by BF Novelletto, M. Fusello, A. Battaggia
13 FEB –
Dear Director,
we hope to do what is pleasant and of interest to QS readers, to briefly illustrate, in addition to some data, how and why a network of general practitioners in the Veneto region was born and developed who shared the contents, rigorously anonymised, of their computerized medical records.
The “MilleinRete” project, which turned 12 in 2022, was conceived starting in 2008 and formally implemented in 2010, with the contribution of some SIMG sections of the Veneto region. Together with the “Health Search” database (SIMG research institute), “MilleinRete” currently represents, to our knowledge, one of the most important networks of clinical-care data of Italian General Medicine (the only one at a regional level) with a high value epidemiological.
The fundamental objectives of this project were, and still are, the improvement of the professional performances of the participating physicians, through continuous peer comparison, audit and translational research, using “IT tutoring” tools.
This database also represents the starting point for the activity of listening and analyzing the training and professional needs of General Medicine.
The doctors adhering to the network, all users of the Millewin® management software, were initially trained to record data in the folder in a very accurate way, as formally demonstrated through the ITOT index (an algorithm for assessing registration quality), validated and used also in Health Search.
The data of “MilleinRete” are recognized by the Veneto Region as a reliable database of General medicine.
The distribution of the assisted population is perfectly superimposable on the ISTAT data of the Veneto, with absolute deviations, in the various strata, generally less than one percentage point.
GPs are distributed in 6 of the 7 Venetian provinces (only Rovigo is not represented).
The management of the network was fully assumed by SVEMG (Venetian School of General Medicine).
In the Report, which is freely available for anyone interested at the web address: https://svemg.it/report-milleinrete-2022/, there are data referring to 10 years of activity updated to 12/21/2021.
In this decade, the workload has progressively increased: from an average of 54 contacts per day per doctor in 2011 to an average of 74 contacts per day in 2021. This figure was essentially associated with a linear and progressive increase, of activities not electively pertinent to the medical act itself. The trend in the number of outpatient and home visits over the decade is, in fact, rather fluctuating but without heavy fluctuations.
Phone calls experienced a peak only in the years corresponding to the Sars-Cov2 epidemic, while the number of remaining reasons for contact (recipes, certificates, bureaucratic activity, etc.) shows a linear and progressive ten-year increase: from 3.10 contacts per capita in 2011, recorded under the item “other”, they rose to 6.14 in 2021, which corresponds to an increase of +98%. During the decade, the care burden pertaining to elderly and multimorbid patients (Charlson Index ≥4) progressively and linearly increased.
Patients with multiple chronic conditions they represented 5% of the population in 2011 and 8% in 2021, with an increase in prevalence of +60%.
Patients over 65 they represented 24% in 2011 and 29% in 2021, with an increase in prevalence of +20%.
The distribution of over-65s and “multi-soft” within the individual cases, on the basis of the variance linked to the randomness of the sample, it is, as is logical, extremely heterogeneous.
Considering the 2021 data the number of elderly per doctor is distributed within a range that goes from 201 to 745 patients, while the number of multimorbid patients within a range of 43 to 253 per doctor.
This observation obviously makes laughable any assessment of professional performance based on unweighted, or underweighted, spending standards only ‘by gender and age, as is usually done.
They are represented within the network different territorial organizational forms.
37.11% of patients are followed by Integrated group medicines (resolution of the Veneto Region in 2015), 39.64% from Simple Group Medicines18.98% from Medicine in Rete; only 4.27% from MMG singles. 61.85% of the population is followed in structures where at least one nurse works and 71.08% in structures where at least one study collaborator works.
These data make it possible to study the extent to which different organizational forms are or are not able to condition the levels of assistance provided to citizens. For example, compared to other organizational forms, the “Integrated Group Medicines” during the toughest period of the epidemic (the year 2020), guaranteed a greater number of contacts, outpatient visits, blood pressure readings, hemoglobin prescriptions glycated and diabetes visits.
The Veneto dataset “MilleinRete” represents an important and precious source of information produced by local medicine and the Report illustrates, among other things, details relating to relevant chronic diseases: hypertension, diabetes, atrial fibrillation, heart failure, stroke, asthma, COPD, neoplasms, osteoporosis, obesity.
Sources other than GPs’ medical records, such as SDO, consumption data, personal data databases, etc. (ie the tools usually used by the Public Administration), do not allow the analysis of welfare aspects that leave no trace in the administrative datasets. “MilleinRete”, on the other hand, allows for an all-encompassing and detailed snapshot of the daily clinical-assistance activity of family doctors, substantially little known not only to the general public but also, unfortunately, to our administrators.
Despite the 74 reasons for daily contacts, the quality of assistance from family doctors, to a population that is progressively aging, and whose chronic problems seem to be increasing more rapidly than aging itself, nevertheless seems to “hold”.
This impression provided the starting point for a research based on the “MilleinRete” data (presented at the SIMG National Congress in 2021), which highlighted the assistance advantages offered, in a pandemic emergency situation, by complex organizations such as Integrated Group Medicines.
Some data, included in the Report, which is not aimed at this objective, suggest the same thing. The prevalence of subjects of normal weight, for example, demonstrates an increase of 13% over the decade: out of all patients with BMI, the percentage with BMI was detected ≥18.5<25 (normopeso) corrisponde nel 2012 al 45.4% e nel 2021 al 51.6%. Nel corso dello stesso periodo nei pazienti con dato registrato la percentuale di soggetti praticanti light physical activities increased by 25.5% (44.7% in 2012, 56.1% in 2021).
The percentage of subjects exposed to smoke of cigarettes in 2012 corresponded to 22.2% of subjects with recorded data and in 2021 to 19.1%, resulting in a reduction of 13.9%. Finally, the average daily consumption of alcohol in patients with registered data it corresponded, in 2012 to 2.5 alcoholic units, in 2021 to 0.5.
The coherence of the data pertaining to all the lifestyles investigated, which have significantly improved over the last decade, suggests that these results are very likely also the result of family doctors’ suggestions on the adoption of correct lifestyles.
“MilleinRete”, with the enormous variety of information it can provide, has the potential of a real research laboratory. The pathology “Diabetes” is a paradigmatic example. In an observational study pertaining to the mortality of diabetics we have demonstrated, for example, that there is no difference between patients followed only by the general practitioner and between patients referred to specialist advice. The data was frankly what we expected given that the average diabetic phenotype is represented by a patient of advanced age and with numerous comorbidities.
“MilleinRete” therefore represents an important tool for promptly intercepting territorial signals pertinent to welfare aspects worthy of further study. Just to give a few examples, the higher prevalence recorded for some types of cancer compared to the average of Health Search, as well as an important underdiagnosis of the Metabolic Syndrome, Obesity and NAFLD (non-alcoholic fatty liver disease) object, the latter, of audits carried out by SVEMG.
Bruno Franco Novelletto
President and Dir. Div. Training and Research SVEMG
Massimo Fusello
Vice President and Div. Planning and Development SVEMG
Alexander Battaggia
Scientific manager “MilleinRete”
February 13, 2023
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