Professor Roger Boyle CBE National Director for Heart Disease and Stroke Department of Health PCI in the UK: Fit for service? A view from the Department of Health

CONFLICTS OF INTEREST I work for the Department of Health!

Acknowledgement I have drawn on Peter Ludman’s work quite extensively

Death rate per 100,000 population Target: 40% minimum reduction from baseline rate baselineProgresstarget Source: ONS (ICD ; ICD10 I00-I99) SAVING LIVES Circulatory Disease Mortality Target Death rates from All Circulatory Disease in England and target Persons under Rates are calculated using the European Standard Population to take account of differences in age structure. ICD9 data for 1993 to 1998 and 2000 have been adjusted to be comparable with ICD10 data for 1999 and 2001 onwards. 3 year average Progress since baseline: A fall of 40.3% Target achieved five years ahead of schedule Immortality guaranteed by 2026

69 in English NHS 16 private

BCIS Peer Review System New PCI centres should be subject to BCIS peer review BEFORE starting Minimum number of cases should be 200 per year with clear plans to increase to 400 per year Minimum of three operators Arrangements for surgical cover Network agreement to the service

England – Total Waiters – by SHA – April 2004 – August Angiography Last 3 years 5 months

England – Total Waiters – by SHA – April 2004 – August PCI Last 3 years 5 months PCI

Rationale for NIAP Need for test of feasibility in NHS Need for cost-effectiveness data relevant to NHS

PPCI Lysis No Reperfusion

NIAP and National Guidance launch event Key issues –General acceptance of direction of travel –Debate regarding the proportion of the population that would still require thrombolysis –DH estimate that we can reach 97% of population, others more like 80% Other issues –Some pushback regarding our statement advising against hybrid models

Lord Voldemort of Worthing

Peter Weissberg Medical Director BHF “We must not replace a first class thrombolysis service, which is proven to save lives, with a second class angioplasty service, which might not.”

MINAP data

Sunday Mirror Mail on Sunday

Reperfusion Services NHS Improvement Survey – November 2008 PPCI hospitals43 24/7 service28 Restricted hours20 Thrombolysis and PPCI20 Hybrid service restricted hours PPCI and thrombolysis 12

Future Network Plans 10 networks have full 24/7 PPCI service 6 networks have a business case for PPCI Of these: 3 networks plan to have 24/7 PPCI by March network will commence in Jan in the process of developing business case Some hybrid service due to travel times and 120 minute window

Results from ALKK Zahn et al Heart 2008; 94: P for trend 0.004

18,504 consecutive patients in US Moscucci et al, JACC 2005; 46: Adjusted odds ratio of adverse CV events by volume per operator

Paris PCI registry Spaulding et al European Heart J 2006; 27:

MINAP – STEMI IN HOURS & OUT OF HOURS – 2007 Per Week (average) - By SHA of Admission Based on 55% In Hours / 45% Out of Hours AVE PER WEEK Missing Data London Chest

Consensus event 24 th September One fifth of England’s cardiologists present General agreement that Networks were the right building blocks for planning purposes for angioplasty services General agreement that BCIS had a major role in setting standards and continuing peer review visits General agreement that we should move to reporting and publishing outcome data Less consensus as to how and where PCI services should be provided Also doubts about minimum numbers for PPCI

Lord Voldemort of Worthing

Cardiac Networks