1. Size Matters Peter F Ludman MA MD FRCP University Hospital Birmingham

2. NO CONFLICT OF INTEREST TO DECLARE

3. Size Matters Characteristics for high quality PCI –Unit size activity volume Training Research –Network size On call fatigue –Measures of performance Process analysis Outcome analyses

4. Size Matters Characteristics for high quality PCI –Unit size activity volume Training Research –Network size On call fatigue –Measures of performance Process analysis Outcome analyses

5. PCI - E volution of Institutional Volume v Outcome Ho Circulation 2000;101:1806

7. Stent use v MACE

8. Role of Stents 199718,940 POBA and 25,336 Stent PCI Brown AHJ 2003:146;1071

9. Role of Stents 199718,940 POBA and 25,336 Stent PCI Brown AHJ 2003:146;1071

10. Volume-Outcome Still relevant today?

15. 150 mph → 0 mph... 2 sec

18. PCI Decision to treat by PCI What lesions to treat Techniques When to stop Clinical judgment Patient co-morbidity Standards of care before PCI Standards of care after PCI Operator dexterity

19. Spaulding EHJ 2006:27;1054 Hospital Volume v MACE Emergency PCI Greater Paris Registry 2001 and 2002 –37,848 PCI procedures –44 centres

20. Spaulding EHJ 2006:27;1054 Hospital Volume v MACE Emergency PCI Mortality

21. Spaulding EHJ 2006:27;1054 Hospital Volume v MACE Emergency PCI Mortality

22. Spaulding EHJ 2006 27 1054 Hospital Volume v MACE Emergency PCI MACCE

23. Spaulding EHJ 2006 27 1054 Hospital Volume v MACE Emergency PCI MACCE

24. Volume - Outcome

25. Zahn R et al, Heart July 2007 on line Volume – Outcome Arbeitsgemeinschaft leitende kardiologische Krankenhausärzte (ALKK)

26. Zahn Ret al, Heart July 2007 on line Volume – Outcome Arbeitsgemeinschaft leitende kardiologische Krankenhausärzte (ALKK) p for trend = 0.004 p for trend = 0.84

27. Operator Volume v MACE Moscussi J Am Coll Cardiol 2005;46:625–32 18,504 procedures in 2002 14 hospitals in Michigan All high volume institutions MACE

28. Operator Volume v MACE by Quartiles of Risk Moscussi J Am Coll Cardiol 2005;46:625–32 Low Risk CasesHigh Risk Cases

29. Operator Volume v MACE by Quartiles of Risk Moscussi J Am Coll Cardiol 2005;46:625–32 Low Vol High Vol Low vol High vol Low Risk Cases High Risk Cases

30. ‘Practice makes Perfect’

31. Size Matters Characteristics for high quality PCI –Unit size activity volume Training Research –Network size On call fatigue –Measures of performance Process analysis Outcome analyses

34. Circadian Variation Dawson D. Nature 1997;388:235 Cognitive psychomotor performance of hand–eye coordination Hours of wakefulness Blood Alcohol conc (%)

35. Circadian Variation 1702 consecutive PPCI (Zwolle 1994 to 2000) Henriques JPS JACC 2003;41:2138–42 * P<0.01 # P=0.03 # * *

36. Circadian Variation Assali A et al CCI 2006;67:221 p=0.03 p=0.02 PPCI n=273

37. Circadian Variation Assali A et al CCI 2006;67:221

38. Circadian Variation Pathophysiology Platelet aggregation Coronary flow Viscosity Cortisol Epinephrine APTT Endogenous tPA Fibrinogen Fibrinolytic factors Patient characteristics Risk profile Delayed conscious awareness of pain Performance of the Healthcare team

39. Circadian Variation Assali A et al CCI 2006;67:221 ?

40. Size Matters Characteristics for high quality PCI –Unit size activity volume Training Research –Network size On call fatigue –Measures of performance Process analysis Outcome analyses

41. Hall J. NEJM 2007;356:1475-1479 DTB times for Individual Patients Procedural change in lab activation Statistical Process Control

42. Upper Control Limit Upper Warning Predicted Actual Lower Control Limit UHB Cumulative Funnel plots Data from 2006 Derivations from Tony Roberts and Robert Morley

43. Conclusion Size matters, but it is not the only thing that matters