[ANMCO Position paper: Choosing Wisely - ANMCO proposals for 2023]. / Position paper ANMCO: Choosing Wisely ­ le proposte dell'ANMCO nel 2023.

Nowadays, a progressive and exponential increase in the use of invasive and non-invasive instrumental diagnostics and therapeutic services has been shown. Although unnecessary, instrumental examinations are often largely prescribed, replacing clinical evaluation. Their correct use, on the contrary, would address precise epidemiological and clinical contexts. Therefore identifying whether a test or procedure is appropriate or not plays a crucial role in clinical practice. Several documents from scientific societies and expert groups indicate the most appropriate cardiovascular diagnostic and therapeutic procedures. The international Choosing Wisely campaign invited the main scientific societies to identify five techniques or treatments used in their field that are often unnecessary and may potentially damage patients. The Italian Association of Hospital Cardiologists (ANMCO) joined the project identifying the five cardiological practices in our country at greater risk of inappropriateness in 2014. This list has recently been updated. Moreover, possible solutions to this problem have been proposed.

[The fox guarding the henhouse. Who decides diagnostic criteria?] / Affidare alla volpe il compito di proteggere le galline. Chi decide i criteri diagnostici?

To reduce overprescribing, the consequences due to the invention of new diseases and the systematic reduction of threshold values have been studied, and projects to reduce procedures of low efficacy, the number of prescribed drugs, and procedures at risk of inappropriateness have been developed. The composition of committees establishing diagnostic criteria was never addressed. To avoid this problem (de-diagnosing) four procedures should be implemented: 1) diagnostic criteria should be assigned to a committee of general practitioners, clinical specialists, experts like epidemiologists, sociologists, philosophers, psychologists, economists, and representatives of citizens and patients; 2) experts do not have relevant conflicts of interest; 3) criteria should be set up as recommendations to facilitate discussion between a physician and a patient on the decision whether to begin a treatment and not as a recommendation functional to overprescription; 4) criteria should be periodically revised to approach the process closer to the experiences and needs of physicians and patients.

[When medicine is respectful.] / Quando la medicina è rispettosa.

There is a relevant gap between the medicine learned on books and the clinical practice made of suffering humans facing us. Guidelines recommendations don't usually cover this aspect. The Slow Medicine movement, born in 2011, stands as a model a sober respectful and right healthcare. Everyone is entitled to express himself freely: a respectful medicine receives worths, choices and tendencies of the patient in every moment of his life. The keystone of slow decisions is to respect patient's freedom and autonomy, and to recognize his ability to make decisions even if he is elderly and frail. Listening to a patient's biography and welcoming his personal needs and expectations allows the physician to spread comfort, trust and gratification.

[Polypharmacy and deprescribing in cardiology]. / Politerapia e deprescrizione in cardiologia.

Inappropriate prescribing of diagnostic procedures and treatments should be avoided for good medical practice. Furthermore, the therapeutic plan of each patient should be regularly revised, activating deprescription procedures to reduce the dosage or to discontinue unnecessary drugs. It has widely been reported that the number of drugs taken by each patient increases over the years and adverse events caused by polypharmacy therapy are increasingly reported. Polypharmacy is due to multimorbidity related to longer life expectancy, but it is also induced by drug manufacturers' pressures, the practice of prescribing one product to counteract the adverse effects of another, the division into subspecialties inducing clinicians to solve the specific problem regardless of the patient therapeutic profile, and the uncritical implementation of current guidelines. The recommendations published by scientific societies for the international Choosing Wisely project allow to identify practices at risk of inappropriateness, and programs are available to help evaluating the risks of several drug associations, taking into consideration different aspects of pharmacology, drug interactions, potentially inappropriate in the elderly, according to different criteria from the scientific literature. The safety of reducing or withdrawing under strict medical supervision some cardiovascular treatments has been demonstrated, with documented benefits for the patients.

Choosing Wisely, the reasons for its success.

The philosophy and the history of the International Choosing Wisely movement, launched in the U.S. in 2012, are described. It grew and spread beyond what it was anticipated at the beginning because there is a rising concern of the medical community regarding the appropriate use of procedures and treatments placed into the market before an adequate evaluation of risks and benefits. Not only healthcare providers, but also patients, citizens and politicians, are becoming aware of the consequences of inappropriate decisions and behaviors since inappropriateness has economic (waste of resources), clinical (risks), but also ethical implications. In Italy the movement was launched and still is coordinated by the Slow Medicine organization, that created the campaign Doing more does not mean doing better - Choosing Wisely Italy, which aimed to improve clinical appropriateness through the reduction of unnecessary tests and treatments and the dialogue between physicians and patients. Currently, 44 societies of physicians, nurses, pharmacists and physiotherapists identified 230 recommendations about tests, treatments and procedures commonly used in Italy's clinical practice that do not provide any benefit to most patients but may cause harm.

"Hosting" an implantable cardioverter defibrillator: A phenomenological inquiry.

Implantable cardioverter defibrillators (ICDs) can reduce unexpected cardiac mortality, but they also have a dramatic impact on a patient's quality of life. We aimed to explore ICD recipients' experiences in order to foster improvements in the quality of care. Analyses were done using a descriptive phenomenological method, based on qualitative interview data from a purposive sample of 20 ICD recipients. Four main themes emerged: living with fear; relying on technology; knowing about the ICD and how to live with it; and coping with the effects of the ICD on daily life. ICD recipients lived in a constant state of fear due to the presence of the device and the uncertainty related to the potential electrical shocks it could deliver. This fear was compounded by changes that severely affected the quality of their daily life. ICD recipients felt they were always on the brink of death, and that although they received sufficient technical information they did not feel they received meaningful information to help them accept, live with, and cope with the device. Emotional information and support, rather than technical information, must be provided to ICD recipients to give them the ability to cope with the everyday threats they perceive because of the device. Qualitative evidence may help professionals tackle known threats to patients' quality of life and increase the quality of care.

[Individual response to treatment: from Withering to contemporary medicine]. / La risposta individuale ai trattamenti. Da Withering alla medicina di oggi.

This is an essay dealing with the 1785 cohort study by William Withering (the "account"), in which he reported the results of the treatment with foxglove (Digitalis purpurea) in 163 patients suffering from various forms of hydropsy (water retention). Withering reported the results of all patients, and classified them into responders and non-responders. He identified the responders as suffering from heart failure. In the 18th century, medical treatments were judged as successful if they complied with the criteria a priori of the theory of the four humors, and not on the patient's response to the treatment. Withering was the first not only to compare the patient's conditions before and after treatment, but also to identify the individual clinical characteristics of the patients who responded. In modern medicine, drugs are released on the market and approved for use after what is known as "population-derived clinical research", principally randomized controlled trials, and guidelines. More than 200 years ago, Withering anticipated the current and growing trend towards individual responses to treatment, and personalized medicine.

[Patients facing with the decision to undergo percutaneous coronary intervention]. / I pazienti di fronte alla decisione di sottoporsi ad angioplastica.

Percutaneous coronary intervention (PCI) is a common procedure to treat coronary artery stenoses. Several studies had demonstrated that PCI does not reduce the risk of death or myocardial infarction when performed to patients with stable angina. However it has been observed that most patients believe that PCI will reduce their risk for death and myocardial infarction. On the other hand, cardiologists generally acknowledge the limitation of PCI according to the current literature.Cardiologists' decision to refer a patient to PCI is based on factors other then perceived benefits such as fear of missing a needed procedure, defensive medicine, desire of demonstrating their professional competence, vested professional and economic interests, accomplish patient expectation, the so called oculo-stenotic reflex, when a lesion is dilated regardless the clinical indication. Patients' misleading perception of harm and benefits of a procedure is mainly related to the cognitive dissonance, when individuals tend to reduce the conflict of an uncomfortable decision adopting information, which are likely to reduce their discomfort. Furthermore, patients believe that doing more means doing better, that technologic intervention are better than pharmacological treatment that in turn are better than doing nothing. Finally, they assume that a procedure is really effective since their physician suggested it.It should be emphasized that physicians and patients do not communicate successfully about key decision and how little we know about patient understanding of the factors that influence important medical care decisions. Although considerable attention is given to facilitating informed consent, patients' perceived benefits of elective PCI do not match existing evidence, as they overestimated both the benefits and urgency of their procedures. These findings suggest that an even greater effort at patient education is needed prior to elective PCI to facilitate fully informed decision-making.