Paul Sergeant, K.U.Leuven, Belgium

Transcription

1 Strategy in Coronary Therapy Paul Sergeant, K.U.Leuven, Belgium

2 Strategy To graft diagonal 1, diagonal 2 To graft LAD To graft CX1, CX2

3 Strategy map of coronary surgery financial perspective internal perspective To improve patient s t survival and quality of life in anticipation of the socio-economic changes customer perspective optimisation of intangible assets

4 To improve patient s survival and quality of life in anticipation of the socio-economic changes customer perspective Patient - no procedural mortality - no procedural morbidity - improved life expectancy - improved quality of life - no personal costs - once in-a-lifetime proc. - rapid professional or private reintegration Society - patient-satisfaction - cost-containment and - cost-performance

5 Personal interface with risk in general Moore 1965

6 Improved life expectancy normal life expectancy Belgium 2006 USA healthy 22 non-healthy M F Years Age at surgery Age at surgery

7 Improved life expectancy Natural history of CAD

8 COURAGE NEJ Med 2007;356:15 OAT NEJ Med 2006;355:23

9 No procedural mortality

10 No procedural mortality Months Survival Hazard

11 No procedural mortality/morbidity

12 No procedural mortality/morbidity Death / Stroke / Infarct / Re intervention Where is the non interventional therapy? 40 Rate (%) Taxus 23.4% Cumula ative Event 20 at 1 year 12.4% vs 17.8% P=0.002 CABG 16.3% Months Since Allocation Cumulative KM Event Rate ± 1.5 SE; log rank P value;*binary rates ITT population

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14 Improved life expectancy

15 The ultimate survival curve version KUL K.U.Leuven % Years

16 Improved quality of life The assessment of two year cardiac functional status after any cardiac surgery in the Falcoz sample (ATS 2006;81: ): a satisfactory status for 74 % of men and 57 % of women an unsatisfactory status for 26 % of men and 43 % of women

17 Once in a lifetime procedure CABG N redo by year KULeuven /pt a anast. as N /pt a anast. 2.0/pt a anast /pt a anast

18 To improve patient s survival and quality of life in anticipation of the socio economic changes Designing i and delivering i therapeutic ti services to patient and society internal perspective Establishing and leveraging relationships with patient t and society it select, acquire and retain Develop and deliver new therapeutic processes at lesserriskor risk lessercost Conforming to societal regulations and socio economic changes safety, health

19 A patient specific prediction

20 Optimised therapeutic and surgical differential therapy

21 Optimised therapeutic and surgical differential therapy

22 Designing and delivering therapeutic services to patient t and society it

23 Designing and delivering therapeutic services to patient and society The Ferrari issue

24 Designing and delivering therapeutic services to patient and society Single versus composite arterial graft Soon after the operation arterial composite Y grafts can significantly increase blood flow in response to conditions of increased MVO² keeping normal the myocardial O² supply to demand ratio. Eur J Cardio Thorac Surg :81 85 The LITA shows a marked adaptability to flow dynamics. The proximal tract of the LITA in the composite group is able to match increased flow requirements. This pattern is probably a consequence of the increase of blood flow due to the lower vascular resistance of the composite graft system and to the active dilatation of the LITA/LIMA. Eur J Cardio Thorac Surg : The proximal and mid segment of the LIMA adapts considerably in size (at 12 yrs) to the larger outflow area of the composite graft. Interact Cardiovasc and Thor Surg

25 Designing and delivering therapeutic services to patient and society Competition of flow Native competitive flow Competition of flow between a graft and the primary inflow of the grafted vessel. e.g. LIMA to LAD in competition with primary flow in LAD Graft competitive flow Eur J Cardiothorac ; Competition of flow between a graft and another graft perfusing the same territory (with or without lesions between both anastomoses).in consequence a single graft to a territory can have a better patency versus two grafts to the same territory. e.g. LIMA to LAD in competition with vein between aorta and diagonal vessel.

26 Develop and deliver new therapeutic services at lesser risk or lesser cost Birds flying in formation fly 70 % further than solo birds, using the same amount of energy

27 Develop and deliver new therapeutic services at lesser risk or lesser cost PCAB % O 80 On-pump 70 -CPR - Cardiogenic shock + pulmon oedema 60 - Cardiogenic shock + saturation <90 % - Cardiogenic shock + CI < 1 l/m² 50 Off-pump - All other patients 40 - All other infarct patients - redo, intramural, intraseptal 30 - small and calcified vessels left main 20 - cardiomegaly - surgeon in training seminars 900 scholars 52 countries Year of Surgery

28 Develop and deliver new therapeutic services at lesser risk or lesser cost

29 CABG off pump (N=3247) CABG on pump (N=1585)

30 Develop and deliver new therapeutic services at lesser risk or lesser cost CABG on pump (N=1583) CABG off pump (N=3247)

31 Develop and deliver new therapeutic services at lesser risk or lesser cost Annihilation of stroke (since 5 yrs) Restrict the combined carotid CABG procedures to patients in unstable neurological condition, even in the presence of severe stenosis, uni or bilateral. (since 5 yrs) Absolutely no touch aorta (since 3 yrs) Upgrade anti coagulation anti aggregation therapy immediately after surgery from prophylactic to therapeutic levels and for the duration of the hospital stay, if needed ddup to one month. (since 1 yr) Close LAA appendage in all patients

32 To improve patient s survival and quality of life in anticipation of the socio economic changes Human capital knowledge, skills, attitude Optimisation of the intangible assets Information capital databases, networks, education Organisation capital culture, alignment, teamwork

33 Optimization of intangible assets

34 Anaesthesia: traffic control Surgery: pilot

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36 Optimisation of the information capital

37 Optimisation of the information capital Performance Induced learning conceptual learning virtual it llearning Autonomous learning Dutton Acad Manag Rev 1984;9:235 OPCAB CABG Learning process should be high conceptual and high operational Lapré Manag Science 2000;46:5:597

38 Optimisation of the information capital deconstruction into teachable components

39 Optimisation of the information capital Conceptual learning

40 Induced learning: Virtual learning

41 Optimisation of the human capital Virtual learning Virtual simulation projects simulation creation awards 2011 EACTS Lisboa 2011 Porto Allegre Brazil 2011 Bloemfontein S Africa 2011 Alessandria Egypt... simulator use projects 2011 EACTS Lisboa 2011 Bloemfontein Egypt

42 Optimisation of the information capital The Cardio thoracic surgicalbrain project Educational objectives: ISCP Educational objects: webinars, MMCTS, PDF files, websites, e learning Educational assessments: e learnings, LMS, portfolio, CMS

43 To improve patient s survival and quality of life in anticipation of the socio economic changes financial i perspective Improve productivity and cost structure Optimise medical resource utilisation Enhance value for patient and society

44 Operating Room reengineering Human Resources CABG ECC CABG OPCAB One anaesthesiologist One anaesthesiologist One anaesthesia nurse One scrub nurse One scrub nurse One surgeon One surgeon One first assistant (often a resident) One second assistant One running nurse One perfusionist

45 Operating Room Reengineering Material Instrumentarium Add some instruments Penn type intermediary and long needle holders 180 degree return scissors Straight scissors Small, shallow, eye lid retractors in different sizes Easy bulldogs for instrument placement Long (25 cm)tourniquet guide Delete 50instruments

46 Effects of re engineering CABG on Costs and charges A new CABG does not increase or decrease, but has the potential to impact on costs and charges, dependent from degree of reengineering and socio economic environment. Effect on every patient through a reengineering of production line Large N Smallamount Human resources Material resources Hugeeffect Effect on some patients through a reduction of complications Small N Large amount Dialysis Stroke Revision for bleeding Huge effect

47 Risk versus Benefit Scylla and Charybdis Calabria Sicily Homerus Od. xii. 73, &c., 235, &c.