Professor Roger Boyle CBENational Director for Heart Disease and Stroke

Department of Health

PCI in the UK: Fit for service?

A view from the Department of Health

CONFLICTS OF INTEREST

I work for the Department of Health!

Acknowledgement

I have drawn on Peter Ludman’s work quite

extensively

0

20

40

60

80

100

120

140

160

1993/4/5 1995/6/7 1997/8/9 1999/2000/1 2001/2/3 2003/4/5 2005/6/7 2007/8/9 2009/10/11

Death rate per 100,000 population

Target:

40%minimum reduction from1995-97 baseline rate

baseline Progress target

Source: ONS (ICD9 390-459; ICD10 I00-I99)

141.0

84.6

SAVING LIVES Circulatory Disease Mortality TargetDeath rates from All Circulatory Disease in England 1993-2006 and targetPersons under 75

84.2

Rates are calculated using the European Standard Population to take account of differences in age structure.

ICD9 data for 1993 to 1998 and 2000 have been adjusted to be comparable with ICD10 data for 1999 and 2001 onwards.

3 year average

Progress since baseline:

A fall of 40.3%Target achieved

five yearsahead ofschedule

Immortalityguaranteed by 2026

69 in English NHS16 private

BCIS Peer Review System

• New PCI centres should be subject to BCIS peer review BEFORE starting

• Minimum number of cases should be 200 per year with clear plans to increase to 400 per year

• Minimum of three operators

• Arrangements for surgical cover

• Network agreement to the service

0

500

1000

1500

2000

2500

3000

3500

4000

4500

Ap

r-04

Ma

y-Ju

n-0

4Ju

l-04

Au

g-0

4S

ep-

04

Oct

-04

No

v-0

4D

ec-

04

Jan-

05

Fe

b-0

5M

ar-

05

Ap

r-05

Ma

y-Ju

n-0

5Ju

l-05

Au

g-0

5S

ep-

05

Oct

-05

No

v-0

5D

ec-

05

Jan-

06

Fe

b-0

6M

ar-

06

Ap

r-06

Ma

y-Ju

n-0

6Ju

l-06

Au

g-0

6S

ep-

06

Oct

-06

No

v-0

6D

ec-

06

Jan-

07

Fe

b-0

7M

ar-

07

Ap

r-07

Ma

y-Ju

n-0

7Ju

l-07

Au

g-0

7S

ep-

07

Oct

-07

No

v-0

7D

ec-

07

Jan-

08

Fe

b-0

8M

ar-

08

Ap

r-08

Ma

y-Ju

n-0

8Ju

l-08

Au

g-0

8

East Midlands

Eastern

London

North East

North West

South Central

South East Coast

South West

West Midlands

Yorkshire & Humber

Year (All) Quarter (All) First Last (All) Trust Short (All) Old SHA (All) Intervention Angiography

Sum of Total

Period

New SHA

England – Total Waiters – by SHA – April 2004 – August 2008 - Angiography

Last 3 years 5 months

0

200

400

600

800

1000

1200

1400

1600

Apr

-04

May

-Ju

n-0

4Ju

l-04

Aug

-04

Sep

-04

Oct

-04

Nov

-04

Dec

-04

Jan-

05

Fe

b-0

5M

ar-0

5A

pr-0

5M

ay-

Jun-

05

Jul-0

5A

ug-0

5S

ep-0

5O

ct-0

5N

ov-0

5D

ec-0

5Ja

n-0

6F

eb-

06

Mar

-06

Apr

-06

May

-Ju

n-0

6Ju

l-06

Aug

-06

Sep

-06

Oct

-06

Nov

-06

Dec

-06

Jan-

07

Fe

b-0

7M

ar-0

7A

pr-0

7M

ay-

Jun-

07

Jul-0

7A

ug-0

7S

ep-0

7O

ct-0

7N

ov-0

7D

ec-0

7Ja

n-0

8F

eb-

08

Mar

-08

Apr

-08

May

-Ju

n-0

8Ju

l-08

Aug

-08

East Midlands

Eastern

London

North East

North West

South Central

South East Coast

South West

West Midlands

Yorkshire & Humber

Year (All) Quarter (All) First Last (All) Trust Short (All) Old SHA (All) Intervention PCI

Sum of Total

Period

New SHA

England – Total Waiters – by SHA – April 2004 – August 2008 - PCI

Last 3 years 5 monthsPCI

Rationale for NIAP

• Need for test of feasibility in NHS

• Need for cost-effectiveness data relevant to NHS

PPCI

Lysis

No Reperfusion

NIAP and National Guidance launch event

• Key issues– General acceptance of direction of travel– Debate regarding the proportion of the

population that would still require thrombolysis– DH estimate that we can reach 97% of

population, others more like 80%

• Other issues– Some pushback regarding our statement

advising against hybrid models

Lord Voldemort of Worthing

Peter WeissbergMedical Director BHF

“We must not replace a first class thrombolysisservice, which is proven to save lives, with a second

class angioplasty service, which might not.”

MINAP data

Sunday Mirror

Mail on Sunday

Reperfusion ServicesNHS Improvement Survey – November 2008

PPCI hospitals 43

24/7 service 28

Restricted hours 20

Thrombolysis and PPCI 20

Hybrid service restricted hours PPCI and thrombolysis

12

Future Network Plans

• 10 networks have full 24/7 PPCI service

• 6 networks have a business case for PPCI

Of these:

• 3 networks plan to have 24/7 PPCI by March 2009

• 1 network will commence in Jan 2010

• 12 in the process of developing business case

Some hybrid service due to travel times and 120 minute window

Results from ALKK

4.413.97

3.182.78

00.5

11.5

22.5

33.5

44.5

Mo

rtal

ity

(%)

4-166 196-323 327-520 521-2204

Quartiles of PCI volume

STEMIs and nSTEMIs only

Zahn et al Heart 2008; 94: 329-35

P for trend 0.004

18,504 consecutive patients in US

Moscucci et al, JACC 2005; 46:625-632

Adjusted odds ratio of adverse CV events by volume per operator

Paris PCI registry

2.42

8.54

0.62

2.01

6.75

0.62

0 2 4 6 8 10

Overall

Emergencies

Planned

> 400 procedures peryear

<400 procedures peryear

Spaulding et al European Heart J 2006; 27: 1054-1060

3932 31 28 27 23 21 20 20 18

32

26 2523 22

1917 17 16 15

0

10

20

30

40

50

60

70

80

NorthWest

Yorkshire&

Humber

WestMidlands

SouthWest

East ofEngland

London EastMidlands

SouthEast

Coast

SouthCentral

NorthEast

STEMI OOH pw

STEMI In Hours pw

Hospital Code (All) Country England Hospital (All)

SHA

Data

MINAP – STEMI IN HOURS & OUT OF HOURS – 2007 Per Week (average) - By SHA of Admission

Based on 55% In Hours / 45% Out of Hours AVE PER WEEK

Missing Data

LondonChest

Consensus event 24th September

• One fifth of England’s cardiologists present• General agreement that Networks were the right

building blocks for planning purposes for angioplasty services

• General agreement that BCIS had a major role in setting standards and continuing peer review visits

• General agreement that we should move to reporting and publishing outcome data

• Less consensus as to how and where PCI services should be provided

• Also doubts about minimum numbers for PPCI

Lord Voldemort of Worthing

Cardiac Networks