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What do we mean by quality in PCI? Case review – it does change practice

What do we mean by quality in PCI? Case review – it does change practice. Adam de Belder

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What do we mean by quality in PCI? Case review – it does change practice

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  1. 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 Centre Brighton ACI 2011

  2. GMC - revalidation • …requires evaluating clinical activity and outcome as key elements to being a good clinician

  3. RCP • ……personal, effective, high quality clinical audit will be expected as evidence to grant revalidation..

  4. 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….

  5. 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?

  6. 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 meeting • 3 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

  7. Process • Random selection process

  8. Unique identifier Hospital no.

  9. Random number generator between numbers of patients identified for that month, by non-clinical third party

  10. Final list chosen for 1 month – 15/150

  11. Meeting – the review committee telecardiology

  12. Opportunity for feedback and discussion between operator and review committee • Final decision on database

  13. 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

  14. 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.

  15. SUBSEQUENT analysis n=242 INITIAL analysis n=326

  16. Figure 3 Overall analysis

  17. 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

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