BCIS Audit Returns Adult Interventional Procedures Jan 2005 to Dec 2005 Peter F Ludman BCIS National Audit Officer On behalf of British Cardiovascular Intervention Society Manchester 2006

Audit Domains: Structure 2005 data: Ludman

Barnet General Barnsley Chesterfield Royal Colchester General Darent Valley Hospital Dorset County Hosp Hope Hospital, Salford Diagnostic Angiography New Angiography Only Centres data: Ludman Maidstone Hospital Medway Maritime Hospital Royal Bolton St Richards, Chichester Wigan Royal Infirmary William Harvey, Ashford

Goring Hall N Staffs Nuffield Little Aston 3 Stopped Changes in Centre’s Activity data: Ludman 7 Started PCI Bradford Royal Infirmary Hemel Hempstead General Derbyshire Royal Infirmary Queen Alexandra Hospital, Portsmouth Rochdale Bournemouth Whipp's cross 1 PCI → angio BUPA Bristol

UK Centres data: Ludman

83 87 PCI centres Angiography only Centres 2005

UK Countries PCI Centres in 2005 ScotlandNHS7 Private1 EnglandNHS54 Private17 N Ireland2 Wales2 Total83

PCI Data Requested Form C CCAD Form A & B

UK Interventional and Diagnostic centres 2005 No.No cath data No PCI data Caths (% of total) PCIs (% of total) NHS Interventional 65 Private Interventional 18 Diagnostic only 87 TOTAL data: Ludman

Centres Providing No Data London Independent 2005 data: Ludman

UK Interventional and Diagnostic centres 2005 No.No cath data No PCI data Caths (% of total) PCIs (% of total) NHS Interventional 652 Private Interventional 18 Diagnostic only 87 TOTAL170 Missing angiography data estimated from 2004 figures 2005 data: Ludman Northern General, Sheffield Royal Brompton

UK Interventional and Diagnostic centres 2005 No.No cath data No PCI data Caths (% of total) PCIs (% of total) NHS Interventional 652 Private Interventional 183 Diagnostic only 87 TOTAL data: Ludman BMI Park, Notts London Independent London Bridge Missing angiography data estimated from 2004 figures

UK Interventional and Diagnostic centres 2005 No.No cath data No PCI data Caths (% of total) PCIs (% of total) NHS Interventional 652 Private Interventional 183 Diagnostic only 876 TOTAL data: Ludman Arrowe Park Hospital (Currie) Chesterfield Royal (Cooke) Dewsbury (Smyllie) Great Western Hosp (McCrea) Neville Hall Hospital (Hutchison) Woolwich, QE (Shakespeare) Missing angiography data estimated from 2004 figures

UK Interventional and Diagnostic centres 2005 No.No cath data No PCI data Caths (% of total) PCIs (% of total) NHS Interventional 6520 Private Interventional 1831 Diagnostic only 876NA TOTAL 170 Missing PCI data estimated from 2004 figures 2005 data: Ludman London independent

UK Interventional and Diagnostic centres 2005 No.No cath data No PCI data Caths (% of total) PCIs (% of total) NHS Interventional ,847 (68%) Private Interventional ,299 (5%) Diagnostic only 876NA 55,636 (27%) TOTAL , data: Ludman

UK Interventional and Diagnostic centres 2005 No.No cath data No PCI data Caths (% of total) PCIs (% of total) NHS Interventional ,847 (68%) 66,841 (95%) Private Interventional ,299 (5%) 3,301 (5%) Diagnostic only 876NA 55,636 (27%) NA TOTAL ,78270, data: Ludman

PCI per Angiogram ratio 2005 data: Ludman

PCI per Angiogram ratio ESC Survey data: Ludman Cook S for WG 10 of the ESC. EuroIntervention 2006;1:374

Population estimates Mid 2005 Scotland 5.09 m England m Wales 2.96 m est: Rx in Wales: 2.2 m Northern Ireland 1.72 m est: Welsh Rx in England 0.8 m Total UK: 60.2 m Total Rx in England m 2005 data: Ludman

Total UK PCI Procedures 2005 data: Ludman

PCI activity to 2005 (UK) 2005 data: Ludman

Rate of increase in PCI numbers pmp 2005 data: Ludman

Total PCIs in the UK Countries by Type of Institution Total No.s of PCI 2005 data: Ludman

PCIs/million UK Countries (2000 to 2005) 2005 data: Ludman

PCI vs Isolated CABG Numbers (UK) 1991 to 2005 Note:CABG data for financial yr all PCI v NHS CABG 2005 data: Ludman

PCI vs Isolated CABG Ratio (UK) 2000 to data: Ludman

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

No. of Interventional Consultants (NHS centres) Note: if work at two NHS centres will be counted twice Includes cardiologists and radiologists 2005 data: Ludman Data from: 64 of 65 centres

No. of Interventional Consultants (NHS centres 2005) 2005 data: Ludman Mean Note: if work at two NHS centres will be counted twice

Mean PCI/consultant No. of PCIs per Consultant (NHS Centres) 2005 data from 64 of 65 centres Note: data from institutional volume divided by No operators per institution 2005 data: Ludman

Visiting Interventionists (NHS Centres) 2005 data from 64 of 65 centres 2005 data: Ludman

Surgical Cover ( all 65 NHS centres) 2005 data: Ludman

Surgical Cover (all 83 NHS and Private Centres) On siteOff 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

Day Case PCI 29 of 70 Units performing day case PCI –7 more than data: Ludman Data from: 70 of 83 centres +53% +21%

Day Case PCI data: Ludman

Primary PCI Routine Rx for STEMI 2005 data: Ludman NHS Centres only Working Hours Only24/7 Number of centres

Audit Domains Structure Appropriateness Process Outcome 2005 data: Ludman

Annual returns Procedure Specific Data Form C CCAD Form A & B Data Quality

CCAD Import Issues Mandatory Fields (6) 1.01 Hospital Identifier 1.02 Local Patient Identifier 3.01 Date and time of operation 1.06 Birth Date 2.01 Clinical Syndrome 2.02 Indication for Intervention field 1field 2field 3field 103 …… Patient 1 Patient 2 Patient n …..

CCAD Import Issues Mandatory Fields (6) 1.01 Hospital Identifier 1.02 Local Patient Identifier 3.01 Date and time of operation 1.06 Birth Date 2.01 Clinical Syndrome 2.02 Indication for Intervention Must be date AND time

CCAD Import Issues Mandatory Fields (6) 1.01 Hospital Identifier 1.02 Local Patient Identifier 3.01 Date and time of operation 1.06 Birth Date 2.01 Clinical Syndrome 2.02 Indication for Intervention Duplicates occur if re-import with any of these changed Identifies a Unique record

CCAD Import Issues Mandatory Fields (6) 1.01 Hospital Identifier 1.02 Local Patient Identifier 3.01 Date and time of operation 1.06 Birth Date 2.01 Clinical Syndrome 2.02 Indication for Intervention

CCAD Import Issues 2.02 Indication for Intervention 1Stable - angina 2Stable - coronary/LV anatomy 3ACS - UA, NSTEMI or convalescent STEMI 4ACS - Primary PCI for STEMI (no lysis) 5ACS - Facilitated PCI for STEMI (lysis + PCI) 6ACS - Rescue PCI for STEMI (failed lysis) 7ACS - PCI for reinfarction (no lysis) 8ACS - Rescue PCI for reinfarction (failed lysis) 9Staged procedure 10Hybrid procedure 11Acute or subacute PCI thrombosis 12Bail out following acute complication of diagnostic cardiac catheterisation 98Unlisted 99Unknown 2.01 Clinical Syndrome Stable Acute coronary syndrome (ACS/AMI) Cannot be

CCAD Import Issues Indication for Intervention 1Stable - angina 2Stable - coronary/LV anatomy 3ACS - UA, NSTEMI or convalescent STEMI 4ACS - Primary PCI for STEMI (no lysis) 5ACS - Facilitated PCI for STEMI (lysis + PCI) 6ACS - Rescue PCI for STEMI (failed lysis) 7ACS - PCI for reinfarction (no lysis) 8ACS - Rescue PCI for reinfarction (failed lysis) 9Staged procedure 10Hybrid procedure 11Acute or subacute PCI thrombosis 12Bail out following acute complication of diagnostic cardiac catheterisation 98Unlisted 99Unknown 2.01 Clinical Syndrome Stable Acute coronary syndrome (ACS/AMI) Cannot be

CCAD Import Issues Indication for Intervention 1Stable - angina 2Stable - coronary/LV anatomy 3ACS - UA, NSTEMI or convalescent STEMI 4ACS - Primary PCI for STEMI (no lysis) 5ACS - Facilitated PCI for STEMI (lysis + PCI) 6ACS - Rescue PCI for STEMI (failed lysis) 7ACS - PCI for reinfarction (no lysis) 8ACS - Rescue PCI for reinfarction (failed lysis) 9Staged procedure 10Hybrid procedure 11Acute or subacute PCI thrombosis 12Bail out following acute complication of diagnostic cardiac catheterisation 98Unlisted 99Unknown 2.01 Clinical Syndrome Stable Acute coronary syndrome (ACS/AMI) Procedure Urgency Elective Urgent Emergency Salvage Must be

In Hospital Mortality Potential for ‘double counting’ Indication – stable, elective Outcome – SAT, repeat PCI Discharge status - Dead Indication – SAT, emergency Outcome – Death Discharge status - Dead 1 st PCI Stable Elective SAT2 nd PCIDeath

Analysis England and Wales Form C CCAD Aggregate analysis by centre (Mortality double counting eliminated) Merge Cleaned Data cleansing

Analysis Scotland and N Ireland Form C

England and WalesScotland and N Ireland Merge Final counts

CCAD Data for 2005 from Barts The London CTC Liverpool Royal Bournemouth Bradford RI Bristol RI Castle Hill Derby Royal Birmingham Heartlands Freeman St Georges Glenfield Hemel Hempstead Harefield King’s King Edward VII Leeds GI Manchester RI New Cross Northern General Royal Brompton North Hampshire Derriford Queen Alex Portsmouth Queen Elizabeth B’ham John Radcliffe Royal Devon & Exeter Royal Free Royal Sussex James Cook Southend St Peter’s St Thomas’s St Mary’s Torbay UCL University Hospital Wales Victoria Hosp Whipps cross Wythenshaw 2005 data: Ludman

CCAD data quality % Total 2005 PCI data in CCAD (E&W) 2005 data: Ludman % of Total As Sept 06

CCAD data quality Centres with > 80% of Total 2005 PCI data in CCAD 2005 data: Ludman As Sept 06 % of Total 2005 PCI data in CCAD

CCAD data quality Centres with > 80% of Total 2005 PCI data in CCAD 2005 data: Ludman As Sept 06 % of Total 2005 PCI data in CCAD

CCAD data quality Centres with < 80% of Total 2005 PCI data in CCAD 2005 data: Ludman % of Total 2005 PCI data in CCAD As Sept centres no 2005 data

CCAD data quality 2005 data: Ludman % of CCAD data with Hospital Outcome recorded (E&W) All of the following fields are NOT blank: 4.01 Hospital outcome 4.03 Status at Discharge 4.04 Discharge Date

CCAD data quality 2005 data: Ludman % of CCAD data with Hospital Outcome recorded (E&W) As Sept 06

STEMI

PCI for STEMI data: Ludman 7% of all PCI (5.5% 2004)

PCI for STEMI data: Ludman

PCI for All STEMI 2005 data from NHS centres Total 4921procedures 0 or No data 2005 data: Ludman

PCI for All STEMI 2005 data: Ludman

Primary PCI for STEMI 2005 data from NHS Centres Total 2916 procedures 0 or No data 2005 data: Ludman

Primary PCI for STEMI 2005 data: Ludman

Primary PCI for STEMI 2005 data: Ludman As Percentage of Each Centre’s PCI Activity

PCI for Stable v ACS Of Total PCIs performed –44% Acute (UA/NSTEMI/STEMI) –56% Stable 2005 data: Ludman

Stent procedures 2005 data from 53 of 65 centres 2005 data: Ludman

PCI using any Stent Type 2005 data from 58 of 83 Centres 2005 data: Ludman

Stent per PCI ratio 2005 All cases treated with a stent –38,719 stents used in 23,882 cases –1.62 stents per case Cases using DES –23,363 DES used in 13,075 cases –1.78 stents per case

Drug Eluting Stent cases 2005 data from 80 of 83 centres 2005 data: Ludman NHS and private Mean of % use by Centres

Drug Eluting Stent cases - NHS 2005 data from 63 of 65 NHS centres 2005 data: Ludman

DES use by Centre (NHS) 2005 data: Ludman

Drug Eluting Stent cases 2005 data from 80 of 83 centres 2005 data: Ludman

PCI for Restenosis (2005 data from 49 of 83 centres) Mean: % % % % 2005 data: Ludman

BMS and DES use V PCI for Restenosis 2005 data: Ludman

Use of GP IIb/IIIa blockers 2005 data from 78 of 83 centres Overall mean % use 2005 data: Ludman

GP IIb/IIIa use by Presentation data: Ludman Note: stable and PPCI data from Scotland (Fm C) and E&W (CCAD) UA and NSTEMI E&W only

Multi-vessel Treatment All clinical syndromes 2005 data: Ludman

Multi-vessel Treatment by centre 2005 data: Ludman

Mean (Range) 2005 data: Ludman Multi-vessel Treatment All Clinical Presentations

2005 data: Ludman Multi-vessel Treatment By centre

Additional Interventional Coronary Techniques (1) 2005 data from 77 of 83 centres UnitsNo ∆ % cf 2004 * % of all procs Mean**Range Rotablation % Atherctmy (DCA) 47-36% TEC3350% Laser212-80% Cutting balloon % *% of all UK interventional procedures **Mean number in units using the technique 2005 data: Ludman

Additional Interventional Coronary Techniques (2) 2005 data from 77 of 83 centres UnitsNo ∆ cf 2004 % of all procs MeanRange Thrombectomy % Distal protection % Brachytherapy33-95% data: Ludman

Other Interventional Techniques 2005 data from 77 of 83 centres UnitsNo ∆ cf 2004 % of all procedures MeanRange PTMR % Septal ablation % data: Ludman

Alcohol Mediated Septal Ablation (HOCM) 2005 data: Ludman Total 59 procedures

Other Diagnostic Techniques 2005 data from 77 of 83 centres UnitsNo∆ cf 2004 % of all procedures MeanRange IVUS % Press wire % Flow wire % data: Ludman

Adult non coronary intervention 2005 data from 77 of 83 centres UnitsNo ∆ cf 2004 MeanRange MV plasty % AV plasty % PV plasty % TV plasty 22 0% 11 PDA % ASD * % PFO % data: Ludman * 2 units do not split their ASD/PFO data –here amalgamated to ASD closure

Mitral Balloon Valvuloplasty 2005 data: Ludman Total 153

Adult non coronary intervention 2005 data from 77 of 83 centres UnitsNo ∆ cf 2004 MeanRange VSD congen VSD post MI LAA occlusion data: Ludman

Adult great vessel intervention 2005 data from 77 of 83 centres UnitsNo ∆ cf 2004 MeanRange Coarct / Re-coart % Carotid435+21% Aorta23-57% Pulm art546+44% SVC932-6% data: Ludman

Radial Artery Access 11,010 cases: 15.7% of all PCI (10.2% in 2004) 2005 data: Ludman Data from: 77 of 83 centres

Femoral artery closure devices 2005 data from 75 of 83 centres Mean use by Centre: 47% FA closure in 37% of all PCIs 2005 data: Ludman

Audit Domains Structure Appropriateness Process Outcome

YearData From Total with mortality data Mortality %Range % /54 11,365 (17,344) /53 14,476 (20,511) /58 17,577 (22,902) /61 16,946 (24,899) /63 20,975 (28,133) /66 24,323 (33,652) /64 29,001 (38,992) /64 37,437 (44,913) /73 49,194 (53,261) /78 56,027 (62,780) /83 61,037 (70,142) Mortality - All PCIs All Data from CCAD + Form C 2005 data: Ludman

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) 0.54 (53 of 64) (62 of 73) 0.36 (56 of 73) 0.17 (62 of 73) 0.29 (64 of 73) 0.53 (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 - All PCIs All Data from CCAD + Form C 2005 data: Ludman

All Procedures: Outcome 2005 data: Ludman

Outcome 2005 Total CCAD cleaned data All Patients 2005 data: Ludman No.SuccessNQMIQMI Em CABG Death 22, %0.4%0.2%0.13%0.71%

All as %No.Success Partial success Fail no comp Re- PCI QMI Em CABG Death Stable SV (no CTO) MV (no CTO) SV CTO MV CTO Overall Stable ALL % Outcome 2005 Total CCAD cleaned data 2005 data: Ludman Elective Patients

All as % No.Success Partial success Fail no comp Re- PCI QMI Em CABG Death NSTEMI / UA no shock All STEMI no shock Primary PCI Rescue PCI Shock Outcome 2005 Total CCAD cleaned data 2005 data: Ludman

Summary: Mortality Risk Stratified by Syndrome 2005 data: Ludman

Mortality by Syndrome 2005 data: Ludman

Total Mortality 2005 data from 81 of 83 centres 2005 data: Ludman Mean by Centre = 0.59% Mean all PCI = 0.56% 4 deaths out of 111 PCIs 3 for NSTEMI 1 for shock

Public Reporting of PCI data BCIS Data Monitoring Subgroup P. Ludman / M. Thomas / R. Stables / S. Redwood Data must be analysed and presented in such a way as to avoid causing operators to turn down high risk patients Unit specific data –Risk stratified MACCE outcome –Process data – door to balloon time etc.

Risk Stratified Outcome Centre A Centre B 50 cases Shock, PPCI, Renal failure 50 cases Stable elective, NSTEMI Mortality 15% Mortality 0.5 % RA Mortality 0.5% Risk Adjustment Model

Risk Stratified Outcome North West Quality Improvement Programme risk score A D Grayson, R K Moore, M Jackson, S Rathore, S Sastry, T P Gray, I Schofield, A Chauhan, F F Ordoubadi, B Prendergast, R H Stables Heart 2006;92:658–663

Future Data Quality reports

VLAD (Variable Life Adjusted Display) Case 1 Clinical features: Age - 80 Sex - female Diabetes - Yes Urgent PCI No Shock Predicted risk of in hospital event (MACCE) Death QMI CVA Em CABG Risk Prediction Model

VLAD plots Better Worse Case 1 – risk of MACCE 5 % - No MACCE Up by 0.05 Performance

VLAD plots Better Worse Case 2 – risk of MACCE 60 % - No MACCE Up by 0.6 Performance

VLAD plots Better Worse Case 3 – risk of MACCE 70 % - MACCE Down by 1 – 0.7 = 0.3 Performance

VLAD plots Better Worse Case 4 – risk of MACCE 5 % - MACCE Down by 1 – 0.05 = 0.95 Performance

Summary 2005 (UK) 2005 data: Ludman 83 PCI centres in UK 1,165 PCI pmp in UK Cath : PCI = 34% PCI : CABG = 3.1 : 1 CCAD –40 of 56 units with 2005 data (16 none) –MACE –Stable syndromes Mortality 0.14%, CABG 0.1% –UA / NSTEMI Mortality 0.64%, CABG 0.13% Plans –Data quality to improve –Risk adjusted outcome –Process audit