Transcript PowerPoint-presentation

Kliniska effekter av arbetet
med kvalitetsregister
Bertil Lindahl,
professor i kardiologi, SKL och
Uppsala Clinical Research center.
Historik
Knäplastik; 1975
Höftplastikregistret; 1979
Sv. kv.reg 2012
• 4 på nivå1
• 20 på nivå 2
• 49 på nivå3
73 reg. Som täcker ett
flertal interventioner
och sjukdomar
• 27 Kandidater att bli certifierade
register
Styrning
The och ledning av kvalitetsregister – balans
mellan centralt och lokalt ledarskap
Styrgruppen består av åtta ledamöter, tre representanter
från staten, tre från landstingen, en från kommunen
samt en från Sveriges Kommuner och Landsting.
nationell
registerservice,
SoS
Registerkansli, SKL
Registercentra (6-7)
≈70 Nationella kv.reg
beslutsgrupp.
expertgrupp
referensgrupper
Kunskapsbaserad sjukvård – roll för kv.reg
Pre-clinical
research
Clinical studies,
including RCT.s
Outcome research
Selective implementation
with systematic follow-up
Role for Quality Registries
Systematic
reviews /
guidelines
Implementation in
clinical routine, Clopidogrel
nationally and locally
Follow up of outcome and sideeffects in clinical routine,
nationally and locally
Mätning innan
projektstart
Resultat
Utbildningsperiod
Hur kan kvalitetsregister
användas som stöd för
förbättringsarbete?
SWEDEHEART - Nationell täckning
Sjukhus
Patienter
Hjärtkirurgi
100 %
8
100 %
Angio / PCI
100 %
29
100 %
Hjärtinfarkt
100 %
73
70 %
Sek prev. efter AMI <75 år
85 %
65
55 %
TAVI
100%
7
100%
SWEDEHEART
• Antal fall per år: 80 000 fall
– 20 000 hjärtinfarkt
– 10 000 instabil angina
RIKS-HIA
– 25 000 med annan orsak till symptom
– 40 000 coronarangiografi eller PCI
SCAAR
– 7 000 Hjärtkirurgi
Heart surgery registry
– 6 000 sekundärprevention
SEPHIA
• >500 variabler
• 2737 användare (ffa läkare och sköterskor)
• Vid en given tidpunkt: ~ 60 samtidiga användare
1. Vilja till
ständig förbättring
8. Kulturen
förändras
1
8
7. Resultat
(Mätning
- data!)
2
2. Gemensam
verklighet
(Mätning - data!)
7
3
6
6. Hitta
nya former
(Mätning - data!)
5
4
3. Delad
övertygelse
4. Förmedla visionen
5. Arbetsprocesser
Proportion ACE-inh. in target population
Base-line
Education &
implementation
phase
Measurement I
Treatment adherence - Baseline
100
90
85
80
79
70
60
62
65
63
66
53
50
45
40
30
28
32
20
10
ACE-inh
C
Q
Lipid low
C
Q
Clopido.
C
Q
L.m.w. hep
C
Q
Corai
C
Q
No significant differences at baseline
Treatment adherence - Measurement I
100
92
90
83
80
82
75
73
70
60
71
70
63
53
50
51
40
30
20
10
ACE-inh
C
Q
Lipid low
C Q
Clopido.
C
Q
L.m.w. hep
C
Q
Corai
C
Q
Change in incidence (events/100 patient years)
Adjusted*
between pre- and post interventions period (1-y f-u)
QUICC Hospital
Unadjusted
Not QUICC Hospital
-2.8 ( -5.26- -0.39 )
-9.3 ( -15.5 - -3.1 )
-4.9 ( -11.1 - 1.2)
0.04 ( -2.40 - 2.47 )
-6
-4
-2
0
2
4
Incidence death
6
-20
-10
0
10
20
Incidence morbidity
(hospit. for AMI, angina, CHF or cardiac arrest)
Quality Improvement in acute Coronary Care
Improving guideline adherence through intensive quality
improvement and the use of a National Quality Register in
Sweden for acute myocardial infarction
Peterson, Anette RN; Carlhed, Rickard MD; Lindahl, Bertil MD, PhD; Lindstrom, Gunilla RN;
Aberg, Christina RN; Andersson-Gare, Boel MD, PhD; Bojestig, Mats MD, PhD
Quality Management in Health Care.2007; 16(1):25-37
SCAAR
0,12
Stents used <1000 times excluded
Adjusted
0,11
Braun Coroflex Blue, N=3,761
Hexacath Titan2,
0,10
N=1,974
Abbott Flexmaster Fl, N=1,311
0,09
Medtronic Driver,
N=15,954
Sorin Chrono,
N=2,465
BS Liberté,
N=28,735
Abbott Vision,
N=8,565
Other,
N=3,654
0,08
0,07
0,06
Cumulative risk of Restenosis
0,05
Medtronic Endeavor, N=4,891
BS Taxus Express,
N=3,165
Cordis Cypher,
N=11,513
BS Taxus Liberté,
N=16,357
XienceV / Promus,
N=1,849
0,04
0,03
0,02
0,01
N=104,142 stents
0,00
November 8th 2009. Copyright SCAAR.
0
1
2
Time (Years after stenting)
3
4
5
James, Eurointervention 2009
Utveckling och resultat i
svensk hjärtinfarktvård
senaste decenniet?
RIKS-HIAs kvalitetsindex 2006
Reperf.
Inom rek
Reperf.
Angio
LMWheparin
ASA
Clopidogrel
tid
Betablockad
Statin
ACEI/ARB.
RIKS-HIAs kvalitetsindex 2010
Reperf.
Inom rek
Reperf.
tid
Angio
LMWheparin
ASA
Clopidogrel
Betablockad
Statin
ACEI/ARB.
RIKS-HIAs kvalitetsindex
2005
2011
Association till start av öppen redovisning
Larsson et al. Health Affairs 2012; 31(1)
Mortalitet
Observed mortality
Difference between predicted
and observed mortality
20 publications 2010 – different aspects
•
•
UCR
•
Uppsala Clinical
Research centre
•
•
Cardiovascular and cancer mortality in very elderly postmyocardial infarction patients receiving statin treatment. J.
Am. Coll. Cardiol. 2010;55(13):1362-9.
Eptifibatide is noninferior to abciximab in primary
percutaneous coronary intervention: results from the
SCAAR . J. Am. Coll. Cardiol. 2010;56(6):470-5.
Gender perspective on risk factors, coronary lesions and
long-term outcome in young patients with ST-elevation
myocardial infarction. Heart. 2010;96(6):453-9.
Reperfusion therapy for ST elevation acute myocardial
infarction in Europe: description of the current situation in
30 countries. Cardiovascular Interventions. Eur. Heart J.
2010;31(8):943-57.
Assessing the cost effectiveness of using prognostic
biomarkers with decision models: case study in prioritising
patients waiting for coronary artery surgery. BMJ. 2010 Jan
19;340:b5606.
TASTE
trial flow chart
SCAAR
SWEDE
HEART
Thrombus Aspiration in ST-Elevation myocardial infarction in Scandinavia
Patients with suspected STEMI referred to primary PCI
N = 5000
STEMI diagnosis confirmed at coronary angiography. Informed consent obtained
Online 1:1 randomization in SCAAR, guidewire advancement, i.c. nitroglycerin
Thrombus aspiration and PCI
PCI alone
Immediately after PCI: TIMI flow grade
30 days: all-cause death
1, 2, 5 and 10 years: all-cause death and additional secondary endpoints
Fröbert et al, AHJ 2009
When PCI with indication
STEMI-primary/rescue PCI
and
PCI ad hoc
is registered the system
proposes randomization
Two questions need to be
answered:
Is the patient informed verbally
and accepts participation?
Are inclusion and no exclusion
criteria met?
SCAAR
Inclusion rate
SWEDE
All primary PCI:s
Randomized
HEART
Tack för uppmärksamheten!