1. BCIS Audit Returns Adult Interventional Procedures 2002 Peter F Ludman BCIS National Audit Officer On behalf of British Cardiovascular Intervention Society Brighton 2003

2. Audit Domains Structure Appropriateness Process Outcome

3. Audit Domains Structure Appropriateness Process Outcome

4. UK Intervention Centres

5. 64 65 PCI centres Angiography only Centres 2002

6. UK Interventional and Diagnostic centres 2002 No.No cath data (%) Caths* (% of total) PCIs (% of total) NHS Interventional 480115,681 (70%) 42,007 (94%) Private Interventional 161 (6%) 10,021 (6%) 2,906 (6%) Diagnostic only 6512 (18%) 39,471 (24%) TOTAL129165,17344,913 *Missing data assumed to be equal to previously reported activity

7. Centres not reporting diagnostic numbers Interventional –Harley Street Diagnostic only –Ayr Hospital –Derbyshire Royal Infirmary –Inverclyde Royal Hospital –Lister, Stevenage –Mayday University Hospital –Nevill Hall Hospital, Abergavenny –Northwick Park Hospital –Rotherham Hospital –Royal Gwent, Newport –Salisbury District Hospital –St Mary's, Portsmouth –Sunderland Royal Hospital

8. Angiograms per PCI

9. Angiography : PCI rates Europe 2000

10. Annual Procedures per cath lab (NHS centres) MeanMedianRange Interventional labs Procedures (pa) per lab 11591148437 to 2480 Procedures (pa) per No of weekly sessions 14913149 to 346 Diagnostic labs Caths (pa) per lab*740609150 to 2300 Caths (pa) per No of weekly sessions* 17315350 to 512 *Mobile lab excluded

11. Interventional centres providing NO DATA None

12. Number of PCIs performed in NHS Centres (total per annum)

13. Total UK PCI Procedures

14. Rate of increase in Procedure numbers per million Change in population estimate

15. PCI Rates per million population (UK) Assumes UK population of: 58.8 m mid 2001, 59.2m mid 2002

16. Total PCIs in the UK Countries (2000 to 2002) Total No.s of PCI

17. PCIs/million UK Countries (2000 to 2002) NSF NB Wales data does not include those treated in England

18. Rates of PCI (Commissioned in England 2002/3) NSF

19. PCI rates versus SMR (Commissioned in England 2002/3) Correlation coefficient - 0.3 (p = NS)

20. PCI vs Isolated CABG Numbers (UK) Data from BCIS and SCTS Registry 1.31.5 Ratio PCI:CABG ? 1.7

21. PCI vs CABG breakdown (Commissioned in England 2002/3) Ratio 1.4 : 1

22. PCI and CABG rates per million (Europe 2000) 1.81.4 4.2 0.7 2.0 0.9 1.3 2.8 1.4 2.0 1.7 4.1 5.4 3.3 2.4 3.0 2.3 Ratio PCI:CABG

23. Ratio PCI: CABG (Europe 2000)

24. No. of Interventional Consultants (NHS centres, UK 2002) Mean 2000 5.5 2001 6.1 2002 6.5 Total = 312 Includes local and visitors, cardiologists and radiologists

25. No of PCIs per Consultant (NHS Centres) data from 48 centres Note: data from institutional volume divided by No operators per institution Mean PCI/consultant: 2000125 2001126 2002138

26. Visiting Interventionists (NHS Centres 2002) 4.7 Interventionists/Centre Mean: 156 PCIs/year 7.6 Local + Visitors/Centre Mean: 127 PCIs/year

27. Surgical cover (Data for 2002) On siteOff site No of centres 5311 No. of PCI (% of total) 39763 (89%) 5150 (11%) Mean No. procedures per centre 750468 Operator volume: PCIs per interventionist * 149100 * NHS Centres only

28. Audit Domains Structure Appropriateness Process Outcome

29. Appropriateness Indications –Severity of symptoms –Objective assessment of myocardial ischaemia –Angiographic disease severity –etc. Risk stratification –Clinical presentation –LV function –Renal function –etc.

30. CCAD

31. Audit Domains Structure Appropriateness Process Outcome

32. Minimum Data (form B) Minimal or No data from: No data –None Minimal Data –None

33. Stent procedures 1992 - 2002 2002 data from 63 of 64 centres

34. Stenting in different centres 1998-2002 2002 data from 63 of 64 centres

35. PCI for Restenosis 1998 - 2002 (2002 data from 48 of 64 centres)

36. PCI in patients with past CABG 2002 (Data from 45 of 64 centres) Note: Includes procedures on native vessels and grafts Mean 8.4%

37. Use of GP IIb/IIIa blockers 2002 data from 62 of 64 centres Note: Possible underestimate of small molecule use

38. Abciximab in different centres 1999 - 2002 2002 data from 62 of 64 centres

39. Abciximab use by Clinical Presentation (2002 data from 47 of 64 units)

40. Other Coronary Interventional Techniques (1) 2002 data from 62 of 64 centres UnitsNo∆ % cf 2001 * % of all procs ** Mean *** Range Rotablation27170+170.386.31-37 Atherctmy (DCA) 713-540.031.91-4 TEC112+3000.0312 Laser515-350.0331-9 Cutting ballon471226+372.726.11-93 Thrombectomy ¥ 20147+1530.398.71-37 Brachytherapy7143+100.3220.47-52 *% of all UK interventional procedures **Mean number in units using the technique ***Range in units using the technique ¥ PercuSurge, Rescue, Angiojet, X-sizer

41. Other Coronary Interventional Techniques (2) 2002 data from 62 of 64 centres UnitsNo∆ % cf 2001 * % of all procedures ** Mean *** Range PTMR 128+470.0628 Septal ablation 24+1000.0121-3 Distal protection 968+940.157.62-19 Self reported data not specially requested *% of all UK interventional procedures **Mean number in units using the technique ***Range in units using the technique

42. Non coronary cardiac intervention 2002 data from 62 of 64 centres UnitsNo∆ % cf 2001 % of all procedures ** Mean *** Range MV plasty 33199-200.4461-23 AV plasty 66-650.0111 PV plasty 926-100.062.91-8 TV plasty 110.00211 PDA 823-440.052.91-6 ASD* 23335+130.7514.62-51 PFO* 1593+1580.26.21-28 VSD (self reported) 28+1670.0244 * Some centres give combined data for ASD/PFO closure

43. Mitral Balloon Valvuloplasty 2002 33 of 64 centres perform MBV

44. Great vessel intervention 2002 data from 62 of 64 centres UnitsNo∆ % cf 2001 * % of all procedures ** Mean *** Range Coarct / Re-coart733+270.074.71-17 Carotid476+37000.17191-70 Data below not specifically requested Pulm art2100.0251-9 SVC270.023.52-5 Aorta120.00422

45. Other Diagnostic Techniques 2002 data from 62 of 64 centres UnitsNo∆ % cf 2001 *% of all procedures ** Mean *** Range IVUS 36877+32.5%2.024.41-217 Angioscopy 00000 Data below not specifically requested Press wire 7137+83%0.319.61-44 Flow wire 00000 *% of all UK interventional procedures **Mean number in units using the technique ***Range in units using the technique

46. Other procedures 2002 data from 62 of 64 centres UnitsNo∆ % cf 2001 * % of all procs ** Mean *** Range Foreign body removal 5160.043.21-11 Embolisation8240.0531-9 Groin closure48 15,700 +8535.03274-3100 Data below not specifically requested Pericardiotomy11 Spinal cord stimulator 1220.00222

47. Audit Domains Structure Appropriateness Process Outcome

48. ANY Outcome Data (form C) Inadequate or No Data City Hospital, Birmingham Yorkshire Heart Centre University Hosp. Of Wales Edinburgh Royal Infirmary London Chest Freeman, Newcastle Northern Gen. Hosp. Sheffield St Bartholomew's Plymouth Derriford Ross Hall Hospital London Independent St Anthony's The Priory, Birmingham HCI, Glasgow (Golden Jubilee National Hospital) Harley Street Clinic Yorkshire Clinic, Bradford BUPA Lea (Cambridge)

49. HOSPITAL outcome Data (form C) No data from: Cath lab only –Blackpool Victoria –Yorkshire Heart Centre –St Mary's –Papworth Hospital –Glasgow Western Infirmary –Wythenshawe, Manchester –City Gen. Hosp. Stoke –Hairmyres –BMI Alexander, Manchester –London Bridge Hospital –BUPA Leicester –Cromwell –The Priory, Birmingham –Yorkshire Clinic, Bradford –BUPA Lea (Cambridge) Unspecified –Belfast City –Hull RI & Castle Hill –Walsgrave Hospital, Coventry –Manchester Royal Infirmary –Heart Hospital (Middlesex/UCH –Northern Gen. Hosp. Sheffield –St George's –Eastbourne –Wellington Hospital –BUPA Leeds –Ross Hall Hospital –London Independent –St Anthony's –Harley Street Clinic –Bristol BUPA –Park, Nottingham

50. All PCI Procedures: Mortality Includes all centres reporting cath lab outcome or hospital outcome

51. All PCI procedures: Outcome Includes all centres reporting cath lab outcome or hospital outcome

52. All Procedures: Outcome

53. Stenting and outcome 1992-2002 2002 CABG data from 53, resten data from 48 of 64 centres

54. Stenting and the need for emergency CABG (2002 data from 53 of 64 centres)

55. Stenting and procedures for restenosis (2002 data from 48 of 64 centres)

56. Centres providing complete data on HOSPITAL outcome (2002) Aberdeen Royal Infirmary Belfast Royal Victoria Birmingham Heartlands University Hospital, Birmingham Guy's and St Thomas‘ Bristol Royal Infirmary Hammersmith Hospital Harefield Hospital Kings College Hospital Edinburgh Western Liverpool CTC John Radcliffe, Oxford Royal Brompton Hospital Glenfield, Leicester Royal Free Southampton University Hospital James Cook, Middlesbrough Nottingham City KE VII, Midhurst Morriston, Swansea Royal Sussex, Brighton RCH Truro, Treliske Taunton & Somerset

57. Hospital Outcome 2002 Data from 23 centres All Patients

58. Hospital Outcome 2002 Data from 23 centres Elective Patients

59. Hospital Outcome 2002 Data from 23 centres Does not account for clinical syndrome CABG patients includes Rx of native and grafts Patients with previous bypass grafts Patients treated for restenosis

60. Hospital Outcome 2002 Data from 23 centres Acute coronary syndromes (UA/NSTEMI) Includes all classified as treated for UA and post MI angina (stable and unstable)

61. Hospital Outcome 2002 Data from 21 centres Patients Rx for acute vessel closure

62. Hospital Outcome 2002 Data from 23 centres Patients Rx for STEMI

63. PCI for STEMI (2002 data from 47 of 64 units) Data from units reporting cath or hosp outcome 4.8% of all PCI activity

64. Hospital MACE Overview 2002 (Data from 23 centres, 19,606 patients)

65. CCAD

66. BCIS / CCAD project Dataset 5.1.2 Data collection / transmission Pilot site experience Future plans

67. Dataset Version 5.1 –Finalised at meeting 12-2-03 Dataset –Sections 1 to 5 (5 = optional fields) –Modifications Overall structure invariant for 2 years (2005) –103 fields and short code options Volatile menu items can be updated at short notice (8) –On BCIS web site and CCAD web site www.bcis.org.uk/ www.ccad.org.uk/ccadweb.nsf

68. BCIS / CCAD Practical issues –Collecting the data –Transmitting the data

69. CCAD Central Server Local Lotus Notes Database Encryption The Basic CCAD Package Lotus Notes front end Local database Encrypted link to CCAD Maintained centrally –Automatic menu update –Automatic software update Limitations: One computer for data input Difficulties linking with other hospital systems No lesion specific data

70. Connection to other Databases Item 1Item 2Item 3Item 103 …… Patient 1 Patient 2 Patient n ….. Comma separated values file CCAD Central Server Local Lotus Notes Database Encryption Definition: www.ccad.org.uk See CCAD downloads

71. PCI Database on Hospital Server Lab results server PAS server Audit clerk SpR or consultant computer Cath lab data entry Fu data entry Include partial data, updated by subsequent transfers CCAD Central Server Local Lotus Notes Database Encryption

72. CCAD Central Server Local Lotus Notes Database Encryption CAD Local N = 963

73. CCAD Central Server Local Lotus Notes Database Encryption CAD Central N = 3696

74. CCAD Central Server Local Lotus Notes Database Encryption Data completeness Procedure - indications Procedural details Procedure - outcome

75. Indications

78. Indications - detail

79. CCAD Central Server Local Lotus Notes Database Encryption Data completeness Procedure - indications Procedural details Procedure - outcome

80. Procedure - detail

81. CCAD Central Server Local Lotus Notes Database Encryption Data completeness Procedure – indications Procedural details Procedure - outcome

82. Outcome

83. Outcome – detail (1)

84. Outcome – detail (2)

85. Analysis of CCAD dataset Benchmarking –Any unit can compare their practice with UK wide average using Lotus Notes software (as MINAP) ONS link –Post discharge event free outcome Death, re-intervention etc. BCIS Council position –Additional analysis to be arranged ? via University statistical department –Methodology of analysis controlled by the profession via BCIS –? 3 year cycle of results analysis –Data monitoring committee as a means of peer review –Accept that the type of analysis will continue to evolve

86. BCIS / CCAD pilot sites

87. Plans Pilot sites continue Encourage other sites to start collecting dataset version 5.1 –decide on system to be used –contact CCAD for Lotus gateway set up instructions –0207 391 8028 Full roll out by April 2004

88. Conclusions Steady increase in PCI activity in UK –England and Scotland NSF rates for PCI have been exceeded –Increase in PCI:CABG ratio –MACE rates remain satisfactory BCIS-CCAD project –Important progress

89. Extra Information Additional slides with details of –Dataset version 5.1 version code –Volatile menu items

90. Dataset – Version Code Version history –5.1 as ‘finalised’ in Feb 2003 –5.1.1as presented at London Roadshow –5.1.2 as presented at Leeds Roadshow Plan to present BCIS and SCTS datasets to ISB Jan 2003

91. Dataset – Version Code 5.1.2

92. Dataset – Version Code 5.1.2 Version 6: After approval of definitions by the Information Standards Board

93. Dataset – Version Code 5.1.2 Increments whenever a new menu item is added to volatile lists (e.g. new DES) Version 6: After approval of definitions by the Information Standards Board

94. Dataset – Version Code 5.1.2 Version 6: After approval of definitions by the Information Standards Board Increments whenever a new menu item is added to volatile lists (e.g. new DES) Increments with subtle changes in text, typos, clarification of definitions etc.

95. Dataset Maintenance Central Repository (IA) Dataset details Field numbers, Field prompts, Short and long codes Definition and notes Format details Excel WorkbookBCIS Web site Dataset CCAD Lotus Notes Dataset help text / files NHS Data Dictionary

96. Dataset Maintenance

97. Dataset fields Important aspects not contained in current dataset –(Structure) –Appropriateness –Process –Outcome Current definitions of clinical syndromes Track the use of new equipment –Drug eluting stents –Distal protection –Etc.

98. Dataset 5.1 examples Indication for intervention –1. Stable – angina –2. Stable – coronary anatomy –3. ACS – no acute STEMI –4. ACS - primary PCI for STEMI (no lysis) –5. ACS – Facilitated PCI for STEMI (lysis + PCI) –6. ACS – Rescue PCI (failed lysis) –7. ACS – PCI for re-infarction no lysis –8. ACS – Rescue PCI for re-infarction (failed lysis) –9. Staged procedure –10. Hybrid procedure –11. Acute / subacute thrombosis at recent PCI site (30/7) –12. Bail out following diagnostic cardiac catheterisation

99. Dataset 5.1 – Event Timing STEMI (anterior ST elevation) Thrombolysis Good resolution More chest pain ST depression Cath and proceed to LAD PCI Awaiting ETT pre Dx Date/time 1 Date/time 2 PCI data Time: Date/time 2 ECG: ST depression

100. Volatile menus 8 fields with volatile menu items –Drug Eluting Stents –Emboli protection –Diagnostic devices –Procedural devices –Thrombus removal –Brachytherapy –Arterial access management –Peri-procedure drugs

102. Volatile menus Any potential changes to be directed to BCIS audit secretary (PFL) –Discussed with BCIS Council audit committee –CCAD informed update dataset version held with Tony Dallimore –update spreadsheet on BCIS –update CCAD web site and Lotus Notes

103. Dataset stakeholders BCIS –Detailed analysis of most of dataset –Track activity and changes in patterns of Rx Structure Appropriateness Process Outcome Roger Boyle –NHS data –Appropriate professional self regulation DOH (general public) –Provision of safe care Hospital outcome of stable SV disease