BCIS Audit ReturnsAdult Interventional Procedures

Jan 2005 to Dec 2005Peter F LudmanBCIS National Audit OfficerOn behalf ofBritish Cardiovascular Intervention SocietyManchester 2006

Audit Domains:

Structure2005 data: Ludman

Diagnostic Angiography 200513 New Angiography Only Centres 20052005 data: Ludman

Barnet GeneralBarnsleyChesterfield RoyalColchester GeneralDarent Valley HospitalDorset County HospHope Hospital, Salford

Goring HallN Staffs NuffieldLittle Aston3 StoppedChanges in Centres Activity 20052005 data: Ludman 7 Started PCI1 PCI angioBUPA Bristol

UK Centres - 2005

8387PCI centresAngiography onlyCentres2005

UK CountriesPCI Centres in 2005

ScotlandNHS7Private1EnglandNHS54Private17N Ireland2Wales2Total83

PCI Data RequestedForm CCCADForm A & B

UK Interventional and Diagnostic centres2005

Centres Providing No DataLondon Independent

UK Interventional and Diagnostic centres2005Missing angiography data estimated from 2004 figuresNorthern General, SheffieldRoyal Brompton

UK Interventional and Diagnostic centres2005BMI Park, NottsLondon IndependentLondon BridgeMissing angiography data estimated from 2004 figures

UK Interventional and Diagnostic centres2005Arrowe 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

UK Interventional and Diagnostic centres2005Missing PCI data estimated from 2004 figuresLondon independent

UK Interventional and Diagnostic centres2005

UK Interventional and Diagnostic centres2005

PCI per Angiogram ratio

PCI per Angiogram ratioESC Survey 2003Cook S for WG 10 of the ESC. EuroIntervention 2006;1:374

Population estimatesMid 2005Scotland 5.09 mEngland 50.43 mWales 2.96 mest: Rx in Wales: 2.2 mNorthern Ireland 1.72 mest: Welsh Rx in England 0.8 mTotal UK: 60.2 m Total Rx in England 51.23 m

Total UK PCI Procedures

Year

Centres

Total Procedures

Rate per million

Increase

(%)

1991

52

9,933

174

1992

52

11,575

203

16.5

1993

53

12,937

227

11.8

1994

54

14,624

256

13.0

1995

54

17,344

304

18.6

1996

53

20,511

359

18.1

1997

58

22,902

402

11.7

1998

61

24,899

437

8.7

1999

63

28,133

494

13

2000

66

33,652

590

20

2001

64

38,992

664

12.5

2002

64

44,913

759

14.3

2003

73

53,261

894

17.8

2004

77

62,780

1050

17.4

2005

83

70,142

1165

11.0

PCI activity to 2005 (UK)

Rate of increase in PCI numbers pmp

Total PCIs in the UK Countriesby Type of InstitutionTotal No.s of PCI

PCIs/million UK Countries(2000 to 2005)

PCI vs Isolated CABG Numbers (UK)1991 to 2005 Note:CABG data for financial yrall PCI v NHS CABG

PCI vs Isolated CABG Ratio (UK)2000 to 2005

Number of PCIs performed in 2005(per NHS Centre)Data from: all 65 NHS centresMean = 1028

No. of Interventional Consultants(NHS centres)Note: if work at two NHS centres will be counted twiceIncludes cardiologists and radiologistsData from: 64 of 65 centres

No. of Interventional Consultants(NHS centres 2005)Mean2000 5.52001 6.1 6.5 6.7 7.42005 7.0Note: if work at two NHS centres will be counted twice

MeanPCI/consultant2000125200112620021382003139 1432005 145No. of PCIs per Consultant (NHS Centres) 2005 data from 64 of 65 centresNote: data from institutional volume divided by No operators per institution

Visiting Interventionists(NHS Centres) 2005 data from 64 of 65 centres

Surgical Cover (2005 - all 65 NHS centres)

Surgical Cover(all 83 NHS and Private Centres)

On siteOff siteNo of centres54(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

Day Case PCI29 of 70 Units performing day case PCI7 more than 2004Data from: 70 of 83 centres +53%+21%

Day Case PCI2005

Primary PCIRoutine Rx for STEMI NHS Centres only Working Hours Only24/7Number of centres

Audit DomainsStructureAppropriatenessProcessOutcome2005 data: Ludman

Annual returnsProcedure Specific DataForm CCCADForm A & BData Quality

CCAD Import IssuesMandatory Fields (6)1.01 Hospital Identifier 1.02 Local Patient Identifier 3.01 Date and time of operation 1.06 Birth Date2.01 Clinical Syndrome2.02 Indication for Interventionfield 1field 2field 3field 103Patient 1Patient 2Patient n..

CCAD Import IssuesMandatory Fields (6)1.01 Hospital Identifier 1.02 Local Patient Identifier 3.01 Date and time of operation 1.06 Birth Date2.01 Clinical Syndrome2.02 Indication for InterventionMust be date AND time

CCAD Import IssuesMandatory Fields (6)1.01 Hospital Identifier 1.02 Local Patient Identifier 3.01 Date and time of operation 1.06 Birth Date2.01 Clinical Syndrome2.02 Indication for InterventionDuplicatesoccur if re-import with any of these changedIdentifies aUnique record

CCAD Import IssuesMandatory Fields (6)1.01 Hospital Identifier 1.02 Local Patient Identifier 3.01 Date and time of operation 1.06 Birth Date2.01 Clinical Syndrome2.02 Indication for Intervention

CCAD Import Issues2.01 Clinical SyndromeStableAcute coronary syndrome (ACS/AMI)Cannot be

2.02 Indication for Intervention1Stable - angina2Stable - coronary/LV anatomy3ACS - UA, NSTEMI or convalescent STEMI4ACS - 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 procedure10Hybrid procedure11Acute or subacute PCI thrombosis12Bail out following acute complication of diagnostic cardiac catheterisation98Unlisted99Unknown

CCAD Import Issues2.01 Clinical SyndromeStableAcute coronary syndrome (ACS/AMI)Cannot be

Indication for Intervention1Stable - angina2Stable - coronary/LV anatomy3ACS - UA, NSTEMI or convalescent STEMI4ACS - 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 procedure10Hybrid procedure11Acute or subacute PCI thrombosis12Bail out following acute complication of diagnostic cardiac catheterisation98Unlisted99Unknown

CCAD Import Issues2.01 Clinical SyndromeStableAcute coronary syndrome (ACS/AMI)Procedure UrgencyElectiveUrgentEmergencySalvageMust be

Indication for Intervention1Stable - angina2Stable - coronary/LV anatomy3ACS - UA, NSTEMI or convalescent STEMI4ACS - 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 procedure10Hybrid procedure11Acute or subacute PCI thrombosis12Bail out following acute complication of diagnostic cardiac catheterisation98Unlisted99Unknown

In Hospital MortalityPotential for double countingIndication stable, electiveOutcome SAT, repeat PCIDischarge status - DeadIndication SAT, emergencyOutcome DeathDischarge status - Dead1st PCIStableElectiveSAT2nd PCIDeath

AnalysisEngland and WalesForm CCCADAggregate analysis by centre(Mortality double counting eliminated) Merge

CleanedData cleansing

AnalysisScotland and N IrelandForm C

England and WalesScotland and N IrelandMergeFinal counts

CCAD Data for 2005 from BartsThe LondonCTC LiverpoolRoyal BournemouthBradford RIBristol RICastle HillDerby RoyalBirmingham HeartlandsFreemanSt GeorgesGlenfieldHemel HempsteadHarefieldKingsKing Edward VIILeeds GIManchester RINew CrossNorthern GeneralRoyal BromptonNorth HampshireDerrifordQueen Alex PortsmouthQueen Elizabeth BhamJohn RadcliffeRoyal Devon & ExeterRoyal FreeRoyal SussexJames CookSouthendSt PetersSt ThomassSt MarysTorbayUCLUniversity Hospital WalesVictoria HospWhipps crossWythenshaw

CCAD data quality% Total 2005 PCI data in CCAD (E&W)% of TotalAs Sept 06

CCAD data qualityCentres with > 80% of Total 2005 PCI data in CCADAs Sept 06% of Total 2005 PCI data in CCAD

CCAD data qualityCentres with > 80% of Total 2005 PCI data in CCADAs Sept 06% of Total 2005 PCI data in CCAD

CCAD data qualityCentres with < 80% of Total 2005 PCI data in CCAD% of Total 2005 PCI data in CCADAs Sept 0616 centres no 2005 data

CCAD data quality% of CCAD data with Hospital Outcome recorded (E&W)All of the following fields are NOT blank:

4.01 Hospital outcome4.03 Status at Discharge4.04 Discharge Date

CCAD data quality% of CCAD data with Hospital Outcome recorded (E&W)As Sept 06

STEMI

PCI for STEMI20057% of all PCI(5.5% 2004)

PCI for STEMI2005

PCI for All STEMI 2005 data from NHS centresTotal 4921procedures0 or No data

PCI for All STEMI

Primary PCI for STEMI 2005 data from NHS CentresTotal 2916 procedures0 or No data

Primary PCI for STEMI

Primary PCI for STEMIAs Percentage of Each Centres PCI Activity

PCI for Stable v ACSOf Total PCIs performed44% Acute (UA/NSTEMI/STEMI)56% Stable

Stent procedures2005 data from 53 of 65 centres

PCI using any Stent Type2005 data from 58 of 83 Centres

Stent per PCI ratio2005All cases treated with a stent38,719 stents used in 23,882 cases1.62 stents per caseCases using DES23,363 DES used in 13,075 cases1.78 stents per case

Drug Eluting Stent cases2005 data from 80 of 83 centresNHS and privateMean of % use by Centres

Drug Eluting Stent cases - NHS2005 data from 63 of 65 NHS centres

DES use by Centre (NHS)

Drug Eluting Stent cases2005 data from 80 of 83 centres

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

BMS and DES use V PCI for Restenosis

Use of GP IIb/IIIa blockers2005 data from 78 of 83 centresOverall mean % use

GP IIb/IIIa use by Presentation2005Note: stable and PPCI data from Scotland (Fm C) and E&W (CCAD) UA and NSTEMI E&W only

Multi-vessel TreatmentAll clinical syndromes

Multi-vessel Treatmentby centre

Mean (Range)Multi-vessel TreatmentAll Clinical Presentations

Multi-vessel TreatmentBy centre - 2005

Additional Interventional CoronaryTechniques (1)2005 data from 77 of 83 centres*% of all UK interventional procedures**Mean number in units using the technique

UnitsNo % cf 2004* % of all procsMean** RangeRotablation37479+42%0.68131-55Atherctmy (DCA)47-36%0.011.81-3TEC3350%0.00411Laser212-80%0.1761- 7Cutting balloon471019-12%1.5221-348

Additional Interventional CoronaryTechniques (2)2005 data from 77 of 83 centres

OtherInterventional Techniques2005 data from 77 of 83 centres

UnitsNo cf 2004% of all proceduresMean RangePTMR16- 14%0.00166Septal ablation14593.5 %0.14.21-14

Alcohol Mediated Septal Ablation(HOCM)2005 - Total 59 procedures

Other Diagnostic Techniques2005 data from 77 of 83 centres

UnitsNo cf 2004% of all proceduresMean RangeIVUS41840+ 20%1.2201-79

Press wire532089+ 63%3.039217Flow wire1030-74.8%0.0431-9

Adult non coronary intervention2005 data from 77 of 83 centres* 2 units do not split their ASD/PFO data here amalgamated to ASD closure

UnitsNo cf 2004Mean RangeMV plasty31153-7.2 %51-17AV plasty836+64%4.51-8PV plasty721-19%31-12TV plasty220%11PDA1277+97.4%6.41-41ASD *31539+13.5%172-80PFO31461+21.6%151-69

Mitral Balloon ValvuloplastyTotal 153

Adult non coronary intervention2005 data from 77 of 83 centres

UnitsNo cf 2004Mean RangeVSD congen10282.81-7VSD post MI7192.71-7LAA occlusion2115.52-9

Adult great vessel intervention2005 data from 77 of 83 centres

UnitsNo cf 2004Mean RangeCoarct / Re-coart1045+28%4.51-12Carotid435+21%8.81-30Aorta23-57%1.51-2Pulm art546+44%9.21-23SVC932-6%3.61-13

Radial Artery Access11,010 cases: 15.7% of all PCI (10.2% in 2004)Data from: 77 of 83 centres

Femoral artery closure devices2005 data from 75 of 83 centresMean use by Centre: 47%FA closure in 37% of all PCIs

Audit DomainsStructureAppropriatenessProcessOutcome

Mortality - All PCIsAll Data from CCAD + Form C

YearData FromTotal with mortality dataMortality %Range %199535/5411,365(17,344)0.690-3.4199637/5314,476(20,511)0.720-3.2199741/5817,577(22,902)0.910-10199844/6116,946(24,899)0.800-9.1199948/6320,975(28,133)0.610-4200048/6624,323(33,652)0.640-2.6200145/6429,001(38,992)0.750-2.8200253/6437,437(44,913)0.540-1.9200364/7349,194(53,261)0.530-2.0200466/7856,027(62,780)0.560-2.2200581/8361,037(70,142)0.590-3.6

MACE - All PCIsAll Data from CCAD + Form C

Year% ProcedureSuccess% QMI % Re PCI for acute closure % Em. CABGMortality (%)1995891.41.90.691996901.41.70.721997921.21.10.891998920.80.70.801999900.570.480.612000920.60.40.642001940.50.40.75200292(51 of 64)0.57(49 of 64)0.33(50 of 64)0.28(53 of 64)0.54(53 of 64)200392(62 of 73)0.36(56 of 73)0.17(62 of 73)0.29(64 of 73)0.53(64 of 73)200493.5(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

All Procedures: Outcome

Outcome 2005Total CCAD cleaned dataAll Patients

No.SuccessNQMIQMIEm CABGDeath22,15491.7%0.4%0.2%0.13%0.71%

Outcome 2005Total CCAD cleaned dataElective Patients

All as %No.SuccessPartialsuccessFail no compRe-PCIQMIEm CABGDeathStable SV(no CTO)709595.12.60.210.420.130.14MV(no CTO)257293.54.70.540.140..360.110.2SV CTO6446827.40.10.40.10MV CTO46564.729.32.30000.92Overall StableALL1029191.4%0.180.40.10.14

Outcome 2005Total CCAD cleaned data

All as %No.SuccessPartial successFail no compRe-PCIQMIEm CABGDeathNSTEMI / UA no shock707892.42.93.10.40.60.130.64All STEMIno shock173393.31.32.40.40.42.0Primary PCI112691.61.62.40.40.33.2Rescue PCI69590.12.23.20.40.64.3Shock22368.14.56.71.8024

Summary: MortalityRisk Stratified by Syndrome

Mortality by Syndrome

Total Mortality2005 data from 81 of 83 centresMean by Centre = 0.59%Mean all PCI = 0.56%4 deaths out of 111 PCIs3 for NSTEMI1 for shock

Public Reporting of PCI dataBCIS Data Monitoring SubgroupP. 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 dataRisk stratified MACCE outcomeProcess data door to balloon time etc.

Risk Stratified OutcomeCentre ACentre B50 casesShock,PPCI,Renal failure50 casesStable elective,NSTEMIMortality 15%Mortality 0.5 %RA Mortality 0.5%RA Mortality 0.5%RiskAdjustmentModel

Risk Stratified OutcomeNorth West Quality Improvement Programme risk scoreA 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;92:658663

Future Data Quality reports

VLAD(Variable Life Adjusted Display)Case 1Clinical features:Age - 80Sex - femaleDiabetes - YesUrgent PCINo ShockPredicted risk of in hospital event(MACCE) Death QMI CVA Em CABG

Risk Prediction Model

VLAD plotsBetterWorseCase 1 risk of MACCE 5 % - No MACCEUp by 0.05Performance

VLAD plotsBetterWorseCase 2 risk of MACCE 60 % - No MACCEUp by 0.6Performance

VLAD plotsBetterWorseCase 3 risk of MACCE 70 % - MACCEDown by 1 0.7 = 0.3Performance

VLAD plotsBetterWorseCase 4 risk of MACCE 5 % - MACCEDown by 1 0.05 = 0.95Performance

83 PCI centres in UK1,165 PCI pmp in UKCath : PCI = 34%PCI : CABG = 3.1 : 1CCAD40 of 56 units with 2005 data (16 none) MACEStable syndromesMortality 0.14%, CABG 0.1%UA / NSTEMIMortality 0.64%, CABG 0.13%PlansData quality to improveRisk adjusted outcomeProcess auditSummary 2005 (UK)

http://www.statistics.gov.uk/cci/nugget.asp?id=6In mid-2004 the UK was home to 59.8 million people, of which 50.1 million lived in England -England 50,093,800 (83.7 per cent of the total UK population) - Scotland 5,078,400 (8.5 per cent) - Wales 2,952,500 (4.9 per cent) - Northern Ireland 1,710,300 (2.9 per cent)Assumes UK population of:58.8 m mid 2001, 59.2m mid 2002, 59.6 mid 2003, 59.8 mid 2004