nefroogia ed aconomia

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gli aspetti farmacoeconomici delal nefrologia

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BMJ VOLUME 325 16 NOVEMBER 2002 bmj.com

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Willingness to pay

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Soglie assolute Afro D Amro A Euro A Searo B Searo D Wpro A GDP per capita * $1.695 $39.950 $30.439 $4.959 $1.990 $30.708 3 x GDP per capita * $5.086 $119.849 $91.318 $14.876 $5.971 $92.123 GDP = Gross domestic product ; < GDP per capita (Very cost-effective) ; 1-3 x GDP per capita (cost-effective) ; > 3 x GDP per capita (not cost-effective)

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4 i tipi di analisi economiche: MINIMIZZAZIONE DEI COSTI (cost minimisation) COSTO-BENEFICIO (cost-benefit) COSTO EFFICACIA (cost-effectiveness) COSTO UTILITÀ (cost utility) Farmacoeconomia: TIPI DI ANALISI Economic evaluation relates outputs of competing interventions to the resources consumed Kernick DP, BMJ, 316, 1998

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Al fine del confronto viene costruito un rapporto (COSTO/ESITO) in cui gli esiti definiti in termini clinici vengono rapportati ai costi: L ’ analisi “ costo-efficacia ” aiuta ad individuare tra diverse alternative quella ottimale rispetto ad un dato obiettivo . . c) Costo-efficacia (Cost-effectiveness analysis:CEA) Fondamentale nell ’ analisi costo-efficacia è la revisione e la sintesi delle evidenze disponibili relative alla problematica affrontata . Non e’ quindi il denaro che conta ma l’efficacia della prestazione

La piramide dell’Evidenza:

La piramide dell ’ Evidenza Studi randomizzati e controllati condotti in doppio cieco Ricerca “ in-vitro ” e su modelli cellulari Ricerca su modelli animali Editoriali, rassegne, ed opinioni di “ esperti ” Casi clinici Serie di casi e Studi trasversali Studi caso-controllo Studi di coorte RCT DB RCT Studi randomizzati e controllati Meta-analisi Clinical Trials

I TRATTAMENTI SOSTITUTIVI DELLA FUNZIONE RENALE IN ITALIA: ASPETTI CLINICI, ECONOMICI E SOCIALI STUDIO CENSIS – 2009 - DATI PIEMONTE:

I TRATTAMENTI SOSTITUTIVI DELLA FUNZIONE RENALE IN ITALIA: ASPETTI CLINICI, ECONOMICI E SOCIALI STUDIO CENSIS – 2009 - DATI PIEMONTE

Come si risparmia in Nefrologia?:

Come si risparmia in Nefrologia? Ridurre le alterazioni metaboliche della IRC Ridurre l ’ ingresso in dialisi Ridurre le complicazioni legate all ’ uremia

Percentuali di pazienti a cui è stata segnata una creatininemia e’ 49% :

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 7796 = 49% 51 % 16% 33%

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Insufficienza renale Dr. G. Quintaliani 12 9132 pts 19% = 1 su 5 7631 461 1040 1.2 Prevalenza - Incidenza Un terzo dei pazienti aveva IRC

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early! late! too late! 13 Ma quando iniziano le alterazioni metaboliche?

Modificazioni del PTH e fosforo insorgono nelle fasi iniziali delle nefropatie croniche:

89-60 59-50 49-40 39-30 29-20 <20 GFR (mL/min/1.73 m 2 ) Iperparatiroidismo Anemia Acidosi metabolica Iperpotassiemia Iperfosforemia Moranne O et al. J Am Soc Nephrol 2009;20:164 Il 90% dei pazienti con HPTH (>60 pg/ml) aveva un GFR < 50 ml/min Il 90% dei pazienti con iperfosforemia (>4.3 mg/dl) aveva un GFR < 37 ml/min Modificazioni del PTH e fosforo insorgono nelle fasi iniziali delle nefropatie croniche

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15 There appears to be an association between higher serum levels of phosphorus and mortality in this population

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Go, et al. NEJM 2004 Epidemiological link between CKD and CVD x11 Death from Any Cause Cardiovascular Events x7 Hospitalization X 4.5

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Luca Degli Esposti 1, Stefania Saragoni 1,Stefano Buda 1, Alessandra Sturani 2,Giuseppe Quintaliani 3, Sandra Bartolucci 4,Roberta Di Turi 5, Paolo Lilli 6, Guido Didoni 7, Ezio Degli Esposti 1

Come si risparmia in Nefrologia?:

Come si risparmia in Nefrologia? Ridurre le alterazioni metaboliche della IRC Ridurre l ’ ingresso in dialisi Ridurre gli errori medici

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Occurrence of renal failure or death in patients in Study A including follow-up through 10 mo after study completion. LEVEY A S et al. JASN 1999;10:2426-2439 ©1999 by American Society of Nephrology

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Results: Treatment with a low-protein diet was more effective in terms of QALYs: the difference was always in favour of dietary treatment from a 0.09 QALYS after the first two years, 0.16 after three years, 0.36 after five years and up to a differential of 0.93 year after the first 10 years of treatment. In terms of cost-effectiveness, the dietary treatment was always dominant in all intervals considered. The dominance is due to the fact that the treatment is more effective in terms of QALYs and at the same time is less expensive.

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Dati di 9/17 regioni RIDT, 2000-2008, 35.000 soggetti 2011

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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.

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Quasi 30.000 euro in tre anni

Come si risparmia in Nefrologia?:

Come si risparmia in Nefrologia? Ridurre le alterazioni metaboliche della IRC Ridurre l ’ ingresso in dialisi Ridurre gli errori clinici Appropriatezza Errori

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La vera “ spending review ” o i veri tagli: Togliere quello che non serve o non è provato

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Thus, we found that publication of a large, expensive, randomized controlled trial in patients receiving hemodialysis had no immediate impact on clinical practice. The use of a common cardiovascular medication in this patient population appears to be influenced by other factors .

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Besarab Oncologist 2009 Ferro ed eritropoiesi Ferro Elaborazione Dr. Quintaliani E' fondamentale che le riserve di ferro siano portate a livelli accettabili Senza ferro anche l'eritropoietina e' inutile

ERRORI:

ERRORI

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Medication errors in patients with reduced creatinine clearance are harmful and costly; A chart review was performed on adult patients hospitalized during a 20-month study period with serum creatinine over 1.5 mg/dl who were exposed to drugs that are nephrotoxic or cleared by the kidney Among 109,641 patients, 17,614 had reduced creatinine clearance , in a random sample of 900 of these patients, there were 498 potential ADEs and 90 ADEs., 91% were preventable , 51% were serious, 44% were significant, and 4.5% were life threatening. All 82 preventable events could have been intercepted by renal dose checking

Studio ira inghilterra:

Studio ira inghilterra Only 50% of AKI care considered good Poor assessment of risk factors Unacceptable delay in recognition in AKI in 43% 22 pts died with a primary diagnosis of post-admission AKI which was predictable and avoidable Complications missed (13%), avoidable (17%) or badly managed (22%) 33% of patients had inadequate investigations 29% had inadequacies in clinical management Poor recognition of acute illness, hypovolaemia and sepsis

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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.

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A total of 1551 deaths were reviewed. A combination of organizational factors, such as the lack of timely access to emergency haemodialysis and human factors such as poor communication contributed to patient death from these causes

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La mortalità acuta (entro 48h da una iperpotassiemia) era piu ’ alta nel gruppo dei NON nefrologi

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Timing of referral emerged to be a significant factor impacting homogeneity in the mortality outcome. Our results suggest significantly higher mortality and increased early hospitalization of chronic kidney disease subjects referred late to nephrologists as compared with earlier referred subjects.

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Our analyses show reduced mortality and hospitalization, better uptake of peritoneal dialysis, and earlier placement of arteriovenous fistula for hemodialysis with early nephrology referral.

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Conclusions As for the Emilia-Romagna region of Italy, in-hospital mortality for MI is increasing over the last years, and mortality seems to be related with patients ’ comorbidities and presence of advanced stages of CKD. However, this study shows that renal dysfunction is associated with mortality from stroke , with significantly higher Ors than those of other established risk factors, such as age, comorbidities, and AF. information on kidney function is routinely available to clinicians at hospital presentation, and its evaluation could suggest the burden of vascular damage.

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Throughout the inquiry we heard evidence of underfunding, meaning that a gap had developed between the level of resources properly needed to meet the stated goals of the unit and the level actually available. There were constant shortages of trained nursing staff. The level of specialists was always below the level deemed appropriate by the relevant professional bodies. The consultants lacked junior support. They were expected to care for patients in places that were several hundred yards apart and to hold outreach clinics all over the region

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Uso incongruo della formula Iperteso non controllato

La Clinical Competence:

La Clinical Competence Disponibilita ’ di letteratura scientifica premier evidence-based clinical decision support resource

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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.

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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 per il trattamento 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

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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.

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“ 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.

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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

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Clinici e societa ’ scientifiche Politica e direttori generali

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Nephrol Dial Transplant. 2007 Jul;22(7):1955-62. Epub 2007 Apr 4.

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Rates of Death at Three Years from Cardiovascular Causes According to the Estimated GFR in Post-MI Adults Anavekar NS et VALIANT Study Group Follow Up: 24.7 months Patients with Cr >2.5 mg/dl excluded

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ESRD e Mortalità http://www.usrds.org

Un risparmio sicuro ?:

Un risparmio sicuro ? USA : circa 25-30% dei pazienti in dialisi ITALIA : circa 13-16% dei pazienti in dialisi (circa 38.000) con circa 4900 morti/anno Se in Italia avessimo la stessa mortalità americana avremmo un risparmio di 8700-4900= 3800 = 171 milioni anno risparmiati senza contare pensioni, accompagnamento ed invalidita ’

Rosuvastatina in dialisi studio poe vs doe:

Rosuvastatina in dialisi studio poe vs doe Conclusions In patients undergoing hemodialysis, the initiation of treatment with rosuvastatin lowered the LDL cholesterol level but had no significant effect on the composite primary end point of death from cardiovascular causes, nonfatal myocardial infarction, or nonfatal stroke. There was also no significant effect on all-cause mortality (13.5 vs. 14.0 events per 100 patient-years; hazard ratio, 0.96; 95% CI, 0.86 to 1.07; P=0.51). (ClinicalTrials.gov number, NCT00240331 [ClinicalTrials.gov] .) Results After 3 months, the mean reduction in low-density lipoprotein (LDL) cholesterol levels was 43% in patients receiving rosuvastatin, from a mean baseline level of 100 mg per deciliter.

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Go, A. S. et al. N Engl J Med 2004;351:1296-1305 Death from Any Cause Cardiovascular Events Hospitalization x11 x7 X 4.5 Conclusions . These findings highlight the clinical and public health importance of chronic renal insufficiency . Fattore di rischio indipendente

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