1. 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

2. Audit Domains: Structure 2005 data: Ludman

3. Barnet General Barnsley Chesterfield Royal Colchester General Darent Valley Hospital Dorset County Hosp Hope Hospital, Salford Diagnostic Angiography 2005 13 New Angiography Only Centres 2005 2005 data: Ludman Maidstone Hospital Medway Maritime Hospital Royal Bolton St Richards, Chichester Wigan Royal Infirmary William Harvey, Ashford

4. Goring Hall N Staffs Nuffield Little Aston 3 Stopped Changes in Centre’s Activity 2005 2005 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

5. UK Centres - 2005 2005 data: Ludman

6. 83 87 PCI centres Angiography only Centres 2005

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

15. PCI Data Requested Form C CCAD Form A & B

16. 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 TOTAL170 2005 data: Ludman

17. Centres Providing No Data London Independent 2005 data: Ludman

18. 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

19. 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 TOTAL170 2005 data: Ludman BMI Park, Notts London Independent London Bridge Missing angiography data estimated from 2004 figures

20. 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 170 2005 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

21. 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

22. UK Interventional and Diagnostic centres 2005 No.No cath data No PCI data Caths (% of total) PCIs (% of total) NHS Interventional 6520 139,847 (68%) Private Interventional 1831 10,299 (5%) Diagnostic only 876NA 55,636 (27%) TOTAL 170205,782 2005 data: Ludman

23. UK Interventional and Diagnostic centres 2005 No.No cath data No PCI data Caths (% of total) PCIs (% of total) NHS Interventional 6520 139,847 (68%) 66,841 (95%) Private Interventional 1831 10,299 (5%) 3,301 (5%) Diagnostic only 876NA 55,636 (27%) NA TOTAL 170205,78270,142 2005 data: Ludman

24. PCI per Angiogram ratio 2005 data: Ludman

25. PCI per Angiogram ratio ESC Survey 2003 2005 data: Ludman Cook S for WG 10 of the ESC. EuroIntervention 2006;1:374

26. Population estimates Mid 2005 Scotland 5.09 m England 50.43 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 51.23 m 2005 data: Ludman

27. Total UK PCI Procedures 2005 data: Ludman

28. PCI activity to 2005 (UK) 2005 data: Ludman

29. Rate of increase in PCI numbers pmp 2005 data: Ludman

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

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

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

33. PCI vs Isolated CABG Ratio (UK) 2000 to 2005 2005 data: Ludman

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

35. 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

36. No. of Interventional Consultants (NHS centres 2005) 2005 data: Ludman Mean 2000 5.5 2001 6.1 2002 6.5 2003 6.7 2004 7.4 2005 7.0 Note: if work at two NHS centres will be counted twice

37. Mean PCI/consultant 2000125 2001126 2002138 2003139 2004 143 2005 145 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

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

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

40. 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 1065.6435.2 PCIs per interventionist (all 65 NHS centres only): 167.4114.4 2005 data: Ludman

41. Day Case PCI 29 of 70 Units performing day case PCI –7 more than 2004 2005 data: Ludman Data from: 70 of 83 centres +53% +21%

42. Day Case PCI 2005 2005 data: Ludman

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

44. Audit Domains Structure Appropriateness Process Outcome 2005 data: Ludman

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

46. 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 …..

47. 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

48. 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

49. 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

50. 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

51. 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

52. 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

53. 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

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

55. Analysis Scotland and N Ireland Form C

56. England and WalesScotland and N Ireland Merge Final counts

57. 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

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

59. 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

60. 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

61. 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 06 16 centres no 2005 data

62. 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

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

64. STEMI

65. PCI for STEMI 2005 2005 data: Ludman 7% of all PCI (5.5% 2004)

66. PCI for STEMI 2005 2005 data: Ludman

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

68. PCI for All STEMI 2005 data: Ludman

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

70. Primary PCI for STEMI 2005 data: Ludman

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

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

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

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

75. 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

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

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

78. DES use by Centre (NHS) 2005 data: Ludman

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

80. PCI for Restenosis (2005 data from 49 of 83 centres) Mean: 20024.9% 20034.3% 2004 3.6% 2005 3.8% 2005 data: Ludman

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

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

83. GP IIb/IIIa use by Presentation 2005 2005 data: Ludman Note: stable and PPCI data from Scotland (Fm C) and E&W (CCAD) UA and NSTEMI E&W only

84. Multi-vessel Treatment All clinical syndromes 2005 data: Ludman

85. Multi-vessel Treatment by centre 2005 data: Ludman

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

87. 2005 data: Ludman Multi-vessel Treatment By centre - 2005

88. Additional Interventional Coronary Techniques (1) 2005 data from 77 of 83 centres UnitsNo ∆ % cf 2004 * % of all procs Mean**Range Rotablation37479+42%0.68131-55 Atherctmy (DCA) 47-36%0.011.81-3 TEC3350%0.00411 Laser212-80%0.1761- 7 Cutting balloon471019-12%1.5221-348 *% of all UK interventional procedures **Mean number in units using the technique 2005 data: Ludman

89. Additional Interventional Coronary Techniques (2) 2005 data from 77 of 83 centres UnitsNo ∆ cf 2004 % of all procs MeanRange Thrombectomy40508+40 %0.72131-69 Distal protection43514-6.5%0.73121-65 Brachytherapy33-95%0.00411-3 2005 data: Ludman

90. Other Interventional Techniques 2005 data from 77 of 83 centres UnitsNo ∆ cf 2004 % of all procedures MeanRange PTMR 16- 14%0.00166 Septal ablation 14593.5 %0.14.21-14 2005 data: Ludman

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

92. Other Diagnostic Techniques 2005 data from 77 of 83 centres UnitsNo∆ cf 2004 % of all procedures MeanRange IVUS 41840+ 20%1.2201-79 Press wire 532089+ 63%3.039217 Flow wire 1030-74.8%0.0431-9 2005 data: Ludman

93. Adult non coronary intervention 2005 data from 77 of 83 centres UnitsNo ∆ cf 2004 MeanRange MV plasty 31153 -7.2 % 51-17 AV plasty 836 +64% 4.51-8 PV plasty 721 -19% 31-12 TV plasty 22 0% 11 PDA 1277 +97.4% 6.41-41 ASD * 31539 +13.5% 172-80 PFO 31461 +21.6% 151-69 2005 data: Ludman * 2 units do not split their ASD/PFO data –here amalgamated to ASD closure

94. Mitral Balloon Valvuloplasty 2005 data: Ludman Total 153

95. Adult non coronary intervention 2005 data from 77 of 83 centres UnitsNo ∆ cf 2004 MeanRange VSD congen 10282.81-7 VSD post MI 7192.71-7 LAA occlusion 2115.52-9 2005 data: Ludman

96. Adult great vessel intervention 2005 data from 77 of 83 centres UnitsNo ∆ cf 2004 MeanRange Coarct / Re-coart1045+28%4.51-12 Carotid435+21%8.81-30 Aorta23-57%1.51-2 Pulm art546+44%9.21-23 SVC932-6%3.61-13 2005 data: Ludman

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

98. 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

99. Audit Domains Structure Appropriateness Process Outcome

100. YearData From Total with mortality data Mortality %Range % 199535/54 11,365 (17,344) 0.690-3.4 199637/53 14,476 (20,511) 0.720-3.2 199741/58 17,577 (22,902) 0.910-10 199844/61 16,946 (24,899) 0.800-9.1 199948/63 20,975 (28,133) 0.610-4 200048/66 24,323 (33,652) 0.640-2.6 200145/64 29,001 (38,992) 0.750-2.8 200253/64 37,437 (44,913) 0.540-1.9 200364/73 49,194 (53,261) 0.530-2.0 200466/78 56,027 (62,780) 0.560-2.2 200581/83 61,037 (70,142) 0.590-3.6 Mortality - All PCIs All Data from CCAD + Form C 2005 data: Ludman

101. Year % Procedure Success % QMI % Re PCI for acute closure % Em. CABG Mortality (%) 1995891.41.90.69 1996901.41.70.72 1997921.21.10.89 1998920.80.70.80 1999900.570.480.61 2000920.60.40.64 2001940.50.40.75 2002 92 (51 of 64) 0.57 (49 of 64) 0.33 (50 of 64) 0.28 (53 of 64) 0.54 (53 of 64) 2003 92 (62 of 73) 0.36 (56 of 73) 0.17 (62 of 73) 0.29 (64 of 73) 0.53 (64 of 73) 2004 93.5 (63 of 78) 0.30 (57 of 78) 0.30 (61 of 78) 0.21 (64 of 78) 0.56 (66 of 78) 200590.20.240.120.59 MACE - All PCIs All Data from CCAD + Form C 2005 data: Ludman

102. All Procedures: Outcome 2005 data: Ludman

103. Outcome 2005 Total CCAD cleaned data All Patients 2005 data: Ludman No.SuccessNQMIQMI Em CABG Death 22,15491.7%0.4%0.2%0.13%0.71%

104. All as %No.Success Partial success Fail no comp Re- PCI QMI Em CABG Death Stable SV (no CTO) 709595.12.60.210.420.130.14 MV (no CTO) 257293.54.70.540.140..360.110.2 SV CTO 6446827.40.10.40.10 MV CTO 46564.729.32.30000.92 Overall Stable ALL 1029191.4%0.180.40.10.14 Outcome 2005 Total CCAD cleaned data 2005 data: Ludman Elective Patients

105. All as % No.Success Partial success Fail no comp Re- PCI QMI Em CABG Death NSTEMI / UA no shock 707892.42.93.10.40.60.130.64 All STEMI no shock 173393.31.32.40.4 2.0 Primary PCI 112691.61.62.40.40.33.2 Rescue PCI 69590.12.23.20.40.64.3 Shock 22368.14.56.71.8024 Outcome 2005 Total CCAD cleaned data 2005 data: Ludman

106. Summary: Mortality Risk Stratified by Syndrome 2005 data: Ludman

107. Mortality by Syndrome 2005 data: Ludman

108. 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

109. 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.

110. 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

111. 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

112. Future Data Quality reports

113. 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

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

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

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

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

118. 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