DGH v Tertiary Intervention Is there really a conflict? “The BCIS Perspective” Dr Martyn Thomas Kings College Hospital BCIS President

MY CONFLICTS OF INTEREST ARE: Research Support: Boston Scientific, Cordis and Medtronic Advisory Board for: Boston, Cordis, Abbott, Lilly and Nycomed.

DGH v Tertiary Intervention (p.s. surgical v non surgical centres!) Is there really a conflict? “The BCIS Perspective” What “experience” do I have to give such a talk? What “experience” do I have to give such a talk? - BCIS President - Currently perform PCI at Kings College Hospital (Teriary) AND the “Mayday Hospital” (DGH). Gives some perspective!!

DGH v Tertiary Intervention Is there really a conflict? “The BCIS Perspective” Where does the UK stand in worldwide terms with regard to revascularisation??

Total UK PCI Procedures 2005 data: Ludman

A worldwide perspective.

UK Centres data: Ludman

What are the current guidelines: for a new PCI centre?

What are the current guidelines: for an operator?

Number of PCIs performed in 2005 ( per NHS Centre) 2005 data: Ludman Data from: all 65 NHS centres Mean = 1028

Surgical Cover

Surgical cover

Year % Procedure Success % QMI % Re PCI for acute closure % Em. CABG Mortality (%) (51 of 64) 0.57 (49 of 64) 0.33 (50 of 64) 0.28 (53 of 64) (62 of 73) 0.36 (56 of 73) 0.17 (62 of 73) 0.29 (64 of 73) (63 of 78) 0.30 (57 of 78) 0.30 (61 of 78) 0.21 (64 of 78) 0.56 (66 of 78) MACE (2005) - All PCIs All Data from CCAD + Form C 2005 data: Ludman

Surgical Cover (all 83 NHS and Private Centres) On site Off site No of centres 54(65%)29(35%) No. of PCI (% of total) 57,545(82%)12,622(18%) Mean No. PCI per centre PCIs per interventionist (all 65 NHS centres only): data: Ludman

Tertiary (Surgical) and DGH (Non-Surgical) centres receiving BCIS visits since 2004 (the “Truth!”. 1:20 is a Surgical centre!

Tertiary (surgical centre) Paranoia Where is all the work? What will we do?

The Model (DOH) 3 levels of revascularisation tested; 1900, 2200 and 2500 per million, by levels of revascularisation tested; 1900, 2200 and 2500 per million, by % increase in ICDs, reaching latest NICE guidelines by % increase in ICDs, reaching latest NICE guidelines by A range of 5-15% increase in interventions for EP/arrythmias. A range of 5-15% increase in interventions for EP/arrythmias.

NB: BCS 2004 proposed per million for PCI alone!! NB: BCS 2004 proposed per million for PCI alone!!

The Model Revasc rates by 2015 PCI:CABG ratio /mill2.9:13.1:13.5:1 2200/mill3.2:13.4:14.2:1 2500/mill3.4:13.8:14.9:1

Where will PCI take place in the future?

Implications for cath lab capacity

Potential growth areas ? For the surgical centres “Hole” closure: PFO, ASD etc. “Hole” closure: PFO, ASD etc. Percutaneous Valve therapy. Percutaneous Valve therapy. Intramyocardial injection therapy Intramyocardial injection therapy “Gene/cell” therapy. “Gene/cell” therapy.

Specific “issues” with a change toward PCI in non-surgical centres (not outcome related!) Changes needed in the organisation of some interventional research. Changes needed in the organisation of some interventional research. Case Mix (the Tariff). Case Mix (the Tariff).

Interventional Research Consequences of a “devolved service” Currently a “handful” of surgical centres have the infra-structure, and perform international multicentre randomised trials and registries. Currently a “handful” of surgical centres have the infra-structure, and perform international multicentre randomised trials and registries. For FIM type cases this requires relatively straightforward lesions………..these will be increasingly rare in the surgical centres. For FIM type cases this requires relatively straightforward lesions………..these will be increasingly rare in the surgical centres. A change of infra-structure/research staff etc will therefore be necessary for this activity to continue. A change of infra-structure/research staff etc will therefore be necessary for this activity to continue.

The Tariff Problems of Case Mix E15: Percutaneous coronary intervention E15: Percutaneous coronary intervention Elective £3660 Elective £3660 Non-elective £4758 Non-elective £4758 CABG elective £7195 CABG elective £7195 CABG non elective £8748 CABG non elective £8748 Kings MFF 1.3 Kings MFF % uplift +16% uplift Leads to PCI elective=£5519 and PCI non elective=£7175 Leads to PCI elective=£5519 and PCI non elective=£7175

Tertiary centre: year cases referred from DGH 60% unstable and 40% stable 25% multiple stents Simple elective: make £500, Complex elective: lose £1000 Simple elective: make £500, Complex elective: lose £1000 Simple non-elective: make £1,500, Complex non- elective: lose 1,500 Simple non-elective: make £1,500, Complex non- elective: lose 1,500 Revenue: Revenue: Simple non-elective: +£67,500 Simple non-elective: +£67,500 Complex non-elective: -£22,500 Complex non-elective: -£22,500 Simple elective: +£15,000 Simple elective: +£15,000 Complex elective: -£10,000 Complex elective: -£10,000 Net income= +£50,000 Net income= +£50,000

Tertiary centre: year 2 25 cases referred from DGH (all complex), 75 cases done in non surgical centre. Non-surgical centre: Non-surgical centre: Simple non-elective: +£67,500 Simple non-elective: +£67,500 Simple complex: +£15,000 Simple complex: +£15,000 Revenue: +£82,500 Revenue: +£82,500 Tertiary centre: Tertiary centre: Complex non-elective: -£22,500 Complex non-elective: -£22,500 Complex elective: -£10,000 Complex elective: -£10,000 Revenue: -£32,500 Revenue: -£32,500

Potential consequences of the Tariff and non-surgical centre PCI. Potential diversion of revascularisation toward surgery because of “skewed” case mix leading to PCI being non-viable. Potential diversion of revascularisation toward surgery because of “skewed” case mix leading to PCI being non-viable. Potential of “profiteering” of DGH at the expense of Quality. Potential of “profiteering” of DGH at the expense of Quality.

Personnel view!! Fully supportive of non-surgical centre PCI, as long as volume and expertise are maintained. Fully supportive of non-surgical centre PCI, as long as volume and expertise are maintained. Here are the last x2 cases at the Mayday………….last Thursday. Here are the last x2 cases at the Mayday………….last Thursday.

Conclusions  Training and experience has more influence on outcome of PCI than location.  As long as individual and institutional volumes are maintained BCIS fully supports the development of non-surgical centre PCI.  Strong links between the surgical centre and non-surgical centre with exchange of personnel and audit data in both directions is essential.  Achievement of “European” type rates of revascularisation cannot be done without full use of the non-surgical cath labs.

Conclusions  Development of research infrastructure within the non-surgical centres should be encouraged.  Surgical centre operators should be encouraged to “support” non-surgical centres, including performing PCI sessions.  Some form of tariff sharing may be required across Networks to make all units viable and to avoid distortion of clinical practice for financial reasons.