MINAP: MINAP: Equity of Access in the National Databases in Wales? Swansea University/ABMU, NICOR Swansea University/ABMU, Clive Weston Clinical Director MINAP

MINAP National Heart Attack audit Wales, England, Northern Ireland > 10 years; 80-90,000 cases per year Originally designed to record and promote improved care of STEMI Continuous, comprehensive, national audit 130 data-items pre-hospital & in-hospital management Incorporated into NICOR

NICOR Congenital surgery Pacing & devices New technologies e.g. TAVI Heart FailureMINAP Adult cardiac surgery Intervention: PCI British Cardiac Audits (national)

Wales – 2014/15 n=5891 (total records) 4371 (74%) final diagnosis of ACS 3233 (74%) documented first heart attack – nSTEMI 2700 (62%) – 65% male – STEMI 1671 (38%) – 70% male Median age: – nSTEMI male 69 y; nSTEMI female 74 y – STEMI male 64.8 y; STEMI female 71.3 y

Of STEMI getting reperfusion In Wales 81.7% patients had primary PCI compared to 79.5% in 2013/14. – c.f. England: 99.3%; Northern Ireland: 94% Of 433 cases where thrombolysis was given in E/W/NI, 182 were given in Wales – 68 by ambulance personnel – 46.4% within 1 hour of calling for help; median DTN 30 min; median CTN 64min – 86.2% go on to have angiogram during admission

Hospital thrombolysis Only three hospitals in E/W/NI report giving thrombolysis to 20 or more patients with STEMI – all N.Wales Those reporting 3-19 patients: – 3 hospitals in NI; 4 hospitals in England (incl. Isle of Wight); Jersey; Isle of Man Median DTN 30 min (c.f. 46 min in Eng) Median CTN 64 min (c.f. 104 min in Eng)

PPCI in Wales N Wales 16% of all reperfusion is PPCI S Wales 99% of all reperfusion Hospitals reporting PPCI 2014/15 – Glan Clwyd26 – Morriston342 – Royal Gwent21 – UHW393

Timeliness of PPCI DTB: In Wales 84% of 782 eligible patients were treated with primary PCI within 90 minutes of arrival compared to 87% of 491 in 2013/14. CTB: In Wales 70.2% were treated within 150 minutes of calling for help (and 43.7% within 120 minutes), compared with 75% patients within 150 minutes, and 52% within 120 minutes in 2013/14.

Timeliness of PPCI: Liverpool Median DTB 31 min – 98.5% treated within 90 mins (of arrival) Median CTB 107 mins – 78.3% treated within 150 mins (of call) – 50% of those inter-hospital transfers achieve 150 min CTB c.f. 96% of direct admissions

Inter-hospital transfers In Wales, 79.8% patients receiving primary PCI were admitted directly to interventional hospitals. For direct admissions, 76.4% had a CTB within 150 minutes and 47.3% within 120 minutes. c.f. 28.6% within 150 minutes and 19.5% within 120 minutes following ‘inter-hospital transfers’. Median CTB 123 min c.f. 181 min

For nSTEMI (n=2741) 87.6% ‘seen by cardiologist’ (within first 24 h) – same in North & South 68% admitted to cardiac ward in North and 74.5% in South [reflection of case ascertainment?] Angiography before discharge 83% in North and 75% in South Delay to angiography for all Wales (excluding inter-hospital transfer) – 0-24 h 8.5% h 16.9% – h 15.7% >96 h 41.5% – h 17.4% NICE Quality Standard = within 72 Hr

Secondary prevention medication 81% of patients in N Wales discharged following ACS on all drugs for which they are eligible 59% in S Wales [Max number of drugs = 5 (two antiplatelets; ACEi or ARB; BB; statin)]

Length of Stay (Median + interquartile range) STEMI 3 days (2 – 6 days) nSTEMI 5 days (3 – 10 days) i.e. 25% of patients with STEMI have a length of stay of >6 days 25% of those with nSTEMI have a length of stay of > 10 days

Continuing problems with participation Case ascertainment and Data quality – Minimum data standards – Access to HES (PEDW) – Adjusted 30-day mortality - reliable identification and reasonable management of ‘outliers’ ‘Data (collector’s) fatigue’ – Perceived/actual dual data collection – BCIS vs MINAP (audits of procedure vs event) – What’s the point? Resource allocation at local level

Continuing problems Data for research vs data for QI/QA Accommodating new treatments in old datasets – Incorporating PROMS/PREMS New demands – e.g. (NHSE) Best Practice Tariff; CSQM; MyNHS Commissioning through evaluation (CtF) – Individual operator level outcomes Accessibility to/interpretation of results Timeliness and frequency of reports – Inadequate responsiveness

Do we need Prudent Audit? Only collect what no-one else is collecting Only collect data that cannot be accessed ‘automatically’ Link to (validated) routine administrative data wherever possible Only collect data that has immediate relevance – Don’t worry about, “If only…”