bcis audit returns of interventional procedures 2001 edinburgh 2002 mark de belder bcis national...

BCIS Audit Returns of Interventional Procedures 2001

Edinburgh 2002

Mark de BelderBCIS National Audit Officer

on behalf of Council of the

British Cardiovascular Intervention Society

UK Intervention Centres

Year No. Centres

1991 521992 521993 531994 54

1995 54

1996 531997 58

1998 61

1999 63

2000 66

2001 64

Ayrshire & Arran stopped; Sandwell stopped; Taunton started; Heart Hospital merged with Middlesex/UCH

UK Interventional & Diagnostic Centres 2001

No. No Dataon Caths

(%)

Caths(% oftotal)

PCIs(% oftotal)

NHSInterventional

48 5(10%)

100,350(70%)+17%

36,698(94%)+19%

PrivateInterventional

16 4(25%)

8,407(5.8%)-2%

2,294(5.9%)-16%

Diagnosticonly

62 4(6.5%)

35,086(24%)+13%

0

TOTAL 126 - 143,843+15%

38,992+16%

Making assumptions about no. of caths done in centres not reporting, estimated caths in UK approx 155,500 = 4.0caths/PCI (4.3 in 2000). 2.8caths/PCI in intervention centres (range 1.2-60, 3.5 in 2000), 2.7 in NHS centres (3.5 in 2000) and 3.7 in Private centres (unchanged)

Centres providing NO DATA

The Priory Hospital, Birmingham

Centres providing NO or MINIMAL data on Centre Description Form

Royal Devon & Exeter

Wellington Hospital Ross Hall Hospital St Anthony’s Hospital The Priory Hospital, Birmingham Harley Street Clinic

Centres providing NO or MINIMAL DATAon Minimum Data Form

No data The Priory,

Birmingham

Minimal Data Royal Devon & Exeter

Wellington Ross Hall Hospital St Anthony’s BUPA Bristol

Centres with MINIMAL or NO DATAon Outcome Form

Belfast City City, Birmingham Bristol Royal Infirmary Yorkshire Heart Centre UH Wales, Cardiff London Chest Freeman, Newcastle Northern, Sheffield St Bartholomew’s Royal Devon & Exeter Derriford, Plymouth Eastbourne

Wellington Ross Hall London Independent St Anthony’s The Priory, Birmingham Harley St Clinic BUPA Bristol BUPA Lea Cambridge

NB Harefield, MRI, Oxford, Brompton and St Mary’s much improved!

Centres with no HOSPITAL Outcome Data

Cath Lab Data Only Belfast City City Hospital, Birmingham Blackpool Bristol Royal Infirmary Yorkshire Heart Centre Papworth Glasgow Western General Hairmyres Morriston, Swansea Eastbourne BMI Alexander, Manchester BUPA Leeds London Bridge Hospital BUPA Leicester St Anthony’sl HCI Glasgow Harley Street Clinic

Unspecified Data Univ. Hosp. Of Wales Edinburgh Royal Infirmary Glasgow Royal Infirmary The London Chest Manchester Royal Infirmary Wythenshawe Heart/Middlesex/UCH Freeman, Newcastle Northern Gen. Sheffield St Bartholomew’s Royal Devon & Exeter Derriford, Plymouth Taunton

Unspecified DataWellingtonCromwellRoss HallLondon IndependentThe Priory, BirminghamBUPA BristolYorkshire Clinic, BradfordBUPA Lea, Cambridge

Number of procedures in NHS CentresTotal number of procedures per annum

0

2

4

6

8

10

12

<100 -200 -300 -400 -500 -600 -700 -800 -900 -1000 >1000

2000

2001

Total UK PCI Procedures

Year Centres TotalProcedures

Rate permillion

%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 38,992 684? 16

PCI Rates per million population (UK)

0

100

200

300

400

500

600

700'8

5

'88

'90

'92

'94

'96

'98

'00

?

PCI Rates per million population (UK)

0

100

200

300

400

500

600

700'8

5

'88

'90

'92

'94

'96

'98

'00

Census: UK population 58.8m

663pm

PCI vs Isolated CABG Rates (UK)Data from BCIS and SCTS Registry

0

5000

10000

15000

20000

25000

30000

35000

40000

45000

'91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01

BCISSCTS

NSF Targets

To increaserevascularisations by3000 per annum byApril 2002

To achieve a PCI rateof at least 750/million(time unspecified)

NSF Targets - Some thoughts

1. To increase to 750 pm PCIs, would need a 13% growth in PCI activity

2. To increase to 750 pm CABGs*, would need a 57% growth in CABG activity

3. To increase to 1500 pm revascularisations with 500 by CABG and 1000 by PCI, would need a 5% growth in CABG and a 51% growth in PCI

1 will almost certainly occur in 2002

2 will almost certainly not occur for some years

3 is highly feasible with sufficient resources diverted to PCI* including isolated CABG and combined valve+CABG

PCI: UK 1996-2000 & 2001 vs Other European Countries 1996/2000

0

500

1000

1500

2000

2500

PCIs/million

Ita UK Spa Fin Gre Aust Swi Fra Ger

1996

2000

2001

+180%

+64%+53%

+70%+19%

+55%+40% +40%

+44%

If growth in PCI in UK continues at same rate, it will take >10 years to reach levels of PCI currently performed in France or Switzerland

Total revascularisation rates per million in European countries in

2000

0

500

1000

1500

2000

2500

3000

3500

Hun Spa Pol Por Gre UK Ita Cze Fin Aus Lux Fra Bel Nor Ice Swi Ger

PCI and CABG rates per million in European countries in 2000

0

500

1000

1500

2000

2500

Pol Gre Spa Hun Por Fin UK Ita Bel Cze Nor Lux Fra Ice Swi Aus Ger

PCICABG

1.8 1.4 4.20.7

2.0

0.91.3

2.8

1.4

2.0

1.7

4.1 5.43.3

2.4

3.0

2.3

Angiography and PCI rates per million in European countries in 2000

0

1000

2000

3000

4000

5000

6000

7000

8000

Pol Gre Spa Hun Por Fin UK Ita Bel Cze Nor Lux Fra Ice Swi Aus Ger

AngioPCI

2.83.2 2.8 6.6

4.0 3.34.3 3.0 2.6 3.2

2.72.5 2.6

2.5 2.73.4

3.3

PCI Centres per million in European countries in 2000

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

Hun Pol UK Fin Nor Por Cze Spa Lux Ita Fra Bel Aus Ice Swi Ger

PCIs per PCI Centre in European countries in 2000

0

100

200

300

400

500

600

700

800

Spa Por Hun Ita Bel Swi Aus Fin Ice Pol Ger Fra UK Cze Lux Nor

PCI numbers in UK CountriesTotal PCIs

25610

2618 3007

1181377 922

30785

21593485

1351542 886

0

5000

10000

15000

20000

25000

30000

35000

EnglandNHS

EnglandPrivate

Scotland"NHS"

ScotlandPrivate

N. Ireland Wales*

20002001

+20% -18% +16% +14% +12% -4%

*Does not account for patients referred from N. Wales to English centres

PCI in UK countries 2000 and 2001PCIs/million population

574618

815

318

670715

912

305

0100200300400500600700800900

1000

England Scotland N.Ireland Wales*

20002001

+17% +16% +12% -4%

*Does not account for patients referred from N. Wales to English Centres

Response to the NSF? Changes in PCI Numbers by NHS centre in England

2001 vs 2000For centres performing >100 PCI’s/year

-40%

-20%

0%

20%

40%

60%

80%

100%

120%

140%

Changes in PCI Numbers by “NHS” centre in Scotland, N.Ireland & Wales

2001 vs 2000For centres performing >100 PCI’s/year

-10%

0%

10%

20%

30%

40%

50%

60%

70%Scotland N.Ireland Wales

No. of Consultant Interventionists in NHS Centres, 2001

data from 48 centres

0

2

4

6

8

10

12

No of Centres

1 2 3 4 5 6 7 8 9 10 11 12 13 14

No of Consultants/Centre

Average 6.1 / Centre (5.5 in 2000)Total 292 = 287 Cardiologists and 5 Interventional Radiologists

NHS Centres with and without Visiting Interventionists

22 26

94106

0

94

0

20

40

60

80

100

120

No Visitors Visitors

CentresLocal Int.Visitors

No Visitor Centres: 4.3 Interventionists/Centre, doing an average of 160 PCIs/yearVisitor Centres: 4.0 Local and 3.7 Visitors/Centre, doing an average of 130 PCIs/year

No of PCIs per Consultant in NHS Centres, 2001

data from 48 centres

0

5

10

15

20

25

No of Centres

0-50 51-100 101-150 151-200 201-250 >250

No PCIs/Consultant

Average 126 / Consultant (125 in 2000)

All PCI Procedures Mortality 2001 data from 45 centres

Year Data From: Total Mortality % Range %

1991 9,071(9,933)

0.48

1992 43/52 10,483(11,575)

0.71 0-3.5

1993 44/53 11,859(12,937)

0.59 0-2.7

1994 44/54 12,598(14,624)

0.60 0-2.7

1995 35/54 11,365(17,344)

0.69 0-3.4

1996 37/53 14,476(20,511)

0.72 0-3.2

1997 41/58 17,577(22,902)

0.91 0-10

1998 44/61 16,946(24,899)

0.80 0-9.1

1999 48/63 20,975(28,133)

0.61 0-4

2000 48/66 24,323(33,652)

0.64 0-2.6

2001 45/64 29,001(38,992)

0.75 0-2.8

All PCI procedures2001 data from 42 centres

Year Total Vessels/case

Success % MI % Em.CABG

Mortality%

1991 9,933 86 1.6 2.6 0.48

1992 11,575 1.17 88 1.4 2.0 0.71

1993 12,937 1.09 89 1.1 1.9 0.59

1994 14,624 1.15 90 1.0 1.6 0.60

1995 17,344 1.17 89 1.4 1.9 0.69

1996 20,511 1.17 90 1.4 1.7 0.72

1997 15,667(22,902)

1.16 92 1.2 1.1 0.89

1998 18,560(24,899)

1.24 92 0.8 0.7 0.80

1999 19,889(28,133)

1.11 90 0.57 0.48 0.61

2000 20,939(33,652)

1.21 92 0.6 0.4 0.7

2001 26,923(38,992)

1.22 94 0.5 0.4 0.75

Stent procedures 1992 - 20012001 data from 58 centres

0102030405060708090

% of all PCIs

'92 '93 '94 '95 '96 '97 '98 '99 '00 '01

Year

86%

Stenting in different centres 1998-20012001 data from 58 centres

0

5

10

15

20

25

30

35

40

No. of Centres

31-40 41-50 51-60 61-70 71-80 81-90 >90

% Stented

1998

1999

2000

2001

Impact of Stenting 1992-20012001 data from 42 centres

Year % Stented % PCI forRestenosis

% needingEm.CABG

1992 2.7 11.6 2.0

1993 5.6 12.3 2.0

1994 13.5 11.4 1.8

1995 27.6 9.6 1.9

1996 45.9 9.4 1.5

1997 60 7.4 1.1

1998 69 5.2 0.6

1999 79 4.8 0.48

2000 85 6.2 0.4

2001 87 5.4 0.4

Stenting and the need for emergency CABG

(2001 data from 42 centres)

0

10

2030

40

50

60

7080

90

100

'92 '93 '94 '95 '96 '97 '98 '99 '00 '01

Year

%

0

0.5

1

1.5

2

2.5

%

% Stent

% Em.CABG

Stenting and procedures for restenosis

(2001 data from 42 centres)

0

10

2030

40

50

60

7080

90

100

'92 '93 '94 '95 '96 '97 '98 '99 '00 '01

Year

%

0

2

4

6

8

10

12

14

%

% Stent

% Restenosis

PCI for Restenosis 1998 - 2001(2001 data from 42 centres)

0%

10%

20%

30%

40%

50%

60%

% of Centres

0-5 5.1-10 10.1-15 >15

% for Restenosis

1998199920002001

Stent Procedures 1992 - 20012001 data from 25 centres

1992 1993 1994 1995 1996 1997 1998 1999 2000 2001

Elective 179 341 834 2,595 2,373 3,170(45%)

(7.5-100)

3,376(56%)(0-100)

7,244(64%)

(19-100)

9,365(75%)

(19-100)

11,136(91%)

(50-100)

Sub-optimal 2,166 2,759(39%)(0-98)

2,238(37%)(0-100)

3,909(31%)(0-83)

2,773(22%)(0-79)

987(8%)(0-44)

Bail-out 140 286 1,086 1,269 429 975(14%)(0-52)

410(6.8%)(0-27)

538(4.8%)(0-35)

299(2.4%)(0-35)

169 (1.4%)(0-7.5)

% Bail-out 44 46 44 33 16 14 6.8 4.8% 2.4% 1.4%

Total StentProcedures

319 660 1,937 4,574 9,165 7,096of

11,905

6,024of

12,507

11,691of

19,769

12,437of

27,057

12,292of

31,729

Stent use 1997 - 2001(2001 data from 25 centres)

0102030405060708090

100

% of all stented cases

ES SOS BOS

Stent use

19971998199920002001

ReoPro in different centres 1999 - 20012001 data from 56 centres

0

5

10

15

20

25

30

No. of Centres

0_10

11_2

0

21_3

0

31_4

0

41_5

0

51_6

0

61_7

0

71_8

0

81_9

0

>90

% ReoPro

1999

2000

2001

ReoPro used in 38% (cf 22% in 2000)1001 cases using eptifibatide(927) or tirofiban (74) reported

Total reported GP IIb/IIIa use =41%

ReoPro use 1997 - 20012001 data from 56 centres

0%5%

10%15%20%25%30%35%40%45%

% use

1997 1998 1999 2000 2001

Year

ReoProTotal GP2b/3a

Other procedures 2001 - 1

PTCRA DCA TEC Laser CB Thromb

Centres 20+

6+

2+

5+

43++

11-

No. 145+

28+

3+

23-

894++

58*+

Mean 7.3-

4.7+

- 4.6+

21++

5.3+

Range 1-47 1-9 - 1-18 1-125 1-9

+, =, - : increase, no change or decrease compared to 2000* mainly X-sizer, some Rescue device

Other procedures 2001 - 2BrachyRx P(D)MR IVUS Angio-

scopyGroin

closure*

Centres 7+

1+

31+

0-

38+

Number 130++

19+

662++

0-

8465++

Mean 19+

- 21+

- 223++

Range 3-53 - 2-183 - 2-923

+, =, - : increase, no change, or decrease compared to 2000* Mainly Angioseal

Other Procedures 2001 - 3

MVplasty AVplasty PVplasty TVPlasty Coart/Re-coarct

Centres 32-

7=

9+

0-

6+

No. 248+

17+

29+

0-

26+

Mean 7.8+

2.4+

3.2+

- 4.3+

Range 1-26 1-5 1-14 - 1-16

+, =, - : increase, no change, or decrease compared to 2000


PDA ASD* PFO* VSD

Centres 8+

22+

7+

3+

No. 41++

297++

36++

3+

Mean 5.1+

13.5+

5.1+

-

Range 1-22 2-39 3-8 -

+, =, - : increase, no change or decrease compared to 2000* Some centres give combined data for ASD/PFO closure


Renal Sub-clavian

Pulm.artery

Aorta SVC Carotid

Centres 1=

0-

1+

1+

2-

2+

No. 1-

0-

1+

1+

2-

2+

Mean - - - - - -

Range - - - - - -


Other procedures 2001 - 6FB

removalEmboln. Pericard. Pressure

WireFlowWire

SeptalAbln.

Embolis’nProtection

Device

Centres 7-

8-

1=

4+

1=

2+

7+

Number 18+

17-

1-

75++

1-

2-

35++

Mean 2.6+

2.1-

- 19+

- - 5+

Range 1-8 1-5 - 6-32 - - 1-10


Centres providing complete or near complete data on

Hospital Outcome 2001 (26, cf 18 2000) Aberdeen Belfast Royal Victoria Birmingham Heartlands Birmingham QE Guy’s & St Thomas’s Hammersmith Harefield* Hull Royal Infirmary King’s College Hospital Walsgrave, Coventry Edinburgh Western Liverpool CTC John Radcliffe, Oxford Brompton

Glenfield Royal Free Stoke Southampton St George’s* St Mary’s* James Cook UH, Middlesbrough Nottingham City Hospital KE VIIth, Midhurst Royal Sussex County, Brighton RCH Truro

Park, Nottingham

* Data incomplete

Hospital Outcome 2001All patients

Data from 26 centres

No.(centres)

Success PartialSuccess

Failed RepeatPCI

CABG MI Death(Range)

20,168(26)

92% (87-96)

2.7% (0.1-7.3)

3.8%(0-8.1)

0.5%(0-1.3)

0.4%(0-2.7)

0.7%(0-2.7)

1.0%(0-2.8)

Examples of different case-mix

Centre ElectiveNo CTO

CTO cases UA Shock Non-shockMI cases

Post MI

1(n=907)

30% 4.4% 16% 1.8% 11% 29%

2(n=788)

44% - 34% - 5.3% 14%

3(n=1134)

59% 4.9% 36% 0.5% 1.2% 24%

4(n=788)

48% 2.4% 31% 1.3% 0% 11%

5(n=313)

81% 19% 3.5% 0% 0% 0%

Hospital Outcome 2001Elective patients

No.(centres)


RepeatPCI


StableSingle Ves(no CTO)

7424(25)

95% (90-100)

1.2% (0-5.4)

0.3%(0-1.4)

0.3%(0-1.2)

0.3%(0-2.8)

0.2%(0-2.2)

StableMultivessel(no CTO)

2057(24)

94%(80-100)

4.3%(0-18)

0.8%(0-2.9)

0.2%(0-20)

0.9%(0-8.2)

0.4%(0-1.4)

Single VesCTO

1064(24)

67%(33-100)

2.6%(0-11)

0.1%(0-0.9)

0.5%(0-2.2)

0% 0.2%(0-1.7)

MultivesselInc. CTO

907(23)

82%(0-100)

12%(0-67)

0.6%(0-2.4)

0.3%(0-10)

0.3%(0-1.6)

0.6 %(0-10)

Hospital Outcome 2001Patients with previous CABG and those

treated for restenosis

No.(centres)


RepeatPCI


CABG pts * 1527(24)

89%(72-100)

4.8%(0-20)

0.3%(0-1.5)

0.3%(0-4.1)

0.6%(0-2.3)

0.7%(0-4.1)

Restenosis * 1088(24)

93%(81-100)

3.0%(0-7.8)

0.5%(0-23.8

0.2%(0-7.7)

0.8%(0-33)

0.7%(0-7.7)

* does not account for clinical syndrome

Hospital Outcome 2001Unstable angina

No.(Centres)


RepeatPCI

CABG Q MI Death(Range)

Single VesUA

4553(26)

95%(78-99)

1.6%(0-5.7)

0.5%(0-2.6)

0.5%(0-11)

0.6%(0-3.5)

0.7%(0-11)

MultivesselUA

1387(26)

90%(76-100)

7.9%(0-22)

0.4%(0-2.4)

0.2%(0-2.2)

0.9%(0-20)

0.7%(0-40)

Hospital Outcome 2001Acute closure

No.(Centres)


RepeatPCI

CABG Q MI Death(Range)

Acuteclosure

98(21)

73%(0-100)

3.6%(0-40)

2.2%(0-13)

7.1%(0-100)

16%(0-100)

11%(0-33)

Hospital Outcome 2001Acute MI patients

No.(Centres)


RepeatPCI

CABG re-MI Death(Range)

PrimaryPTCA

352(21)

90%(56-100)

2.6 %(0-11)

1.4%(0-22)

0.9 %(0-11)

2.3 %(0-22)

4.3%(0-13)

SalvagePTCA

578(22)

86%(50-100)

2.4%(0-7.1)

1.0%(0-3.8)

0.5%(0-5)

1.0%(0-5)

3.8%(0-14)

Re-MIPTCA

258(19)

90%(50-100)

3.1%(0-18)

2.7%(0-14)

0.8%(0-13)

4.7%(0-18)

3.1%(0-50)

Shock 167(22)

59%(0-100)

7.8%(0-17)

2.4%(0-25)

2.0%(0-33)

0.6%(0-25)

35%(0-100)

Hospital Outcome 2001Post MI patients

No.(Centres)


RepeatPCI

CABG Re-MI

Death(Range)

Post MI UA 1796(22)

94%(86-100)

2.3%(0-6.9)

0.2%(0-2.9)

0.4%(0-4)

0.7%(0-2.9)

0.9%(0-3.4)

Post MIStable/+ETT

609(18)

92%(70-100)

1.7%(0-11)

0.8%(0-2.6)

0% 0.8%(0-6.7)

1.0%(0-6.4)

ALL MIPatients

3104(22)

90%(80-100)

2.8%(0-6.7)

0.9%(0-6.3)

0.6%(0-4.4)

1.4%(0-12.5)

3.7%(0-12.5)

Comparison of data reported from a single centre with other contributing centres

Syndrome No Success orPartial Succ.

CBG MI or re-MI Death

Elective1V

196 192 (98%) 0 0 0

No CTO 6654 6401 (96%) 21 (0.3%) 22 (0.3%) 19 (0.2%)

All Unstable 149 143 (96%) 1 (0.7%) 0 1 (0.7%)

Angina 5335 2158 (94%) 24 (0.4%) 38 (0.7%) 41 (0.8%)

Rescue 73 62 (85%) 1 (1.4%) 2 (2.7%) 5 (6.8%)

PCI 509 447 (88%) 2 (0.4%) 4 (0.8%) 17 (3.4%)

All ShockPCI

16 5 (31%) 2 (13%) 0 11 (69%)(95%CI 41-89%)

(Primary &Rescue)

151 106 (70%) 2 (1.3%) 1 (0.7%) 48 (32%)(95%CI 25-40%)

Shock data 1997-2001 from same centre

Year No. Mortality %

1997 16 7 44%

1998 13 6 46%

1999 22 10 45%

2000 15 5 33%

2001 16 11 69%

TOTAL 82 39 48%

Statistical variability? Worsening of quality? Sicker patients?What is mortality of patients NOT treated with revascularisation?

BCIS/CCAD Update

10 Test Centre Process Incorporate lessons learned

(February 2003)? National participation in 2003/4 ……but many centres still

struggling to get the process started

Conclusions

Continued growth in PCI but not as much as expected NSF revascularisation rates not yet met Lower rate of growth in Wales Growth rates in individual centres in UK very variable Elective stenting is the default mode of treatment Increased use of GP IIb/IIIa inhibitors but wide

variation between centres (different case-mix or different interpretation of their role?)

Conclusions

Growth in PCI is proportionately faster but numerically significantly slower than in most other comparable Western European countries (and UK has higher prevalence and incidence of disease than most of these countries)

Need a significant “spurt” over next few years if we are to offer comparable services

UK population currently much less likely to undergo angiography

If angiography done, less likely to receive PCI in UK Ratio of PCI:CABG much smaller in UK Fewer PCI centres per head of population in UK (but

those available perform reasonable numbers of PCI)

Acknowledgements

Sally Wilson Huon Gray Dr Willibald Maier Professor Bernie Meier European Society of Cardiology All contributing centres

BCIS Audit Status 2001

We’ve continued to track the growth and development of PCI in the UK

We are able to provide syndrome specific outcome data to use as bench-marks

We have collaborated with the DoH with the development of CCAD - a patient-specific database

BCIS Audit - Still to do Ensure that CCAD does what it is supposed

to do Establish an analysis and reporting system Bring a degree of rationality into debates

about outcomes and use the system to improve quality of care to patients, not to bash interventionists

Develop a similar process for non-coronary interventions

Improving quality of care

Practice evidence-based medicine Provide better access to care with shorter waiting

lists– More angiography (especially ACS patients)– More PCI

Reduce complications to a minimum– More up front use of GP IIb/IIIa’s– More clopidogrel

Reduce restenosis– Drug eluting stents

bcis audit returns of interventional procedures 2001 edinburgh 2002 mark de belder bcis national...

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