Quality Standards forPatients Treated by PCI
Peter F Ludman
NO CONFLICT OF INTEREST TO DECLARE
• Caution about ‘standards’
• Overall Structure for assessing outcomes
• What are Quality Standards
• Options for Standards
Quality Standards forPatients treated by PCI
• Caution about ‘standards’
• Overall Structure for assessing outcomes
• What are Quality Standards
• Options for Standards
Quality Standards forPatients treated by PCI
Robert Liston 1794-1847
Robert Liston
• 1st Professor of Surgery UCL• 1st Operation under GA in Europe• Prior to anaesthetics:
– Speed• ↓ Pain Survival
• Quality = Speed– “the fastest knife in the West End. He could
amputate a leg in 2 ½ minutes”
• A High Quality Service?
• Results:– Amputation 2 ½ minutes
• Patient died from gangrene
– Assistant’s fingers inadvertently cut through• Assistant died from gangrene
– Cut coat tails of distinguished surgical spectator• Died of ‘fright’
Robert Liston
Trolley waits
• It is unacceptable that some patients have to wait on trolleys before being admitted to hospital
• 2000 target– Trolley wait to < 12 hr
• 2004 target– Trolley wait < 4 hours
Target ‘reports’• Inadequate resource Creativity
• Patients held in ambulances– clock doesn't start
England 2007-08Time spent in A&E
http://www.ic.nhs.uk/statistics-and-data-collections
Local Variation in Patternhttp://www.ic.nhs.uk/statistics-and-data-collections
Nationalpattern
Extremes
England 2007-08Time spent in A&E
http://www.ic.nhs.uk/statistics-and-data-collections
England 2007-08Time spent in A&E
http://www.ic.nhs.uk/statistics-and-data-collections
England 2007-08Time spent in A&E
http://www.ic.nhs.uk/statistics-and-data-collections
• 66% of all patients are sent to ward in last 10 min of 4 hours deadline
• ? Correct decision
• ? Correct wards
Measurement of Quality
• Aim– Highest quality of care for patients– Outcomes are the true measure of quality
• But– No single outcome captures results of care– Measures may be too narrow
• single department / single intervention• May destabilize care in unmeasured area
– Measures may be too broad• entire hospital rates of acquired infection
– Measure of process are convenient but surrogates– Measurement leads to gaming
• Caution about ‘standards’
• Overall Structure for assessing outcomes
• What are Quality Standards
• Options for Standards
Quality Standards forPatients treated by PCI
Outcome Measurement HierachyPorter NEJM 2010;363:2477
Tier 1Health Status Achieved or
Retained
Survival
Degree of Health or recovery
Tier 2 Process of recovery
Time to recovery and return to normal activity
Disutility of care ortreatment process
Tier 3 Sustainability of health
Sustainability of health &nature of recurrences
Long term consequencesof therapy
Outcome Measurement HierachyPorter NEJM 2010;363:2477
Tier 1Health Status Achieved or
Retained
Survival
Degree of Health or recovery
Tier 2 Process of recovery
Time to recovery and return to normal activity
Disutility of care ortreatment process
Tier 3 Sustainability of health
Sustainability of health &nature of recurrences
Long term consequencesof therapy
Outcome Measurement HierachyPorter NEJM 2010;363:2477
Tier 1Health Status Achieved or
Retained
Survival
Degree of Health or recovery
Tier 2 Process of recovery
Time to recovery and return to normal activity
Disutility of care ortreatment process
Tier 3 Sustainability of health
Sustainability of health &nature of recurrences
Long term consequencesof therapy
Outcome Measurement HierachyPorter NEJM 2010;363:2477
Tier 1Health Status Achieved or
Retained
Survival
Degree of Health or recovery
Tier 2 Process of recovery
Time to recovery and return to normal activity
Disutility of care ortreatment process
Tier 3 Sustainability of health
Sustainability of health &nature of recurrences
Long term consequencesof therapy
Outcome Measurement Hierachy
SurvivalMortality post procedure
Risk adjustment
Degree of Health or recovery
Functional levelCCS class / QoL measures
Time to recovery and return to normal activity
Time to referral / to investigation to Rx / to recovery post Rx / time to return to normal
activities / return to work
Disutility of care ortreatment process
MACCE / delay to emergency Rx / pain / access site comps / drug side effects / appropriateness of Rx /
medical errors
Sustainability of health &nature of recurrences
Maintained freedom from symptoms / need for repeat PCI / staged procedures
Long term consequencesof therapy
Stent thrombosis / drug side effects
Features for Outcome measures
• Important to patients
• Occurrence sufficiently frequent
• Features to incorporate entire hierarchy
• Practical issues regarding measurement– Care with measures that encourage gaming– Objective, standardised and clearly defined– Methods for gathering data
• Caution about ‘standards’
• Overall Structure for assessing outcomes
• What are Quality Standards
• Options for Standards
Quality Standards forPatients treated by PCI
White Paper July 2010
Equity and Excellence:Liberating the NHS
Quality Standards
Quality Standards
• Specific concise statements that:– Act as markers of high quality, cost-effective
patient care across a pathway or clinical area– Derived from best available evidence– Produced collaboratively with NHS and social
care, with their partners and service users
http://www.nice.org.uk/guidance/qualitystandards/
National Quality Board
• Established 2009
• Champion quality and ensure alignment in quality throughout NHS
• ‘Multi-stakeholder’ board
National Quality Board
NQBPrioritisationCommittee
Refer topicsto NICE
NICE topicExpert Group
• Draw up draft standards– based on NICE guidance and
– other NHS ‘accredited’ sources
6/52Field testingconsultation
NICE Quality Standards Program Board
NICEGuidance Executive
Published on NICE website
Ministers
Use of Quality Standards• Patients and Public
– Information regarding the quality of care they can expect to receive
• Clinical staff– Ensure care provided is based on latest evidence and best practice
• Audit• Governance• Professional development and revalidation
• Provider organisations– A framework for Quality Accounts– Assess the quality of care being delivered– Highlight areas for improvement and monitor changes
• Commissioners– Ensure best care being delivered via contracting process– Incentive payments (Commissioning for quality improvement CQUIN)– Demonstration of World Class commissioning competencies
• Caution about ‘standards’
• Overall Structure for assessing outcomes
• What are Quality Standards
• Options for Standards
Quality Standards forPatients treated by PCI
NICE guidance so far• Technology Appraisals
– Drug Eluting Stents TA 152 (July 2008)• DES if artery < 3 mm diameter or lesion > 15mm long• Price difference between BEM and DES <= £300
– Prasugrel in ACS TA 182 (Oct 2009)• Primary PCI• Stent thrombosis on clopidogrel• Diabetics with ACS
– MPI TA73 (Nov 2003) partially updated• Recommended Ix if established CAD and Sx post MI of
after revasc– Thrombolysis TA52 (Oct 2002)
NICE guidance so far• Technology Appraisals
– Drug Eluting Stents TA 152 (July 2008)• DES if artery < 3 mm diameter or lesion > 15mm long• Price difference between BEM and DES <= £300
– Prasugrel in ACS TA 182 (Oct 2009)• Primary PCI• Stent thrombosis on clopidogrel• Diabetics with ACS
– MPI TA73 (Nov 2003) partially updated• Recommended Ix if established CAD and Sx post MI of
after revasc– Thrombolysis TA52 (Oct 2002)
BCIS datasetSingle lesions
only
NICE guidance so far
• Technology Appraisals in Progress– Ticagraor for ACS (July 2011)– Bivalirudin for STEMI (?)
NICE guidance so far
• Clinical Guidelines– Secondary Prevention CG48 (May 2007)
• Life style / Rehab / Medication / Ix / Revasc– Chest pain recent onset CG95 (March 2010)
• Acute– Mx based on diagnosis, timing of pain, Tn, ECG
• Stable CAD likelihood– 10-29% Coro Ca2+ Ix other cause / 64 CT/ angio– 30-60% functional imaging– 61-90% angiography
NICE guidance so far
• Clinical Guidelines (cont)– UA and NSTEMI CG94 (March 2010)
NICE guidance so far
• Clinical Guidelines (cont)– UA and NSTEMI CG94 (March 2010) Grace
Score > 3%
NICE guidance so far
• Clinical Guidelines (cont)– UA and NSTEMI CG94 (March 2010) Grace
Score > 3%
Cath < 96 hrsMDTConsider:
2b-3a / bival
NICE
• Currently limited
• World literature
• ESC and AHA Guidelines
Stable v ACS
Stableangina
↓ Symptoms
ACS ↓ Recurrent events↓ Mortality
Outcome Measurement Hierachy
SurvivalMortality post procedure
Risk adjustment
Degree of Health or recovery
Functional levelCCS class / QoL measures
Time to recovery and return to normal activity
Time to referral / to investigation to Rx / to recovery post Rx / time to return to normal
activities / return to work
Disutility of care ortreatment process
MACCE / delay to emergency Rx / pain / access site comps / drug side effects / appropriateness of Rx /
medical errors
Sustainability of health &nature of recurrences
Maintained freedom from symptoms / need for repeat PCI / staged procedures
Long term consequencesof therapy
Stent thrombosis / drug side effects
Outcome Measurement Hierachy
SurvivalMortality post procedure
Risk adjustment
Degree of Health or recovery
Functional levelCCS class / QoL measures
Time to recovery and return to normal activity
Time to referral / to investigation to Rx / to recovery post Rx / time to return to normal
activities / return to work
Disutility of care ortreatment process
MACCE / delay to emergency Rx / pain / access site comps / drug side effects / appropriateness of Rx /
medical errors
Sustainability of health &nature of recurrences
Maintained freedom from symptoms / need for repeat PCI / staged procedures
Long term consequencesof therapy
Stent thrombosis / drug side effects
Stable angina
Outcome Measurement Hierachy
SurvivalMortality post procedure
Risk adjustment
Degree of Health or recovery
Functional levelCCS class / QoL measures
Time to recovery and return to normal activity
Time to referral / to investigation to Rx / to recovery post Rx / time to return to normal
activities / return to work
Disutility of care ortreatment process
MACCE / delay to emergency Rx / pain / access site comps / drug side effects / appropriateness of Rx /
medical errors
Sustainability of health &nature of recurrences
Maintained freedom from symptoms / need for repeat PCI / staged procedures
Long term consequencesof therapy
Stent thrombosis / drug side effects
Stable angina
Safety and Symptoms
Patient Reported Outcome Measures
Outcome Measurement Hierachy
SurvivalMortality post procedure
Risk adjustment
Degree of Health or recovery
Functional levelCCS class / QoL measures
Time to recovery and return to normal activity
Time to referral / to investigation to Rx / to recovery post Rx / time to return to normal
activities / return to work
Disutility of care ortreatment process
MACCE / delay to emergency Rx / pain / access site comps / drug side effects / appropriateness of Rx /
medical errors
Sustainability of health &nature of recurrences
Maintained freedom from symptoms / need for repeat PCI / staged procedures
Long term consequencesof therapy
Stent thrombosis / drug side effects
ACS
Outcome Measurement Hierachy
SurvivalMortality post procedure
Risk adjustment
Degree of Health or recovery
Functional levelCCS class / QoL measures
Time to recovery and return to normal activity
Time to referral / to investigation to Rx / to recovery post Rx / time to return to normal
activities / return to work
Disutility of care ortreatment process
MACCE / delay to emergency Rx / pain / access site comps / drug side effects / appropriateness of Rx /
medical errors
Sustainability of health &nature of recurrences
Maintained freedom from symptoms / need for repeat PCI / staged procedures
Long term consequencesof therapy
Stent thrombosis / drug side effects
ACS Safety and Process
Key Quality Standards• Safety
– Major Averse Events• Risk adjusted
Key Quality Standards• Safety
– Major Averse Events• Risk adjusted
• Elective– Symptoms and Quality of Life
• ACS (non-STEMI)– Structure / appropriateness / process
• STEMI– Speed
UK MINAP Data
0102030405060708090
100
2008/2 2008/3 2008/4 2009/1 2009/2 2009/3 2009/4 2010/1
%
Primary PCILysis
McLenachan for NHS Improvement Heart
0
20
40
60
80
100
120
0 1 2 3 4
No Rx
PPCI (120 min delay)
PPCI DelayM
orta
lity
%
Time delay to presentation / Rx
Early presentersHigh risk
Late presentersLow risk
PPCI Symptom to Balloon• PPCI, n=1791
1 year mortality is increased by 7.5%for each 30 minute delay
De Luca Circ 2004;109:1223
PPCI Door to Balloon Delay
• National Registry of Myocardial Infarction• n=29,222
McNamara JACC 2006:47;2180
High risk
Low risk
AnteriorDMHR>100BP<100
PPCI Door to Balloon Delay
• NRMI, n=29,222• Relative Risk per extra 15-Minutes DTB time
Compared with DTB of 90 Minutes
McNamara JACC 2006:47;2180adapted by Nalamothu
PPCI Door to Balloon Delay
• NRMI, n=29,222• Relative Risk per extra 15-Minutes DTB time
Compared with DTB of 90 MinutesEach 15-minute ↓ Door-to-Balloon time
was associated with6.3 fewer deaths per 1000 patients
McNamara JACC 2006:47;2180adapted by Nalamothu
Timings in PPCI
Patient delay
EMS delay
15 min DTBTransport to PCI centre
Onset ofSTEMI
FMC Reperfusion
System Delay
Terkelsen JAMA 2010;304:763
PPCI System Delay• Western Denmark 2002-2008• n=6,209
Cum Mortality30.8%28.1%23.3%15.4%
Terkelsen JAMA 2010;304:763
PPCI Mortality v Pre Hospital Δ
• Aarhus County Denmark• Urban and Rural implementation of Pre Hospital
Diagnosis• System delay
• Pre Hospital Diagnosis: 92 min• No Pre Hospital Diagnosis: 153 min
Sorensen EHJ Dec 2010.1093/eurheartj/ehq437
Δ 1 hour
PPCI Mortality v Pre Hospital Δ
• Aarhus County Denmark, System delaySorensen EHJ Dec 2010.1093/eurheartj/ehq437
93 16784 122Δ 38 min Δ 74 min
PPCI Mortality v Pre Hospital ΔSorensen EHJ Dec 2010.1093/eurheartj/ehq437
All cause Mortalitymedian of 4.3 yr FU
31 v 18%Pre-hospital diagnosis
HR after adjustment = 0.68
PPCI Mortality v Pre Hospital ΔSorensen EHJ Dec 2010.1093/eurheartj/ehq437
PPCI Call to Balloon timeBy Admission Route
106
161
114
0
50
100
150
200
250
Direct IHT ALL
Median CTBmin
(+/- IQR)
2009 data: Ludman
PPCI Call to Balloon timeBy Admission Route
106
161
114
0
50
100
150
200
250
Direct IHT ALL
Median CTBmin
(+/- IQR)
2009 data: Ludman
73.9% Direct v 26.1% IHT
Conclusion
• Overview of the politics of ‘Quality Standards’• Clinical governance and quality of patient care is
underpinned by standards
• Not measured not assessed• Once measured inevitable change in its value• Many hidden traps to what you measure and
how you use it to improve a service
The End
Top Related