BCIS Audit Returns Adult Interventional Procedures

Transcription

1 BCIS Audit Returns Adult Interventional Procedures Jan 2009 to Dec 2009 Peter F Ludman BCIS National Audit Lead On behalf of British Cardiovascular Intervention Society Cardiff October 2010

2 Structure New centres Total PCI numbers No of PCIs per unit and per angio Diagnostic cath lab utilization PCI pmp and by country PCI activity by centre PCI Operators Surgical cover Day case activity Primary PCI units PCI Procedure specific data CCAD data completeness and quality Databases used for collection Demographics Appropriateness Indication for PCI / Clinical syndrome PPCI activity (by unit, pmp, by vessel) Stents (BMS and DES) Adjunctive therapy LV support Shock Multi-vessel treatment Additional interventional techniques Arterial access routes complications Contents Process of care Delays data completeness Delays to treatment Primary PCI CTB times by unit / by admit route DTB times by unit / by admit route Circadian distribution Treatment times Treatment delays Non coronary intervention HOCM septal ablation Transcatheter Aortic Valve Implantation UK TAVI Registry Other adult structural intervention Outcome MACCE Outcome by syndrome ONS tracked mortality PPCI / Rescue / Shock Outcome by lesion subset ONS tracked mortality CTO / ulms Risk adjusted outcomes

3 Structure

4 Angiography Centres 2009 New Centres North Tyneside Centres ceasing activity Queen Mary s Sidcup Cambrideg Lea (Spire) Queen s Medical Centre

5 PCI Centres 2009 New PCI Centres Watford General PCI centres from existing angiography units Glan Clwyd (Rhyll) Northampton General Ealing

6 PCI Centres 2009 PCI Centres stopped Hemel Hempstead (moved to Watford) Hull (moved to Castle Hill) Glasgow Royal Informary Glasgow Western Infirmary

7 UK Centres 2009 PCI Angio only No. of Centres

8 2009 Angiography (76) PCI (105)

9 PCI Centres in 2009 UK Countries Scotland NHS 5 Private 1 England NHS 77 Private 16 N Ireland 3 Wales 3 Total 105

10 UK Interventional and Diagnostic centres 2009 NHS Interventional Private Interventional Diagnostic only No. TOTAL 181 No cath data No PCI data na Caths (% of total) PCIs (% of total) Aggregate forms

11 UK Interventional and Diagnostic centres 2009 NHS Interventional Private Interventional Diagnostic only No. TOTAL 181 No cath data No PCI data na Caths (% of total) PCIs (% of total) Aggregate forms

12 UK Interventional and Diagnostic centres No. Royal Gwent NHS Interventional Private Interventional Diagnostic only TOTAL 181 No cath data 2009 No PCI data NO DATA PROVIDED Huddersfield Royal Infirmary Princess Royal University Royal Surrey County South Tyneside District 76 5 na Caths (% of total) Dr S Ikram PCIs (% of total) Dr RN Stevenson Dr S Kawatowski Dr E Leatham Dr A Nasser Aggregate forms

13 UK Interventional and Diagnostic centres NHS Interventional Private Interventional Diagnostic only # No cath data 2009 No PCI data Caths PCIs ,294 81, ,256 1, ,703 - TOTAL ,253 83,130 Aggregate forms

14 PCI activity to 2009 (UK) PCI per million PCI Procedures ,331 83, PCI per million , PCI Procedure Numbers Aggregate forms

15 Rate of increase in PCI numbers pmp Rate of Increase (%) Aggregate forms

16 PCI per Angiogram ratio % Aggregate forms

17 PCI per Angiogram ratio By Individual PCI Units % Number of PCI procedures

18 Diagnostic only Centres Cath lab utilization Number of Cases per Session Total Number of Diagnostic Angiograms Only fixed labs (no shared or mobile) Does not account for sessions for pacing etc

19 Diagnostic only Centres Cath lab utilization Number of Sessions per Week Total Number of Diagnostic Angiograms Only fixed labs (no shared or mobile) Does not account for sessions for pacing etc

20 Diagnostic only Centres Cath lab utilization No. of Angiograms per cath lab Total Number of Diagnostic Angiograms Only fixed labs (no shared or mobile)

21 Total PCIs in the UK Countries by Type of Institution Total No.s of PCI England NHS England Private Scotland NHS Scotland Private N. Ireland Wales Aggregate forms

22 Total PCIs in the UK Countries by Type of Institution Total No.s of PCI England NHS England Private Scotland NHS Scotland Private N. Ireland Wales Aggregate forms

23 Population estimates Mid 2009 Total UK: 61.8 m Scotland m Northern Ireland m England m est: N. Welsh pop 0.7m 0.45m served locally ( 0.22 for 2009) 0.25m Rx in England ( 0.48 for 2009) Total Rx in England m Wales 2.99 m est: Rx in Wales: 2.74 m

24 PCIs/million UK Countries England Scotland N. Ireland Wales Aggregate forms

25 PCI vs Isolated CABG Numbers (UK) 1991 to PCI CABG Note: CABG data for financial yr Aggregate forms

26 PCI vs Isolated CABG Ratio (UK) 2000 to 2009 Ratio Aggregate forms

27 Number of PCIs performed in 2009 (per NHS Centre) Mean = Number of PCIs Individual Centres 21 Centres performing < 400 cases (20%) Data from: all NHS centres Aggregate forms

28 Number of PCIs performed in Centres performing < 400 procedures St Mary's London (<2002) Lister (2006) Wigan Royal Infirmary (2007) Glan Clwyd (2009) Watford General (2009) Wexham Park (2006) Conquest (2007) Great Western (2006) Torbay (2004) St Peter's (2003) Northampton General (2009) Lincoln County (2008) Eastbourne (2006) Bradford Royal Infirmary (2005) Kings Mill (2008) Kent and Sussex (2008) Frenchay (2008) Whipps Cross (2005) QE Woolwich (2007) Darent Valley (2008) Ealing (2009) PCI program start date

29 No. of Interventional Consultants (NHS centres) Number % Total Increase 0 Note: if work at two NHS centres will be counted twice Includes cardiologists and radiologists

30 No. of Consultant in each unit (NHS Centres 2009) Number of Consultants in each unit Total PCIs in each Unit Note: if work at two NHS centres will be counted twice

31 No. of Consultant in each unit (NHS Centres 2009) Mean Number of Operators per Unit Note: if work at two NHS centres will be counted twice

32 PCI per Consultant Unit case number / Number of operators Number of PCIs

33 No. of PCIs per Consultant (NHS Centres 2009) Total PCIs / Number of Consultants Total PCIs in each Unit Note: Data from institutional volume divided by No operators per institution Some consultants work in multiple institutions

34 On v Off Site Surgery All Centres (NHS and private) 100% 80% Off Site On Site 60% 40% 20% % 0% Aggregate forms

35 On v Off Site Surgery NHS Centres only 100% 80% Off Site On Site 60% 40% 20% % 0% Aggregate forms

36 Surgical Cover ( all NHS centres) Off site On Site PCIs per Centre Mean Median Individual Centres Aggregate forms

37 Surgical Cover (all 105 NHS and Private Centres) On site No of centres 50 (48%) No. of PCI (% of total) 56,548 (71%) Off site 54 (52%) 26,582 (29%) Mean No. PCI per centre (all) Mean No. PCI per centre (NHS) Aggregate forms

38 Day Case PCI 58 of 92 Units performing day case PCI Number % Number % of all PCI Data from: 92 of 105 centres

39 Day Case PCI As Percentage of all PCI activity 2009 Data from 92 of 105 centres % Number of PCI procedures

40 Primary PCI Routine Rx for STEMI Working Hours 24/7 Percentage of NHS Centres 100% 80% 60% 40% 20% 0% NHS Centres only % 80% 60% 40% 20% 0% Number of centres Working Hrs includes all 24/7 sites

41 PPCI 2009 No PPCI PPCI day PPCI 24/7

42 Structure New centres Total PCI numbers No of PCIs per unit and per angio Diagnostic cath lab utilization PCI pmp and by country PCI activity by centre PCI Operators Surgical cover Day case activity Primary PCI units PCI Procedure specific data CCAD data completeness and quality Databases used for collection Demographics Appropriateness Indication for PCI / Clinical syndrome PPCI activity (by unit, pmp, by vessel) Stents (BMS and DES) Adjunctive therapy LV support Shock Multi-vessel treatment Additional interventional techniques Arterial access routes complications Contents Process of care Delays data completeness Delays to treatment Primary PCI CTB times by unit / by admit route DTB times by unit / by admit route Circadian distribution Treatment times Treatment delays Non coronary intervention HOCM septal ablation Transcatheter Aortic Valve Implantation UK TAVI Registry Other adult structural intervention Outcome MACCE Outcome by syndrome ONS tracked mortality PPCI / Rescue / Shock Outcome by lesion subset ONS tracked mortality CTO / ulms Risk adjusted outcomes

43 Procedure Specific Analysis Participation in CCAD Total No. of Centres Data to CCAD England NHS Private 16 5 Wales 3 3 Missing Ealing King Mill QE Woolwich N Ireland 3 2 Scotland NHS 7 6 Private 1 0

44 Procedure Specific Analysis Participation in CCAD Total No. of Centres Data to CCAD England NHS Missing Private 16 5 Wales 3 3 N Ireland 3 2 Belfast City Scotland NHS 7 6 Private 1 0

45 Procedure Specific Analysis Participation in CCAD Total No. of Centres Data to CCAD England NHS Missing Private 16 5 Wales 3 3 N Ireland 3 2 Scotland NHS 7 6 Hairmyres Private 1 0

46 Procedure Specific Analysis Participation in CCAD Total No. of Centres Data to CCAD Participation England NHS % Private % Wales % N Ireland % Scotland NHS % Private 1 0 0%

47 Front end Database used BCIS Tomcat PATS Medcon Cardaas Lotus Notes Datacam Minerva Cardiobase Infoflex Cardex In house PIMS Prism Xper and Prism Webhiss

48 Data Quantity

49 CCAD data UK PCI data in CCAD as % of Reported Totals YKC. RHH. Capio PHN. Ros Yorkshire LNH. LEB. Leeds MHO. BMI s HBP. IND. BUPA London KMH. BUPA Nuffield Manor Park Hall Clinic, Independent Kings HosMill pital Leeds GWH. Queen HAI. Hairm Hull & CBS. BUPA CRO. EAL. Elizabeth yres East BMI. Crom Ealing Hos Riding AHM. BFT. BMI ANT. PHB. BMI Belfast Meriden Southam well pital, BAT. CRG. Royal ESU. St BMI Alexandra City QAP. NPH. Craigavon United East Anthony's Priory pton Surrey RIA. RVB. BAL. Queen Northwick HAM. Aberdeen Royal Barts Alexandra Park Area Hos pital Bath Victoria the SGH. Southam GEO. Ham NCR. pton St m George's ersm Royal ith Infirm London PMS. KCH. The RFH. New General King's Great Royal Cros Western Free s ary SUN. WAT. Sunderland FRY. Frenchay College Watford RSC. Royal WDH. WRG. CLW. DVH. Suss Dorset Worthing General Royal BRI. HSC. Glan Darent ex County Bris Harley Clwyd Valley CHG. NOR. Cheltenham CHH. TOR. DUD. tol Royal Street DGH Castle Torbay City Infirm Clinic Trust ary NGS. Norfolk Northern & Norwich General Hill EBH. UHW. Birm ingham FRE. STO. WEX. University Heartlands Freem General an NHH. North Wexham North Staffordshire Park of WHH. MOR. Ham William Morris pshire BHR. Royal MAY. Berks Mayday PLY. BRD. GJH. Golden PAP. hire and University Derriford Harvey ton Wales Papworth Battle Bradford Jubilee STH. HH. St Harefield Royal Infirm WRC. RDE. Worcestershire Royal Devon LIS. Thom & Exeter Lister as ' ary UCL. University VIC. SCM. Jam NTH. QEB. es Northam Queen Cook SPH. STM. University St St College Victoria Royal Peter's Mary's KGH. KSX. NIN. pton Elizabeth Kettering Kent Ninewells General & FRM. GRL. CHN. DER. DGE. Frim Glenfield General Suss ex BHL. Liverpool BOU. Royal CGH. Nottingham Derby Eas ley Park Royal tbourne Heart Bournem Conques City Infirm DGH BHH. and MRI. WYT. Manches BAS. Rochdale Ches outh t ary t LIN. LGI. Wythenshawe ter Bas Royal ildon Infirm General Infirm ary MPH. Lincoln Yorkshire SAN. Sandwell HHW. Taunton County Heart ary AMG. Wycom District Wellington & Som Centre WHC. Whipps ERI. NHB. Royal Cros WAL. be General ers et AEI. RCH. RAD. Royal infirm s Walsgrave University LBH. Royal Royal John Brom ary London Albert Cornwall Radcliffe pton of Edinburgh Edward Bridge Infirm ary As August

50 CCAD data UK PCI data in CCAD as % of Reported Totals YKC. RHH. Capio PHN. Ros Yorkshire LNH. LEB. Leeds MHO. BMI s HBP. IND. BUPA London KMH. BUPA Nuffield Manor Park Hall Clinic, Independent Kings HosMill pital Leeds GWH. Queen HAI. Hairm Hull & CBS. BUPA CRO. EAL. Elizabeth yres East BMI. Crom Ealing Hos Riding AHM. BFT. BMI ANT. PHB. BMI Belfast Meriden Southam well pital, BAT. CRG. Royal ESU. St BMI Alexandra City QAP. NPH. Craigavon United East Anthony's Priory pton Surrey RIA. RVB. BAL. Queen Northwick HAM. Aberdeen Royal Barts Alexandra Park Area Hos pital Bath Victoria the SGH. Southam GEO. Ham NCR. pton St m George's ersm Royal ith Infirm London PMS. KCH. The RFH. New General King's Great Royal Cros Western Free s ary SUN. WAT. Sunderland FRY. Frenchay College Watford RSC. Royal WDH. WRG. CLW. DVH. Suss Dorset Worthing General Royal BRI. HSC. Glan Darent ex County Bris Harley Clwyd Valley CHG. NOR. Cheltenham CHH. TOR. DUD. tol Royal Street DGH Castle Torbay City Infirm Clinic Trust ary NGS. Norfolk Northern & Norwich General Hill EBH. UHW. Birm ingham FRE. STO. WEX. University Heartlands Freem General an NHH. North Wexham North Staffordshire Park of WHH. MOR. Ham William Morris pshire BHR. Royal MAY. Berks Mayday PLY. BRD. GJH. Golden PAP. hire and University Derriford Harvey ton Wales Papworth Battle Bradford Jubilee STH. HH. St Harefield Royal Infirm WRC. RDE. Worcestershire Royal Devon LIS. Thom & Exeter Lister as ' ary UCL. University VIC. SCM. Jam NTH. QEB. es Northam Queen Cook SPH. STM. University St St College Victoria Royal Peter's Mary's KGH. KSX. NIN. pton Elizabeth Kettering Kent Ninewells General & FRM. GRL. CHN. DER. DGE. Frim Glenfield General Suss ex BHL. Liverpool BOU. Royal CGH. Nottingham Derby Eas ley Park Royal tbourne Heart Bournem Conques City Infirm DGH BHH. and MRI. WYT. Manches BAS. Rochdale Ches outh t ary t LIN. LGI. Wythenshawe ter Bas Royal ildon Infirm General Infirm ary MPH. Lincoln Yorkshire SAN. Sandwell HHW. Taunton County Heart ary AMG. Wycom District Wellington & Som Centre WHC. Whipps ERI. NHB. Royal Cros WAL. be General ers et AEI. RCH. RAD. Royal infirm s Walsgrave University LBH. Royal Royal John Brom ary London Albert Cornwall Radcliffe pton of Edinburgh Edward Bridge Infirm ary As August 2010 No Data

51 CCAD data UK PCI data in CCAD as % of Reported Totals YKC. Capio Yorkshire Clinic RHH. Ross Hall PHN. BMI Park MHO. Manor LNH. Leeds Nuffield LEB. BUPA Leeds KMH. Kings Mill IND. London Independent HBP. BUPA, Hull & East Riding HAI. Hairmyres GW H. Queen Elizabeth, W oolwich EAL. Ealing CRO. Cromwell CBS. BUPA Southampton BMI. BMI Meriden BFT. Belfast City AHM. BMI Alexandra As August 2010 No Data

52 CCAD data UK PCI data in CCAD as % of Reported Totals YKC. RHH. Capio PHN. Ros Yorkshire LNH. LEB. Leeds MHO. BMI s HBP. IND. BUPA London KMH. BUPA Nuffield Manor Park Hall Clinic, Independent Kings HosMill pital Leeds GWH. Queen HAI. Hairm Hull & CBS. BUPA CRO. EAL. Elizabeth yres East BMI. Crom Ealing Hos Riding AHM. BFT. BMI ANT. PHB. BMI Belfast Meriden Southam well pital, BAT. CRG. Royal ESU. St BMI Alexandra City QAP. NPH. Craigavon United East Anthony's Priory pton Surrey Hos RIA. RVB. BAL. Queen Northwick HAM. Aberdeen Royal Barts Alexandra Park Area pital Bath Victoria the SGH. Southam GEO. Ham NCR. pton St m George's ersm Royal ith Infirm London PMS. KCH. The RFH. New General King's Great Royal Cros Western Free s ary SUN. WAT. Sunderland FRY. Frenchay College Watford RSC. Royal WDH. WRG. CLW. DVH. Suss Dorset Worthing General Royal BRI. HSC. Glan Darent ex County Bris Harley Clwyd Valley CHG. NOR. Cheltenham CHH. TOR. DUD. tol Royal Street DGH Castle Torbay City Infirm Clinic Trust ary NGS. Norfolk Northern & Norwich General Hill EBH. UHW. Birm ingham FRE. STO. WEX. University Heartlands Freem General an NHH. North Wexham North Staffordshire Park of WHH. MOR. Ham William Morris pshire BHR. Royal MAY. Berks Mayday PLY. BRD. GJH. Golden PAP. hire and University Derriford Harvey ton Wales Papworth Battle Bradford Jubilee STH. HH. St Harefield Royal Infirm WRC. RDE. Worcestershire Royal Devon LIS. Thom & Exeter Lister as ' ary UCL. University VIC. SCM. Jam NTH. QEB. es Northam Queen Cook SPH. STM. University St St College Victoria Royal Peter's Mary's KGH. KSX. NIN. pton Elizabeth Kettering Kent Ninewells General & FRM. GRL. CHN. DER. DGE. Frim Glenfield General Suss ex BHL. Liverpool BOU. Royal CGH. Nottingham Derby Eas ley Park Royal tbourne Heart Bournem Conques City Infirm DGH BHH. and MRI. WYT. Manches BAS. Rochdale Ches outh t ary t LIN. LGI. Wythenshawe ter Bas Royal ildon Infirm General Infirm ary MPH. Lincoln Yorkshire SAN. Sandwell HHW. Taunton County Heart ary AMG. Wycom District Wellington & Som Centre WHC. Whipps ERI. NHB. Royal Cros WAL. be General ers et AEI. RCH. RAD. Royal infirm s Walsgrave University LBH. Royal Royal John Brom ary London Albert Cornwall Radcliffe pton of Edinburgh Edward Bridge Infirm ary As August 2010 < 90%

53 CCAD data UK PCI data in CCAD as % of Reported Totals PHB. BMI Priory ANT. St Anthony's ESU. East Surrey < 90% BAT. Royal United Bath CRG. Craigavon Area NPH. Northwick Park QAP. Queen Alexandra BAL. Barts and the London RVB. Royal Victoria RIA. Aberdeen Royal Infirmary HAM. Hammersmith As August

54 CCAD data UK PCI data in CCAD as % of Reported Totals YKC. RHH. Capio PHN. Ros Yorkshire LNH. LEB. Leeds MHO. BMI s HBP. IND. BUPA London KMH. BUPA Nuffield Manor Park Hall Clinic, Independent Kings HosMill pital Leeds GWH. Queen HAI. Hairm Hull & CBS. BUPA CRO. EAL. Elizabeth yres East BMI. Crom Ealing Hos Riding AHM. BFT. BMI ANT. PHB. BMI Belfast Meriden Southam well pital, BAT. CRG. Royal ESU. St BMI Alexandra City QAP. NPH. Craigavon United East Anthony's Priory pton Surrey RIA. RVB. BAL. Queen Northwick HAM. Aberdeen Royal Barts Alexandra Park Area Hos pital Bath Victoria the SGH. Southam GEO. Ham NCR. pton St m George's ersm Royal ith Infirm London PMS. KCH. The RFH. New General King's Great Royal Cros Western Free s ary SUN. WAT. Sunderland FRY. Frenchay College Watford RSC. Royal WDH. WRG. CLW. DVH. Suss Dorset Worthing General Royal BRI. HSC. Glan Darent ex County Bris Harley Clwyd Valley CHG. NOR. Cheltenham CHH. TOR. DUD. tol Royal Street DGH Castle Torbay City Infirm Clinic Trust ary NGS. Norfolk Northern & Norwich General Hill EBH. UHW. Birm ingham FRE. STO. WEX. University Heartlands Freem General an NHH. North Wexham North Staffordshire Park of WHH. MOR. Ham William Morris pshire BHR. Royal MAY. Berks Mayday PLY. BRD. GJH. Golden PAP. hire and University Derriford Harvey ton Wales Papworth Battle Bradford Jubilee STH. HH. St Harefield Royal Infirm WRC. RDE. Worcestershire Royal Devon LIS. Thom & Exeter Lister as ' ary UCL. University VIC. SCM. Jam NTH. QEB. es Northam Queen Cook SPH. STM. University St St College Victoria Royal Peter's Mary's KGH. KSX. NIN. pton Elizabeth Kettering Kent Ninewells General & FRM. GRL. CHN. DER. DGE. Frim Glenfield General Suss ex BHL. Liverpool BOU. Royal CGH. Nottingham Derby Eas ley Park Royal tbourne Heart Bournem Conques City Infirm DGH BHH. and MRI. WYT. Manches BAS. Rochdale Ches outh t ary t LIN. LGI. Wythenshawe ter Bas Royal ildon Infirm General Infirm ary MPH. Lincoln Yorkshire SAN. Sandwell HHW. Taunton County Heart ary AMG. Wycom District Wellington & Som Centre WHC. Whipps ERI. NHB. Royal Cros WAL. be General ers et AEI. RCH. RAD. Royal infirm s Walsgrave University LBH. Royal Royal John Brom ary London Albert Cornwall Radcliffe pton of Edinburgh Edward Bridge Infirm ary As August 2010 UK E&W (NHS) Scotland (NHS) N. Ireland PCIs 83,130 71,277 7,153 3,049 In CCAD 77,578 69,074 5,896 1,577 Missing 5,552 2,203 1,257 1,472 % Missing 6.7% 3.1% 17.6% 48.3%

55 Data Quality

56 Risk Stratified Outcome A D Grayson et al Heart 2006;92: NWQIP risk adjustment model

57 % Completeness 12 fields required for risk adjusted outcome NWQIP Top score potential = 1200

58

59 Demographics Age (mean) 64.3 yrs 64.4 yrs 65.0 yrs Sex (male) 73.6% 73.8% 73.9% Diabetic 17.5% 18.0% 18.2% Previous CABG 8.5% 9.1% 8.6% Previous PCI 18.6% 21.1% 22.3% Previous MI 29.5% 30.2% 28.8% CCAD

60 Demographics - Age Male: mean = 63.7 Female: mean = No. PCIs Male 07 Male 08 Male 09 Female 07 Female 08 Female 09 <= >90 Age (yrs) CCAD

61 Demographics - Age 75 Mean Age(yrs) Number of PCI procedures

62 Demographics Ethnic Origin Year n 43,929 48,581 57,733 Caucasian 92.3% 92.0% 93.0% Asian 6.7% 7.1% 6.16% Black 0.83% 0.72% 0.71% Oriental 0.2% 0.17% 0.15% CCAD

63 Structure New centres Total PCI numbers No of PCIs per unit and per angio Diagnostic cath lab utilization PCI pmp and by country PCI activity by centre PCI Operators Surgical cover Day case activity Primary PCI units PCI Procedure specific data CCAD data completeness and quality Databases used for collection Demographics Appropriateness Indication for PCI / Clinical syndrome PPCI activity (by unit, pmp, by vessel) Stents (BMS and DES) Adjunctive therapy LV support Shock Multi-vessel treatment Additional interventional techniques Arterial access routes complications Contents Process of care Delays data completeness Delays to treatment Primary PCI CTB times by unit / by admit route DTB times by unit / by admit route Circadian distribution Treatment times Treatment delays Non coronary intervention HOCM septal ablation Transcatheter Aortic Valve Implantation UK TAVI Registry Other adult structural intervention Outcome MACCE Outcome by syndrome ONS tracked mortality PPCI / Rescue / Shock Outcome by lesion subset ONS tracked mortality CTO / ulms Risk adjusted outcomes

64 Clinical Syndrome % PCI Performed for each Indication Stable Unstable CCAD

65 Clinical Syndrome % PCI in patients with Acute syndromes by unit volume 100 % Acute cases Number of PCI procedures

66 Indication for PCI 100% % 60% 40% STEMI NSTEMI/UA Stable Other 20% %

67 Indication for PCI 38.28% 20.25% Stable NSTEMI / UA STEMI Other 1.69% 39.78% CCAD

68 Indication for PCI Stable NSTEMI / UA STEMI Other 38.28% 20.25% 1.69% 39.78% CCAD

69 Indication for PCI Other Stable NSTEMI / UA 1.4 STEMI Other % 20.25% 1.69% % % Staged Hybrid SAT Bailout CCAD

70 Indication for PCI Stable NSTEMI / UA STEMI Other 38.28% 20.25% 1.69% 39.78% CCAD

71 PCI for STEMI All STEMI Primary PCI Rescue CCAD

72 Primary PCI for STEMI Absolute number PPCI (2009) Number of PPCI cases Number of any type of PCI procedure

73 Primary PCI for STEMI % PPCI of total activity (2009) % of total PCI Activity Number of any type of PCI procedure

74 Primary PCI UK Countries Total Number of PPCI England Scotland Wales CCAD

75 Primary PCI UK Countries PPCI pmp England Scotland Wales UK Total CCAD

76 Primary PCI European Countries Widimsky P EHJ 2010;31:

77 PPCI Multi-vessel disease Of 13,208 cases Single epicardial territory > 75%: 9163 More than 1 territory > 75%: % PPCI with multi-vessel disease Single vessel PCI 90.1%

78 PPCI Treated Epicardial Territory Number LMS LAD Cx RCA

79 PPCI Treated Epicardial Territory 2% 41% 42% LMS LAD Cx RCA 15%

80 Stents

81 Procedures using Stents % of Procedures '92 '94 '96 '98 '00 '02 '04 '06 '08 Year 92 aggregate data up to 2007, CCAD for 2008 on

82 Procedures using Stents Mean = 92% % PCI with stent Number of PCI procedures CCAD

83 PCI with Drug Eluting Stents Mean of % use by Centres % DES cases ? CCAD

84 PCI with Drug Eluting Stents Mean = 63.5% % PCI with DES Number of PCI procedures

85 PCI with Drug Eluting Stents By Syndrome % DES cases Stable UA / NSTEMI PPCI CCAD

86 Drug Eluting Stent % PCI with DES Scotland England Wales N. Ireland Country Data to 2007 NHS only Data for 2008 and 2009 all units from CCAD

87 Stents per Case Mean number of stents per case CCAD

88 Mean Stents per Case (by PCI unit) 2.5 Stents per case Number of PCI procedures

89 BMS and DES use V PCI for Restenosis '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 ' % PCI with any Stent % PCI with DES % PCI for restenosis

90 Procedures for Restenosis % by total unit activity % PCI for restenosis Number of PCI procedures

91 Adjunctive therapy % of Procedures Any IIb/IIIa antag Abciximab Eptifibatide Tirofiban Bivalirudin Prasugrel

92 GP IIb/IIIa Antagonists Use by Presentation % Procedures w ith any GP IIb/IIIa blocker Stable UA NSTEMI PPCI CCAD

93 LV Support Data for circulatory support available for 71,771 procedures LV Support Number % Inotropes % % IABP % %

94 LV Support % IABP use by total unit activity % IABP used Number of PCI procedures

95 Cardiogenic Shock % Cases with shock by PCI unit Shock in 1.8% of cases (1416 of 77,660)

96 Cardiogenic Shock % Cases with shock by PCI unit Shock in 1.8% of cases (1416 of 77,660)

97 % Shock Cases Treated with IABP support by total PCI unit activity Mean = 50.6% % Shock treated with IABP Total number of PCI procedures

98 LV Support % cases using IABP v LV function Data from 38,939 cases % Good LV Moderate Poor

99 Multi-Vessel Disease

100 Multi-vessel Treatment 100 % of all PCIs Vessels Treated per case

101 Multi-Lesion Treatment % of all PCIs > Number of Lesions treated per case

102 Multi-Lesion Treatment % Lesions per case Vessels per case

103 Additional Interventional Coronary Techniques Units No % cf 2008 Mean* Max Cases Rotablation % Laser % Cutting balloon % Thrombectomy % Distal protection % *Mean number in units using the technique Aggregate data

104 Rotational Atherectomy % of Cases using Rota Total Number of PCI procedures

105 Other Diagnostic Techniques Max Units No cf 2008 Mean Cases IVUS % Press wire %

106 IVUS and Pressure Wire % Cases with device IVUS PW Total Number of PCI procedures

107 Arterial access

108 Radial Artery Access % Cases using Radial Access

109 Radial Artery Access % Cases using radial access Total number of PCI procedures

110 Radial Artery Access Clinical Syndrome % Cases using Radial Access Stable ACS not STEMI PPCI

111 Femoral closure devices % PCI via FA using closure device FA closure (PCI from FA) 2006 = 39.6% 2007 = 50.7% 2008 = 53.6% 2009 = 57.1% % Total Number of PCIs from Femoral Artery

112 Access site complications Complications to hospital Dx: False aneurysm, haemorrhage, arterial occlusion / dissection Any other surgical intervention % of all cases As listed False aneurysm Haemorrhage As listed + all other

113 Complication by Access route Complications to hospital Dx: False aneurysm Haemorrhage (retroperitoneal, delay Dx, surgery) Art occlusion / dissection Any need for surgery % of all cases Femoral Radial

114 Complication by Access route CVA 0.2 % Cases with CVA Femoral Radial

115 Structure New centres Total PCI numbers No of PCIs per unit and per angio Diagnostic cath lab utilization PCI pmp and by country PCI activity by centre PCI Operators Surgical cover Day case activity Primary PCI units PCI Procedure specific data CCAD data completeness and quality Databases used for collection Demographics Appropriateness Indication for PCI / Clinical syndrome PPCI activity (by unit, pmp, by vessel) Stents (BMS and DES) Adjunctive therapy LV support Shock Multi-vessel treatment Additional interventional techniques Arterial access routes complications Contents Process of care Delays data completeness Delays to treatment Primary PCI CTB times by unit / by admit route DTB times by unit / by admit route Circadian distribution Treatment times Treatment delays Non coronary intervention HOCM septal ablation Transcatheter Aortic Valve Implantation UK TAVI Registry Other adult structural intervention Outcome MACCE Outcome by syndrome ONS tracked mortality PPCI / Rescue / Shock Outcome by lesion subset ONS tracked mortality CTO / ulms Risk adjusted outcomes

116 Time Delays to Treatment

117 Time fields Data completeness For Healthcheck 09/10 BCIS Field No. Patients treated for STEMI by Primary PCI MINAP Field No Date/time of symptom onset Date/time of arrival at first hospital Date/time of arrival at PCI hospital 3.26 Date/time of first balloon inflation Discharge date 4.01 > 90% completeness in each

118 Time fields Data completeness

119 Time fields Data completeness

120 Time fields Data completeness

121 Primary PCI

122 Primary PCI 2009: Rx for STEMI (NHS centres) Funnel analysis for TIMING DELAYS all units performing > 10 cases of PPCI (patients with onset of symptoms in the community) Excludes patients in cardiogenic shock Excludes those needing pre-pci ventilation

123 PCI for Acute Sx Four admission scenarios 2009 data: Ludman Admitted from the community Already in hospital Admission to Non-PCI centre Direct admission to PCI centre Transfer to PCI centre is a PCI centre is a Non-PCI centre

124 PCI for Acute Sx Four admission scenarios 2009 data: Ludman Admitted from the community Already in hospital Admission to Non-PCI centre Direct admission to PCI centre Transfer to PCI centre

125 PCI for Acute Sx Four admission scenarios 2009 data: Ludman Admitted from the community Admission to Non-PCI centre D1 Direct admission to PCI centre Transfer to PCI centre D2 device

126 Primary PCI Direct and IHT: Call to Balloon times < 150 min % CTB < 150 min 75.3% Number of Cases

127 PCI for Acute Sx Four admission scenarios 2009 data: Ludman Admitted from the community Admission to Non-PCI centre D1 Direct admission to PCI centre Transfer to PCI centre D2 device

128 Primary PCI Direct and IHT: PCI Door to Balloon < 90 min 87.3% % DTB < 90 min Number of Cases

129 PCI for Acute Sx Four admission scenarios 2009 data: Ludman Admitted from the community Admission to Non-PCI centre D1 D2 Direct admission to PCI centre V Transfer to PCI centre device

130 PCI for Acute Sx Four admission scenarios 2009 data: Ludman Admitted from the community Admission to Non-PCI centre D1 Direct admission to PCI centre Transfer to PCI centre D2 device

131 Primary PCI Direct: Call to Balloon times < 150 min 85.1% % CTB < 150 min Number of Cases

132 PCI for Acute Sx Four admission scenarios 2009 data: Ludman Admitted from the community Admission to Non-PCI centre D1 Direct admission to PCI centre Transfer to PCI centre D2 device

133 Primary PCI IHT: Call to Balloon times < 150 min % CTB < 150 min 45.1% Number of Cases

134 PCI for Acute Sx Four admission scenarios 2009 data: Ludman Admitted from the community Admission to Non-PCI centre D1 D2 Direct admission to PCI centre V Transfer to PCI centre device

135 PCI for Acute Sx Four admission scenarios 2009 data: Ludman Admitted from the community Admission to Non-PCI centre D1 Direct admission to PCI centre Transfer to PCI centre D2 device

136 Primary PCI IHT: PCI Door to Balloon times < 90 min 92.2% % DTB < 90 min Number of Cases

137 PCI for Acute Sx Four admission scenarios 2009 data: Ludman Admitted from the community Admission to Non-PCI centre D1 Direct admission to PCI centre Transfer to PCI centre D2 device

138 Primary PCI Direct: Door to Balloon times < 90 min % DTB < 90min 85.6% Number of Cases

139 Primary PCI Summary % Cases CTB < 150 min DTB < 90 min 20 0 All Direct IHT

140 Primary PCI Summary 26.1% IHT v 73.9% Direct % Cases CTB < 150 min DTB < 90 min 20 0 All Direct IHT

141 PPCI circadian analysis 2009 data All cases with the PCI indication recorded as Primary PCI Includes shock, ventilation Only exclusions where there are missing date/time fields

142 Primary PCI procedures Time of first device Total 12,141 Total 10,173 16% Rx in day time only centres

143 Primary PCI procedures Time of first device 19:00 to 07:00 = 12 /day 23:00 to 06:00 = 7 /day Total 12,141 NB: +20% false activation + variability

144 PPCI Call to Balloon time IHT and Direct admissions 140 Median CTB: All centres Mins Median= Hour of Day Number Number of Cases: All centres Hour of Day Includes shock and ventilation

145 PPCI Call to Balloon time IHT and Direct admissions Median CTB: 24-7 centres Mins Hour of Day 700 Number of Cases: 24-7 centres Number Includes shock and ventilation Hour of Day

146 PPCI Call to Balloon time Direct only Mins Number Median CTB: All centres Number of Cases: All centres Median=106 min Hour of Day Hour of Day Includes shock and ventilation

147 PPCI Call to Balloon time Direct only Includes shock and ventilation

148 PPCI Call to Balloon time IHT only Median=161min Includes shock and ventilation

149 PPCI Call to Balloon time IHT only Includes shock and ventilation

150 PPCI Call to Balloon time By Admission Route 250 Median CTB min (+/- IQR) Direct IHT ALL Includes shock and ventilation

151 PPCI Door to Balloon Time Direct Admissions Median 47 min (IQR 27-74)

152 PPCI Door to Balloon Time IHT Median 30 min (IQR 22-55)

153 PPCI Door to Balloon time By Admission Route Median DTB min (+/- IQR) Direct IHT ALL Includes shock and ventilation

154 Structure New centres Total PCI numbers No of PCIs per unit and per angio Diagnostic cath lab utilization PCI pmp and by country PCI activity by centre PCI Operators Surgical cover Day case activity Primary PCI units PCI Procedure specific data CCAD data completeness and quality Databases used for collection Demographics Appropriateness Indication for PCI / Clinical syndrome PPCI activity (by unit, pmp, by vessel) Stents (BMS and DES) Adjunctive therapy LV support Shock Multi-vessel treatment Additional interventional techniques Arterial access routes complications Contents Process of care Delays data completeness Delays to treatment Primary PCI CTB times by unit / by admit route DTB times by unit / by admit route Circadian distribution Treatment times Treatment delays Non coronary intervention HOCM septal ablation Transcatheter Aortic Valve Implantation UK TAVI Registry Other adult structural intervention Outcome MACCE Outcome by syndrome ONS tracked mortality PPCI / Rescue / Shock Outcome by lesion subset ONS tracked mortality CTO / ulms Risk adjusted outcomes

155 Adult Non Coronary Intervention

156 Alcohol Mediated Septal Ablation Units No cf 2008 Mean Max Septal ablation % Number of Procedures Individual Centres

157 Adult non coronary intervention Units No. cf 2008 Mean Max Cases MV plasty % AV plasty % PV plasty % TV plasty PDA % ASD PFO %

158 PFO Closure 120 Number of Procedures Individual Centres

159 Adult non coronary intervention Units No cf 2008 Mean VSD congen % 2 5 VSD post MI % LAA occlusion Paravalvular leak closure Max % 3.6 6

160 Adult great vessel intervention Units No cf 2008 Mean Max Coarct / Re-coart % 8 17 Carotid % Aorta % 8 12 Pulm art % 4 8

161 Transcatheter Valves Units No Mean Max Cases Transcatheter Aortic Valve Implantation (TAVI) CoreValve: Femoral CoreValve: Subclavian Edwards: Femoral Edwards: Apical Total = 551

162 UK TAVI Centres TAVI Cases to Dec 31 st 2009 Royal Brompton 114 St Thomas s 102 Glenfield 85 King's College 71 Royal Sussex County 63 Leeds General Infrmy 48 Wythenshawe 48 St George's 44 Bristol Royal Infrmy 43 (Royal Victoria, Belfast 43) John Radcliffe 29 Liverpool Heart and Chest 27 Hammersmith 27 Victoria 24 New Cross 23 Papworth 23 Barts and the London 22 Freeman 12 Southampton General 11 North Staffs 11 Queen Elizabeth 10 Derriford 9 James Cook 8 Manchester Royal Infrmy 7 London Bridge 6 Morriston 5

163 26 Centres 872 Patients Additional 43 cases from Belfast not included in any further analyses

164 UK TAVI Registry The United Kingdom Transcatheter Aortic Valve Implantation Registry 100% of consecutive UK TAVI implants 1 st Jan 2007 to 31 st Dec 2009 Mortality tracking linkage of central TAVI database with the Office of National Statistics (ONS) 872 TAVI procedures 862 successful valve implants, 10 unsuccessful Data as Additional 43 cases from Belfast not included

165 UK TAVI Registry The United Kingdom Transcatheter Aortic Valve Implantation Registry Number of TAVI by year Data as

166 UK TAVI Registry The United Kingdom Transcatheter Aortic Valve Implantation Registry Number of Valves Implanted undeployed device in 10 cases Medtronic CoreValve (n=460) Edwards Sapien (n=402) 3 Unknown Other* Transapical Transfemoral Data as *41 subclavian, 2 other

167 UK TAVI Registry Demographics Data as All Male 52% Age median (IQR) yr 83 (78-87) Age range (yr) Diabetes 23% Prior CABG 26% PVD 32% CAD 48% LMS disease 5.6%

168 UK TAVI Registry Demographics Data as All Transfemoral Other routes Male 52% 52% 54% p=ns Age median (IQR) yr 83 (78-87) 83 (78-87) 83 (79-87) p=ns Age range (yr) Diabetes 23% 23% 23% p=ns Prior CABG 26% 23% 33% p=0.002 PVD 32% 23% 51% p< CAD 48% 44% 57% P< LMS disease 5.6% 4.6% 8.0% p=ns

169 UK TAVI Registry Demographics Data as All Transfemoral Other routes Male 52% 52% 54% p=ns Age median (IQR) yr 83 (78-87) 83 (78-87) 83 (79-87) p=ns Age range (yr) Diabetes 23% 23% 23% p=ns Prior CABG 26% 23% 33% p=0.002 PVD 32% 23% 51% p< CAD 48% 44% 57% P< LMS disease 5.6% 4.6% 8.0% p=ns

170 100% UK TAVI Registry Demographics Data as % 80% 70% 60% 50% 40% 30% 20% 10% 0% All Transfemoral Other routes NYHA I NYHA II NYHA III NYHA VI All Transfemoral Other routes Angina 43% 44% 39%

171 UK TAVI Registry Case Mix Data as All Peak AV gradient (mmhg) 80 Valve Area (cm 2 ) 0.68 LVEF>50% 64% LVEF < 30% 8% Logistic EURO Score 21.6%

172 UK TAVI Registry Case Mix Data as All Transfemoral Other routes Peak AV gradient (mmhg) p=ns Valve Area (cm 2 ) p=ns LVEF>50% 64% 65% 63% p=ns LVEF < 30% 8% 7% 9% p=ns Logistic EURO Score 21.6% 20.3% 24.5% P<0.01

173 UK TAVI Registry Case Mix Data as All Transfemoral Other routes Peak AV gradient (mmhg) p=ns Valve Area (cm 2 ) p=ns LVEF>50% 64% 65% 63% p=ns LVEF < 30% 8% 7% 9% p=ns Logistic EURO Score 21.6% 20.3% 24.5% P<0.01

174 UK TAVI Registry In Outcomes % Non Hierarchical MACCE All Transfemoral Other Routes Data as Breakdown 54 (6.2%) of patients died 88 (10.1%) died or had MI or CVA 10 died subsequent to CVA or MI 34 had CVA or MI and survived 0 Death MI CVA Other MACCE All Transfemoral Other routes TIA 0.6% 0.3% 1.1% Emergency Surgical AVR 0.7% 0% 2.2%

175 UK TAVI Registry In Outcomes Data as Edwards Sapien Medtronic CoreValve Transfemoral Other route p< p= p=ns 5 p= Major Vascular Complication* Pacemaker 0 Major Vascular Complication* Pacemaker *Major vascular injury or later vascular injury requiring surgery

176 UK TAVI Centres Mortality tracking to Dec 31 st 2009 TAVI (intention to Rx) n=872 Mortality tracked by ONS n=842 Not ONS tracked: life status reported at 1 year or discharge n=30 Not tracked Unknown outcome n=0 Tracking Survival curves based on n=872

177 UK TAVI Registry Overall Survival Data as Median FU: 330 days 0 30/7 6/12 1 yr 18/12 2 yr Survival 93.1% 84.4% 80.3% 77.6% 75.1% n at risk

178 UK TAVI Registry Data as Transfemoral Other p= cases route unknown 0 30/7 6/12 1 yr 18/12 2 yr Survival: Transfemoral 94.8% 86.5% 82.4% 80.4% 78.3% Number at risk Survival: Other routes 89.1% 79.6% 75.5% 71.1% 66.5% Number at risk

179 UK TAVI Registry Data as Medtronic Corevalve Edwards Sapien p=n.s. 10 cases no valve deployed 0 30/7 6/12 1 yr 18/12 2 yr Survival: CoreValve 94.5% 86.3% 81.6% 79.8% 77.6% Number at risk Survival: Edwards Sapien 91.1% 82.7% 79.5% 75.6% 72.2% Number at risk

180 UK TAVI Registry Minimising the learning curve? Data as Unproctored case Subsequent cases Proctored case First 20 cases p=n.s. p=n.s.

181 UK TAVI Registry Data as Log Euroscore 0-20% Log Euroscore 20-40% Log Euroscore >40% P= /7 1 yr 18/12 2 yr ES 0-20% n at risk ES 20-40% n at risk ES > 40% n at risk

182 UK TAVI Registry Conclusion Successful implementation of a National dataset UK wide data collection All procedures prospectively captured Incorporates complete experience of all centres including the proctored learning curves Collaboration between all involved Mortality tracking Encouraging early results In hospital mortality: 6.2% 30/7 mortality: 6.9% 1 yr mortality: 19.7%

183 Percutaneous Valves Units No % cf 2008 Mean Max Pulmonary Valve % 7 14

184 Percutaneous Valves - Mitral Units No % cf 2009 Mean Max Cases Mitral Valve Repair Mitra-clip % Viacor 0 Carillon 0 Monarch Total = 35

185 Structure New centres Total PCI numbers No of PCIs per unit and per angio Diagnostic cath lab utilization PCI pmp and by country PCI activity by centre PCI Operators Surgical cover Day case activity Primary PCI units PCI Procedure specific data CCAD data completeness and quality Databases used for collection Demographics Appropriateness Indication for PCI / Clinical syndrome PPCI activity (by unit, pmp, by vessel) Stents (BMS and DES) Adjunctive therapy LV support Shock Multi-vessel treatment Additional interventional techniques Arterial access routes complications Contents Process of care Delays data completeness Delays to treatment Primary PCI CTB times by unit / by admit route DTB times by unit / by admit route Circadian distribution Treatment times Treatment delays Non coronary intervention HOCM septal ablation Transcatheter Aortic Valve Implantation UK TAVI Registry Other adult structural intervention Outcome MACCE Outcome by syndrome ONS tracked mortality PPCI / Rescue / Shock Outcome by lesion subset ONS tracked mortality CTO / ulms Risk adjusted outcomes

186 Outcome

187 Data sources Success, Mortality CVA and Emergency CABG QMI Denominator: Total PCI procedures except PCI for STEMI NQMI Denominator: Total PCIs for stable symptoms

188 Methodology Multiple procedures mortality PCI PCI 1 yr PCI Death 3

189 Methodology Multiple procedures mortality PCI PCI 1 yr PCI Death 3 CCAD mortality counts Identifies multiple procedures and only counts one death

190 Methodology Multiple procedures mortality PCI PCI 1 yr PCI Death 3 Kaplan Meier Survival Subsequent procedures reclassified as re-pci

191 Methodology Multiple procedures mortality PCI PCI 1 yr PCI Death 30 days 30 days

192 Methodology Multiple procedures mortality PCI PCI 1 yr PCI Death 30 days 30 days 30/7 death

193 Methodology Multiple procedures mortality PCI PCI 1 yr PCI Death 30 days 30 days 30/7 death 30/7 survivor

194 Methodology Multiple procedures mortality PCI PCI 1 yr PCI Death 30 days 30 days 30/7 death Censored 30/7 survivor

195 MACE - All PCIs Year Procedure Success (%) QMI % NQMI (stable) (%) Em CABG (%) CVA (%) Mortality (%) 30 day Mortality (%) (from ONS)

196 Adverse Outcomes - Death Mortality to Discharge (self reported) Overall mean = 1.21 % % Number of PCI procedures

197 Adverse Outcomes - Death 30/7 ONS tracked mortality Overall mean = 2.0 % % Number of PCI procedures

198 Adverse Outcomes - CVA % of all cases with CVA (not TIA) Overall mean = 0.08 % % Number of PCI procedures

199 Adverse Outcomes CABG % of all cases needing emergency CABG Overall mean = 0.08 % % Number of PCI procedures

200 Adverse Outcome Death and emergency CABG '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 % Mortality em CABG

201 Peri-procedural Complications

202 Outcome 2009 Elective Patients All as % No. cases Success Partial success Fail no comp Re- PCI QMI Em CABG CVA Death Stable SV (no CTO) MV (no CTO) 19, SV CTO MV CTO OVERALL STABLE All Stable

203 Outcome 2009 All as % No. Success Partial success Fail no comp Re-PCI QMI Em CABG CVA Death In hosp Death 30/7 ONS NSTEMI / UA no shock All STEMI no shock 26, , *Primary PCI 13, *Rescue PCI 1, Shock *all PPCI (includes shock / ventilation etc)

204 Summary: Mortality Risk Stratified by Syndrome 6 % All Elective UA / NSTEMI Primary PCI Rescue

205 Summary: Mortality Risk Stratified by Syndrome 40 % All Elective UA / NSTEMI 4.3 Primary PCI Rescue Shock

206 Primary PCI (excludes shock/vent) Mortality to Discharge (self reported) % Mortality to Discharge 2.3% Number of PPCI procedures Shock and ventilation excluded

207 Primary PCI (excludes shock/vent) 30 day ONS tracked Mortality 2009 data: Ludman % Mortality at 30 days Number of PPCI procedures Shock and ventilation excluded

208 Primary PCI (excludes shock/vent) 30 day ONS tracked Mortality % Mortality at 30 days 3.4% Number of PPCI procedures Shock and ventilation excluded

209 Primary PCI (includes shock/vent) 30 day ONS tracked Mortality 2009 data: Ludman % Mortality at 30 days 6.2% Number of PPCI procedures Shock and ventilation INCLUDED

210 Primary PCI ONS Tracked Mortality of 2008 data Time 0 30/7 6/12 1 yr Mortality 5.7% 7.5% 9.0% Number at risk Shock and ventilation Included

211 Primary PCI (>80yrs) ONS Tracked Mortality of 2008 data 11.5% PPCI in patients 80 yr 0 30/7 6/12 1 yr Mortality: Age >= % 20.3% 24.8% Number at risk Mortality: Age < % 5.9% 6.9% Number at risk Shock and ventilation Included

212 Primary PCI % cases over 80 (2008 data) % of cases with age over 80 yrs 11% Number of PPCI procedures

213 Primary PCI -? Case selection % Cases over 80 (2009 data) % of cases with age over 80 yrs 11.7% Number of PPCI procedures

214 Primary PCI -? Case selection % Cases over 80 (2009 data) % of cases with age over 80 yrs 11.7% Number of PPCI procedures

215 Primary PCI (Shock) ONS Tracked Mortality of 2008 data 6.2% PPCI in Shock 0 30/7 6/12 1 yr Mortality: Shock 42.7% 48.0% 50.2% Number at risk Mortality: No Shock 3.2% 4.9% 6.3% Number at risk Shock and ventilation Included

216 Primary PCI (Diabetes) ONS Tracked Mortality of 2008 data 13.2% PPCI in Diabetics 0 30/7 6/12 1 yr Mortality: Diabetic 8.1% 12.8% 15.9% Number at risk Mortality: No Diabetes 5.3% 7.1% 8.3% Number at risk Shock and ventilation Included

217 Bypass grafts PCI of SVG and Arterial 2009 All as % No. Success Partial success Fail no comp Re- PCI QMI Em CABG In Hosp Death 30/7 Death Centre x = 1860 of 2111 cases in 2008

218 Bypass Grafts (all types - SVG and IMA etc) 2008 Distal protection in 16.8% % 100% % 60% 40% Distal protection used No distal protection 20% 0% Exclude centre x from 2008 calc

219 Chronic Total Occlusions 2009 Inadequate data cleaning for previous analyses Current analysis excludes any CTO performed in context of acute coronary syndrome

220 Chronic Total Occlusions 2009 Analysis From complete 2009 BCIS dataset Number of CTO attempted > Clinical Syndrome = stable 3928 Life Status tracked via ONS 3569 Analysis

221 Chronic Total Occlusions 2009 Demographics All 2009 CTO 2009 Age (mean) 65.0 yrs 63.9 yrs Sex (male) 73.9% 79.8% Diabetic 18.2% 21% Previous CABG 8.6% 30% Previous PCI 22.3% 33% Previous MI 28.8% 45.3%

222 Chronic Total Occlusions 2009 Of 2,739 single vessel treatment Graft 2% Cx 18% LAD 30% RCA 50%

223 Chronic Total Occlusions 2008 Data with ONS track to May 2010 Time 0 30/7 6/12 1 yr Mortality 0.5% 1.3% 2.7% Number at risk

224 Chronic Total Occlusions 2008 Data with ONS track to May 2010 PCI Success PCI Failure 0 30/7 6/12 1 yr Mortality: PCI Success 0.4% 0.9% 1.8% Number at risk Mortality: PCI failed 0.7% 2.1% 3.7% Number at risk

225 Unprotected LMS Including Shock and STEMI All as % No. Success Partial success Fail no comp Re- PCI QMI Em CABG In Hosp Death Death 30/7 (ONS)

226 Unprotected LMS Total number of PCIs % for Rx of ulms

227 Unprotected LMS 2008 Data with ONS track to May 2010 Excluding Shock, PPCI, PH CABG Total 840 patients Demographics All 2009 ulms 2008 Age (mean) 65.0 yrs 70.0 yrs Diabetic 18.2% 20.6% Previous PCI 22.3% 25.7% Previous MI 28.8% 40.0%

228 Unprotected LMS 2008 Data with ONS track to May 2010 Time 0 30/7 6/12 1 yr Mortality 5.4 % 9.3 % 12.4% Number at risk

229 Unprotected LMS 2008 Data with ONS track to May /7 6/12 1 yr Mortality: Stable 2.9% 5.2% 6.6% Number at risk Mortality: UA / NSTEMI 7.8 % 13.4% 18.1% Number at risk

230 Risk Adjusted Outcome

231 Assessment of unit specific performance data Cumulative Funnel Plots for each unit Plots of each unit s overall risk adjusted outcome

232 NWQIP Model Observed MACCE Predicted MACCE +3 σ +2 σ -2 σ -3 σ

233 Outcome MACCE for 2007, 2008 and 2009 After all PCIs for 2007, 2008 and 2009 Risk Adjusted MACCE (for unit x) = Observed MACCE (all cases) X Observed MACCE Predicted MACCE (for unit x)

234 Outcome Data for 2007, 2008 and 2009 % MACCE Observed MACCE = 1.4% Mean 1.37% Number of PCI procedures

235 Outcome Data for 2007, 2008 and 2009 Risk Adjusted MACCE % MACCE Number of PCI procedures