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Tendencias en Calidad en EUA: El Caso de la Prevención

Secundaria

Dr. Francisco López JiménezDr. Francisco López Jiménez

Profesor Titular de Cardiología y Medicina Interna, Profesor Titular de Cardiología y Medicina Interna, Clínica Mayo, Rochester, MN, USAClínica Mayo, Rochester, MN, USA

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Compliance with Chronic Coronary Artery Disease Secondary

Prevention Guidelines in the USA

Victoria Zysek D.O., M.B.A.*, Véronique L. Roger M.D. M.P.H.*,†, Virend K. Somers M.D., Ph.D.*, Henry H. Ting M.D., M.B.A.*, Ondrej Sochor M.D.‡,

Randal Thomas M.D., M.S.*, Juliette Liesinger B.A.* †, Francisco Lopez-Jimenez M.D., M.S.*

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Secondary Prevention of CAD in the USA

• Key interventions have shown to decrease the rate of recurrent events and mortality in CAD patients

• Data and trends from population studies are lacking

• We analyzed 62,160 people from NHANES from 1999 to 2010

• Included 2,615 people with history of CAD

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Conclusions

• Evidence-based secondary prevention Evidence-based secondary prevention strategies for CAD are underusedstrategies for CAD are underused

• Some improvement over timeSome improvement over time

• Causes are likely multifactorialCauses are likely multifactorial

• Cannot separate poor compliance from Cannot separate poor compliance from low prescription rateslow prescription rates

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1. What is Quality of Care?

Definition of qualityDefinition of quality• EffectiveEffective• EfficientEfficient• TimingTiming• AccessibleAccessible• SafeSafe• ValueValue

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Case Review

The chair of the cath labThe chair of the cath lab

The oldest cardiologistThe oldest cardiologist

The one with highest volumesThe one with highest volumes

The one with more publicationsThe one with more publications

The one with a patentThe one with a patent

The one with the lowest rate of The one with the lowest rate of complications, highest success ratescomplications, highest success rates

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2. How is Quality Measured?

SubjectiveSubjective

ImportantImportant

Processes Outcomes

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Processes

• % of patients with CAD on % of patients with CAD on aspirinaspirin

• % of patients with low EF on ACE% of patients with low EF on ACE

• Time from door to balloon in PCITime from door to balloon in PCI

• Mistakes in interpretation of Mistakes in interpretation of echoecho

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Outcomes• Hospital mortalityHospital mortality

• Complications during coronary Complications during coronary angiogramangiogram

• Pacemaker site infection, LV Pacemaker site infection, LV perforationperforation

• Readmission rateReadmission rate

• Cardiac arrest in a patient without Cardiac arrest in a patient without monitormonitor

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3. Who Cares About Quality?

•PatientsPatients

• Insurance companiesInsurance companies

•Hospitals/providers who Hospitals/providers who provide qualityprovide quality

•Government?Government?

•All of usAll of us

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4. Do I Need to Review the Quality of Care I (we) Provide?

The 95% ruleThe 95% rule

Experience means less mistakesExperience means less mistakes

We gain experience when we make We gain experience when we make mistakesmistakes

Do we know the quality of care we Do we know the quality of care we provide?provide?

There is always room for improvementThere is always room for improvement

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5. How to Improve Quality of Care?

The doctorThe doctor’’s approachs approach

ErrorError PunishmentPunishment

• Insulin dose 20U vs 20 units• Wrong patient • Patient got the wrong test

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The systems’ engineering approach

• Root-Cause AnalysisRoot-Cause Analysis• Flow map of the process of careFlow map of the process of care• Pareto ChartPareto Chart• Ask all areas involved in the processAsk all areas involved in the process

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Methods Used by Experts in Quality

• LEANLEAN• Six SigmaSix Sigma• Cycles of rapid Cycles of rapid

improvementimprovement

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The Concept of Systems’ Improvement is not New

Mayo contributions to medical Mayo contributions to medical systemssystems•Medical chartMedical chart•Specialists in health careSpecialists in health care•Air tubes systemsAir tubes systems•ColorColor’’s systems system

Many organizations have Many organizations have contributed for yearscontributed for years

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6. Is it Really Possible to Make Major Gains in Quality of Care?

ExamplesExamples

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Resultados del Proyecto de Calidad Manejo optimo en pacientes Con Insuficiencia Cardiaca

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Proyecto de Reduccion de Tiempo De la Puerta-A la Arteria

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7. What is coming?

Transparency/Accountability

• Reportable events. The case of MNReportable events. The case of MN

• Hospital mortality for MI, CHFHospital mortality for MI, CHF

• Readmission rates for MI, CHFReadmission rates for MI, CHF

• Outpatient management of CAD, Outpatient management of CAD, CHF, AFCHF, AF

Mortalidad a 30 dias de un Infarto delMyocardio

Mortalidad a 30 dias de Egreso, Insuficiencia Cardiaca

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8. Is quality improvement expensive?

•Cost-Saving strategiesCost-Saving strategies

•Cost-Effective strategiesCost-Effective strategies

•The mistake of saving now, spending later…The mistake of saving now, spending later…

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Total Medicare Reimbursements/Enrollee – 2005Total Medicare Reimbursements/Enrollee – 2005Hospital Referral RegionsHospital Referral Regions

CP1322680-12

Baltimore Baltimore 9,2179,217Baltimore Baltimore 9,2179,217

Boston Boston 9,1259,125Boston Boston 9,1259,125

ClevelandCleveland 8,0028,002ClevelandCleveland 8,0028,002

Durham, NCDurham, NC 7,0847,084Durham, NCDurham, NC 7,0847,084

Rochester, MNRochester, MN 6,3756,375Rochester, MNRochester, MN 6,3756,375

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Summary

•The GoodThe Good

•The BadThe Bad

•The UglyThe Ugly

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Thank youThank you

lopez@mayo.edulopez@mayo.edu