BCIS Audit Returns Adult Interventional Procedures 2002

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BCIS Audit ReturnsAdult Interventional
Procedures2002

• Peter F Ludman
• BCIS National Audit Officer
• On behalf of
• British Cardiovascular Intervention Society

Brighton 2003
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Audit Domains

• Structure
• Appropriateness
• Process
• Outcome

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Audit Domains

• Structure
• Appropriateness
• Process
• Outcome

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UK Intervention Centres
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2002
PCI centres
64
Angiography only Centres
65
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UK Interventional and Diagnostic centres2002
Missing data assumed to be equal to previously
reported activity
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Centres not reporting diagnostic numbers

• Interventional
• Harley Street

• Diagnostic only
• Ayr Hospital
• Derbyshire Royal Infirmary
• Inverclyde Royal Hospital
• Lister, Stevenage
• Mayday University Hospital
• Nevill Hall Hospital, Abergavenny
• Northwick Park Hospital
• Rotherham Hospital
• Royal Gwent, Newport
• Salisbury District Hospital
• St Mary's, Portsmouth
• Sunderland Royal Hospital

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Angiograms per PCI
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Angiography PCI ratesEurope 2000
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Annual Procedures per cath lab(NHS centres)
Mobile lab excluded
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Interventional centres providing NO DATA

• None

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Number of PCIs performed in NHS Centres(total
per annum)
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Total UK PCI Procedures
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Rate of increase in Procedure numbers per million
Change in population estimate
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PCI Rates per million population (UK)
Assumes UK population of 58.8 m mid 2001, 59.2m
mid 2002
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Total PCIs in the UK Countries(2000 to 2002)
Total No.s of PCI
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PCIs/million UK Countries(2000 to 2002)
NSF
NB Wales data does not include those treated in
England
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Rates of PCI(Commissioned in England 2002/3)
NSF
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PCI rates versus SMR (Commissioned in England
2002/3)
Correlation coefficient - 0.3 (p NS)
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PCI vs Isolated CABG Numbers (UK)Data from BCIS
and SCTS Registry
1.3
1.5
Ratio PCICABG
? 1.7
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PCI vs CABG breakdown(Commissioned in England
2002/3)
Ratio 1.4 1
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PCI and CABG rates per million(Europe 2000)
Ratio PCICABG
2.3
3.3
5.4
2.4
4.1
3.0
1.7
1.4
2.8
2.0
0.9
4.2
1.3
1.8
1.4
2.0
0.7
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Ratio PCI CABG(Europe 2000)
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No. of Interventional Consultants(NHS centres,
UK 2002)
Total 312 Includes local and visitors,
cardiologists and radiologists
Mean 2000 5.5 2001 6.1 2002 6.5
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No of PCIs per Consultant (NHS Centres)data from
48 centres
Mean PCI/consultant 2000 125 2001 126 2002 138
Note data from institutional volume divided by
No operators per institution
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Visiting Interventionists(NHS Centres 2002)

4.7 Interventionists/Centre Mean 156 PCIs/year
7.6 Local Visitors/Centre Mean 127 PCIs/year
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Surgical cover(Data for 2002)
NHS Centres only
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Audit Domains

• Structure
• Appropriateness
• Process
• Outcome

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Appropriateness

• Indications
• Severity of symptoms
• Objective assessment of myocardial ischaemia
• Angiographic disease severity
• etc.
• Risk stratification
• Clinical presentation
• LV function
• Renal function
• etc.

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(No Transcript)
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Audit Domains

• Structure
• Appropriateness
• Process
• Outcome

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Minimum Data (form B) Minimal or No data from

• No data
• None

• Minimal Data
• None

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Stent procedures 1992 - 20022002 data from 63 of
64 centres
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Stenting in different centres 1998-20022002 data
from 63 of 64 centres
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PCI for Restenosis 1998 - 2002(2002 data from 48
of 64 centres)
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PCI in patients with past CABG 2002(Data from 45
of 64 centres)
Mean 8.4
Note Includes procedures on native vessels and
grafts
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Use of GP IIb/IIIa blockers2002 data from 62 of
64 centres
Note Possible underestimate of small molecule use
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Abciximab in different centres 1999 - 20022002
data from 62 of 64 centres
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Abciximab use by Clinical Presentation(2002 data
from 47 of 64 units)
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Other CoronaryInterventional Techniques (1)2002
data from 62 of 64 centres
of all UK interventional procedures Mean
number in units using the technique Range in
units using the technique
PercuSurge, Rescue, Angiojet, X-sizer
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Other CoronaryInterventional Techniques (2)2002
data from 62 of 64 centres
Self reported data not specially requested
of all UK interventional procedures Mean
number in units using the technique Range in
units using the technique
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Non coronary cardiac intervention2002 data from
62 of 64 centres
Some centres give combined data for ASD/PFO
closure
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Mitral Balloon Valvuloplasty2002
33 of 64 centres perform MBV
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Great vessel intervention2002 data from 62 of 64
centres
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Other Diagnostic Techniques2002 data from 62 of
64 centres
of all UK interventional procedures Mean
number in units using the technique Range in
units using the technique
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Other procedures2002 data from 62 of 64 centres
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Audit Domains

• Structure
• Appropriateness
• Process
• Outcome

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ANY Outcome Data (form C)Inadequate or No Data

• City Hospital, Birmingham
• Yorkshire Heart Centre
• University Hosp. Of Wales
• Edinburgh Royal Infirmary
• London Chest
• Freeman, Newcastle
• Northern Gen. Hosp. Sheffield
• St Bartholomew's
• Plymouth Derriford

• Ross Hall Hospital
• London Independent
• St Anthony's
• The Priory, Birmingham
• HCI, Glasgow (Golden Jubilee National Hospital)
• Harley Street Clinic
• Yorkshire Clinic, Bradford
• BUPA Lea (Cambridge)

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HOSPITAL outcome Data (form C)No data from

• Unspecified
• Belfast City
• Hull RI Castle Hill
• Walsgrave Hospital, Coventry
• Manchester Royal Infirmary
• Heart Hospital (Middlesex/UCH
• Northern Gen. Hosp. Sheffield
• St George's
• Eastbourne
• Wellington Hospital
• BUPA Leeds
• Ross Hall Hospital
• London Independent
• St Anthony's
• Harley Street Clinic
• Bristol BUPA
• Park, Nottingham

• Cath lab only
• Blackpool Victoria
• Yorkshire Heart Centre
• St Mary's
• Papworth Hospital
• Glasgow Western Infirmary
• Wythenshawe, Manchester
• City Gen. Hosp. Stoke
• Hairmyres
• BMI Alexander, Manchester
• London Bridge Hospital
• BUPA Leicester
• Cromwell
• The Priory, Birmingham
• Yorkshire Clinic, Bradford
• BUPA Lea (Cambridge)

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All PCI Procedures Mortality
Includes all centres reporting cath lab outcome
or hospital outcome
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All PCI procedures Outcome
Includes all centres reporting cath lab outcome
or hospital outcome
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All Procedures Outcome
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Stenting and outcome 1992-20022002 CABG data
from 53, resten data from 48 of 64 centres
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Stenting and the need for emergency CABG (2002
data from 53 of 64 centres)
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Stenting and procedures for restenosis (2002
data from 48 of 64 centres)
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Centres providing complete data on HOSPITAL
outcome(2002)

• Aberdeen Royal Infirmary
• Belfast Royal Victoria
• Birmingham Heartlands
• University Hospital, Birmingham
• Guy's and St Thomas
• Bristol Royal Infirmary
• Hammersmith Hospital
• Harefield Hospital
• Kings College Hospital
• Edinburgh Western
• Liverpool CTC
• John Radcliffe, Oxford

• Royal Brompton Hospital Glenfield, Leicester
• Royal Free
• Southampton University Hospital
• James Cook, Middlesbrough
• Nottingham City
• KE VII, Midhurst
• Morriston, Swansea
• Royal Sussex, Brighton
• RCH Truro, Treliske
• Taunton Somerset

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Hospital Outcome 2002Data from 23 centres
All Patients
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Hospital Outcome 2002Data from 23 centres
Elective Patients
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Hospital Outcome 2002Data from 23 centres
Patients with previous bypass grafts Patients
treated for restenosis
Does not account for clinical syndrome CABG
patients includes Rx of native and grafts
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Hospital Outcome 2002Data from 23 centres
Acute coronary syndromes (UA/NSTEMI)
Includes all classified as treated for UA and
post MI angina (stable and unstable)
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Hospital Outcome 2002Data from 21 centres
Patients Rx for acute vessel closure
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Hospital Outcome 2002Data from 23 centres
Patients Rx for STEMI
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PCI for STEMI(2002 data from 47 of 64 units)
4.8 of all PCI activity
Data from units reporting cath or hosp outcome
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Hospital MACE Overview 2002(Data from 23
centres, 19,606 patients)
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BCIS / CCAD project

• Dataset 5.1.2
• Data collection / transmission
• Pilot site experience
• Future plans

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Dataset

• Version 5.1
• Finalised at meeting 12-2-03
• Dataset
• Sections 1 to 5 (5 optional fields)
• Modifications
• Overall structure invariant for 2 years (2005)
• 103 fields and short code options
• Volatile menu items can be updated at short
  notice (8)
• On BCIS web site and CCAD web site
• www.bcis.org.uk/
• www.ccad.org.uk/ccadweb.nsf

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BCIS / CCAD

• Practical issues
• Collecting the data
• Transmitting the data

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The Basic CCAD Package

• Lotus Notes front end
• Local database
• Encrypted link to CCAD
• Maintained centrally
• Automatic menu update
• Automatic software update

• Limitations
• One computer for data input
• Difficulties linking with other hospital systems
• No lesion specific data

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Connection to other Databases
Comma separated values file
Definition www.ccad.org.uk See CCAD downloads
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PAS server
PCI Database on Hospital Server
Local Lotus Notes Database
Lab results server
Include partial data, updated by subsequent
transfers
Encryption
CCAD Central Server
Audit clerk
SpR or consultant computer
Cath lab data entry
Fu data entry
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CAD Local
N 963
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CAD Central
N 3696
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Data completeness Procedure - indications Procedur
al details Procedure - outcome
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Indications
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Indications
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Indications
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Indications - detail
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Data completeness Procedure - indications Procedur
al details Procedure - outcome
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Procedure - detail
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Data completeness Procedure indications Procedur
al details Procedure - outcome
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Outcome
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Outcome detail (1)
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Outcome detail (2)
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Analysis of CCAD dataset

• Benchmarking
• Any unit can compare their practice with UK wide
  average using Lotus Notes software (as MINAP)
• ONS link
• Post discharge event free outcome
• Death, re-intervention etc.
• BCIS Council position
• Additional analysis to be arranged
• ? via University statistical department
• Methodology of analysis controlled by the
  profession via BCIS
• ? 3 year cycle of results analysis
• Data monitoring committee as a means of peer
  review
• Accept that the type of analysis will continue to
  evolve

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BCIS / CCAD pilot sites
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Plans

• Pilot sites continue
• Encourage other sites to start collecting dataset
  version 5.1
• decide on system to be used
• contact CCAD for Lotus gateway set up
  instructions
• 0207 391 8028
• Full roll out by April 2004

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Conclusions

• Steady increase in PCI activity in UK
• England and Scotland
• NSF rates for PCI have been exceeded
• Increase in PCICABG ratio
• MACE rates remain satisfactory
• BCIS-CCAD project
• Important progress

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Extra Information

• Additional slides with details of
• Dataset version 5.1 version code
• Volatile menu items

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Dataset Version Code

• Version history
• 5.1 as finalised in Feb 2003
• 5.1.1 as presented at London Roadshow
• 5.1.2 as presented at Leeds Roadshow
• Plan to present BCIS and SCTS datasets to ISB Jan
  2003

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Dataset Version Code
5.1.2
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Dataset Version Code
5.1.2
Version 6 After approval of definitions by the
Information Standards Board
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Dataset Version Code
5.1.2
Version 6 After approval of definitions by the
Information Standards Board
Increments whenever a new menu item is added to
volatile lists (e.g. new DES)
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Dataset Version Code
5.1.2
Increments with subtle changes in text , typos,
clarification of definitions etc.
Version 6 After approval of definitions by the
Information Standards Board
Increments whenever a new menu item is added to
volatile lists (e.g. new DES)
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Dataset Maintenance
Central Repository (IA) Dataset details Field
numbers, Field prompts, Short and long
codes Definition and notes Format details
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Dataset Maintenance
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Dataset fields

• Important aspects not contained in current
  dataset
• (Structure)
• Appropriateness
• Process
• Outcome
• Current definitions of clinical syndromes
• Track the use of new equipment
• Drug eluting stents
• Distal protection
• Etc.

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Dataset 5.1 examples

• Indication for intervention
• 1. Stable angina
• 2. Stable coronary anatomy
• 3. ACS no acute STEMI
• 4. ACS - primary PCI for STEMI (no lysis)
• 5. ACS Facilitated PCI for STEMI (lysis PCI)
• 6. ACS Rescue PCI (failed lysis)
• 7. ACS PCI for re-infarction no lysis
• 8. ACS Rescue PCI for re-infarction (failed
  lysis)
• 9. Staged procedure
• 10. Hybrid procedure
• 11. Acute / subacute thrombosis at recent PCI
  site (30/7)
• 12. Bail out following diagnostic cardiac
  catheterisation

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Dataset 5.1 Event Timing
STEMI (anterior ST elevation)
Date/time 1
Thrombolysis
Good resolution
Awaiting ETT pre Dx
More chest pain ST depression
PCI data Time Date/time 2 ECG ST depression
Date/time 2
Cath and proceed to LAD PCI
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Volatile menus

• 8 fields with volatile menu items
• Drug Eluting Stents
• Emboli protection
• Diagnostic devices
• Procedural devices
• Thrombus removal
• Brachytherapy
• Arterial access management
• Peri-procedure drugs

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Volatile menus

• Any potential changes to be directed to BCIS
  audit secretary (PFL)
• Discussed with BCIS Council audit committee
• CCAD informed
• update dataset version held with Tony Dallimore
• update spreadsheet on BCIS
• update CCAD web site and Lotus Notes

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Dataset stakeholders

• BCIS
• Detailed analysis of most of dataset
• Track activity and changes in patterns of Rx
• Structure
• Appropriateness
• Process
• Outcome
• Roger Boyle
• NHS data
• Appropriate professional self regulation
• DOH (general public)
• Provision of safe care
• Hospital outcome of stable SV disease

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The End