk 2 (source: Il Progetto Cuore Istituto Superiore di Sanità) 6 Keep your weight under control and keep yourself active (..keep your BMI under 25 and exercise regularly) 7 Make an adequate physical activity (…walking, bycicling, etc at least 30 minutes/day - may also relax you - and avoid staircases…) - see also specific leaflet 8 Check your BP (..You can also check it yourself but only with validated instruments..) 9 Check your cholesterol level 10 Check your blood glucose level

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23 Dr. Walter Locatelli General Director Cardiovascular Prevention Heart Friends around the World San Pellegrino May 17-23 2010 Continuing Medical Education for GPs by ASL of Milan 1 Indipendent Agreed and organized with GPs Compulsory Targeted to CV Risk calculation , Prevention and Counselling based on EB Diagnostic,Clinical and Therapeutic Pathways PDTA agreed with Specialists and Hospitals (- Statins ; - Hypertension, - Diabetes Mellitus type 2 …….) integrated by periodic mailing of “Pillole di Buona Pratica Clinica” for doctors, followed by “Pillole di Educazione Sanitaria” for patients on targeted items and practical booklets for patients

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24 Dr. Walter Locatelli General Director Cardiovascular Prevention Heart Friends around the World San Pellegrino May 17-23 2010 Continuing Medical Education for GPs by ASL of Milan 2 Favouring healthy habits with special focus on nutrition , physical activity and smoking cessation Promoting prolonged breast-feeding and obesity control in children Fostering the use of non-branded drugs, when available, Promoting an EB and appropriate use of diagnostic tests Integrated by periodic mailing of “Pillole di Buona Pratica Clinica” for doctors, followed by “Pillole di Educazione Sanitaria” for patients on targeted items and practical booklets for patients

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25 Heart Friends around the World San Pellegrino May 17-23 2010 Examples of specific issues and campaigns: physical activity Project “Staircases for Health”, encouraging the use of staircases instead of elevators Tools for GPs Posters for the surgeries and the buildings where surgeries are located Special “Pill of Health Education for Citizens” (leaflet with detailed information about benefits and bibliography) , preferably to be handed out as “prescription” to selected pts.

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26 Heart Friends around the World San Pellegrino May 17-23 2010 Staircases for Health: medical reasons total cholesterol ↓ and HDL↑ the strenghtening of the leg muscles is important to maintain a higher bone density and to prevent hip fractures more muscles mean more calories used even at rest the GP usually knows possible individual controindications

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27 Heart Friends around the World San Pellegrino May 17-23 2010 Staircases for Health: sociopsychological reasons It is simple It may be started at any age, even old It is acceptable to any culture It has no cost and requires no equipment It may be graduated at will and does not require an ongoing commitment It may save time No group is required It may be inserted easily in any routine It may be adopted also at work Especially important in cities It saves energy and is eco-friendly

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28 Heart Friends around the World San Pellegrino May 17-23 2010 Examples of specific issues and campaigns: Food as an alternative to omega-3 drugs Omega-3 fatty acids as drugs have a protective effect on mortality after a myocardial infarction and are therefore fully paid by the Italian NHS for this indication, making up the 1.4% of the total drug expenditure in Italy in 2004, not counting the out-of-the-pocket expenditure as primary prevention. A Mediterranean diet, enriched by moderate quantities of fat fish, walnuts, soy and flax-seeds, has been shown to give a similar advantage (de Lorgeril et al. Eur Heart J, 18:13, 1997; Burr et al., 1989) and may be suggested to the whole population

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29 Heart Friends around the World San Pellegrino May 17-23 2010 Primary Care Research in CV Prevention  “Rischio & Prevenzione”: Ongoing participation of GPs of Milan in a large (860 Italian GPs in 57ASLs) , randomized, multicentric , double-blind trial all run in Primary Care, aimed to verify the effectiveness of prevention with omega 3 in a population at high CV risk, in modifying “hard” indicators during a 5 year follow-up, supervised by Mario Negri Institute “Prevenzione e cura del cardiodiabete” Collaboration of GPs with 3 large hospitals for evaluating the prevalence of DM in patients with IMA and for evaluating the CV in their first-grade relatives  “CAPRESS Study” Collaboration of GPs with a University Hospital to evaluate additional parameters non included in CV risk charts to better stratify people at intermediate risk ……..

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30 Dr. Walter Locatelli General Director Cardiovascular Prevention Heart Friends around the World San Pellegrino May 17-23 2010 Thank You very much for your attention and enjoy Your stay in Italy and in Lombardy!

Tags: cardiology

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