Lombardy Region has planned a population based study to test an innovative model of taking charge of chronic patients. Objective of the study is to evaluate the effectiveness of the project through the analysis of specific outcomes. The participating General Practitioners (GPs) were 186. They were enrolled 5,655 patients with diabetes and 10,506 with hypertension. The experimental group was compared within the cohorts of patients of General Practitioners adherents and between patients of GPs not adherent. The patients included in the trial presented an increase of most of the monitoring indicators of the adherence of pathways. The comparison between GPs showed an increase of the same indicators. It was found an increase of the outcomes of the experimental setting but also in patients and GPs not participating. Possible explanations to the phenomenon are to be found in the application of the Decree Law of 19 June 2015 and in previous clinical governance projects conducted in general practice. Implement models of take in charge and develop the projects involving the GPS in groups increases adherence to clinical pathways. The public health must commit themselves to promoting randomized studies, however, use appropriate statistical methods allows the evaluation of non-randomized population based studies.
Keywords: Indicators, Chronic care Models, Chronic Disease, General Practice, Governance, Public Health System