NEYNL v2 - Nicor · 2020-01-24 · cardiac rhythm management, having evolved from the more simple...

2011Clinical Audit of Heart Rhythm DevicesPacemaker, ICD and CRT

North & East Yorkshire and NorthernLincolnshire Cardiac Network

David CunninghamSenior Strategist, NICOR

Morag CunninghamCRM Database Coordinator, NICOR

Richard CharlesChairman, Heart Rhythm UK Device Audit Group

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Acknowledgments

The implant registration data that allows the construction of reports such as this is contributed on avoluntary basis by all pacemaker implanting hospitals in the United Kingdom. The data is held inthe National Pacemaker Database, established in 1977 by Dr Anthony Rickards, and now part ofthe Central Cardiac Audit Database (CCAD) which runs the national cardiac audits as part of theNational Institute for Cardiovascular Outcomes Research (NICOR), which is part of UniversityCollege London.

Anonymised extracts from the National Pacemaker Database were used to generate this report,with the express permission of the owners of the data, Heart Rhythm UK and the full agreement ofthe Department of Health Heart Team and HQIP.

This national clinical audit is funded as part of the National Clinical Audit & Patient OutcomeProgramme (NCAPOP), which is managed by the Healthcare Quality Improvement Partnership(HQIP – www.hqip.org.uk).

The preparation of this report was supported by HQIP. Data collection was carried out by NICORwith support provided from NHS Improvement (www.improvement.nhs.uk) and the CardiacNetworks. The study was performed with the knowledge and support of the British CardiovascularSociety and Heart Rhythm UK. Clinical review of the report was carried out by Dr Richard Charles,Chairman of the Heart Rhythm UK Audit Group. The report may be downloaded fromwww.devicesurvey.com.

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Contents

Acknowledgments ......................................................................................2

Contents....................................................................................................3

Introduction to the 2011 Reports ................................................................4

The National Clinical Audit Report ...............................................................5

Overview of Device Implants in the UK........................................................7

How does the UK compare with Europe? .....................................................9

Data Quality Statement ............................................................................ 14

Data Completeness and Data Quality for Key Hospitals in this Network ...... 15

2011 Implant Rates in the Cardiac Networks.............................................. 17

PCTs/LHBs in the Network ........................................................................ 20

Correcting Implant Rates for Age and Sex ................................................. 21

Relative Need for Pacemakers, ICDs and CRTs........................................... 23

Centres providing Device Implants to this Network..................................... 24

10 Year Implant Trends – Network v National............................................ 25

Provider Hospitals: which hospitals serve which PCTs/LHBs?....................... 26

Geographical Location of Implants ............................................................ 30

Pacing Mode in this Network: Physiological vs Non-Physiological ................. 32

Pacing Mode for New Implants by Centre .................................................. 33

Physiological Pacing in Sick Sinus Syndrome .............................................. 34

ECG Indication for New Pacemaker Implants ............................................. 35

New Pacemaker Implant Rates corrected for Age and Sex .......................... 36

New ICD Implant Rates corrected for Age and Sex..................................... 37

New Implant Rate Maps ........................................................................... 38

Pacemaker Implant Deficit in 2011............................................................ 39

Conclusions ............................................................................................. 40

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Introduction to the 2011 Reports

The Heart Rhythm UK Device Audit Group (formerly the Network DevicesSurvey Group), now in its ninth consecutive year of work, continues its auditof cardiac rhythm management, and particularly the level of provision ofcardiac pacemakers, implantable defibrillators and cardiac resynchronisationtherapy in England and Wales. This year the seventh consecutive annualnational report has been published, covering clinical activity in 2011, and it isa pleasure for me to welcome its publication. You will find the national reportat www.devicesurvey.com.

The report’s principal focus remains the provision of data on the total volumeand equity of provision of implantable cardiac devices, corrected for thedemographic structure of the population. The methodology allows validcomparison of activity between and within different Network areas, and thusbenchmarking of activity. This year the audit has used population data fromthe 2011 census, rather than serial extrapolations from the 2001 census,which should be borne in mind when comparing implant activity in this reportwith those from previous years. A summary account of cardiac arrhythmiaablation activity is now a fixed and valuable section of the report, and onewhich will be developed further in future reports.

Work over the past two years has resulted in this being a full clinical audit ofcardiac rhythm management, having evolved from the more simple pastsurveys of implantable device activity. Completion of an increased number ofdata fields has been encouraging, and I congratulate all those involved,particularly cardiac physiologists, arrhythmia nurses and clinicians who haveworked so hard to ensure data collection. Clinical audit lies at the heart ofunderstanding the quality and effectiveness of what we do for patients, andour performance compared to national and professional guidelines.

The report provides an excellent contemporary picture of cardiac device andarrhythmia ablation activity in the NHS in England and Wales. Enormousprogress has been made, driven by the advances in clinical science andtechnology and the hard work of NHS staff who translate these advances intopractice. There is always scope for improvement, and this report highlightsthat volumes and equity of service provision of arrhythmia services in the NHSsometimes falls short by international comparison. However, the progressmade to date is encouraging and I commend this report to all colleagues whoplan, commission or deliver cardiac arrhythmia services for patients inEngland and Wales.

Professor Huon GrayInterim National Clinical Director for Cardiovascular Disease,Dept of Health (England)& Consultant Cardiologist, University Hospital of Southampton

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The National Clinical Audit Report

The Heart Rhythm UK Device Audit Group (formerly the Network DeviceSurvey Group) is pleased to present its seventh set of annual reports coveringthe calendar year 2011. Our name change is not a mere re-branding;consistent with the aspirations set out in my Introduction to the 2010 Report,it reflects our steady progress towards a full clinical audit, and our integralrelationship with our national society. Furthermore, the transfer of the cardiacaudits during 2011, including this device audit, to the aegis of NICOR (theNational Institute for Cardiovascular Outcomes Research based at UniversityCollege, London) has been a wholly positive development which will greatlyenhance the probability that the audit will indeed survive, develop andflourish in future.

Whilst it is crucial for us to expand the clinical outcomes content of the Auditreport, it remains a vital task of this Report to present data describing thetotal volume and equity of provision of the major cardiac implantable devicetherapies – pacemakers for bradycardia (PM), implantable cardioverterdefibrillators (ICDs) for cardiac arrest and cardiac resynchronisation therapy(CRT) for advanced heart failure – across all Cardiac Networks in England andWales. The core methodology of the survey remains unchanged, allowingvalid direct comparison between Cardiac Networks, Primary Care Trusts (LocalHealth Boards in Wales) and between the national reports for 2009, 2010, thecurrent report for 2011, and all previous annual reports. A full account of themethodology is presented within the National Report. This report continues touse the current professionally accepted targets for each device class, as inprevious years – 700 new implants/million(M) population for PM, 100 newimplants/M for ICD and 130 total (new + replacement)/M for CRT, althoughthere is a compelling case to revisit these targets in the light of currentEuropean trends. UK performance must be viewed in the context of ourEuropean neighbours; as we have previously emphasised, there is evidenceneither of over-prescribing of devices in Europe, nor is there evidence that theprevalence of the conditions for which a device is indicated, based on currentprofessional guidelines, differs between the UK and Western Europe.

What are the headline results for 2011? In England, the PM new implant rateis 525/M, a small fall from 2010 which establishes a disappointing flat linefrom 2009. The ICD new rate is 77/M, a 6.9% increase over 2010, whilst theCRT total rate is 113/M, marking an abrupt halt to the consistent year-on-yearrise since 2001. The performance of the NHS in England continues tocompare unfavourably with most of the developed European economies.Wales demonstrates striking and commendable increases in implant rates forPM and CRT, whilst falls in implant rates in Northern Ireland for ICD and CRTarrest its erstwhile progress, although the ICD implant rate there continues tofar exceed the rest of the UK. Data returns from Scotland show signs ofimprovement for complex devices but remain sadly depleted, as in previousyears. It can be emphasised with confidence that the overall provision of

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cardiac implantable devices by the NHS remains inadequate to meet theneeds of the population at risk.

Inequity of provision of devices still afflicts the NHS but has noticeablydecreased due to a general regression towards the (inadequate) meanimplant rate. A regression towards the target would have been more welcome.To spell it out yet again, your chances of getting the life saving or lifeenhancing device you need depends critically on where you live.

The 2011 Reports continue our drive to present the clinical data whichsupport the prescription of complex devices in particular.

Finally, it is again a pleasure to recognise both the efforts of hard pressedclinical staff at implanting centres who submit their data and the continuedinput of constructive criticism from all who are charged with, and wish to see,the provision of a top class device service in the UK. To all colleagues we offerour thanks for their contribution to the resource we offer here.

Dr Richard CharlesEmeritus Consultant Cardiologist,Liverpool Heart and Chest HospitalChairman, Heart Rhythm UK Audit Group

The National Audit of Cardiac Rhythm Management2011 Report can be downloadedfrom www.devicesurvey.com.

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Overview of Device Implants in the UK

General note: up to 2010, population estimates were year-on-year projectionsfrom ONS of the population, extrapolating from the 2001 census. In generalthese projections tend to under-estimate the true population. The 2011 ratesuse the population from the 2011 census, so a slight increase in actualimplant rate might be masked by replacing a population under-estimate witha true estimate. (Note: the rates in these graphs are NOT adjusted for ageand sex).

New Pacemakers

Comments

Pacemaker implant rate inEngland again remainsstatic (524 per millionpopulation).

Large increase in newpacemaker rate in Wales

No increase in pacing ratein N Ireland.

Data submissions fromScotland have improvedbut are still incomplete.

0

100

200

300

400

500

600

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

year

pe

rm

illi

on

po

pu

lati

on

England

Wales

Scotland

N Ireland

New ICDs

Comments

ICD rate fell slightly in NIreland but is still wellabove the rest of the UK.

England and Wales ratesremain very similar, with amodest increase in 2011.

Dramatic rise in Scottishrate actually reflects betterdata submission, but is stillnot 100% complete.

0

20

40

60

80

100

120

140

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

year

pe

rm

illi

on

po

pu

lati

on

England

Wales

Scotland

N Ireland

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Total CRTs

Comments

The total CRT rate (allimplants CRT-P and CRT-D) for England failed toincrease for the first yearsince these devices wereintroduced.

There was a largeincrease in the CRT ratein Wales and a largedrop in N Ireland.

The CRT rate in Scotlandremains very low and isone of the lowest inEurope.

0

20

40

60

80

100

120

140

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

year

pe

rm

illi

on

po

pu

lati

on

England

Wales

Scotland

N Ireland

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How does the UK compare with Europe?

Pacemaker New Implant Rate 2011per million population

0 100 200 300 400 500 600 700 800 900 1000 1100 1200

Azerbaijan

Ukraine

Armenia

Bosnia Herzegovina

Macedonia

Russia

Luxembourg

Belarus

Montenegro

Bulgaria

Israel

San Marino

Serbia

Netherlands

Latvia

Portugal

Croatia

Slovenia

Greece

UK

Slovakia

Norway

Poland

Switzerland

Belgium

Denmark

Lithuania

Czech Republic

Malta

Estonia

Finland

Sweden

Italy

France

Iceland

Germany

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ICD New Implant Rate 2011per million population

0 50 100 150 200 250 300

Ukraine

Georgia

Russia

Armenia

Bulgaria

Macedonia

Bosnia Herzegovina

Belarus

Latvia

Lithuania

Serbia

Montenegro

Malta

Estonia

Spain

Greece

UK

Portugal

Iceland

Luxembourg

Sweden

Israel

France

Finland

Switzerland

Slovakia

Netherlands

Norway

Belgium

Poland

Italy

Denmark

Germany

Czech Republic

San Marino

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CRT Total Implant Rate 2011per million population

0 50 100 150 200 250

Morocco

Ukraine

Egypt

Azerbaijan

Armenia

Georgia

Belarus

Bosnia Herzegovina

Russia

Tunisia

Macedonia

Romania

Croatia

Bulgaria

Cyprus

Montenegro

Latvia

Lithuania

Greece

Luxembourg

Serbia

Slovenia

Portugal

Iceland

Spain

Malta

Ireland

Belgium

Estonia

Slovakia

Finland

Poland

Israel

Switzerland

Hungary

Sweden

Norway

San Marino

UK

Austria

France

Netherlands

Czech Republic

Denmark

Germany

Italy

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Comments and Analysis of UK Implant Rates compared to Europe

UK device implant rates have lagged behind our European neighbours fordecades. The situation is not improving, it is getting worse.

It is clear from the graphs above that small countries with a low GDP cannotafford to implant cardiac devices. The UK is not in that situation. To comparelike with like, we took an average of European countries with a populationover 10 million and a GDP per capita of at least $10,000 in 2011.

The nine countries selected for comparison were Netherlands, Germany,France, Belgium, Italy, Spain, Portugal, Greece and the Czech Republic. Thetable below shows the UK implant rates and the population-weightedEuropean average rates.

UK 2011 Europe 2011

Pacemaker newimplant rate

524 697

ICD new implant rate 76 146

CRT total implant rate 113 142

Clearly there remains an enormous deficit in new implant rates forpacemakers and ICDs. The target (set some years ago) of 700 newimplants per million for pacemakers seems to be still valid incomparison with Europe.

However, the target of 100 for new ICD implants appears low incomparison with Europe, although still much higher than the UK iscurrently achieving.

The European average CRT rate is 10% higher than the Heart RhythmUK/BSH target rate of 130 and so this target probably does not need tobe reviewed at the moment.

All data in this section was extracted from the EHRA White Book 2012:The Current Status of Electrophysiology in ESC Member Countries.

The book can be found athttp://www.escardio.org/communities/EHRA/publications/Documents/ehra-white-book-2012.pdf

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New Pacemaker Implant Rate – Europe 2011

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Data Quality Statement

The quality of the analyses in this report is only as good as the quality of thedata on which it is based.

That data is originally submitted by hospitals to the National PacemakerDatabase. If there is a deficit in registration, or if registrations do not containa valid postcode, then analysis gaps are inevitable.

Data is then anonymised and extracted to provide the basis of this analysis.To minimise the risk of deficit errors, a threshold of 98% for registration andpostcode completeness is sought for each hospital. Overall networkcompleteness must reach 98% or a report will not be issued.

Every effort is made to ensure this report is as accurate as possible - howeverplease contact us if you identify any residual problem and we will try tocorrect the error promptly.

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Data Completeness and Data Quality forKey Hospitals in this Network

Listed below are the most important data fields and their completion rates with CLINICALLYVALID entries. Note that any code which translates to “Unknown” or “Uncoded” is notconsidered to be clinically valid.

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2011 Implant Rates in the Cardiac Networks

There has been a noticeable decrease in variability across networks in 2011.This has resulted from a decrease in rate for the highest rate implantingnetworks and an increase in the lower rate networks. Unfortunately thismeans that none of the networks now implant up to the target rate of 700 forpacemakers. It would have been preferable to see regression towards thetarget rather than regression towards the mean. As it stands, it appears thata clinically inadequate national average is being sought as an acceptable levelof performance, when the focus should be on improvement to the levels ofour Western European neighbours.

The grey line represents the national average rate. The blue line is thenational target rate.

new Pacemaker rate 2011adjusted for age and sex

0 100 200 300 400 500 600 700 800

Herefordshire and Worcestershire Cardiac Network

Coventry & Warwickshire Cardiovascular Network

Shropshire & Staffordshire Cardiac Network

North Wales

South Wales

Essex Cardiac and Stroke Network

South East London Cardiac & Stroke Network

Avon, Gloucestershire, Wiltshire & Somerset Cardiac and Stroke Network

Cardiac and Stroke Networks in Lancashire and Cumbria

East Midlands Cardiac & Stroke Network

Peninsula Cardiac Managed Clinical Network

Birmingham, Sandwell and Solihull Cardiac and Stroke Network

Black Country Cardiovascular Network

Surrey Heart & Stroke Network

North Trent Network of Cardiac Care

Greater Manchester & Cheshire Cardiac Network

West Yorkshire Cardiac Network

South Central Cardiovascular Network

Anglia Stroke and Heart Network

Cheshire & Merseyside Cardiac Network

Kent Cardiovascular Network

North of England Cardiovascular Network

North Central London Cardiac & Stroke Network

South West London Cardiac Network

North East London Cardiac and Stroke Network

Bedfordshire and Hertfordshire Heart and Stroke Network

North & East Yorkshire and Northern Lincolnshire Cardiac Network

Sussex Heart Network

Dorset Cardiac Network

North West London Cardiac and Stroke Network

The national target rate is 700 implants per million population. Nonetwork reaches this level.

NB: North Walesand South Waleshave a higher thanaverage need forpacing so theadjusted ratesshown here arelower than theunadjustednational rate forWales shown onPage 7.

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ICD


new ICD rate 2011adjusted for age and sex

0 20 40 60 80 100 120










South Wales

North Wales




















Dorset and NE London are to be commended for maintaining theirimplant rates at or above the national target of 100. Sussex has seena significant increase and has also reached the target, as has SWLondon.

Hereford & Worcester has seen an improvement from an extremely lowlevel (<40) to nearly 60. The rate in Lancs & Cumbria remains very low.For some reason the rate in SE London has fallen catastrophically, andthis needs further examination.

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CRT


total CRT rate 2011adjusted for age and sex

0 20 40 60 80 100 120 140 160 180 200




South Wales







North Wales




















Eleven networks have achieved the Heart Rhythm UK/BSH target of130 total CRT implants per million

North Trent are implanting at only half of the target rate. A numberof other networks are well below average and even further belowthe target rate.

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PCTs/LHBs in the Network

Code PCT/LHB Population

North & East Yorkshire and Northern Lincolnshire Cardiac Network 1,291,994

5EF North Lincolnshire 163,546

5NV[5E2]

North Yorkshire and York[Selby and York]

238,461

5NV[5KK]

North Yorkshire and York[Scarborough, Whitby and Ryedale]

138,012

5NW East Riding Of Yorkshire 334,673

5NX Hull 256,123

TAN North East Lincolnshire Care Trust 161,179

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Correcting Implant Rates for Age and Sex

Calculating Need

Most pacemakers are implanted forconduction system disease, which ispredominantly a disease of the elderly.The graph shows the percentage of thepopulation in 5 year age bands, and thepercentage of pacemaker implants. Only11% of the population are aged 70 ormore, but they receive 76% of allpacemaker implants.

Men also receive more pacemakers thanwomen. Although the national average newimplant rate is 528, it reaches more than11,000 in men aged more than 90 (right). Sothe proportion of older people in a localpopulation will strongly influence how manypacemakers need to be implanted.

If we examine closely the age and sex distribution of the local population of a PCT (LHB inWales) or Network, we can work out how many pacemakers we would EXPECT to seeimplanted, compared to the national average. The ratio of the local and national rate iscalled 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% areaged 70 or more, compared to the national average of 11%. This means that this networkdoesn't need as many pacemaker implants relative to the nation as a whole. TheirRelative 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. TheirRelative 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 theNational Average. That means we should correct for relative need. So, for example ifNorth 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'sadjusted rate is 840 divided by 140% = 600.

So the adjusted rates for these two areas are the same, despite the major apparentdifference in their unadjusted rates.

Implantable Defibrillators

The diseases for which ICDs areimplanted are not the same as forpacemakers, and tend to occur inslightly younger people. Thesediseases are principally ischaemicheart disease and cardiomyopathy.

We therefore need to calculate a

separate relative need factor for ICDs.The graph (right) of new ICD implantrate in 2010 and 2011 shows thatICDs are also predominantlyimplanted 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, butjust slightly less in magnitude than for pacemakers. Sussex, for instance, has a relativeICD need of 138%.

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Relative Need for Pacemakers, ICDs and CRTs

National new implant rates 2011:

Pacemaker: .524. ICD: .76. CRT: .113.new implants new implants total implants

A PCT with a relatively OLD population will need relatively MORE implantscompared to a PCT with a young population, because the incidence ofindications for pacing and ICD is higher in older people.

Code PCT/LHB

RelativeNeed

forPacing

RequiredRate to be

comparablewith

nationalaverage

RelativeNeed

for ICD

RequiredRate to be

comparablewith

nationalaverage

RelativeNeed

for CRT

RequiredRate to be

comparablewith

nationalaverage

North & East Yorkshireand NorthernLincolnshire CardiacNetwork

112% 586 110% 84 112% 127

5EFNorthLincolnshire

107% 563 109% 83 110% 125

5NV [5E2]

NorthYorkshire andYork[Selby andYork]

106% 554 105% 80 106% 120

5NV [5KK]

NorthYorkshire andYork[Scarborough,Whitby andRyedale]

138% 721 125% 95 133% 150

5NWEast RidingOf Yorkshire

127% 664 123% 94 129% 145

5NX Hull 87% 456 91% 70 89% 100

TANNorth EastLincolnshireCare Trust

108% 565 106% 81 108% 122

Note: "Required" implant rates are relative to the national average rate, but are corrected

depending on the age and sex distribution of the local population.

For Pacemakers, the required implant rate will be higher if the percentage of older peoplein the PCT is higher.

For ICDs and CRTs, the same general rule applies, but the pattern is slightly different,because these devices have a different age/sex distribution.

These relative rates will be used to correct the observed rates and produce a truerreflection of local implant rates vs. local need.

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Centres providing Device Implants to this Network

Centres that implanted at least 10 devices in this network in 2011

Centre Pacemaker ICD CRT

CHH Castle Hill Hospital 474 59 127

YDH York District Hospital 259 0 2

LGI Leeds General Infirmary 39 57 62

GGH Diana Princess of Wales Hospital Grimsby 129 0 1

SCU Scunthorpe General Hospital 114 0 0

SCA Scarborough General Hospital 110 0 0

SCM James Cook University Hospital 20 2 5

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10 Year Implant Trends – Network v National

Pacemakers(national target: 700new implants permillion population)

PM implant rateremains slightly abovethe national averagebut below the nationaltarget rate.

ICD(national target: 100new implants permillion population)

ICD rate has increaseddramatically over thepast 2 years and isnow similar to thenational average.

New Pacemaker Implant Rateadjusted for age and sex of network population

200

250

300

350

400

450

500

550

600

650

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

year

rate

per

mil

lio

np

op

ula

tio

n

National

North & East Yorkshire and NorthernLincolnshire Cardiac Network

New ICD Implant Rateadjusted for age and sex of network population

0

10

20

30

40

50

60

70

80

90

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

year

rate

per

mil

lio

np

op

ula

tio

n

National

North & East Yorkshire andNorthern Lincolnshire CardiacNetwork

Total CRT Implant Rateadjusted for age and sex of network population

0

20

40

60

80

100

120

140

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

year

rate

per

mil

lio

np

op

ula

tio

n

National

North & East Yorkshire andNorthern Lincolnshire CardiacNetwork

CRT(national target: 130total implants permillion population)

CRT implant rate hasimproved again in2011 and is consistentwith the nationaltarget.

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Provider Hospitals:which hospitals serve which PCTs/LHBs?

All implants in this cardiac network in 2011

PACEMAKERS

PCT/LHB Implanting Centre Implants

5EF SCU Scunthorpe General Hospital 94

North Lincolnshire CHH Castle Hill Hospital 24

GGHDiana Princess of Wales HospitalGrimsby 4

LGI Leeds General Infirmary 2

PAP Papworth Hospital 1

5NV [5E2] YDH York District Hospital 184

North Yorkshire and York [Selby and York] CHH Castle Hill Hospital 4

PIN Pinderfields General Hospital 4

DID Doncaster Royal Infirmary 3


DEW Dewsbury District Hospital 2

BHL Liverpool Heart and Chest Hospital 1

HAR Harrogate District Hospital 1

NGS Northern General Hospital 1

5NV [5KK] SCA Scarborough General Hospital 72North Yorkshire and York [Scarborough,Whitby and Ryedale] YDH York District Hospital 51


SCM James Cook University Hospital 20

CHH Castle Hill Hospital 16

BRI Bristol Royal Infirmary 1

HAR Harrogate District Hospital 1

QAPQueen Alexandra HospitalPortsmouth 1

5NW CHH Castle Hill Hospital 242

East Riding of Yorkshire SCA Scarborough General Hospital 37

YDH York District Hospital 24

SCU Scunthorpe General Hospital 18


HBP BUPA Hospital Hull & East Riding 5

GRL Glenfield Hospital 1


PIN Pinderfields General Hospital 1

- 27 -

5NX CHH Castle Hill Hospital 183

Hull Teaching LGI Leeds General Infirmary 3


SCA Scarborough General Hospital 1

TAN GGHDiana Princess of Wales HospitalGrimsby 125

North East Lincolnshire CHH Castle Hill Hospital 5


SCU Scunthorpe General Hospital 2

HSC Harley Street Clinic 1


ROT Rotherham General Hospital 1

- 28 -

ICDsImplantable Cardioverter Defibrillators


5EF CHH Castle Hill Hospital 9

North Lincolnshire LGI Leeds General Infirmary 2

5NV [5E2] LGI Leeds General Infirmary 39North Yorkshire and York [Selby andYork] CHH Castle Hill Hospital 3

5NV [5KK] LGI Leeds General Infirmary 5North Yorkshire and York[Scarborough, Whitby and Ryedale] CHH Castle Hill Hospital 3


NHB Royal Brompton Hospital 1

SGH Southampton General Hospital 1

WYT Wythenshawe Hospital 1


East Riding of Yorkshire LGI Leeds General Infirmary 7

RAD John Radcliffe Hospital 1


VIC Lancashire Cardiac Centre Blackpool 1




TAN CHH Castle Hill Hospital 4

North East Lincolnshire LGI Leeds General Infirmary 2

FRE Freeman Hospital 1

- 29 -

CRTsCardiac Resynchronisation Therapy


5EF CHH Castle Hill Hospital 12

North Lincolnshire NGS Northern General Hospital 2

5NV [5E2] LGI Leeds General Infirmary 9North Yorkshire and York [Selby andYork] YDH York District Hospital 2

5NV [5KK] LGI Leeds General Infirmary 40North Yorkshire and York [Scarborough,Whitby and Ryedale] CHH Castle Hill Hospital 7



East Riding of Yorkshire LGI Leeds General Infirmary 9

DEW Dewsbury District Hospital 1




BHLLiverpool Heart and ChestHospital 1

NHB Royal Brompton Hospital 1

TAN CHH Castle Hill Hospital 17

North East Lincolnshire LGI Leeds General Infirmary 2

GGHDiana Princess of Wales HospitalGrimsby 1

RSC Royal Sussex County Hospital 1

- 30 -

Geographical Location of Implants

Pacemaker Implants

- 31 -

Complex Implants (ICD and CRT)

- 32 -

Pacing Mode in this Network:Physiological vs Non-Physiological

There is ample evidence that atrial-based pacing modes (also known asphysiological pacing modes) improve patients’ quality of life, and may alsoprolong survival. NICE Guidance (TA88, 2005) has confirmed the desirabilityof physiological pacing when appropriate.

30 years ago all pacemakers were ventricular-based, i.e. the only part of theheart which was stimulated was the lower chambers. Increasingly, atrial-based (mainly dual chamber) pacing has replaced the ventricular modes, atrend which is beneficial to patients.

It is not possible, or desirable, to completely eradicate ventricular pacing.Patients in permanent atrial fibrillation cannot benefit from atrial-based pacing,and this is a significant subgroup in the elderly.

Mode% for thisnetwork

% for England

Atrial based pacing

DDDR 53.0% 66.9%

DDD 6.2% 2.4%

AAIR - 0.01%

AAI - 0.003%

Other - 0.03%

Ventricular based pacing

VVIR 40.5% 29.9%

VVI 0.3% 0.8%

The proportion of physiological pacing in this network is very low, andwell below the national average.

- 33 -

Pacing Mode for New Implants by Centre

Only implants in this network

Mode DDDR DDD AAIR AAIOther

physiologicalAll

PhysiologicalVVIR VVI

National 66.9% 2.4% 0.0% 0.0% 0.03% 69.3% 29.9% 0.8%

This network 53.0% 6.2% 0.0% 0.0% 0.0% 59.1% 40.5% 0.5%

Castle HillHospital

52.1% 14.1% 0.0% 0.0% 0.0% 66.2% 33.8% 0.0%

York DistrictHospital

65.3% 0.8% 0.0% 0.0% 0.0% 66.0% 34.0% 0.0%

DianaPrincess ofWalesHospitalGrimsby

48.1% 1.6% 0.0% 0.0% 0.0% 49.6% 47.3% 3.1%

ScarboroughGeneralHospital

47.3% 0.0% 0.0% 0.0% 0.0% 47.3% 52.7% 0.0%

LeedsGeneralInfirmary

86.1% 0.0% 0.0% 0.0% 0.0% 86.1% 13.9% 0.0%

ScunthorpeGeneralHospital

21.1% 0.0% 0.0% 0.0% 0.0% 21.1% 78.9% 0.0%

James CookUniversityHospital

75.0% 5.0% 0.0% 0.0% 0.0% 80.0% 20.0% 0.0%

Scunthorpe, Grimsby and Scarborough implant more ventricular basedthan physiological devices. Their rates of physiological pacing areamongst the lowest in the country.

Castle Hill, York, Leeds and Middlesborough implant physiologicaldevices at or above the national average.

Note: ‘Pacing Mode’ is based on the maximum mode of which the device iscapable, and not the programmed mode at the end of the procedure.

- 34 -

Physiological Pacing in Sick Sinus Syndrome

Only implants in this network

There is ample evidence from major clinical trials and support from NICEguidelines (NICE Technology Appraisal 88, 2005) that use of ventricularpacing 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. dualchamber or atrial). The Western European average in 2005 was 92% atrialbased pacing for SSS. In the UK the average was 81% in 2009, 84% in 2010and 84% in 2011.

Any percentage of ventricular based pacing greater than 10% has beenshaded pink, and may be considered higher than desirable. A percentagegreater than 20% is considered definitely too high and is shown in a shadedred box. Percentages greater than 50% are shown shaded black.

Number of implantsfor Sick Sinus

Syndrome

% AtrialBasedPacing

% VentricularBasedPacing

England 83.7% 16.3%

This network 78.3% 21.7%

Castle Hill Hospital 118 86.4% 13.6%

York District Hospital 78 82.1% 17.9%

Diana Princess of WalesHospital Grimsby

38 71.1% 28.9%

Scarborough GeneralHospital

29 65.5% 34.5%

Scunthorpe GeneralHospital

20 35.0% 65.0%

All hospitals in the network implant more than 10% ventricular devices,contrary to NICE guidance.

The rate is very high at Grimsby and Scarborough, and at Scunthorpethe rate of 65% is the highest in the country and deserves furtherexamination.

Note: Any hospital in the network but not in this list did not code at least 10 implants as SSS.

Note: For this analysis only ECG codes E1-E5 are used for SSS. Code E6 is excluded.

- 35 -

ECG Indication for New Pacemaker Implants

ECG Indication for all new implants in England 2011

AF + HB/brady

22%

Complete heart block

21%

Incomplete heart

block

23%

Other

6%

Sick sinus syndrome

28%

AF: atrial fibrillationHB: heart blockBrady: bradycardia

CompleteHB

IncompleteHB

AF+HB/brady

SickSinus

SyndromeOther

National 21.3% 23.0% 22.2% 27.5% 5.9%

This Network 18.8% 19.4% 25.6% 25.3% 10.8%

Castle Hill Hospital 17.1% 18.7% 23.1% 25.1% 16.1%

York District Hospital 20.8% 23.4% 25.5% 28.6% 1.6%

Diana Princess of WalesHospital Grimsby

16.8% 17.8% 32.7% 24.8% 7.9%

Scarborough General Hospital 25.6% 12.2% 27.8% 24.4% 10.0%

Scunthorpe General Hospital 11.6% 17.4% 38.4% 18.6% 14.0%

James Cook University Hospital 26.3% 31.6% 5.3% 31.6% 5.3%

Leeds General Infirmary 31.6% 26.3% 10.5% 15.8% 15.8%

- 36 -

New Pacemaker Implant Ratescorrected for Age and Sex

Explanatory note:

The "corrected rate” (R), expressed as implants per million population, iscalculated using the following formula:

610.

xCB

AR

whereA = number of new implantsB = populationC = relative need

2011 New Pacemaker Implant Rates for PCTs in this Network

PopulationNeed

forPacing

New PMImplants

CorrectedNew PMImplant

Rate

Deficit/Excess

comparedto targetrate of

700

ENGLAND 100% 524

This network 1,291,994 112% 946 588 -16%

5EF North Lincolnshire 163,546 107% 105 598 -15%

5NV[5E2]


238,461 106% 158 623 -11%

5NV[5KK]


138,012 138% 152 801 14%

5NW East Riding Of Yorkshire 334,673 127% 268 632 -10%

5NX Hull 256,123 87% 154 692 -1%

TAN North East Lincolnshire Care Trust 161,179 108% 109 627 -10%

- 37 -

New ICD Implant Ratescorrected for Age and Sex

2011 New ICD Implant Rates for PCTs in this Network

PopulationNeed

forICD

New ICDImplants

CorrectedNew ICDImplant

Rate

Deficit/Excess

comparedto targetrate of

100

ENGLAND 100% 76

This network 1,291,994 110% 326 77 -23%

5EF North Lincolnshire 163,546 109% 11 62 -38%

5NV[5E2]


238,461 105% 40 156 56%

5NV[5KK]


138,012 125% 12 70 -30%

5NW East Riding Of Yorkshire 334,673 123% 34 82 -18%

5NX Hull 256,123 91% 19 81 -19%

TAN North East Lincolnshire Care Trust 161,179 106% 6 35 -65%

Note: values between 95% and 105% are not considered significantly different from thetarget rate so are in black text.

- 38 -

New Implant Rate Maps

- 39 -

Pacemaker Implant Deficit in 2011

The table below shows how many extra pacemakers each PCT would need tocommission to bring the implant rate up to the national recommended targetrate for new pacemaker implants (700).

If the value shown is zero, then the PCT is already commissioning enoughdevices to reach the target rate.

Pacemaker Implant Deficit in 2011

Population

Deficit/Excess

comparedto target

rate of 700

NewPacemaker

ImplantDeficit

(number ofdevices)

5EF North Lincolnshire 163,546 -15% 17

5NV[5E2]


238,461 -11% 18

5NV[5KK]


138,012 14% 0

5NW East Riding Of Yorkshire 334,673 -10% 23

5NX Hull 256,123 -1% 2

TAN North East Lincolnshire Care Trust 161,179 -10% 12

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- 40 -

Conclusions

The Network population is older than average so there is a 12% higher need

for pacemakers and 10% for ICDs compared to the national average.

The PM implant rate is virtually static, and tracks just above the national

average. A further substantial rise in the ICD implant rate in 2011 brings it in

line with the national average. A further rise in the CRT rate makes it

consistent with the national target.

There is a marked variability in device implant rates between the PCTs in the

Network.

Data quality and completeness is good, although there are some data deficits

for complex devices.

For cardiac pacing the Network continues in 2011 to report a very low

utilisation of physiological pacing modes, and a correspondingly high rate of

ventricular pacing. Rates of ventricular pacing continue to be particularly high

at implanting centres in Scunthorpe, Scarborough and Grimsby, and remain

severely and inappropriately high for the treatment of sick sinus syndrome.

This is not compliant with NICE guidance or the published literature. This

issue has been highlighted in each NEYNL Network report since 2007.

There has been a marked and commendable increase in ICD implantation

since 2009, bringing the Network up to the national average.

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