BCIS Audit Returns Adult Interventional Procedures Jan 2005 to Dec 2005

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BCIS Audit ReturnsAdult Interventional
ProceduresJan 2005 to Dec 2005

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

Manchester 2006
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2005 data Ludman
Audit Domains Structure
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Diagnostic Angiography 2005
13 New Angiography Only Centres 2005
2005 data Ludman
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Changes in Centres Activity 2005
Goring Hall N Staffs Nuffield Little Aston
3 Stopped
2005 data Ludman
1 PCI ? angio
BUPA Bristol
7 Started PCI
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UK Centres - 2005
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2005
PCI centres
83
Angiography only Centres
87
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UK Countries PCI Centres in 2005
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PCI Data Requested
Form A B
OR
CCAD
Form C
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UK Interventional and Diagnostic centres2005
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Centres Providing No Data

• London Independent

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UK Interventional and Diagnostic centres2005
Northern General, Sheffield Royal Brompton
Missing angiography data estimated from 2004
figures
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UK Interventional and Diagnostic centres2005
BMI Park, Notts London Independent London Bridge
Missing angiography data estimated from 2004
figures
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UK Interventional and Diagnostic centres2005
Arrowe Park Hospital (Currie) Chesterfield
Royal (Cooke) Dewsbury
(Smyllie) Great Western Hosp (McCrea) Neville
Hall Hospital (Hutchison) Woolwich, QE
(Shakespeare)
Missing angiography data estimated from 2004
figures
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UK Interventional and Diagnostic centres2005
London independent
Missing PCI data estimated from 2004 figures
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UK Interventional and Diagnostic centres2005
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UK Interventional and Diagnostic centres2005
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PCI per Angiogram ratio
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PCI per Angiogram ratioESC Survey 2003
Cook S for WG 10 of the ESC. EuroIntervention
20061374
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Population estimates
Mid 2005
Total UK 60.2 m
Scotland 5.09 m
Northern Ireland 1.72 m
England 50.43 m
est Welsh Rx in England 0.8 m
Total Rx in England 51.23 m
Wales 2.96 m est Rx in Wales 2.2 m
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Total UK PCI Procedures
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PCI activity to 2005 (UK)
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Rate of increase in PCI numbers pmp
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Total PCIs in the UK Countriesby Type of
Institution
Total No.s of PCI
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PCIs/million UK Countries(2000 to 2005)
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PCI vs Isolated CABG Numbers (UK)1991 to 2005
Note CABG data for financial yr all PCI v NHS
CABG
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PCI vs Isolated CABG Ratio (UK)2000 to 2005
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Number of PCIs performed in 2005(per NHS Centre)
Mean 1028
Data from all 65 NHS centres
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No. of Interventional Consultants(NHS centres)
Data from 64 of 65 centres
Note if work at two NHS centres will be counted
twice Includes cardiologists and radiologists
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No. of Interventional Consultants(NHS centres
2005)

• Mean
• 2000 5.5
• 2001 6.1
• 6.5
• 6.7
• 7.4
• 2005 7.0

Note if work at two NHS centres will be counted
twice
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No. of PCIs per Consultant (NHS Centres) 2005
data from 64 of 65 centres

• Mean
• PCI/consultant
• 2000 125
• 2001 126
• 2002 138
• 2003 139
• 143
• 2005 145

Note data from institutional volume divided by
No operators per institution
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Visiting Interventionists(NHS Centres) 2005 data
from 64 of 65 centres
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Surgical Cover (2005 - all 65 NHS centres)
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Surgical Cover(all 83 NHS and Private Centres)
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Day Case PCI

• 29 of 70 Units performing day case PCI
• 7 more than 2004

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Data from 70 of 83 centres
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Day Case PCI2005
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Primary PCIRoutine Rx for STEMI
Working Hours Only
24/7
Number of centres
NHS Centres only
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Audit Domains
2005 data Ludman

• Structure
• Appropriateness
• Process
• Outcome

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Annual returnsProcedure Specific Data
Form A B
OR
CCAD
Form C
Data Quality
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CCAD Import Issues
field 1
field 2
field 3
field 103

Patient 1
Patient 2
..
Patient n

• Mandatory Fields (6)
• 1.01 Hospital Identifier
• 1.02 Local Patient Identifier
• 3.01 Date and time of operation
• 1.06 Birth Date
• 2.01 Clinical Syndrome
• 2.02 Indication for Intervention

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CCAD Import Issues

• Mandatory Fields (6)
• 1.01 Hospital Identifier
• 1.02 Local Patient Identifier
• 3.01 Date and time of operation
• 1.06 Birth Date
• 2.01 Clinical Syndrome
• 2.02 Indication for Intervention

Must be date AND time
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CCAD Import Issues

• Mandatory Fields (6)
• 1.01 Hospital Identifier
• 1.02 Local Patient Identifier
• 3.01 Date and time of operation
• 1.06 Birth Date
• 2.01 Clinical Syndrome
• 2.02 Indication for Intervention

Identifies a Unique record
Duplicates occur if re-import with any of these
changed
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CCAD Import Issues

• Mandatory Fields (6)
• 1.01 Hospital Identifier
• 1.02 Local Patient Identifier
• 3.01 Date and time of operation
• 1.06 Birth Date
• 2.01 Clinical Syndrome
• 2.02 Indication for Intervention

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CCAD Import Issues

• 2.01 Clinical Syndrome
• Stable
• Acute coronary syndrome (ACS/AMI)

Cannot be
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CCAD Import Issues

• 2.01 Clinical Syndrome
• Stable
• Acute coronary syndrome (ACS/AMI)

Cannot be
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CCAD Import Issues

• 2.01 Clinical Syndrome
• Stable
• Acute coronary syndrome (ACS/AMI)

• Procedure Urgency
• Elective
• Urgent
• Emergency
• Salvage

Must be
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In Hospital MortalityPotential for double
counting
Stable Elective
1st PCI
SAT
2nd PCI
Death
Indication stable, elective Outcome SAT,
repeat PCI Discharge status - Dead
Indication SAT, emergency Outcome
Death Discharge status - Dead
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AnalysisEngland and Wales
CCAD
Form C
Data cleansing
Aggregate analysis by centre (Mortality double
counting eliminated)
Merge Cleaned
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AnalysisScotland and N Ireland
Form C
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England and Wales
Scotland and N Ireland
Merge
Final counts
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CCAD Data for 2005 from

• Barts
• The London
• CTC Liverpool
• Royal Bournemouth
• Bradford RI
• Bristol RI
• Castle Hill
• Derby Royal
• Birmingham Heartlands
• Freeman
• St Georges
• Glenfield
• Hemel Hempstead
• Harefield
• Kings
• King Edward VII
• Leeds GI
• Manchester RI
• New Cross

• Derriford
• Queen Alex Portsmouth
• Queen Elizabeth Bham
• John Radcliffe
• Royal Devon Exeter
• Royal Free
• Royal Sussex
• James Cook
• Southend
• St Peters
• St Thomass
• St Marys
• Torbay
• UCL
• University Hospital Wales
• Victoria Hosp
• Whipps cross
• Wythenshaw

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CCAD data quality Total 2005 PCI data in CCAD
(EW)
of Total
As Sept 06
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CCAD data qualityCentres with gt 80 of Total
2005 PCI data in CCAD
As Sept 06
of Total 2005 PCI data in CCAD
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CCAD data qualityCentres with gt 80 of Total
2005 PCI data in CCAD
As Sept 06
of Total 2005 PCI data in CCAD
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CCAD data qualityCentres with lt 80 of Total
2005 PCI data in CCAD
16 centres no 2005 data
of Total 2005 PCI data in CCAD
As Sept 06
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CCAD data quality
of CCAD data with Hospital Outcome recorded
(EW)
All of the following fields are NOT blank 4.01
Hospital outcome 4.03 Status at Discharge 4.04
Discharge Date
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CCAD data quality
of CCAD data with Hospital Outcome recorded
(EW)
As Sept 06
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STEMI
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PCI for STEMI2005
7 of all PCI (5.5 2004)
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PCI for STEMI2005
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PCI for All STEMI2005 data from NHS centres
Total 4921procedures
0 or No data
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PCI for All STEMI
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Primary PCI for STEMI2005 data from NHS Centres
Total 2916 procedures
0 or No data
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Primary PCI for STEMI
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Primary PCI for STEMI
As Percentage of Each Centres PCI Activity
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PCI for Stable v ACS

• Of Total PCIs performed
• 44 Acute (UA/NSTEMI/STEMI)
• 56 Stable

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Stent procedures2005 data from 53 of 65 centres
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PCI using any Stent Type2005 data from 58 of 83
Centres
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Stent per PCI ratio2005

• All cases treated with a stent
• 38,719 stents used in 23,882 cases
• 1.62 stents per case
• Cases using DES
• 23,363 DES used in 13,075 cases
• 1.78 stents per case

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Drug Eluting Stent cases2005 data from 80 of 83
centres
Mean of use by Centres
NHS and private
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Drug Eluting Stent cases - NHS2005 data from 63
of 65 NHS centres
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DES use by Centre (NHS)
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Drug Eluting Stent cases2005 data from 80 of 83
centres
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PCI for Restenosis(2005 data from 49 of 83
centres)

• Mean
• 2002 4.9
• 2003 4.3
• 3.6
• 3.8

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BMS and DES use V PCI for Restenosis
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Use of GP IIb/IIIa blockers2005 data from 78 of
83 centres
Overall mean use
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GP IIb/IIIa use by Presentation2005
Note stable and PPCI data from Scotland (Fm C)
and EW (CCAD) UA and NSTEMI EW only
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Multi-vessel TreatmentAll clinical syndromes
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Multi-vessel Treatmentby centre
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Multi-vessel TreatmentAll Clinical Presentations
Mean (Range)
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Multi-vessel TreatmentBy centre - 2005
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Additional Interventional CoronaryTechniques
(1)2005 data from 77 of 83 centres
of all UK interventional procedures Mean
number in units using the technique
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Additional Interventional CoronaryTechniques
(2)2005 data from 77 of 83 centres
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OtherInterventional Techniques2005 data from
77 of 83 centres
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Alcohol Mediated Septal Ablation(HOCM)
2005 - Total 59 procedures
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Other Diagnostic Techniques2005 data from 77 of
83 centres
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Adult non coronary intervention2005 data from 77
of 83 centres
2 units do not split their ASD/PFO data here
amalgamated to ASD closure
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Mitral Balloon Valvuloplasty
Total 153
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Adult non coronary intervention2005 data from 77
of 83 centres
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Adult great vessel intervention2005 data from 77
of 83 centres
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Radial Artery Access
11,010 cases 15.7 of all PCI (10.2 in 2004)
Data from 77 of 83 centres
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Femoral artery closure devices2005 data from 75
of 83 centres
Mean use by Centre 47 FA closure in 37 of all
PCIs
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Audit Domains

• Structure
• Appropriateness
• Process
• Outcome

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Mortality - All PCIsAll Data from CCAD Form C
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MACE - All PCIsAll Data from CCAD Form C
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All Procedures Outcome
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Outcome 2005Total CCAD cleaned data
All Patients
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Outcome 2005Total CCAD cleaned data
Elective Patients
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Outcome 2005Total CCAD cleaned data
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Summary MortalityRisk Stratified by Syndrome
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Mortality by Syndrome
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Total Mortality2005 data from 81 of 83 centres
Mean by Centre 0.59 Mean all PCI 0.56
4 deaths out of 111 PCIs 3 for NSTEMI 1 for
shock
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Public Reporting of PCI data

• BCIS Data Monitoring Subgroup
• P. Ludman / M. Thomas / R. Stables / S. Redwood
• Data must be analysed and presented in such a way
  as to avoid causing operators to turn down high
  risk patients
• Unit specific data
• Risk stratified MACCE outcome
• Process data door to balloon time etc.

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Risk Stratified Outcome
50 cases Shock, PPCI, Renal failure
Centre A
Risk Adjustment Model
RA Mortality 0.5
Mortality 15
Centre B
50 cases Stable elective, NSTEMI
RA Mortality 0.5
Mortality 0.5
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Risk Stratified Outcome

• North West Quality Improvement Programme risk
  score
• A D Grayson, R K Moore, M Jackson, S Rathore, S
  Sastry, T P Gray, I Schofield, A Chauhan, F F
  Ordoubadi, B Prendergast, R H Stables Heart
  200692658663

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Future Data Quality reports
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VLAD(Variable Life Adjusted Display)
Case 1
Predicted risk of in hospital event (MACCE)
Death QMI CVA Em CABG
Clinical features Age - 80 Sex -
female Diabetes - Yes Urgent PCI No Shock
Risk Prediction Model
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VLAD plots
Case 1 risk of MACCE 5 - No MACCE
Up by 0.05
Better
Performance
Worse
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VLAD plots
Case 2 risk of MACCE 60 - No MACCE
Up by 0.6
Better
Performance
Worse
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VLAD plots
Case 3 risk of MACCE 70 - MACCE
Down by 1 0.7 0.3
Better
Performance
Worse
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VLAD plots
Case 4 risk of MACCE 5 - MACCE
Down by 1 0.05 0.95
Better
Performance
Worse
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Summary 2005 (UK)

• 83 PCI centres in UK
• 1,165 PCI pmp in UK
• Cath PCI 34
• PCI CABG 3.1 1
• CCAD
• 40 of 56 units with 2005 data (16 none)
• MACE
• Stable syndromes
• Mortality 0.14, CABG 0.1
• UA / NSTEMI
• Mortality 0.64, CABG 0.13
• Plans
• Data quality to improve
• Risk adjusted outcome
• Process audit