Lựa chọn khôn ngoan trong điều trị tích cực tim mạch cái gì có lợi, cái gì không
Bạn đang xem bản rút gọn của tài liệu. Xem và tải ngay bản đầy đủ của tài liệu tại đây (1.74 MB, 23 trang )
14th Vietnam National Congress of Cardiology
Da Nang, Vietnam
October 11-14, 2014
Choosing Wisely in the ICU
What Works and What Doesn’t
Gregory W. Barsness, MD, FACC, FAHA, FSCAI
Director, Mayo Clinic Cardiac Intensive Care Unit
Director, Mayo Clinic EECP Laboratory
©2013 MFMER | slide-1
Disclosures
No pertinent financial conflicts
©2013 MFMER | slide-2
Learning Objectives
• Identify Top 5 ICU practices that DON’T work
• Costly
• Ineffective or harmful
• Ethical practice concerns
• Identify high-yield strategies that DO benefit ICU
patients
• Patient Activation and Adherence
• Understand the systems approach to optimizing
ICU care
©2013 MFMER | slide-3
Process Adherence and Outcome
In-hosp mortality (%)
7
6
5.95
5.16
5
4
3
Adjusted
Unadjusted
6.33
5.07
4.97
4.63
4.16
4.17
Every 10% in guidelines adherence
2
11% in mortality
1
0
<=25%
25-50%
50-75%
>=75%
Hospital composite quality quartiles
Peterson, et al. ACC 2004
©2013 MFMER | slide-4
Things That Don’t Work in ICU
Choosing Wisely Campaign
• Much of current US care is duplicative, unnecessary
and/or potentially harmful
• Up to 30% of care activities may not improve
patient health or well-being
• Partnership between ABIM and Consumer Reports
• Assist physicians and patients to identify overuse
• Lessons learned applicable to developing systems
• Avoid waste, increase quality
• Able to shift resources to priority health needs
• Collaborative use of limited resources
©2013 MFMER | slide-5
©2013 MFMER | slide-6
Excessive Testing
Imperative to Reduce Waste
• Common diagnostic tests often ordered at recurring
intervals (rather than as necessary)
• CXR, ECG, WBC, serum chemistries
• Increases costs without benefit and may lead to harm
• Excessive phlebotomy, nutritional issues
• “False” positives
• Statistical boundaries (95% CI)
• Unnecessary evaluation of non-pathological
test results with associated morbidity
• “Test only when the result matters”
©2013 MFMER | slide-7
©2013 MFMER | slide-8
Transfusion in Critical Illness or Bleeding
Pooled Meta-Analysis in 2364 Patients
MACE
Salpeter, et al. AJM 2014
©2013 MFMER | slide-9
Transfusion in Critical Illness or Bleeding
Pooled Meta-Analysis in 2364 Patients
In-Hospital Mortality
Restrictive transfusion trigger of Hgb <7:
NNT to prevent 1 death is 33
Salpeter, et al. AJM 2014
©2013 MFMER | slide-10
Things That Do Work in ICU
• Infection Surveillance and Control
• Collaborative Engagement of healthcare team
• Patient Activation and Adherence
• Shared decision-making
• Public education campaigns
• Community-based Hypertension
Management, Vietnam National Heart Inst.
• Engage entire community in education
• Committed healthcare workers reinforce
lessons of benefit of hypertension control
Quang Ngoc Nguyen, et al. Plos One 2012
©2013 MFMER | slide-15
Critical Illness Care
Patient and Family Perspective
©2013 MFMER | slide-16
Costs of Non-Adherence
• Social Cost
• 125,000 deaths per year in US
• 33-69% of medication-related admissions
• Economic Cost
• $100-300 billion in direct and indirect costs
“Drugs don’t work in patients who don’t take them.”
C. Everett Koop, MD
©2013 MFMER | slide-17
Medication “Noncompliance”
Incidence and Implications
• Mayo: 20% not taking prescribed clopidogrel 414 months after DES
(Mayo Clinic, unpublished data)
• Stent thrombosis occurred in 1 of 4 patients who
discontinued antiplatelet therapy
(Iakovou et al. 2005 JAMA)
• Dual antiplatelet compliance may depend on
communication and education
(Garavalia et al. 2011 Eur J Cardiovasc Nurs )
©2013 MFMER | slide-18
PREMIER Registry
Thienopyridine D/C After DES for MI
2498 pts at 19 US sites
Mortality
500 DES-treated MI pts
with thienopyridine
prior to discharge
13.6% discontinuation
by 30 days after DES
(12.1% DC all meds)
Risk factors:
Age
Socio-economic
Pre-existing disease
Spertus et al. Circ 2006
©2013 MFMER | slide-19
How to Improve Adherence
Decision Aids in Acute Setting
• Non-preference sensitive
• Weight of evidence favors one option
• Emergency treatment
• Technical decisions (stent size)
• Preference-sensitive decisions
• Alternative, valid options (“equipoise”)
• Trade-off for risks vs. benefits
• or requires patient motivation
Wennberg et al. Health Affairs 2002
©2013 MFMER | slide-21
How to Improve Adherence
Decision Aids in Follow-Up
• Non-preference sensitive
• Weight of evidence favors one option
• Emergency treatment
• Technical decisions (stent size)
• Preference-sensitive decisions
• Alternative, valid options (“equipoise”)
• Trade-off for risks vs. benefits
• or requires patient motivation
Wennberg et al. Health Affairs 2002
©2013 MFMER | slide-22
Decision Aid After AMI
15% 6-Mo Mortality Risk (GRACE Score)
150
850
75
75
850
Shah et al. AHA 2012
©2013 MFMER | slide-23
Randomized Shared-Decision Making
Medication Adherence at 6 Months
106 Patients with AMI
Shah et al. AHA 2012
©2013 MFMER | slide-24
Long-Term Medication Adherence
Impact of Reinforcement
292 Post-MI Patients in Olmsted County
Cardiac Rehabilitation enrollment: RR 0.66-0.70
Mild association of smoking with nonadherence
No other identified risks
Shah, et al. AJM 2009
©2013 MFMER | slide-25
Medication Persistence
Impact of Cardiac Rehab Enrollment
100%
Year 1
Year 3
80%
60%
40%
20%
0%
Statin
Aspirin
ACEI/ARB
Beta
Blocker
Courtesy T. Allison
©2013 MFMER | slide-26
Conclusions
• Avoiding unnecessary testing and treatments is
cost effective and associated with improved
outcomes
• Avoid harm and reallocate scarce resources
• Non-adherence has significant associated
social and economic costs
• >100 different associated factors
• System intervention and adherence to
evidence-based practices may improve
compliance and outcome
©2013 MFMER | slide-27
Mayo Clinic
Rochester, MN
CAM ON
CP1124540-1
©2013 MFMER | slide-28
