BCIS Audit Returns Adult Interventional Procedures

Jan 2007 to Dec 2007

Peter F Ludman BCIS National Audit Lead On behalf of British Cardiovascular Intervention Society

Crewe 2008 Contents 2007 data: Ludman

• Structure • Process of care – New centres – Changes to Dataset – Total PCI numbers (cut many ways) – Delays to treatment NSTEMI – No of procedures per unit – Delays to treatment Primary PCI – Effects of new units on existing units • Non coronary intervention – PCI Operators – HOCM septal ablation – Surgical cover – Mitral valuloplasty – Day case activity – Other adult structural intervention – Primary PCI units – Transcutaneous Aortic Valves • PCI Procedure specific data • Outcome – CCAD – MACCE – data completeness – ONS tracking – Demographics – Outcome by lesion and syndrome – indication for PCI / Clinical syndrome – Mortality by coronary syndrome – Stents (BMS and DES) – Mortality for PCI of bypass grafts, – Adjunctive therapy CTO, LMS – LV support – Models for risk adjusted outcome – Multi-vessel treatment – Cumulative funnel plots – Additional interventional techniques – Arterial access Structure 2007 data: Ludman Angiography Centres 2007

2007 data: Ludman New Centres Royal Glamorgan Hospital Kingston Hospital Tameside Hospital Addenbrookes Hospital Queen Mary’s Sidcup

Centres ceasing activity BMI princess Margaret, Windsor Inverclyde BUPA Murrayfield PCI Centres 2007

2007 data: Ludman

PCI Centres stop Western General Edinburgh (moved to ERI) King Edwards, Midhurst PCI Centres 2007

New PCI Centres 2007 data: Ludman BMI Meriden Frimley Park Hospital

PCI centres from existing angiography units Conquest, Hastings Dorset County Hospital Essex Heart Centre, Basildon Ninewells Hospital, Dundee Queen Elizabeth Hospital, Woolwich Wigan Royal Infirmary Wycombe Hospital UK Centres 2007

PCI Angio only 2007 data: Ludman 120 91 98 100 83

80 90 87 85 60

40 No. of Centres of No. 20

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 UK Centres 2007

Angiography (85) PCI (98) 2007

Angiography (85)

PCI (98) PCI Centres in 2007 UK Countries

Scotland NHS 7 Private 1 England NHS 69 Private 16 N Ireland 3 Wales 2 Total 98 PCI Data Sources

All UK England Wales Angio Only Aggregate PCI Audit form Audit form partial Scotland (via MINERVA upload)

CCAD UK Interventional and Diagnostic centres

2007 2007 data: Ludman

No. No No Caths PCIs cath PCI (% of total) (% of total) data data NHS 81 2 0 158,250 75,017 Interventional Private 17 0 0 7,038 2,356 Interventional Diagnostic 85 2 na 58,350 0 only TOTAL 183 223,638 77,373

Aggregate forms PCI activity to 2007 (UK) 2007 data: Ludman

PCI per million PCI Procedures 1800 90000 77,373 1600 80000 73,612 1400 70000 1269 1216 1200 60000

1000 50000

800 40000

600 30000 PCI per million

400 20000 PCI Procedure Numbers

200 10000

0 0 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Aggregate forms Rate of increase in PCI numbers pmp

2007 data: Ludman

5 Rate of Increase (%) of Increase Rate

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Aggregate forms PCI pmp Europe 2007 Widimsky P, ESC 2008 4000 D IZR A 3500 B I SLO 3000 PL NL 2500 CZ NO CH 2000 S DK 1500 FIN H E 1000 UK TR 500 HR SRB BG 0 SK RO PCI / million / year RU PCI per Angiogram ratio

2007 data: Ludman

35 34.6% 30

25 20 % Angio/PCI 15 (all UK) 10 5 0 1998 2000 2002 2004 2006 Aggregate forms Total PCIs in the UK Countries by Type of Institution

Total No.s of PCI 2007 data: Ludman

70000 63433 60000 2000 2001 50000 2002 40000 2003 30000 2004 2292 6438 2005 20000 64 2006 10000 2899 2247 2007 0 England England Scotland Scotland N. Ireland Wales NHS Private NHS Private Aggregate forms Total PCIs in the UK Countries by Type of Institution

Total No.s of PCI 2007 data: Ludman

7000 6438 6000 2000 2001 5000 2002 4000 2292 2003 2899 2004 3000 2247 2005 2000 2006 1000 64 2007 0 England England Scotland Scotland N. Ireland Wales NHS Private NHS Private Aggregate forms Population estimates

Mid 2007 2007 data: Ludman Total UK: 60.975 m Scotland 5.144 m

Northern Ireland 1.759 m

England 51.093 m est: Welsh Rx in England 0.8 m Total Rx in England 51.9 m

Wales 2.98 m est: Rx in Wales: 2.2 m PCIs/million UK Countries

1800 2007 data: Ludman 1648 1600 1267 1264 2000 1400 2001 1200 1031 2002 1000 2003 800 2004 600 2005 2006 400 2007 200 0 England Scotland N. Ireland Wales

Aggregate forms PCI vs Isolated CABG Numbers (UK) 1991 to 2007

2007 data: Ludman

80000 70000

60000 PCI 50000 CABG 40000 30000 20000 10000

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Note: CABG data for financial yr Aggregate forms PCI vs Isolated CABG Ratio (UK) 2000 to 2007

2007 data: Ludman

4 3.1 3.1 3 3 2.5 2.1 Ratio 2 1.8 1.6 1.3 1

2000 2001 2002 2003 2004 2005 2006 2007

Aggregate forms Number of PCIs performed in 2007 (per NHS Centre)

Mean = 926 2007 data: Ludman

3500 3000 2500 2000 1500

1000 Number of PCIs 500 0 Individual Centres

Data from: all NHS centres Aggregate forms Number of PCIs performed in 2007 (per NHS Centre)

Mean = 926 2007 data: Ludman

3500 3000 2500 2000 1500

1000 Number of PCIs 500 0 Individual Centres 29 Centres performing < 400 cases (36%)

Data from: all NHS centres Aggregate forms Number of PCIs performed in 2007

10 Centres performing < 200 procedures 2007 data: Ludman

St Peter's Chertsey (2003)

East Surrey Hospital (2006)

Dorset County (2007)

Wycombe Hospital (2007)

Ninewells, Dundee (2007)

QE Woolwich (2007)

Wigan Royal Inf (2007)

Southend (2007)

Frimley Park (2007)

Conquest Hosptial (2007)

0 20 40 60 80 100 120 140 160 180 200 PCI program start date Number of PCIs performed in 2007

19 Centres performing 200 to 400 procedures 2007 data: Ludman

Sandwell District Hospital (2003) Mayday Hospital (2006) North hampshire Hospital (2003) William Harvey, Kent (2006) Rochdale Inf (2005) Wexham Park (2006) Royal United Bath (2006) Worthing Hospital (2006) Derbyshire Royal inf (2005) Torbay Hospital (2004) Northwick Park (2003) Craigavon Hospital (2006) Great Western Hospital (2006) Sunderland Hospital (2006) Golden Jubilee Hospital (2003) Hemel Hempstead (2005) Bradford Royal Inf (2005) Eastbourne (2006) Whipps Cross (2005)

0 50 100 150 200 250 300 350 400 PCI program start date Effect of New Centres

2007 data: Ludman

Brighton Effect of New Centres

2007 data: Ludman

Brighton

Worthing Hastings

Eastbourne Effect of New Centres

2007 data: Ludman 2000 1800 1600 CGH. Conquest 1400 Hospital 1200 WRG. Worthing Hospital 1000 DGE. Eastbourne 800 600 RSC. Royal Sussex 400 County Hospital 200 0 2002 2003 2004 2005 2006 2007 No. of Interventional Consultants (NHS centres)

2007 data: Ludman

600 547 40 519 500 35 424 441 30 400 362 312 25 292 Total 300 20 % Increase 15 Number 200 10 100 5

0 0

2001 2002 2003 2004 2005 2006 2007

Note: if work at two NHS centres will be counted twice Includes cardiologists and radiologists No. of Interventional Consultants (NHS centres 2007)

2007 data: Ludman

25 Mean 20 2000 5.5 2001 6.1 Number of 15 2002 6.5 Interventional Consultants 10 2003 6.7 2004 7.4 5 2005 7.0 2006 6.9 0 Individual Centres 2007 6.9

Note: if work at two NHS centres will be counted twice No. of PCIs per Consultant (NHS Centres 2007)

2007 data: Ludman 350 300 250 200 150 100

PCIs per Consultant 50 0 Individual Centres

Note: Data from institutional volume divided by No operators per institution Some consultants work in multiple institutions PCI per Consultant Unit case number / Number of operators

150 2007 data: Ludman 145 140 135 130 125 120 115 Numberof PCIs 110 105 100 2000 2001 2002 2003 2004 2005 2006 2007 On v Off Site Surgery All Centres (NHS and private)

2007 data: Ludman

100%

28 80% 38 45

60% Off Site On Site 40% 55 53 53 20% 54%

0% 2005 2006 2007

Aggregate forms On v Off Site Surgery NHS Centres only

2007 data: Ludman

100%

80% 26 37 42 60% Off Site On Site 40% 38 38 39 20% 48% 0% 2005 2006 2007

Aggregate forms Surgical Cover (2007 - all 81 NHS centres)

2007 data: Ludman

Off site On Site

3500 3000 2500 PCIs per 2000 Mean Centre 1500 1471 1000 500 420 0 Individual Centres

Aggregate forms Surgical Cover (all 98 NHS and Private Centres)

2007 data: Ludman

On site Off site No of centres 53 45 (54%) (46%) No. of PCI (% of total) 59,455 17,918 (77%) (23%) Mean No. PCI per centre (all) 1122 398 Mean No. PCI per centre (NHS) 1471 420

Aggregate forms Day Case PCI

• 47 of 87 Units performing day case PCI 2007 data: Ludman

10000 25

9000 8589

8000 20

7000

6000 5780 15 Number 5000 4603 % % of all PCI Number 4000 11 10 3018 7.8 3000 2492 2000 +49% 5 +53% +26% 1000 +21%

0 0 2003 2004 2005 2006 2007

Data from: 87 of 98 centres Day Case PCI (2007 Data from 87 of 98 centres)

2007 data: Ludman

1000 900 800 700 600 Number of 500 PCIs 2006 400 2007 300 200 100 0 Individual Centres Primary PCI Routine Rx for STEMI

2007 data: Ludman Working Hours 24/7 100% 100%

80% 80%

60% 60%

40% 40% 50 38 20% 28 32 20% 22 28 13 13 18

0% 0% 5 Percentage of NHS CentresNHS of Percentage

2004 2005 2006 2007 2008 2004 2005 2006 2007 2008

Number of centres

81 NHS Centres only Working Hrs includes all 24/7 sites Contents 2007 data: Ludman

Participation 2007 data: Ludman Total No. of Data to Participation Centres CCAD England NHS 67 (69)* 67 100% Private 16 6 37% Wales 2 2 100% N Ireland 3 0 0 Scotland NHS 7 7 via link* 100%

*2 new centres not yet linked ‘Front end’ Database used

BCIS Tomcat 1111 PATS 2 2 1 4 18 Lotus Notes 4 Minerva Datacam 5 Medcon Carddas GE Paper 5 15 Infoflex local db 8 Prism 11 Cardiobase 11 Cardex isoft PAS Centricity CCAD data quality 2007 data: Ludman PCI data in CCAD as % of Reported Totals

Wycombe Hospital HemelBradford Hempstead Royal InfirmaryGeneral Derbyshire Royal Infimary Royal BournemouthVictoria Hospital Walsgrave Hospital (UniversityRoyal HospitalCornwall Coventry) Hospital Wigan Royal Infirmary, Royal AlbertNew Edward Cross InfirmaryHospital Northwick Park Hospital CheltenhamCity General Hospital Sunderland Royal Hospital SouthamptonHeart GeneralHospital Hospital (UCLH) Queen Alexandra Hospital Queen ElizabethSt Peter'sHospital, Hospital Bham Norfolk & Norwich Hospital Royal Brompton Hospital and Harefield NHSFreeman Trust, Brompton Hospital Derriford Hospital HarleyMorriston Street Hospital Clinic Wellington Hospital CromwellTorbay Hospital StSouthend Thomas' Hospital James Cook University Hospital Sandwell District General Hospital Royal Brompton HospitalFrimley and Park Harefield Hospital NHS NHS Trust, Foundation Harefield Trust, site BirminghamEastbourne City Hospital Royal Berkshire andConquest Battle Hospital Liverpool Cardiothoracic Centre Rochdale Infirmary, Silver Heart Unit PenineYorkshire Acute Hospital Heart Centre Trust University Hospital of Wales Royal DevonRoyal & Exeter Free Hospital Glenfield Hospital BirminghamNorth HampshireHeartlands Hospital Nottingham City Hospital WythenshawePapworth Hospital Worthing Hospital ManchesterMayday University Royal InfirmaryHospital Whipps Cross University Hospital RoyalNorthern Sussex General County Hospital John Radcliffe Hospital LondonBristol Bridge Royal InfirmaryHospital Castle Hill Hospital (Hull and East YorkshireTaunton & NHS Somerset Trust) HammersmithNinewells Hospital Royal infirmary of Edinburgh KingsHairmyres College Hospital London Chest Hospital, Barts and the London St Mary'sLister Hospital AberdeenRoyal United Royal InfirmaryHospital Glasgow Western Infirmary Great Western Hospital, Wiltshire Cardiac Centre GoldenSt George's Jubilee Hospital William Harvey Hospital, East Kent Hospitals NHS Trust GlasgowBMI RoyalPriory InfirmaryHospital East Surrey Hospital, Surrey and Sussex NHS trust WexhamSt Anthony's Park Hospital 0 50 100 150 200 As Sept 08 CCAD data quality 2007 data: Ludman PCI data in CCAD as % of Reported Totals

Hairmyres Hospital Kings College Hospital London Chest Hospital, Barts and the London St Mary's Hospital Lister Hospital Royal United Hospital Aberdeen Royal Infirmary Glasgow Western Infirmary Great Western Hospital, Wiltshire Cardiac Centre St George's Hospital Golden Jubilee Hospital William Harvey Hospital, East Kent Hospitals NHS Trust BMI Priory Hospital Glasgow Royal Infirmary East Surrey Hospital, Surrey and Sussex NHS trust St Anthony's Hospital Wexham Park Hospital

0 20 40 60 80 100 As Sept 08 CCAD data quality 2007 data: Ludman PCI data in CCAD as % of Reported Totals Centres with < 90% of their activity in CCAD

0 20 40 60 80 100 As Sept 08 CCAD data quality 2007 data: Ludman PCI data in CCAD as % of Reported Totals

Wycombe Hospital HemelBradford Hempstead Royal InfirmaryGeneral Derbyshire Royal Infimary Royal BournemouthVictoria Hospital Walsgrave Hospital (UniversityRoyal HospitalCornwall Coventry) Hospital Wigan Royal Infirmary, Royal AlbertNew Edward Cross InfirmaryHospital Northwick Park Hospital CheltenhamCity General Hospital Sunderland Royal Hospital SouthamptonHeart GeneralHospital Hospital (UCLH) Queen Alexandra Hospital Queen ElizabethSt Peter'sHospital, Hospital Bham Norfolk & Norwich Hospital Royal Brompton Hospital and Harefield NHSFreeman Trust, Brompton Hospital Derriford Hospital HarleyMorriston Street Hospital Clinic Wellington Hospital CromwellTorbay Hospital StSouthend Thomas' Hospital James Cook University Hospital Sandwell District General Hospital 2007 Royal Brompton HospitalFrimley and Park Harefield Hospital NHS NHS Trust, Foundation Harefield Trust, site BirminghamEastbourne City Hospital Royal Berkshire andConquest Battle Hospital 69,822 cases Liverpool Cardiothoracic Centre Rochdale Infirmary, Silver Heart Unit PenineYorkshire Acute Hospital Heart Centre Trust University Hospital of Wales Royal DevonRoyal & Exeter Free Hospital Glenfield Hospital BirminghamNorth HampshireHeartlands Hospital Nottingham City Hospital Missing data: WythenshawePapworth Hospital Worthing Hospital ManchesterMayday University Royal InfirmaryHospital Whipps Cross University Hospital 3,476 cases of RoyalNorthern Sussex General County Hospital John Radcliffe Hospital LondonBristol Bridge Royal InfirmaryHospital 73,298* Castle Hill Hospital (Hull and East YorkshireTaunton & NHS Somerset Trust) HammersmithNinewells Hospital Royal infirmary of Edinburgh 4.7% KingsHairmyres College Hospital London Chest Hospital, Barts and the London St Mary'sLister Hospital AberdeenRoyal United Royal InfirmaryHospital Glasgow Western Infirmary Great Western Hospital, Wiltshire Cardiac Centre GoldenSt George's Jubilee Hospital William Harvey Hospital, East Kent Hospitals NHS Trust GlasgowBMI RoyalPriory InfirmaryHospital East Surrey Hospital, Surrey and Sussex NHS trust WexhamSt Anthony's Park Hospital 0 50 100 150 200 As Sept 08 *total of cases performed by units uploading to CCAD CCAD data quality 2006 data: Ludman PCI data in CCAD as % of Reported Totals

BHH. Rochdale Infirmary BAL. Barts and the London BHR. Royal Berkshire and Battle GRL. Glenfield Hospital HHH. Hemel Hempstead General HHW. Wellington Hospital LGI. Yorkshire Heart Centre FRE. Freeman Hospital RDE. Royal Devon & Exeter Hospital WRG. Worthing Hospital RAD. John Radcliffe Hospital SAN. Sandw ell District General DUD. City Hospital QEB. Queen Elizabeth Hospital, CHG. Cheltenham General Hospital STH. St Thomas' Hospital 2006 WAL. Walsgrave Hospital SCM. James Cook University Hospital WYT. Wythenshaw e Hospital TOR. Torbay Hospital SPH. St Peter's Hospital QAP. Queen Alexandra Hospital PAP. Papw orth Hospital MOR. Morriston Hospital MAY. Mayday University Hospital Missing data: LIS. Lister Hospital KES. King Edw ard Seventh Hospital DER. Derby Royal Infimary CRO. Cromw ell Hospital 4,300 cases of BRD. Bradford Royal Infirmary BOU. Royal Bournemouth Hospital HAM. Hammersmith Hospital HSC. Harley Street Clinic 56,000 MRI. Manchester Royal Infirmary NOR. Norfolk & Norw ich Hospital HH. Harefield Hospital BHL. Cardiothoracic Centre Liverpool WHC. Whipps Cross University 7.7% NHB. Royal Brompton Hospital CHN. Nottingham City Hospital NGS. Northern General Hospital UHW. University Hospital of Wales DGE. Eastbourne DGH PLY. Derriford Hospital EBH. Birmingham Heartlands Hospital NCR. New Cross Hospital BAT. Royal United Hospital Bath MPH. Taunton & Somerset NHH. North Hampshire Hospital SEH. Southend Hospital RFH. Royal Free Hospital WHH. William Harvey Hospital BRI. Bristol Royal Infirmary KCH. King's College Hospital RCH. Royal Cornw all Hospital CHH. Castle Hill Hospital VIC. Victoria Hospital PMS. The Great Western Hospital RSC. Royal Sussex County Hospital GEO. St George's Hospital PHB. BMI Priory Hospital UCL. University College Hospital ANT. St Anthony's Hospital SUN. Sunderland Royal Hospital STM. St Mary's Hospital ESU. New East Surrey Hospital WEX. Wexham Park Hospital 0 50 100 150 200 As Sept 07 Data Quality Risk Stratified Outcome A D Grayson et al Heart 2006;92:658–663

• NWQIP risk adjustment model % Completeness 12 fields required for risk adjusted outcome NWQIP

Top score potential = 1200 2006 2006

Top Dogs

Under Dogs 2006 2007 Demographics

2007 data: Ludman n=69,677

Age (mean) 64.3 yrs Diabetic 17.5% Previous CABG 8.5% Previous PCI 18.6% Previous MI 29.5%

CCAD Demographics

2007 data: Ludman n=43,929

Ethnic Origin Caucasian 92.3% Asian 6.7% Black 0.83% Oriental 0.2%

CCAD Demographics - Age

Male: mean = 63.1 2007 data: Ludman Female: mean = 67.7

16000 14000 12000 10000 No. PCIs 8000 6000 Male 4000 Female 2000

>90

<=30

31-40 41-50 51-60 61-70 71-80 81-90 Age (yrs)

CCAD Clinical Syndrome

– 47% Stable 2007 data: Ludman – 53% Unstable

100 90 80 70 60 % PCIs for 50 Unstable Sx 40 30 20 10 0 Individual Centres

CCAD Clinical Syndrome

2007 data: Ludman

60 53.2 50 % PCI 46.8 Stable Performed for 40 Unstable each Indication 30

0 2005 2006 2007

CCAD Indication for PCI

2007 data: Ludman Stable 40.48% NSTEMI / UA STEMI 13.24% Other

1.18%

45.10%

CCAD Indication for PCI

Stable 2007 data: Ludman NSTEMI / UA Other STEMI Other 1 40.48% 0.8 Staged 0.6 13.24% Hybrid % SAT 0.4 1.18% Bail out 0.2

0 45.10% CCAD Indication for PCI

Stable 2007 data: Ludman NSTEMI / UA STEMI Other Other

40.48% PCI for Stent Thrombosis: 144 of 64,266 13.24% 0.22%

1.18% (2006 = 0.22%)

45.10% CCAD Indication for PCI

Stable 2007 data: Ludman NSTEMI / UA STEMI STEMI Other

40.48%

13.24%

1.18%

45.10% CCAD Indication for PCI

Stable 2007 data: Ludman NSTEMI / UA STEMI STEMI Other 9 40.48% 8 7 6 Primary 13.24% % 5 Facilitated 4 Rescue 1.18% 3 2 1 0 45.10% CCAD PCI for STEMI

2007 data: Ludman 9000 8153 8000 7000 2001 5866 5902 6000 13.24% of UK PCI 2002 5000 2003 3930 4000 2004 2581 2005 3000 1936 2006 2000 2007 1000 0 All STEMI Primary PCI Rescue

CCAD PCI for STEMI

2007 data: Ludman 9000 8153 8000 7000 2001 5866 5902 6000 2002 5000 2003 3930 4000 2004 2581 2005 3000 1936 2006 2000 2007 1000 0 All STEMI Primary PCI Rescue

CCAD Primary PCI for STEMI 2007 data from NHS Centres

Total 5902 procedures 2007 2007 data: Ludman

600

500

400 Number of 300 procedures 200

100

0 Hospitals

CCAD Primary PCI for STEMI

2007 data: Ludman 2004 2005 2006 2007

600

500

400 Number of 300 procedures 200

100

0 Hospitals CCAD E&W + Scot Primary PCI UK Countries

Total Number of PPCI 2007 data: Ludman

6000

5000 4784

4000

3000 2007

2000

1000 616 74 0 England Scotland Wales

MINAP records 4228 E&W 2007 CCAD Primary PCI UK Countries

PPCI pmp 2007 data: Ludman

140 119.75 120 100 92.17 92.5 80 2007 60 40 20 0 England Scotland Wales

CCAD Stents Procedures using Stents

2007 data: Ludman

100 94.7 90 80 70 60 % of 50 Procedures 40 30 20 10 0 '92 '94 '96 '98 '00 '02 '04 '06 Year

CCAD Drug Eluting Stent cases

Mean of % use by Centres 2007 data: Ludman

80 70 62 63.5 60 53 55 50 40 30 17 20

% DES casesDES% 10 ? 0

2002 2003 2004 2005 2006 2007

NHS and private Drug Eluting Stent cases - NHS

2007 data: Ludman 100 80.1 80 60.7 65 2003 2004 60 49.3 52.2 % Cases 43.2 42 2005 using DES 40 33 2006 20 2007 0 Scotland England Wales N. Ireland Country Stents per Case

Mean stents per case 2005 = 1.62 2007 data: Ludman 2006 = 1.63 2007 = 1.55 2 1.8 1.6 1.4 1.2 Stents per 1 PCI 0.8 0.6 0.4 0.2 0 Individual Centres CCAD BMS and DES use V PCI for Restenosis

2007 data: Ludman 100 14 90 12 80 70 10 60 8 % Stent 50 %DES % Restenosis 40 6 30 4 20 2 10 0 0 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07

PCI for re-stenosis from CCAD Adjunctive therapy Use by Type

2007 data: Ludman 40 31.79 25.31 30 % of Procedures 20

10 4.94 1.59 1.27 0

Tirofiban Abciximab Eptifibatide Bivalirudin

Any IIb/IIIa antag

CCAD GP IIb/IIIa Antagonists Use by Presentation

2007 data: Ludman 100 90 80 % Procedures 70 with any GP 60 2005 50 IIb/IIIa 2006 blocker 40 30 2007 20 10 0

UA PPCI Stable NSTEMI

CCAD LV Support

Data available for 56,737 procedures, 868 shock cases 2007 data: Ludman

LV Support Number % Inotropes 322 0.57 % IABP 983 1.73 %

7 6 5 IABP 4 % per unit 3 2007 2 1 0 Individual centres Multi-vessel Disease Multi-vessel Treatment

Mean vessels per case 2007 = 1.25 2007 data: Ludman 2006 = 1.31 100 78.5 80

% of all 60 2006 PCIs 40 18.3 2007 20 2.9 0 1 2 3 Vessels Treated per case

CCAD Multi-Lesion Treatment

Mean lesions per case 2006 = 1.53 2007 data: Ludman 2007 = 1.49 100

80 65.4 60 % of all PCIs 40 24.3 20 7.6 2.8 0 1 2 3 >3 Number of Lesions treated per case

CCAD E&W Multi-vessel Treatment

2 2007 data: Ludman 1.9 1.8 1.7 Treated 1.6 Vessels 1.5 per Case Mean (Range) 1.4 1.28 1.3 1.23 1.2 1.1

2000 2001 2002 2003 2004 2005 2006 2007 CCAD Multi-vessel Treatment By centre - 2007

2007 data: Ludman

2 1.9 1.8 1.7 1.6 Vessels per 1.5 PCI 1.4 1.3 1.2 1.1 1 Individual Centres

CCAD Additional Interventional Coronary Techniques

2007 data: Ludman ∆ % cf Units No Mean* Range 2006 Rotablation 42 844 +34% 20 1-104 Laser 9 82 +290% 9 2-24 Cutting balloon 65 1050 +40% 16 1-170 Thrombectomy 52 1483 +98 % 29 1-236

Distal protection 59 738 +43% 13 1-88

*Mean number in units using the technique Aggregate data Rotablation

2007 data: Ludman

120

100

80 Number of 60 cases 2007 40

0 Individual Centres

Aggregate data Other Diagnostic Techniques

2007 data: Ludman

Units No ∆ cf 2006 Mean Range IVUS 57 2068 + 88% 36 2-250

Press wire 72 3903 + 38% 54 1-267 IVUS

2007 data: Ludman

16 14 12 10 % of cases 8 2007 6 4 2 0 Individual Centres

Aggregate data Pressure Wire

2007 data: Ludman 25

15 % of cases 10 2007

0 Individual Centres

Aggregate data Radial Artery Access

2007 data: Ludman

30 28.1

25 21.3 20 % Cases 15.7 using Radial 15 Access 10.2 10

0 2004 2005 2006 2007

Aggregate data to 2006, CCAD 2007 Radial Artery Access

2006 2007 2007 data: Ludman

90 80 70 % Cases 60 using 50 Radial 40 Access 30 20 10 0 Individual Centres

CCAD Femoral artery closure devices

FA closure (PCI from FA) 2006 = 39.6% 2007 data: Ludman 2007 = 50.7%

100 90 80 % PCIs 70 from FA 60 using a 50 40 Closure 30 Device 20 10 0 Individual Centres CCAD Complication by Access route

Complications to hospital Dx: False aneurysm 2007 data: Ludman Haemorrhage (retroperitoneal, delay Dx, surgery) Art occlusion Art dissection Any need for surgery

FA: 1.1% RA: 0.6% 432 of 37,444 70 of 12,127 Contents 2007 data: Ludman

2007 data: Ludman Dataset Updates

2007 data: Ludman

Door 1

Door 2 Symptom Call

Door 1 Balloon Home Dataset Updates

2007 data: Ludman

Door 1

Door 2 Symptom Call

Door 1 Balloon Home Dataset Updates

Single data point 2007 data: Ludman ? Door 1 or Door 2

Symptom Call

Balloon Home Dataset Updates to 5.4.4

2007 data: Ludman Data point added Data point Jan 09 added June 08 Door 1

Door 2 Symptom Call

Door 1 Balloon Home Dataset Updates to 5.4.4

Data point 2007 data: Ludman added Data point Jan 09 added June 08 Door 1

Door 2 Symptom Call

Door 1 Balloon Home Call to PCI time Door to PCI time (all admission routes) Time fields Data completeness For Healthcheck 08/09

BCIS Patients treated for STEMI by MINAP Field Field No. Primary PCI No. 2.07 Date/time of symptom onset 3.01 2.08 Date/time of arrival at first hospital 3.06 5.26 Date/time of arrival at PCI hospital 3.26 Date/time of first balloon inflation 3.09 4.04 Discharge date 4.01 > 90% completeness in each Top Dogs Under Dogs PCI for Acute Sx

Four admission scenarios 2007 data: Ludman

Admitted from Already the community in hospital

Admission to Non-PCI centre

Direct admission Transfer Hospital is a Hospital is a to PCI centre to PCI centre PCI centre Non-PCI centre PCI for Acute Sx

Four admission scenarios 2007 data: Ludman

Admitted from Already the community in hospital

Admission to Non-PCI centre

Direct admission Transfer Hospital is a Hospital is a to PCI centre to PCI centre PCI centre Non-PCI centre NSTEMI / UA / Convalescent STEMI Direct admission to PCI centre - 2007

64,266 cases with admit route data 2007 data: Ludman 26,028 Rx for NSTEMI / UA / Convst STEMI 6,473 direct admissions 3,317 with time delay data Excluded data from units with > 5 cases

Time n=3,317 Units Mean of units’ median times Symptom to arrival 4.85 Hours Door to PCI 3.2 Days PCI to discharge 1.2 Days Length of Stay 4.9 Days PPCI for STEMI Direct admission to PCI centre - 2007

Units with PPCI as default strategy for Rx of STEMI 2007 data: Ludman (day time or 24/7, exclude units with < 5 cases)

Time Units Mean of units’ median times Symptom to arrival 2.46 Hours n=1792 Door to Balloon 61.7 Min n=1758 PCI to discharge 3.15 Days n=2197 Length of Stay 3.28 Days n=1821 PPCI for STEMI Direct admission to PCI centre - 2007

Units with PPCI as default strategy for Rx of STEMI 2007 data: Ludman (day time or 24/7, exclude units with < 5 cases)

Time Units Mean of units’ median times Symptom to arrival 2.46 Hours n=1792 Door to Balloon 61.7 Min n=1758 PCI to discharge 3.15 Days n=2197 Length of Stay 3.28 Days n=1821 Door to Balloon Time From Community direct to PCI centre 2007

Units with PPCI as default strategy for Rx of STEMI 2007 data: Ludman (Day time or 24/7) n=1758 120 mean 61.67 min 90

Minutes 60 (Median)

0 Individual Centres Data from 21 of 38 units Door to Balloon Time From Community direct to PCI centre 2007

Units with PPCI as default strategy for Rx of STEMI 2007 data: Ludman n=1758 120 mean 59.4

90 mean 67.2

Minutes 60 (Median) 24/7 Day Time Only 30

0 Individual Centres Data from 6 of 16 day only units 15 of 22 24/7 units Door to Balloon Time From Community direct to PCI centre 2007

Units with PPCI as default strategy for Rx of STEMI 2007 data: Ludman (Day time or 24/7) n=1767 100 90 80 70 % Cases 60 with DTB 50 < 90 min 40 30 20 10 0 Individual Centres Data from 21 of 38 units Door to Balloon Time From Community direct to PCI centre 2007

Units with PPCI as default strategy for Rx of STEMI 2007 data: Ludman n=1767 100

% Cases 60 with DTB 24/7 < 90 min 40 Day Time Only 20

0 Individual Centres Data from 6 of 16 day only units 15 of 22 24/7 units Contents 2007 data: Ludman

• Structure • Process of care – New centres – Changes to Dataset – Total PCI numbers (cut many ways) – Delays to treatment NSTEMI – No of procedures per unit – Delays to treatment Primary PCI – Effects of new units on existing units • Non coronary intervention – PCI Operators – HOCM septal ablation – Surgical cover – Mitral valuloplasty – Day case activity – Other adult structural intervention – Primary PCI units – Transcutaneous Aortic Valves • PCI Procedure specific data • Outcome – CCAD – MACCE – data completeness – ONS tracking – Demographics – Outcome by lesion and syndrome – indication for PCI / Clinical syndrome – Mortality by coronary syndrome – Stents (BMS and DES) – Mortality for PCI of bypass grafts, – Adjunctive therapy CTO, LMS – LV support – Models for risk adjusted outcome – Multi-vessel treatment – Cumulative funnel plots – Additional interventional techniques – Arterial access Adult Non Coronary Intervention Alcohol Mediated Septal Ablation

∆ cf Units No Mean Range 2007 data: Ludman 2006 Septal ablation 12 49 -3.9% 4.1 1-9

14 12 10 2004 8 2005 6 2006 4 2007

2 Number of Procedures 0 Individual Centres Adult non coronary intervention

2007 data: Ludman

∆ cf Units No. Mean Range 2006 MV plasty 30 154 +11 % 5.1 1-17 AV plasty 6 26 +13% 1 1-10 PV plasty 7 27 +125% 3.9 1-27 TV plasty 1 1 0% 1 1 PDA 12 98 +113% 8.2 1-45 ASD 33 573 17 1-78 PFO 35 791 22.6 1-83 Mitral Balloon Valvuloplasty

Total 154 2007 data: Ludman

18 16 14 12 10 8 2007 6 4

Number of MBV Procedures 2 0 Individual Centres Adult non coronary intervention

2007 data: Ludman

∆ cf Units No Mean Range 2006 VSD congen 7 21 -9% 3 1-6 VSD post MI 9 19 +12% 2 1-5 LAA occlusion 0 0 0 0 Adult great vessel intervention

2007 data: Ludman

∆ cf Units No Mean Range 2005 Coarct / Re-coart 10 82 +19% 8.2 1-16 Carotid 4 61 -3% 15 1-41 Aorta 2 62 +417% 31 11-51 Pulm art 8 29 +38% 3.6 1-9 Transcatheter Valves

2007 data: Ludman

∆ % cf Units No Mean Range 2006 Transcatheter Aortic Valve Implantation (TAVI) CoreValve 5 55 11 2-28 Edwards: Femoral 2 11 5.5 1-10 Edwards: Apical 1 6 6 6 Total = 72 Transcatheter Valves

• TAVI Dataset agreed 2007 data: Ludman – Collection via CCAD – Web browser interface – Version: 3.5 – Available from BCIS web site (www.bcis.org.uk) Percutaneous Valves

2007 data: Ludman

∆ % cf Units No Mean Range 2006 Other Pulmonary Valve 3 30 -21% 10 1-26 Mitral Valve Repair 0 Contents 2007 data: Ludman

• Success, Mortality and Emergency CABG – CCAD – Aggregate forms (Some England pp, NI)

• QMI – CCAD – Denominator: Total PCI procedures except PCI for STEMI (only tiny numbers of STEMI treated in units not submitting to CCAD)

• NQMI – CCAD – Denominator: Total PCIs for stable symptoms Mortality - All PCIs All Data from CCAD + private + N Ireland 2007 data: Ludman

Total with Year Data From Mortality % Range % mortality data 11,365 1995 35/54 (17,344) 0.69 0-3.4 14,476 1996 37/53 (20,511) 0.72 0-3.2 17,577 1997 41/58 (22,902) 0.91 0-10 16,946 1998 44/61 (24,899) 0.80 0-9.1 20,975 1999 48/63 (28,133) 0.61 0-4 24,323 2000 48/66 (33,652) 0.64 0-2.6 29,001 2001 45/64 (38,992) 0.75 0-2.8 37,437 2002 53/64 (44,913) 0.54 0-1.9 49,194 2003 64/73 (53,261) 0.53 0-2.0 56,027 2004 66/78 (62,780) 0.56 0-2.2 61,037 2005 81/83 (70,142) 0.59 0-3.6 69,151 2006 83/91 (73,692) 0.74 0-3.0 All 98 77,373 2007 units 0.89 0-3.9 Total Mortality

Mean all PCI = 0.89% 2007 data: Ludman

4 3.5 3 2.5 2 1.5

Mortality (%) 1 0.5 0 Individual Centres Mortality Validation ONS Tracking

2007 data: Ludman Mortality Validation ONS Tracking

2007 data: Ludman

Not tracked (missing NHS No.)

Died 27-12-06, 20 days post PCI Mortality Validation ONS track as 21-2-2008

2007 data: Ludman 2006 2007

PCI in CCAD PCI in CCAD 50,666 64,224

Tracked Tracked 48,495 39,392 95.7% 61% Mortality Validation

2007 data: Ludman 2

1.5

2007 1

2006 % Mortality % 0.5

0 Unit 2 4 6 7 10 20 30 reported In ONS tracked mortality by Hospital days post PCI date Death Mortality Validation

2007 data: Ludman 2

1.5

2007 1

2006 % Mortality % 0.5

0 Unit 2 4 6 7 10 20 30 reported In ONS tracked mortality by Hospital days post PCI date Death MACE - All PCIs 2007 data: Ludman

% % NQMI Mortality Year Procedure % QMI % Em. CABG Success (stable) (%) 1997 92 1.2 1.1 0.89 1998 92 0.8 0.7 0.80 1999 90 0.57 0.48 0.61 2000 92 0.6 0.4 0.64 2001 94 0.5 0.4 0.75 2002 92 0.57 0.28 0.54 (51 of 64) (49 of 64) (53 of 64) (53 of 64) 2003 92 0.36 0.29 0.53 (62 of 73) (56 of 73) (64 of 73) (64 of 73) 2004 93.5 0.30 0.21 0.56 (63 of 78) (57 of 78) (64 of 78) (66 of 78) 2005 90.2 0.24 0.12 0.59 2006 95.5 0.15 0.74 0.09 0.74 2007 92.1 0.14 0.62 0.08 0.89 All Procedures: Outcome

2007 data: Ludman 3.0

2.5

2.0 Mortality % 1.5 em CABG 1.0

0.5

0.0 '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 Outcome 2007

Elective Patients 2007 data: Ludman No. Partial Fail no Em All as % Success Re-PCI QMI Death cases success comp CABG Stable SV 17,205 95.8 3.1 0.29 0.15 0.06 0.09 (no CTO)

MV 5165 92.9 5.8 0.71 0.13 0.29 0.08 0.25 (no CTO)

SV CTO 2470 66.8 30.6 0.16 0.04 0.08 0.2

MV CTO 805 71.1 25.8 2.7 0.12 0 0.25 0.25 Overall Stable ALL 25,645 91.6% 0.24 0.16 0.07 0.14 Outcome 2007

2007 data: Ludman

Partial Fail no Re- Em No. Success QMI Death All as % success comp PCI CABG NSTEMI / UA 24103 no shock 93.4 2.6 3.2 0.3 0.2 0.08 0.61 All STEMI 7485 92.8 1.9 2.7 0.6 0.09 2.6 no shock

Primary PCI 5330 90.1 2.0 2.4 0.5 0.19 4.8

Rescue PCI 2161 90.5 2.1 3.1 0.8 0.05 4.3

Shock 868 67.1 4.1 2.1 0.5 0.50 27.8 Summary: Mortality Risk Stratified by Syndrome

6 2007 data: Ludman 4.8 5 4.3 4 2003 % 3 2004 2005 2 2006 0.89 0.61 2007 1 0.14 0 All Elective UA / Primary Rescue NSTEMI PCI Mortality by Syndrome

40 2007 data: Ludman 35 30 25 2003 % 20 2004 2005 15 2006 10 2007 5 0 All Elective UA / Primary Rescue Shock NSTEMI PCI Bypass grafts PCI of SVG and Arterial 2007

2007 data: Ludman

Partial Fail no Re- Em No. Success QMI Death All as % success comp PCI CABG Bypass Grafts 5008 89.6 2.6 6.8 0.2 0.18 0 0.90 Chronic Total Occlusions 2007

2007 data: Ludman

Partial Fail no Re- Em No. Success QMI Death All as % success comp PCI CABG Chronic Total Occlusion 5092 67.5 9.3 20.7 0.4 0.2 0.16 1.2 Unprotected LMS 2007

2007 data: Ludman

Partial Fail no Re- Em No. Success QMI Death All as % success comp PCI CABG Unprotected LMS 842 83.8 7.4 2.6 0.1 0.48 0.7 7.0

N.B. Includes all clinical presentations (including shock) In hospital outcome PCI Risk Adjustment Models

Date PCIs Outcome Author Database / patient source were N Outcome assessed time point performed Hannan22 New York 1991 5,827 Death In Hospital Hannan23 New York 1991-1994 62,670 Death In Hospital Kimmel24 SCAI registry 1992-1993 10622 Death / MI / emCABG In Hospital Ellis25 6 Hospitals in the United States 1993-1994 12,985 Death / MI / CABG In Hospital O’Connor26 NNE 1994-1996 15,331 Death In Hospital DeBelder27 Single centre, London UK 1995-1996 1500 Death / MI / emCABG In Hospital Ellis13 Cleveland Clinic 1995-1997 6327 Death / MI / emCABG In Hospital

Qureshi28 William Beaumont Hospital, Michigan 1996-1998 9,954 Death In Hospital Singh29 Mayo Clinic 1996-1999 5463 Death / MI / emCABG / In Hospital urCABG / CVA Moscucci30 8 Michigan Hospitals 1997-1999 10,729 Death In Hospital Resnic31 Brigham and Women’s Hospital, 1997-1999 2,804 Death / MI / emCABG In Hospital Boston Shaw32 ACC-NCDR 1998-2000 50,123 Death In Hospital De Luca33 Zwolle 1994-2001 1791 Death 30 day Grayson11 4 hospitals in North West England 2001-2003 9914 Death / MI / emCABG / In Hospital CVA Wu34 NewYork 2002 46,090 Death In Hospital Valgimigli16 Patient from the ARTS II trial35 2003 306 Death / MI /CVA / revasc 30/7, and 300/7 Variable Life Adjusted Display…… VLAD the Impaler

Cumulative Funnel plots Babu Kunadian, Joel Dunning, Anthony P Roberts, Robert Morley, Darragh Twomey, James A Hall, Andrew G C Sutton, Robert A Wright, Douglas F Muir and Mark A de Belder BMJ 2008;336:931-4 Cumulative MACCE

MACCE in case 4 50 Case 9 MACCE in case 10 1 in 4 1 in 9 2 in 10 45 mean 25% mean 11% mean 20% 40 35 30 25 20

MACCE % MACCE 15 10 5 0

Case 0Case 1Case 2Case 3Case 4Case 5Case 6Case 7Case 8Case 9 Case 10Case 11 Cumulative MACCE

50 Predicted MACCE 45 40 10% 35 5% 30 25 20 MACCE % MACCE 15 10 5 0

Case 0Case 1Case 2Case 3Case 4Case 5Case 6Case 7Case 8Case 9 Case 10Case 11 Cumulative MACCE

50 Predicted MACCE Running Mean 45 40 10% 35 5% 30 7.5% 25 20 MACCE % MACCE 15 10 5 0

Case 0Case 1Case 2Case 3Case 4Case 5Case 6Case 7Case 8Case 9 Case 10Case 11 Cumulative MACCE

50 45 Actual Mean MACCE 40 Predicted Mean MACCE 35 30 25 20 15 MeanMACCE % 10 5 0

Case 0Case 1Case 2Case 3Case 4Case 5Case 6Case 7Case 8Case 9 Case 10Case 11 Cumulative MACCE plots Worse

Worse Should we be concerned? Statistical Control Limits

99.8%

95% Risk Adjusted Outcome Observed MACCE

+3 σ +2 σ -2 σ -3 σ

CCAD CCAD

email Summary 2007 (UK)

• 98 PCI centres in UK • 1,269 PCI pmp in UK • Rise in PCI remains small • CCAD a successful tool • Outcomes similar to 2006 • Plans – Improve delays to PPCI reporting – Risk adjusted outcome BUT beware the pitfalls – In depth analysis of the CCAD dataset • Additional data on the web site The End

Acknowledgments • Andrew Donald – Programmer at CCAD • Tony Roberts and Robert Morley – Statistical process control chart development • Owen Nicholas – Statistician at NICOR • Rachel Slack, Jill Pell, Keith Oldroyd – Scottish database contacts Appendix

• Modifications to slides since presentation: – Slide 25: Change to a hospital name on slide – Slide 59: Corrected errors in calculation of unit specific ratio of acute to stable coronary syndromes