Modelli a confronto L'ASSISTENZA AI MALATI CRONICI - Gavino Maciocco - Medicina Democratica
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L’ASSISTENZA AI MALATI CRONICI
Modelli a confronto
Gavino Maciocco
gavino.maciocco@unifi.it
109: 3112–21.
67344-8.
www.thelancet.com Vol 366 October 29, 2005
The neglected epidemic of chronic disease
Published online The reduction of chronic disease is not a Millennium and policymakers can no longer afford to ignore. The call
October 5, 2005
DOI:10.1016/S0140-6736(05)
Development Goal (MDG). While the political fashions by Kathleen Strong and colleagues4 for the world to set a
67454-5 have embraced some diseases—HIV/AIDS, malaria, and target to reduce deaths from chronic disease by 2%
See Comment page 1512 tuberculosis, in particular—many other common annually—to prevent 36 million deaths by 2015—
See Series page 1578
conditions remain marginal to the mainstream of global deserves to be added to the existing eight MDGs.
action on health. Chronic diseases are among these Without concerted and coordinated political action,
neglected conditions. the gains achieved in reducing the burden of infectious
Chronic diseases represent a huge proportion of disease will be washed away as a new wave of
human illness. They include cardiovascular disease (30% preventable illness engulfs those least able to protect
of projected total worldwide deaths in 2005), cancer themselves. Let this series be part of a new international
(13%), chronic respiratory diseases (7%), and diabetes commitment to deny that outcome.
(2%). Two risk factors underlying these conditions are
key to any population-wide strategy of control— Richard Horton
tobacco use and obesity. These risks and the diseases The Lancet, London NW1 7BY, UK
they engender are not the exclusive preserve of rich 1 Yusuf S, Hawken S, Öunpuu S, on behalf of the INTERHEART study group.
Effect of potentially modifiable risk factors associated with myocardial
nations. Quite the contrary.1 Chronic diseases are a larger infarction in 52 countries (The INTERHEART study). Lancet 2004;
problem in low-income settings. Research into chronic 364: 937–52.
2 Sorensen G, Gupta PC, Pednekar MS. Social disparities in tobacco use
diseases in resource-poor nations remains embryonic. in Mumbai, India: the roles of occupation, education, and gender.
Am J Public Health 2005; 95: 1003–08.
But what evidence there is2,3 shows just how critical it 3 Pampel FC. Patterns of tobacco use in the early epidemic stages: Malawi
will be to intervene early in the epidemic’s course. There and Zambia, 2000–2002. Am J Public Health 2005; 95: 1009–15.
4 Strong K, Mathers C, Leeder S, Beaglehole R. Preventing chronic diseases:
is an unusual opportunity before us to act now to how many lives can we save? Lancet 2005; 366: 1578–82.
prevent the needless deaths of millions. Do we have the 5 Epping-Jordan JE, Galea G, Tukuitonga C, Beaglehole R. Preventing chronic
diseases: taking stepwise action. Lancet 2005; published online Oct 5.
insight and resolve to respond? DOI:10.1016/S0140-6736(05)67342-4.
With a new series of articles,4–7 for which we thank the 6 Reddy KS, Shah B, Varghese C, Ramadoss A. Responding to the threat of
chronic diseases in India. Lancet 2005; published online Oct 5.
superb efforts of Robert Beaglehole, The Lancet aims to DOI:10.1016/S0140-6736(05)67343-6.
fill a gap in the global dialogue about disease. It is a 7 Wang L, Kong L, Wu F, Bai Y, Burton R. Preventing chronic diseases in
China. Lancet 2005; published online Oct 5. DOI:10.1016/S0140-
surprising and important gap, one that health workers 6736(05)67344-8.
1514 www.thelancet.com Vol 366 October 29, 2005
Obesity Trends Among U.S. Adults
between 1985 and 2009
• In 1990 ten states had a prevalence of obesity less than 10% and no
states had prevalence equal to or greater than 15%.
• By 1999, no state had prevalence less than 10%, eighteen states had a
prevalence of obesity between 20-24%, and no state had prevalence
equal to or greater than 25%.
• In 2009, only one state (Colorado) and the District of Columbia had a
prevalence of obesity less than 20%. Thirty-three states had a
prevalence equal to or greater than 25%; nine of these states (Alabama,
Arkansas, Kentucky, Louisiana, Mississippi, Missouri, Oklahoma,
Tennessee, and West Virginia) had a prevalence of obesity equal to or
greater than 30%.
Obesity Trends* Among U.S. Adults
BRFSS, 1990, 1999, 2009
1990 1999
2009
No Data
USA. N. CASI DI DIABETE DAL 1980 AL 2010
USA. Mappa della prevalenza dell’obesità negli Stati (in rosso
scuro la prevalenza è uguale o superiore al 30%).
USA. Mappa delle contee in cui la speranza di vita alla nascita mostra uno stop nella crescita o una regressione (punti arancioni e rossi).
prominent food researcher who has resigned
from Cornell University after six papers were
retracted by JAMA and its specialty journals
over suspicions of P-hacking.
WHICH IS?
Playing around with data until you find a
correlation that meets the statistical standard
for significance, which is P less than 0.05.
REMIND ME WHAT P IS
ort in the British
ancer. Cancer
LIFE P measures the probability that any
correlation has arisen by chance. If it’s less
K is launching a
o raise awareness
EXPECTANCY than 0.05 (one in 20) that’s taken as good
enough to reject the chance explanation and
weight increases the UK life expectancy regard the correlation as real.
pes of cancer. did not improve in
CAN YOU GIVE ME AN EXAMPLE?
2015 to 2017 and Wansink did an experiment in an Italian
students remained at restaurant where half the customers paid
face worsened
medical school
and shrinkage of
79.2 years
for males and
half price for a buffet meal. He was convinced
there would be a correlation between how
much they paid and how much they enjoyed
82.9
try medical degree the food. But there wasn’t.
opping candidates years for A FAILED EXPERIMENT, THEN?
e backgrounds
females. It fell by Not at all. He encouraged a graduate student
profession,
0.1 years for males to slice and dice the data until she found a
rned in a letter to
significant result. Try breaking up the diners
of the Royal Society and females in into groups, he suggested: “males, females,
The proposal to Scotland and Wales, lunch goers, dinner goers, people sitting
MC registration and for males in alone, people eating with groups of two,
d of the first year people eating in groups of more than two,
Northern Ireland
n training to and so on.”
rom medical school [Office for National
o blame, they said, Statistics] DID IT WORK? da BMJ, 24.2.2018
oundation year Like a dream. In a year she had published fourEPIDEMIA DI OBESITA’ NEL MONDO. PROIEZIONI AL 2030. FONTE OECD
50% United States
45%
Mexico
40%
35%
30% Canada
% of obesity
25%
Spain
20%
England Italy
15%
Korea
10%
France
5% Switzerland
0%
1970 1980 1990 2000 2010 2020 2030
Year• Le diseguaglianze nella salute, tra paesi e all’interno dei paesi, non sono mai state così grandi nella storia recente. Noi viviamo in un mondo di paesi ricchi pieni di gente povera e malata. • La crescita delle malattie croniche minaccia di allargare ancora di più questo gap. Gli sforzi per prevenire queste malattie vanno contro l’interesse commerciale di operatori economici molto potenti e questa è una delle sfide più grandi da affrontare nella promozione della salute.
• Negli anni 80, quando parlavamo di collaborazione multisettoriale per la salute ciò significava lavorare insieme a settori amici, come istruzione, casa, nutrizione, acqua e igiene. Quando la sanità collaborava con il settore educativo e con quello che si occupava di acquedotti e fognature, i conflitti d’interesse erano una rarità.
Oggi a convincere le persone a condurre stili di vita sani e adottare comportamenti salubri ci si scontra con forze che non sono così amiche. Anzi non lo sono per niente. Gli sforzi per prevenire le malattie croniche vanno contro gli interessi commerciali di potenti operatori economici. Secondo me, questo è la più grande sfida che si trova di fronte la promozione della salute.
• E non si tratta più solo dell’industria del tabacco (Big Tobacco). La sanità pubblica deve fare i conti con l’industria del cibo (Big Food), delle bevande gassate (Big Soda) e alcoliche (Big Alcohol). Tutte queste industrie hanno paura delle regole, e si proteggono usando le stesse, ben note tattiche. Queste includono gruppi d’opinione, lobbies, promesse di autoregolamentazione, cause legali, ricerche finanziate dall’industria che hanno lo scopo di confondere le prove e tenere il pubblico nel dubbio.
Le malattie croniche - specialmente le malattie
cardiovascolari, il diabete, il cancro e le malattie respiratorie
croniche - sono trascurate, nonostante la consapevolezza del
grave carico che esse provocano
Le politiche globali e nazionali non sono riuscite a
fermare – in molti casi anzi hanno contribuito a
diffondere – le malattie croniche. Attualmente sono
facilmente disponibili soluzioni a basso costo e di
alta efficacia per la prevenzione delle malattie
croniche; il fallimento nella risposta è oggi un
problema politico, piuttosto che tecnicoMalattie croniche.
La catena delle cause
• Reddito Fattori di • Accessibilità
• Istruzione
• Classe sociale
rischio • Utilizzazione
• Qualità
• Sedentarietà
Determinanti • Eccesso di peso Assistenza
sociali • Fumo
• Alcol sanitaria• “Nonostante si viva in un mondo dominato dalle patologie croniche, nei luoghi di cura si pratica una medicina quasi esclusivamente per acuti: all’alba del XXI secolo persistono i modelli del XIX secolo” • (R. Rozzini e M. Trabucchi, 2013)
Dr Hart. data are consistent with the hypothesis
Anticipatory population
Health care helps reduce mortality. I
BMJ7 1991;302:1509-13 the Care
new contract, which encourage th
Twenty five years of case finding and audit in a socially deprived
community BMJ VOLUME 302 22 JUNE 1991
Julian Tudor Hart, Colin Thomas, Brian Gibbons, Catherine Edwards, Mary Hart, Janet Jones,
Margaret Jones, Pam Walton
Abstract development of structured process, may diminish
Objective-To evaluate audit and case finding health outputs.
(whole population care) in a community over 25
years. Introduction
Design-Contemporary screening for and audits
of care of chronic disease and risk factors; retro- For health as for commodity production, absolute
Julian Tudor Hart spective review of computerised practice records; growth conceals relative decline. By 1980 the United
and comparisons of mortality and social indices with Kingdom ranked highest in the European Community
neighbouring communities. and Scandinavia for all causes mortality in men and
Setting-One general practice in Glyncorrwg, women aged 45-64.'
Our aim was to improvehealth in West theGlamorgan. The close and causal relation between mortality,
morbidity, and social class for all major causes2' is the
Subjects- 1800 people registered with the practice
in 1987 and 558 people who died from 1964 to 1987, main explanation for the exceptionally high mortality
whole registered population by
whose records had been retained. and morbidity in Scotland, Northern Ireland, and
Main outcome measures -Detection of high blood parts of northern England and south Wales, for all
pressure, smoking, airways obstruction, obesity, causes as well as for coronary disease. As inequalities in
identifying treatable problems atprevalence
an andofalcohol
diabetes, Saturday 27 Feb
problems in adults aged 20-79; wealth have grown so have inequalities in sickness and
smoking in this population and in death.4 These differences are compounded by in-
hypertensive and diabetic groups; age standardised creasing inequalities in clinical resources available to
mortality ratios in relation to indices of social deal with them: fed by the market, the inverse care law'
earlv, often presymptomatic stage,
deprivation. thrives. As predicted by thoughtful economists,67 the
new general practitioner contract accelerates previous
Results-In the population aged 20-79 (1207
patients) 249 (21%) had peak expiratory flow rate less trends, promoting investment in high earning practices
and to learn from our by
mistakes than 50% of expected value or which THE improved by serving affluent areas, where care is easier,8 and
LAW in practices whoseinterpreted earnings are eit
15% or more with an inhaled I3 agonist, 207 (17%) had discourages
INVERSE CARE investment
lowest,
body mass index at or over 30 kg/m2, 118 (10%) had TUDOR HART whose patients are poorer and sicker,
high whose or
users,
looking for them systematically.
Department of General
Practice, St Mary's
untreated mean arterial pressures
159/104 mm Hg (three readings),
greater
Health
JULIAN
than
Centre,
80 (7%) (65 (16%)
Glyncorrwg
costs are higher, and whose clinical work
difficult.'
Port Talbot, Glamorgan, Wales
them
the
is from
more the
valid evid
Hospital Medical School, men, 15 (4%) women) had recognised alcohol As the Cardiff' and Ipswich" studies of non-insulin consult
London W2 1PG problems, and 35 (3%) had diabetes. dependent
The availability
The proportion ofdiabetes exemplified,
good medical routine higher
care management
the N.H.S., a
Julian Tudor Hart, FRCGP, Summary
of men aged 20-64 who said they smoked fell tendsfrom of chronic disease in general practice
to vary inversely with the need for compares badly
lecturer with routine hospital outpatient differences
practice. For the in
61% (290/476) in 1968-70 to 36%the
it in (162/456) in 1985served. This inverse care law
population that Titmuss’s
general population, rule of halves'2 still applies,
This proactive policy depended on the not
Department of Geography, whereas that of women whooperates smoked more
was unchanged
completelyonly where medical care is most
for hypertension but also probably no for other
significant
University of Swansea, (43%, 187/436 v 42%, 190/448 respectively).
exposed to In
market 116
forces, and
health risksless
in so where such
which demands relate littleof needs. As car
to medical
Swansea SA2 8PP screened hypertensive patients group mean
exposure is reduced. blood The market distribution
of magnitude, half of all of
specific health needs
treatment an order Class gradie
practice organisation, teamwork,
Colin Thomas, PHD, lecturer pressure fell from 186/110 medical
mm Hg before
to 146/84 mm Hg at 1987 audit, as did
care is a primitive
the proportion are and
not historically
known, half of those known are nottohelped,
outdated
not effective.
and
this view.
Aber/Blaengwynfi Health of smokers (56% v 20%), but body mass index and half the
social form, and any return to help given isfurther
it would exag- "
One conclu
Centre, West Glamorgan gerate the maldistribution This
of paper describes
medical resources. an attempt, sustained over 25
and structured records.
Brian Gibbons, MRCGP,
total cholesterol concentration showed no significant
change. In 34 diabetic patients mean blood pressure years, to contain or reverse these trends classes have hi
in
health variablessicker
one small
or less l
general practitioner Saturday
and the proportion of smokers fell (171/93 Interpreting
mm Hg v community
the27 February
by assessing 1971
Evidence throughout
... it is usefSperimemtare il CCM a
FirenzeTHE CHRONIC CARE MODEL
2008 -2010
German Disease Management Program
Arruolati GDMP
2006 2012
Diabete tipo 1 29.000 156.000
Diabete tipo 2 1.948.000 3.749.000
Cancro della
67.000 126.000
mammella
Cardiopatia
635.000 1.700.000
ischemica
Asma 6.000 799.000
BPCO 8.000 633.000
Totale 2.693.000 7.163.000LA
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