Strategie diagnostiche ed impiego delle risorse nel mondo reale Evento Formativo ANMCO 14 dicembre 2006 Bologna Strategie diagnostiche ed impiego delle risorse nel mondo reale Andrea Rubboli Unità Operativa di Cardiologia Ospedale Maggiore Bologna

Erogazione media della gestione raccomandata 54.9% (IC 95% 54.3-55.5) (N Engl J Med 2003; 348: 2635-2645) Erogazione media della gestione raccomandata 54.9% (IC 95% 54.3-55.5)

Ostacoli all’attuazione delle linee guida 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 (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

Linee Guida recenti per la diagnosi ed il trattamento dell’Embolia Polmonare Acuta Anno Società Scientifica Rivista 1999 American Thoracic Society Am J Respir Crit Care Med 160: 1043-1066 2000 European Society of Cardiology Eur Heart J 21: 1301-1336 2001 ANMCO-SIC Ital Heart J Suppl 2: 1342-1356 2003 American College of Emergency Physicians Ann Emerg Med 2003 41: 257-270 British Thoracic Society Thorax 58: 470-484 2004 Spanish Society of Pulmonology and Thoracic Surgery Arch Bronconeumol 40: 580-594

Changing Practice Patterns in the Workup of Pulmonary Embolism Claudia 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

Autore Tipo studio Centri partecipanti Durata studio Numero pz. (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. 204 centri tedeschi 16 mesi 1001 Rubboli A et al. (1998) Analisi retrospettiva Ospedale Maggiore, Bologna 24 mesi 127 Goldhaber SZ et al. (1999) 52 centri europei e nordamericani 22 mesi 2454 Roncon L et al. 191 Unità Operative nella Regione Veneto 12 mesi 880 Saro et al. Ospedale Valdecilla, Santander 251 Burkill GJ et al. 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) Indagine di imaging iniziale ECOGRAFIA VENOSA AAII 200 $ SCINTIGRAFIA POLMONARE V/Q 400 $ ANGIO TC 500 $ se alta probabilità anticoagulazione se bassa probabilità no anticoagulazione se intermedia probabilità test aggiuntivo (angio TC o angiopneumografia) se + anticoagulazione se + anticoagulazione se – test aggiuntivo (V/Q o angio TC) Costo per vita salvata 24.004 $ 35.906 $ 17.208 $

Most useful imaging test First imaging test ordered 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, MD Barry 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) Most useful imaging test First imaging test ordered

Importance of selected factors when ordering a first imaging test 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% (Clifford RW et al, Acad Radiol 2006; 13: 434-446)

Casistica Ospedale Maggiore - Bologna Anno 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)

Indagini aggiuntive dopo 1° test diagnostico Casistica Ospedale Maggiore - Bologna, Anno 2004 9% 27% 75%

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) 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

ordering and monitoring Strategie per incrementare l’aderenza alle linee guida Raise awareness of acute PE in own practice Create initiatives to improve knowledge of management processes Implement a process to facilitate and simplify ordering 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)

Relazione fra costo e informatività delle varie indagini diagnostiche Ecodoppler AAII D-dimero Angiografia Angio-TC Ecocardiogramma Troponine, BNP ECG, Rx Torace, EGA Scintigrafia Informazioni Costo

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)