wales – mid and south west cardiac network - bhrsbhrs.com/files/files/audit reports/2009-mid and...
TRANSCRIPT
Wales – Mid and South West Cardiac Network
David Cunningham Director, Central Cardiac Audit Database
Richard Charles Chairman, Network Device Survey Group
Morag Cunningham CRM Database Coordinator, Central Cardiac Audit Database
Adél de Lange Data analyst, Central Cardiac Audit Database
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This report was generated by the Network Device Survey Group and was commissioned by the Department of Health's Heart Services Team (Vascular Programme).
If you wish further information please contact the Heart Services Team (Vascular Programme):
403 Wellington House 133-155 Waterloo Road London SE1 8UG England Phone: 0207 972 2000
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Contents
Analysis of Provision of Heart Rhythm Devices for
Wales – Mid and South West Cardiac Network
Data Quality Statement ............................................................................................... 4 Overview of Device Implants in the UK ............................................................................. 6 PCTs/LHBs in the Network ............................................................................................ 8 Network Age and Sex Distribution ................................................................................... 9 Correcting Implant Rates for Age and Sex.........................................................................11 Relative need for Pacemakers and ICDs ...........................................................................13 New and Total PM and ICD Implants...............................................................................14 Geographical location of pacemaker implants .....................................................................17 New and Total PM and ICD Implants...............................................................................18 CRT implants in this network ........................................................................................20 Which hospitals serve which PCTs/LHBs? ..........................................................................24 Pacing Mode for New Implants......................................................................................27 Pacing Mode for Sick Sinus Syndrome..............................................................................29 ECG Indication for New Implants ...................................................................................31 Corrected and Actual New Implant Rates ..........................................................................32 New Implant rate maps for Wales – Mid and South West Cardiac Network ...................................37 New pacing implant rate 2009.......................................................................................38 ICD new implant rate 2009 ..........................................................................................39 Pacing Implant Deficit in 2009 ......................................................................................40 Conclusions ............................................................................................................41
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Data Quality Statement The quality of the analyses in this report is only as good as the quality of the data that supports it. That data is originally submitted by hospitals to the National Pacemaker Database. If there is a deficit in registration, or if registrations do not contain a valid postcode, then analysis gaps are inevitable. Data is then anonymised and extracted to provide the basis of the analysis by the Survey Group. Permission to do so has been given by Heart Rhythm UK and by the Department of Health Vascular Team. To minimise the risk of deficit errors, a threshold of 98% for registration and postcode completeness is sought for each hospital. Overall network completeness MUST reach 98% or a report will not be issued. Every effort is made to ensure this report is as accurate as possible - however please contact us if you identify any residual problem and we will try to correct the error promptly. Below is a list of important hospitals for this network and their completeness of VALID postcodes during the study period.
Valid Postcodes
Overall network average 100.00%
Main implant Centres
MOR.Morriston Hospital 100.00%
NEV.Nevill Hall Hospital 87.67%
POW.Princess Of Wales Hospital 100.00%
RSS.Royal Shrewsbury Hospital 100.00%
UHW.University Hospital of Wales 99.68% Note: Implant centres shown have implanted at least 10 devices in the network.
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Data Quality and Completeness Listed below are important fields and their completion rates with valid entries.
All Devices ICD, CRT-D & CRT-P
Network / Implant Centre Valid Post Code
Valid NHS No
Valid Sex Valid Age ECG Symptom Aetiology
Target 98.0% 98.0% 98.0% 98.0% 90.0% 90.0% 90.0%
England 99.4% 72.7% 99.5% 99.5% 91.9% 90.8% 81.3%
This Network 100.0% 86.0% 100.0% 100.0% 95.5% 95.9% 91.0%
Morriston Hospital 100.0% 98.5% 100.0% 100.0% 97.9% 98.1% 92.5%
Princess Of Wales Hospital 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% -
University Hospital of Wales 99.7% 9.4% 100.0% 100.0% 99.0% 99.2% 96.2%
CRT-D & ICD CRT-D & CRT-P
Network / Implant Centre NYHA
Dyspnoea Status
LV Function
ICD Indication
QRS duration
Overall index of valid data
completeness
Target 90.0% 90.0% 90.0% 90.0% 90.0%
England 38.2% 46.8% 33.3% 12.6% 73.3%
This Network 83.7% 86.5% 81.7% 50.9% 90.8%
Morriston Hospital 94.9% 96.2% 97.4% 81.8% 96.9%
Princess Of Wales Hospital - - - - 105.1%
University Hospital of Wales 63.9% 73.5% 39.2% 14.6% 76.5%
Target Achieved
Below 50% of target
( - ) = No Implants
Notes:
1. Implant centres shown have contributed at least 5% of Pacemaker implant activity in the network.
2. Completeness is shown for all registered procedures for a centre, not just procedures in this network.
3. Overall index is an average for each centre of each field as a ratio of the target, and can exceed 100%.
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Overview of Device Implants in the UK
New pacemakers Comments:
• The ten year average growth rate is 4.6%
• Implant rates rose in England, Wales and Northern Ireland. (There is a substantial shortfall in data submission from Scotland).
• New pacing rate remains highest in England (531 new implants per million population in 2009).
New ICD implants Comments:
• The ten year average growth rate is 14.9%
• ICD implant rate remains highest in N Ireland. (There is a substantial shortfall in data submission from Scotland).
• ICD implant rate remained static in England and rose slightly in Wales in 2009.
0
100
200
300
400
500
600
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
year
per million population
England
Wales
Scotland
N Ireland
0
20
40
60
80
100
120
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
year
per million population
England
Wales
Scotland
N Ireland
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New CRT implants Comments
• New CRT rate increased significantly in England and Wales.
• New CRT rate is the highest in England.
• The new CRT rate decreased significantly in N Ireland in 2009. (There is a substantial shortfall in data submission from Scotland).
Total CRT implants
Comments
• The total CRT rate rose significantly in England and Wales.
• Total CRT implants Rate was highest in England (99 total implants per million population in 2009).
0
10
20
30
40
50
60
70
80
90
100
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
year
per million population
England
Wales
Scotland
N Ireland
0
20
40
60
80
100
120
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
year
per million population
England
Wales
Scotland
N Ireland
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PCTs/LHBs in the Network
Wales – Mid and South West Cardiac Network Total population 0.99 million.
Code PCT/LHB Population Old PCT (where relevant*)
6A3 Pembrokeshire 116,300
6A4 Ceredigion 77,200
6A5 Neath Port Talbot 135,300
6A6 Swansea 224,700
6B3 Bridgend 129,900
6B7 Carmarthenshire 176,000
6C4 Powys 129,200 * The revision of PCT boundaries in 2006 has resulted in some PCTs being "split" across Cardiac Network boundaries. In these cases only the relevant portion of the new PCT will be included in this report, as defined by the old PCT boundaries.
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Network Age and Sex Distribution Population data from ONS, based on mid-2006 population estimates
Data for England Average age: 39.5
(for comparison): % aged 70+: 11.60%
Wales – Mid and South West Cardiac Network
Population
PCT / LHB Age Male Female Age Male Female
6A3Population: 116,800 0-5: 3,400 3,000 46-50: 3,600 3,700
Average age: 42.5 6-10: 3,800 3,600 51-55: 4,000 4,300
% aged 70+: 14.0% 11-15: 4,000 4,100 56-60: 4,300 4,600
16-20: 3,700 3,500 61-65: 3,600 3,800
21-25: 2,800 2,700 66-70: 3,300 3,300
26-30: 2,500 2,700 71-75: 2,800 3,000
31-35: 3,000 3,500 76-80: 2,000 2,600
36-40: 3,700 4,000 81-85: 1,300 2,100
41-45: 3,900 4,100 85+: 700 1,800
6A4Population: 77,300 0-5: 1,700 1,600 46-50: 2,400 2,500
Average age: 41.8 6-10: 2,100 1,900 51-55: 2,600 2,700
% aged 70+: 13.5% 11-15: 2,300 2,100 56-60: 2,900 2,900
16-20: 2,900 3,000 61-65: 2,300 2,300
21-25: 3,900 4,100 66-70: 2,000 2,000
26-30: 1,600 1,700 71-75: 1,600 1,800
31-35: 2,000 1,900 76-80: 1,300 1,700
36-40: 2,300 2,400 81-85: 1,000 1,300
41-45: 2,400 2,400 85+: 500 1,200
6A5Population: 135,400 0-5: 3,600 3,400 46-50: 4,600 4,700
Average age: 41.6 6-10: 4,100 4,000 51-55: 4,600 4,700
% aged 70+: 13.3% 11-15: 4,700 4,400 56-60: 4,500 4,700
16-20: 4,500 4,400 61-65: 3,700 3,800
21-25: 3,700 3,400 66-70: 3,300 3,400
26-30: 3,300 3,500 71-75: 2,700 3,300
31-35: 4,100 4,400 76-80: 2,200 3,100
36-40: 4,800 5,000 81-85: 1,400 2,500
41-45: 4,900 5,200 85+: 700 2,100
Pembrokeshire
* Older than national average
Ceredigion
* Older than national average
Neath Port Talbot
* Older than national average
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Population
PCT / LHB Age Male Female Age Male Female
6A6Population: 224,600 0-5: 6,000 5,900 46-50: 7,100 7,500
Average age: 41.1 6-10: 6,500 6,200 51-55: 7,000 7,300
% aged 70+: 13.4% 11-15: 7,300 6,700 56-60: 7,100 7,800
16-20: 7,900 7,600 61-65: 5,800 6,100
21-25: 8,700 8,000 66-70: 5,400 5,700
26-30: 5,900 5,900 71-75: 4,700 5,500
31-35: 6,800 7,200 76-80: 3,700 4,700
36-40: 7,700 7,900 81-85: 2,500 4,100
41-45: 7,700 7,800 85+: 1,400 3,500
6B3 Population: 129,900 0-5: 3,700 3,600 46-50: 4,200 4,200
Average age: 40.6 6-10: 4,100 3,900 51-55: 4,200 4,400
% aged 70+: 12.0% 11-15: 4,500 4,300 56-60: 4,300 4,500
16-20: 4,300 4,100 61-65: 3,500 3,700
21-25: 3,300 3,200 66-70: 3,000 3,300
26-30: 3,500 3,500 71-75: 2,500 3,000
31-35: 4,400 4,800 76-80: 1,900 2,500
36-40: 5,000 5,100 81-85: 1,300 2,200
41-45: 4,800 4,900 85+: 600 1,600
6B7Population: 175,900 0-5: 4,800 4,400 46-50: 5,700 6,100
Average age: 42.4 6-10: 5,500 5,200 51-55: 6,000 6,200
% aged 70+: 14.3% 11-15: 5,900 5,500 56-60: 6,500 6,600
16-20: 5,700 5,500 61-65: 5,300 5,300
21-25: 4,400 4,500 66-70: 4,600 4,700
26-30: 4,000 4,200 71-75: 3,900 4,400
31-35: 4,900 5,400 76-80: 3,200 4,100
36-40: 5,700 6,200 81-85: 2,000 3,500
41-45: 5,700 6,300 85+: 1,100 2,900
6C4Population: 129,300 0-5: 3,300 3,100 46-50: 4,200 4,400
Average age: 43.2 6-10: 4,100 3,700 51-55: 4,700 4,700
% aged 70+: 14.7% 11-15: 4,500 4,100 56-60: 5,000 5,200
16-20: 4,100 3,600 61-65: 4,000 4,100
21-25: 2,800 2,500 66-70: 3,500 3,500
26-30: 2,900 2,700 71-75: 3,100 3,300
31-35: 3,700 3,800 76-80: 2,400 3,000
36-40: 4,400 4,600 81-85: 1,700 2,400
41-45: 4,500 4,600 85+: 1,000 2,100
Powys
* Older than national average
Bridgend
Carmarthenshire
* Older than national average
Swansea
* Older than national average
Note: A PCT is considered to be older than average the percentage for aged 70+ is greater than or equal to 13.1% and it is considered to be younger than average if the percentage for aged 70+ is less than or equal to 10.3%.
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Correcting Implant Rates for Age and Sex
Calculating Need • Most pacemakers are implanted for
conduction system disease, which is predominantly a disease of the elderly. The graph (right) shows the percentage of the population in 5 year age bands, and the percentage of pacemaker implants. Only 11% of the population are aged 70 or more, but they receive 76% of all pacemaker implants.
• Men also receive more pacemakers than women. Although the national average new implant rate is 531, it reaches more than 11,000 in men aged more than 90 (right). So the proportion of older people in a local population will strongly influence how many pacemakers need to be implanted.
• If we examine closely the age and sex distribution of the local population of a PCT (LHB in Wales) or Network, we can work out how many pacemakers we would EXPECT to see implanted, compared to the national average. The ratio of the local and national rate is called the Relative Need, and we calculate this for both pacemakers and ICDs.
• So, for example, in North East London the population is relatively young. Only 8% are aged 70 or more, compared to the national average of 11%. This means that this network doesn't need as many pacemaker implants relative to the nation as a whole. Their Relative Need for Pacing is calculated to be 80% of the national average.
• In contrast, Sussex has a more elderly population, with 16% aged 70 or over. Their Relative Need for Pacing is 140%.
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Using Relative Need • We want to make a fair and valid comparison between PCTs/LHBs, Networks and the National
Average. That means we should correct for relative need. So, for example if North London has a pacing rate of 480, and Sussex has a rate of 840, are they different? North London's adjusted rate is 480 divided by relative need (80%) = 600. Sussex's adjusted rate is 840 divided by 140% = 600.
• So the adjusted rates for these two areas are the same, despite the major apparent difference in their unadjusted rates.
Implantable Defibrillators • The diseases for which ICDs are
implanted are not the same as for pacemakers, and tend to occur in slightly younger people. These diseases are principally ischaemic heart disease and cardiomyopathy.
• We therefore need to calculate a separate relative need factor for ICDs. The graph (right) of new ICD implant rate in 2006 shows that ICDs are also predominantly implanted in older people.
• Unlike pacemakers, the ICD implant rate starts to decline over the age of 75. The influence of a local elderly population of need for ICDs will therefore still be present, but just slightly less in magnitude than for pacemakers. Sussex, for instance, has a relative ICD need of 138%.
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Relative need for Pacemakers and ICDs Wales – Mid and South West Cardiac Network
Indicative new implant rate Pacemakers: 531 ICD: 62
(average for England 2009)
Average age: 39.44
A PCT with a relatively OLD population will need relatively MORE pacemaker and ICD implants compared to a PCT with a young population, because the incidence of indications for pacing and ICD is higher in older people.
Average age
Expected pacing new implant rate
Compared to national average
Expected ICD new
implant rate
Compared to national average
6A3 Pembrokeshire 42.5 660 124.3% 76 122%
6A4 Ceredigion 41.8 640 120.7% 72 115%
6A5 Neath Port Talbot 41.6 615 116.0% 69 112%
6A6 Swansea 41.1 622 117.2% 68 110%
6B7 Carmarthenshire 42.4 667 125.8% 74 119%
6C4 Powys 43.2 684 129.0% 75 121%
6B3 Bridgend 40.6 563 106.2% 67 107%
Cardiac Network - Relative Need for New Implant Rate
Wales – Mid and South West Cardiac Network 635 119.77% 71 114.54%
England (for comparison)
England 531 100% 62 100%
Note: "Expected" pacing and ICD rates are relative to national average rate, but are corrected depending on the age and sex distribution of the local population (see Page 12). For Pacemakers, the expected implant rate will be higher if the percentage of older people in the PCT is higher. For ICDs, the same general rule applies, but the pattern is slightly different, because ICD implant rates peak at age 70 and then decrease rapidly. These relative rates will be used to correct the observed rates and produce a truer reflection of local implant rates vs. local need.
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New and Total PM and ICD Implants
Wales – Mid and South West Cardiac Network
Pacemakers
The following hospitals implanted pacemakers in patients from this cardiac network in 2009. A new pacemaker centre will implant nearly 100% new implants, and the longer a centre has been implanting, the higher the percentage of replacements implants. The national average for replacement implants is 22.82% of the total workload. This should always be borne in mind when forecasting future workload.
2009 Replacement implants
Centre New
Implants Total
Implants % of total
MOR Morriston Hospital 316 417 24.22%
POW Princess Of Wales Hospital 56 56
UHW University Hospital of Wales 7 34 79.41%
RSS Royal Shrewsbury Hospital 20 25 20.00%
NEV Nevill Hall Hospital 10 13 23.08%
HCH Hereford County Hospital 3 6 50.00%
BRC Bristol Children's Hospital 2 3 33.33%
BRI Bristol Royal Infirmary 2 3 33.33%
RGH Royal Glamorgan Hospital 2 3 33.33%
QEB Queen Elizabeth Hospital 2 3 33.33%
STO University Hospital North Staffs 2 2
GWE Royal Gwent Hospital 2 2
WWG West Wales General 1 1
BOL Bolton Royal Infirmary 1 1
DGE Eastbourne DGH 1 1
RDE Royal Devon & Exeter Hospital 1 1
BHL Liverpool Heart and Chest Hospital 1
PHB Priory Hospital 1 1
NHB Royal Brompton Hospital 1 1
UCL University College Hospital 1 1
HAM Hammersmith Hospital 1 1
WAT Watford General Hospital 1
WRX Maelor Hospital 1 1
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Pacemaker implant trends
Pacemaker New Implant Rate
adjusted for age and sex of network population
100
150
200
250
300
350
400
450
500
550
600
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
year
per million population
Mid and South West Wales
England
Pacemaker All Implant Rate
adjusted for age and sex of network population
0
100
200
300
400
500
600
700
800
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
year
per million population
Mid and South West Wales
England
16
Pacemaker new implant rate in context Is the PCT new implant rate too high or too low, compared to the national target of 700? The funnel plot below shows the national target (grey line) and the upper (green) and lower (red) control limits. PCTs are shown in light blue circles, and this network's PCTs are shown as larger blue circles. If a PCT's rate is above the green line, it may be excessively high. If it is below the red line, it may be too low.
0
200
400
600
800
1000
1200
0 200,000 400,000 600,000 800,000 1,000,000 1,200,000 1,400,000
PCT population
PCT pacemaker new implant rate
PCT New Implant Rate
National Target
Upper Control Limit
Low er Control Limit
PCT in This Netw ork
significantly above national target
consistent w ith national target
significantly below national target
Funnel plots are a way of displaying performance against a national average or target. Here, the national target of 700 is shown as a horizontal grey line. The small blue dots represent the new implant rate (y-axis) in each PCT in the country plotted against that PCTs population (x-axis). The individual PCTs in THIS NETWORK are plotted as larger blue circles. The CONTROL LIMITS determine whether a PCT's new implant rate is significantly greater than (green line) or less than (red line) the national target. The statistical significance level was chosen to ensure that the total risk of one or more PCTs being outside the control limits by random chance is no more than 5%.
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Geographical location of pacemaker implants
Wales – Mid and South West Cardiac Network
18
New and Total PM and ICD Implants
Wales – Mid and South West Cardiac Network
Implantable Cardioverter Defibrillators (ICDs)
The following hospitals implanted ICDs in patients from this cardiac network in 2009.
2009 Replacement implants
Centre New
Implants Total
Implants % of total
MOR Morriston Hospital 46 57 19.30%
UHW University Hospital of Wales 5 7 28.57%
STO University Hospital North Staffs 5 5
QEB Queen Elizabeth Hospital 2 3 33.33%
STM St Marys Hospital 2 2
BHL Liverpool Heart and Chest Hospital 1 1
MRI Manchester Royal Infirmary 1
19
ICD implant trends
ICD New Implant Rate
adjusted for age and sex of network population
0
10
20
30
40
50
60
70
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
year
per million population
Mid and South West Wales
England
ICD All Implant Rate
adjusted for age and sex of network population
0
10
20
30
40
50
60
70
80
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
year
per million population
Mid and South West Wales
England
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CRT implants in this network Wales – Mid and South West Cardiac Network Heart failure is a major and growing public health problem in all Western countries, and is associated with high morbidity and mortality despite optimal medical therapy. Clinical trials of high scientific quality published in recent years have consistently found that cardiac resynchronisation therapy (CRT) improves symptoms, quality of life, exercise tolerance and survival in appropriately chosen patients with advanced heart failure and evidence of left ventricular dyssynchrony who are refractory to optimal medical therapy. CRT involves simultaneous pacing of the left and right ventricles (CRT-P), and may be combined, in the same device, with a defibrillation function (CRT-D). Although CRT involves pacing the heart, it should not be confused with 'classical' pacing for bradycardia - the vast majority of CRT recipients do not require pacing for bradycardia. The function of pacing is to make the ventricles beat at the same time ('resynchronisation'). Within this report, data for CRT-P and CRT-D are quantified separately from pacing and ICD data respectively. In the UK, CRT is provided predominantly by tertiary centres with a special interest in cardiac device therapy. Despite the high prevalence of heart failure, uptake of CRT in the UK is amongst the lowest in Western Europe. NICE published guidelines on the cost effectiveness of CRT in 2007, and it is expected that clinical demand for CRT therapy will continue to rise significantly in coming years.
CRT implanting hospitals in this network
CRT-D CRT-P
1999 Harefield Hospital 1
CRT-D CRT-P
2000 Bristol Royal Infirmary 1
Morriston Hospital 1
University Hospital of Wales 1
CRT-D CRT-P
2001 Morriston Hospital 1 2
CRT-D CRT-P
2002 Morriston Hospital 1
Royal Shrewsbury Hospital 1
University Hospital of Wales 4
CRT-D CRT-P
2003 University Hospital of Wales 4 1
Morriston Hospital 2 2
Royal Brompton Hospital 1
Queen Elizabeth Hospital 1
CRT-D CRT-P
2004 Morriston Hospital 3 7
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2004 University Hospital of Wales 1 3
Bristol Royal Infirmary 2
Royal Brompton Hospital 1
St George's Hospital 1
CRT-D CRT-P
2005 Morriston Hospital 6 2
University Hospital of Wales 1 2
Wellington Hospital North 1
Royal Brompton Hospital 1
CRT-D CRT-P
2006 Morriston Hospital 11 4
University Hospital of Wales 3 2
Queen Elizabeth Hospital 2
University Hospital North Staffs 2
CRT-D CRT-P
2007 University Hospital of Wales 11 8
Morriston Hospital 8 9
Royal Brompton Hospital 1
University Hospital North Staffs 2
University College Hospital 1
CRT-D CRT-P
2008 Morriston Hospital 15 9
University Hospital of Wales 5 4
Queen Elizabeth Hospital 2 1
St Thomas Hospital 2
University Hospital North Staffs 1
CRT-D CRT-P
2009 Morriston Hospital 17 15
University Hospital of Wales 4 8
University College Hospital 3
Royal Brompton Hospital 2 1
Bristol Royal Infirmary 2
Queen Elizabeth Hospital 1
Royal Glamorgan Hospital 1
University Hospital North Staffs 1
Good Hope General Hospital 1
St George's Hospital 1
22
CRT implant trends
Note: Low voltage CRT devices ( CRT-P) pace both the left and right ventricles. High voltage CRT devices (CRT-D) combine this function with a defibrillation capability.
CRT New Implant Rate
adjusted for age and sex of network population
0
10
20
30
40
50
60
70
80
90
100
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
year
per million population
Mid and South West Wales
England
CRT All Implant Rate
adjusted for age and sex of network population
0
20
40
60
80
100
120
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
year
per million population
Mid and South West Wales
England
23
The European Picture
European data for 2009 shows that the UK has average CRT implant rates compared to the Western Europe implant rates, and far below the rate in the U.S.A..
Total CRT-P & CRT-D Implants 2009
0 20 40 60 80 100 120 140 160 180 200
Italy
Germany
Portugal
Netherlands
Denmark
Austria
Sweden
France
UK
Belgium
Switzerland
Ireland
Norway
Spain
Finland
24
Which hospitals serve which PCTs/LHBs? all implants for this cardiac network in 2009
Wales – Mid and South West Cardiac Network
Pacemakers
6A3.Pembrokeshire Total Implants 2009
MOR Morriston Hospital 64
UHW University Hospital Of Wales 5
BRC Bristol Children's Hospital 2
BRI Bristol Royal Infirmary 1
HAM Hammersmith Hospital 1
6A4.Ceredigion Total Implants 2009
MOR Morriston Hospital 31
UHW University Hospital Of Wales 2
WWG West Wales General 1
RSS Royal Shrewsbury Hospital 1
QEB Queen Elizabeth Hospital 1
WAT Watford General Hospital 1
6A5.Neath Port Talbot Total Implants 2009
MOR Morriston Hospital 57
POW Princess Of Wales Hospital 24
UHW University Hospital Of Wales 4
BRI Bristol Royal Infirmary 2
RGH Royal Glamorgan Hospital 1
6A6.Swansea Total Implants 2009
MOR Morriston Hospital 123
GWE Royal Gwent Hospital 2
POW Princess Of Wales Hospital 1
UHW University Hospital Of Wales 1
WRX Maelor Hospital 1
6B3.Bridgend Total Implants 2009
POW Princess Of Wales Hospital 31
MOR Morriston Hospital 27
UHW University Hospital Of Wales 10
RGH Royal Glamorgan Hospital 2
BRC Bristol Children's Hospital 1
6B7.Carmarthenshire Total Implants 2009
MOR Morriston Hospital 106
UHW University Hospital Of Wales 6
NHB Royal Brompton Hospital 1
UCL University College Hospital 1
25
6C4.Powys Total Implants 2009
RSS Royal Shrewsbury Hospital 24
NEV Nevill Hall Hospital 13
MOR Morriston Hospital 9
UHW University Hospital Of Wales 6
HCH Hereford County Hospital 6
STO University Hospital North Staffs 2
QEB Queen Elizabeth Hospital 2
DGE Eastbourne DGH 1
PHB Priory Hospital 1
RDE Royal Devon & Exeter Hospital 1
BHL Liverpool Heart And Chest Hospital 1
BOL Bolton Royal Infirmary 1
Implantable Cardioverter Defibrillators (ICDs)
6A3.Pembrokeshire Total Implants 2009
MOR Morriston Hospital 8
UHW University Hospital Of Wales 1
6A4.Ceredigion Total Implants 2009
MOR Morriston Hospital 5
UHW University Hospital Of Wales 1
6A5.Neath Port Talbot Total Implants 2009
MOR Morriston Hospital 5
6A6.Swansea Total Implants 2009
MOR Morriston Hospital 17
6B3.Bridgend Total Implants 2009
UHW University Hospital Of Wales 3
STM St Marys Hospital 2
MOR Morriston Hospital 1
6B7.Carmarthenshire Total Implants 2009
MOR Morriston Hospital 19
6C4.Powys Total Implants 2009
STO University Hospital North Staffs 5
QEB Queen Elizabeth Hospital 3
UHW University Hospital Of Wales 2
MOR Morriston Hospital 2
MRI Manchester Royal Infirmary 1
BHL Liverpool Heart And Chest Hospital 1
26
Cardiac Resynchronisation Therapy (CRT)
6A3.Pembrokeshire Total Implants 2009
UHW University Hospital Of Wales 2
MOR Morriston Hospital 2
UCL University College Hospital 2
NHB Royal Brompton Hospital 1
6A4.Ceredigion Total Implants 2009
UHW University Hospital Of Wales 2
MOR Morriston Hospital 2
6A5.Neath Port Talbot Total Implants 2009
MOR Morriston Hospital 9
BRI Bristol Royal Infirmary 2
UHW University Hospital Of Wales 1
RGH Royal Glamorgan Hospital 1
UCL University College Hospital 1
6A6.Swansea Total Implants 2009
MOR Morriston Hospital 6
NHB Royal Brompton Hospital 2
6B3.Bridgend Total Implants 2009
MOR Morriston Hospital 6
UHW University Hospital Of Wales 1
6B7.Carmarthenshire Total Implants 2009
MOR Morriston Hospital 7
UHW University Hospital Of Wales 5
GEO St George's Hospital 1
6C4.Powys Total Implants 2009
UHW University Hospital Of Wales 1
GHS Good Hope General Hospital 1
QEB Queen Elizabeth Hospital 1
STO University Hospital North Staffs 1
27
Pacing Mode for New Implants for this cardiac network
Wales – Mid and South West Cardiac Network
Pacemakers
Mode % for this network England %
Atrial based modes
DDDR 31.99% 58.46%
DDD 25.83% 5.90%
AAIR 0.24% 0.50%
AAI 0.00% 0.04%
DDI 0.00% 0.02%
DDIR 0.00% 0.03%
Ventricular based modes
VVIR 28.20% 32.02%
VVI 13.74% 1.86%
VDDR 0.00% 0.03%
VDD 0.00% 0.29%
Note: The Mode table percentage calculations do not include any records where the mode was blank or unknown.
Note: The Network and England charts’ percentage segments are calculated based on the records in the Mode table but also include all records where the mode was blank or unknown.
England
Atrial
based
65%
Ventricular
based
34%
Blank/
Unknown
1%
Network
Ventricular
based
38%Atrial
based
59%
Blank/
Unknown
2.5%
28
Pacing Mode for New Implants major implanting hospitals in this cardiac network
Wales – Mid and South West Cardiac Network
VVI VVIR AAI AAIR DDD DDDR VDD VDDR Atrial Based Pacing
NATIONAL 1.9% 32.3% 0.0% 0.5% 6.0% 59.0% 0.3% 0.0% 65.5%
This Network 2.6% 36.1% 0.0% 0.5% 14.7% 46.1% 0.0% 0.0% 61.3%
MOR.Morriston Hospital 16.7% 28.9% 0.0% 0.0% 28.2% 26.2% 0.0% 54.4%
POW.Princess Of Wales Hospital 10.7% 30.4% 0.0% 0.0% 32.1% 26.8% 0.0% 58.9%
UHW.University Hospital of Wales
0.0% 0.0% 0.0% 0.0% 14.3% 85.7% 0.0% 100.0%
Note: Implant centres shown have contributed at least 5% of Pacemaker implant activity in the network.
Note: The Mode table for major implanting hospitals’ percentage calculations do not include any records where the mode was blank or unknown.
NB: As from 2007, mode is based on the maximum mode of which the device is capable and not the mode at the end of the procedure.
29
Pacing Mode for Sick Sinus Syndrome
There is ample evidence from major clinical trials and support from NICE guidelines (NICE Technology Appraisal 88, 2005) that use of ventricular pacing modes in patients with sick sinus syndrome can lead to poor outcomes, notably an increased incidence of atrial fibrillation and pacemaker syndrome. Pacing modes in sick sinus syndrome should be atrial based (i.e. dual chamber or atrial). The Western European average in 2005 was 92% atrial based pacing for SSS. In the UK the average was 76% in 2008 and 81% in 2009. Any percentage of ventricular based pacing greater than 10% has been shaded pink, and may be considered higher than desirable. A percentage greater than 20% is considered definitely too high and is shown in a shaded red box. Percentages greater than 50% are shown shaded black. NB: the % of atrial based pacing shown for a centre applies only to patients residing in THIS NETWORK and may differ overall.
New Implants for Sick Sinus
Syndrome in this network
Atrial-based New Implants for SSS in this network
Ventricular-based New Implants for SSS in this network
MOR.Morriston Hospital 73 69.9% 30.1%
POW.Princess Of Wales Hospital 16 68.8% 31.3%
Note: Any hospital in the network not in this list did not code at least 10 implants as SSS.
Note: For this analysis only ECG codes E1-E5 are used
NB: As from 2007, mode is based on the maximum mode of which the device is capable and not the mode at the end of the procedure.
References 1. TA88 Bradycardia - dual chamber pacemakers: Information for the public. NICE 23 February 2005. http://www.nice.org.uk/TA88
30
The European Picture Atrial based pacing in the UK is low compared to most of Europe.
% Atrial-based pacing for Sick Sinus Syndrome2003 (most recent survey)
60% 65% 70% 75% 80% 85% 90% 95%
Denmark
Sweden
Austria
France
FR Yugoslavia
Belgium
LATVIA
Norway
UK
Netherlands
Turkey
Spain
NB: As from 2007, mode is based on the maximum mode of which the device is capable and not the mode at the end of the procedure.
31
ECG Indication for New Implants
Wales – Mid and South West Cardiac Network
Complete
HB Incomplete
HB AF +
HB/brady Sick sinus syndrome
Other
NATIONAL 22.1% 21.7% 23.4% 25.9% 6.8%
This Network 38.7% 16.1% 18.6% 23.6% 3.0%
6A3.Pembrokeshire 39.6% 16.7% 14.6% 25.0% 4.2%
6A4.Ceredigion 25.9% 18.5% 29.6% 25.9% 0.0%
6A5.Neath Port Talbot 43.1% 6.2% 15.4% 32.3% 3.1%
6A6.Swansea 43.3% 15.6% 17.8% 21.1% 2.2%
6B3 .Bridgend 35.8% 15.1% 28.3% 17.0% 3.8%
6B7.Carmarthenshire 35.7% 16.7% 20.2% 25.0% 2.4%
6C4.Powys 38.9% 33.3% 5.6% 16.7% 5.6%
AF: atrial fibrillation HB: heart block Brady: bradycardia
32
Corrected and Actual New Implant Rates
Pacemakers
Expected and Actual New Implant Rates Explanatory note: The "Raw" new implant rate is the actual implant rate of new pacemakers per million population in each PCT. The "corrected" rate is the raw rate, adjusted for relative need – so if a PCT has an aging population, its relative need is > 100% and its corrected rate will be reduced to reflect that need. Comparisons between PCTs and with network and national averages should be made using corrected rate.
Wales – Mid and South West Cardiac Network
England Average 531
Network average (unadjusted) 445
Network average (corrected for age and sex) 372
New Implant Rate 2009
Population
Relative need for PM
Raw Corrected
6A3 Pembrokeshire
116,300 124.3% 481 387
6A4 Ceredigion
77,200 120.7% 382 316
6A5 Neath Port Talbot
135,300 116.0% 488 421
6A6 Swansea
224,700 117.2% 430 367
6B7 Carmarthenshire
176,000 125.8% 497 395
6C4 Powys
129,200 129.0% 378 293
6B3 Bridgend
129,900 106.2% 430 405
33
How much does the implant rate vary in this network? Of course there will always be some random variation in implant rate. This NORMAL CAUSE variation is not considered likely to exceed 5% of the total implant rate for pacing. Variation IN EXCESS of 10% may be considered due to another (SPECIAL) cause, such as referral patterns or varying implantation policies between trusts.
Variability Index for this Cardiac Network
12.9%
1% RATING: small excess variation in implant rates between PCTs
34
New Pacemaker Implant Rates The Western European average new implant rate for 2003 and 2004 was 700 per million population. This figure is also now the HRUK target and will be used as the basis for comparison.
Wales – Mid and South West Cardiac Network
England Average 531
Network average (unadjusted) 445
Network average (corrected for age and sex) 372
Population Corrected New Implant Rate
2009
Deficit/ Excess 2009
compared to rate of 700
6A3 Pembrokeshire
116,300 387 -45%
6A4 Ceredigion
77,200 316 -55%
6A5 Neath Port Talbot
135,300 421 -40%
6A6 Swansea
224,700 367 -48%
6B3 Bridgend
129,900 405 -42%
6B7 Carmarthenshire
176,000 395 -44%
6C4 Powys
129,200 293 -58%
35
Corrected and Actual New Implant Rates
Implantable Cardioverter Defibrillators (ICDs)
Explanatory note:
The "Raw" new implant rate is the actual implant rate of new ICDs per million population in each PCT. The "Corrected" rate is the raw rate, adjusted for relative need - so if a PCT has an aging population, its relative need is > 100% and its corrected rate will be reduced to reflect that need. Comparisons between PCTs should be made using Corrected rate.
Wales – Mid and South West Cardiac Network
England Average 62
Network average (unadjusted) 62
Network average (corrected for age and sex) 54
New Implant Rate 2009
Population
Relative need for ICD
Raw Corrected
6A3 Pembrokeshire
116,300 121.8% 60 49
6A4 Ceredigion
77,200 115.0% 65 56
6A5 Neath Port Talbot
135,300 111.5% 22 20
6A6 Swansea
224,700 109.7% 58 53
6B3 Bridgend
129,900 106.8% 38 36
6B7 Carmarthenshire
176,000 119.0% 97 81
6C4 Powys
129,200 121.0% 85 70
36
New ICD Implant Rates A target figure of 100 implants per million is used as a basis for comparison, based on recent NICE guidance.
Wales – Mid and South West Cardiac Network
England Average 62
Network average (unadjusted) 62
Network average (corrected for age and sex) 54
Population Corrected New Implant Rate
2009
Deficit/ Excess 2009
compared to rate of 100
6A3 Pembrokeshire
116,300 49 -51%
6A4 Ceredigion
77,200 56 -44%
6A5 Neath Port Talbot
135,300 20 -80%
6A6 Swansea
224,700 53 -47%
6B3 Bridgend
129,900 36 -64%
6B7 Carmarthenshire
176,000 81 -19%
6C4 Powys
129,200 70 -30%
37
New Implant rate maps for Wales – Mid and South West Cardiac Network
38
New pacing implant rate 2009 comparison with Heart Rhythm UK target (700)
Wales – Mid and South West Cardiac Network
Pacemaker New Implants 2009adjusted for age and sex
compared to target figure of 700 per million
-70% -60% -50% -40% -30% -20% -10% 0%
Neath Port Talbot
Bridgend
Carmarthenshire
Pembrokeshire
Swansea
Ceredigion
Powys
39
ICD new implant rate 2009
Wales – Mid and South West Cardiac Network
ICD New Implants 2009adjusted for age and sex
compared to target figure of 100 per million
-90% -80% -70% -60% -50% -40% -30% -20% -10% 0%
Carmarthenshire
Powys
Ceredigion
Swansea
Pembrokeshire
Bridgend
Neath Port Talbot
40
Pacing Implant Deficit in 2009 comparison with HRUK recommendations
Wales – Mid and South West Cardiac Network
The graph shows the NUMBER of additional new pacemakers implants that each PCT needs to implant to bring them up to the HRUK target rate.
Deficit in New Pacemaker Implants 2009compared to Heart Rhythm UK target rate of 700
-100
-90
-80
-70
-60
-50
-40
-30
-20
-10
0
Ceredigion
Bridgend
Neath Port Talbot
Pembrokeshire
Carmarthenshire
Powys
Swansea
41
Conclusions
Wales – Mid and South West Cardiac Network � The population is much older than the average for England and Wales. Because of
this there is a 20% extra need for pacemakers and a 15% extra need for ICDs compared to average.
� The network pacemaker new implant rate increased slightly and remained below the
national average. � The network ICD new implant rate increased notably and remained below the
national average. � The CRT total implant rate is static and remained below the national average. � The proportion of atrial based pacing (59%) is lower than the national average of
65%. � Princess Of Wales Hospital (31%) and Morriston Hospital (30%) have higher rates of
ventricular based pacemaker implants for sick sinus syndrome; this is not compliant with NICE TAG 88 (2005).