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
Systo
lic B
P (
mm
Hg)
Follow-up, yrs 0 1 2 3 4 5 6 0 1 2 3 4 5 6
Dia
sto
lic B
P (
mm
Hg)
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
um
ula
tive F
ata
l C
HD
an
d N
on
fata
l
MI eve
nt
rate
(%
)
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
Hemoglobin achieved
Infections
Phosphate achieved
Albumin sustained
Survival and SMR
Hospitalization 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
Su
rviv
al
(%)
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
P=0.002
1.5
>1.5
Pati
en
ts (
%)
60
50
40
30
20
10
0 Statins Beta-Blockers ACE-Inhibitors/ARBs
Penggunaan Obat-obat Cardioprotective untuk
Chronic Renal Insufficiency (CRI) underutilized
All CRI
Aspirin 27.3%
Beta blockers 33.9%
ACE inhibitors 58.2%
CRI with Established CVD
Aspirin 45.3%
Beta blockers 50.4%
ACE inhibitors 57.3%
Tonelli M et al. J Am Soc Nephrol. 2001;12:1729-1733.
304 Consecutive Patients With Creatinine Clearances ≤75 mL/min But
Not On Dialysis (Mean 30.3 ± 18 mL/min)
Meskipun risiko kematian kardiovaskuler 10 kali lebih besar
dibandingkan dengan Populasi lain
Round 2 pengumpulan data, analisis, dan evaluasi
Round 2: Anggota Expert panel meranking ulang indicators untuk validitas
Diskusi Expert panel untuk membahas indikator yang valid & modifikasinya
Menyediakan referensi updated untuk kajian disagreement pada Round 1
Round 1: hasil analisis untuk bahan expert panel discussion
Round 1: Anggota Expert panel secara independent meranking indicator untuk validitas
Kompilasi quality indicators yang relevan dari literature, guidelines, dan experts
Proses untuk melakukan outcome assessment
Domain
• Struktur
• Proses
• Appropriateness
• Outcome
Level pengukuran
• Rumah sakit atau dokter
Sumber data untuk assessment
• Cancer registries
• Data set administrasi
• Medical record
The ideal surgical outcome
Persiapan pre operasi
Pelaksanaan operasi
Outcome baik
Persiapan operasi
Pelaksanaan operasi
Outcome buruk
Spektrum input-proses-output/outcome
Input Proses Output/outcome
1. Pasien
2. Dokter
3. Perawat
4. Petugas
5. Lain-2
1. SOP
2. Guideline
3. Standard tx
4. Prosedur
5. Evaluasi
1. Disease
2. Disability
3. Discomfort
4. Dissatisfaction
5. Death
Pasien Umur
Sex
Severity
Comorbidity Life style
Pendidikan
Pekerjaan
Sosioekonomi
Not always ideal
Persiapan pre operasi
Pelaksanan operasi
The big black box
Outcome
baik
Unexpected
Outcome
Not always ideal
Persiapan pre operasi
Pelaksanan operasi
The big black box
Outcome baik
Unexpected
Outcome
Nurse Puasa
Cukur
Desinfektan Antibiotika profilaksi
Kateter
Infus
Not always ideal
Persiapan pre operasi
Pelaksanan operasi
The big black box
Outcome baik
Unexpected
Outcome
Penunjang
MRI
CT Scan
Konsul Perbaikan
KU
Radiologi
Lab
Not always ideal
Persiapan pre operasi
Pelaksanan operasi
The big black box
Outcome baik
Unexpected
Outcome
Gizi Diet
Restriksi
Breakfast Glycaemic
control
Informasi
Timing
Not always ideal
Persiapan pre operasi
Pelaksanan operasi
The big black box
Outcome baik
Unexpected
Outcome
Ahli Bedah
Ahli anestesi
Nurse
CSSD
Konsultan
Not always ideal
Persiapan pre operasi
Pelaksanan operasi
The big black box
Outcome baik
Unexpected
Outcome
Faktor Penyulit
Transfusi
Wrong patient
Wrong site
Wrong surgery
Unexpected finding
Not always ideal
Persiapan pre operasi
Pelaksanan operasi
The big black box
Outcome baik
Unexpected
Outcome
Faktor Penyulit
Transfusi
Wrong patient
Wrong site
Wrong surgery
Unexpected
finding
Ahli Bedah
Ahli anestesi
Nurse
CSSD
Konsultan
Gizi Diet
Restriksi
Breakfast Glycaemic
control
Informasi
Timing
Penunjang
MRI
CT Scan
Konsul Perbaikan
KU
Radiologi
Lab
Nurse Puasa
Cukur
Desinfektan Antibiotika profilaksi
Kateter
Infus
Penundaan
operasi Sistem
penjadwalan
Utilisasi OK
Inefisiensi SDM
Inefisiensi fasilitas
Biaya operasion
al
Biaya pasien
aLOS panjang
HAI
Dampak thd
sistem
Circulus Vitiosus
Assuring Quality
Siapkan action plans untuk improvement
Mengidentifikasi root cause terjadinya kesenjangan outcome
Catat outliers dan gaps relative terhadap outcome standards
Catat trend data
Monitors outcomes regularly
Quality Improvement Team
Proses Quality assurance dan quality improvement process sangat
essential—bahkan critical—untuk setiap program.
Structured Outcome Data Collection
Organized Into Categories
Data
Driven
Data
Compared
Quality Assurance Methodology
Data outcome dikumpulkan berdasar kategori
Data diekspresikan sebagai % dalam target
Data dibandingkan dengan rata-rata nasional
Data dibandingkan dengan bulan sebelumnya
Apakah outcome memuaskan
Pay for Performance (P4P)
A response to:
Rising medical cost trends
Growth in chronic care
Increased utilization
Purchaser demands
Fee-for-service encourages overuse
Capitation encourages underuse
Neither rewards quality care
Metode untuk mengevaluasi, menyusun laporan, dan
memberi kompensasi kepada dokter untuk perceived level
of quality yang dilakukan
American Medical Association. Physician Pay For Performance Initiatives. A whitepaper. Available
at: http://www.ama-assn.org/ama/pub/category/14416.html.
Why Payers Want P4P
9=most important, 1=least important
Med-Vantage, Inc., Provider Pay for Performance Incentive Programs: 2004 National Survey Results. 2005.
8.27
7.22
6.68
6.59
6.16
5.93
5.23 Employer Pressures
Improved Clinical Outcomes
Alignment With Other Initiatives
Market differentiation/Positive Image
Reducing Medical Errors/ Improved Patient Safety
Need for Better Data Collection and Reporting
Improved Medical Loss Ratio, Lower Costs
Providers Can Gain From P4P
Opportunity to improve patient care
More money for delivering quality care
Groups can negotiate higher annual price increases for meeting quality targets
Winning incentive awards can provide a competitive advantage through increased
practice recognition
Payers cannot reward every provider with higher payments.
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