Outcome measurement International perspective. 7 th February 2014

Transcription

1 Outcome measurement International perspective 7 th February 2014

2 Variation in health outcomes is an international problem 2x 4x 9x 18x 20x 36x variation in 30- day mortality rate from heart attack in US variation in bypass surgery mortality in the UK variation in complication rates from radical prostatectomies in the Netherlands variation in reoperation rates after hip surgery in Germany variation in mortality after colon cancer surgery in Sweden variation in capsule complications after cataract surgery in Sweden Variations in health outcomes can be found in care teams, within institutions, nationally, internationally 1

3 Magic bullets we have tried to reduce variation Clinical pathways, standardized care protocols Evidence- based medicine, guidelines Checklists Lean management Process measures EMR, computer- aided decision support ( ) 2

4 Physicians typically don t believe in top down solutions Clinical pathways, care protocols Evidence- based medicine, guidelines Checklists Lean management Process measures EMR, computer- aided decision support ( ) 3

5 Santeon a group of top clinical hospitals that wants to explore pioneering solutions and to provide best care 4

6 Our core belief Physicians, nurses and therapists are intelligent, creative people who must acquire and synthesize knowledge and often adapt established guidelines to make the best treatment decision for an individual patient but (as every person who works in an environment of insecurity ) they need meaningful and timely feedback in order to learn and improve 5

7 Martini Martini-Klinik faculty am UKE GmbH Strukturierter Qualitätsbericht 2010 Nine consultants, different specialization, equal voting rights A-2 Institutionskennzeichen des Krankenhauses 6

8 ]GIF$DT)([ rethral sphincter is essential to preserving RP. The pelvic floor is a complex system of mic forces. The insertion of the urethral this system is the prerequisite for its lar function [7]. In this paper, we describe r an individualised apical preparation to functional length of the urinary sphincter c integrity during RP. and patients (medial dorsal raphe), providing a point of fixation (Fig. 3) [6,13]. The puboperinealis portion of the levator ani (puboperinealis muscle, levator urethrae muscle) forms a hammock around the urethra and terminates at the perineal body between the urethra and the anterior aspect of the rectum (Fig. 3) [14]. Voluntary contraction of the puboperinealis and rectourethralis muscle pulls the urethra forward and upward, resulting closure and termination of the urinary stream [7]. Further lateral Urethral sphincter support to muscle the sphincter is is provided partially by the Mueller s covered ligaments by the prostate (ischioprostatic ligaments, Walsh s pillars) [7,10,12,15,16] (Fig. 3), which tive patients who underwent RP between May 2008 analysed. All surgical procedures were performed by urgeons (T.S., H.H., M.G.). The prospective collection of by our internal reviewer board, and all patients formed consent. All surgical cases were performed pubic approach described by the authors previously ffect of our surgical modifications on early and longa statistically representative cohort, a consecutive n full functional-length urethra [non-fflu; n = 285] undergoing surgery by the three surgeons within 1 yr inence rates were assessed using a self-administrated d 12 mo after removal of the catheter. Continence was of no pads and no leakage of urine. To assure the of our surgical modifications, we performed intraential frozen sections from the cranial and caudal of the urethra during the development phase of the cryosections showed tumour-free margins. Since July itionally inked the intraprostatic urethral resection ss exactly the rate of positive surgical margins (PSMs) y our modified technique. considerations y anatomic and functional studies, an important the urethral sphincter is located intraprostatically and the colliculus seminalis Source: Eur [2,3,6,8,11,13]. Urol 60 (2011): The Fig. 1 Transversal section of the prostatic apex. A considerable part of the urethral sphincter is located intraprostatically between the prostatic apex and the colliculus seminalis. SMS = smooth muscle sphincter; SS = striated sphincter (rhabdosphincter); CS = colliculus seminalis; PA = prostatic apex. 7

9 ]GIF$DT)([ Depending on localization up to 40% of sphincter muscle tissue are lost by removing the prostate 322 EUROPEAN UROLOGY 60 (2011) Fig. 2 Anatomic variability of the prostatic apex. Depending on the individual apex shape, between 10% and 40% of the functional urethra is covered by parenchymal apex tissue. Otherwise, the prostatic apex is covered by some muscular tissue on the ventral and rectal aspects as rudiments of embryonic and adolescent prostatic development. Source: Eur Urol 60 (2011): can easily be reconstructed by integration into the ventral anastomotic puboperinealis portion of the levator ani to the urethra and the perineal sutures during RP to avoid deviations of the urethra Surgical technique body is carefully preserved when it is gently pushed distally, enabling 8 clear visualisation of the circumference of the urethra. During dissection of the dorsal venous complex (DVC), a space between the DVC and the fascia of the rhabdosphincter can be identified by blunt preparation with

10 3 Monatsbrief Potenz Example slide quality review IIEF-5-Score 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 1-7 schwere ED 8-11 mittelschwere ED mild-mittelschwere ED milde ED keine ED Confidential! Operateur n keine ED (%) milde ED (%) mild- mittelschwere ED mittelschwere ED (%) (%) 1-7 schwere ED (%) kein GV (%) Graefen c 22 6 (27.3) 4 (18.2) 1 (4.5) 1 (4.5) 6 (27.3) 4 (18.2) Haese o 26 2 (7.7) 5 (19.2) 3 (11.5) 2 (7.7) 4 (15.4) 10 (38.5) Heinzer n 30 0 (0.0) 1 (3.3) 0 (0.0) 2 (6.7) 15 (50.0) 12 (40.0) Huland fi 36 4 (11.1) 5 (13.9) 4 (11.1) 2 (5.6) 10 (27.8) 11 (30.6) Michl d 27 1 (3.7) 3 (11.1) 5 (18.5) 3 (11.1) 6 (22.2) 9 (33.3) Salomon e 13 0 (0.0) 5 (38.5) 2 (15.4) 0 (0.0) 1 (7.7) 5 (38.5) n Schlomm 12 0 (0.0) 2 (16.7) 3 (25.0) 1 (8.3) 2 (16.7) 4 (33.3) t Steuber 21 1 (4.8) 1 (4.8) 3 (14.3) 3 (14.3) 4 (19.0) 9 (42.9) i Budäus a 3 0 (0.0) 1 (33.3) 0 (0.0) 1 (33.3) 0 (0.0) 1 (33.3) Heuer l 1 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 1 (100.0) gesamt (7.3) 27 (14.1) 22 (11.5) 18 (9.4) 123 (64.4) 66 (34.6) 9

11 FFLU = full functional-length urethra. ]GIF$DT)([ salvage or palliative setting (not included in the analyses), 406 patients with the FFLU technique, and 285 patients with our conventional (non-fflu) technique. There were no significant differences in baseline and surgical characteristics between the FFLU and non-fflu groups (Table 1). The continence rates at 7 d and 12 mo after catheter removal were 50.1% and 96.9% in the FFLU group and 30.1% and 94.7% in the non-fflu group, respectively ( p < 0.001, p = 0.59; Fig. 10 and 11; Table 2). The reported number of required pads correlated significantly with the reported urinary leakage during coughing, laughing, sneezing, or Comparison of outcome data in the quality review showed interesting variation Fig. 11 Urinary control 1 wk after catheter removal.fflu = full functional length urethra. 10

12 ]GIF$DT)([ After showing favorable results, FFLU was rapidly adopted 326 EUROPEAN UROLOGY 60 (2011) Source: Eur Urol 60 (2011): Fig. 10 Impact of full functional-length urethra preparation on early urinary continence in a consecutive series of 691 radical prostatectomies. Average numbers of pads used in a 24-h period per patient were calculated on a monthly basis and presented for each surgeon. St. FFLU Antonius = full 2014 functional-length JDW.pptx urethra. 11

13 physical activities (data not shown). The two groups had no significant differences in the overall frequency of PSMs ( p = 0.39), PSMs in pt2 tumours ( p = 0.78), and PSMs in the separately inked intraprostatic urethral resection boarder (Table 1). One year after radical prostatectomy, FFLU patient still showed improved continence rates Table 2 Urinary control 12 months after radical prostatectomy FFLU (n = 324) Non-FFLU (n = 282) No. (%) No. (%) p Pads/24 h (96.9) 231 (94.7) (2.2) 10 (4.1) (0.6) 2 (0.8) >5 1 (0.3) 1 (0.4) FFLU = full functional-length urethra. use of a catheter Every patients consecu the resu the effec question removal individu function after cat remainin techniqu patients with th postoper Source: Eur Urol 60 (2011):

14 Patient- reported outcomes one year after prostatectomy - Martini Klinik and average German Hospitals Martini Klinik 93,5 % Average German Hospitals Average German Hospitals 75,5 % 56,7 % Martini Klinik 34,7 % Martini Klinik 0,4 % Average German Hospitals 4,5 % 1 yr full con+nence 1yr severe erec+le dysfunc+on 1yr severe urinary incon+nence Source: Martini Klinik, BARMER GEK Report Krankenhaus 2012, Patient- reported outcomes (EORTC- PSM), 1 year after treatment,

15 Rapid growth after launch of Martini Klinik in ,225 1,973 Prostatectomies/year, # +18,5% CAGR. 1,755 Martini Klinik Hamburg University Medical Center, Urology Department 1,335 1,541 1, Source: Martini Klinik, quality report 14

16 Key success factors for outcome- driven care improvement Develop a system that continuously screens literature and other sources (fellowships, meetings, site visits) for interesting outcome variation Discuss variations openly and provide freedom to try out new solutions See outcome variations as a chance for collective learning and improving Lead by example, walk the talk and start change and learning at the top of the pyramid Create a we challenge the status quo culture (Apple!) Find international partners to compare with best practice solutions can often be found in unexpected places 15

17 ICHOM is a nonprofit dedicated to accelerating development and impact of outcomes measurement ICHOM's three founders with the desire to unlock the potential of VBHC......launched ICHOM as a nonprofit + Independent 501(c)3 organization + Idealistic and ambitious goals + Global focus + Engages diverse stakeholders Our mission: We are transforming health care by empowering clinicians worldwide to measure and compare their patients outcomes and to learn from each other how to improve. 16

18 ICHOM organizes Working Groups to define Standard Sets of outcomes we recommend all providers track ICHOM Standard Set Outcomes Measures ICHOM facilitates a process with international physician and registry leaders and patient representatives to develop a global Standard Set of outcomes that really matter to patients Physician and registry leaders Patient representatives Tier 1 Tier 2 Tier 3 17

19 Example: ICHOM Localized Prostate Cancer Working Group Adam Glaser, St James Institute of Oncology; NHS Jim Catto, University of Sheffield, European Urology Frank Sullivan Prostate Cancer Institute John Fitzpatrick, Irish Cancer Society Anna Bill- Axelson, Swedish Prostate Cancer Registry Hartwig Huland and Markus Graefen, Martini Klinik Michael Froehner, Günter Feick*, Bundesverband Prostatakrebs Selbsthilfe (BPS); Europa UOMO Thomas Wiegel, University Hospital Ulm Steven Jay Frank, MD Anderson David Swanson, MD Anderson Andrew Vickers, MSKCC Adam Kibel, Dana Farber/BWH Michael O Leary, Dana Farber/BWH Anthony D Amico, Dana Farber/BWH Neil Martin, Dana Farber/BWH Michael Blute, MGH Howard Sandler, Cedars- Sinai Ronald Chen, University of North Carolina Dan Hamstra, University of Michigan Ash Tewari, Weill Cornell Medical College *Patient representative C.H. Bangma, Erasmus Medical Center Francesco Montorsi, European Urology Editor in Chief Alberto Briganti, Vita- Salute San Raffaele University Hospital, Milan Jabob Ramon, Sheba Medical Center Kim Moretti, South Australian Prostate Cancer Clinical Outcome Collaborative Mark Frydenberg, Prostate Cancer Registry of Victoria Ian Roos*, Cancer Voices Victoria 18

20 ICHOM Standard Set for Localized Prostate Cancer Treatment approaches covered Watchful waiting Active surveillance Prostatectomy External beam radiation therapy Brachytherapy Androgen Deprivation Treatment Other 2013 ICHOM. All rights reserved. When using this set of outcomes, or quoting therefrom, in any way, we solely require that you always make a reference to ICHOM a s the source so that this organization can continue i ts work to define more standard outcome sets. 19

21 Once Standard Set Is Defined, ICHOM Working Group Goal Is To Drive Adoption Flyer User Manual Academic Publication A Standard Set of Outcome Metrics for Measuring the Impact of Prostate Cancer Treatment Beautifully designed rendition of ICHOM Standard Set Promoted at conferences, Harvard health care courses, and on the ICHOM website Full detail of Standard Set for institutions interested to start collecting or payors looking to integrate into reimbursement programs Includes definitions, inclusion and exclusion criteria, time points for data collection, and index events Announces the Standard Set to the medical community Explains process to arrive at Standard and motivation for each outcome and risk factor selected 20

22 ICHOM s ultimate goal is to accelerate the pace of learning and improvement based on meaningful global comparisons Data Collection Capturing data Physician reported PROMs EMRs other databases Aggregation for for use use Reporting & Using Data Analysis and Insight Report generation Value based actions 21

23 In our first year, we ve successfully developed Standard Sets in four conditions, and now we want to ramp up quickly Conditions targeted for 2014 Stroke Hip and knee osteoarthritis Macular degeneration Lung cancer Parkinson s disease Depression and anxiety Cleft lip and palate... 22

24 ICHOM's plan is to cover more than 50 conditions by conditions 12 conditions 24 conditions 40 conditions 50+ conditions Share of disease burden in industrialized countries 37% 45% 57% 70% 9%

25 We are proud of our Sponsoring Partners 1. Excluding donations by Cofounders 24