what’s happened in 2007 and why? mark de belder president british cardiovascular intervention...
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What’s happened in 2007 and why?What’s happened in 2007 and why?
Mark de BelderMark de BelderPresidentPresident
British Cardiovascular Intervention SocietyBritish Cardiovascular Intervention Society
12691216
77,373
73,612
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1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
PC
I pe
r m
illio
n
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10000
20000
30000
40000
50000
60000
70000
80000
90000
PC
I P
roce
dure
Num
bers
PCI per million
PCI Procedures
PCI activity to 2007 (UK)PCI activity to 2007 (UK) 2007 data: Ludman
Aggregate forms
NSF
PCIPCI’s’s (all) per million inhabitants per year (all) per million inhabitants per year 2007 2007Widimsky P, ESC 2008Widimsky P, ESC 2008
0
500
1000
1500
2000
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3000
3500
4000
PCI / million / year
D
IZR
A
B
I
SLO
PL
NL
CZ
NO
CH
S
DK
FIN
H
E
UK
TR
HR
SRB
BG
SK
RO
PCI vs Isolated CABG Rates (UK)PCI vs Isolated CABG Rates (UK)Estimated 5 year growth: 2002Estimated 5 year growth: 2002
0
20000
40000
60000
80000
100000
120000
140000
'91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08
SCTSBCIS
All revasc:>2700 pm3.3:1 PCI:CABGPCI >2000 pm
PCI vs Isolated CABG Rates (UK)PCI vs Isolated CABG Rates (UK)Estimated 5 year growth: 2002Estimated 5 year growth: 2002
0
20000
40000
60000
80000
100000
120000
140000
'91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08
SCTSBCISSCTS actualBCIS actual
All revasc:>2700 pm3.3:1 PCI:CABGPCI >2000 pm
Actual in 2007: All revascularisation 1685pm; PCI 1269pm; CABG 416pm3.1:1 PCI:CABG
Influences on requirements/deliveryInfluences on requirements/delivery
PositivePositive• Growth in infrastructureGrowth in infrastructure• More interventional More interventional
cardiologistscardiologists• Primary PCIPrimary PCI• NICE ACS Guidelines 2009?NICE ACS Guidelines 2009?
– Equity of accessEquity of access• NSF and established interface NSF and established interface
between primary and secondary between primary and secondary carecare– RACPCsRACPCs– Appropriate investigation of Appropriate investigation of
IHDIHD– NICE AP guidelines NICE AP guidelines
2009/2010?2009/2010?• New evidence?New evidence?• Work of the CVC?Work of the CVC?
NegativeNegative• Lack of infrastructureLack of infrastructure• Too few interventional (and Too few interventional (and
other) cardiologistsother) cardiologists• Belief in thrombolysisBelief in thrombolysis• ICTUS believersICTUS believers• COURAGE and the impact of COURAGE and the impact of
secondary preventionsecondary prevention• Concerns about DESConcerns about DES• Smoking banSmoking ban• Healthier lifestyles (diet, Healthier lifestyles (diet,
exercise)exercise)• Changes in air pollutantsChanges in air pollutants• Global warming?Global warming?• New evidence?New evidence?• Economic downturn?Economic downturn?• Work of the CVC?Work of the CVC?
Hospitalized STEMI treatment in Europe.Hospitalized STEMI treatment in Europe.
National registries dataNational registries data ((**estimates of national opinion leaders)estimates of national opinion leaders)
95
05
92
17
85
0
15
75
12
13
75
5
20
74
18
8
72
2
26
70
20
10
70
15
15
68
6
26
60
12
28
59
14
27
50
15
35
45
40
15
45
16
39
40
40
20
39
26
35
35
40
25
19
44
37
17
21
62
14.9
61.4
23.7
13
26
61
9
50
41
8
29
62
4
50
46
5
15
80
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
NL CZ SLO NO DK B PL CH HR S H D IL FIN I E SK A P SRB UK BG GR TR RO RU
P-PCI TL No reperfusion* * ** *** * **
Clinical SyndromeClinical Syndrome
2007 data: Ludman
CCAD
46.8
53.2
0
10
20
30
40
50
60
70
80
2005 2006 2007
% PCI Performed for
each Indication
Stable
Unstable
13.24%
1.18%
40.48%
45.10%
StableNSTEMI / UASTEMIOther
Indication for PCIIndication for PCI
2007 data: Ludman
CCAD
PCI for STEMIPCI for STEMI
5866
8153
3930
5902
1936
2581
0
1000
2000
3000
4000
5000
6000
7000
8000
9000
All STEMI Primary PCI Rescue
2001
2002
2003
2004
2005
2006
2007
2007 data: Ludman
CCAD
Variation in patients with STEMI treated with Variation in patients with STEMI treated with lysis or no reperfusion undergoing angiographylysis or no reperfusion undergoing angiography
MINAP dataMINAP datapersonal communication – John Birkheadpersonal communication – John Birkhead
Hosps Median % Percentile 25 Percentile 75
2006 214 63% 43% 81%
2007 210 63% 48% 78%
2008 205 67% 48% 80%
Issues relating to Non-STEMI ACSIssues relating to Non-STEMI ACS
• ESC & US guidelines support early ESC & US guidelines support early angiography with a view to early (within angiography with a view to early (within 72hrs) revascularisation by either PCI or 72hrs) revascularisation by either PCI or CABG in higher risk subsetsCABG in higher risk subsets
• Rates of angiography and revascularisation Rates of angiography and revascularisation vary considerably across England (MINAP vary considerably across England (MINAP - John Birkhead, personal communication)- John Birkhead, personal communication)
Non-STEMI ACS patientsNon-STEMI ACS patients
25941
2987533009
0
5000
10000
15000
20000
25000
30000
35000
40000
2005 2006 2007
Procedures performed for
non-STEMI ACS
Variation in patients with nonSTEMI ACS Variation in patients with nonSTEMI ACS undergoing angiographyundergoing angiography
MINAP dataMINAP datapersonal communication – John Birkheadpersonal communication – John Birkhead
Hosps Median % Percentile 25 Percentile 75
2006 212 60% 40% 82%
2007 207 57% 41% 75%
2008 203 63% 47% 78%
Stable patientsStable patients
39280 3795136211
0
5000
10000
15000
20000
25000
30000
35000
40000
2005 2006 2007
Procedures performed for stable angina
Non-STEMI ACS patientsNon-STEMI ACS patients
25941
2987533009
36211
0
5000
10000
15000
20000
25000
30000
35000
40000
2005 2006 2007
Non-STEMI
Stable
Procedure urgency 2000 to 2007
0
100
200
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500
600
700
800
2000 2001 2002 2003 2004 2005 2006 2007
Urgent
Elective
Emergency
Changing case mix - JCUHChanging case mix - JCUH
Changing case mix - JCUHChanging case mix - JCUH
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10
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100
2003 2004 2005 2006 2007 2008
%
STEMI
Non-STEMI ACS
Stable
Angiography (85)
PCI (98)
2007Where is the workWhere is the work
being done?being done?
PCI per ConsultantPCI per ConsultantUnit case number / Number of operatorsUnit case number / Number of operators
100105110
115120125130135
140145150
2000 2001 2002 2003 2004 2005 2006 2007
Nu
mb
er
of
PC
Is
2007 data: Ludman
0
500
1000
1500
2000
2500
3000
3500
PCIs per Centre
Individual Centres
Off site On Site
Surgical CoverSurgical Cover (2007 - all 81 NHS centres)
2007 data: Ludman
420
1471
Mean
Aggregate forms
Surgical CoverSurgical Cover(all 98 NHS and Private Centres)(all 98 NHS and Private Centres)
On siteOn site Off siteOff siteNo of centresNo of centres 5353
(54%)(54%)
4545(46%)(46%)
No. of PCI No. of PCI (% of total)(% of total) 59,45559,455(77%)(77%)
17,91817,918(23%)(23%)
Mean No. PCI per centre (all) Mean No. PCI per centre (all) 11221122 398398
Mean No. PCI per centre (NHS)Mean No. PCI per centre (NHS) 14711471 420420
2007 data: Ludman
Aggregate forms
Development of off-site centresDevelopment of off-site centres
PositivesPositives• Increased access to careIncreased access to care• Provides local careProvides local care• Main drive historically was to provide service when Main drive historically was to provide service when
regional tertiary centre could not provide appropriate level regional tertiary centre could not provide appropriate level of activityof activity
NegativesNegatives• Smaller infrastructure, fewer support staffSmaller infrastructure, fewer support staff• Smaller teams, smaller volumes of activitySmaller teams, smaller volumes of activity• May be harder to liase between interventional and surgical May be harder to liase between interventional and surgical
colleaguescolleagues• International literature shows potential for worse outcomesInternational literature shows potential for worse outcomes
Effect of New CentresEffect of New Centres
2007 data: Ludman
Brighton
Effect of New CentresEffect of New Centres
2007 data: Ludman
Worthing
Eastbourne
Hastings
Brighton
Effect of New CentresEffect of New Centres
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2000
2002 2003 2004 2005 2006 2007
CGH. ConquestHospital
W RG. W orthingHospital
DGE. Eastbourne
RSC. Royal SussexCounty Hospital
2007 data: Ludman
Effect of New CentresEffect of New Centres
0
500
1000
1500
2000
2500
3000
3500
2002 2003 2004 2005 2006 2007
BOU. RoyalBournemouthGeneral Hospital
SGH. SouthamptonGeneral Hospital
2007 data: Ludman
Downsizing of larger unitsDownsizing of larger units
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1000
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3500
BAL PAP STH GEO FRE RAD RSC NGS HH KCH SCM NHB WYT PLY STM QEB STO WAL BRI UCL
2003
2004
2005
2006
2007
Numbers of PCIs neededNumbers of PCIs needed
• NSF 2000NSF 2000– 1500 revascularisations pmp1500 revascularisations pmp– 750 PCI / 750 CABG750 PCI / 750 CABG
• BCS Workforce document 2005BCS Workforce document 2005– 2200-3000 PCI pmp2200-3000 PCI pmp
• DoH Stocktake exercise 2007DoH Stocktake exercise 2007– 1900, 2200, 2500 revascularisations pmp1900, 2200, 2500 revascularisations pmp– 3:1 ratio PCI:CABG3:1 ratio PCI:CABG– ~1400, 1650, 1900 PCIs pmp~1400, 1650, 1900 PCIs pmp
• ““Services are saturated” versus Services are saturated” versus “We’re clearly under-providing”“We’re clearly under-providing”
ConclusionsConclusions• Growth in activity is likely to depend on growth in Growth in activity is likely to depend on growth in
PPCI and angioplasty for non-STEMI ACS PPCI and angioplasty for non-STEMI ACS patientspatients
• Considerable regional differences are likely to be Considerable regional differences are likely to be ironed outironed out– Updated guidelinesUpdated guidelines
• Delivery of services should be determined by a Delivery of services should be determined by a review of the changing epidemiology and review of the changing epidemiology and evidence base for PCIevidence base for PCI– Importance of the Clinical Network and SHAImportance of the Clinical Network and SHA
• We’re moving from a “cold” to a “hot” serviceWe’re moving from a “cold” to a “hot” service• Should all PCI centres be 24/7 services?Should all PCI centres be 24/7 services?