Clinical Audit of Heart Rhythm Devices Pacemaker, ICD and CRT South West London Cardiac Network

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1 2011 Clinical Audit of Heart Rhythm Devices Pacemaker, ICD and CRT South West London Cardiac Network David Cunningham Senior Strategist, NICOR Morag Cunningham CRM Database Coordinator, NICOR Richard Charles Chairman, Heart Rhythm UK Device Audit Group

2 Acknowledgments The implant registration data that allows the construction of reports such as this is contributed on a voluntary basis by all pacemaker implanting hospitals in the United Kingdom. The data is held in the National Pacemaker Database, established in 1977 by Dr Anthony Rickards, and now part of the Central Cardiac Audit Database (CCAD) which runs the national cardiac audits as part of the National Institute for Cardiovascular Outcomes Research (NICOR), which is part of University College 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 of the Department of Health Heart Team and HQIP. This national clinical audit is funded as part of the National Clinical Audit & Patient Outcome Programme (NCAPOP), which is managed by the Healthcare Quality Improvement Partnership (HQIP The preparation of this report was supported by HQIP. Data collection was carried out by NICOR with support provided from NHS Improvement ( and the Cardiac Networks. The study was performed with the knowledge and support of the British Cardiovascular Society 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 from

3 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 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 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 Conclusions

4 Introduction to the 2011 Reports The Heart Rhythm UK Device Audit Group (formerly the Network Devices Survey Group), now in its ninth consecutive year of work, continues its audit of cardiac rhythm management, and particularly the level of provision of cardiac pacemakers, implantable defibrillators and cardiac resynchronisation therapy in England and Wales. This year the seventh consecutive annual national report has been published, covering clinical activity in 2011, and it is a pleasure for me to welcome its publication. You will find the national report at The report s principal focus remains the provision of data on the total volume and equity of provision of implantable cardiac devices, corrected for the demographic structure of the population. The methodology allows valid comparison of activity between and within different Network areas, and thus benchmarking of activity. This year the audit has used population data from the 2011 census, rather than serial extrapolations from the 2001 census, which should be borne in mind when comparing implant activity in this report with those from previous years. A summary account of cardiac arrhythmia ablation activity is now a fixed and valuable section of the report, and one which will be developed further in future reports. Work over the past two years has resulted in this being a full clinical audit of cardiac rhythm management, having evolved from the more simple past surveys of implantable device activity. Completion of an increased number of data fields has been encouraging, and I congratulate all those involved, particularly cardiac physiologists, arrhythmia nurses and clinicians who have worked so hard to ensure data collection. Clinical audit lies at the heart of understanding the quality and effectiveness of what we do for patients, and our performance compared to national and professional guidelines. The report provides an excellent contemporary picture of cardiac device and arrhythmia ablation activity in the NHS in England and Wales. Enormous progress has been made, driven by the advances in clinical science and technology and the hard work of NHS staff who translate these advances into practice. There is always scope for improvement, and this report highlights that volumes and equity of service provision of arrhythmia services in the NHS sometimes falls short by international comparison. However, the progress made to date is encouraging and I commend this report to all colleagues who plan, commission or deliver cardiac arrhythmia services for patients in England and Wales. Professor Huon Gray Interim National Clinical Director for Cardiovascular Disease, Dept of Health (England) & Consultant Cardiologist, University Hospital of Southampton - 4 -

5 The National Clinical Audit Report The Heart Rhythm UK Device Audit Group (formerly the Network Device Survey Group) is pleased to present its seventh set of annual reports covering the calendar year 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 integral relationship with our national society. Furthermore, the transfer of the cardiac audits during 2011, including this device audit, to the aegis of NICOR (the National Institute for Cardiovascular Outcomes Research based at University College, London) has been a wholly positive development which will greatly enhance the probability that the audit will indeed survive, develop and flourish in future. Whilst it is crucial for us to expand the clinical outcomes content of the Audit report, it remains a vital task of this Report to present data describing the total volume and equity of provision of the major cardiac implantable device therapies pacemakers for bradycardia (PM), implantable cardioverter defibrillators (ICDs) for cardiac arrest and cardiac resynchronisation therapy (CRT) for advanced heart failure across all Cardiac Networks in England and Wales. The core methodology of the survey remains unchanged, allowing valid direct comparison between Cardiac Networks, Primary Care Trusts (Local Health Boards in Wales) and between the national reports for 2009, 2010, the current report for 2011, and all previous annual reports. A full account of the methodology is presented within the National Report. This report continues to use the current professionally accepted targets for each device class, as in previous years 700 new implants/million(m) population for PM, 100 new implants/m for ICD and 130 total (new + replacement)/m for CRT, although there is a compelling case to revisit these targets in the light of current European trends. UK performance must be viewed in the context of our European neighbours; as we have previously emphasised, there is evidence neither of over-prescribing of devices in Europe, nor is there evidence that the prevalence of the conditions for which a device is indicated, based on current professional guidelines, differs between the UK and Western Europe. What are the headline results for 2011? In England, the PM new implant rate is 525/M, a small fall from 2010 which establishes a disappointing flat line from The ICD new rate is 77/M, a 6.9% increase over 2010, whilst the CRT total rate is 113/M, marking an abrupt halt to the consistent year-on-year rise since The performance of the NHS in England continues to compare unfavourably with most of the developed European economies. Wales demonstrates striking and commendable increases in implant rates for PM and CRT, whilst falls in implant rates in Northern Ireland for ICD and CRT arrest its erstwhile progress, although the ICD implant rate there continues to far exceed the rest of the UK. Data returns from Scotland show signs of improvement for complex devices but remain sadly depleted, as in previous years. It can be emphasised with confidence that the overall provision of - 5 -

6 cardiac implantable devices by the NHS remains inadequate to meet the needs of the population at risk. Inequity of provision of devices still afflicts the NHS but has noticeably decreased due to a general regression towards the (inadequate) mean implant 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 life enhancing device you need depends critically on where you live. The 2011 Reports continue our drive to present the clinical data which support the prescription of complex devices in particular. Finally, it is again a pleasure to recognise both the efforts of hard pressed clinical staff at implanting centres who submit their data and the continued input 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 offer our thanks for their contribution to the resource we offer here. Dr Richard Charles Emeritus Consultant Cardiologist, Liverpool Heart and Chest Hospital Chairman, Heart Rhythm UK Audit Group The National Audit of Cardiac Rhythm Management 2011 Report can be downloaded from

7 Overview of Device Implants in the UK General note: up to 2010, population estimates were year-on-year projections from ONS of the population, extrapolating from the 2001 census. In general these projections tend to under-estimate the true population. The 2011 rates use the population from the 2011 census, so a slight increase in actual implant rate might be masked by replacing a population under-estimate with a true estimate. (Note: the rates in these graphs are NOT adjusted for age and sex). New Pacemakers Comments England Wales Scotland N Ireland Pacemaker implant rate in England again remains static (524 per million population). per million population Large increase in new pacemaker rate in Wales 100 No increase in pacing rate in N Ireland year Data submissions from Scotland have improved but are still incomplete. New ICDs Comments ICD rate fell slightly in N Ireland but is still well above the rest of the UK. England and Wales rates remain very similar, with a modest increase in per million population England Wales Scotland N Ireland Dramatic rise in Scottish rate actually reflects better data submission, but is still not 100% complete year - 7 -

8 Total CRTs Comments The total CRT rate (all implants CRT-P and CRT- D) for England failed to increase for the first year since these devices were introduced. per million population England Wales Scotland N Ireland There was a large increase in the CRT rate in Wales and a large drop in N Ireland year The CRT rate in Scotland remains very low and is one of the lowest in Europe

9 How does the UK compare with Europe? Pacemaker New Implant Rate 2011 per million population Germany Iceland France Italy Sweden Finland Estonia Malta Czech Republic Lithuania Denmark Belgium Switzerland Poland Norway Slovakia UK Greece Slovenia Croatia Portugal Latvia Netherlands Serbia San Marino Israel Bulgaria Montenegro Belarus Luxembourg Russia Macedonia Bosnia Herzegovina Armenia Ukraine Azerbaijan

10 ICD New Implant Rate 2011 per million population San Marino Czech Republic Germany Denmark Italy Poland Belgium Norway Netherlands Slovakia Switzerland Finland France Israel Sweden Luxembourg Iceland Portugal UK Greece Spain Estonia Malta Montenegro Serbia Lithuania Latvia Belarus Bosnia Herzegovina Macedonia Bulgaria Armenia Russia Georgia Ukraine

11 CRT Total Implant Rate 2011 per million population Italy Germany Denmark Czech Republic Netherlands France Austria UK San Marino Norway Sweden Hungary Switzerland Israel Poland Finland Slovakia Estonia Belgium Ireland Malta Spain Iceland Portugal Slovenia Serbia Luxembourg Greece Lithuania Latvia Montenegro Cyprus Bulgaria Croatia Romania Macedonia Tunisia Russia Bosnia Herzegovina Belarus Georgia Armenia Azerbaijan Egypt Ukraine Morocco

12 Comments and Analysis of UK Implant Rates compared to Europe UK device implant rates have lagged behind our European neighbours for decades. The situation is not improving, it is getting worse. It is clear from the graphs above that small countries with a low GDP cannot afford to implant cardiac devices. The UK is not in that situation. To compare like with like, we took an average of European countries with a population over 10 million and a GDP per capita of at least $10,000 in The nine countries selected for comparison were Netherlands, Germany, France, Belgium, Italy, Spain, Portugal, Greece and the Czech Republic. The table below shows the UK implant rates and the population-weighted European average rates. UK 2011 Europe 2011 Pacemaker new implant rate ICD new implant rate CRT total implant rate Clearly there remains an enormous deficit in new implant rates for pacemakers and ICDs. The target (set some years ago) of 700 new implants per million for pacemakers seems to be still valid in comparison with Europe. However, the target of 100 for new ICD implants appears low in comparison with Europe, although still much higher than the UK is currently achieving. The European average CRT rate is 10% higher than the Heart Rhythm UK/BSH target rate of 130 and so this target probably does not need to be 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 at ehra-white-book-2012.pdf

13 New Pacemaker Implant Rate Europe

14 Data Quality Statement The quality of the analyses in this report is only as good as the quality of the data on which it is based. That data is originally submitted by hospitals to the National Pacemaker Database. If there is a deficit in registration, or if registrations do not contain a 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 and postcode completeness is sought for each hospital. Overall network completeness must reach 98% or a report will not be issued. Every effort is made to ensure this report is as accurate as possible - however please contact us if you identify any residual problem and we will try to correct the error promptly

15 Data Completeness and Data Quality for Key Hospitals in this Network Listed below are the most important data fields and their completion rates with CLINICALLY VALID entries. Note that any code which translates to Unknown or Uncoded is not considered to be clinically valid. Please note Mayday University Hospital has been renamed Croydon University Hospital

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17 2011 Implant Rates in the Cardiac Networks There has been a noticeable decrease in variability across networks in This has resulted from a decrease in rate for the highest rate implanting networks and an increase in the lower rate networks. Unfortunately this means that none of the networks now implant up to the target rate of 700 for pacemakers. It would have been preferable to see regression towards the target rather than regression towards the mean. As it stands, it appears that a clinically inadequate national average is being sought as an acceptable level of performance, when the focus should be on improvement to the levels of our Western European neighbours. The grey line represents the national average rate. The blue line is the national target rate. new Pacemaker rate 2011 adjusted for age and sex North West London Cardiac and Stroke Network Dorset Cardiac Network Sussex Heart Network North & East Yorkshire and Northern Lincolnshire Cardiac Network Bedfordshire and Hertfordshire Heart and Stroke Network North East London Cardiac and Stroke Network South West London Cardiac Network North Central London Cardiac & Stroke Network North of England Cardiovascular Network Kent Cardiovascular Network Cheshire & Merseyside Cardiac Network Anglia Stroke and Heart Network South Central Cardiovascular Network West Yorkshire Cardiac Network Greater Manchester & Cheshire Cardiac Network North Trent Network of Cardiac Care Surrey Heart & Stroke Network Black Country Cardiovascular Network Birmingham, Sandwell and Solihull Cardiac and Stroke Network Peninsula Cardiac Managed Clinical Network East Midlands Cardiac & Stroke Network Cardiac and Stroke Networks in Lancashire and Cumbria Avon, Gloucestershire, Wiltshire & Somerset Cardiac and Stroke Network South East London Cardiac & Stroke Network Essex Cardiac and Stroke Network South Wales North Wales Shropshire & Staffordshire Cardiac Network NB: North Wales and South Wales have a higher than average need for pacing so the adjusted rates shown here are lower than the unadjusted national rate for Wales shown on Page 7. Coventry & Warwickshire Cardiovascular Network Herefordshire and Worcestershire Cardiac Network The national target rate is 700 implants per million population. No network reaches this level

18 ICD The grey line represents the national average rate. The blue line is the national target rate. new ICD rate 2011 adjusted for age and sex North East London Cardiac and Stroke Network Dorset Cardiac Network Sussex Heart Network South West London Cardiac Network North West London Cardiac and Stroke Network Cheshire & Merseyside Cardiac Network North Central London Cardiac & Stroke Network Bedfordshire and Hertfordshire Heart and Stroke Network Surrey Heart & Stroke Network Kent Cardiovascular Network Black Country Cardiovascular Network West Yorkshire Cardiac Network Birmingham, Sandwell and Solihull Cardiac and Stroke Network East Midlands Cardiac & Stroke Network North & East Yorkshire and Northern Lincolnshire Cardiac Network North of England Cardiovascular Network Essex Cardiac and Stroke Network South Central Cardiovascular Network Avon, Gloucestershire, Wiltshire & Somerset Cardiac and Stroke Network North Wales South Wales Peninsula Cardiac Managed Clinical Network Anglia Stroke and Heart Network Greater Manchester & Cheshire Cardiac Network Shropshire & Staffordshire Cardiac Network Herefordshire and Worcestershire Cardiac Network Coventry & Warwickshire Cardiovascular Network South East London Cardiac & Stroke Network North Trent Network of Cardiac Care Cardiac and Stroke Networks in Lancashire and Cumbria Dorset and NE London are to be commended for maintaining their implant rates at or above the national target of 100. Sussex has seen a significant increase and has also reached the target, as has SW London. Hereford & Worcester has seen an improvement from an extremely low level (<40) to nearly 60. The rate in Lancs & Cumbria remains very low. For some reason the rate in SE London has fallen catastrophically, and this needs further examination

19 CRT The grey line represents the national average rate. The blue line is the national target rate. total CRT rate 2011 adjusted for age and sex Dorset Cardiac Network North West London Cardiac and Stroke Network Kent Cardiovascular Network Birmingham, Sandwell and Solihull Cardiac and Stroke Network South East London Cardiac & Stroke Network Sussex Heart Network North East London Cardiac and Stroke Network Cardiac and Stroke Networks in Lancashire and Cumbria Greater Manchester & Cheshire Cardiac Network South West London Cardiac Network Cheshire & Merseyside Cardiac Network North & East Yorkshire and Northern Lincolnshire Cardiac Network North Central London Cardiac & Stroke Network West Yorkshire Cardiac Network Anglia Stroke and Heart Network Peninsula Cardiac Managed Clinical Network South Central Cardiovascular Network Surrey Heart & Stroke Network Bedfordshire and Hertfordshire Heart and Stroke Network North Wales Black Country Cardiovascular Network Coventry & Warwickshire Cardiovascular Network Shropshire & Staffordshire Cardiac Network Essex Cardiac and Stroke Network North of England Cardiovascular Network Herefordshire and Worcestershire Cardiac Network South Wales Avon, Gloucestershire, Wiltshire & Somerset Cardiac and Stroke Network East Midlands Cardiac & Stroke Network North Trent Network of Cardiac Care Eleven networks have achieved the Heart Rhythm UK/BSH target of 130 total CRT implants per million North Trent are implanting at only half of the target rate. A number of other networks are well below average and even further below the target rate

20 PCTs/LHBs in the Network Code PCT/LHB Population South West London Cardiac Network 1,412,154 5A5 Kingston 160,436 5K9 Croydon 364,815 5LG Wandsworth 307,710 5M6 Richmond and Twickenham 187,527 5M7 Sutton and Merton 391,

21 Correcting Implant Rates for Age and Sex Calculating Need Most pacemakers are implanted for conduction system disease, which is predominantly a disease of the elderly. The graph shows the percentage of the population in 5 year age bands, and the percentage of pacemaker implants. Only 11% of the population are aged 70 or more, but they receive 76% of all pacemaker implants. Men also receive more pacemakers than women. Although the national average new implant rate is 528, it reaches more than 11,000 in men aged more than 90 (right). So the proportion of older people in a local population will strongly influence how many pacemakers need to be implanted. If we examine closely the age and sex distribution of the local population of a PCT (LHB in Wales) or Network, we can work out how many pacemakers we would EXPECT to see implanted, compared to the national average. The ratio of the local and national rate is called 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% are aged 70 or more, compared to the national average of 11%. This means that this network doesn't need as many pacemaker implants relative to the nation as a whole. Their Relative 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. Their Relative Need for Pacing is 140%

22 Using Relative Need We want to make a fair and valid comparison between PCTs/LHBs, Networks and the National Average. That means we should correct for relative need. So, for example if North 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's adjusted rate is 840 divided by 140% = 600. So the adjusted rates for these two areas are the same, despite the major apparent difference in their unadjusted rates. Implantable Defibrillators The diseases for which ICDs are implanted are not the same as for pacemakers, and tend to occur in slightly younger people. These diseases are principally ischaemic heart disease and cardiomyopathy. We therefore need to calculate a separate relative need factor for ICDs. The graph (right) of new ICD implant rate in 2010 and 2011 shows that ICDs are also predominantly implanted 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, but just slightly less in magnitude than for pacemakers. Sussex, for instance, has a relative ICD need of 138%

23 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 implants compared to a PCT with a young population, because the incidence of indications for pacing and ICD is higher in older people. Code PCT/LHB Relative Need for Pacing Required Rate to be comparable with national average Relative Need for ICD Required Rate to be comparable with national average Relative Need for CRT Required Rate to be comparable with national average South West London Cardiac Network 75% % 62 76% 86 5A5 Kingston 82% % 65 80% 91 5K9 Croydon 77% % 64 78% 89 5LG Wandsworth 55% % 52 58% 65 5M6 Richmond and Twickenham 86% % 68 84% 95 5M7 Sutton and Merton 82% % 65 81% 92 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 people in 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 truer reflection of local implant rates vs. local need

24 Centres providing Device Implants to this Network Centres that implanted at least 10 devices in this network in 2011 Centre Pacemaker ICD CRT GEO St George's Hospital MAY Croydon University Hospital NHB Royal Brompton Hospital STM St Mary's Hospital Paddington KTH Kingston Hospital STH St Thomas' Hospital ANT St Anthony's Hospital UCL University College Hospital EPS Epsom Hospital HSC Harley Street Clinic HAM Hammersmith Hospital LBH London Bridge Hospital KCH King's College Hospital

25 10 Year Implant Trends Network v National New Pacemaker Implant Rate adjusted for age and sex of network population Pacemakers (national target: 700 new implants per million population) rate per million population National The pacing rate rose slightly and remains above the national average. 250 South West London Cardiac Network year 120 New ICD Implant Rate adjusted for age and sex of network population ICD (national target: 100 new implants per million population) rate per million population rate per million population year Total CRT Implant Rate adjusted for age and sex of network population National South West London Cardiac Network year National South West London Cardiac Network ICD rate rose to well above the national average. CRT (national target: 130 total implants per million population) CRT implant rate fell in 2011 but is consistent with the national target

26 Provider Hospitals: which hospitals serve which PCTs/LHBs? All implants in this cardiac network in 2011 PACEMAKERS PCT/LHB Implanting Centre Implants 5A5 KTH Kingston Hospital 46 Kingston GEO St George's Hospital 31 STH St Thomas' Hospital 7 ANT St Anthony's Hospital 7 NHB Royal Brompton Hospital 6 UCL University College Hospital 1 BFH Broomfield Hospital 1 EPS Epsom Hospital 1 HSC Harley Street Clinic 1 RSU Royal Surrey County Hospital 1 SPH St Peter's Hospital 1 5K9 MAY Croydon University Hospital 137 Croydon GEO St George's Hospital 20 LBH London Bridge Hospital 6 NHB Royal Brompton Hospital 5 ANT St Anthony's Hospital 5 STH St Thomas' Hospital 4 KCH King's College Hospital 4 UCL University College Hospital 3 RCH Royal Cornwall Hospital

27 5LG GEO St George's Hospital 76 Wandsworth STM St Mary's Hospital Paddington 17 STH St Thomas' Hospital 15 NHB Royal Brompton Hospital 12 KTH Kingston Hospital 3 WES Chelsea & Westminster Hospital 3 ANT St Anthony's Hospital 2 HAM Hammersmith Hospital 2 HSC Harley Street Clinic 2 KCH King's College Hospital 2 LBH London Bridge Hospital 2 FRM Frimley Park Hospital 1 UCL University College Hospital 1 MAY Croydon University Hospital 1 SPH St Peter's Hospital 1 ZZZ unknown hospital 1 5M6 STM St Mary's Hospital Paddington 39 Richmond and Twickenham NHB Royal Brompton Hospital 19 KTH Kingston Hospital 17 GEO St George's Hospital 16 ANT St Anthony's Hospital 9 HSC Harley Street Clinic 5 HAM Hammersmith Hospital 4 STH St Thomas' Hospital 3 HHW Wellington Hospital 1 CMH Central Middlesex Hospital 1 RFH Royal Free Hospital 1 5M7 GEO St George's Hospital 162 Sutton and Merton NHB Royal Brompton Hospital 22 EPS Epsom Hospital 18 KTH Kingston Hospital 9 ANT St Anthony's Hospital 7 STH St Thomas' Hospital 4 MAY Croydon University Hospital 4 SPH St Peter's Hospital 4 STM St Mary's Hospital Paddington 2 ESU East Surrey Hospital 1 HSC Harley Street Clinic 1 LBH London Bridge Hospital 1 NHH North Hampshire Hospital 1 RDE Royal Devon & Exeter Hospital

28 ICDs Implantable Cardioverter Defibrillators PCT/LHB Implanting Centre Implants 5A5 GEO St George's Hospital 14 Kingston NHB Royal Brompton Hospital 1 STH St Thomas' Hospital 1 UCL University College Hospital 1 STM St Mary's Hospital Paddington 1 5K9 GEO St George's Hospital 16 Croydon UCL University College Hospital 4 HH Harefield Hospital 2 KCH King's College Hospital 2 NHB Royal Brompton Hospital 1 5LG GEO St George's Hospital 15 Wandsworth NHB Royal Brompton Hospital 4 STH St Thomas' Hospital 4 HAM Hammersmith Hospital 2 BAL Barts and The London 1 STM St Mary's Hospital Paddington 1 5M6 NHB Royal Brompton Hospital 8 Richmond and Twickenham STM St Mary's Hospital Paddington 6 GEO St George's Hospital 4 HHW Wellington Hospital 2 UCL University College Hospital 1 HSC Harley Street Clinic 1 5M7 GEO St George's Hospital 42 Sutton and Merton NHB Royal Brompton Hospital 3 HH Harefield Hospital 1 HHW Wellington Hospital 1 UCL University College Hospital 1 BRI Bristol Royal Infirmary 1 SPH St Peter's Hospital 1 STM St Mary's Hospital Paddington

29 CRTs Cardiac Resynchronisation Therapy PCT/LHB Implanting Centre Implants 5A5 NHB Royal Brompton Hospital 13 Kingston GEO St George's Hospital 5 STH St Thomas' Hospital 2 HSC Harley Street Clinic 1 UCL University College Hospital 1 LBH London Bridge Hospital 1 SPH St Peter's Hospital 1 STM St Mary's Hospital Paddington 1 5K9 GEO St George's Hospital 5 Croydon NHB Royal Brompton Hospital 5 UCL University College Hospital 5 KCH King's College Hospital 2 STH St Thomas' Hospital 1 5LG GEO St George's Hospital 18 Wandsworth NHB Royal Brompton Hospital 8 STM St Mary's Hospital Paddington 3 STH St Thomas' Hospital 2 UCL University College Hospital 1 HAM Hammersmith Hospital 1 5M6 STM St Mary's Hospital Paddington 11 Richmond and Twickenham NHB Royal Brompton Hospital 7 GEO St George's Hospital 3 HAM Hammersmith Hospital 2 HSC Harley Street Clinic 1 UCL University College Hospital 1 SPH St Peter's Hospital 1 5M7 GEO St George's Hospital 27 Sutton and Merton NHB Royal Brompton Hospital 12 UCL University College Hospital

30 Geographical Location of Implants Pacemaker Implants Please note Mayday Hospital has been renamed Croydon University Hospital

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 as physiological pacing modes) improve patients quality of life, and may also prolong survival. NICE Guidance (TA88, 2005) has confirmed the desirability of physiological pacing when appropriate. 30 years ago all pacemakers were ventricular-based, i.e. the only part of the heart which was stimulated was the lower chambers. Increasingly, atrialbased (mainly dual chamber) pacing has replaced the ventricular modes, a trend 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 this network % for England Atrial based pacing DDDR 69.1% 66.9% DDD 0.4% 2.4% AAIR % AAI % Other 0.1% 0.03% Ventricular based pacing VVIR 30.1% 29.9% VVI 0.3% 0.8% The proportion of physiological pacing in this network is very similar to the national average

33 Pacing Mode for New Implants by Centre Only implants in this network Mode DDDR DDD AAIR AAI Other physiological All Physiological VVIR VVI National 66.9% 2.4% 0.0% 0.0% 0.03% 69.3% 29.9% 0.8% This network 69.1% 0.4% 0.0% 0.0% 0.1% 69.7% 34.4% 0.5% St George's Hospital Croydon University Hospital Royal Brompton Hospital Kingston Hospital St Mary's Hospital Paddington St Thomas' Hospital St Anthony's Hospital Epsom Hospital 76.4% 1.0% 0.0% 0.0% 0.0% 77.4% 22.6% 0.0% 53.5% 0.0% 0.0% 0.0% 0.0% 53.5% 46.5% 0.0% 78.1% 0.0% 0.0% 0.0% 1.6% 79.7% 18.8% 1.6% 60.0% 0.0% 0.0% 0.0% 0.0% 60.0% 40.0% 0.0% 72.4% 0.0% 0.0% 0.0% 0.0% 72.4% 27.6% 0.0% 75.8% 0.0% 0.0% 0.0% 0.0% 75.8% 24.2% 0.0% 60.0% 0.0% 0.0% 0.0% 0.0% 60.0% 40.0% 0.0% 63.2% 0.0% 0.0% 0.0% 0.0% 63.2% 36.8% 0.0% use of physiological pacing is notably high at St George's and Brompton hospitals. the rate of physiological pacing is low at Croydon, Kingston and St Anthony's hospitals. Note: Pacing Mode is based on the maximum mode of which the device is capable, 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 NICE guidelines (NICE Technology Appraisal 88, 2005) that use of ventricular pacing 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. dual chamber or atrial). The Western European average in 2005 was 92% atrial based pacing for SSS. In the UK the average was 81% in 2009, 84% in 2010 and 84% in Any percentage of ventricular based pacing greater than 10% has been shaded pink, and may be considered higher than desirable. A percentage greater than 20% is considered definitely too high and is shown in a shaded red box. Percentages greater than 50% are shown shaded black. Number of implants for Sick Sinus Syndrome % Atrial Based Pacing % Ventricular Based Pacing England 83.7% 16.3% This network 83.8% 16.2% St George's Hospital % 10.5% St Mary's Hospital Paddington % 4.8% Croydon University Hospital % 23.1% Kingston Hospital % 17.6% Physiological pacing rate for SSS is very high at St Mary's Hospital but lower than is desirable at Kingston and Croydon Hospitals. 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 Sick sinus syndrome 28% AF + HB/brady 22% Other 6% Complete heart block 21% Incomplete heart block 23% AF: atrial fibrillation HB: heart block Brady: bradycardia Complete HB Incomplete HB AF+ HB/brady Sick Sinus Syndrome Other National 21.3% 23.0% 22.2% 27.5% 5.9% This Network 22.0% 21.3% 27.4% 25.0% 4.3% St George's Hospital 24.7% 24.3% 20.5% 29.3% 1.3% Croydon University Hospital 16.3% 12.5% 46.2% 18.3% 6.7% Royal Brompton Hospital 25.0% 15.9% 29.5% 15.9% 13.6% St Mary's Hospital Paddington 16.7% 14.8% 27.8% 38.9% 1.9% Kingston Hospital 13.0% 34.8% 39.1% 10.9% 2.2% St Thomas' Hospital 17.9% 21.4% 21.4% 25.0% 14.3% Epsom Hospital 29.4% 35.3% 23.5% 11.8% 0.0% St Anthony's Hospital 17.6% 35.3% 17.6% 29.4% 0.0%

36 New Pacemaker Implant Rates corrected for Age and Sex Explanatory note: The "corrected rate (R), expressed as implants per million population, is calculated using the following formula: R A B. C x10 6 where A = number of new implants B = population C = relative need Population Need for Pacing New PM Implants Corrected New PM Implant Rate Deficit/ Excess compared to target rate of 700 ENGLAND 100% 526 This network 1,412,154 75% % 5A5 Kingston 160,436 82% % 5K9 Croydon 364,815 77% % 5LG Wandsworth 307,710 55% % 5M6 Richmond and Twickenham 187,527 86% % 5M7 Sutton and Merton 391,666 82% %

37 New ICD Implant Rates corrected for Age and Sex Population Need for ICD New ICD Implants Corrected New ICD Implant Rate Deficit/ Excess compared to target rate of 100 ENGLAND 100% 77 This network 1,412,154 81% % 5A5 Kingston 160,436 84% % 5K9 Croydon 364,815 83% % 5LG Wandsworth 307,710 67% % 5M6 Richmond and Twickenham 187,527 89% % 5M7 Sutton and Merton 391,666 85% % Note: values between 95% and 105% are not considered significantly different from the target 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 to commission to bring the implant rate up to the national recommended target rate for new pacemaker implants (700). If the value shown is zero, then the PCT is already commissioning enough devices to reach the target rate. Population Deficit/ Excess compared to target rate of 700 New Pacemaker Implant Deficit (number of devices) 5A5 Kingston 160,436-18% 20 5K9 Croydon 364,815-30% 78 5LG Wandsworth 307,710-11% 24 5M6 Richmond and Twickenham 187,527-17% 22 5M7 Sutton and Merton 391,666-14% 39 0 Kingston Croydon Wandsworth Richmond and Twickenham Sutton and Merton implant deficit

40 Conclusions The Network population is young so there is a relatively low need for pacing, particularly in Wandsworth where the need is only 75% of the national average. Across the whole network the need for pacing and ICDs is 19% less than the national average. Growth in both the PM and ICD implant rates bring them, respectively, above the national average and in line with the national target. A moderate fall in CRT rate still retains the Network at the national target rate for this device class. Croydon PCT appears to be an outlier for low implant rates within the Network. Data quality and completeness fields for administrative and basic clinical details are generally satifactory with some deficits, especially at London Bridge Hospital. However, for complex device fields there are major data deficits for all hospitals serving the Network, except Royal Brompton and St. George's Hospitals. Correction of these deficits will enhance the value of future audits. The use of physiological pacing modes is generally higher than the national average across the Network, although there is considerable variation between implanting centres. However, for sick sinus syndrome, higher than desirable rates of ventricular pacing are seen at three hospitals, notably Croydon and Kingston Hospitals - this is not compliant with NICE guidance. By contrast, commendably high rates of physiological pacing for this diagnosis are reported at St. Mary's Hospital, Paddington