I PDTA cinque domande all`esperto

Transcription

LE NOVITÀ DEI SISTEMI DI GESTIONE DELLA
QUALITÀ IN SANITÀ: I PDTA COME ELEMENTO DI
VALUTAZIONE SPERIMENTALE
I PDTA cinque domande all’esperto
Prof. Massimiliano Panella
Presidente European Pathway Association (www.E-P-A.org)
Università degli Studi del Piemonte Orientale “Amedeo Avogadro”
[email protected]
Bologna, 29 Novembre 2012
© E-P-A European Pathway Association
Le domande di oggi
1. Quale è la differenza fra processo e percorso (PDTA)?
2. Esistono rappresentazioni grafiche obbligatorie di un PDTA?
Matrice? Flow chart? È necessaria e/o opportuna una
schede/checklist, cartacea o informatica, che accompagna
ogni paziente lungo il PDTA ?
3. Sulla base di quanto emerge da queste schede, si può fare
un'analisi dello "scostamento“. Come si fa? Si fa sempre?
Con quali strumenti?
4. Il coinvolgimento di associazioni di utenti: quali le
esperienze? Quali i vantaggi? Quali le difficoltà ?
5. È abituale e/o opportuno effettuare un'analisi dell'impatto
economico della creazione di un PDTA? È difficile ? Quali le
esperienze?
1. Definizione
• Quale è la differenza fra processo e percorso
(PDTA)? E le evidenze scientifiche?
La definizione europea
•
I percorsi assistenziali sono un intervento complesso per
prendere decisioni ed organizzare in modo condiviso
l’assistenza di un ben definito gruppo di pazienti in un intervallo
di tempo precisato.
Gli interventi complessi in Sanità
• Gli interventi complessi in Sanità, terapeutici o
preventivi, sono composti da un numero di singoli
elementi che sembrano essenziali al corretto
funzionamento dell’intervento sebbene l’ “ingrediente
attivo’’ è difficile da specificare.
• Se si considera un trial randomizzato controllato di un
farmaco vs. placebo come il più semplice di uno
spettro di studi, allora il confronto tra una stroke unit
con l’assistenza tradizionale è il più complesso.
• Se un ricercatore trova, nel disegnare il proprio studio,
difficoltà nel definire precisamente quali sono gli
“ingredienti attivi” di un intervento e come correlano
gli uni con gli altri, è probabilmente alle prese con un
intervento complesso.
Fonte: MRC, 2000, 2008
La definizione europea
•
•
I percorsi assistenziali sono un intervento complesso per
prendere decisioni ed organizzare in modo condiviso
l’assistenza di un ben definito gruppo di pazienti in un intervallo
di tempo precisato.
Le caratteristiche che definiscono i percorsi includono:
– La definizione esplicita degli obiettivi e degli elementi chiave
dell’assistenza basati su evidenze, best practice e aspettative del
paziente;
– La facilitazione di comunicazione, coordinamento dei ruoli, e messa
in sequenza delle attività di team assistenziali multidisciplinari,
pazienti e famigliari;
– La documentazione, il monitoraggio e la valutazione degli
scostamenti e degli outcome;
– L’identificazione delle appropriate risorse.
•
Lo scopo di un percorso assistenziale è aumentare la qualità
delle cure nel continuum dell’assistenza, migliorando gli esisti
clinici risk adjusted, promuovendo la sicurezza e aumentando la
soddisfazione dei pazienti, e ottimizzando l’uso delle risorse.
Fonte: European Pathway Association, 2005, 2008
PDTA come “intervento complesso”
• Cosa costituisce un PDTA? Ovvero … Quali
ingredienti?
Componenti attive
• Studio EQCP (European Quality of Care
Pathway):
– Feedback sulla performance attuale
dell’organizzazione (su processi e team)
– Set di evidence based key interventions
– Metodologia per lo sviluppo e per
l’implementazione di PDTA
Feedback performance attuale
© E-P-A European
Source: Pathway
VanhaechtAssociation
K, 2012
Evidence based key interventions
Metodologia PDTA
Quesito 1
• Quale è la differenza fra processo e percorso
(PDTA)? E le evidenze scientifiche?
– Intervento complesso: intervento multicomponente
(comprese le evidenze) di gestione di processi
assistenziali
2. Formato
• Esistono
rappresentazioni
grafiche
obbligatorie di un PDTA? Matrice? Flow
chart? È necessaria e/o opportuna una
schede/checklist, cartacea o informatica,
che accompagna ogni paziente lungo il
PDTA?
Modelli
LOW
WEB-MODEL
HUB-MODEL
Level
Of
Agreement
CHAIN-MODEL
HIGH
HIGH
Level of predictability
LOW
Source: Vanhaecht, K., Panella, M., Van Zelm, R., Sermeus, W. (2010). What about care pathways?
In Ellershaw (red), Care of the dying, second edition. Oxford University Press, Oxford
Produzione
International / National /
Regional Level
(not organization specific)
Model pathway
Local level
(organization
specific)
Operational pathway
P
A
T
I
E
N
T
(prospective)
(prospective)
Assigned pathway
Patient level
(organization &
patient specific)
V
E
R
S
I
O
N
(prospective)
Completed pathway
(retrospective)
Stile
• 2 scuole di pensiero sui PDTA
– Scuola inglese: implementazione di linee guida,
molto dettagliati
• Integrated care pathway: ICP
– Scuola americana: organizzazione degli interevnti
chiave di un processo assistenziale
• Care pathway, clinical pathway: CP
Formato: Flow Chart (1)
Emergency Mobile Service
Emergency Department (ED)
Pre-hospital phase
In–hospital phase
Focused Clinical History
& Examination
Stroke
signs and
symptoms?
no
Re-evaluation by
standardized assessment
Stabilization and
investigations
Evaluation for
other path
Blood tests
First 24 hrs
yes
Oxygen therapy (if required)
- Isotonic crystalloids (for
resuscitation, if needed)
Decide notification of the
receiving institution (ED) about
impending arrival of a patient
with suspected stroke
ECG
ECD
Brain imaging
(CT or MR if
CT delayed)
Vascular
investiogations
Neurologist
consuiltation
no
Stroke
confirmed?
yes
Haemorragic
stroke?
no
Ischemic stroke
or transient ischemic
attack (TIA)
yes
Transfer to
Neurosurgery
Admission in
Neurological Unit
1
Massimiliano Panella*, Sara Marchisio, Romeo Brambilla, Kris Vanhaecht and Francesco Di Stanislao
A cluster randomized trial to assess the effect of clinical pathways for patients with stroke: results of the
clinical pathways for effective and appropriate care study BMC Medicine 2012, 10:71
Neurological Unit
(Stay)
1
TIA or hischemic
stroke
First 24 hrs and later
Aspirin is
indicated?
Give aspirin
(160-325 mg)
Consider alternative
antiplatelets
Identification aspiration risk
and nutritional risk
Monitor fluid loss and
intake
Monitoir weight and BMI
Assess swallowing and
hydratation
Physiological
monitoring
Check electrolytes
periodically
Blood pressure
Pulse rate &
Respiratory rate
Mantein blood
glucose between
4-11mmol/L
2
Oxigen saturation
Oxygen <95%?
yes
Give oxigen
no
No oxigen therapy is
raccomended
Neurological Unit (Stay)
Early neurological
deterioration
Hypo or Hyperglycaemia
Electrolytedisturbances
Aspiration pneumonia or
other seplis
Hypothermia or
hypethermia
First 24 hrs and later
2
Assessment and
management of
complications
Dehyfdratation and
malnutrition
Hypertension
Pressure ulcer
Intracranical
hypertensiion
Large middle
cerebral artery or
cerebellar infarcts
Consider furosemide
or mannitol and
hyperventilation
Refer to Neurosurgery for possible
decompressive hemicraniectomy within
48 hs of symptom onset
3
Neurological/general Unit &
Rehabilitation Unit (RU) (Stay)
3
Physiatric/physiotherapist
assessment
Early
mobilization
Disphagic and phasic
assessment
(within 48 hs)
Neurological/general
/Rehabilitation Unit (Discharge)
Assessment of
disabilities
Global assessment
(tobacco.lipemia,
glicaemia, ECG)
Rehabilitation Plan
2nd day and later
Neurological
balance
Tranfer to
Rahabilitation ward
yes
Criteria for
admission in
RU?
no
Consider
alternative setting
for chronic care
Neurological, vital
signs, temperature
Prosecution of:
examination &
assessement
Plan the patient’s
activities
General
examination
Neurological
assessment and
exhamination
Assessment of
residual disabilies
Psichological support to
prevent depression
Screening patient
for depression
Family
information &
involvement
Discharge care plan
(rehabilitation &
nursing, diet,
medication, lifestyle)
Swallow &
nutritional options
Rehabilitation
needs
Outpatient
(Follow-up at 3 month)
Arrangement for
prosecution of
rahabilitation
Schedule follow-up &
continuity of care
(rehabilitation)
Risk of skin lesions
Medication &
nutritional plan
update
Consultations
(psychiatric, speech
therapist)
Discharge
Rehabilitation
treatment
Formato: GANTT (1)
Formato: GANTT (2)
Formato: protocollo
Per me …
Pezzo di carta?
Quesito 2
• Esistono
rappresentazioni
grafiche
obbligatorie di un PDTA? Matrice? Flow
chart? È necessaria e/o opportuna una
schede/checklist, cartacea o informatica,
che accompagna ogni paziente lungo il
PDTA?
– La via della spada
3. Scostamenti
• Sulla base di quanto emerge da queste
schede, si può fare un'analisi dello
"scostamento“. Come si fa? Si fa sempre?
Analisi degli scostamenti
• Analisi della variabiltà del PDTA:
– prospettica, concorrente, comprensiva (tutti i
pazienti, tutti i processi), sistematica (audit
trimestrali), ad hoc.
• Mediante l’uso di:
– variations grids,
mapping, audit.
control
charts,
process
• Su sistemi informativi:
– ad hoc (prevalentemente).
• Con utilizzo:
– organizzazione specifico.
Variation grids – un esempio
VARIANCE
VARIANCECODES
CODES
a.a.Chest
Chestpain
pain>=3
>=3
b.b.Systolic
B7P
Systolic B7P<90
<90or>180
or>180mmHg
mmHg
c.c.Brady-arrhythmias
Brady-arrhythmias
d.d.Ventricular
Ventriculararrhythmias
arrhythmias
e.e.Haematoma
Haematoma
f.f.Back
Backororgroin
groinpain
pain>=4
>=4
g.g.Bleeding
Bleeding
h.h.Temperature
Temperature>100°
>100°
i.i.MD
modify
the
MD modify thepathway
pathway
j.j.Skin
integrity
compromised
Skin integrity compromised
k.k.Dissection
Dissection
l.l.Procedure-related
Procedure-relatedinfarct
infarctororextension
extension
m.
Other
m. Other
Indicator
Intervention
Expected outcomes
Consults/referrals
Interventional Cardiologist
Pastoral Care prn
tests
EKG as ordered and prn
ACT before and 1 hr post
eparin drip discontinued while
sheath in
Bed rest, affected leg
immobilized while sheath in
HOB 30° max elevation while
sheath in
Walk 8 hr after sheath removal
VS q 15 minx4; q 30 min x4
then q 2 hr
Assess A-line waveform, groin
site, distal pulses, mentation,
rhythm, and pain with VS
System assessment q 4 hr
Low fat, Low Cholesterol level
II
Finger foods first meal
IV or saline lock as ordered
Urinary cath in/out if indicated
Encouraged po fluids
Heparin drip (wean as
ordered)
TG drip (wean as ordered)
Ancef IVPB until sheath
removed
Administer ASA, sleeper,
sedation, analgesics, and O2
as ordered
Reinforce diagnosis
information, activity
restrictions, postprocedure
care, and to report bleeding or
chest discomfort to nurse
Patinbet/family aware of
postprocedure plan of care
Patient/family emotional/spiritual
needs addressed
EKG with normal limits
Steady decline in value to less
than 160
No bleeding complication
No complication r/t skin immobility
No bleeding or hematoma at site
Activity/Skin and
Tissue Integrity
Neurovascular
Cardiac
Respiratory
Fluids
Nutrition
Elimination
Medication
Teaching
Var.
Code
Initials
d. AM
Notes
Patients
needss to
be treated
with
VS WNL
A-line Patent- good waveform
Drsg. Dry and intact
Distal pulses palpable
AAO x 3
Absence of dysrhythmias and pain
Able to tolerate diet
Maintain adequate hydration
Urine output adequate
Freedom from ischemic pain
Remains comfortable
Freedom from infection
Exhibits restful sleep
Patient/family understanding of
activity restrictions and when to
notify nurse
VARIANCE CODES
Signature/Initials:
d.
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
chest pain >=3
systolic B7P <90 or>180 mmHg
Bradydysrhythmias
Ventricular Dysrhythmias
Hematoma
Back or groin pain >=4
Bleeding
Temperature >100°
MD alters pathway
Skin integrity compromised
Dissection
Procedure-related infarct or
extension
other
Panella M. The impact of pathways: a significant decrease in mortality. Int J Care Path 2009; 13:
57-61 European Pathway Association
© E-P-A
Compliance con l’ecocordiogramma
90
80
70
60
50
ICP group
40
Control Group
30
20
10
0
1st trimester
2nd trimester
Ecocardiogramma
in Pronto Soccorso
CAUSE
29 esami non eseguiti
5
8
2
6
4
1
1
2
pazienti: trasferiti ad altro ospedale
pazienti : ecocardiografo non disponibile il P.S.
pazienti : ecocardiogramma dimenticato
pazienti : non necessario (NYHA I)
pazienti : nessuna spiegazione
pazienti : referto perso
pazienti : morto prima dell’esame
pazienti : ritardato
Discussione
nel team
Variation grids – risultati
physician
clinical
81.8%
motivated
organizational
18.2%
total
56.4%
not motivated
total
43.6%
nurse
52.3%
47.6%
62.7%
37.3%
Panella M. The impact of pathways: a significant decrease in mortality. Int J Care Path 2009; 13:
57-61 European Pathway Association
© E-P-A
Control charts: ACE-inibitori
Con PDTA
65
observed
expected (%)
mean (%)
+2SD
57,5
-2SD
50
jan-05
feb-05
mar-05
apr-05
may-05
jun-05
jul-05
Senza PDTA
67,5
60
52,5
observed
45
expected (%)
37,5
mean (%)
30
+2SD
22,5
-2SD
15
7,5
0
jan-05
feb-05
mar-05
apr-05
may-05
jun-05
jul-05
Panella M. The impact of pathways: a significant decrease in mortality. Int J Care Path 2009; 13: 57-61
Process indicator
n/N (%)
§
Antithrombotic prophylaxis
119/120 (99.2)
§
Administration of analgesic medication postoperative
119/120 (99.2)
§
Assessment of Hemoglobin pre-operative
114/120 (95.0)
§
Early mobilization within 24/48 postoperative hours
§
Antibiotic prophylaxis
§
Adequate X-rays of affected hip
95/120 (79.2)
§
Surgery within 24 hours after admission
84/120 (70.0)
§
Visit of social worker
65/120 (60.8)
§
Assessment of cognitive status pre-operative
69/120 (57.5)
§
Social history recorded in patient pre-operativet
65/120 (54.2)
§
Pressure ulcers prevention
64/120 (53.3)
§
Assessment of pre-fracture mobility status
58/120 (48.3)
§
Nutrition: food intake assessment
37/120 (30.8)
§
Pressure ulcers risk assessment
33/120 (27.5)
§
Adequate analgesia postoperative
28/120 (23.3)
§
Assessment of cognitive status at start mobilization
28/120 (23.3)
§
Assessment of fluid balance
22/120 (18.3)
§
Assessment of pre-fracture falls
18/120 (15.0)
§
Nutrition: diet advice or support
11/120 (9.2)
§
Surgical wound drain
46/120 (38.3)
§
Pre-operative traction
65/120 (54.2)
§
Urine catheterization
80/120 (66.7)
94/112 (83.9)
100/120 (83.3)
Quesito 3
• Sulla base di quanto emerge da queste
schede, si può fare un'analisi dello
"scostamento“. Come si fa? Si fa sempre?
– Si, strumenti di CQI, si, in funzione dei sistemi
informativi disponibili
4. Coinvolgimento utenti
• Il coinvolgimento di associazioni di utenti:
quali le esperienze? Quali i vantaggi?
Quali le difficoltà ?
Victory for caring pathway families
•
•
•
Minister pledges new law so
patients can’t be put on endof-life regime but consulting
relatives
Health Secretary Jeremy Hunt
will vouch to make doctors
explain end-of-life caring to
patients’ relatives
Putting patients on a ‘death
pathway’ though consulting
their families will be outlawed
subsequent week
Tim Shipman posted on November 2, 2012
•
•
The LCP, that leads to
genocide in an normal of 33
days, is designed to palliate
a pain and shake for patients
who are terminally ill. Health
trusts have however faced a
assign that it has been stale
to dive a deaths of these
patients.
Patients have had feeding
tubes cold while their kin
were unknowingly that they
been placed on a pathway
•
•
Last
night
Mr
Hunt
pronounced he would bless
a ‘basic right’ of patients to
be concerned in decisions
when they are mortally sick.
He
threatened
‘tough
consequences’ for hospitals
that destroy to consult.
Patients and their families
will be means to sue health
trusts that mangle a manners
and doctors who omit their
wishes face being struck off
for misconduct.
Quesito 4
• Il coinvolgimento di associazioni di utenti:
quali le esperienze? Quali i vantaggi?
Quali le difficoltà?
– L’esperienza del PDTA diabete
5. Analisi economica
• È abituale e/o opportuno effettuare un'analisi
dell'impatto economico della creazione di un
PDTA? È difficile? Quali le esperienze?
Studi primari (2007-2012)
• Studi effettuati:
–
–
–
–
–
3 osservazionali, nessun controllo
7 pre/post
7 quasi-sperimentali
6 RCT
4 cRCT
• Studi in corso d’opera:
– 4 cRCT
Studi secondari (2007-2012)
•
Metanalisi:
–
–
–
–
•
Bailey EJ, Morris PS, Kruske SG, Chang AB. Clinical pathways for chronic cough in children. Cochrane Database Syst
Rev. 2008 Apr 16;(2):CD006595.
Rotter T, Kugler J, Koch R, Gothe H, Twork S, van Oostrum JM, Steyerberg EW. A systematic review and meta-analysis
of the effects of clinical pathways on length of stay, hospital costs and patient outcomes. BMC Health Serv Res. 2008 Dec
19;8:265.
Barbieri A, Vanhaecht K, Van Herck P, Sermeus W, Faggiano F, Marchisio S, Panella M. Effects of clinical pathways in
the joint replacement: a meta-analysis.BMC Med. 2009 Jul 1;7:32
Rotter T, Kinsman L, James E, Machotta A, Gothe H, Willis J, Snow P, Kugler J. Clinical pathways: effects on professional
practice, patient outcomes, length of stay and hospital costs. Cochrane Database Syst Rev. 2010 Mar 17;3:CD006632
Revisioni sistematiche:
–
–
–
–
–
–
–
–
–
–
Kwan J. Care pathways for acute stroke care and stroke rehabilitation: from theory to evidence. J Clin Neurosci. 2007
Mar;14(3):189-200.
Lemmens L, Van Zelm RT, Vanhaecht K, Kerkkamp H. Systematic review: Indicators to evaluate effectiveness of clinical
pathways for gastrointestinal surgery. Journal of Evaluation in Clinical Practice 2008;14: 880-7.
Chudyk AM, Jutai JW, Petrella RJ, Speechley M. Systematic review of hip fracture rehabilitation practices in the elderly.
Arch Phys Med Rehabil. 2009 Feb;90(2):246-62.
Neuman MD, Archan S, Karlawish JH, Schwartz JS, Fleisher LA. The relationship between short-term mortality and quality
of care for hip fracture: a meta-analysis of clinical pathways for hip fracture. J Am Geriatr Soc. 2009 Nov;57(11):2046-54.
Epub 2009 Sep 28.
Van Herck P, Vanhaecht K, Deneckere S, Bellemans J, Panella M, Barbieri A, Sermeus W. Key interventions and
outcomes in joint arthroplasty clinical pathways: a systematic review. J Eval Clin Pract. 2010 Feb;16(1):39-49
Ilott I, Booth A, Rick J, Patterson M. How do nurses, midwives and health visitors contribute to protocol-based care? A
synthesis of the UK literature. Int J Nurs Stud. 2010 Jun;47(6):770-80. Epub 2010 Feb 18. Review.
Lodewijckx C, Sermeus W, Panella M, Deneckere S, Leigheb F, Decramer M, Vanhaecht K, for the EQCP study group.
Impact of care pathways for in-hospital management of COPD exacerbation: a systematic review. Int J Nurs Stud.
2011;48:1445-56.
Leigheb F, Vanhaecht K, Sermeus W, Lodewijckx C, Deneckere S, Boonen S, Boto PA, Mendes RV, Panella M.The Effect
of Care Pathways for Hip Fractures: A Systematic Review. Calcif Tissue Int. 2012 Apr 3. [Epub ahead of print].
DOI:10.1007/s00223-012-9589-2
Deneckere S, Euwema M, Van Herck P, Lodewijckx C, Panella M, Sermeus W, Vanhaecht K. Care pathways lead to
better teamwork: Results of a systematic review. Soc Sci Med. 2012 Jul;75(2):264-8. Epub 2012 Apr 20.
Kul S, Barbieri A, Milan E, Montag I, Vanhaecht K, Panella M. Effects of care pathways on the in-hospital treatment of
heart failure: a systematic review. BMC Cardiovasc Disord. 2012 Sep 25;12(1):81. [Epub ahead of print]
Rotter T et al., 2009
•
•
Clinical pathways for hospitalized children and adults of every
age and indication
17 randomised controlled trials (RCT) and controlled clinical
trials (CCT), met inclusion criteria, representing 4,070 patients:
– Significant shortening of LOS.
– Subgroup-analysis for invasive procedures a stronger LOS
reduction (weighted mean difference (WMD) -2.5 days versus -0.8
days)).
– No evidence of differences in readmission to hospitals, OR= 1.1
(95% CI: 0.57 to 2.08)
– No differences for in-hospital complications. OR = 0.7 (95% CI:
0.49 to 1.0).
– 4 studies showed significantly lower costs for the pathway group
Rotter T, Kugler J, Koch R, Gothe H, Twork S, van Oostrum JM, Steyerberg EW. A systematic review and meta-analysis of
the effects of clinical pathways on length of stay, hospital costs and patient outcomes. BMC Health Serv Res. 2008 Dec
19;8:265.
Barbieri A et al., 2009
• Clinical pathways for hip and knee replacement.
• Twenty-two studies were included in the metaanalysis (1RCT).
• Total sample of 6,316 patients.
• The aggregate overall results showed significantly:
–
–
–
–
fewer patients suffering postoperative complications
shorter length of stay
lower costs during hospital stay
no significant differences in discharge to home.
Barbieri A, Vanhaecht K, Van Herck P, Sermeus W, Faggiano F, Marchisio S, Panella M. Effects of clinical pathways in the
joint replacement: a meta-analysis.BMC Med. 2009 Jul 1;7:32
Van Herck P et al., 2010
• Clinical pathways for total joint arthroplasty
• 34 of the 4055 publications were included:
– Improved process and financial outcomes.
– The effects on clinical outcome are mixed.
– Evidence on team and service outcome is lacking.
Van Herck P, Vanhaecht K, Deneckere S, Bellemans J, Panella M, Barbieri A, Sermeus W. Key interventions and outcomes
in joint arthroplasty clinical pathways: a systematic review. J Eval Clin Pract. 2010 Feb;16(1):39-49.
Rotter T et al., 2010
• Effect of clinical pathways on professional practice,
patient outcomes, length of stay and hospital costs.
• Twenty-seven studies involving 11,398 participants:
– reduction in in-hospital complications (OR = 0.58: 95%CI
0.36 - 0.94)
– improved documentation (OR = 13.65: 95%CI 5.38 34.64).
– no evidence of differences in readmission to hospital or inhospital mortality.
– Length of stay reported significant reductions.
– A decrease in hospital costs/ charges was also observed,
ranging from WMD +261 US$ favouring usual care to WMD 4919 US$ favouring clinical pathways.
Rotter T, Kinsman L, James E, Machotta A, Gothe H, Willis J, Snow P, Kugler J. Clinical pathways: effects on professional
practice, patient outcomes, length of stay and hospital costs. Cochrane Database Syst Rev. 2010 Mar 17;3:CD006632.
Ilott I et al., 2010
• 33 studies describing the development of protocols,
guidelines and care pathways in the United Kingdom
between 1991 and 2006.
• The development process was idiosyncratic, being
embedded within a specific context underplays what
is known about the complexity of innovation and
change in health care organisations
• Most papers encapsulated practitioner rather than
research knowledge.
• Authors were so positive about their standardised
approach to care, neglecting other aspects such as
– the costs of their time and
– the problems of implementation and
– sustainability.
Ilott I, Booth A, Rick J, Patterson M. How do nurses, midwives and health visitors contribute to protocol-based care? A synthesis of
the UK literature. Int J Nurs Stud. 2010 Jun;47(6):770-80. Epub 2010 Feb 18. Review.
Kul S. et al., 2012
• Care pathways in the hospital treatment of heart
failure
• Seven studies met the study inclusion criteria and
were included in the systematic review with a total
sample of 3,690 patients.
• The combined overall results showed that care
pathways have a significant positive effect on
mortality and readmission rate.
• A shorter length of hospital stay was also
observed compared with the standard care group.
• No significant difference was found in the
hospitalisation costs.
Una conclusione (sbagliata?) …
• «Clinical
reduced
improved
impacting
costs».
pathways are associated with
in-hospital complications and
documentation without negatively
on length of stay and hospital
Source: Rotter T. 2010
Quesito 5
• È abituale e/o opportuno effettuare un'analisi
dell'impatto economico della creazione di un
PDTA? È difficile? Quali le esperienze?
– Abituale no, opportuno si … Molto difficile, ABC e
costi di implementazione
Conclusioni

I PDTA cinque domande all`esperto

Transcription

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