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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
Other Procedures 2001 - 4
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
Other Procedures 2001 - 5
Renal Sub-clavian
Pulm.artery
Aorta SVC Carotid
Centres 1=
0-
1+
1+
2-
2+
No. 1-
0-
1+
1+
2-
2+
Mean - - - - - -
Range - - - - - -
+, =, - : increase, no change, or decrease compared to 2000
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
+, =, - : increase, no change, or decrease compared to 2000
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)
Success PartialSuccess
RepeatPCI
CABG MI Death(Range)
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)
Success PartialSuccess
RepeatPCI
CABG MI Death(Range)
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)
Success PartialSuccess
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)
Success PartialSuccess
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)
Success PartialSuccess
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)
Success PartialSuccess
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