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What do we mean by quality in PCI? Case review – it does change practice
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Transcript of What do we mean by quality in PCI? Case review – it does change practice
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What do we mean by quality in PCI?Case review – it does change practice
Adam de Belder Blows LJH, Dixon GF, Behan M, Allen R, Cohen AS, Dickinson K, Furniss S, Hatrick RI, Hildick-Smith DH, Holmberg SRM, Hyde JAJ, Kneale B, Lewis ME, Lloyd G, Patel NR, Pegge N, Signy M, Sulke AN, Trivedi U, Walker DM, de Belder AJ
On behalf of the Sussex Cardiac Network
Sussex Cardiac CentreBrighton
ACI 2011
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GMC - revalidation
…requires evaluating clinical activity and outcome as key elements to being a good clinician
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RCP
……personal, effective, high quality clinical audit will be expected as evidence to grant revalidation..
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How to identify maverick behaviour in cardiology, and
what to do about it?Wait until disaster hits and “get them” (rarely been a successful strategy)
Everyone knew they were mad, it was just a matter of time..
They’ve not even been trained…nice bloke though
Uses the same kit as he always did – 8French for everything
Never refers to surgery
Never refers for PCI
Never refers….
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Background
Audit for PCI identifies operator / institutional volumes and focuses on in hospital MACE
Crude tools for defining successful PCI
Fails to address:Should the procedure be undertaken?Is the strategy appropriate?Is the outcome satisfactory?
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A mechanism to evaluate PCI performance on a network-wide basis
• The network:- 1 tertiary centre, 3 district general hospitals- 10 interventionalists
- 1750 PCI procedures annually
• Monthly review meeting3 reviewers (1 cardiac surgeon, 1 tertiary and 1 DGH interventionalist) on rotational basis
10% of cases (NHS and private) randomly selected
Minimum of 1 case per operator
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Process
Random selection process
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Unique identifier
Hospital no.
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Random number generatorbetween numbers of patientsidentified for that month, bynon-clinical third party
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Final list chosen for 1 month – 15/150
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Meeting – the review committee
telecardiology
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Opportunity for feedback and discussion between operator and review committee
Final decision on database
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Examination of:- Appropriateness of intervention
- Lesion assessment- Strategy - Outcome- Need for detailed notes review (? Symptoms, non-invasive
assessment of ischaemia, comorbidity)
Confidential feedback to operator
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Independent analysis after 326 patients and results fed back to operators. Presented anonymously with information about the individual compared to peers
Further analysis performed after the next 242 patients to determine any changes in practice.
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Outcome Satisfactory?
0%
20%
40%
60%
80%
100%No
Borderline
Yes
Strategy Appropriate?
0%
20%
40%
60%
80%
100%No
Questionable
Yes
Lesion sufficiently severe?
0%
20%
40%
60%
80%
100% No
Borderline/Questionable
Yes
Anatomy suitable?
0%
20%
40%
60%
80%
100%No
Borderline/Questionable
Yes
Outcome Satisfactory?
0%
20%
40%
60%
80%
100%No
Borderline
Yes
Strategy Appropriate?
0%
20%
40%
60%
80%
100%No
Questionable
Yes
Lesion sufficiently severe?
0%
20%
40%
60%
80%
100% No
Borderline/Questionable
Yes
Anatomy suitable?
0%
20%
40%
60%
80%
100%No
Borderline
Yes
INITIAL analysis n=326 SUBSEQUENT analysis n=242
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84
86
88
90
92
94
96
98
100
Anatomy suitable
Lesion severe enough
Strategy appropriate
Outcome satisfactory
First analysis Second analysis
%
* p=0.017
*
Figure 3 Overall analysis
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Conclusions
Overall, demonstration that appropriate standards of care are maintained
Feedback allows debate and provokes thought about PCI decisions
No penalties
This model identifies patterns of interventional practice
Allows development of practice across the network, protecting patients and operators alike