kent cardiovascular network

Kent Cardiovascular Network

David Cunningham Director, Central Cardiac Audit Database

Richard Charles Chairman, Network Device Survey Group

Morag Cunningham CRM Database Coordinator, Central Cardiac Audit Database

Adél de Lange Data analyst, Central Cardiac Audit Database

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Acknowledgments The implant registration data that allows the construction of reports such as this is contributed on a voluntary basis by all pacemaker implanting hospitals in the United Kingdom.

The data is held in the National Pacemaker Database, established in 1977 by Dr Anthony Rickards, and now part of the Central Cardiac Audit Database (CCAD – www.ccad.org.uk) which runs the national cardiac audits as part of the National Institute for Cardiovascular Outcomes Research (NICOR), which is part of University College London.

Anonymised extracts from the National Pacemaker Database were used to generate this report, with the express permission of the owners of the data, Heart Rhythm UK and the full agreement of the Department of Health Heart Team and HQIP.

This national audit is funded as part of the National Clinical Audit & Patient Outcome Programme (NCAPOP), which is managed by the Healthcare Quality Improvement Partnership (HQIP – www.hqip.org.uk).

The preparation of this report was supported by HQIP. Data collection was carried out by CCAD with support provided from NHS Improvement (www.improvement.nhs.uk) and the Cardiac Networks.

The study was performed with the knowledge and support of the British Cardiovascular Society and Heart Rhythm UK.

Clinical review of the report was carried out by Dr Richard Charles, Chairman of the Network Devices Survey Group.

The report may be downloaded from www.devicesurvey.com

British Cardiovascular Society

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Contents Analysis of Provision of Heart Rhythm Devices for Kent Cardiovascular Network Acknowledgments ....................................................................................................... 2 Data Quality Statement................................................................................................. 4 Overview of Device Implants in the UK .............................................................................. 6 The Range of New Implant rate 2010 ................................................................................ 8 PCTs/LHBs in the Network ............................................................................................ 11 Network Age and Sex Distribution ................................................................................... 12 Correcting Implant Rates for Age and Sex.......................................................................... 13 Relative need for Pacemakers and ICDs ............................................................................ 15 New and Total PM and ICD Implants................................................................................ 16 Geographical location of pacemaker implants...................................................................... 20 New and Total PM and ICD Implants................................................................................ 21 CRT implants in this network ......................................................................................... 23 Geographical location of Complex Devices implants............................................................... 26 Which hospitals serve which PCTs/LHBs?........................................................................... 28 Pacing Mode for New Implants ....................................................................................... 32 Pacing Mode for Sick Sinus Syndrome............................................................................... 34 ECG Indication for New Implants .................................................................................... 36 Corrected and Actual New Implant Rates........................................................................... 37 New Implant rate maps for Kent Cardiovascular Network........................................................ 41 New pacing implant rate 2010........................................................................................ 42 ICD new implant rate 2010 ........................................................................................... 43 Pacing Implant Deficit in 2010........................................................................................ 44 Conclusions.............................................................................................................. 45

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The quality of the analyses in this report is only as good as the quality of the data that supports it. That data is originally submitted by hospitals to the National Pacemaker Database. If there is a deficit in registration, or if registrations do not contain a valid postcode, then analysis gaps are inevitable. Data is then anonymised and extracted to provide the basis of the analysis by the Survey Group. To minimise the risk of deficit errors, a threshold of 98% for registration and postcode completeness is sought for each hospital. Overall network completeness MUST reach 98% or a report will not be issued. Every effort is made to ensure this report is as accurate as possible - however please contact us if you identify any residual problem and we will try to correct the error promptly. Below is a list of important hospitals for this network and their completeness of VALID postcodes during the study period.

Valid Postcodes

Overall network average 100.00%

Main implant Centres

DVH.Darent Valley Hospital 100.00% KCH.King's College Hospital 100.00% KSX.Kent & Sussex Hospital 100.00% LBH.London Bridge Hospital 98.15% MAI.Maidstone General Hospital 100.00% MDW.Medway Maritime Hospital 100.00% NHB.Royal Brompton Hospital 100.00% QEQ.Queen Elizabeth the Queen Mother 100.00% STH.St Thomas' Hospital 100.00% WHH.William Harvey Hospital 100.00%

Note: Implant centres shown have implanted at least 10 devices in the network.

Data Quality Statement

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Data Quality and Completeness Listed below are important fields and their completion rates with valid entries.

All Devices ICD, CRT-D & CRT-P

Network / Implant Centre Valid Post Code

Valid NHS No

Valid Gender Valid DOB ECG Symptom Aetiology

Target 98.0% 98.0% 98.0% 98.0% 90.0% 90.0% 90.0%

England 99.4% 84.0% 99.9% 99.8% 94.5% 94.0% 94.6%

This Network 100.0% 82.1% 99.8% 99.8% 95.0% 93.7% 97.6%

Darent Valley Hospital 100.0% 95.2% 100.0% 100.0% 98.2% 98.2% 100.0%

Kent & Sussex Hospital 100.0% 94.2% 100.0% 99.4% 98.1% 97.4% 100.0%

Maidstone General Hospital 100.0% 92.4% 100.0% 100.0% 95.8% 97.3% 100.0%

Medway Hospital 100.0% 48.3% 100.0% 100.0% 95.1% 77.8% 100.0% Queen Elizabeth the Queen Mother 100.0% 81.2% 100.0% 100.0% 97.8% 97.8% 100.0%

St Thomas Hospital 100.0% 93.0% 99.1% 100.0% 99.8% 100.0% 99.6%

William Harvey Hospital 100.0% 94.9% 100.0% 100.0% 98.6% 98.6% 98.1%

CRT-D & ICD CRT-D & CRT-P

Network / Implant Centre NYHA

Dyspnoea Status

LV Function

ICD Indication QRS

duration

Overall index of valid data

completeness

Target 90.0% 90.0% 90.0% 90.0% 90.0%

England 63.5% 74.5% 57.5% 27.9% 84.4%

This Network 56.0% 75.9% 11.7% 40.1% 79.6%

Darent Valley Hospital 100.0% 89.5% 0.0% 0.0% 85.7%

Kent & Sussex Hospital 100.0% 100.0% 0.0% - 95.2%

Maidstone General Hospital 98.2% 98.2% 0.0% 0.0% 85.9%

Medway Hospital 10.0% 23.3% 96.7% 7.1% 73.1% Queen Elizabeth the Queen Mother 67.3% 83.6% 85.5% 33.3% 89.8%

St Thomas Hospital 52.3% 95.3% 3.4% 0.0% 81.9%

William Harvey Hospital 44.7% 87.2% 93.6% 26.1% 89.8%

Target Achieved

Below 50% of target

( - ) = No Implants

Notes: 1. Implant centres shown have contributed at least 5% of Pacemaker implant activity in the network. 2. Completeness is shown for all registered procedures for a centre, not just procedures in this network. 3. Overall index is an average for each centre of each field as a ratio of the target, and can exceed 100%.

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Overview of Device Implants in the UK

New pacemakers Comments: • The ten year average

growth rate is 4.1% • Implant rates decreased

slightly in England and in Wales. The new PM implant rates decreased significantly in Northern Ireland.

• There is a substantial shortfall in data submission from Scotland, data has been suppressed post 2008.

• New pacing rate remains highest in England (528 new implants per million population in 2010).

New ICD implants Comments: • The ten year average growth

rate is 14.9%

• ICD implant rate remains highest in N Ireland. (There is a substantial shortfall in data submission from Scotland).

• ICD implant rate increased significantly in England and in Wales in 2010.

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New CRT implants Comments • New CRT rate increased

significantly in England and remained the highest rate.

• The new CRT rate also increased in N Ireland, Wales and Scotland in 2010. (There is a substantial shortfall in data submission from Scotland).

Total CRT implants

Comments • The total CRT rate rose

significantly in England for the last three years.

• Total CRT implants Rate was highest in England (114 new implants per million population in 2010).

• The total CRT rate also increased in N Ireland, Wales and Scotland in 2010. (There is a substantial shortfall in data submission from Scotland).

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grey line represents national average

The Range of New Implant rate 2010

Pacemaker New Implant rate 2010adjusted for age and sex

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Coventry & Warwickshire Cardiovascular Network

Herefordshire and Worcestershire Cardiac Network

Avon, Gloucestershire, Wiltshire & Somerset Cardiac and Stroke Network

Shropshire & Staffordshire Cardiac Network

East Midlands Cardiac and Stroke Network

Birmingham, Sandwell and Solihull Cardiac and Stroke Network

Peninsula Heart and Stroke Network

North East London Cardiac and Stroke Network

South East London Cardiac & Stroke Network

North Trent Network of Cardiac Care

Anglia Stroke and Heart Network

North Central London Cardiac & Stroke Network

Essex Cardiac and Stroke Network

Black Country Cardiovascular Network

West Yorkshire Cardiac Network

South Central Cardiovascular Network

Greater Manchester & Cheshire Cardiac Network

Cardiac and Stroke Networks in Cumbria and Lancashire

Cheshire & Merseyside Cardiac Network

South West London Cardiac Network

North of England Cardiovascular Network

Sussex Heart Network

North West London Cardiac and Stroke Network


North & East Yorkshire and Northern Lincolnshire Cardiac Network

Surrey Heart & Stroke Network

Bedfordshire and Hertfordshire Heart and Stroke Network

Dorset Cardiac Network

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The Range of New Implant rate 2010 grey line represents national average

ICD New Implant rate 2010adjusted for age and sex

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The Range of Total Implant rate 2010 grey line represents national average

All CRT Total Implant rate 2010adjusted for age and sex includes CRTD and CRTP

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PCTs/LHBs in the Network Kent Cardiovascular Network Total population 1.63 million. Code PCT/LHB Population Old PCT (where relevant*) 5L3 Medway 251,678 5P9 West Kent 662,435 5QA Eastern and Coastal Kent 720,483

* The revision of PCT boundaries in 2006 has resulted in some PCTs being "split" across Cardiac Network boundaries. In these cases only the relevant portion of the new PCT will be included in this report, as defined by the old PCT boundaries.

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Network Age and Sex Distribution Population data from ONS, based on mid-2006 population estimates

Data for England Average age: 39.5 (for comparison): % aged 70+: 11.60%


PopulationPCT / LHB Age Male Female Age Male Female

5L3Population: 251,678 0-5: 7,798 7,761 46-50: 8,795 8,952 Average age: 38.4 6-10: 8,317 7,625 51-55: 7,774 7,658 % aged 70+: 9.2% 11-15: 8,856 8,571 56-60: 7,991 8,276

16-20: 9,408 8,660 61-65: 6,402 6,440 21-25: 8,123 7,956 66-70: 4,950 5,244 26-30: 7,745 8,286 71-75: 3,902 4,381 31-35: 8,174 8,564 76-80: 2,839 3,660 36-40: 9,563 10,099 81-85: 1,721 2,925 41-45: 10,242 10,193 85+: 1,114 2,713

5P9Population: 662,435 0-5: 20,175 19,242 46-50: 23,696 23,364 Average age: 40.4 6-10: 20,890 19,823 51-55: 20,253 21,014 % aged 70+: 11.6% 11-15: 22,448 21,835 56-60: 22,595 23,167

16-20: 22,247 20,875 61-65: 18,297 19,075 21-25: 16,434 16,184 66-70: 14,354 15,615 26-30: 18,094 18,516 71-75: 12,252 13,881 31-35: 20,470 21,792 76-80: 9,540 12,068 36-40: 24,564 26,401 81-85: 5,803 9,394 41-45: 26,769 27,608 85+: 4,204 9,496

5QAPopulation: 720,483 0-5: 20,364 19,019 46-50: 23,572 23,965 Average age: 41.5 6-10: 21,343 20,451 51-55: 21,139 22,651 % aged 70+: 13.4% 11-15: 24,442 22,770 56-60: 24,642 26,076

16-20: 24,602 24,329 61-65: 21,292 22,538 21-25: 22,407 22,220 66-70: 17,318 18,436 26-30: 18,819 19,359 71-75: 14,294 16,261 31-35: 18,906 21,031 76-80: 11,356 15,151 36-40: 23,851 25,808 81-85: 7,949 12,669 41-45: 25,917 27,025 85+: 5,785 12,726

Eastern and Coastal Kent

* Older than national average

Medway

* Younger than national

average

West Kent

Note: A PCT is considered to be older than average the percentage for aged 70+ is greater than or equal to 13.1% and it is considered to be younger than average if the percentage for aged 70+ is less than or equal to 10.3%.

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Correcting Implant Rates for Age and Sex Calculating Need • Most pacemakers are implanted for

conduction system disease, which is predominantly a disease of the elderly. The graph (right) shows the percentage of the population in 5 year age bands, and the percentage of pacemaker implants. Only 11% of the population are aged 70 or more, but they receive 76% of all pacemaker implants.

• Men also receive more pacemakers

than women. Although the national average new implant rate is 528, it reaches more than 11,000 in men aged more than 90 (right). So the proportion of older people in a local population will strongly influence how many pacemakers need to be implanted.

• If we examine closely the age and sex distribution of the local population of a PCT (LHB in Wales) or

Network, we can work out how many pacemakers we would EXPECT to see implanted, compared to the national average. The ratio of the local and national rate is called the Relative Need, and we calculate this for both pacemakers and ICDs.

• So, for example, in North East London the population is relatively young. Only 8% are aged 70 or

more, compared to the national average of 11%. This means that this network doesn't need as many pacemaker implants relative to the nation as a whole. Their Relative Need for Pacing is calculated to be 80% of the national average.

• In contrast, Sussex has a more elderly population, with 16% aged 70 or over. Their Relative Need for

Pacing is 140%.

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Using Relative Need • We want to make a fair and valid comparison between PCTs/LHBs, Networks and the National

Average. That means we should correct for relative need. So, for example if North London has a pacing rate of 480, and Sussex has a rate of 840, are they different? North London's adjusted rate is 480 divided by relative need (80%) = 600. Sussex's adjusted rate is 840 divided by 140% = 600.

• So the adjusted rates for these two areas are the same, despite the major apparent difference in their

unadjusted rates.

Implantable Defibrillators • The diseases for which ICDs are

implanted are not the same as for pacemakers, and tend to occur in slightly younger people. These diseases are principally ischaemic heart disease and cardiomyopathy.

• We therefore need to calculate a

separate relative need factor for ICDs. The graph (right) of new ICD implant rate in 2006 shows that ICDs are also predominantly implanted in older people.

• Unlike pacemakers, the ICD implant rate starts to decline over the age of 75. The influence of a local

elderly population of need for ICDs will therefore still be present, but just slightly less in magnitude than for pacemakers. Sussex, for instance, has a relative ICD need of 138%.

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Indicative new implant rate Pacemakers: 528 ICD: 72 (average for England 2010) Average age: 39.44

A PCT with a relatively OLD population will need relatively MORE pacemaker and ICD implants compared to a PCT with a young population, because the incidence of indications for pacing and ICD is higher in older people.

Average age

Expected pacing new implant rate

Compared to national average

Expected ICD new

implant rate

Compared to national average

5L3 Medway 38.4 441 83.6% 67 94%

5P9 West Kent 40.4 540 102.4% 74 103%

5QA Eastern and Coastal Kent 41.5 609 115.4% 78 110%

Cardiac Network - Relative Need for New Implant Rate

Kent Cardiovascular Network 555 105.23% 75 104.71%

England (for comparison)

England 528 100% 72 100%

Note: "Expected" pacing and ICD rates are relative to national average rate, but are corrected depending on the age and sex distribution of the local population (see Page 12). For Pacemakers, the expected implant rate will be higher if the percentage of older people in the PCT is higher. For ICDs, the same general rule applies, but the pattern is slightly different, because ICD implant rates peak at age 70 and then decrease rapidly. These relative rates will be used to correct the observed rates and produce a truer reflection of local implant rates vs. local need.

Relative need for Pacemakers and ICDs

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Pacemakers

The following hospitals implanted pacemakers in patients from this cardiac network in 2010. A new pacemaker centre will implant nearly 100% new implants, and the longer a centre has been implanting, the higher the percentage of replacements implants. The national average for replacement implants is 21.79% of the total workload. This should always be borne in mind when forecasting future workload.

2010 Replacement implants

Centre New Implants

Total Implants % of total

QEQ Queen Elizabeth the Queen Mother 224 255 12.16% WHH William Harvey Hospital 189 239 20.92% MAI Maidstone General Hospital 151 190 20.53% MDW Medway Maritime Hospital 105 166 36.75% KSX Kent & Sussex Hospital 99 115 13.91% DVH Darent Valley Hospital 86 108 20.37% STH St Thomas' Hospital 64 89 28.09% LBH London Bridge Hospital 21 26 19.23% KCH King's College Hospital 20 21 4.76% NHB Royal Brompton Hospital 7 11 36.36% CGH Conquest Hospital 5 7 28.57% UCL University College Hospital 2 3 33.33% GWH Queen Elizabeth Hospital Woolwich 2 3 33.33% RSC Royal Sussex County Hospital 2 2 BAL Barts and The London 2 2 CON Conquest Hospital 1 1 ESU East Surrey Hospital 1 1 KTH Kingston Hospital 1 1 IND London Independent Hospital 1 1 LGI Leeds General Infirmary 1 1 DGE Eastbourne DGH 1 1 GEO St George's Hospital 1 HAR Harrogate District Hospital 1 1 PAP Papworth Hospital 1 1 KGG King George Hospital 1 1 RFH Royal Free Hospital 1 1 HAM Hammersmith Hospital 1 1 GUY Guys Hospital 1

New and Total PM and ICD Implants

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STM St Mary's Hospital Paddington 1 1 STO University Hospital of North Staffordshire 1 1 HSC Harley Street Clinic 1 HH Harefield Hospital 1 1

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Pacemaker implant trends

Pacemaker New Implant Rateadjusted for age and sex of network population

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Pacemaker new implant rate in context Is the PCT new implant rate too high or too low, compared to the national target of 700? The funnel plot below shows the national target (grey line) and the upper (green) and lower (red) control limits. PCTs are shown in light blue circles, and this network's PCTs are shown as larger blue circles. If a PCT's rate is above the green line, it may be excessively high. If it is below the red line, it may be too low.

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Funnel plots are a way of displaying performance against a national average or target. Here, the national target of 700 is shown as a horizontal grey line. The small blue dots represent the new implant rate (y-axis) in each PCT in the country plotted against that PCTs population (x-axis). The individual PCTs in THIS NETWORK are plotted as larger blue circles. The CONTROL LIMITS determine whether a PCT's new implant rate is significantly greater than (green line) or less than (red line) the national target. The statistical significance level was chosen to ensure that the total risk of one or more PCTs being outside the control limits by random chance is no more than 5%.

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Geographical location of pacemaker implants

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Implantable Cardioverter Defibrillators (ICDs)

The following hospitals implanted ICDs in patients from this cardiac network in 2010.

2010 Replacement implants

Centre New Implants

Total Implants % of total

WHH William Harvey Hospital 26 31 16.13% MAI Maidstone General Hospital 28 28 QEQ Queen Elizabeth the Queen Mother 25 26 3.85% STH St Thomas' Hospital 17 25 32.00% MDW Medway Maritime Hospital 20 23 13.04% KCH King's College Hospital 15 17 11.76% DVH Darent Valley Hospital 14 14 KSX Kent & Sussex Hospital 8 8 UCL University College Hospital 5 5 LBH London Bridge Hospital 3 5 40.00% NHB Royal Brompton Hospital 3 5 40.00% HH Harefield Hospital 1 2 50.00% BAL Barts and The London 1 1 GEO St George's Hospital 1 SGH Southampton General Hospital 1 1 FRE Freeman Hospital 1 BAS Essex Cardiothoracic Centre 1 1 UHW University Hospital of Wales 1 1

New and Total PM and ICD Implants

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ICD implant trends

ICD New Implant Rateadjusted for age and sex of network population

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ICD All Implant Rateadjusted for age and sex of network population

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Kent Cardiovascular Network Heart failure is a major and growing public health problem in all Western countries, and is associated with high morbidity and mortality despite optimal medical therapy. Clinical trials of high scientific quality published in recent years have consistently found that cardiac resynchronisation therapy (CRT) improves symptoms, quality of life, exercise tolerance and survival in appropriately chosen patients with advanced heart failure and evidence of left ventricular dyssynchrony who are refractory to optimal medical therapy. CRT involves simultaneous pacing of the left and right ventricles (CRT-P), and may be combined, in the same device, with a defibrillation function (CRT-D). Although CRT involves pacing the heart, it should not be confused with 'classical' pacing for bradycardia - the vast majority of CRT recipients do not require pacing for bradycardia. The function of pacing is to make the ventricles beat at the same time ('resynchronisation'). Within this report, data for CRT-P and CRT-D are quantified separately from pacing and ICD data respectively. In the UK, CRT is provided predominantly by tertiary centres with a special interest in cardiac device therapy. Despite the high prevalence of heart failure, uptake of CRT in the UK is amongst the lowest in Western Europe. NICE published guidelines on the cost effectiveness of CRT in 2007, and it is expected that clinical demand for CRT therapy will continue to rise significantly in coming years. CRT implanting hospitals in this network

CRT-D CRT-P

2008 St Thomas' Hospital 98 12 William Harvey Hospital 25 13 Medway Maritime Hospital 20 11 King's College Hospital 20 8 Queen Elizabeth the Queen Mother 12 6 Maidstone General Hospital 13 5 London Bridge Hospital 6 1 University College Hospital 1 2 Royal Brompton Hospital 1 2 St George's Hospital 1 Barts and The London 1 Harefield Hospital 1

CRT-D CRT-P

2009 St Thomas' Hospital 53 15 Maidstone General Hospital 27 15 William Harvey Hospital 27 4 Queen Elizabeth the Queen Mother 17 8 King's College Hospital 7 1 University College Hospital 3 1

Medway Maritime Hospital 3 1

London Bridge Hospital 3

Barts and The London 2

CRT implants in this network

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2009 Harefield Hospital 2

Royal Brompton Hospital 1 1

Papworth Hospital 1

Darent Valley Hospital 1

Harley Street Clinic 1

Wexham Park Hospital 1

St George's Hospital 1

CRT-D CRT-P 2010 St Thomas' Hospital 54 7

Maidstone General Hospital 26 17 Queen Elizabeth the Queen Mother 28 13 William Harvey Hospital 16 7 Medway Maritime Hospital 7 7 Darent Valley Hospital 5 6

King's College Hospital 7 3

Royal Brompton Hospital 4 2

St George's Hospital 2

London Bridge Hospital 1 1

Hammersmith Hospital 1 1

Harley Street Clinic 1

Harefield Hospital 1

Royal Sussex County Hospital 1

Barts and The London 1

University College Hospital 1

Queen Elizabeth Hospital Woolwich 1

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CRT implant trends

Note: Low voltage CRT devices ( CRT-P) pace both the left and right ventricles. High voltage CRT devices (CRT-D) combine this function with a defibrillation capability.

CRT New Implant Rateadjusted for age and sex of network population

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Geographical location of Complex Devices implants

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The European Picture European data for 2010 shows that the UK has average CRT implant rates compared to the Western Europe implant rates, and far below the rate in the U.S.A..

Total CRT-P & CRT-D Implants 2010

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Which hospitals serve which PCTs/LHBs? all implants for this cardiac network in 2010


Pacemakers

5L3.Medway Total Implants 2010 MDW Medway Maritime Hospital 109 MAI Maidstone General Hospital 7 STH St Thomas' Hospital 4 WHH William Harvey Hospital 2 NHB Royal Brompton Hospital 2 DVH Darent Valley Hospital 1 KCH King's College Hospital 1 LBH London Bridge Hospital 1 LGI Leeds General Infirmary 1 5P9.West Kent Total Implants 2010 MAI Maidstone General Hospital 178 KSX Kent & Sussex Hospital 115 DVH Darent Valley Hospital 107 STH St Thomas' Hospital 54 KCH King's College Hospital 16 LBH London Bridge Hospital 15 MDW Medway Maritime Hospital 10 CGH Conquest Hospital 7 WHH William Harvey Hospital 4 NHB Royal Brompton Hospital 4 UCL University College Hospital 3 GWH Queen Elizabeth Hospital Woolwich 3 BAL Barts and The London 2 IND London Independent Hospital 1 GUY Guys Hospital 1 KTH Kingston Hospital 1 HAR Harrogate District Hospital 1 GEO St George's Hospital 1 PAP Papworth Hospital 1 QEQ Queen Elizabeth the Queen Mother 1 RSC Royal Sussex County Hospital 1 ESU East Surrey Hospital 1 STO University Hospital of North Staffordshire 1 KGG King George Hospital 1 5QA.Eastern and Coastal Kent Total Implants 2010 QEQ Queen Elizabeth the Queen Mother 254

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WHH William Harvey Hospital 233 MDW Medway Maritime Hospital 47 STH St Thomas' Hospital 31 LBH London Bridge Hospital 10 NHB Royal Brompton Hospital 5 MAI Maidstone General Hospital 5 KCH King's College Hospital 4 CON Conquest Hospital 1 HH Harefield Hospital 1 DGE Eastbourne DGH 1 RFH Royal Free Hospital 1 RSC Royal Sussex County Hospital 1 HSC Harley Street Clinic 1 STM St Mary's Hospital Paddington 1 HAM Hammersmith Hospital 1


5L3.Medway Total Implants 2010 MDW Medway Maritime Hospital 17 UCL University College Hospital 2 STH St Thomas' Hospital 2 KCH King's College Hospital 2 FRE Freeman Hospital 1 LBH London Bridge Hospital 1 MAI Maidstone General Hospital 1 DVH Darent Valley Hospital 1 NHB Royal Brompton Hospital 1 GEO St George's Hospital 1 5P9.West Kent Total Implants 2010 MAI Maidstone General Hospital 27 KCH King's College Hospital 13 DVH Darent Valley Hospital 13 STH St Thomas' Hospital 11 KSX Kent & Sussex Hospital 8 LBH London Bridge Hospital 3 UCL University College Hospital 2 WHH William Harvey Hospital 1 MDW Medway Maritime Hospital 1 NHB Royal Brompton Hospital 1 BAS Essex Cardiothoracic Centre 1 BAL Barts and The London 1

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5QA.Eastern and Coastal Kent Total Implants 2010 WHH William Harvey Hospital 30 QEQ Queen Elizabeth the Queen Mother 26 STH St Thomas' Hospital 12 MDW Medway Maritime Hospital 5 NHB Royal Brompton Hospital 3 HH Harefield Hospital 2 KCH King's College Hospital 2 SGH Southampton General Hospital 1 LBH London Bridge Hospital 1 UCL University College Hospital 1 UHW University Hospital of Wales 1

Cardiac Resynchronisation Therapy (CRT)

5L3.Medway Total Implants 2010 STH St Thomas' Hospital 13 MDW Medway Maritime Hospital 10 GEO St George's Hospital 1 KCH King's College Hospital 1 HAM Hammersmith Hospital 1 5P9.West Kent Total Implants 2010 MAI Maidstone General Hospital 41 STH St Thomas' Hospital 23 DVH Darent Valley Hospital 11 KCH King's College Hospital 5 NHB Royal Brompton Hospital 4 HH Harefield Hospital 1 MDW Medway Maritime Hospital 1 HSC Harley Street Clinic 1 RSC Royal Sussex County Hospital 1 GWH Queen Elizabeth Hospital Woolwich 1 UCL University College Hospital 1 5QA.Eastern and Coastal Kent Total Implants 2010 QEQ Queen Elizabeth the Queen Mother 41 STH St Thomas' Hospital 25 WHH William Harvey Hospital 23 KCH King's College Hospital 4 MDW Medway Maritime Hospital 3 NHB Royal Brompton Hospital 2 MAI Maidstone General Hospital 2 LBH London Bridge Hospital 2

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HAM Hammersmith Hospital 1 BAL Barts and The London 1 GEO St George's Hospital 1

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for this cardiac network


Pacemakers

Mode % for this network England % Atrial based modes

DDDR 63.33% 61.54% DDD 2.93% 4.53% AAIR 0.10% 0.52% AAI 0.00% 0.05% DDI 0.00% 0.06% DDIR 0.00% 0.02% Other 0.20% 0.15%

Ventricular based modes VVIR 30.30% 31.28%

VVI 2.73% 1.57%

VDDR 0.30% 0.04%

VDD 0.10% 0.25%

Note: The Mode table percentage calculations do not include any records where the mode was blank or unknown.

Note: The Network and England charts’ percentage segments are calculated based on the records in the Mode table but also include all records where the mode was blank or unknown.

Pacing Mode for New Implants

England

Atrial

based

66%

Ventricular

based

33%

Blank/

Unknown

1%

Network

Ventricular

based

33%

Atrial

based

67%

Blank/

Unknown

0.4%

33

Pacing Mode for New Implants major implanting hospitals in this cardiac network


VVI VVIR AAI AAIR DDD DDDR VDD VDDR Atrial Based Pacing

NATIONAL 1.6% 31.4% 0.0% 0.5% 4.5% 61.7% 0.3% 0.0% 66.8%

This Network 2.7% 30.4% 0.0% 0.1% 2.9% 63.5% 0.1% 0.3% 66.5%

DVH.Darent Valley Hospital 3.5% 40.7% 0.0% 0.0% 8.1% 47.7% 0.0% 0.0% 55.8%

KSX.Kent & Sussex Hospital 1.0% 24.2% 0.0% 0.0% 0.0% 74.7% 0.0% 0.0% 74.7%

MAI.Maidstone General Hospital 0.7% 17.2% 0.0% 0.0% 3.3% 78.8% 0.0% 0.0% 82.1%

MDW.Medway Hospital 1.0% 29.5% 0.0% 0.0% 1.0% 68.6% 0.0% 0.0% 69.5% QEQ.Queen Elizabeth the Queen Mother 9.1% 44.7% 0.0% 0.0% 5.0% 41.1% 0.0% 0.0% 46.1%

STH.St Thomas Hospital 0.0% 39.3% 0.0% 0.0% 0.0% 60.7% 0.0% 0.0% 60.7%

WHH.William Harvey Hospital 0.5% 22.2% 0.0% 0.0% 2.1% 74.6% 0.5% 0.0% 76.7%

Note: Implant centres shown have contributed at least 5% of Pacemaker implant activity in the network.

Note: The Mode table for major implanting hospitals’ percentage calculations do not include any records where the mode was blank or unknown.

NB: As from 2007, mode is based on the maximum mode of which the device is capable and not the mode at the end of the procedure.

34

There is ample evidence from major clinical trials and support from NICE guidelines (NICE Technology Appraisal 88, 2005) that use of ventricular pacing modes in patients with sick sinus syndrome can lead to poor outcomes, notably an increased incidence of atrial fibrillation and pacemaker syndrome. Pacing modes in sick sinus syndrome should be atrial based (i.e. dual chamber or atrial). The Western European average in 2005 was 92% atrial based pacing for SSS. In the UK the average was 81% in 2009 and 84% in 2010. Any percentage of ventricular based pacing greater than 10% has been shaded pink, and may be considered higher than desirable. A percentage greater than 20% is considered definitely too high and is shown in a shaded red box. Percentages greater than 50% are shown shaded black. NB: the % of atrial based pacing shown for a centre applies only to patients residing in THIS NETWORK and may differ overall.

New Implants for Sick Sinus

Syndrome in this network

Atrial-based New Implants for SSS in

this network

Ventricular-based New Implants for

SSS in this network DVH.Darent Valley Hospital 20 65.0% 35.0% KSX.Kent & Sussex Hospital 21 95.2% 4.8% MAI.Maidstone General Hospital 49 93.9% 6.1% MDW.Medway Hospital 22 100.0% 0.0% QEQ.Queen Elizabeth Queen Mother 51 56.9% 43.1% STH.St Thomas’ Hospital 12 83.3% 16.7% WHH.William Harvey Hospital 67 92.5% 7.5%

Note: Any hospital in the network not in this list did not code at least 10 implants as SSS.

Note: For this analysis only ECG codes E1-E5 are used


References 1. TA88 Bradycardia - dual chamber pacemakers: Information for the public. NICE 23 February 2005. http://www.nice.org.uk/TA88

Pacing Mode for Sick Sinus Syndrome

35

The European Picture Atrial based pacing in the UK is low compared to most of Europe.

% Atrial-based pacing for Sick Sinus Syndrome2003 (most recent survey)

60% 65% 70% 75% 80% 85% 90% 95%

Denmark

Sweden

Austria

France

FR Yugoslavia

Belgium

LATVIA

Norway

UK

Netherlands

Turkey

Spain


36


Complete HB

Incomplete HB

AF + HB/brady

Sick sinus syndrome Other

NATIONAL 22.7% 22.8% 23.5% 27.5% 6.2%

This Network 24.0% 18.6% 20.6% 27.4% 9.4%

5L3.Medway 36.3% 21.3% 17.5% 21.3% 3.8%

5P9.West Kent 25.6% 16.5% 21.1% 27.2% 9.6%

5QA.Eastern and Coastal Kent 20.5% 20.0% 20.7% 28.6% 10.1%

AF: atrial fibrillation HB: heart block Brady: bradycardia

ECG Indication for New Implants

37

Pacemakers

Expected and Actual New Implant Rates Explanatory note: The "Raw" new implant rate is the actual implant rate of new pacemakers per million population in each PCT. The "corrected" rate is the raw rate, adjusted for relative need – so if a PCT has an aging population, its relative need is > 100% and its corrected rate will be reduced to reflect that need. Comparisons between PCTs and with network and national averages should be made using corrected rate.

Kent Cardiovascular Network England Average 528 Network average (unadjusted) 609 Network average (corrected for age and sex) 584

New Implant Rate 2010

Population Relative need

for PM Raw Corrected

5L3 Medway

251,678 83.6% 342 409

5P9 West Kent

662,435 102.4% 645 630

5QA Eastern and Coastal Kent

720,483 115.4% 668 579

How much does the implant rate vary in this network? Of course there will always be some random variation in implant rate. This NORMAL CAUSE variation is not considered likely to exceed 5% of the total implant rate for pacing. Variation IN EXCESS of 10% may be considered due to another (SPECIAL) cause, such as referral patterns or varying implantation policies between trusts. Variability Index for this Cardiac Network

21.4%

1% RATING: high variation in implant rates between PCTs

Corrected and Actual New Implant Rates

38

New Pacemaker Implant Rates The Western European average new implant rate for 2003 and 2004 was 700 per million population. This figure is also now the HRUK target and will be used as the basis for comparison.


England Average 528 Network average (unadjusted) 609 Network average (corrected for age and sex) 584

Population

Corrected New Implant Rate

2010

Deficit/ Excess 2010

compared to rate of 700

5L3 Medway

251,678 409 -42%

5P9 West Kent

662,435 630 -10%


720,483 579 -17%

39

Corrected and Actual New Implant Rates


Explanatory note:

The "Raw" new implant rate is the actual implant rate of new ICDs per million population in each PCT. The "Corrected" rate is the raw rate, adjusted for relative need - so if a PCT has an aging population, its relative need is > 100% and its corrected rate will be reduced to reflect that need. Comparisons between PCTs should be made using Corrected rate. Kent Cardiovascular Network England Average 72 Network average (unadjusted) 103 Network average (corrected for age and sex) 101

New Implant Rate 2010

Population Relative need

for ICD Raw Corrected

5L3 Medway

251,678 93.7% 99 106

5P9 West Kent

662,435 103.4% 109 105


720,483 109.8% 100 91

40

New ICD Implant Rates A target figure of 100 implants per million is used as a basis for comparison, based on recent NICE guidance.


England Average 72 Network average (unadjusted) 103 Network average (corrected for age and sex) 101

Population

Corrected New Implant Rate

2010

Deficit/ Excess 2010

compared to rate of 100

5L3 Medway

251,678 106 6%

5P9 West Kent

662,435 105 5%


720,483 91 -9%

41

New Implant rate maps for Kent Cardiovascular Network

42

comparison with Heart Rhythm UK target (700)


Pacemaker New Implants 2010adjusted for age and sex

compared to target figure of 700 per million

-45% -40% -35% -30% -25% -20% -15% -10% -5% 0%

West Kent


Medway

New pacing implant rate 2010

43


ICD New Implants 2010adjusted for age and sex

compared to target figure of 100 per million

-10% -8% -6% -4% -2% 0% 2% 4% 6% 8%

Medway

West Kent


ICD new implant rate 2010

44

comparison with HRUK recommendations


The graph shows the NUMBER of additional new pacemakers implants that each PCT needs to implant to bring them up to the HRUK target rate.

Deficit in New Pacemaker Implants 2010compared to Heart Rhythm UK target rate of 700

-120

-100

-80

-60

-40

-20

0

Wes

t Ke

nt

Med

way

East

ern

and

Coas

tal

Kent

Pacing Implant Deficit in 2010

45


The age structure of the Network is slightly older than the national average, and consequently has a 5% higher need for pacemakers and 5% for ICDs.

The network new pacemaker implant rate decreased and the Network remains

above the national average, although still short of the national target.

The network new ICD implant rate increased significantly and is just above the national target.

The CRT total implant rate has increased in 2010; the rate is above the national

average and below the national target.

The proportion of atrial based pacing (67%) is slightly higher than the national average.

Queen Elizabeth the Queen Mother (43%) and Darent Valley Hospital (35%) have

higher than desirable rates of ventricular based pacemaker implants for sick sinus syndrome; this is not compliant with NICE TAG 88 (2005).

All implanting centres have major deficits for clinical data registration (see p5). The

value of the audit will be enhanced if these deficits can be addressed in 2011.

Conclusions

kent cardiovascular network

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