Strategie diagnostiche ed impiego delle risorse

nel mondo reale

Andrea Rubboli

Unità Operativa di Cardiologia

Ospedale Maggiore

Bologna

Evento Formativo ANMCO

14 dicembre 2006

Bologna

Erogazione media della gestione raccomandata

54.9% (IC 95% 54.3-55.5)

(N Engl J Med 2003; 348: 2635-2645)

Physician-related

Lack of awareness/familiarity with guidelines Lack of agreement with guidelines Negative attitudes to guidelines Pressure of time Forgetfulness Perceived lack of support from peers Lack of confidence in performing procedure Lack of outcome expectancy Inertia of previous practice

Guideline-related

Evidence insufficiently strong Difficult to understand/inconvenient Inconsistent

Environmental

Inappropriate skill mix/lack of staff Lack of forcing strategies Lack of reminder system Increased costs Patient preferences

Ostacoli all’attuazione delle linee guida

(modificata da Caprini JA et al, Manag Care 2006; 15: 49-66)

Nell’Embolia Polmonare Acuta:

quadro clinico proteiforme

coinvolgimento di numerose e differenti

professionalità

necessità di tecnologia sofisticata

numerosità/ridondanza delle linee guida

Anno Società Scientifica Rivista

1999 American Thoracic Society Am J Respir Crit Care Med160: 1043-1066

2000 European Society of Cardiology Eur Heart J21: 1301-1336

2001 ANMCO-SIC Ital Heart J Suppl2: 1342-1356

2003 American Collegeof Emergency Physicians

Ann Emerg Med 200341: 257-270

2003 British Thoracic Society Thorax 58: 470-484

2004 Spanish Society of Pulmonologyand Thoracic Surgery

Arch Bronconeumol 40: 580-594

Linee Guida recenti per la diagnosi ed il trattamento

dell’Embolia Polmonare Acuta

82,9

0,6

7,94,4 3,2

63,5

22,8

4,82,1

6,8

0

20

40

60

80

100

RVQ RVQ-SOD RVQ-PAG RVQ-CVG Other

Test sequences

(%)

1988 1991

Changing Practice Patterns in the Workup of Pulmonary EmbolismClaudia I. Henshke, MD, PhD; Ion Mateescu, BS; and David F. Yankelevitz, MD

(Chest 1995; 107: 940-945)

RVQ: scintigrafia polmonare

SOD: Ecodoppler AAII

PAG: angiopneumografia

CVG: flebografia

(Ital Heart J 2000; 1: 585-594)

Autore Tipo studio Centri partecipanti Durata studio Numero pz.

Ferrari E et al.(1997)

Registro prospettico 16 centri francesi 30 mesi 387

Kasper W et al.(1997)

Registro prospettico 204 centri tedeschi 16 mesi 1001

Rubboli A et al. (1998)

Analisi retrospettiva Ospedale Maggiore, Bologna

24 mesi 127

Goldhaber SZ et al. (1999)

Registro prospettico 52 centri europei e nordamericani

22 mesi 2454

Roncon L et al.(1999)

Registro prospettico 191 Unità Operative nella Regione Veneto

12 mesi 880

Saro et al.(1999)

Analisi retrospettiva Ospedale Valdecilla, Santander

24 mesi 251

Burkill GJ et al.(1999)

Inchiesta mediante questionario

327 centri nel Regno Unito e EIRE

-- --

(Rubboli A & Euler DE, Ital Heart J 2000; 1: 585-594)

“There is no doubt that CT pulmonary

angiography should now be considered the

central imaging investigation in suspected

pulmonary embolism”

(Miller AC & Boldy DAR, Thorax 2003; 58: 463)

Diagnosis of pulmonary embolism: a cost-effectiveness analysis

(Doyle NM et al, Am J Obst Gynecol 2004; 191: 1019-1023)

ECOGRAFIA VENOSA AAII

200 $

SCINTIGRAFIA POLMONARE V/Q

400 $

ANGIO TC

500 $

se + anticoagulazione se + anticoagulazione se – test aggiuntivo (V/Q o angio TC)

se alta probabilità anticoagulazione se bassa probabilità no anticoagulazione se intermedia probabilità test aggiuntivo

(angio TC o angiopneumografia)

Indagine di imaging iniziale

Costo per vita salvata

24.004 $ 35.906 $ 17.208 $

CT Pulmonary Angiography is the First-Line

Imaging Test for Acute Pulmonary Embolism:

A Survey of US Clinicians

Clifford R. Weiss, MD, John C. Scatarige, MD, Gregory B. Diette, MD, MHS, Edward F. Haponik, MDBarry Merriman, MD, Elliott K. Fishman, MD

Russell H. Morgan Department of Radiology and Radiological Sciences, and Department of Medicine, Division of Pulmonary and Critical Care Medicine

The Johns Hopkins University School of Medicine, Baltimore, MD

(Acad Radiol 2006; 13: 434-446)

86,7

8,3

0,0 2,5 0,00

20

40

60

80

100

CTPA V-P US PA Other

Imaging Test

71,4

19,7

5,81,7 1,0

0

20

40

60

80

100

CTPA V-P US PA Other

Imaging Test

Most useful imaging test First imaging test ordered

Question Percent

Severity of illness 87.5%

Pre-test clinical probability of PE 84.6%

Degree to which a test is validated in the literature 82.5%

How soon the results will be available 72.1%

Risk of adverse reaction during the test 53.8%

Confidence in interpreting physician 52.9%

Additional information, not related to PE, that the test may provide 49.2%

Degree of resistance received from imaging facility or personnel 16.3%

Time of day/day of week 14.2%

Examination covered by insurance 7.9%

Radiation dose to patient 6.7%

Importance of selected factors when ordering a first imaging test

(Clifford RW et al, Acad Radiol 2006; 13: 434-446)

Casistica Ospedale Maggiore - BolognaAnno 2004

Analisi retrospettiva codice di dimissione 415.1

68 pazienti: M/F 33/35; età media: 72.5 14 anni; range 28-97

Totale: 166 indagini di imaging (2.5/paziente)

0

10

20

30

40

50

60

Angio TC Scintigrafia EcodoppAAI I Ecocardio

1° indagine 2° indagine 3° indagine 4° indagine

0 5 10 15 20 25 30 35

EcodopplerAAII

Scintigrafia

Angio TC

NO indagini aggiuntive SI indagini aggiuntive

9%

27%

75%

Indagini aggiuntive dopo 1° test diagnostico

Casistica Ospedale Maggiore - Bologna, Anno 2004

Present diagnostic strategies for acute pulmonary thromboembolism; results of a

questionnaire in a restrospective trial conducted by the Respiratory Nuclear Medicine

Working Group of the Japanese Society of Nuclear Medicine

(Kawamoto M et al, Ann Nucl Med 2002; 8: 549-555)

9%

43%

25%

23%

agree undetermined disagree no opinion

Question # 6.

In the situation in which V/P lung scintigraphy is

performed as the 1st method for evaluating

pulmonary thromboembolism, and the results

suggest pulmonary thromboembolism we do not

perform further examinations

Strategie per incrementare l’aderenza alle linee guida

1. Raise awareness of acute PE in own practice

2. Create initiatives to improve knowledge of

management processes

3. Implement a process to facilitate and simplify

ordering

4. Incorporate a feedback process to assess impact

of changes and detect improvements in clinical

practice and outcomes

local audit

CME

ordering and monitoring charts

audit and feedback,linking back to stage 1

(modificata da Caprini JA et al, Manag Care 2006; 15: 49-66)

Ecodoppler AAII

D-dimero

Angiografia

Angio-TC

Ecocardiogramma

Troponine, BNP

ECG, Rx Torace, EGA

Scintigrafia

Relazione fra costo e informatività delle varie

indagini diagnostiche

Costo

Informazioni

Symtom Klyniska fynd Riskfaktorer

EKG Blodgas

Instabil Hemodynamik Stabil hemodynamik Lungröntgen

Ekokardiografi hjärt-ljungsjd ej hjärt-ljungsjd

högerkammarsvikt neg Spiral CT Lungscint (Spiral CT)

TROMBOLYS Spiral CT pos neg hög intermediär låg normal

pos neg HEPARIN HEPARIN STOPP

Spiral CT

hjärt-ljungsjd ej hjärt-ljungsjd stark svag-måttlig Angio

klin misstanke (Spiral CT,

Angio Sök alternativ diag Ultraljud ben bilat)

(ultraljud ben bilat) Angio neg pos

(Ultraljud ben bilat) Ultraljud ben bilat HEPARIN

pos neg

(Lapidus L, et al. 1997) HEPARIN STOPP

(Rubboli A & Euler DE, Ital Heart J 2000; 1: 585-594)