Orientador: Prof. Doutor Fausto José da Conceição Alexandre Pinto Tese especialmente

236 Pages·2017·10.77 MB·English

Orientador: Prof. Doutor Fausto José da Conceição Alexandre Pinto
Tese especialmente elaborada para a obtenção do grau de Doutor em Medicina,
especialidade de Cardiologia

Orientador: Prof. Doutor Fausto José da Conceição Alexandre Pinto
Tese especialmente elaborada para a obtenção do grau de Doutor em Medicina,
especialidade de Cardiologia
The opinions expressed are the sole responsability of the author

Orientador: Prof. Doutor Fausto José da Conceição Alexandre Pinto
Tese especialmente elaborada para a obtenção do grau de Doutor em Medicina,
especialidade de Cardiologia
Júri:
Presidente: Doutor José Augusto Gamito Melo Cristino, Professor Catedrático e Presidente do Conselho
Científico da Faculdade de Medicina da Universidade de Lisboa.
Vogais:
- Doutor Lino Manuel Martins Gonçalves, Professor Catedrático da Faculdade de Medicina da Universidade
de Coimbra;
- Doutor Henrique José Cyrne de Castro Machado Carvalho, Professor Convidado do Instituto de Ciência
Biomédicas Abel Salazar da Universidade do Porto;
- Doutor Fausto José da Conceição Alexandre Pinto, Professor Catedrático da Faculdade de Medicina de
Lisboa (Orientador);
- Doutor António Cândido Vaz Carneiro, Professor Associado com Agregação da Faculdade de Medicina de
Lisboa;
- Doutora Ana Maria Gomes de Almeida, Professora Associada com Agregação da Faculdade de Medicina
da Universidade de Lisboa;
- Doutora Dulce Alves Brito, Professora Auxiliar Convidada da Faculdade de Medicina da Universidade de
Lisboa.
The opinions expressed are the sole responsability of the author
As opiniões expressas nesta publicação são da exclusiva responsabilidade do seu autor
The texts published in this thesis had the authorization by the editors
where they were originally published, to be here reproduced.
Preface
Learning is a treasure that will follow its owner everywhere.
Chinese proverb
At this stage of my medical journey, I take this opportunity to reflect on the motivation
behind my PhD. At the beginning of my career as a specialist, I had the opportunity
to be involved in an academic project. By then, though, all my efforts were focused
on achieving the greatest possible experience on interventional cardiology and in the
desire to expand it to regional hospitals which had hardly any access to it. By that
time, in the late eighties, early nineties of the past century, intervention cardiology was
a discipline concentrated in a few hospitals and with scarce possibilities of access by
young cardiologists. After the initial training with Professors Amadeo Betriu and António
Serra in Barcelona, it was in Santa Cruz Hospital, with professor Seabra Gomes, that
I found a place where clinical practice, teaching and research live together in a way
that I felt I could be identified with. Taking into account that experience which ultimately
boosted my development project of intervention cardiology at Hospital Garcia de Orta.
Innovation and new technologies are essential for the development of healthcare systems.
But without efficient integration, they represent only a rise in costs without health results.
It’s important that, in their training, health professionals can acquire management skills
which enable them to have instruments to maximize resource management.
Acute coronary syndromes in recent years have been targeted by major innovation
both in medical devices and pharmaceuticals. Because treatment is heavily dependent
on the time in which it is administered, and because resources are not available in a
well-distributed manner, there is a need for optimisation of all stages in the chain - from
diagnosis to treatment.
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Preface
I have always had a great interest in myocardial infarction. Not only on the disease
and all the complexity in the physiopathology involved and possibilities of therapeutic
improvement, but also in preventive measures, on clearly identified risk factors and the
best ways to improve patient rehabilitation. It was within the scientific community, the
Portuguese Society of Cardiology - initially within the Working Group of Interventional
Cardiology and subsequently in the Portuguese Association of Cardiovascular
Intervention - that I found the main instruments which enabled me to help the
improvement of the performance in the national approach to acute coronary syndromes.
From an early stage in my career, I was aware that physicians devoted much of their
time on “what to do” then “how to do”. The acute myocardial infarction is a paradigm
of this phenomenon.
Technological developments have allowed a great improvement in clinical results. At
the same time, detailed guidelines that indicate the best ways to achieve these results
have been published. The bottom line is that, in daily practice, many patients are still
not treated in accordance with the guidelines.
Although every one of us give our best to treat the patient according to leges artis, the
complexity involved in the entire chain, mostly on the organizational level - particularly
in communication - led to worst results than expected. Knowing that I needed a better
knowledge of these organizational processes led me to attend a post-graduation and
a master`s degree in management in health organizations. The master´s thesis, which I
discuss in 2009, under the theme “Risk management in primary angioplasty”, aimed to
identify the main “failures” in the treatment of myocardial infarction and the search for
solutions to overcome them. It was on that same year that we saw the birth of a project
of the European Society of Cardiology (ESC): “Stent for Life” (SFL). This matched
what I was already looking for some time: an initiative to allow the registration and the
characterization of primary angioplasty in Portugal, as well as to investigate the main
obstacles to good system performances, along with the implementation of specific
programmes that would enable the improvement of the entire chain of events involved
in the complexity of acute coronary syndromes in general, and STEMI in particular.
Since its beginning, in 2002, we have given the greatest attention and tried to contribute
to the success of the registries of the Portuguese Society of Cardiology. A project so
complete as SFL, looks not only to the moment of the myocardial infarction, but its
II Contribution for the CharaCterization and performanCe improvement of primary angioplasty in portugal
PhD Dissertation in MeDicine . HÉLDER HORTA pEREIRA . 2017
Preface
prevention and rehabilitation. For that, it is necessary to monitor and assess tools
which allow us to understand where we came from, where we are at the moment, and
where we want to go. Given the fact that PSC registries are continuous, unaudited and
volunteer dependent, we obtained an authorization from the National Data Collection
Centre in Cardiology (CNPD), to collect the data in a prospective way, once a year,
during a month period. We essentially collect the data related to the performance
of the treatment of myocardial infarction, particularly the data related to the primary
angioplasty access and time delays in the circuit. All cardiology centres in Portugal
mainland participated in this annual survey, which allow us to get a very reliable
perspective of primary angioplasty and the main barriers to its performance.
SFL international had precise objectives, obtained quantitatively, with focus on the
number of primary angioplasties per year and per million inhabitants. Since the
beginning, we consider that this quantitative target was also important to gather
qualitative elements. In myocardial infarction, it is not only important to treat more
patients, but to treat them as quickly as possible. On the other side, we must be aware
that these projects required the help of experts in management of health organizations.
We found that help at ISCTE, having received the support of Professor Luís Martins.
Under this collaboration, we conducted a market survey, on a national level, which
allowed us to perceive that an important percentage of the Portuguese population still
ignores heart attack symptoms. We find out a clear need for rapprochement between
the medical pragmatic approach of the main barriers to the good performance of the
healthcare organizations with the specialized vision of management schools. At present,
there are paths of research based on theoretical contributions of studies on the impact
of certain projects as “change agents” of the healthcare institutions. The analysis of
success factors, the evaluation of leadership, compliance of the participants, the role
of professional associations, the so called “relation coordination” are key elements of
analysis that in our opinion should be further integrated in this project soon.
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Acknowledgments
I would like to thank all who, directly or indirectly, contributed to the realization of this
project.
To Prof. Fausto Pinto for his full support, availability and precious advice. To Prof. Luis
Martins, who gave me a wider vision of healthcare organizations and new lines of
research.
A very special thanks to Dr. Sofia de Mello, who embraces SFL initiative since the
beginning with great enthusiasm and further contribute to its success. Since the first
moment, Sofia was a project enthusiast. She and I discussed almost every day and in
detail, all the programs that we were building and planning tasks that were far beyond
the moment of primary angioplasty, and included primary prevention, rehabilitation and
education.
A very special thanks to Dr. Ernesto Pereira, for his encouragement and his cooperation
in data collection, and for his friendship.
To Dr. Silvia Vitorino, and to Dr. Rita Calé for their cooperation in data collection and
analysis.
To APIC presidents: Dr. Leitão Marques for having supported the candidacy of SFL
process, and to Dr. Rui Campante Teles, who supported the continuation of the
program. I’m also thankful to Dr. Lidia de Sousa, Dr. Manuel Almeida and Dr Marco
Costa for supporting the project and great help in all organizational APIC and tasks.
To Dr. Silvia Monteiro, Dr. Pedro Jerónimo de Sousa, Dr. Jorge Mimoso, Dr. Jorge
Marques and Dr. Renato Fernandes for the organization of regional and educational
SFL programs.
To Dr. Pedro Coelho dos Santos for his help in the communication campaigns and to
Dr. João Ferreira for inspiring ideas and support for the project.
IV Contribution for the CharaCterization and performanCe improvement of primary angioplasty in portugal
PhD Dissertation in MeDicine . HÉLDER HORTA pEREIRA . 2017