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  • Nama : Prof. dr. Iwan Dwiprahasto, MMedSc, PhD

    Riwayat pendidikan

    Dokter, FK UGM tahun 1987

    S-2: MMedSc (Farmakoepidemiologi), Newcastle University Australia, 1993

    S-3: PhD, London School of Hygiene & Tropical Medicine, England, 2000

    Jabatan:

    1. Ketua Umum PB IKAFI (Ikatan Farmakologi Indonesia)

    2. Ketua, Komite Pendidikan, Pelatihan, dan Pengembangan RS. Dr. Sardjito

    3. Board of Governor, International Clinical Epidemiology Network (INCLEN)

    4. Ketua, Komite Sistem Informasi, Universitas Gadjah Mada

    5. Dewan Pakar Perhimpunan Rumah Sakit Indonesia (PERSI)

    6. Tim Ahli Menteri Kesehatan untuk Evaluasi Harga Obat

    7. Tim Ahli untuk DPHO, PT Askes Indonesia

    8. Komite Uji Kompetensi Dokter Indonesia

    9. Komite Nasional (KOMNAS) DOEN (Daftar Obat Esensial Nasional)

    10. Komite Nasional (KOMNAS) Penilaian Obat Jadi Badan POM

    11. Komite Nasional (KOMNAS) Informatorium Obat Nasional Indonesia (IONI)

    12. Editor, Berkala Ilmu Kedokteran

    13. Editor, Indonesian Journal of Clinical Epidemiology and Biostatistics

    Curriculum vitae

  • Mutu outcome klinik pada

    sistem pelayanan kesehatan

    Iwan Dwiprahasto

    Bag. Farmakologi/CE&BU FK UGM

  • Jocelyn Wildenstein

  • Jackie Stallone

  • From the perspective of a GoC Program

    Untuk kepentingan pasien

    Melakukan penyesuaian, perbaikan, better implementation

    Memantau input, proses, output/outcome

    Outcome Management is the set of activities designed to monitor, and adjust as required, the way in which the Program, and its associated Services, Processes and

    Activities, contribute to meeting the needs of Patients/population.

    7

  • how each output of an activity

    contributes to an immediate outcome,

    how these immediate outcomes

    contribute to an intermediate

    outcome,

    and how these intermediate

    outcomes contribute to a final outcome.

    8

  • Perspektif pasien

    Apakah semua pasien

    Mengerti penyakitnya

    Mengerti dampak dari penyakitnya

    Diberitahu berbagai opsi

    terapi

    Mendapat informasi tentang

    probabilitas

    Memiliki komitmen

    Puas/sangat puas

  • Mengapa harus peduli terhadap

    outcome?

    Providing high-quality care is the RIGHT THING TO DO

    Patients need, expect, and deserve quality care

    The National Committee for Quality Assurance (NCQA)

    estimates that 80,000 Americans die each year because

    they do not receive evidence-based care.

  • Need for Quality: Americans Receive Only Half of

    Recommended Care

    RAND Corporation. The First National Report Card on Quality of Health Care in America. 2006.

    Available at: www.rand.org.

    • Patients fail to receive needed services 46% of the time

    • Patients receive services they do not need 11% of the time

    0 10 20 30 40 50 60 70 80 90 100

    Percentage of Recommended Care Received

    N=6,700

    Hypertension

    Stroke

    Depression

    Coronary artery disease

    Asthma

    High cholesterol

    Headache

    Diabetes

    Pneumonia

    Alcohol dependence

  • Pengukuran Outcome secara Proaktif

    Diperlukan assessment terhadap

    Patient survival Hospitalization

    rates Costs Adherence to quality benchmarks

    Pay for performance (P4P) sebagai titik masuk

    Esensial untuk menyediakan “quality care “

    measure – intervene – measure – adjust

    Putting systems in place now will improve quality today and help to

    demonstrate it (if needed) tomorrow.

  • 70

    75

    80

    85

    90

    130

    135

    140

    145

    150

    ALLHAT Mean Systolic and Diastolic Blood

    Pressure During Follow-up

    S y s to

    lic B

    P (

    m m

    H g )

    Follow-up, yrs 0 1 2 3 4 5 6 0 1 2 3 4 5 6

    D ia

    s to

    lic B

    P (

    m m

    H g )

    Chlorthalidone

    Amlodipine

    Lisinopril

    Chlorthalidone

    Amlodipine

    Lisinopril

    ALLHAT Research Group. JAMA. 2002;288:2981-2997.

    Copyright ©2002, American Medical Association. www.hypertensiononline.org

    SBP=systolic blood pressure DBP=diastolic blood pressure

    Dibanding chlorthalidone:

    DBP significantly lower in

    amlodipine group (~1 mmHg).

    Dibanding chlorthalidone:

    SBP significantly higher in

    amlodipine (~1 mmHg) and

    lisinopril (~2 mmHg) groups.

  • 0

    4

    8

    12

    16

    20

    ALLHAT Primary Outcome

    by Treatment Group C

    u m

    u la

    ti v e F

    a ta

    l C

    H D

    a n

    d N

    o n

    fa ta

    l

    M I e v e

    n t

    ra te

    ( %

    )

    Time to event, yrs

    0 1 2 3 4 5 6

    15255

    9048

    9054

    7

    No. at Risk

    Chlorthalidone

    Amlodipine

    Lisinopril

    14477

    8576

    8535

    13820

    8218

    8123

    13102

    7843

    7711

    11362

    6824

    6662

    6340

    3870

    3832

    2956

    1878

    1770

    209

    215

    195

    Chlorthalidone

    Amlodipine

    Lisinopril

    www.hypertensiononline.org ALLHAT Research Group. JAMA. 2002;288:2981-2997.

    Copyright ©2002, American Medical Association.

  • Sorafenib (US$ 1800/vial)

  • % Pasien yang mendapat tindakan

    • Transplantasi

    • Hemodialisis

    • Peritoneal Dialysis (CAPD atau APD)

    Structured training/retraining program?

    Patient survival

    Infection rates

    Hospitalization rates

    Mortality rates

    Continuous Ambulatory Peritoneal Dialysis (CAPD),

    Ambulatory Peritoneal Dialysis (APD)

    Clinic-Specific

    Which Outcomes?

  • Which Outcomes?

    Patient- Specific

    Hemoglobi n achieved

    Infections

    Phosphate achieved

    Albumin sustained

    Survival and SMR

    Hospitaliza tion rates

    Access

    Patient satisfaction

  • Clinical Performance Measures (CPMs)

    Menyediakan “tools” untuk mengukur quality of care kepada praktisi

    Didasarkan pada Evidence-based Clinical Practice Guidelines

    Menetapkan seberapa sering outcome terjadi

    Menetapkan apakah SOP dilaksanakan

    American Heart Association. Available at:

    http://www.americanheart.org/presenter.jhtml?identifier=3012906.

    Clinic-specific CPMs

    Patient-specific CPMs

    Clinical practice guidelines for

    HD/PD

  • Clinical Practice Guidelines for Peritoneal

    Adequacy, Update 2006

    National Kidney Foundation. KDOQI Clinical Practice Guidelines for Peritoneal Dialysis Adequacy: 2006

    Update. Am J Kidney Dis. 2006;48(suppl):S91-S97.

    Initiation of Dialysis

    Peritoneal Dialysis Solute Clearance Targets and Measurements

    Preservation of Residual Kidney Function

    Maintenance of Euvolemia

    Quality Improvement Programs

    Pediatric Peritoneal Dialysis

  • Highlights of 2006 Update of

    HD Adequacy Guidelines

    National Kidney Foundation. KDOQI Clinical Practice Guidelines for Hemodialysis Dialysis Adequacy:

    2006 Update. Am J Kidney Dis. 2006;48(suppl):S2-S90.

    Perlu edukasi bagi pasien dan petugas

    tentang pilihan renal- replacement jika tercapai

    CKD stage 4

    Dosis dialisis dipertahankan sama

    dengan yang direkomendasikan

    sebelumnya

    Hindari bahan-2 nefrotoksik untuk

    mempertahankan fungsi ginjal yang tersisa

    Frekuensi dan lamanya dialisis berdasarkan

    fungsi ginjal yang tersisa

  • Ilustrasi hasil evaluasi

    11% pasien hemodialysis dan

    30% pasien dengan peritoneal dialysis di AS menerima dosis dialisis yang inadekuat

    Bass EB et al. Am J Kidney Dis. 2004;44:695-705. Goodkin DA et al. Am J Kidney Dis. 2004;44(suppl 2):S16-S21.

    The crude RR untuk mortalitas di

    AS 2 kali lebih besar daripada

    Eropa dan 5 kali lebih besar

    daripada di Jepang

    S u

    rv iv

    a l

    (% )

    100

    90

    80

    70

    60

    50

    40

    30 0.0 0.5 1.0 1.5 2.0 2.5 3.0

    Years

    Europe

    US

    Japan

  • Low Use of Recommended Drugs

    in CKD Post-MI

    Use of recommended drugs after mi by level of kidney function

    (serum creatinine concentration in mg/dL, unadjusted).

    MI = myocardial infarction, ACE = angiotensin converting enzyme, ARB = angiotensin-II receptor blocker

    Winkelmayer WC et al. Clin J Am Soc Nephrol. 2006;1:796-801.

    Kurang dari separuh pasien CKD menerima obat yang

    direkomendasikan untuk post MI

    P=0.02

    P=0.006