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Size Matters

Size Matters

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Size Matters

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  1. Size Matters Peter F Ludman MA MD FRCP University Hospital Birmingham

  2. NO CONFLICT OF INTEREST TO DECLARE

  3. Size Matters • Characteristics for high quality PCI • Unit size • activity volume • Training • Research • Network size • On call fatigue • Measures of performance • Process analysis • Outcome analyses

  4. Size Matters • Characteristics for high quality PCI • Unit size • activity volume • Training • Research • Network size • On call fatigue • Measures of performance • Process analysis • Outcome analyses

  5. PCI - Evolution ofInstitutional Volume v Outcome Ho Circulation 2000;101:1806

  6. Stent use v MACE

  7. Role of Stents Brown AHJ 2003:146;1071 1997 18,940 POBA and 25,336 Stent PCI

  8. Role of Stents Brown AHJ 2003:146;1071 1997 18,940 POBA and 25,336 Stent PCI

  9. Volume-Outcome Still relevant today?

  10. 150 mph → 0 mph ... 2 sec

  11. PCI Clinical judgment Decision to treat by PCI Patient co-morbidity What lesions to treat Standards of care before PCI Operator dexterity Techniques When to stop Standards of care after PCI

  12. Hospital Volume v MACEEmergency PCI Spaulding EHJ 2006:27;1054 • Greater Paris Registry • 2001 and 2002 • 37,848 PCI procedures • 44 centres

  13. Hospital Volume v MACEEmergency PCI Spaulding EHJ 2006:27;1054 Mortality

  14. Hospital Volume v MACEEmergency PCI Spaulding EHJ 2006:27;1054 Mortality

  15. Hospital Volume v MACEEmergency PCI Spaulding EHJ 2006 27 1054 MACCE

  16. Hospital Volume v MACEEmergency PCI Spaulding EHJ 2006 27 1054 MACCE

  17. Volume - Outcome

  18. Volume – OutcomeArbeitsgemeinschaft leitende kardiologische Krankenhausärzte (ALKK) Zahn R et al, Heart July 2007 on line

  19. Volume – OutcomeArbeitsgemeinschaft leitende kardiologische Krankenhausärzte (ALKK) Zahn Ret al, Heart July 2007 on line p for trend = 0.004 p for trend = 0.84

  20. Operator Volume v MACE Moscussi J Am Coll Cardiol 2005;46:625–32 18,504 procedures in 2002 14 hospitals in Michigan All high volume institutions MACE

  21. Operator Volume v MACEby Quartiles of Risk Moscussi J Am Coll Cardiol 2005;46:625–32 Low Risk Cases High Risk Cases

  22. Operator Volume v MACEby Quartiles of Risk Moscussi J Am Coll Cardiol 2005;46:625–32 Low vol High vol Low Vol High Vol Low Risk Cases High Risk Cases

  23. ‘Practice makes Perfect’

  24. Size Matters • Characteristics for high quality PCI • Unit size • activity volume • Training • Research • Network size • On call fatigue • Measures of performance • Process analysis • Outcome analyses

  25. Circadian Variation Dawson D. Nature 1997;388:235 Cognitive psychomotor performance of hand–eye coordination Hours of wakefulness Blood Alcohol conc (%)

  26. Circadian Variation Henriques JPS JACC 2003;41:2138–42 • 1702 consecutive PPCI (Zwolle 1994 to 2000) # * * # P=0.03 * P<0.01

  27. Circadian Variation Assali A et al CCI 2006;67:221 PPCI n=273 p=0.02 p=0.03

  28. Circadian Variation Assali A et al CCI 2006;67:221

  29. Circadian Variation • Patient characteristics • Risk profile • Delayed conscious awareness of pain • Pathophysiology • Platelet aggregation • Coronary flow • Viscosity • Cortisol • Epinephrine • APTT • Endogenous tPA • Fibrinogen • Fibrinolytic factors Performance of the Healthcare team

  30. Circadian Variation Assali A et al CCI 2006;67:221 ?

  31. Size Matters • Characteristics for high quality PCI • Unit size • activity volume • Training • Research • Network size • On call fatigue • Measures of performance • Process analysis • Outcome analyses

  32. DTB times for Individual Patients Statistical Process Control Hall J. NEJM 2007;356:1475-1479 Procedural change in lab activation

  33. UHB Cumulative Funnel plotsData from 2006 Derivations from Tony Roberts and Robert Morley Upper Control Limit Upper Warning Predicted Actual Lower Control Limit

  34. Conclusion Size matters, but it is not the only thing that matters