Pereira H, SFL Stent for Life, Portugal

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1 Stent for Life, Portugal

2 Stent For SFL Initiative in Portugal: Improving quality by shortening patients and system delays in Portugal Hélder Pereira, SFL Champion Albufeira, 27 April2014

3 Stent for Life Portugal Where we started Quality Assessment Our Current Program Market Research Study Conclusion

4 Where we started 4

5 Implement an Action Plan to Increase P-PCI To increase the use of primary PCI to more than 70% among all ST segment elevation myocardial infarction patients, To achieve primary PCI rates of more than 600 per one million inhabitants per year, To offer 24/7 service for primary PCI procedures at all invasive facilities to cover the country STEMI population need. J.Knot: How to set up an effective national primary angioplasty network: lessons learned from five European countries (EuroIntervention, August 2009).

6 Stent for Life Reperfusion Therapies (<2008): Non Revascularized 37% 44% Fibrinolysis 19% Primary PCI <200 P-PCI/million/year Reperfusion therapy for ST elevation acute myocardial infarction in Europe: description of the current situation in 30 countries. P. Widimsky et al. Eur. Heart.J. 2010;31: doi: /eurheartj/ehp492

7 Stent for Life Reperfusion Therapies Differ in Countries (situation in years for most countries) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% CZ SLO DE CH NO DK PL HR SE HU BE IL IT FIN AT FR SK ES LAT UK BG PO SRB GR TR RO P-PCI Thrombolysis No reperfusion Reperfusion therapy for ST elevation acute myocardial infarction in Europe: description of the current situation in 30 countries. P. Widimsky et al. Eur. Heart.J. 2010;31: doi: /eurheartj/ehp492

8 Stent for Life Reperfusion Therapies (2011): Non Revascularized 25% 7% Fibrinolysis 68% Primary PCI 299 P-PCI/million/year* Registo Nacional de SCA; SPC * PNDCCV Inquérito Unidades de Saúde 2011

9 Stent for Life Portugal Barriers Identification Patients E.M.S. network Hospital Only 23% of STEMI patients call 112 Communication with P-PCI Centers Strategic PCI Hospitals w/o 24/7 Long Patient Delay Secondary transport 9 Long System Delay

10 Where we are

11 Primary PCI Evolution P-PCI/ Million/Year * From PNDCCV Inquérito Unidades de Saúde 2013 * From APIC Survey 2013

12 Steen D. Kristensen et al. Blue bars are data from 2007 and red bars are data from 2010/2011

13 Primary PCI vs Fibrinolysis Coronary Care Units Fibrinolysis P-PCI From PNDCCV Inquérito Unidades de Saúde 2013

14 Primary PCI vs Other PCI 100% % 60% 40% P-PCI Other 20% 0%

15 Primary PCI per Regions (2012) 500 P-PCI Continente Norte Centro LVT Alentejo Algarve 32 From PNDCCV Inquérito Unidades de Saúde 2013

16 500 Primary PCI per Regions (2012 vs 2013) Continente Norte Centro LVT Alentejo Algarve 32 From PNDCCV Inquérito Unidades de Saúde 2013

17 Quality Assessment

18 Quantity and Quality P-PCI/million/year Symptoms-FMC/ /Call 112 EMS System Delay

19 Quality Assessment Portuguese Registry of Interventional Cardiology Moment Survey Market Research Studies

20 Portuguese Registry of Interventional Cardiology (RNCI) Since 2013, all P-PCI centers are sending data to RNCI

21 Portuguese Registry of Interventional Cardiology

22 Portuguese Registry of Interventional Cardiology Benchmark:

23 Moment Survey (SFL Portugal) Moment Zero (n=201) May 2011 Moment One (n=196) May 2012 Moment Two (n=244) May 2013

24 Symptoms to FMC Symptoms-FMC Moment Two May 2013 Moment One May Moment Zero Moment One Moment Two Moment Zero May (min)

25 Patients who called INEM Call % 30% 33% 38% 37% 20% 10% 0% Moment Zero Momento One Momento Two May 2011 May 2012 May 2013

26 FMC - EKG Moment Two 15 Moment One 15 Moment Zero 17 (min)

27 (min) Time-to-Treatment - Primary PCI Center - D2B Moment Two 55 Moment One 53 Moment Zero

28 Time-to-Treatment Goals for P-PCI - Directly-Admitted vs Transferred Patients -

29 Time-to-Treatment Goals for P-PCI - Directly-Admitted Patients - Bates E et al. NEJM 2013:369;889

30 Time-to-Treatment Goals for P-PCI - Transfer Patients - Bates E et al. NEJM 2013:369;889

31 Three Different Scenarios: Patients transported by the EMS to P-PCI Hospitals Patients who transport themselves to P-PCI Hospitals Patients who transport themselves to Non-P-PCI Hospitals

32 Patients who underwent a health institution without P-PCI 70% 60% 50% 40% 30% 20% 10% 0% P=0,005 62% 47% 48% Moment Zero Moment One Moment Two May 2011 May 2012 May 2013 LOCAL HOSPITAL

33 Door-in-Door-out Time (DIDO) LOCAL HOSPITAL P-PCI HOSPITAL Moment Two 115 Moment One 106 Moment Zero 97 P=0,

34 Door-to-Balloon Patients Arriving Directly to P-PCI Hospital: ( ) 96 min (71-146) P<0,001 P-PCI HOSPITAL 50 min (30-75)

35 Manchester Triage Triage Moment Zero Moment One Moment Two p Red 5.4% (n=8) 10.6% (n=13) 5.7% (n=9) Orange 77.7% (n=115) 66.7% (n=82) 78.3% (n=123) Yellow 14.2% (n=21) 21.1% (n=26) 13.4% (n=21) Other 2.7% (n=4) 1.6% (n=9) 2.5% (n=4) % 23% 16%

36 Time to Reperfusion Therapy Treatment Delay < 120 min: 12% 10% 8% 6% 8% 12% 9% 4% 2% 0% Moment Zero Moment One Moment Two May 2011 May 2012 May 2013

37 Stent for Life Portugal Quality Control: Moment Surveys Symptoms-FMC FMC-PPCI D2B Moment Two May Moment One May (min) Moment Zero May Patient Delay System Delay

38 Market Research Study

39 Market Research Study - Stent for Life - Sofia Portela slportela@iscte.pt Rui Menezes rui.menezes@iscte.pt February 2014

40 ACT NOW SAVE A LIFE What would you do in case of MI? Call a doctor Chamava um médico Telefonava a um familiar ou amigo Call a friend or relative Ia para o hospital de carro Go to a hospital by car 0% 1% 6% Other Call line Saúde 24 Press chest Basic life support Don t know Call an ambulance Chamava uma ambulância 91% Other Outro 2% Sofia Portela & Rui Menezes

41 ACT NOW SAVE A LIFE What s the emergency number? 95% 3% 1% 0% 1% 0% 0% Don t Não know sei Sofia Portela & Rui Menezes

42 Patients who called INEM Call % 30% 33% 38% 37% 20% 10% 0% Moment Zero Momento One Momento Two

43 ACT NOW SAVE A LIFE Myocardial infarction and stroke are the same disease? 8% 16% 77% Sim Yes Não No Não Doesn t sei know 77 % answered No, however 25,5% do not know to describe any difference Sofia Portela & Rui Menezes

44 ACT NOW SAVE A LIFE What s the typical symptom of MI? Symptoms Sintomas related to enumerados MI têm todos a ver com enfarte 24% Any symptoms Nenhum is sintoma related to enumerado MI tem a ver com enfarte Alguns dos sintomas enumerados têm a ver com Some symptoms are related to MI, some other no enfarte e outros sintomas não 27% 28% All symptoms Todos are os related sintomas Stroke enumerados têm a ver com AVC Some symptoms Alguns are related dos sintomas MI, some enumerados other are têm related a ver to com stroke enfarte e outros têm a ver com AVC 4% 5% Do not know the typical Não symptom sei qual of o sintoma MI típico de enfarte 21% Sofia Portela & Rui Menezes

45 STEMI vs Stoke

46 Our Current Program

47 Stent for Life Programs STENT Follow goes to Primary Prevention Secondary Prevention the School STENT SAVE HER S LIFE Cost- -Effectiveness Study

48 North Regional Meetings (P-PCI Hospitals, Non-PCI Hospitals, EMS, Regional Authorities) Center LVT Alentejo Algarve North: Jorge Marques Centre: Marco Costa Lisbon and Vale do Tejo: Pedro Sousa Alentejo: Renato Fernandes Algarve: Jorge Mimoso

49

50 Improving quality by shortening patients and system delays in Portugal Summary: Patient delay: Maintain/increase the population awareness campaign; System delay: Consolidation of EMS-Hospital partnership; Improve the national network; Increase professional motivation; Other measures: Motivate industry partners; Persuade the Ministry of Health to be a partner of the campaign; Standardize optimal medical treatment; Educational programs for health personnel and patients

51 Conclusions Barriers Identification Patients E.M.S. network Hospital Only 23% of STEMI patients call 112 Communication with P-PCI Centers Strategic PCI Hospitals 24/7 Long Patient Delay Secondary transport Long System Delay

52 Thank you

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