The Swedish approach: Quality Assurance with Clinical Quality Registries the RIKS-HIA example
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1 The Swedish approach: Quality Assurance with Clinical Quality Registries the RIKS-HIA example Ulf Stenestrand, MD, PhD Department of Cardiology University Hospital Linköping Chairman RIKS-HIA
2 Register of Information and Knowledge about Swedish Heart Intensive care Admissions General information 8.. (out of hospitals in Sweden >. ICCU-admissions since 1 Annually. new admissions Annually. acute MI > % of CCU admissions Sweden Population million Size larger than Germany
3 Features of RIKS-HIA All consecutive patients at all participating hospitals are entered into the registry hours x 3 days Fully complies to European standard definitions of variables CARDS Based on a unique personal identification number given to every Swedish citizen at birth Non cardiac baseline information added by merging with other national registries Outcome such as new hospitalization or death is added by merging with other national registries this ensures 1% follow-up with no time limit
4 Data validity Information is entered over the Internet into RIKS-HIA or transferred from electronic patient records. The web-based interface has a number of logic controls for data being entered. Continuous validation and control of data is performed by an external monitor. These controls have detected on average % correct and non missing data entered
5 Purpose Develop acute coronary care by: Continuous information about patients (number & characteristics, therapy and outcome. Continuous feed-back about development and outcome at your own hospital Comparison with national guidelines, national standard and similar hospitals
6 Quality indicators = adherence to treatment goals according to guidelines How large is the variation in therapies between hospitals? Does the therapy change according to new guidelines? Does outcome improve with changed therapy? Does individual hospital s quality of care improve in relation to new treatment goals? Does individual hospital s quality of care affect outcome?
7 Quality indicators = adherence to treatment goals according to guidelines How large is the variation in therapies between hospitals? Does the therapy change according to new guidelines? Does outcome improve with changed therapy? Does individual hospital s quality of care improve in relation to new treatment goals? Does individual hospital s quality of care affect outcome?
8 Beta-blockers in MI < 8 year * # ( ' & % 1 Proportion beta-blockers by year # ( ' & % Proportion beta-blockers by hospital ' ( % &! ( %( ( & ' (% & ' &' ' ' & % (& ( %&%% % &' & ( '((%' % ' ( & & ' % Uppsala Clinical Research Centre (( & ( % & % '& &'(% ( %&( %( ' %' % & (' &
9 3 1 Measures in MI at different hospitals year ACE-inh./ A-block Betablocker Lipid lowering Coronary angiogram
10 Coronary angiogram in NSTEMI <8 years Discharged alive and at least 1 of the following alternatives: - Diabetes - Previous MI - ST-depression on EKG - Pulmonary rales - LVEF <% To receive a point % needed to receive angiogram =!. = A /.+!. :;. #1 -.+ = ; - A ? -!! > = = -. /=.+ <- :; ! # 3 ++ #! 1 - (& % % & ' (. -!++/13 +!,+--+ -!++' Mean value Level to receive point RIKS-HIA annual report
11 Proportion coronary angiogram during hospital stay in MI Proportion coronary angiogram. ( ' & % ' ( % & ' Women '! < years '(&! Women - years B*(! Women >= years Men '! < years '(&! Men - years B*(! Men >= years.!.,!,,' Patients with MI discharged alive, Sweden 1- RIKS-HIA annual report
12 Lipid lowering drugs at discharge in MI <8 years Patients are discharged alive with a total-cholesterol >, or LDL-Cholesterol >, mmol/l To receive a point % was required 1.+ =. A / -!. - = /=.+ 1 /.+ - > =! = 3 -! ++?.+ <- ;.+ :;. #1 -! A. :;. 3 - #!!.+ # = % % & ' ( + -!++ +!,+--+ -!++' Mean value Level to receive point 3% RIKS-HIA annual report
13 Development lipid lowering drugs at discharge by year, age and gender in MI 1 - Proportion coronary angiogram + ( ' & % ' ( % & ' Women < years Women - years Women >= years Men < years Men - years Men >= years '! '(&! B*(! '! '(&! B*(! Patients with MI discharged alive with total-cholesterol >, or LDL-Cholesterol >, mmol/l, Sweden 1- + C. D + -B&>B,+.!' RIKS-HIA annual report
14 Quality indicators = adherence to treatment goals according to guidelines How large is the variation in therapies between hospitals? Does the therapy change according to new guidelines? Does outcome improve with changed therapy? Does individual hospital s quality of care improve in relation to new treatment goals? Does individual hospital s quality of care affect outcome?
15 3-day mortality by year, age and gender in MI 1 - % % - 3-day mortality ' ( % & ' Women < years Women - years Women >= years Men < years Men - years Men >= years '! '(&! B*(! '! '(&! B*(! RIKS-HIA annual report ( % -
16 & F..CD Mortality % Year % & > Days E ' ( % & (.++.- MI patients - years. old in Sweden,'(&!, 1- RIKS-HIA annual report
17 3-day mortality by region year MI <8 years *& Mortality 3 days 1% % - 1% % % - =. / G South Stockholm South-east F North Central F. % -,!,' C-, D West RIKS-HIA annual report
18 1-year mortality by region year MI <8 years % *% Mortality 1 year!- % 1% 1% % % South Stockholm South-east - =. G / F Central West F.!-,!,& C-, D North RIKS-HIA annual report
19 3-day mortality by county and by hospital MI <8 years Mortality *& = :;. #1-1 :;. 3 < A. #! = -. /=.+ -.+! > =.! # /! ! -!? 1. = 3 - ; = A % % 1% 1% % >.-% Mortality by hospital % -,!,+ -B*+,'C-, D RIKS-HIA annual report
20 Quality indicators = adherence to treatment goals according to guidelines How large is the variation in therapies between hospitals? Does the therapy change according to new guidelines? Does outcome improve with changed therapy? Does individual hospital s quality of care improve in relation to new treatment goals? Does individual hospital s quality of care affect outcome?
21 Quality index Quality index is a relative index that aims to reflect the hospitals adherence to national (and ESC guidelines in acute MI. The index is based on measures that are recommended with high priority 1 3 (in a scale 1 to 1 in patients with indication and no contraindication for the treatment. 1 point was given to hospitals above the level of the ¼ that have the best adherence to national guideline previous year for each individual measure. A maximum of points can be achieved. RIKS-HIA annual report
22 Lipid lowering drugs at discharge in MI <8 years Patients are discharged alive with a total-cholesterol >, or LDL-Cholesterol >, mmol/l To receive a point % was required 1.+ =. A / -!. - = /=.+ 1 /.+ - > =! = 3 -! ++?.+ <- ;.+ :;. #1 -! A. :;. 3 - #!!.+ # = % % & ' ( + -!++ +!,+--+ -!++' Mean value Level to receive point 3% RIKS-HIA annual report
23 Treatments at discharge in MI <8 years where the patients fulfill the treatment guidelines! - 3! > = = - ;? = -! #!. A = -!.+ / -. :;. #1 <- /= =.+ -! :;. 3 A. # % & ' ( -- +!,+--+ -!++' ASA 8% =? <- - =!. =! -.+ A.! :;. #1 1 ; :;. 3 /.+ /=.+! A # = ++.+ / > = #! % & ' ( # -!++ +!,+--+ -!++' Beta-blocker 1% =!.+ /.+ <-! - -? :;. # > = -! 3.+! :; = = ; #! A = A # /= % & ' ( H+-!++/13 H1G-- -!++ +!,+--+ -!++' +!,+--+ -!++' Clopidogrel 81% = - =! - - / /=.+! A! = > = - 1. / <-. :;. #1. -! ;.+? - ++ # 8..+ = :;. 3!.+.+ A. #! (( % & ' ( RAS-blocker % RIKS-HIA annual report
24 -. =?! - /=.+ - <- # ; /! =! A - = -. :; ! = -! A.. #! - ++ % & ' ( A& % A&+!.,+ C--+!-!++D -.+.! = A / :;. 3! =! /= = - > = =!?. # 1. ; - -! A. < #! ++ % & ' ( A % A+!.,+ C--+!-!++D RIKS-HIA annual report
25 Quality index based on recommended treatment according to national guidelines Quality index per hospital year! = -! / =! A -. /.+ /=.+? # > = ; :;. #1 3 A. < = -!! -. :;. 3 #! % & ' ( A' % A'+!.,+ C--+!-!++D RIKS-HIA annual report
26 Quality index development #! ++ :; Quality A' index ( ' & % /=.+ A - /.+ /= -!! ! =! <- - = # 3.+ A ? -! = % & ' ( Quality index A& - RIKS-HIA annual report
27 Quality indicators = adherence to treatment goals according to guidelines How large is the variation in therapies between hospitals? Does the therapy change according to new guidelines? Does outcome improve with changed therapy? Does individual hospital s quality of care improve in relation to new treatment goals? Does individual hospital s quality of care affect outcome?
28 3-day mortality in MI related to hospital quality index. -% % Proportion dead 3 days % ' % % & 3% % % 1% % & ' B*( - - >= A Quality index & -% + A,'C!,--+ -!++D RIKS-HIA annual report
29 Quality indicators, quality index and patients health Adherence to guidelines varies! Average adherence to guidelines improves! Average outcome improves with changed care? Individual hospital s quality of care measured as quality index in relation to new treatment goals improve! Individual hospital s quality of care measured as quality index is related to outcome patients health!
30 Proportion of the last patients in respective target group that achieved the goal My hospital Average of best hospitals
31 Proportion of target population that received coronary angiogram. Patients in groups of 1 My hospital
32 On-line reports in RIKS-HIA RAS-blockade Reperfusion in STEMI
33 Quality reports in your own hospital On-line, includes everything that has been entered before midnight the previous evening. Mortality updated once a month by adding data from the National Population Registry Quarterly quality reports are automatically mailed to a free number of subscribers
34 Summary Complications and death are so uncommon that they cannot be used as quality indicators for individual hospitals. Adherence to guidelines and evidence based therapy is thus a better indicator of quality of care. Quality index is an attempt to summarize adherence to guidelines. Quality registries can help improving adherence to guidelines and thereby outcome and patient health
35 Thank you for your attention
36 Then Now Future Uniformed Uninterested Unequal - large regional differences Low compliance to guidelines Informed Interested, debate Less regional differences Better compliance to guidelines Halved mortality in 1 years More information Interested, natural No regional differences Total compliance to guidelines Further improved survival Even better quality support Thank you for your attention!
37 *! 3 :; A. - > = -. =.+ 1.+! <- -! - ; #!. = -? - / min Symptom to PCI Median 1 min 8 min Delay by Hospital :;. 3 #! ; -! - > = ! <-.+ 1 * min ER to PCI Median 1 min 1 min ' & % %' & & & ' =--IH3C-D % ' & IH3C-D..C-,(+D!=-- +-IH3,!,' C-,(+D! - +-IH3,!,' - '--
38 Treatments at discharge in MI <8 years where the patients fulfill the treatment guidelines = -! -!! 1 -.!.+ A - /=.+ # ;? /.+ > = A :;. #1 / - = = -..+ = -! 8..+ :; #! % & ' ( JGIH3-=-!++/13 +!,+--+ -!++' LMWH/Heparin/ Fondaparinux or PCI < 1 day NSTEMI % A! =. = #.+ /=.+! - / - = /.+? <- ;!.+! > = :;. 3 A. = :;. #1 -! ++ 3 #!.+ '& % & ' ( IH3-+ -!++13G### +!,+--+ -!++' Primary PCI STEMI % - # = / = - /=.+? 1. <-! /.+!! = A! > = :;. 3 ; = :;. #1 A. -! #! (% % & ' ( F+ -!++13G### +!,+--+ -!++' Primary PCI or thrombolysis STEMI 3% RIKS-HIA annual report
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