275 Trends in the quality of myocardial infarction management in France: from evidence-based medicine to optimal clinical pathways

Background and Objectives Evidence-based medicine has brought about a marked improvement in the management of myocardial infarction with ST elevation (STEMI). STEMI is a high-priority health issue. Coronary reperfusion techniques are highly effective especially when carried out promptly. Mortality rate at 1 month was 20% in 1990, 14% in 1995, 9% in 2000, and has been stable (about 7%) since 2005. The aim of practice improvement is to develop even better care pathways, for the benefit of more patients, to achieve even prompter reperfusion. However, mortality rate is probably not an appropriate indicator to measure the clinical impact of improvement initiatives as we are approaching the optimal rate, other factors are important, and new populations of patients are being recruited. Our objective was to develop indicators to measure quality within the patient9s clinical pathway and clinical outcomes. Program In France, emergency medicine services (EMS) and intensive care units in cardiology (ICUC) cooperate closely in urging the general public to call the EMS (call number 15) immediately in cases of chest pain. This helps guarantee swift arrival of EMS on scene and rapid treatment initiation. A national cooperative group, in association with HAS, has developed tools for a patient-centred quality programme that goes from practice improvement (implementation of consensus conference guidelines on optimal pre-hospital management) to practice measurement throughout care using clinical practice indicators (CPI). The quality dimensions are Efficacy (E) and Safety (S) (evidence-based) and Access (A) to best care (professional consensus). Results Seven CPIs, shared by EMS and ICUC, were developed for the acute phase of the clinical pathway of MI patients: percentage of emergency calls, of direct transport by mobile intensive care units to ICUC (A, E, S), of reperfusions regardless of technique (E, A), delays in reperfusion for each technique (E, A), percentage of patients receiving appropriate antiplatelet treatment (E, S), and percentage of patients receiving analgesics (E). These CPIs form part of the databases dedicated to the ‘STEMI—EMS—ICUC’ pathway. Data analysis has revealed improvements in the percentage of calls to EMS, of direct transport to the ICUC and of reperfusions, and in delays to reperfusion therapy. Mortality rate is stable (see HAS 2009 report: ‘Programme Infarctus 2007-2010, ensemble, ameliorons la prise en charge de l9infarctus du myocarde’, Bilan 2009. Etape 1, de la douleur a la reperfusion - Etape 2, de la reperfusion a la sortie de l9hopital - Etape 3, suivi post infarctus apres la sortie de l9hopital.). In an analysis of three different databases relating to catchment areas with different constraints and medical demographics, results were similar despite the different ways in which guidelines were implemented, thus highlighting the clinical relevance of these standardised CPIs. An enlarged concatenation should enable better modelling of items needing improvement and the selection of the most relevant indicators for monitoring the clinical impact of improvement initiatives. Discussion and Conclusion The use of CPIs to circumscribe the patient9s care pathway improved quality of care, confirming the robustness of our model. A global approach to quality supported by health professionals, patients and health organisations enables translation of treatments with proven efficacy in clinical trials on selected patients into the ‘greatest benefit for the greatest number’ in real life. The CPIs developed for the various steps of a clinical pathway—that have been established, implemented and analysed with the professionals concerned - can be used to monitor and guarantee quality of care, thus reconciling public health and evidence-based medicine. The percentage of beneficiaries is an indicator of clinical impact and mortality rate is an indicator of absence of drift. However, there is a need for innovative CPIs in order to include post acute phase care, risk factors, and quality of life into the assessment of the patient9s clinical pathway. Contexte et objectifs La medecine fondee sur les preuves a contribue a ameliorer de facon spectaculaire la prise en charge de l9infarctus ST+ (IDM), enjeu de sante prioritaire: les differentes therapeutiques de reperfusion coronaire sont d9une efficacite remarquable, encore meilleure si realisees au plus vite. La mortalite a 1 mois est passee de 20% en 1990, 14% (1995), a 9% (2000), pour se stabiliser aux alentours de 7% depuis 2005. Des filieres de soins optimales, pour plus de patients, pour une reperfusion encore plus rapide, constituent un objectif majeur d9amelioration des pratiques, dont l9impact clinique sera probablement difficilement objectivable par la mortalite: approche des taux optimaux, autres facteurs influant, recrutement de nouveaux malades. L9objectif de ce travail est de developper des indicateurs pour mesurer la qualite des soins et les resultats cliniques. Programme La medecine d9urgence et la cardiologie cooperent etroitement en France pour sensibiliser la population a appeler le n° d9urgence « 15 » et reduire les delais de prise en charge. Pour definir le parcours de soins optimal, le groupe national de cooperation, en lien avec la HAS, a elabore les outils d9un programme integre centre sur le patient: depuis l9amelioration des pratiques - conference de consensus (CdC): prise en charge et parcours optimal en France avant l9arrivee en cardiologie—a la mesure des pratiques et de l9impact clinique—indicateurs de pratique clinique (IPC) sur le parcours patient. Resultats CdC comme IPC couvrent les champs Qualite-ESA: Efficacite (E) Securite (S), de niveaux de preuve eleves, et Acces (A), consensus professionnel. Sept IPC partages bornent les pratiques a la phase aigue: % d9appel au 15, % d9orientation directe en USIC (A, E, S), % de reperfusion, quelle qu9en soit la technique (E, A), delai de reperfusion par technique (E, S, A), % d9antiagregants plaquettaires appropries (E, S), % d9antalgiques (E). Ces IPC ont ete integres aux bases de donnees dediees aux filieres IDM -Urgence-Cardiologie. Ils ont montre que (i) une amelioration dans le temps des IPC—appel au 15, orientation en USIC, % et delais de reperfusions - (ii) une mortalite stable (cf rapport public HAS—groupe de cooperation 2009: ‘Programme Infarctus 2007-2010, ensemble, ameliorons la prise en charge de l9infarctus du myocarde’, Bilan 2009. Etape 1, de la douleur a la reperfusion - Etape 2, de la reperfusion a la sortie de l9hopital - Etape 3, suivi post infarctus apres la sortie de l9hopital.). L9uniformisation des IPC et la recherche d9indicateurs d9impact encouragent la mise en commun de differentes bases. Dans 3 observatoires de pratiques - de contraintes geographiques et demographies medicales differentes - l9homogeneite des resultats des IPC au regard des differentes organisations deployees pour implementer la CdC, conforte la pertinence clinique des indicateurs. La concatenation elargie des IPC permettra de mieux modeliser les points a ameliorer et de selectionner les indicateurs les plus pertinents pour suivre l9impact clinique des demarches d9amelioration. Discussion et conclusion Des parcours patient marques par des IPC Qualite-ESA permettent d9ameliorer la qualite des soins dans la vraie vie, ce qui confirme la robustesse du modele propose. Cette approche globale de la qualite portee par les professionnels de sante, les patients et les organisations sanitaires, permet d9appliquer dans la pratique quotidienne, au benefice du plus grand nombre, les traitements d9efficacite demontree par les essais cliniques sur des patients selectionnes. Des IPC Qualite-ESA sur les etapes cles – definis, recueillis et analyses en lien avec les professionnels – permettent de suivre et de garantir la qualite des soins, reconciliant dans la mise en œuvre, sante publique et medecine fondee sur les preuves. Si le nombre de patients beneficiaires constitue sans nul doute un indicateur d9impact clinique, si le suivi de la mortalite doit garantir l9absence de derive, demeurent a identifier des indicateurs d9impact clinique novateurs, integrant egalement la prise en charge apres la phase aigue, la maitrise des facteurs de risque et la qualite de vie.