Appropriatezza Chirurgica Definizione degli Standard

URO-ONCOLOGIA

Tommaso Prayer Galetti - Clinica Urologica Azienda Ospedaliera Università Padova

Giario Conti – Azienda Ospedaliera S. Anna, Como.

IEZZONI ALGEBRA OF EFFECTIVENESS

The American Journal of Surgery (2009)

198 (Suppl to November 2009), S19–S27

� Indicazioni al trattamento – “Guidelines”

� Complicanze peri e post operatorie –”Incident Reporting”

� Costi – “DRG”

� Durata degenza – “SDO”

� Aspetti tecnici

� Risultati� Sopravvivenza

� Qualità della vita post-intervento

� Continenza

� Potenza erettile

� Informazione

OUTCOMES MISURABILI in UROLOGIA

GUIDELINES in UROLOGIA

ES: «La Sorveglianza Attiva nel Carcinoma Prostatico»

Maria Laura Chiozza

SC Qualità e Accreditamento Azienda Ospedaliera di Padova

Incident reporting > eventi sentinella

Segnalazioni reazioni avverse da farmaci – incidenza pre-programmata !

FONTE dei DATI per la Valutazione della Qualità

prolonged length of stay (> 11 days) thromboembolic events

90-day readmission 90-day mortality

Patients with mean level of all covariates (PSA, Gleason score,EPE, SVI, LNI, year of surgery)

5-year predicted probability of freedom from recurrence by surgeon.

Treated by surgeons with a minimum of 40 prior cases.

J Urol. 2010 March ; 183(3): 977–982

Conclusions

MARGINI CHIRURGICI POSITIVI

MARGINE CHIRURGICO POSITIVO

MARGINE CHIRURGICO

IATROGENO

MARGINI CHIRURGICI POSITIVI

Forest plot of 5-year predicted probability of freedom from recurrence by surgeon.

Treated by surgeons with a minimum of 40 prior cases & Surgical Margins (SM+).

“Significant heterogeneity in BCR rates (P = 0.001) suggests that differences in outcome between surgeons

go over and above removing all tissue positive for cancer by gross pathology.”

J Urol. 2010 March ; 183(3): 977–982

Adjusted multivariate analysis

assessing for predictors for

Clavien grade IV or V complication

among urologic procedures

Clavien PA, Sanabria JR, Strasberg SM. Proposed classification of complications of

surgery with examples of utility in holecystectomy. Surgery 1992;111:518-26.

Clavien Classification

Data set: 119 articles reporting outcomes in 22,530 patients

(42 RCTs and 77 retrospective series)

NO articles met all criteria of the 10 short-term surgical outcomes,

“The inconsistency of reporting and the lack of accepted principles of

accrual, display, and analysis of complication data argue strongly for the

creation and generalized use of standards for reporting this information”

Rate of complications reported with radical prostatectomy

AUA Prostate Cancer Guidelines rev. 2012

BJU Int 2013:1-8. doi:10.1111/bju.12407

Urinary continence at 1 year after RP stratified by treatment era

89-100% for patients treated with RALP

80-97% for patients treated with open- RP

NOTE:

1. The major limitations of the included studies were the frequent

retrospective study design and the use of different assessment tools

preventing a proper comparison between techniques and series.

2. Wide surgeon dependent variation

eau guidelines 2015 : “Patients should be informed that functional outcome after

Sex Med and open prostatectomy will be similar”

Eur Urol 2012 Sep;62(3):418-30.

Mean Urinary Continence Rates at 12 months

Surgeons in 3 groups by erectile strength outcome.

total of 207 patients of 4 surgeons with bestoutcomes.

total of 290 patients of surgeons with intermediate outcomes.

total of 270 patients of 5 surgeons with worst outcomes

Vol. 189, 1295-1301, April 2013

METHODOLOGY in REPORTING OUTCOMES AFTER RP

Trifecta

Continence, potency and cancer control

Pentafecta

“Trifecta” + peri-operative complications &

positive surgical margins rates

Bianco FJ Jr, Scardino PT, Eastham JA. Radical prostatectomy: long-term cancer control and recovery of sexual

and urinary function (“Trifecta”). Urology 2005 Nov;66(5 Suppl):83-94.

Patel VR, Sivaraman A, Coelho RF, et al. Pentafecta: a new concept for reporting outcomes of robotassisted

laparoscopic radical prostatectomy. Eur Urol 2011 May;59(5):702-7.

TRENDS in Urology about

Chirurgia: Indicatori di Esito “Ministeriali”

ParametroTipologia

Atto Medico ValoreIndicatore di

% pazienti che necessitano di

un ulteriore ricovero entro

30 giorni dall’intervento

Chirurgia < 5 % Qualità dell’intervento

Secondo le linee guida NICE, dovrebbero essere eseguite almeno 150 procedure

robotiche all’anno affinché tale investimento risulti costo-efficace

Published number of cases recommended to achieve

competency for robotic-assisted radical prostatectomy

Evidence-based data are limited but suggest an

increased prevalence of adverse patient safety

events for robotic prostatectomy early in the

national diffusion period.

Learning curves for robotic urologic surgery are

subjectiveand based on non-validated metrics.

“ The urological community should develop

rigorous, evidence-based processes by which

future technological innovations may diffuse in

an organized and safe manner”

Il contesto futuro

LEAN MANAGEMENTseeks to eliminate any waste of time, effort or

money by identifying each step in a business

process and then revising or cutting out steps

that do not create value. The philosophy has

its roots in manufacturing.

ORGANIZZAZIONE per INTENSITA’ di CURADirigenza Medica 20.3.2015

Can Urol Assoc J 2011;5(5): 342-8;DOI:10.5489/cuaj.11002

Recommendations for the primary assessment of NMIBC Recommendations for the primary assessment of NMIBC Recommendations for the primary assessment of NMIBC

Recommendations for the primary assessment of NMIBC

Performance of individual steps:

Perform TURB systematically

in individual steps !

Special situations

Pathological Report

PDTA – Percorsi Diagnostico Terapeutici Assistenziali

Strumento finalizzato all’ introduzione delle

Linee Guida (LG) nel contesto locale (CL)

Ricadute:

� Organizzative

� Assistenziali

� Medico - legali

� Economiche

Di fatto definiscono Standard di Qualità.

Slow medicine

� Implicazioni cliniche�creazione di un “linguaggio comune",

�documentazione dell’attività svolta,

�verifica dei risultati clinici ottenuti,

�miglioramento dei risultati ottenuti

.

� Implicazioni amministrativi�gestione del rischio clinico

�allocazione delle risorse

�superamento di una logica solo economica

�compartecipazione alla gestione strategica

STANDARD DI QUALITÀ in UROLOGIA

� Adeguata Informazione