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

GMC - revalidation

…requires evaluating clinical activity and outcome as key elements to being a good clinician

RCP

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

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….

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?

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

Process

Random selection process

Unique identifier

Hospital no.

Random number generatorbetween numbers of patientsidentified for that month, bynon-clinical third party

Final list chosen for 1 month – 15/150

Meeting – the review committee

telecardiology

Opportunity for feedback and discussion between operator and review committee

Final decision on database

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

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.

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

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

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