prospective analysis of clinical outcome: influence on surgical professional development
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Professor MJ Underwood Division of Cardiothoracic Surgery, Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong. Prospective Analysis of Clinical Outcome: Influence on Surgical Professional Development. Questions. What is Professional Development ? - PowerPoint PPT PresentationTRANSCRIPT
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Prospective Analysis of Clinical Outcome: Influence on Surgical Professional Development
Professor MJ Underwood
Division of Cardiothoracic Surgery,
Chinese University of Hong Kong,
Prince of Wales Hospital,
Hong Kong
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Questions
What is Professional Development ?
How does it relate to Clinical Outcomes ?
How does it relate to a National Database?
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Personal Viewpoint
UK System
Hong Kong Initiatives
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Continuing Professional Development (CPD)
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Continuing Professional Development (CPD)
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Interrelates
– Clinical– Managerial– Professional
PROVISION OF HIGH-QUALITY PATIENT CARE
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Interrelates
– Clinical– Managerial– Professional
PROVISION OF HIGH-QUALITY PATIENT CARE
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General Medical Council Guidance - 2006
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High Quality Patient Care = Quality Assurance Programme in Cardiac Surgery
AIM :
Provide ‘safest’ journey for the patient during their hospital stay with ‘acceptable’ outcome defined by international standards.
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Quality Assurance Components
Quality Assurance Programme
Institutional Process
Patient Outcome (results)
Appropriate Care
Patient Satisfaction
Fiscal Responsibility
Audit,Multidisciplinary Mortality and Morbidity Meetings
Multidisciplinary Case Conferences, Audit
Audit
Audit
Audit
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ESSENTIAL: Quality Assurance Components
Practical Factors
Local Data Collection– Internal/External Validation
National Data Collection– Internal/External Validation– Data Confidentiality/Safeguards
International Data Comparison– Calibration, Comparison
Personal/Surgical Factors
Commitment Culture Consistent
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CPD=High Quality Care=Quality Assurance=Data Collection =Data Analysis
How do we collect data ?
How do we analyze data ?
High Quality Care
Data Collection
Data Analysis
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DATA COLLECTION: Surgical Perspectives
Accurate Validated
– Internal/External
Available for Analysis– ‘real-time’ for risk monitoring
Internationally Compatible Security
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Data Collection: Summary
‘Validated’
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Influencing Events
1994-96 Senior Registrar Bristol Royal Infirmary
1997 Fontan Scholarship Brussels
1999-2002 Consultant/Senior Lecturer Bristol Heart Institute
1995 External Review
1998 GMC Enquiry
2001 Public Enquiry
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Senior Lecturer/Consultant (1999-On)– Audit Lead Cardiac Services– Clinical Governance Lead– R and D Quality Assurance Lead
Consolidating Data Collection and Reporting
Contribution to CEPOD Public Presentation of Results External Validation of BRI Data
Collection Development of Sub-Specialist
Databases
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Saturday 27 June 1998
BMJ
All changed, changed utterly
British medicine will be transformed by the Bristol case
Richard smith, Editor
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Continuous Professional Development: Institutional Reporting
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Continuous Professional Development: Individual Reporting
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Prospective Analysis of Clinical Outcome: Where are we in Hong Kong ?
Institution of Computerized Data Collection and Analysis System
– Automated demographic data
Data Input at ‘point of clinical care’
Dedicated Database Manager– Accuracy, validation processes
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Automated Demographics and Risk Calculation
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Direct Comparison of Risk Scoring Systems: Testing
Receiver Operating Characteristic (ROC) Curves– Area represents probability that risk predictor accurately
discriminates between death and survival– Area of 1 = Perfect– Closer to 1 better, Closer to 0.5 less accurate
Calibration Plots– Plot observed vs expected events in calibration plot– Chi-squared value used as measure of accuracy of
matching
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Risk-Scoring in the UK Population
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Validation of Euroscore in Hong Kong%
Tru
e po
sitiv
es
% False positives
0
20
40
60
80
100
0 10 20 30 40 50 60 70 80 90 100
ROC Area 0.819: modified Euroscore
ROC Curve for PWH Manual Euroscore
% T
rue
posi
tives
% False positives
0
20
40
60
80
100
0 10 20 30 40 50 60 70 80 90 100
ROC Area 0.823: logistic Euroscore
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Influence of Risk-Stratified Data Analysis on Professional
Development.
Monitor actual mortality and morbidity vs predicted– Essential for Quality Assurance Progamme
Compare with International Data
Patient status at discharge RA-CUSUM (modified Euroscore)
Actual
Expected
Deaths
Years
0
5
10
15
2005 2006
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Comparison of Risk-Profiles: East vs West !
But:– Does risk-validation hold for sub-groups ?
– Is there a need for ‘population specific’ risk assessment
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Hong Kong Cardiac Database: Overview
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A National Database :Unique Practical Challenges from a Surgeon
Differing data collection mechanisms– How merge ?
Accuracy and validity– What infrastructure ?
Security– Who see’s the data ?
Data Analysis– Who analyses the data?
Presentation and Publication– Who ?
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Hong Kong Cardiac Database: Overview
Chinese Cardiac Surgical Database
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Professional Development/Clinical Outcome/National Database: Summary
Inter-related– inseparable
Inevitable– ‘consumer’/provider
driven
Irreversible– USA, UK, Europe
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Editor's choice
Individual performance data: revelation and revolution
Welcome to a new world. Be brave.
Kamran Abbasi, acting editor
BMJ 2005;330: (5 March)