Doll Jacob A, Overton Robert, Patel Manesh R, Rao Sunil V, Sketch Michael H, Harrison J Kevin, Tcheng James E
From the Section of Cardiology, VA Puget Sound Health Care System, Seattle, WA (J.A.D.); Division of Cardiology, Department of Medicine, University of Washington, Seattle, WA (J.A.D.); Duke Clinical Research Institute, Durham, NC (R.O., M.R.P., S.V.R.); and Division of Cardiology, Department of Medicine, Duke University School of Medicine, NC (M.R.P., S.V.R., M.H.S., J.K.H., J.E.T.).
Circ Cardiovasc Qual Outcomes. 2017 Aug;10(8). doi: 10.1161/CIRCOUTCOMES.116.003538.
Morbidity and mortality conference is a common educational and quality improvement activity performed in cardiac catheterization laboratories, but best practices for case selection and for maximizing the effectiveness of peer review have not been determined.
We reviewed the 10-year percutaneous coronary intervention morbidity and mortality conference experience of an academic medical center. Cases were triggered for review by the occurrence of prespecified procedural events. Summary reports from morbidity and mortality conference discussions were linked to clinical data from the Duke Databank for Cardiovascular Disease to compare baseline and procedural characteristics and to assess postdischarge outcomes. Of 11 786 procedures, from 2004 to 2013, 157 (1.3%) were triggered for review. The most frequent triggering events were cardioversion/defibrillation (72, 0.6%), unplanned use of mechanical circulatory support (64, 0.5%), and major dissection (41, 0.3%). Selected procedures were more likely to include high-risk features, such as ST-segment-elevation myocardial infarction, cardiogenic shock, and multivessel disease, and were associated with higher mortality at 30 days. Only a minority of triggering events were caused by controversial or unacceptable physician behavior.
This 10-year experience outlines the processes for conduct of an effective percutaneous coronary intervention morbidity and mortality conference, including a novel approach to case selection and structured peer review leading to actionable quality interventions. The prespecified clinical triggers, captured in the natural workflow by laboratory staff, identified complex cases that were associated with poor patient outcomes.
发病率和死亡率会议是心脏导管实验室开展的一项常见的教育及质量改进活动，但病例选择及使同行评议效果最大化的最佳实践尚未确定。
我们回顾了一家学术医疗中心10年的经皮冠状动脉介入治疗发病率和死亡率会议经验。通过预先设定的手术事件触发病例进行审查。发病率和死亡率会议讨论的总结报告与杜克心血管疾病数据库的临床数据相关联，以比较基线和手术特征，并评估出院后结局。在2004年至2013年的11786例手术中，157例（1.3%）被触发进行审查。最常见的触发事件是心脏复律/除颤（72例，0.6%）、机械循环支持的非计划使用（64例，0.5%）和严重夹层（41例，0.3%）。所选手术更有可能包括高危特征，如ST段抬高型心肌梗死、心源性休克和多支血管病变，且与30天较高的死亡率相关。只有少数触发事件是由有争议或不可接受的医生行为引起的。
这10年的经验概述了有效开展经皮冠状动脉介入治疗发病率和死亡率会议的流程，包括一种新的病例选择方法和结构化同行评议，从而带来可采取行动的质量干预措施。实验室工作人员在自然工作流程中捕获的预先设定的临床触发因素，识别出了与患者不良结局相关的复杂病例。
