Abstract 268: Using Lean Methodology to Reduce Variation in Care of Acute Coronary Syndrome Patients

2016 ◽  
Vol 9 (suppl_2) ◽  
Author(s):  
Andrew Kmetic ◽  
Guy Fradet ◽  
Ronnalea Hamman ◽  
Carol Laberge ◽  
Carol Galte
Keyword(s):  
Regional Variation ◽  
Best Practice ◽  
Point Of Care ◽  
Coronary Revascularization ◽  
Patient Characteristics ◽  
Care Staff ◽  
Multiple Sources ◽  
Patient Journey ◽  
Coronary Syndrome ◽  
Decision Points

Background: Regional variation in the utilization of health services is a well-documented phenomenon in health care with numerous studies reporting substantial and unexplained variations in coronary revascularization. In the Canadian province of British Columbia (BC), five cardiac centers provide coronary revascularization services. In 2011 Cardiac Services BC (CSBC) undertook a study that identified substantial regional variation in coronary revascularization that could not be explained by patient characteristics or risk factors. Following this initial project, CSBC launched an initiative to help better understand the regional variations and possibly devise and implement strategies to reduce them. Methods: Using Lean methodology, we are mapping the key processes of care for ACS patients across BC (initially excluding emergent STEMI and cardiogenic shock) at each cardiac centre. The ACS patient journey will be mapped from admission to discharge through several key decision points that determine whether they will continue through to diagnostic catheterization and revascularization or to be medically managed alone. The key decision points are: 1. Decision to refer to diagnostic catheterization and subsequent transfer if necessary. 2. Decision to continue to a revascularization procedure (PCI or CABG) after diagnostic catheterization. The map will summarized these key decision points using multiple sources of data: 1. Flow and patient volumes into and out of each of these decision 2. Times between decision points and key care processes 3. Clinical influencers (ex: standard orders, best practice, established patterns of referral, and consultations) and non-clinical influencers (ex: resource capacity, transportation) that are considered at each decision point (process mapping and interview data). Discussion: BC is attempting to reduce unexplained variation in coronary revascularization using the Lean methodology to take a systematic approach to the analysis of the process of ACS care across the province. Involving physicians and point of care staff in the detailed mapping process has proven to be a significant step in engaging key stakeholders in the project by allowing input into the process of describing the factors affecting variation of practice at each site. The next step is to convene provincially to determine where to improve standardized practice in order to improve patient outcomes at key points along the value stream.

Abstract 378: Using Lean Methodology to Reduce Variation in Care of Acute Coronary Syndrome Patients

2015 ◽  
Vol 8 (suppl_2) ◽  
Author(s):  
Guy Fradet ◽  
Carol Laberge ◽  
Andrew Kmetic ◽  
Ronnalea Hamman
Keyword(s):  
Decision Making ◽  
Acute Coronary Syndrome ◽  
Regional Variation ◽  
Coronary Revascularization ◽  
Patient Characteristics ◽  
Care Utilization ◽  
Process Of Care ◽  
Patient Journey ◽  
Coronary Syndrome ◽  
Decision Points

Background: Regional variation in the utilization of health services is a well-documented phenomenon in health care with numerous studies reporting substantial and unexplained variations in coronary revascularization. In the Canadian province of British Columbia (BC), five cardiac centers provide coronary revascularization services. In 2011 Cardiac Services BC (CSBC) undertook a study that identified substantial regional variation in coronary revascularization that could not be explained by patient characteristics or risk factors. Following this initial project, CSBC launched an initiative to help better understand the regional variations and possibly devise and implement strategies to reduce them. To get a better understanding of the different processes of care/utilization, one of the approaches used is the application of Lean methodology to the care of acute coronary syndrome (ACS) patients. Methods: Lean methodology is being applied to the patient journey of ACS patients. At each revascularization center Value Steam Maps process maps (VSM) are being prepared through a series of meetings with support, frontline, administrative and clinical staff (see attached example). For each VSM the goal is to identify key decision points in the process of care for ACS patients and to drill down on (Root Cause Analysis) on the decision making environment and criteria used to determine the utilization of coronary revascularization services. Once VSM have been completed they will be compared across sites for similarities and differences. The differences in decision making will then be assessed to determine their effect on variation in utilization across the centers. Discussion: BC is attempting to reduce unexplained variation in coronary revascularization using the Lean methodology to take a systematic approach to the analysis of the process of ACS care across the province. The next step will be to determine to what extent it is possible to standardize decision making at the key decision points across the HAs. Standardization will be achieved through a mix of best practices, evidence and application of guidelines. While the undertaking is still in the early stages it is expected that it will lead to, at the very least, ACS patients receiving the same care regardless of where they receive their care in BC.

scholarly journals Precision population analytics: population management at the point-of-care

2020 ◽  
Author(s):  
Paul C Tang ◽  
Sarah Miller ◽  
Harry Stavropoulos ◽  
Uri Kartoun ◽  
John Zambrano ◽  
...  
Keyword(s):  
Treatment Option ◽  
Best Practice ◽  
Point Of Care ◽  
Treatment Options ◽  
Treatment Decision ◽  
Index Patient ◽  
Type Ii Diabetes Mellitus ◽  
Real World Data ◽  
Decision Points ◽  
Using Data

Abstract Objective To present clinicians at the point-of-care with real-world data on the effectiveness of various treatment options in a precision cohort of patients closely matched to the index patient. Materials and Methods We developed disease-specific, machine-learning, patient-similarity models for hypertension (HTN), type II diabetes mellitus (T2DM), and hyperlipidemia (HL) using data on approximately 2.5 million patients in a large medical group practice. For each identified decision point, an encounter during which the patient’s condition was not controlled, we compared the actual outcome of the treatment decision administered to that of the best-achieved outcome for similar patients in similar clinical situations. Results For the majority of decision points (66.8%, 59.0%, and 83.5% for HTN, T2DM, and HL, respectively), there were alternative treatment options administered to patients in the precision cohort that resulted in a significantly increased proportion of patients under control than the treatment option chosen for the index patient. The expected percentage of patients whose condition would have been controlled if the best-practice treatment option had been chosen would have been better than the actual percentage by: 36% (65.1% vs 48.0%, HTN), 68% (37.7% vs 22.5%, T2DM), and 138% (75.3% vs 31.7%, HL). Conclusion Clinical guidelines are primarily based on the results of randomized controlled trials, which apply to a homogeneous subject population. Providing the effectiveness of various treatment options used in a precision cohort of patients similar to the index patient can provide complementary information to tailor guideline recommendations for individual patients and potentially improve outcomes.

Regional Differences in the Ratio of Observed and Expected In-hospital Mortality for Acute Coronary Syndrome Patients in China: The Improving Care for Cardiovascular Disease in China-Acute Coronary Syndrome Project Analysis

Angiology ◽  
2021 ◽  
pp. 000331972110313
Author(s):  
Jing Wen Yong ◽  
Yue Yan Xing ◽  
Meng Ge Zhou ◽  
Na Yang ◽  
Yong Chen Hao ◽  
...  
Keyword(s):  
Cardiovascular Disease ◽  
Acute Coronary Syndrome ◽  
Hospital Mortality ◽  
Regional Variation ◽  
Patient Characteristics ◽  
National Registry ◽  
Patient Specific ◽  
Improvement Project ◽  
Coronary Syndrome ◽  
The Difference

Previous studies reported regional variations in in-hospital acute coronary syndrome (ACS) mortality, but the reasons for that were not clearly defined. We explored whether differences in patient characteristics could explain regional variation. The Improving Care for Cardiovascular Disease in China (CCC)-ACS project is an ongoing national registry and quality improvement project, involving 150 tertiary hospitals from 30 provinces across China. We applied a prediction model that included patient-specific variables to calculate the expected in-hospital mortality. For each province, we reported the observed, expected in-hospital mortality and the risk-adjusted ratio which is based on the observed divided by the expected mortality. From 2014 to 2018, 79 585 ACS patients were enrolled. The average in-hospital mortality was 1.8%. There was a wide variation in the in-hospital mortality among different provinces (0.2-3.9%). Patient characteristics explained part of this variation because of differences in the expected in-hospital mortality (0.7-2.8%). There was a substantial variation in the risk-adjusted ratio among provinces (0.2-3.5), which suggests that the variations in the mortality cannot be completely explained by the differences in patient characteristics. In conclusion, we observed a wide regional variation in mortality for ACS, part of which could be explained by the difference in patient characteristics.

Towards personalised management for non-variceal upper gastrointestinal bleeding

Gut ◽  
2021 ◽  
pp. gutjnl-2020-323846
Author(s):  
Joseph J Y Sung ◽  
Loren Laine ◽  
Ernst J Kuipers ◽  
Alan N Barkun
Keyword(s):  
Gastrointestinal Bleeding ◽  
Upper Gastrointestinal Bleeding ◽  
Point Of Care ◽  
Management Strategies ◽  
Patient Characteristics ◽  
Professional Societies ◽  
Assessment And Treatment ◽  
Three Stages ◽  
Endoscopic Assessment ◽  
Upper Gastrointestinal

Guidelines from national and international professional societies on upper gastrointestinal bleeding highlight the important clinical issues but do not always identify specific management strategies pertaining to individual patients. Optimal treatment should consider the personal needs of an individual patient and the pertinent resources and experience available at the point of care. This article integrates international guidelines and consensus into three stages of management: pre-endoscopic assessment and treatment, endoscopic evaluation and haemostasis and postendoscopic management. We emphasise the need for personalised management strategies based on patient characteristics, nature of bleeding lesions and the clinical setting including available resources.

scholarly journals AB0237 INFECTIONS IN PATIENTS WITH RHEUMATOID ARTHRITIS TREATED WITH RITUXIMAB AND ANTI-TNF INHIBITOR

2021 ◽  
Vol 80 (Suppl 1) ◽  
pp. 1144.2-1144
Author(s):  
N. Zehraoui ◽  
R. Benaziez.Boutaleb ◽  
H. Hafirassou ◽  
F. Mechid ◽  
N. Bahaz ◽  
...  
Keyword(s):  
Rheumatoid Arthritis ◽  
Best Practice ◽  
Biological Therapy ◽  
Patient Characteristics ◽  
Inadequate Response ◽  
Tnf Inhibitor ◽  
Clinical Rheumatology ◽  
Number Of Patients ◽  
Serious Infections ◽  
Comparative Risk

Background:Biological therapies have significantly improved the management of rheumatoid arthritis (RA). These molecules are very effective, but are known for their specific risks, especially infectious. It depends on several factors including the type of molecule used.Objectives:The objective of our study is to compare the rate of infection in RA patients treated with rituximab and anti-TNFα.Methods:Prospective, observational, monocentric study. Were included RA patients (ACR / EULAR 2010 criteria) treated with rituximab and anti-TNFα (adalimumab, infliximab and Etanercept) after inadequate response to DMARDs.Demographic characteristics, comorbidities, association with methotrexate and corticosteroids were collected and compared for each group.The number, type and severity of the infections in both cases were noted.SPSS (Statistical Package for Social Science) was used for data analysis.Results:40 RA patients treated with rituximab and 31 patients who received anti-TNFα were included.Patient characteristics and Comparison of rate of infection in RA patients between the two groups are summarized in Table 1Table 1.ParametersRituximabAnti-TNFαpNumber of patients4031Average age (years)56,2846,060,01Sexratio0,140,110,7Average duration of evolution (years)15,8313,740,3Patients under corticosteroid (%)97,587,10,08Average corticosteroid dose6,415,480,3patients under methotrexate (%)37,545,20,5Diabetes (%)2016,10,7Patients with infection (%)32,551,60,1Number of infections18240,4Number of serious infections500,04Conclusion:The rate of infections in patients with RA treated with rituximab or anti-TNF was similar. However, the infections observed were more serious in patients with RA treated with rituximabReferences:[1]Fabiola Atzeni MD PhD and al. Infections and Biological Therapy in Patients with Rheumatic Diseases. IMAJ . VOL 18. march-APRIL 2016.[2]Huifeng Yun and al. Comparative Risk of Hospitalized Infection Associated with Biologic Agents in Rheumatoid Arthritis Patients Enrolled in Medicare. ARTHRITIS & RHEUMATOLOGY. Vol. 68, No. 1, January 2016, pp 56–66.[3]Manjari Lahiri and al. Risk of infection with biologic antirheumatic therapies in patients with rheumatoid arthritis. Best Practice & Research Clinical Rheumatology (2015) 1-16.Disclosure of Interests:None declared

Diagnostic accuracy of Instantaneous Wave-Free Ratio (iFR) for the assessment of myocardial ischaemia: a comparison with non-invasive stress imaging

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
L Stazzoni ◽  
L Tessandori ◽  
P Spontoni ◽  
M Angelillis ◽  
C Giannini ◽  
...  
Keyword(s):  
Diagnostic Accuracy ◽  
Myocardial Ischaemia ◽  
Gold Standard ◽  
Coronary Revascularization ◽  
Stress Test ◽  
Invasive Coronary Angiography ◽  
Coronary Syndrome ◽  
Non Invasive ◽  
Coronary Stenoses ◽  
Epicardial Stenosis

Abstract Background Instantaneous Wave-Free Ratio (iFR) allows for the assessment of the haemodynamic effects of epicardial coronary stenoses without the need for hyperaemia; iFR is currently recommended as a means to evaluate myocardial ischaemia. Purpose To assess the diagnostic accuracy of iFR with respect to the identification of coronary epicardial stenoses causing ischemia. Therefore, we combined anatomical (% stenosis at invasive coronary angiography, ICA) and functional (non-invasive imaging stress test, NIST) information to obtain a “gold standard” for the identification of stenoses causing ischaemia. Methods We enrolled 71 patients (52 male, 19 female; age mean 68.4±8.1 years) with chronic coronary syndrome or low-risk acute coronary syndrome without ST segment elevation who had at least a NIST and who had at least one vessel with a 50%-85% stenosis at ICA. iFR was measured in all coronary arteries with stenosis >50% and categorised according to the 0.89 threshold for ischaemia. Results iFR was assessed in 122 vessels. In a per-vessel analysis, in 56.7% ischaemia was present both at iFR and NIST, in 21.3% ischaemia was absent in both, while in 23.0% ischaemia was found at NIST but not confirmed by iFR. The overall accuracy of iFR with respect to NIST was 90.1%. However, when considering as the “gold standard” for coronary disease causing ischaemia the contemporary presence of an epicardial stenosis >70% at ICA and a positive NIST, the diagnostic accuracy of iFR greatly improved. The sensibility, specificity, PPV, NPV and accuracy were 96.5%, 75.0%, 73.3%, 96.7% and 84.4%, respectively. In case of discordance between NIST and iFR, revascularization was based on iFR. At a mean follow-up of 23±18 months, the composite endpoint of MACE (major adverse cardiac events, defined as the composite of all-cause death, nonfatal MI and unplanned coronary revascularization) occurred in 16.4%, while death/MI occurred in 11.9%. Stratification according to the per-patient concordance between iFR and NIST showed no significant differences in rates of MACE (p=0.50) and death/MI (p=0.20). Stratification based on iFR showed a higher death/MI rate in iFR-positive patients (11.9% vs. 0%, p=0.047) and a trend to higher MACE rate (11.9% vs. 4.47% p=0.14), Conclusions The diagnostic accuracy of iFR is low when compared with NIST as the reference for myocardial ischaemia, but it is very high when compared with the combined presence of epicardial stenosis and positive NIST. Therefore, iFR can accurately guide the decision to treat or defer revascularization of intermediate coronary stenoses, being most useful in patients with multivessel CAD and when non-invasive functional data are lacking or discordant with anatomy. Funding Acknowledgement Type of funding source: None

scholarly journals Response shift after coronary revascularization

2021 ◽  
Author(s):  
Tom H. Oreel ◽  
Pythia T. Nieuwkerk ◽  
Iris D. Hartog ◽  
Justine E. Netjes ◽  
Alexander B. A. Vonk ◽  
...  
Keyword(s):  
New York ◽  
Structural Equation ◽  
Life Story ◽  
Coronary Revascularization ◽  
Heart Association ◽  
Response Shift ◽  
Patient Characteristics ◽  
Equation Modeling ◽  
Sf 36 ◽  
New York Heart Association

Abstract Purpose The aims of this study were to investigate (1) the extent to which response shift occurs among patients with coronary artery disease (CAD) after coronary revascularization, (2) whether the assessment of changes in health-related quality of life (HRQoL), controlled for response shift, yield more valid estimates of changes in HRQoL, as indicated by stronger associations with criterion measures of change, than without controlling for response shift, and (3) if occurrences of response shift are related to patient characteristics. Methods Patients with CAD completed the SF-36 and the Seattle Angina Questionnaire (SAQ7) at baseline and 3 months after coronary revascularization. Sociodemographic, clinical and psychosocial variables were measured with the patient version of the New York Heart Association-class, Subjective Significance Questionnaire, Reconstruction of Life Events Questionnaire (RE-LIFE), and HEXACO personality inventory. Oort’s Structural Equation Modeling (SEM) approach was used to investigate response shift. Results 191 patient completed questionnaires at baseline and at 3 months after treatment. The SF-36 showed recalibration and reprioritization response shift and the SAQ7 reconceptualization response shift. Controlling for these response shift effects did not result in more valid estimates of change. One significant association was found between reprioritization response shift and complete integration of having CAD into their life story, as indicated by the RE-LIFE. Conclusion Results indicate response shift in HRQoL following coronary revascularization. While we did not find an impact of response shift on the estimates of change, the SEM approach provides a more comprehensive insight into the different types of change in HRQoL following coronary revascularization.

Assessing the Performance of a Novel Point-of-Care Qualitative Assay for Early Diagnosis of Acute Coronary Syndrome

Cardiology ◽  
2020 ◽  
pp. 1-8
Author(s):  
Ronny Alcalai ◽  
Boris Varshisky ◽  
Ahmad Marhig ◽  
David Leibowitz ◽  
Larissa Kogan-Boguslavsky ◽  
...  
Keyword(s):  
Acute Coronary Syndrome ◽  
Chest Pain ◽  
Diagnostic Accuracy ◽  
Diagnostic Performance ◽  
Troponin I ◽  
Point Of Care ◽  
Final Diagnosis ◽  
Cardiac Biomarkers ◽  
Fatty Acid Binding ◽  
Coronary Syndrome

<b><i>Background:</i></b> Early and accurate diagnosis of acute coronary syndrome (ACS) is essential for initiating lifesaving interventions. In this article, the diagnostic performance of a novel point-of-care rapid assay (SensAheart<sup>©</sup>) is analyzed. This assay qualitatively determines the presence of 2 cardiac biomarkers troponin I and heart-type fatty acid-binding protein that are present soon after onset of myocardial injury. <b><i>Methods:</i></b> We conducted a prospective observational study of consecutive patients who presented to the emergency department with typical chest pain. Simultaneous high-sensitive cardiac troponin T (hs-cTnT) and SensAheart testing was performed upon hospital admission. Diagnostic accuracy was computed using SensAheart or hs-cTnT levels versus the final diagnosis defined as positive/negative. <b><i>Results:</i></b> Of 225 patients analyzed, a final diagnosis of ACS was established in 138 patients, 87 individuals diagnosed with nonischemic chest pain. In the overall population, as compared to hs-cTnT, the sensitivity of the initial SensAheart assay was significantly higher (80.4 vs. 63.8%, <i>p</i> = 0.002) whereas specificity was lower (78.6 vs. 95.4%, <i>p</i> = 0.036). The overall diagnostic accuracy of SensAheart assay was similar to the hs-cTnT (82.7% compared to 76.0%, <i>p</i> = 0.08). <b><i>Conclusions:</i></b> Upon first medical contact, the novel point-of-care rapid SensAheart assay shows a diagnostic performance similar to hs-cTnT. The combination of 2 cardiac biomarkers in the same kit allows for very early detection of myocardial damage. The SensAheart assay is a reliable and practical tool for ruling-in the diagnosis of ACS.

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