Stent for Life, Portugal
Stent For SFL Initiative in Portugal: Improving quality by shortening patients and system delays in Portugal Hélder Pereira, SFL Champion Albufeira, 27 April2014
Stent for Life Portugal Where we started Quality Assessment Our Current Program Market Research Study Conclusion
Where we started 4
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).
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;31:943-957 doi:10.1093/eurheartj/ehp492
Stent for Life Reperfusion Therapies Differ in Countries (situation in years 2007-2008 for most countries) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 7 1 14 12 17 13 10 15 15 20 0 25 21 26 26 7 30 2 12 36 40 39 35 37 5 15 44 42 3 31 52 48 50 50 8 10 63 40 15 15 35 55 92 28 35 86 26 30 81 81 44 75 75 72 70 25 33 66 64 59 41 45 49 45 45 29 35 33 30 30 28 24 23 19 19 9 8 5 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;31:943-957 doi:10.1093/eurheartj/ehp492
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
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
Where we are
Primary PCI Evolution 350 300 250 200 150 100 50 0 P-PCI/ Million/Year 2002-2013 299 306 228 243 264 179 105 118 125 132 152 334 * 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 From PNDCCV Inquérito Unidades de Saúde 2013 * From APIC Survey 2013
Steen D. Kristensen et al. Blue bars are data from 2007 and red bars are data from 2010/2011
Primary PCI vs Fibrinolysis Coronary Care Units 4000 3500 3179 3246 3000 2500 2415 2575 2829 2000 1500 1616 1900 Fibrinolysis P-PCI 1000 500 855 702 878 572 421 424 344 0 2006 2007 2008 2009 2010 2011 2012 From PNDCCV Inquérito Unidades de Saúde 2013
Primary PCI vs Other PCI 100% 18 21 21 23 24 25 26 80% 60% 40% P-PCI Other 20% 0% 2007 2008 2009 2010 2011 2012 2013
Primary PCI per Regions (2012) 500 P-PCI 2012 400 300 200 100 306 291 215 453 432 0 Continente Norte Centro LVT Alentejo Algarve 32 From PNDCCV Inquérito Unidades de Saúde 2013
500 Primary PCI per Regions (2012 vs 2013) 453 432438 400 300 200 334 306 291 291 287 215 367 256 100 0 Continente Norte Centro LVT Alentejo Algarve 32 From PNDCCV Inquérito Unidades de Saúde 2013
Quality Assessment
Quantity and Quality P-PCI/million/year Symptoms-FMC/ /Call 112 EMS System Delay
Quality Assessment Portuguese Registry of Interventional Cardiology Moment Survey Market Research Studies
Portuguese Registry of Interventional Cardiology (RNCI) Since 2013, all P-PCI centers are sending data to RNCI
Portuguese Registry of Interventional Cardiology
Portuguese Registry of Interventional Cardiology Benchmark:
Moment Survey (SFL Portugal) Moment Zero (n=201) May 2011 Moment One (n=196) May 2012 Moment Two (n=244) May 2013
Symptoms to FMC Symptoms-FMC Moment Two May 2013 Moment One May 2012 90 102 Moment Zero Moment One Moment Two Moment Zero May 2011 118 0 20 40 60 80 100 120 (min)
Patients who called INEM Call 112 40% 30% 33% 38% 37% 20% 10% 0% Moment Zero Momento One Momento Two May 2011 May 2012 May 2013
FMC - EKG Moment Two 15 Moment One 15 Moment Zero 17 (min) 0 10 20
(min) Time-to-Treatment - Primary PCI Center - D2B Moment Two 55 Moment One 53 Moment Zero 55 0 20 40 60
Time-to-Treatment Goals for P-PCI - Directly-Admitted vs Transferred Patients -
Time-to-Treatment Goals for P-PCI - Directly-Admitted Patients - Bates E et al. NEJM 2013:369;889
Time-to-Treatment Goals for P-PCI - Transfer Patients - Bates E et al. NEJM 2013:369;889
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
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
Door-in-Door-out Time (DIDO) LOCAL HOSPITAL P-PCI HOSPITAL Moment Two 115 Moment One 106 Moment Zero 97 P=0,051 85 90 95 100 105 110 115
Door-to-Balloon Patients Arriving Directly to P-PCI Hospital: (2011-2013) 96 min (71-146) P<0,001 P-PCI HOSPITAL 50 min (30-75)
Manchester Triage Triage Moment Zero Moment One Moment Two p Red 5.4% (n=8) 10.6% (n=13) 5.7% (n=9) 0.184 Orange 77.7% (n=115) 66.7% (n=82) 78.3% (n=123) 0.042 Yellow 14.2% (n=21) 21.1% (n=26) 13.4% (n=21) 0.147 Other 2.7% (n=4) 1.6% (n=9) 2.5% (n=4) 0.852 17% 23% 16%
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
Stent for Life Portugal Quality Control: Moment Surveys Symptoms-FMC FMC-PPCI D2B Moment Two May 2013 90 100 55 Moment One May 2012 102 88 53 (min) Moment Zero May 2011 118 104 55 0 100 200 300 Patient Delay System Delay
Market Research Study
Market Research Study - Stent for Life - Sofia Portela slportela@iscte.pt Rui Menezes rui.menezes@iscte.pt February 2014
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
ACT NOW SAVE A LIFE What s the emergency number? 95% 3% 1% 0% 1% 0% 0% Don t Não know sei 112 115 117 118 119 202 Sofia Portela & Rui Menezes
Patients who called INEM Call 112 40% 30% 33% 38% 37% 20% 10% 0% Moment Zero Momento One Momento Two
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
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
STEMI vs Stoke
Our Current Program
Stent for Life Programs STENT Follow goes to Primary Prevention Secondary Prevention the School STENT SAVE HER S LIFE Cost- -Effectiveness Study
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
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
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
Thank you