1. Consistency in diagnostic and treatment procedures Specifically angiography and angioplasty Dr Alison Round 14 October 2015

2. How the comparators were chosen
A composite of variables:
3 relate to proportion of young people in the population,
2 to measures of ethnicity,
2 to measures of deprivation and health outcomes,
2 to measures of population density,
1 each to proportion of elderly, mobility of population and total population.
Standardised differences between variables added together to find an overall minimal difference
There is no perfect way to do this.

3. Demographics of comparators
CCG
Early CVD (<75) mortality (rank)
Early stroke (<75) mortality (rank)
Late stroke (>75) mortality (rank)
% population living in the most deprived 5th national wards (rank)
% population over 75
NEW Devon
38.6 (8)
11.6 (6)
641.6 (8)
11.3 (8)
9.6 (7)
Gloucestershire
40.3 (9)
12.7 (8)
634.7 (7)
7.2 (4)
7.6 (5=)
Kernow
36.9 (50)
14.7 (10)
855.7 (10)
9.8 (7)
7.2 (3=)
Dorset
30.4 (3)
12.4 (7)
617.4 (6)
7.8 (5)
11.3 (10)
Somerset
35.5 (4)
13.0 (9)
659.0 (9)
3.7 (2)
10.0 (9)
Oxfordshire
29.8 (2)
10.9 (3)
572.0 (3)
5.5 (3)
7.2 (3)
Cambridge and Peterborough
38.4 (7)
7.9 (2)
574.9 (4)
9.4 (6)
7.1 (2)
Nene
37.2 (6)
11.3 (4=)
517.2 (1)
11.8 (9)
6.8 (1)
West Hampshire
28.6 (1)
7.2 (1)
576.6 (5)
<1 (1)
9.8 (8)
Southern Derbyshire
53.4 (10)
540.1 (2)
16.5 (10)

4. Directly standardised rates / 100,000 pop.
Procedure
NEW Devon
Lowest comparator
Highest comparator
England average
Angiography male
480
273
597
448
Angiography female
252
139
364
239
Angioplasty male
223
174
390
220
Angioplasty female 76 51
123 72
CABG male 86 28 94 64
CABG female 21 7 15

5. Why we might consider doing less
NICE guidance on recent onset chest pain CG95
The extent to which bypass surgery confers incremental prognostic benefit in people with three vessel or left main stem disease who are also treated with contemporary secondary prevention therapies (antiplatelet agents, statins, renin-angiotensin system inhibitors) is uncertain
Medical treatment is more cost-effective than early revascularisation with either CABG or PCI in people with stable coronary artery disease including people with type 2 diabetes mellitus. However if symptoms are not controlled, revascularisation is effective and could be cost-effective.

6. Why we might consider doing less
Offer coronary angiography to guide treatment strategy for people with stable angina whose symptoms are not satisfactorily controlled with optimal medical treatment. All people with stable angina should be offered appropriate medical therapy, but if symptoms are not controlled they should be considered for myocardial revascularisation
NICE guidance on chronic heart failure CG108
Coronary revascularisation should not be routinely considered in patients with heart failure due to systolic left ventricular impairment, unless they have refractory angina.