BridgingtheCareGapContinuingMedicalImplementationInc橋接的保健差距實現(xiàn)公司繼續(xù)醫(yī)學(xué)

BridgingtheCareGapContinuingMedicalImplementationInc橋接的保健差距實現(xiàn)公司繼續(xù)醫(yī)學(xué)?ContinuingMedicalImplementation?…...bridgingthecaregapContinuingMedicalImplementation?…...bridgingthecaregap現(xiàn)在是1頁\一共有53頁\編輯于星期日?ContinuingMedicalImplementation?…...bridgingthecaregapContinuingMedicalImplementation?…...bridgingthecaregapCareGapFailureto,translate,transferandutilizemedicalknowledgeeffectively

UsualCare≠bestcarePopulationoutcomesdonotmatchresultsofclinicaltrialsPatient,physicians&payersdonotreapthebenefitsofvalidatedmedicalknowledge現(xiàn)在是2頁\一共有53頁\編輯于星期日?ContinuingMedicalImplementation?…...bridgingthecaregapContinuingMedicalImplementation?…...bridgingthecaregapCareGapThedifferencebetweenwhatweknowandwhatwedoThedifferencebetweenachievableandactualoutcomesThefailuretosystematizeknowledgeandapplyitconsistently現(xiàn)在是3頁\一共有53頁\編輯于星期日?ContinuingMedicalImplementation?…...bridgingthecaregapContinuingMedicalImplementation?…...bridgingthecaregapKnowledgeTranslation

Definition:“Knowledgetranslationistheeffectiveandtimelyincorporationofevidence-basedinformationintothepracticesofhealthprofessionalsinsuchawayastoeffectoptimalhealthcareoutcomesandmaximizethepotentialofthehealthsystem.”AdaptedfromtheCanadianInstitutesforHealthResearchdefinition,2001現(xiàn)在是4頁\一共有53頁\編輯于星期日?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)現(xiàn)在是5頁\一共有53頁\編輯于星期日?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.現(xiàn)在是6頁\一共有53頁\編輯于星期日?ContinuingMedicalImplementation?…...bridgingthecaregapContinuingMedicalImplementation?…...bridgingthecaregapINTERHEART:SummaryNinesimpleriskfactorsarestronglyassociatedwithAMIworldwide.Theseriskfactorsareevenmoreimportantintheyoung,andtheireffectsareconsistentinmenandwomen,acrossallethnicgroupsandallregions.AbnormalApo-B/ApoA-1ratioandsmokingarethemostimportantriskfactorsandaccountfor>2/3ofthePAR.All9riskfactorsaccountfor>90%ofthePARgloballyandinmostregions.IMPLICATIONS:ImplementingpreventivestrategiesbasedonourcurrentknowledgewouldavertthemajorityofprematureCHDworldwide.現(xiàn)在是7頁\一共有53頁\編輯于星期日?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%現(xiàn)在是8頁\一共有53頁\編輯于星期日?ContinuingMedicalImplementation?…...bridgingthecaregapContinuingMedicalImplementation?…...bridgingthecaregapPrimaryPreventionDietarymodification30%fat7%saturatedfat200mg/daycholesterol.Weightloss5-10%TBWPhysicalactivity30min5X/wkSmokingcessation現(xiàn)在是9頁\一共有53頁\編輯于星期日?ContinuingMedicalImplementation?…...bridgingthecaregapContinuingMedicalImplementation?…...bridgingthecaregapPotentialCumulativeImpactof1°PreventionStrategiesSmokingCessation2/3BPreduction20mmHg1/2LDLreduction1mmol/L1/6CumulativePrevention5/6現(xiàn)在是10頁\一共有53頁\編輯于星期日?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現(xiàn)在是11頁\一共有53頁\編輯于星期日?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

ACEinhibitorHOPETrialEUROPATrial?-blockerforpost-MI,HPTorCAD現(xiàn)在是12頁\一共有53頁\編輯于星期日?ContinuingMedicalImplementation?…...bridgingthecaregapContinuingMedicalImplementation?…...bridgingthecaregapTop10EvidenceBased

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

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

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

?-blocker-CHF現(xiàn)在是13頁\一共有53頁\編輯于星期日?ContinuingMedicalImplementation?…...bridgingthecaregapContinuingMedicalImplementation?…...bridgingthecaregapTop10FailurestoImplementEvidenceBasedAdvancesinCVDiseaseASA/Plavix-CAD/ACSUF/LMWHeparinACSThrombolytic/PCI-STEMI?-blockerpost-MIACE-i/ARBCHF/LVdysfunctionPostMIVasculardisease/DMAnticoagulationinatrialfibrillationLipidLowering2°-CAD,CVD,PVD,DM1°-RiskFactorsHTN(hypertension):

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

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

?-blocker-CHF現(xiàn)在是14頁\一共有53頁\編輯于星期日?ContinuingMedicalImplementation?…...bridgingthecaregapContinuingMedicalImplementation?…...bridgingthecaregapGoalsinCardiovascularPreventionIdentifyallpatientswhocouldbenefitStratifyaccordingtoallriskfactorsInitiatetherapyinallwherecost/benefitfavorableAchieveappropriatetargetsor%reductionsProvidelongtermfollow-uptoensureadherenceAchievemortality/morbiditybenefitsattainedinclinicaltrialsTargeteverypatientforoptimalriskstratificationandreduction現(xiàn)在是15頁\一共有53頁\編輯于星期日?ContinuingMedicalImplementation?…...bridgingthecaregapContinuingMedicalImplementation?…...bridgingthecaregapWherecanwehavethegreatestimpactincardiovasculardisease?StrokepreventionHypertensioncontrolAnticoagulationinatrialfibrillationCADSecondarypreventioncocktailMedicalmanagementforsymptomsAppropriaterevascularizationCHFPatienteducationMedicalmanagementforprognosisandsymptomsAdmissionandreadmissionpreventionprograms現(xiàn)在是16頁\一共有53頁\編輯于星期日?ContinuingMedicalImplementation?…...bridgingthecaregapContinuingMedicalImplementation?…...bridgingthecaregapWaystoinfluencepracticeConsensusguidelinesDidacticCMEWorkshopCMEPracticepatternreviewSpecificrecommendationsbylocalexpertsUsualchannelsofcommunicationReminderstrategiesEvidencebasedapplicationtools現(xiàn)在是17頁\一共有53頁\編輯于星期日?ContinuingMedicalImplementation?…...bridgingthecaregapContinuingMedicalImplementation?…...bridgingthecaregapGuidelineImplementationBringtogethernationalexpertsDevelopguideline,consensusstatementorrecommendationPublicationDiffusionDisseminationImplementation現(xiàn)在是18頁\一共有53頁\編輯于星期日?ContinuingMedicalImplementation?…...bridgingthecaregapContinuingMedicalImplementation?…...bridgingthecaregapKnowledgeEvolutionDATA

KnowledgeTranslation

INFORMATION

KnowledgeUtilization

ACTION現(xiàn)在是19頁\一共有53頁\編輯于星期日?ContinuingMedicalImplementation?…...bridgingthecaregapContinuingMedicalImplementation?…...bridgingthecaregapOpportunitiestoImproveCareforPatientsWithCardiovascularDiseaseDespiteoverwhelmingclinicaltrialevidence,expertopinion,nationalguidelines,andavastarrayofeducationalconferences,evidence-based,life-savingtherapiescontinuetobeunderutilizedNewapproachestoimprovingtheuseofproven,guideline-recommended,life-savingtherapiesareclearlyneededFonarowGC.RevCardiovascMed.2002;3:S2-S10.

現(xiàn)在是20頁\一共有53頁\編輯于星期日?ContinuingMedicalImplementation?…...bridgingthecaregapContinuingMedicalImplementation?…...bridgingthecaregapClinicalResearchtoClinicalPractice-LostinTranslation.

ClaudeLenfant,M.D.

NEJM349(9)868-874August282003…bothhealthprovidersandmembersofthepublic,arenotapplyingwhatweknow.…wearenotreapingthefullpublichealthbenefitsofourinvestmentinresearch.…thereisplentyofevidencethat"old"researchoutcomeshavebeenlostintranslationaswell.現(xiàn)在是21頁\一共有53頁\編輯于星期日?ContinuingMedicalImplementation?…...bridgingthecaregapContinuingMedicalImplementation?…...bridgingthecaregapThecaseforknowledgetranslation:shorteningthejourneyfromevidencetoeffect.

BMJ

2003;327:33-35

(5

July03)

Davisetal

Alargegulfremainsbetweenwhatweknowandwhatwepractice.Suchvariationiscommonnotonlyinternationallybutwithincountries.Largegapsalsoexistbetweenbestevidenceandpracticeintheimplementationofguidelines.現(xiàn)在是22頁\一共有53頁\編輯于星期日?ContinuingMedicalImplementation?…...bridgingthecaregapContinuingMedicalImplementation?…...bridgingthecaregapWhymostinterventionstoimprovephysicianprescribingdonotseemtowork.

MajumdarandSoumerai

CMAJ169(1)July82003InterventionsthatrelysolelyonpassiveinformationtransferareineffectiveActiveknowledgetranslationstrategiesareusuallyeffective,althoughtheeffectsaremodest.Interventionsthatincorporate2ormoredistinctstrategies(i.e.,thataremultifaceted)aremorelikelytowork現(xiàn)在是23頁\一共有53頁\編輯于星期日?ContinuingMedicalImplementation?…...bridgingthecaregapContinuingMedicalImplementation?…...bridgingthecaregapTheCanadianCardiovascularSocietyandKnowledgeTranslation:

TurningBestEvidenceintoBestPractice

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

現(xiàn)在是24頁\一共有53頁\編輯于星期日?ContinuingMedicalImplementation?…...bridgingthecaregapContinuingMedicalImplementation?…...bridgingthecaregapPatientHealthManagementPatientsFirst:ClosingtheHealthCareGapinCanadastartswithapremisenoonecandisagreewith:Thingscanbebetterinourhealthcaresystem,ineveryway.Dr.Montaguethengoesontoshowhowpatients,practitionersandpolicy-makerscanmakeincrementalimprovementsthatwillmakethingsbetter.Atthecentreofhisvisionisthepatient,andheprovidesablueprintthatwilldeliveroptimalhealthcareresultswithoutnecessarilyengenderingagreaterburdenonavailable

resources.現(xiàn)在是25頁\一共有53頁\編輯于星期日?ContinuingMedicalImplementation?…...bridgingthecaregapContinuingMedicalImplementation?…...bridgingthecaregapAnalyzingtheCareGapEvidenceGapGuidelineGapDiffusionGapDisseminationGapImplementationGapAdherenceGapOutcomeGapRisingHealthCareCosts現(xiàn)在是26頁\一共有53頁\編輯于星期日?ContinuingMedicalImplementation?…...bridgingthecaregapContinuingMedicalImplementation?…...bridgingthecaregapBarrierstoImplementingRiskFactorManagementinPatientsWithCHD

PhysicianisfocusedonacuteproblemsTimeconstraintsandlackofincentives,

includingreimbursementLackoftraining,includinginadequateknowledge

ofbenefitsandlackofprescriptionexperienceLackofresourcesandfacilitiesLackofspecialist–generalistcommunication;passingonresponsibilityAdaptedfromPearsonTAetal.JAmCollCardiol.1996;27:1039-1047.現(xiàn)在是27頁\一共有53頁\編輯于星期日?ContinuingMedicalImplementation?…...bridgingthecaregapContinuingMedicalImplementation?…...bridgingthecaregapWhytheGap?Lackofinformation-knowledgegapInformationoverload-guidelineoverloadJurisdiction:Whosejobisit?ToobusytoreadrecommendationsPatientoverload/PhysicianshortageIssueoverload/PatientprioritiesLackoftoolsorresourcesConfusion-competingmarketingstrategiesMedico-legalimplications現(xiàn)在是28頁\一共有53頁\編輯于星期日?ContinuingMedicalImplementation?…...bridgingthecaregapContinuingMedicalImplementation?…...bridgingthecaregapWhytheGap?UncertaintyInertiaJurisdictionEffectivenessResourcesContinuityAdherence現(xiàn)在是29頁\一共有53頁\編輯于星期日?ContinuingMedicalImplementation?…...bridgingthecaregapContinuingMedicalImplementation?…...bridgingthecaregapAdherenceGapCostofmedicationsComplacency-patientandphysicianSideeffectsLackofunderstandingMediaimpact/fearsInfrequentmonitoringLackoffeedback現(xiàn)在是30頁\一共有53頁\編輯于星期日?ContinuingMedicalImplementation?…...bridgingthecaregapContinuingMedicalImplementation?…...bridgingthecaregapEvidenceBased

ImplementationToolsCMECMICMIANewParadigmContinuingMedicalImplementation?現(xiàn)在是31頁\一共有53頁\編輯于星期日?ContinuingMedicalImplementation?…...bridgingthecaregapContinuingMedicalImplementation?…...bridgingthecaregapcvtoolbox現(xiàn)在是32頁\一共有53頁\編輯于星期日?ContinuingMedicalImplementation?…...bridgingthecaregapContinuingMedicalImplementation?…...bridgingthecaregapcvtoolbox現(xiàn)在是33頁\一共有53頁\編輯于星期日?ContinuingMedicalImplementation?…...bridgingthecaregapContinuingMedicalImplementation?…...bridgingthecaregapcvtoolbox現(xiàn)在是34頁\一共有53頁\編輯于星期日?ContinuingMedicalImplementation?…...bridgingthecaregapContinuingMedicalImplementation?…...bridgingthecaregapThreeProngedApproachCondensedevidencereviewandguidelinedistillationPatientinformationproductsImplementationtools現(xiàn)在是35頁\一共有53頁\編輯于星期日?ContinuingMedicalImplementation?…...bridgingthecaregapContinuingMedicalImplementation?…...bridgingthecaregapPostMIDischargeSummary現(xiàn)在是36頁\一共有53頁\編輯于星期日?ContinuingMedicalImplementation?…...bridgingthecaregapContinuingMedicalImplementation?…...bridgingthecaregapGuideforComprehensiveCardiovascularRiskReduction現(xiàn)在是37頁\一共有53頁\編輯于星期日?ContinuingMedicalImplementation?…...bridgingthecaregapContinuingMedicalImplementation?…...bridgingthecaregapDyslipidemiaPackage現(xiàn)在是38頁\一共有53頁\編輯于星期日?ContinuingMedicalImplementation?…...bridgingthecaregapContinuingMedicalImplementation?…...bridgingthecaregapLipidOptimizationTool現(xiàn)在是39頁\一共有53頁\編輯于星期日?ContinuingMedicalImplementation?…...bridgingthecaregapContinuingMedicalImplementation?…...bridgingthecaregapHypertensionPackage現(xiàn)在是40頁\一共有53頁\編輯于星期日?ContinuingMedicalImplementation?…...bridgingthecaregapContinuingMedicalImplementation?…...bridgingthecaregapHOPToITT

HypertensionCalendar現(xiàn)在是41頁\一共有53頁\編輯于星期日?ContinuingMedicalImplementation?…...bridgingthecaregapContinuingMedicalImplementation?…...bridgingthecaregapDietInformationSheets現(xiàn)在是42頁\一共有53頁\編輯于星期日?ContinuingMedicalImplementation?…...bridgingthecaregapContinuingMedicalImplementation?…...bridgingthecaregapDietInformationSheets現(xiàn)在是43頁\一共有53頁\編輯于星期日?ContinuingMedicalImplementation?…...bridgingthecaregapContinuingMedicalImplementation?…...bridgingthecaregapOptimalManagementofAtrialFibrillation現(xiàn)在是44頁\一共有53頁\編輯于星期日?ContinuingMedicalImplementation?…...bridgingthecaregapContinuingMedicalImplementation?…...bridgingthecaregapGuideforHFManagement現(xiàn)在是45頁\一共有53頁\編輯于星期日?ContinuingMedicalImplementation?…...bridgingthecaregapContinuingMedicalImplementation?…...bridgingthecaregapMultipleModalitiesofDistributionTargetedmailingsHardcopy/photocopyReprint/re-orderDigitalcopyWebsiteCMEprogramsImplementationnetworks現(xiàn)在是46頁\一共有53頁\編輯于星期日?ContinuingMedicalImplementation?…...bridgingthecaregapCon