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Past development andPast development andfuture outlook on clinicalfuture outlook on clinical

guidelines in Italyguidelines in Italy

Augusto Consoli

Department for Addiction Prevention and Treatment,

National Health Service, Torino 2

Italian Society of Drug Addiction (SITD)

Pompidou Group

Treatment Conference on Guidelines and RecommendationsNicosia 11-13 May 2009


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The considerations that I will try to

carry out in this short presentation areoriented to illustrate the work carriedout in the course of the last 10 years

in Italy, in the difficult process bothcultural that professional andorganizational relative to the

development and the application ofclinic and prevention Guide Lines inaddiction field.


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Guidelines International Network

Medical Clinical Guidelines(publ. 1999-2009)

France 32

Australia 28Germany 15

United Kingdom 12

USA 11

Spain 10

Netherlands 4

Switzerland 4

Canada 2

Norway 2

Russian Fed. 2

International 29http://www.g-i-n.net/


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Italian Guidelines

Oncology 3

Orthopaedics 2

Surgery 2Cardiology 2

Epatology 2

Geriatrics 1Visual diagnostic 1

Pharmachology 1

Virology 1

Psychiatry 1

http://www.pnlg.it/lgn


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But actually in Italy there are many moreGuide Lines in the several fields of

medicine and surgery but the fact, as an

example, that they are not marked on GIN

network is a possible pointer that, in spite ofthe efforts till now made, the spread and the

sharing of the guide lines among the health

professionals in Italy is still to developulteriorly.


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Drug Addiction - International guidelines for:

Prevention

Harm reduction

Substitution treatments

Psychosocial treatments

Treatments for specific groups

(e.g. women, migrants, prisoners)


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In Italy have been carried out some attempts or

documents to develop GuideLines in drug addictionfield

Prevention GL based on:

2002 WHO GL, 2003 NIDA GL, 2005 EMCDDA GL

Methadone treatments

Studio Vedette

Dual diagnosis treatments GLItalian Psychiatry Association on Addiction

Residential and psycho-social treatments pointersPiemonte Working Group on Evidence-Based Healthcare

GL to promote smoking cessationIstituto Superiore di Sanit


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but

its not always easy to distinguish betweenguidelines, protocols, recommendations, bestpractices, standards, policies;

on many issues there is no availability ofrelevant documents based on clinicalevidence, even when already developed byother countries;

there is a cultural resistance to thestandardization of treatments and lowinclination to the use of manuals (exceptwhere there are high technical contents)

a debate is still ongoing about the realpossibility of using the guidelines in clinicalpractice;


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What do we mean by Guidelines?

Operating instructions

on specific, limited and explicit issues (fields ofreference and application);

based on high quality scientific contents (RCT

and meta-analysis);

drafted according to progressive levels ofconsistency;

including procedures for periodic evaluationand review.


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Italian National Project on Guidelines

(PNLG)

Check-list of criteria used to evaluate

guidelines

1. Essential requirements

2. Ethical aspects3. Relevance and appropriateness

4. Structural quality

5. Acceptability6. Technical and scientific validity

7. Applicability

8. OutcomesG. F. Gensini, A. Biggeri, A. Caputi, A.A.Conti, A. Liberati e coll.


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Essential requirements

Statement of the followed methodology

Statement of purpose and scope ofapplication

Support of the best scientific evidenceavailable

Presence of multidisciplinary expertise inthe team

Explanation of the timing and methods ofapplication of the lines and theirmodification

Identification of the recipients andexplanation of the transfer process


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Ethical aspects

Absence of potential conflicts of interest

(for example funding from industry)

Appropriate and relevant topics in terms ofsocial utility

Clarification of objectives expected of eachtreatment

Assessment of cost-benefit


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Relevance and appropriateness

Relevance to public health system

Risk of applying/not applying the treatment

Assessment of costs

Prognostic evaluation

Clinical significance of GL for the quality oflife too

The GL make it easier and more objectivethe decision making process

Provides criterion to evaluate the quality ofcare promoted by GL


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Points of view on GL after focus groups

Pro Cons

Fair to the people Low elasticity

Appropriateness of careLow pertinence tooperational dimension

Protection fromprofessional misconducts

Encouragement of adefensive approach

Support for treatmentevaluation

Quickly overcome byresearch evolution

Better use of availableresources

Expensive to build andmaintain


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Despite some risks, and looking for the advantages

most Italian professionals now agree that the use

of guidelines is essential to improve quality and

adequacy of treatments offered.

But the selection of the contents of such claims,the process of their preparation and procedures for

their implementation and progressive review,

should be part of a plan properly constructed and

maintained.


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For this reason we stress the importanceof:

1.promoting the adequacy and quality of

care, enhancing the availability of

diagnostic and therapeutic instruments;

2.fostering the exchange betweenprofessionals on best practices and

practical operational problems;


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3.supporting the dissemination of the most

updated literature and GL, as NorthAmerican and WHO guidelines, or those

developed in other EU countries, as well as

the evidence of researches carried out at

national and international level;


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4.identifying a working group with

experienced professionals in drug addiction

field, experts in the development of clinical

guidelines, members of scientific societies,

representatives of key national institutions

(eg: Istituto Superiore di Sanit andDipartimento Nazionale Politiche Antidroga),

to support a strategy to develop and

disseminate guidelines for the treatment of

addictions, even identifying a ranking of

topics;


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5.encouraging regional governments to adopt

incentives or rewards for health care centers

that use evidence-based practice and follow

approved clinical guidelines.


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Il Dipartimento Nazionale Politiche AntidrogaIl Dipartimento Nazionale Politiche Antidroga--

DNPADNPAThe role of the National Department for AntiThe role of the National Department for Anti--drugdrug

PoliciesPolicies

However it is necessary to develop nationalpolicies, that favor a homogeneity in the

elaboration and in the spread of GL.

In this direction, an ulterior opportunity is

given by the the activities of the National

Department for Anti-drug Policies (DNPA)structure of the Prime Minister's Office.


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This structure that will be able to develop inthis field important initiatives of sovra-

regional character has started the

elaboration policies addressed in variousfields, beginning from the field of prevention

and treatment of adolescents, thought as

one of the more problematic tasks to face.


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Pompidou Group

Treatment Conference on Guidelines and Recommendations

Nicosia 11-13 May 2009

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