Istituto Neurologico Carlo Besta: ACTide’s role within the Project PDTAR

Diagnostic and Therapeutic Protocol (DTP) for the population and patients with Dementia

ASL Milan – Scientific Coordination:  Neurologic Institute Carlo Besta

Chirchiglia S. – Filippini G. – Morbin M. – Caccioppoli R. – Moser P. – Tramacere I.

According to the Epidemiology National Centre, between 1% and 5% of the population over 65 and 30% of the over 80 suffer from dementia. These figures mean over 20.000 cases within the city of Milan only. Alzheimer is responsible for over 50% of all such cases.

It has been estimated that in Europe by 2030 there will be over 65 million people suffering from Alzheimer.

The Neurological Institute Carlo Besta, in conjunction with the Italian Ministry of Health, has developed and validated a protocol for the early diagnosis of Alzheimer. Such protocol includes a research phase on “biological and generic markers”, diagnosis, cognitive-behavioural tests and guidelines for the deployment of an efficient hospital – primary health care network, focussed on dementia.

To this purpose has been set up a task force under the project identification name of PDTAR (Preventive – Diagnostic – Therapeutic – Rehabilitation Care Pathways), for the population affected by Dementia.

This task force is led by ASL Milan with the scientific coordination of Doctor Graziella Filippini, Director of the Neuroepidemiology department of the Besta Institute.

PDTAR’s guidelines have been detailed by Doctor Saverio Chirchiglia, director of ASL’s Milan Complex Structure District 4:

Appropriateness – A correct diagnosis is a prerequisite, since diagnostic and/or treatment errors may cause harm to patients and their families as well as lead to a misuse of drugs, frequent hospitalizations, repetitive requests for medical consultation, and an increase in the volume of visits to emergency departments.

Integration among health care professionals – a creation of a multi-player support network where General Practitioners, specialist Neurologists or Geriatricians and centres for frailty condition connected to social services commit themselves to ensure appropriate diagnosis, prevention and treatment.

GPs’ central role in this process – GPs informs and supports families, identifies subjects at risk, evaluates and directs the patients, ensures follow-up.

ACTide’s role within the project

Generation of a shared medical record and of a workflow among GPs, Neurologists at Hospitals and “Frailty Centers”, Patient Care Operators assigned by ASL and the supervision centre, that allows a full coordination among the parties.

  • Integration with portal Agor@sl (information system run by ASL Milan)
  • Database setup as well as a provision of information retrieval and export tools.
  • Online hosting of the project, on a secure and validated platform
  • Participation in GPs training sessions

 

 

ACTide Application “Dementia” for General Practitioners: key points

  • Recognition of elderly subjects affected by potential cognitive impairment
  • Clinical evaluation: the creation of the baseline
  • MMSE – administration to patients of the Mini-Mental State Examination tests for the detection of cognitive disorders, within 10-15 minutes; automatic generation of a score and on its basis, patient treatment according to the diagnostic path
  • Patient’s enrollment record
  • Six-monthly follow-up with a new MMSE test for patients who have not been sent to a specialist
  • Information transfer to the specialist take charge of the patient
  • Follow-up with all patients sent to the specialist

Critical factors: short delivery time

March 31st, 2013:

closure of the Clinician’s recruitment phase. As soon as the required number of subscriptions was achieved, the project has been confirmed and the IT infrastructure deployment started.

May 15th, 2013:

  • Online publication of the application Dementia
  • First GPs training session.

Required interoperability with portal Agor@sl

Key requirement to ensure an active participation of physicians to PDTAR and an influx of reports of critical cases in line with epidemiological data was to devise a system that permitted GPs to use a unique login to both the creation of the patient’s record and the automatic import of any existing data within the ASL’s information system belonging to the same subject. The expected number of cases highlighted per each GP was 22/27.

Within few days from the project assignment Nubilaria had devised its strategy to provide complete interoperability via web services, as well as agreed with Doctor Stefano Beligni, IT services ASL Milan, by way of shared, secure procedures of selective data exchange.

Outcome

Project results have demonstrated that the implementation of PDTAR improves the appropriateness of cases directed to specialists. GPs, thanks to training courses and a direct contact with specialists, have gained greater awareness upon Dementia and greater ability to independently assess the patient’s condition, using a simple tool for detecting cognitive impairment (Mini-Mental Examination State – MMSE).

The use of shared electronic medical record has been immediate and has facilitated the communication between GPs and specialists.

The compliance of physicians, in terms of the number of cases reported and managed, has exceeded expectations.

The project coordination centre has provided organizational support to patients, their relatives, GPs, specialists, and it has been instrumental to the activation of a preferential channel for patients with suspected cognitive impairment, by reducing waiting times for specialist visits.

The Figures of this project

The project involves:

  • 2800 Patients with early cognitive impairment or dementia. These people are currently being followed-up according to PDTA instructions
  • 500 general practitioners
  • 18 local clinics (Neurology and Geriatrics), part of the “Istituti Clinici di Perfezionamento (ICP)” Hospital
  • 13 hospital Units for Alzheimer Assessment (UVA)
  • 19 district “Frailty Centers”
  • 19 territorial Points of Fragility.

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