BridgingtheCareGapContinuingMedicalImplementationInc桥接的保健差距实现公司继续医学

BridgingtheCareGapContinuingMedicalImplementationInc桥接(Jie)的保健差距实现公司继续医学©ContinuingMedicalImplementation®…...bridgingthecaregapContinuingMedicalImplementation®…...bridgingthecaregap第一页，共五十三页。©ContinuingMedicalImplementation®…...bridgingthecaregapContinuingMedicalImplementation®…...bridgingthecaregapCareGapFailureto,translate,transferandutilizemedicalknowledgeeffectively

UsualCare≠bestcarePopulationoutcomesdonotmatchresultsofclinicaltrialsPatient,physicians&payersdonotreapthebenefitsofvalidatedmedicalknowledge第二页，共五十三页。©ContinuingMedicalImplementation®…...bridgingthecaregapContinuingMedicalImplementation®…...bridgingthecaregapCareGapThedifferencebetweenwhatweknowandwhatwedoThedifferencebetweenachievableandactualoutcomesThefailuretosystematizeknowledgeandapplyitconsistently第三页，共五十三页。©ContinuingMedicalImplementation®…...bridgingthecaregapContinuingMedicalImplementation®…...bridgingthecaregapKnowledgeTranslation

Definition:“Knowledgetranslationistheeffectiveandtimelyincorporationofevidence-basedinformationintothepracticesofhealthprofessionalsinsuchawayastoeffectoptimalhealthcareoutcomesandmaximizethepotentialofthehealthsystem.”AdaptedfromtheCanadianInstitutesforHealthResearchdefinition,2001第四页，共五十三页。©ContinuingMedicalImplementation®…...bridgingthecaregapContinuingMedicalImplementation®…...bridgingthecaregap

INTER-HEART:RiskofacuteMIassociatedwithriskfactorsintheoverallpopulation

YusufS.EuropeanSocietyofCardiologyCongress2004;August28-September1,2004;Munich,Germany.RiskfactorOddsratioadjustedforage,sex,andsmoking(99%CI)Oddsratioadjustedforall(99%CI)ApoB/ApoA-1(fifthquintilecomparedwithfirst)3.87(3.39-4.42)3.25(2.81-3.76)Currentsmoking2.95(2.72-3.20)2.87(2.58-3.19)Diabetes3.08(2.77-3.42)2.37(2.07-2.71)Hypertension2.48(2.30-2.68)1.91(1.74-2.10)Abdominalobesity2.22(2.03-2.42)1.62(1.45-1.80)Psychosocial2.51(2.15-2.93)2.67(2.21-3.22)Vegetableandfruitsdaily0.70(0.64-0.77)0.70(0.62-0.79)Exercise0.72(0.65-0.79)0.86(0.76-0.97)Alcoholintake0.79(0.73-0.86)0.91(0.82-1.02)Allcombined129.2(90.2-185.0)129.2(90.2-185.0)第五页，共五十三页。©ContinuingMedicalImplementation®…...bridgingthecaregapContinuingMedicalImplementation®…...bridgingthecaregap

INTER-HEART:Population-AttributableRisk(PAR)AcuteMIintheoverallpopulation

RiskfactorPARadjustedforage,sex&smoking99%CI)PARadjustedforall(99%CI)ApoB/ApoA-1(fifthquintilecomparedwithfirst)54.1(49.6-58.6)49.2(43.8-54.5)Currentsmoking36.4(33.9-39.0)35.7(32.5-39.1)Diabetes12.3(11.2-13.5)9.9(8.5-11.5)Hypertension23.4(21.7-25.1)17.9(15.7-20.4)Abdominalobesity33.7(30.2-37.4)20.1(15.3-26.0)Psychosocial28.8(22.6-35.8)32.5(25.1-40.8)Vegetableandfruitsdaily12.9(10.0-16.6)13.7(9.9-18.6)Exercise25.5(20.1-31.8)12.2(5.5-25.1)Alcoholintake13.9(9.3-20.2)6.7(2.0-20.2)Allcombined90.4(88.1-92.4)90.4(88.1-92.4)YusufS.EuropeanSocietyofCardiologyCongress2004;August28-September1,2004;Munich,Germany.第六页，共五十三页。©ContinuingMedicalImplementation®…...bridgingthecaregapContinuingMedicalImplementation®…...bridgingthecaregapINTERHEART:SummaryNinesimpleriskfactorsarestronglyassociatedwithAMIworldwide.Theseriskfactorsareevenmoreimportantintheyoung,andtheireffectsareconsistentinmenandwomen,acrossallethnicgroupsandallregions.AbnormalApo-B/ApoA-1ratioandsmokingarethemostimportantriskfactorsandaccountfor>2/3ofthePAR.All9riskfactorsaccountfor>90%ofthePARgloballyandinmostregions.IMPLICATIONS:ImplementingpreventivestrategiesbasedonourcurrentknowledgewouldavertthemajorityofprematureCHDworldwide.第七页，共五十三页。©ContinuingMedicalImplementation®…...bridgingthecaregapContinuingMedicalImplementation®…...bridgingthecaregapPreventionGoalsforCVDVariableGoalSmoking TotalCessationTotalDietaryFat/SaturatedFat<30%calories/<7%caloriesDietaryCholesterol<200mg/dayPhysicalActivity30-45min.moderateintensity5X/weekBodyWeightbyBodyMassindexInitialBMI

WeightLossGoal25-27.5BMI<25>27.510%relativeweightlossLDLcholesterol(primarygoal)1.6–2.2mmol/L(60-85mg/dL)HDLcholesterol(secondarygoal)1.0mmol/L(>40mg/dL)Triglyceride(secondarygoal)1.7mmol/L(<150mg/dL)BloodPressure<130/80mmHg(<120/80forLVD)DiabetesHbAlc<7.0%第八页，共五十三页。©ContinuingMedicalImplementation®…...bridgingthecaregapContinuingMedicalImplementation®…...bridgingthecaregapPrimaryPreventionDietarymodification30%fat7%saturatedfat200mg/daycholesterol.Weightloss5-10%TBWPhysicalactivity30min5X/wkSmokingcessation第九页，共五十三页。©ContinuingMedicalImplementation®…...bridgingthecaregapContinuingMedicalImplementation®…...bridgingthecaregapPotentialCumulativeImpactof1°PreventionStrategiesSmokingCessation2/3BPreduction20mmHg1/2LDLreduction1mmol/L1/6CumulativePrevention5/6第十页，共五十三页。©ContinuingMedicalImplementation®…...bridgingthecaregapContinuingMedicalImplementation®…...bridgingthecaregapPotentialCumulativeImpactof

2°PreventionTreatmentsRRREventrateEventrateNone8%16%ASA25%6%12%

-Blockers25%4.5%9.0%Lipidlowering30%3.0%6.0%ACE-inhibitors25%2.3%4.6%CardiacRehab25%1.7%3.4%AdaptedfromYusuf,S.Twodecadesofprogressinpreventingvasculardisease.Lancet2002;360:2-3.

CUMULATIVEBENEFITSARELIKELYTOBEINEXCESSOF78%RRR,WHICHISSUBSTANTIAL第十一页，共五十三页。©ContinuingMedicalImplementation®…...bridgingthecaregapContinuingMedicalImplementation®…...bridgingthecaregapCVD2°PreventionCocktailCAD,CVA,TIA,PVD,AAA,Type2DMSameDisease/SameRx:ASALipidTargetsTC<4.5LDL<2.0(1.8)HDL>1.2;TC/HDL<4TG<1.7

ACEinhibitorHOPETrialEUROPATrialß-blockerforpost-MI,HPTorCAD第十二页，共五十三页。©ContinuingMedicalImplementation®…...bridgingthecaregapContinuingMedicalImplementation®…...bridgingthecaregapTop10EvidenceBased

AdvancesinCVDiseaseASA/Plavix-CAD/ACSUF/LMWHeparinACSThrombolytic/PCI-STEMIß-blockerpost-MIACE-i/ARBCHF/LVdysfunctionPostMIVasculardisease/DMAnticoagulationinatrialfibrillationLipidLowering2°-CAD,CVD,PVD,DM1°-RiskFactorsHTN(hypertension):

LDD/ß-blocker/ACE-i/ARB/long-actingCCB

IsolatedSystolicHTN>60:LDD/long-actingDHP-CCB/ARB(avoidß-blockeroralpha-blockerasinitialRx)

ß-blocker-CHF第十三页，共五十三页。©ContinuingMedicalImplementation®…...bridgingthecaregapContinuingMedicalImplementation®…...bridgingthecaregapTop10FailurestoImplementEvidenceBasedAdvancesinCVDiseaseASA/Plavix-CAD/ACSUF/LMWHeparinACSThrombolytic/PCI-STEMIß-blockerpost-MIACE-i/ARBCHF/LVdysfunctionPostMIVasculardisease/DMAnticoagulationinatrialfibrillationLipidLowering2°-CAD,CVD,PVD,DM1°-RiskFactorsHTN(hypertension):

LDD/ß-blocker/ACE-i/ARB/long-actingCCB

IsolatedSystolicHTN>60:LDD/long-actingDHP-CCB/ARB(avoidß-blockeroralpha-blockerasinitialRx)

ß-blocker-CHF第十四页，共五十三页。©ContinuingMedicalImplementation®…...bridgingthecaregapContinuingMedicalImplementation®…...bridgingthecaregapGoalsinCardiovascularPreventionIdentifyallpatientswhocouldbenefitStratifyaccordingtoallriskfactorsInitiatetherapyinallwherecost/benefitfavorableAchieveappropriatetargetsor%reductionsProvidelongtermfollow-uptoensureadherenceAchievemortality/morbiditybenefitsattainedinclinicaltrialsTargeteverypatientforoptimalriskstratificationandreduction第十五页，共五十三页。©ContinuingMedicalImplementation®…...bridgingthecaregapContinuingMedicalImplementation®…...bridgingthecaregapWherecanwehavethegreatestimpactincardiovasculardisease?StrokepreventionHypertensioncontrolAnticoagulationinatrialfibrillationCADSecondarypreventioncocktailMedicalmanagementforsymptomsAppropriaterevascularizationCHFPatienteducationMedicalmanagementforprognosisandsymptomsAdmissionandreadmissionpreventionprograms第十六页，共五十三页。©ContinuingMedicalImplementation®…...bridgingthecaregapContinuingMedicalImplementation®…...bridgingthecaregapWaystoinfluencepracticeConsensusguidelinesDidacticCMEWorkshopCMEPracticepatternreviewSpecificrecommendationsbylocalexpertsUsualchannelsofcommunicationReminderstrategiesEvidencebasedapplicationtools第十七页，共五十三页。©ContinuingMedicalImplementation®…...bridgingthecaregapContinuingMedicalImplementation®…...bridgingthecaregapGuidelineImplementationBringtogethernationalexpertsDevelopguideline,consensusstatementorrecommendationPublicationDiffusionDisseminationImplementation第十八页，共五十三页。©ContinuingMedicalImplementation®…...bridgingthecaregapContinuingMedicalImplementation®…...bridgingthecaregapKnowledgeEvolutionDATA

KnowledgeTranslation

INFORMATION

KnowledgeUtilization

ACTION第十九页，共五十三页。©ContinuingMedicalImplementation®…...bridgingthecaregapContinuingMedicalImplementation®…...bridgingthecaregapOpportunitiestoImproveCareforPatientsWithCardiovascularDiseaseDespiteoverwhelmingclinicaltrialevidence,expertopinion,nationalguidelines,andavastarrayofeducationalconferences,evidence-based,life-savingtherapiescontinuetobeunderutilizedNewapproachestoimprovingtheuseofproven,guideline-recommended,life-savingtherapiesareclearlyneededFonarowGC.RevCardiovascMed.2002;3:S2-S10.

第二十页，共五十三页。©ContinuingMedicalImplementation®…...bridgingthecaregapContinuingMedicalImplementation®…...bridgingthecaregapClinicalResearchtoClinicalPractice-LostinTranslation.

ClaudeLenfant,M.D.

NEJM349(9)868-874August282003…bothhealthprovidersandmembersofthepublic,arenotapplyingwhatweknow.…wearenotreapingthefullpublichealthbenefitsofourinvestmentinresearch.…thereisplentyofevidencethat"old"researchoutcomeshavebeenlostintranslationaswell.第二十一页，共五十三页。©ContinuingMedicalImplementation®…...bridgingthecaregapContinuingMedicalImplementation®…...bridgingthecaregapThecaseforknowledgetranslation:shorteningthejourneyfromevidencetoeffect.

BMJ

2003;327:33-35

(5

July03)

Davisetal

Alargegulfremainsbetweenwhatweknowandwhatwepractice.Suchvariationiscommonnotonlyinternationallybutwithincountries.Largegapsalsoexistbetweenbestevidenceandpracticeintheimplementationofguidelines.第二十二页，共五十三页。©ContinuingMedicalImplementation®…...bridgingthecaregapContinuingMedicalImplementation®…...bridgingthecaregapWhymostinterventionstoimprovephysicianprescribingdonotseemtowork.

MajumdarandSoumerai

CMAJ169(1)July82003InterventionsthatrelysolelyonpassiveinformationtransferareineffectiveActiveknowledgetranslationstrategiesareusuallyeffective,althoughtheeffectsaremodest.Interventionsthatincorporate2ormoredistinctstrategies(i.e.,thataremultifaceted)aremorelikelytowork第二十三页，共五十三页。©ContinuingMedicalImplementation®…...bridgingthecaregapContinuingMedicalImplementation®…...bridgingthecaregapTheCanadianCardiovascularSocietyandKnowledgeTranslation:

TurningBestEvidenceintoBestPractice

TremblayetalCanJCardiol2004;20(12):1195-1198.Estimatesofthesizeofthecaregapindicatethat30%to40%ofpatientsfailtoreceivetreatmentsofproveneffectiveness,20%to25%ofpatientsmayreceivecarethatisnotneededorispotentiallyharmful

第二十四页，共五十三页。©ContinuingMedicalImplementation®…...bridgingthecaregapContinuingMedicalImplementation®…...bridgingthecaregapPatientHealthManagementPatientsFirst:ClosingtheHealthCareGapinCanadastartswithapremisenoonecandisagreewith:Thingscanbebetterinourhealthcaresystem,ineveryway.Dr.Montaguethengoesontoshowhowpatients,practitionersandpolicy-makerscanmakeincrementalimprovementsthatwillmakethingsbetter.Atthecentreofhisvisionisthepatient,andheprovidesablueprintthatwilldeliveroptimalhealthcareresultswithoutnecessarilyengenderingagreaterburdenonavailable

resources.第二十五页，共五十三页。©ContinuingMedicalImplementation®…...bridgingthecaregapContinuingMedicalImplementation®…...bridgingthecaregapAnalyzingtheCareGapEvidenceGapGuidelineGapDiffusionGapDisseminationGapImplementationGapAdherenceGapOutcomeGapRisingHealthCareCosts第二十六页，共五十三页。©ContinuingMedicalImplementation®…...bridgingthecaregapContinuingMedicalImplementation®…...bridgingthecaregapBarrierstoImplementingRiskFactorManagementinPatientsWithCHD

PhysicianisfocusedonacuteproblemsTimeconstraintsandlackofincentives,

includingreimbursementLackoftraining,includinginadequateknowledge

ofbenefitsandlackofprescriptionexperienceLackofresourcesandfacilitiesLackofspecialist–generalistcommunication;passingonresponsibilityAdaptedfromPearsonTAetal.JAmCollCardiol.1996;27:1039-1047.第二十七页，共五十三页。©ContinuingMedicalImplementation®…...bridgingthecaregapContinuingMedicalImplementation®…...bridgingthecaregapWhytheGap?Lackofinformation-knowledgegapInformationoverload-guidelineoverloadJurisdiction:Whosejobisit?ToobusytoreadrecommendationsPatientoverload/PhysicianshortageIssueoverload/PatientprioritiesLackoftoolsorresourcesConfusion-competingmarketingstrategiesMedico-legalimplications第二十八页，共五十三页。©ContinuingMedicalImplementation®…...bridgingthecaregapContinuingMedicalImplementation®…...bridgingthecaregapWhytheGap?UncertaintyInertiaJurisdictionEffectivenessResourcesContinuityAdherence第二十九页，共五十三页。©ContinuingMedicalImplementation®…...bridgingthecaregapContinuingMedicalImplementation®…...bridgingthecaregapAdherenceGapCostofmedicationsComplacency-patientandphysicianSideeffectsLackofunderstandingMediaimpact/fearsInfrequentmonitoringLackoffeedback第三十页，共五十三页。©ContinuingMedicalImplementation®…...bridgingthecaregapContinuingMedicalImplementation®…...bridgingthecaregapEvidenceBased

ImplementationToolsCMECMICMIANewParadigmContinuingMedicalImplementation®第三十一页，共五十三页。©ContinuingMedicalImplementation®…...bridgingthecaregapContinuingMedicalImplementation®…...bridgingthecaregapcvtoolbox第三十二页，共五十三页。©ContinuingMedicalImplementation®…...bridgingthecaregapContinuingMedicalImplementation®…...bridgingthecaregapcvtoolbox第三十三页，共五十三页。©ContinuingMedicalImplementation®…...bridgingthecaregapContinuingMedicalImplementation®…...bridgingthecaregapcvtoolbox第三十四页，共五十三页。©ContinuingMedicalImplementation®…...bridgingthecaregapContinuingMedicalImplementation®…...bridgingthecaregapThreeProngedApproachCondensedevidencereviewandguidelinedistillationPatientinformationproductsImplementationtools第三十五页，共五十三页。©ContinuingMedicalImplementation®…...bridgingthecaregapContinuingMedicalImplementation®…...bridgingthecaregapPostMIDischargeSummary第三十六页，共五十三页。©ContinuingMedicalImplementation®…...bridgingthecaregapContinuingMedicalImplementation®…...bridgingthecaregapGuideforComprehensiveCardiovascularRiskReduction第三十七页，共五十三页。©ContinuingMedicalImplementation®…...bridgingthecaregapContinuingMedicalImplementation®…...bridgingthecaregapDyslipidemiaPackage第三十八页，共五十三页。©ContinuingMedicalImplementation®…...bridgingthecaregapContinuingMedicalImplementation®…...bridgingthecaregapLipidOptimizationTool第三十九页，共五十三页。©ContinuingMedicalImplementation®…...bridgingthecaregapContinuingMedicalImplementation®…...bridgingthecaregapHypertensionPackage第四十页，共五十三页。©ContinuingMedicalImplementation®…...bridgingthecaregapContinuingMedicalImplementation®…...bridgingthecaregapHOPToITT

HypertensionCalendar第四十一页，共五十三页。©ContinuingMedicalImplementation®…...bridgingthecaregapContinuingMedicalImplementation®…...bridgingthecaregapDietInformationSheets第四十二页，共五十三页。©ContinuingMedicalImplementation®…...bridgingthecaregapContinuingMedicalImplementation®…...bridgingthecaregapDietInformationSheets第四十三页，共五十三页。©ContinuingMedicalImplementation®…...bridgingthecaregapContinuingMedicalImplementation®…...bridgingthecaregapOptimalManagementofAtrialFibrillation第四十四页，共五十三页。©ContinuingMedicalImplementation®…...bridgingthecaregapContinuingMedicalImplementation®…...bridgingthecaregapGuideforHFManagement第四十五页，共五十三页。©ContinuingMedicalImplementation®…...bridgingthecaregapContinuingMedicalImplementation®…...bridgingthecaregapMultipleModalitiesofDistributionTargetedmailingsHardcopy/photocopyReprint/re-orderDigitalcopyWebsiteCMEprogramsImplementationnetworks第四十六页，共五十三页。©ContinuingMedicalImplementation®…...bridgingthe