26th January
SESSION XIV – DEBATE
DGH vs Tertiary intervention –
Is there really a conflict?
Department of Health Perspective
Roger Boyle
No conflict of interest to declare
DGH cardiologist Tertiary centre cardiologist
Cardiac surgeons
Cardiology in the district hospital.Report of a working group of the British Cardiac SocietyBr Heart J. 1987; 537-546
“The district cardiologist may wish to maintain skills by participating in catheter sessions….”
A report of a working group of the British CardiacSociety: cardiology in the district hospital.Br Heart J. 1994; 72: 303-308
“It is becoming commonplace for district hospitals to develop their owncatheterisation facilities…………..”
BCS Council Meeting circa 1994
Statement by the Council of the British CardiacSociety. Strategic planning for cardiac servicesand the internal market: role of catheterisationlaboratories in district general hospitals.Br Heart J. 1994; 71: 110-112
DGH cardiologists should be offered specific sessions in tertiary labs
Some DGHs that are geographically disadvantaged might developtheir own labs
Over time, DGH labs would become the norm!!!!!!!!!
BCS Working Group:The changing interface between district hospitalcardiology and the major cardiac centresHeart 1997; 78: 519-523
Main conclusions
• The establishment of new cardiac catheterisation laboratories in DGHs remote from a major centre should be encouraged provided the workload is adequate to ensure efficient use of the facility
• Cardiologists working in districts close to a major centre should be encouraged to catheterise their patients at the centre
UK Centres - 2005
52 52 53 54 54 5358 61 63 66 64 64
738377
87
6568
83
0
20
40
60
80
10019
91
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
No.Centres
PCI Angio only
2005 data: Ludman
England - Revascularisation - Numbers - CABG & PCI 1999/2000-2004/05 (Source: DH Returns)
0
10000
20000
30000
40000
50000
60000
70000
80000
1999-2000 2000-2001 2001-2002 2002-2003 2003-2004 2004-2005estimate
CABG
PCI
Total
Revascularisation trends
Rate per million in England
0
200
400
600
800
1000
1200
1400
1600
1989
/90
1990
/91
1991
/92
1992
/93
1993
/94
1994
/95
1995
/96
1996
/97
1997
/98
1998
/99
1999
/00
2000
/01
2001
/02
2002
/03
2003
/04
2004
/05
2005
/06
CABG
PCI
Total
Angiography waiters from April 2005
0
5,000
10,000
15,000
20,000
25,000
April
May
June Ju
ly
Augus
t
Septe
mbe
r
Octob
er
Novem
ber
Decem
ber
Janu
ary
Febru
ary
Mar
chApr
ilM
ayJu
ne July
Augus
t
Septe
mbe
r
Octob
er
Novem
ber
9+
08-Sep
07-Aug
06-Jul
05-Jun
04-May
03-Apr
02-Mar
01-Feb
0-1
PCI waiters by length of wait April 2002 onwards
0
1,000
2,000
3,000
4,000
5,000
6,000
Apr Jul
OctJa
nApr Ju
lOct
Jan
Apr Jul
OctJa
nApr Ju
lOct
Jan
Apr Jul
Oct
9 to 12
6 to 9
3 to 5
0 to 3
2002/3 2003/4 2004/5 2005/6 2006/7
Southampton – November 2006
SEPHO Revascularisation Model - Version 5 - Rates pmp
0
500
1000
1500
2000
2500
3000
3500
4000
4500
5000
Rate pmp 2003/4
Rate pmp 2015 Model
1900 pmp
2200 pmp
2500 pmp
83
87
PCI centres
Angiography onlyCentres
2005
‘A discussion of the drugs administered in a case of coronary thrombosis is not relevant here – but for pain relief morphine is often given by an attending doctor or on arrival at hospital….the patient should not be questioned unduly or in any way alarmed.’
1970
Heart Attack: Progress Since the NSF
• Percentage of patients treated within 30 minutes of arrival at hospital rose from 38% to 83%
• Paramedics trained to assess, diagnose and provide thrombolysis
• Percentage of patients treated within 60 minutes of a call for help rose from 30% to 65%
• Pilot schemes set up to test feasibility of primary angioplasty in the NHS
Reperfusion treatment 2003-6
0
10
20
30
40
50
60
70
80
90
100
2003 2004 2005 2006
In hospital lysis
Prehospital lysis
PPCI
12.6%
14.4%
%
[plus patients in NIAP not yet transferred~ 2.5%]
Access to PPCI
• 37/68 English & Welsh hospitals with interventional facilities on site perform primary angioplasty
• 14/37 provide an internal service only– Only 4 provide 24/7, the rest lab hours or ‘occasional’
• 23/37 offered a service to other hospitals– Reporting that they provided this to 78 hospitals
– NB only 42 non interventional hospitals said they received a routine PPCI service, suggesting that service to other hospitals might be irregular / occasional
James Cook - Friarage
Leeds- SJUH- Bradford
East London- R London- Whipps X- King George- Oldchurch- Homerton- Newham
Leeds- SJUH- Bradford
SE London-Lewisham-Bromley-Sidcup-Mayday
Manchester (2)-North Mcr-Salford-Stockport-Tameside-Trafford
NW London (3)-Hammersmith-W Middlesex-Ealing-Charing X-St Mary’s-Northwick-Hillingdon-Harefield-Brompton-Hemel
Exeter
Trust Catchment Areas
Secondary - Acute MI Tertiary - CABG
No. of Trusts 153 28
Ave Pop Served 321,000 1.7 million
Largest 787,000 3.2 million
Smallest 104,000 816,000
Acute MI Catchments Tertiary CABG Catchments
Conclusion
• District hospital angiography has improved access to care and the capacity is needed
• Still a great deal of unmet need particularly in the North• We are a long way from providing a comprehensive
PPCI service at the present• Many places are ‘dabbling’• We need a comprehensive strategy within each network
with formal involvement of the ambulance service• No reason to exclude DGHs from providing this but the
rota requirements are onerous