CARDIOVASCULAR

EVALUATION UNIT

Presentation

by Laurie Lambert, PhD

November 28, 2016

MULTIDISCIPLINARY TEAM

Coordinator and

administrative support

DSSET Director

Scientific Professionnals

Medical/ Scientific Advisor

Web site Programmer

DSSET Scientific Advisor

Economist

Graphic Artist

Medical Archivists

Biostatistician

Our goal is to help the health care system provide equal

access to high quality and timely care to the population

of Québec.

Literature review

Field evaluation

Quality standards

Support improvement

EVALUATION FRAMEWORK

ST-Segment Elevation Myocardial Infarction

(STEMI)

5

STEMI EXPERT COMMITTEE

Name Region Speciality

Phillipe L’Allier Stéphane Rinfret Jean-Pierre Déry Richard Harvey

06 06 03 05

Interventional cardiology

Simon Kouz 14 General cardiology Sebastien Maire Dave Ross Eli Segal

12 16 06

Emergency Medecine

Maryse Mercier 04 Internist

Normand Racine RQCT Cardiac failure

6

PREVIOUS SCIENTIFIC PRODUCTS

• Comparison of efficacy, effectiveness and safety of fibrinolysis and PPCI for care of STEMI (2008)

• Care of STEMI : Systematic review of organizational and economics Issues (2008)

• Province-wide field evaluations (2006-7 ; 2008-9)

*UECT: Unité d’évaluation en cardiologie tertiaire

7

ACTIONS TO SUPPORT CHANGE

• Ministerial Action Plan on continuum care for patients with STEMI;

• Individualized results by region and by center ;

• Oral presentations by INESSS with ministerial representatives in many regions across Québec

• Creation of interdisciplinary committees within various hospitals or regions with a goal of improving of processes of care

8

RE-EVALUATE

• Update of literature review

• Establishment of quality standards

• Third field evaluation – 83 Hospitals across Québec ; – Standardized and objective review of medical charts by

UECV’s medical archivists ; – Centralized website with automatic data checks – Linkage with medicoadministrative data in order

to measure short and long term clinical results

HOSPITALS INCLUDED IN THE FIELD EVALUATION (2013-2014)

PPCI WITH DIRECT ADMISSION: DELAY (MINUTES) FIRST MEDICAL CONTACT TO DEVICE BY REGION

79 7981

8487 88 88

91 91

9598

50

60

70

80

90

100

110

120

130

14 16 12 02 QC 05 07 03 15 06 13

% ≤90 min for all Québec ETIAMEST I/II = 42 % ETIAMEST III = 54 %

n 56 140 29 30 768 67 51 99 30 202 57

PPCI WITH DIRECT ADMISSION: IMPACT OF PREHOSPITAL CARE ON DELAY FROM DOOR TO DEVICE

79

70

52

33

24

10

30

50

70

90

110

Sans ambulance Ambulance sansECGPh

Ambulance avecECGPh et ECG

intrahospitalier

Ambulance avecECGPh, sans ECG

intrahospitalier etdirigés en salle

d'urgence

Ambulance avecECGPh, sans ECG

intrahospitalier etdirigés directementen Hémodynamie

High degree of interdependance between various systems involved in the process of care:

• Prehospitalier • Emergency room • Cath lab

n=116 n=37 n=471 n=62 n=81

STEPS TO SUPPORT IMPROVEMENT ?

• How can we support collaborative change ?

• How can we engage and assist stakeholders to achieve the established quality standards ? – individual feedback

– tool kit

– site visits / audit ?

– public reporting ?

LEFT VENTRICULAR ASSIST DEVICES

LVAD

LVAD EXPERT COMMITTEE Name Speciality Organism

Renzo Cecere

Nadia Gianetti

Donna Stanbridge

cardiac surgeon

cardiologist

administrator

CUSM

Michel Carrier

Anique Ducharme

Marie-Andrée Gauthier

cardiac surgeon

cardiologist

nurse

ICM

Éric Charbonneau

Christine Bourgault

Steve Radermaker

cardiac surgeon

cardiologist

psychiatrist

IUCPQ

Jonathan Afilalo cardiologist HGJ

Normand Racine cardiologist RQCT

16

RECOMMENDATIONS

• being eligible for a heart transplant should not be an essential criterion for patient selection

• LVAD should be offered to those patients who are the most likely to benefit in terms of survival and quality of life

• clear and applicable selection criteria should be established and applied uniformly across the centers

• a mandatory provincial registry of LVAD should be created to : – monitor patient selection and clinical outcomes – to aid decision-making concerning the organization of care

FIELD EVALUATION

Treatment strategy according to INTERMACS definitions

Quebec (2013-2015)

N=53 %

INTERMACS (2012-2015)

N= 10436 %

BTT Bridge to transplant 34.0 25.9

BTC Bridge to candidacy - Likely 30.1 17.2

BTC Bridge to candidacy - Moderate 11.3 8.9

BTC Bridge to candidacy - Unlikely 3.8 2.6

DT Destination therapy 15.1 44.3

RT Rescue therapy 3.8 0.4

BTR Bridge to recovery 1.9 0.3

QUALITY STANDARDS

Literature review

Field evaluation

Quality standards

Support improvement

-Development of QI -Toolkit -Site visits -Shared-decision making ?

Transcatheter Aortic Valve Implantation

(TAVI)

TAVI ADVISORY COMMITTEE

Cardiac surgeons Interventional cardiologists

Michel Carrier (ICM) Benoit Daneault (CHUS)

Yoan Lamarche (HSCM/ICM) Réda Ibrahim (ICM)

Benoit de Varennes (CUSM) Philippe Généreux (HSCM)

Éric Dumont (IUCPQ) Giuseppe Martucci (CUSM)

General Cardiologists Josep Rodés-Cabau (IUCPQ)

Jonathan Afilalo (HGJ) Anita Asgar (ICM)

Normand Racine (RQCT) Brian Potter (CHUM)

Geriatrician Nicolo Piazza (CUSM)

Jean-Pierre Beauchemin (IUCPQ)

FIELD EVALUATION

MORTALITY : QUEBEC (2013-2014) VS NATIONAL REGISTRY DATA

INCREASING VOLUME OF TAVI IN QUEBEC

294

340358

0

50

100

150

200

250

300

350

400

2013-2014 2014-2015 2015-2016

Num

ber o

f TAV

I

range across centres 12 - 115

range across centres 30 - 99

range across centres 30 - 125

STS SCORE AND 30-DAY MORTALITY

2013 - 2014 2014 - 2015 2015 - 2016

STS score Median (25e -75e percentile) 5.8 (4 – 8.8) 6.6 (4.4 – 8.9) 4.2 (2.8 – 6.5)

Low Risk

Intermediate Risk

High Risk Prohibitive Risk

STS PROM

<4%

4% to 8%

>8% Predicted risk with surgery of death or major morbidity (all-cause) >50% at 1 y

[ACC / AHA 2014]

NEXT STEPS

Systematic literature review • structures • processes • outcomes • prognostic factors • intermediate risk TAVI

Continued field evaluation of 6 TAVI programmes

• structures • processes of care • patient characteristics • outcomes

establish quality standards for Quebec establish indicators of quality standards

29

THROMBECTOMY

Literature review

Field evaluation

Quality standards

Support improvement

• Characteristics of patients • Processes of care • Clinical outcomes

Impact of a new technology on the system of care for ischemic stroke ?

IMPLANTABLE CARDIAC DEFIBRILLATORS

(ICD)

ICD ADVISORY COMMITTEE

Name Speciality Organism

François Philippon Electrophysiologist IUCPQ

Marc Dubuc Electrophysiologist ICM

Vidal Essebag Electrophysiologist CUSM

Felix-Alejandro Ayala-Paredes Electrophysiologist CHUS

Paolo Costi Electrophysiologist CHUM

Miguel Barrero-Garcia Cardiologist Trois-Rivières

Dominique Grandmont Cardiologist Hôpital de St-Hyacinthe

Paul Farand Cardiologist /administration CHUS

Christine Villemaire ICD Technician ICM

Marianne Dompierre Nurse – coordinator ICM

Marie-Andrée Gauthier Nurse – informed decision Hôpital Lasalle

Normand Racine Cardiologist – heart failure RQCT

WHAT IS THE QUESTION ?

“…. estimating the ICD benefit through risk scores promotes honest communication and evidence-based decision making between patients and physicians to achieve the most appropriate therapy that is consistent with the patient’s values and preferences regarding their quantity and quality of life.” CCS Guidelines 2016

CHOICE OF ICD THERAPY REPLACEMENT? UPGRADE? DEACTIVATION?

• Systematical literature review

• Field evaluation – Characteristics of patients – Processes of care – Clinical outcomes

• Creation of patient committee to integrate the patient perspective

ANALYSIS OF MEDICOADMINISTRATIVE DATA

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Questions?

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