Appropriateness, over-prescription of drugs and responsibility of GPs, let’s clarify

by Giuseppe Belleri

22 APR –

Dear Director,
I would like to add some general considerations on the issue of appropriateness, raised by recent initiatives that have targeted generalists accused of respecting spending averages.

The concept of appropriateness lends itself to improper initiatives due to its complexity: just think that the 2012 ministerial document on clinical governance cites over a dozen national and international definitions, united by their multidimensional and multifaceted character, attributable to the galaxy of quality.

The use of financial parameters, such as spending averages, to evaluate prescriptive inappropriateness is different from economic logic, which concerns the allocation of scarce resources for the achievement of health objectives or clinical outcomes (effectiveness) resulting from choices rational (efficiency and cost-effectiveness) in a framework of distributional equity, in compliance with regulatory standards and good practices recommended by clinical studies, guidelines and shared paths.

Outside of this framework, which mainly concerns prevalent chronic pathologies, the financial parameters unrelated to the clinical results achieved are unsuitable for evaluating the work of a doctor from the point of view of appropriateness which, it is worth remembering, refers only to individuals clinical cases and not to the population size. In fact, as the ministerial document underlines, in practice appropriateness refers to the “correct procedure on the right patient at the right time and in the most suitable setting”, avoiding risks not proportionate to the benefits, over and under use of services and unjustified prescriptive variability.

Inappropriateness can be either excessive or insufficient and is influenced by three variables – relating to epidemiology, the doctor’s choices and the systemic dimension – which may or may not justify the individual statistical deviance of the financial averages:

1 The “weighted” demographic composition of those assisted: higher than average percentages of over-65s, elderly people, civilian invalids, frail non-self-sufficient people, terminally ill patients, etc. can explain part of the possible deviation, as this data is correlated to the increase in spending independently of other parameters.

2 The prevalence of chronic or rare pathologies, documented by the relevant exemptions: for example, if a GP has a high number of diabetics and/or hypertensives in his care, correlated to the previous point and/or to a greater individual diagnostic sensitivity, it will automatically deviate from the average of the population of its area. In theory, a doctor who implements widespread and effective control of risk factors on a large portion of the population could deviate excessively from the averages, but certainly not due to inappropriateness. In fact, a temporary increase in spending on drugs or checks in the short-medium term can contain acute events, complications and functional worsening in the long term and therefore also the costs of hospitalizations or secondary prevention.

3 Prescribing medications with notes and/or suggestions. Not all chronic drugs are the work of the GP as some are induced by the specialists consulted. A paradigmatic example is that of anti-glaucoma eye drops: it is clear that an excess of prescriptions cannot be attributed to the GP since he has no role in the diagnosis and monitoring of ocular hypertension, a risk factor managed in total autonomy by the GP ophthalmologist, but without the related “imputation” of expense. The same argument applies to all chronic drugs subject to a Therapeutic Plan or of almost exclusive specialist prescription for low prevalence or rare pathologies.

The GP cannot be attributed responsibility for all the expenditure that passes through his pen, because he is only one of the actors in the complex prescriptive system distributed between the hospital and the territory, which converts the demand into diagnostic and therapeutic services, many of which fall then on the generalist, for example after a consultation or a hospital stay, as if he were the only one responsible for the entire “supply chain”. For a correct and fair assessment of appropriateness, the costs of induced prescriptions should be deducted from the GP’s “account”, as, among other things, the prescription states with the indication of the “suggested” drug.

In addition to hyper-prescribing, there is also the mirror problem, no less relevant in terms of equity and quality, namely that of hypo-prescribers, who are not automatically “virtuous” doctors, but in a rational vision could on the contrary be accused of a lack of care in relation to the recommendations from the diagnostic pathways, starting from the diagnosis and the prevalence of chronic conditions among their patients. I am not aware that they are summoned, like the alleged over-prescribers, to account for any inappropriateness by default, for example a lack of care which entails more serious health risks than any over-prescribing.

In conclusion, financial averages in the abstract, i.e. unrelated to clinical behavior (process and outcome indicators) and the epidemiology of the individual doctor (personal composition and prevalence of chronic pathologies) have no logical-rational basis and are unjustified on a scientific and scientific level. systemic organisation.

As Grilli and Taroni observed at the beginning of the century, “The processes of production and distribution of health services take place through networks of complex and poorly hierarchical relationships between different organizations and professions, in which none of the numerous actors can exercise the function of command and control and, at the same time, there is no single person to whom overall responsibility can be attributed”.

Giuseppe BelleriFormer GP – Brescia

April 22, 2024
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