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Prospective Analysis of Clinical Outcome: Influence on Surgical Professional Development

Professor MJ Underwood Division of Cardiothoracic Surgery, Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong. Prospective Analysis of Clinical Outcome: Influence on Surgical Professional Development. Questions. What is Professional Development ?

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Prospective Analysis of Clinical Outcome: Influence on Surgical Professional Development

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  1. Professor MJ Underwood Division of Cardiothoracic Surgery, Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Prospective Analysis of Clinical Outcome: Influence on Surgical Professional Development

  2. Questions • What is Professional Development ? • How does it relate to Clinical Outcomes ? • How does it relate to a National Database?

  3. Personal Viewpoint • UK System • Hong Kong Initiatives

  4. Continuing Professional Development (CPD)

  5. Continuing Professional Development (CPD)

  6. Interrelates • Clinical • Managerial • Professional PROVISION OF HIGH-QUALITY PATIENT CARE

  7. Interrelates • Clinical • Managerial • Professional PROVISION OF HIGH-QUALITY PATIENT CARE

  8. General Medical Council Guidance - 2006

  9. High Quality Patient Care = Quality Assurance Programme in Cardiac Surgery • AIM : • Provide ‘safest’ journey for the patient during their hospital stay with ‘acceptable’ outcome defined by international standards.

  10. Quality Assurance Components

  11. Practical Factors Local Data Collection Internal/External Validation National Data Collection Internal/External Validation Data Confidentiality/Safeguards International Data Comparison Calibration, Comparison Personal/Surgical Factors Commitment Culture Consistent ESSENTIAL: Quality Assurance Components

  12. CPD=High Quality Care=Quality Assurance=Data Collection =Data Analysis • How do we collect data ? • How do we analyze data ?

  13. DATA COLLECTION: Surgical Perspectives • Accurate • Validated • Internal/External • Available for Analysis • ‘real-time’ for risk monitoring • Internationally Compatible • Security

  14. Data Collection: Summary ‘Validated’

  15. Influencing Events • 1994-96 Senior Registrar Bristol Royal Infirmary • 1997Fontan Scholarship Brussels • 1999-2002Consultant/Senior Lecturer Bristol Heart Institute 1995 External Review 1998 GMC Enquiry 2001 Public Enquiry

  16. Senior Lecturer/Consultant (1999-On) • Audit Lead Cardiac Services • Clinical Governance Lead • R and D Quality Assurance Lead • Consolidating Data Collection and Reporting • Contribution to CEPOD • Public Presentation of Results • External Validation of BRI Data Collection • Development of Sub-Specialist Databases

  17. Saturday 27 June 1998 BMJ All changed, changed utterly British medicine will be transformed by the Bristol case Richard smith, Editor

  18. Continuous Professional Development: Institutional Reporting

  19. Continuous Professional Development: Individual Reporting

  20. Prospective Analysis of Clinical Outcome: Where are we in Hong Kong ? • Institution of Computerized Data Collection and Analysis System • Automated demographic data • Data Input at ‘point of clinical care’ • Dedicated Database Manager • Accuracy, validation processes

  21. Automated Demographics and Risk Calculation

  22. Direct Comparison of Risk Scoring Systems: Testing • Receiver Operating Characteristic (ROC) Curves • Area represents probability that risk predictor accurately discriminates between death and survival • Area of 1 = Perfect • Closer to 1 better, Closer to 0.5 less accurate • Calibration Plots • Plot observed vs expected events in calibration plot • Chi-squared value used as measure of accuracy of matching

  23. Risk-Scoring in the UK Population

  24. Validation of Euroscore in Hong Kong ROC Area 0.819: modified Euroscore ROC Area 0.823: logistic Euroscore

  25. Influence of Risk-Stratified Data Analysis on Professional Development. • Monitor actual mortality and morbidity vs predicted • Essential for Quality Assurance Progamme • Compare with International Data

  26. Comparison of Risk-Profiles: East vs West ! • But: • Does risk-validation hold for sub-groups ? • Is there a need for ‘population specific’ risk assessment

  27. Hong Kong Cardiac Database: Overview

  28. A National Database :Unique Practical Challenges from a Surgeon • Differing data collection mechanisms • How merge ? • Accuracy and validity • What infrastructure ? • Security • Who see’s the data ? • Data Analysis • Who analyses the data? • Presentation and Publication • Who ?

  29. Hong Kong Cardiac Database: Overview Chinese Cardiac Surgical Database

  30. Professional Development/Clinical Outcome/National Database: Summary • Inter-related • inseparable • Inevitable • ‘consumer’/provider driven • Irreversible • USA, UK, Europe

  31. BMJ 2005;330: (5 March) • Editor's choice • Individual performance data: revelation and revolution • Welcome to a new world. Be brave. • Kamran Abbasi, acting editor

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