Translational and Personalized Medicine Initiative

Transcription

1 Translational and Personalized Medicine Initiative

2 Funders 1. CIHR $9 Million 2. Gov of NL $8 Million 3. IBM $10 Million + Software 4. Atlantic Canada Opportunities Agency $3 Million

3 Quality of Care Projects Utilization Laboratory Imaging Drug Long-Term Care Acute Hospital Hospital Interventions Family Screening Projects Renal Function Carotid Artery Testing Psychotropics in the Elderly Prediction of LTC Bed Needs Remote Monitoring Coronary Revasc. Access to Genetic Testing Lactate Dehyd. Peripheral Artery Testing InterRAII Pharmacy Clinic Stroke Colorectal Cancer Ferritin Personal Care to Nursing Home Early Recovery after Surgery Bariatric Surgery

4 TPMI Project Value A.Influence on Decision-Makers B.Cost-effectiveness of Intervention C.Job Creation D.Commercial Benefits E.Knowledge Translation Outcomes F.Societal Benefits

5 QoC PROJECT REPORT CARD INTERVENTION PLANNED DONE PLANNED STARTED Renal Function --- Yes Yes No LDH Yes No Yes No Ferritin Yes No Yes No Carotid Artery Testing --- Yes Yes Yes Peripheral Artery Testing --- Yes Yes Yes Psychotropic Agents Yes No Yes No Remote Monitoring Yes No Yes Yes Early Recovery After Surgery Yes No Yes No Pharmacy Clinic Yes No Yes No Prediction of LTC Bed Needs Yes No No No InterRAII Yes No No No Personal Care Homes to Nursing Homes --- No No No Coronary Revascularization --- Yes Yes Yes Stroke Yes No Yes No Bariatric Surgery --- Yes No No Genetic Testing Access Yes No No No Familial Colorectal Cancer --- Yes Yes No

6 Development of a Laboratory Utilization Program to Improve Patient Care- Figures and Data Visualisation TPMI QoC Quarterly Report Project PI: Stephen Raab, MD

7 Development of a Laboratory Utilization Program to Improve Patient Care- Figures and Data Visualisation TPMI QoC Quarterly Report Project PI: Stephen Raab, MD

8 Drug Utilization Methods Source Population (N=68,841): 1. Client Registry Patients 65 years or older as of first prescription record 2. Meditech LTC module (n=4134) LTC residents in care as of March 31, 2011 and residents admitted between April 1, 2011 and March 31, NLPDP data Patients had one or more prescription records submitted to NLPDP between April 1, 2007 and March 31, 2014 TPMI QoC DU working group meeting

9 # of people Total number of people Q Q3 Q Q3 Q Q3 Q Q3 Q Quarters

10 Drug prevalence per quarter in LTC facilities

11 Epidemiology of Patients Tested for PVD Number of patients Test Location % Gender 8% Inpatient Outpatient 92% Average age 65 43% 56% Male Female No data

12 Peripheral diagnostic test results % 8% % 51% 1500 <0.29 Severe 14% 1000 Moderate Mild Normal Normal Mild Disease Moderate Disease Severe Disease Other

13 Number of procedures Indications for PVD Testing % Suggests inappropriate utilization % 87% 53% 64% 27% 47% 36% Limb Pain Exercise PVD Present* FU Limb Revas Other Abnormal Normal Total Who are they? Slightly younger, healthier More females More out-patients *PVD Present includes Limb Pain at Rest, Ulcer/Gangrene, Absent Peripheral Pulses, Digital Cyanosis, Cold Sens/Raynaud s, Aneurysm/Pseudo

14 Predictive Modelling for PVD tests Binary: Normal vs. Abnormal (mild + moderate + severe disease) Odds Ratios Indications for testing Co-morbidities/ Risk factors

15 Epidemiology of Carotid Artery Testing In/Outpatient 12% Gender 1% 88% 51% 48% Male Female No data Inpatient Outpatient n = 17, 273 Average age = 69

16 Outcome by Indication % % % % 31% Stroke/TIA/AF 69% Non-specific symptoms Carotid Bruit Other Abnormal Normal % 54%

17 Carotid Artery Test Results 12% 3% % % 1200 Normal >= 50% Stenosis >= 70% Stenosis Complete Occlusion

18 Multivariate Analysis Logistic Regression Reason Combined B S.E. Wald df Sig. Exp(B) Carotid Bruit (1) Non-Specific (2) Other (3) Stroke Indication(4) Age Bracket N/A(1) > 75 (2) (3) GENDER Female (1) Male (2) Hypertension(1) Hyperlipidemia(1) Diabetes(1) Smoking(1) Admitted Patient (1) Constant

19 Project Interventions Utilization Laboratory Imaging Drugs Acute Hospital LTC Hospital Interventions General Intervention Provincial Lab Formulary Electronic Management Process Nursing Home Intervention Remote Monitoring in CHF and COPD Early Recovery After Surgery Electronic System for Planning Drug Eluting Stents (Coronary Revasc) Acute Stroke Unit (Stroke) NL Choosing Wisely

20 Risk Score/100 Test Timing E-Referral Form Digitize Risk Scoring Algorithm Web-based guided referral form Data transferred to CHIA and Vascular Lab

21 # of Procedures Cardiac Revascularization: Number of Procedures by Year # of CATHs # of PCIs # of CABGs Year

22 # of Stents Cardiac Revascularization: Use of Stents by Year Year 183 Total Stents Baremetal Stents Drug Eluting Stents Undeployed Stents

23 Cardiac Revascularization: Age-Standardized Rate of CATHs per 100,000

24 Cardiac Revascularization: Age-Standardized Rate of PCIs per 100,000

25 Cardiac Revascularization: Age-Standardized Rate of CABGs per 100,000

26 CABG-related Procedure: Survival Analysis Cox Regression:

27 Cox Regression: PCI Procedure: Survival Analysis

28 CABG & PCI Combined: Survival Analysis Cox Regression:

29 Choosing Wisely NL Theoretical framework for behaviour change Evidence of utilization in NL Evidence about appropriate utilization from Choosing Wisely Canada Identify intervention and barriers to change behaviour Apply interventions Collect evidence on change in utilization Create policy

30 Quality of Care Evaluation of utilization Choose Wisely NL Peer Comparison E-Management Processes Organizational Change Education Lab Utilization Imaging Lab Utilization Imaging Drug Utilization Drug Utilization Lab Utilization Imaging Long Term Care Drug Utilization Hospitalization Stroke

31 Optimizing Effectiveness of Clinical Feedback Interventions Nature of the desired action 1.Recommend actions that are consistent with established goals and priorities. 2.Recommend actions that can improve are under the recipient s control. 3.Recommend specific actions. Nature of the Data available for feedback 4.Provide multiple instances of feedback. 5.Provide feedback ASAP and at a frequency informed by the number of new patients. 6.Provide individual rather than general data. 7.Choose comparators that reinforce desired behaviour change.

32 Optimizing Effectiveness of Clinical Feedback Interventions Feedback display 8.Closely link the visual display and summary message. 9.Provide feedback in more than one way. 10.Minimize extraneous cognitive load for feedback recipients. Delivering the intervention 11.Address barriers to feedback use. 12.Provide short, actionable messages followed by optional detail. 13.Address credibility of the information. 14 Prevent defensive reactions to feedback. 15.Construct feedback though social interaction.