East Midlands Cardiac and Stroke Network

Transcription

1 David Cunningham Director, Central Cardiac Audit Database Richard Charles Chairman, Network Device Survey Group Morag Cunningham CRM Database Coordinator, Central Cardiac Audit Database Adél de Lange Data analyst, Central Cardiac Audit Database

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 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 CCAD 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 Network Devices Survey Group. The report may be downloaded from British Cardiovascular Society 2

3 Contents Analysis of Provision of Heart Rhythm Devices for Acknowledgments... 2 Data Quality Statement... 4 Overview of Device Implants in the UK... 6 The Range of New Implant rate PCTs/LHBs in the Network...11 Network Age and Sex Distribution...12 Correcting Implant Rates for Age and Sex...15 Relative need for Pacemakers and ICDs...17 New and Total PM and ICD Implants...18 Geographical location of pacemaker implants...22 New and Total PM and ICD Implants...23 CRT implants in this network...25 Geographical location of Complex Devices implants...28 Which hospitals serve which PCTs/LHBs?...30 Pacing Mode for New Implants...35 Pacing Mode for Sick Sinus Syndrome...37 ECG Indication for New Implants...39 Corrected and Actual New Implant Rates...40 New Implant rate maps for...45 New pacing implant rate ICD new implant rate Pacing Implant Deficit in Conclusions

4 Data Quality Statement The quality of the analyses in this report is only as good as the quality of the data that supports it. 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 the analysis by the Survey Group. 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. Below is a list of important hospitals for this network and their completeness of VALID postcodes during the study period. Valid Postcodes Overall network average % Main implant Centres BRT.Burton Hospital % CHN.Nottingham City Hospital 99.79% DER.Derby Royal Infirmary % GGH.Grimsby District General Hospital % GRL.Glenfield Hospital % KGH.Kettering General Hospital % KMH.Kings Mill Hospital % LIN.Lincoln County Hospital % NTH.Northampton General Hospital % PAP.Papworth Hospital 99.82% PIL.Pilgrim Hospital Boston % RAD.John Radcliffe Hospital 99.87% SCU.Scunthorpe General Hospital % WAL.University Hospital Coventry % Note: Implant centres shown have implanted at least 10 devices in the network. 4

5 Data Quality and Completeness Listed below are important fields and their completion rates with valid entries. All Devices ICD, CRT-D & CRT-P Network / Implant Centre Valid Post Code Valid NHS No Valid Sex Valid Age ECG Symptom Aetiology Target 98.0% 98.0% 98.0% 98.0% 90.0% 90.0% 90.0% England 99.4% 84.2% 99.9% 99.8% 94.6% 94.2% 94.6% This Network 100.0% 97.3% 99.9% 99.9% 96.2% 96.0% 93.0% Nottingham City Hospital 99.8% 98.5% 99.6% 99.4% 89.9% 90.3% 80.1% Royal Derby Hospital 100.0% 99.4% 100.0% 100.0% 100.0% 100.0% - Glenfield Hospital 100.0% 99.9% 100.0% 100.0% 99.7% 99.9% 96.3% Kettering General Hospital 100.0% 99.6% 99.6% 100.0% 99.2% 99.2% 100.0% Kings Mill Hospital 100.0% 83.5% 100.0% 100.0% 98.1% 92.5% - Lincoln County Hospital 100.0% 99.5% 100.0% 100.0% 84.3% 84.3% - Northampton General Hospital 100.0% 94.9% 100.0% 100.0% 96.7% 97.1% 100.0% Network / Implant Centre NYHA Dyspnoea Status CRT-D & ICD LV Function ICD Indication CRT-D & CRT-P QRS duration Overall index of valid data completeness Target 90.0% 90.0% 90.0% 90.0% 90.0% England 64.9% 75.5% 58.7% 28.6% 84.9% This Network 72.0% 72.2% 59.7% 70.8% 87.7% Nottingham City Hospital 23.2% 16.2% 33.1% 16.7% 70.8% Royal Derby Hospital % Glenfield Hospital 100.0% 100.0% 100.0% 78.5% 98.9% Kettering General Hospital 100.0% 100.0% 100.0% 96.1% 99.4% Kings Mill Hospital % Lincoln County Hospital % Northampton General Hospital 73.3% 80.0% 76.7% 53.3% 90.6% Target Achieved Below 50% of target ( - ) = No Implants Notes: 1. Implant centres shown have contributed at least 5% of Pacemaker implant activity in the network. 2. Completeness is shown for all registered procedures for a centre, not just procedures in this network. 3. Overall index is an average for each centre of each field as a ratio of the target, and can exceed 100%. 5

6 Overview of Device Implants in the UK New pacemakers Comments: The ten year average growth rate is 4.1% Implant rates decreased slightly in England and in Wales. The new PM implant rates decreased significantly in Northern Ireland. There is a substantial shortfall in data submission from Scotland, data has been suppressed post New pacing rate remains highest in England (528 new implants per million population in 2010). per million population England Wales Scotland N Ireland year New ICD implants Comments: The ten year average growth rate is 14.9% ICD implant rate remains highest in N Ireland. (There is a substantial shortfall in data submission from Scotland). ICD implant rate increased significantly in England and in Wales in per million population England Wales Scotland N Ireland year 6

7 New CRT implants Comments New CRT rate increased significantly in England and remained the highest rate. The new CRT rate also increased in N Ireland, Wales and Scotland in (There is a substantial shortfall in data submission from Scotland). per million population England Wales Scotland N Ireland year Total CRT implants Comments The total CRT rate rose significantly in England for the last three years. Total CRT implants Rate was highest in England (114 new implants per million population in 2010). The total CRT rate also increased in N Ireland, Wales and Scotland in (There is a substantial shortfall in data submission from Scotland). per million population England Wales Scotland N Ireland year 7

8 The Range of New Implant rate 2010 grey line represents national average Pacemaker New Implant rate 2010 adjusted for age and sex Dorset Cardiac Network Bedfordshire and Hertfordshire Heart and Stroke Network Sussex Heart Network North West London Cardiac and Stroke Network South West London Cardiac Network Surrey Heart & Stroke Network North & East Yorkshire and Northern Lincolnshire Cardiac Network Kent Cardiovascular Network North Central London Cardiac & Stroke Network North East London Cardiac and Stroke Network Cardiac and Stroke Networks in Cumbria and Lancashire West Yorkshire Cardiac Network South East London Cardiac & Stroke Network Greater Manchester & Cheshire Cardiac Network North of England Cardiovascular Network South Central Cardiovascular Network Essex Cardiac and Stroke Network North Trent Network of Cardiac Care Anglia Stroke and Heart Network Birmingham, Sandwell and Solihull Cardiac and Stroke Network Black Country Cardiovascular Network Cheshire & Merseyside Cardiac Network Peninsula Heart and Stroke Network Avon, Gloucestershire, Wiltshire & Somerset Cardiac and Stroke Network Shropshire & Staffordshire Cardiac Network Herefordshire and Worcestershire Cardiac Network Coventry & Warwickshire Cardiovascular Network

9 The Range of New Implant rate 2010 grey line represents national average ICD New Implant rate 2010 adjusted for age and sex North East London Cardiac and Stroke Network Dorset Cardiac Network North Central London Cardiac & Stroke Network Kent Cardiovascular Network Bedfordshire and Hertfordshire Heart and Stroke Network South East London Cardiac & Stroke Network North West London Cardiac and Stroke Network South Central Cardiovascular Network Sussex Heart Network North of England Cardiovascular Network Avon, Gloucestershire, Wiltshire & Somerset Cardiac and Stroke Network West Yorkshire Cardiac Network Black Country Cardiovascular Network Surrey Heart & Stroke Network Birmingham, Sandwell and Solihull Cardiac and Stroke Network South West London Cardiac Network North Trent Network of Cardiac Care Cheshire & Merseyside Cardiac Network Greater Manchester & Cheshire Cardiac Network Coventry & Warwickshire Cardiovascular Network Essex Cardiac and Stroke Network Peninsula Heart and Stroke Network Shropshire & Staffordshire Cardiac Network North & East Yorkshire and Northern Lincolnshire Cardiac Network Anglia Stroke and Heart Network Cardiac and Stroke Networks in Cumbria and Lancashire Herefordshire and Worcestershire Cardiac Network

10 The Range of Total Implant rate 2010 grey line represents national average All CRT Total Implant rate 2010 adjusted for age and sex includes CRTD and CRTP Birmingham, Sandwell and Solihull Cardiac and Stroke Network North West London Cardiac and Stroke Network South East London Cardiac & Stroke Network South West London Cardiac Network West Yorkshire Cardiac Network Greater Manchester & Cheshire Cardiac Network Cheshire & Merseyside Cardiac Network Dorset Cardiac Network North Central London Cardiac & Stroke Network Bedfordshire and Hertfordshire Heart and Stroke Network Kent Cardiovascular Network Black Country Cardiovascular Network Surrey Heart & Stroke Network North & East Yorkshire and Northern Lincolnshire Cardiac Network Cardiac and Stroke Networks in Cumbria and Lancashire Sussex Heart Network North East London Cardiac and Stroke Network Peninsula Heart and Stroke Network Anglia Stroke and Heart Network South Central Cardiovascular Network Coventry & Warwickshire Cardiovascular Network Avon, Gloucestershire, Wiltshire & Somerset Cardiac and Stroke Network Herefordshire and Worcestershire Cardiac Network Shropshire & Staffordshire Cardiac Network Essex Cardiac and Stroke Network North of England Cardiovascular Network North Trent Network of Cardiac Care

11 PCTs/LHBs in the Network Total population 3.84 million. Code PCT/LHB Population Old PCT (where relevant*) 5EM Nottingham City 286,378 5N6 Derbyshire County 117,800 5ED.Amber Valley 5N6 Derbyshire County 110,100 5ER.Erewash 5N6 Derbyshire County 112,300 5H7.Derbyshire Dales and South Derbyshire 5N7 Derby City 236,298 5N8 Nottinghamshire County 657,656 5N9 Lincolnshire 688,624 5PA Leicestershire County and Rutland 673,412 5PC Leicester City 289,655 5PD Northamptonshire 669,102 * The revision of PCT boundaries in 2006 has resulted in some PCTs being "split" across Cardiac Network boundaries. In these cases only the relevant portion of the new PCT will be included in this report, as defined by the old PCT boundaries. 11

12 Network Age and Sex Distribution Population data from ONS, based on mid-2006 population estimates Data for England Average age: 39.5 (for comparison): % aged 70+: 11.60% Population PCT / LHB Age Male Female Age Male Female 5EM Population: 286, : 8,511 7, : 7,814 7,796 Average age: : 7,148 6, : 6,647 6,462 % aged 70+: 9.3% 11-15: 7,768 7, : 6,709 6,186 * Younger than national average 5N6 [5ED] 16-20: 11,873 11, : 5,021 5, : 22,409 21, : 4,271 4, : 14,127 12, : 3,956 4, : 10,666 9, : 3,201 4, : 10,509 9, : 2,358 3, : 10,129 8, : 1,433 3,150 Population: 118, : 3,200 3, : 4,000 4,000 Average age: : 3,600 3, : 4,200 4,100 % aged 70+: 12.3% 11-15: 4,000 3, : 4,400 4,400 5N6 [5ER] Nottingham City Derbyshire County [Amber Valley] 16-20: 3,500 3, : 3,400 3, : 2,800 2, : 2,600 2, : 3,000 3, : 2,300 2, : 4,300 4, : 1,800 2, : 4,600 4, : 1,200 2, : 4,400 4, : 600 1,800 Derbyshire County [Erewash] Population: 110, : 3,100 2, : 3,500 3,500 Average age: : 3,500 3, : 3,600 3,500 % aged 70+: 11.6% 11-15: 3,900 3, : 3,900 3, : 3,400 3, : 2,800 2, : 2,800 2, : 2,400 2, : 2,900 3, : 2,000 2, : 4,200 4, : 1,500 2, : 4,500 4, : 1,000 1, : 4,100 4, : 600 1,500 12

13 Population PCT / LHB Age Male Female Age Male Female 5N6 [5H7] Population: 112, : 3,300 3, : 4,000 3,900 Average age: : 3,700 3, : 3,900 3,900 % aged 70+: 10.9% 11-15: 4,000 3, : 4,100 4,000 5N : 3,600 3, : 2,900 2, : 2,600 2, : 2,500 2, : 2,900 3, : 2,100 2, : 4,100 4, : 1,500 2, : 4,800 4, : 1,000 1, : 4,300 4, : 600 1,300 Population: 236, : 7,501 6, : 7,531 7,322 Average age: : 7,335 6, : 6,550 6,375 % aged 70+: 11.7% 11-15: 7,656 7, : 6,659 6,654 5N : 8,147 7, : 5,893 5, : 9,834 9, : 4,803 4, : 7,840 8, : 4,134 4, : 8,376 8, : 3,407 4, : 9,053 9, : 2,262 3, : 8,605 8, : 1,626 3,276 Population: 657, : 17,711 16, : 23,177 23,596 Average age: : 18,751 17, : 20,503 21,158 % aged 70+: 12.2% 11-15: 21,103 19, : 23,160 22,841 5N : 21,727 20, : 19,302 19, : 19,546 18, : 15,136 16, : 18,517 18, : 12,598 14, : 19,534 20, : 9,868 12, : 24,967 25, : 6,731 10, : 26,143 26, : 4,122 9,625 Population: 688, : 17,005 16, : 23,041 24,302 Average age: : 19,284 18, : 21,753 22,265 % aged 70+: 13.9% 11-15: 22,014 20, : 24,822 26,337 * Older than national average Derbyshire County [Derbyshire Dales and South Derbyshire] Derby City Nottinghamshire County Lincolnshire 16-20: 23,286 21, : 22,882 23, : 19,543 18, : 18,878 19, : 16,243 15, : 15,753 16, : 18,059 18, : 12,610 14, : 23,422 24, : 8,313 11, : 25,450 26, : 5,233 11,171 13

14 Population PCT / LHB Age Male Female Age Male Female 5PA Population: 673, : 18,369 17, : 24,006 23,676 Average age: : 19,582 18, : 21,808 21,897 % aged 70+: 11.7% 11-15: 21,604 20, : 23,978 24,222 5PC 16-20: 24,806 22, : 19,652 20, : 24,102 19, : 15,501 15, : 17,346 16, : 12,648 14, : 19,082 20, : 10,070 12, : 25,061 26, : 6,571 9, : 26,524 26, : 4,277 8,998 Population: 289, : 10,898 10, : 9,111 9,045 Average age: : 8,915 8, : 8,040 7,961 % aged 70+: 9.1% 11-15: 9,069 8, : 7,284 6,983 * Younger than national average 5PD 16-20: 10,758 10, : 5,253 5, : 14,597 16, : 4,584 5, : 11,954 11, : 3,927 4, : 10,592 10, : 3,123 4, : 11,006 10, : 2,238 3, : 9,796 9, : 1,547 3,246 Population: 669, : 20,888 20, : 23,594 23,581 Average age: : 20,822 19, : 20,933 21,060 % aged 70+: 10.2% 11-15: 22,340 20, : 22,792 23,097 * Younger than national average Leicestershire County and Rutland Leicester City Northamptonshire 16-20: 23,356 21, : 18,217 18, : 19,855 19, : 13,675 13, : 19,988 19, : 10,777 11, : 22,658 22, : 8,341 10, : 27,172 27, : 5,674 8, : 27,056 26, : 3,837 8,265 Note: A PCT is considered to be older than average the percentage for aged 70+ is greater than or equal to 13.1% and it is considered to be younger than average if the percentage for aged 70+ is less than or equal to 10.3%. 14

15 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 (right) 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%. 15

16 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 2006 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%. 16

17 Relative need for Pacemakers and ICDs Indicative new implant rate Pacemakers: 528 ICD: 72 (average for England 2010) Average age: A PCT with a relatively OLD population will need relatively MORE pacemaker and ICD implants compared to a PCT with a young population, because the incidence of indications for pacing and ICD is higher in older people. Average age Expected pacing new implant rate Compared to national average Expected ICD new implant rate Compared to national average 5EM Nottingham City % 54 75% 5N6 Derbyshire County [5ED] % % 5N6 Derbyshire County [5ER] % % 5N6 Derbyshire County [5H7] % % 5N7 Derby City % 68 94% 5N8 Nottinghamshire County % % 5N9 Lincolnshire % % Leicestershire County and 5PA Rutland % % 5PC Leicester City % 56 78% 5PD Northamptonshire % 71 99% Cardiac Network - Relative Need for New Implant Rate East Midlands Cardiac and Stroke Network % % England (for comparison) England % % Note: "Expected" pacing and ICD rates are relative to national average rate, but are corrected depending on the age and sex distribution of the local population (see Page 12). For Pacemakers, the expected implant rate will be higher if the percentage of older people in the PCT is higher. For ICDs, the same general rule applies, but the pattern is slightly different, because ICD implant rates peak at age 70 and then decrease rapidly. These relative rates will be used to correct the observed rates and produce a truer reflection of local implant rates vs. local need. 17

18 New and Total PM and ICD Implants Pacemakers The following hospitals implanted pacemakers in patients from this cardiac network in A new pacemaker centre will implant nearly 100% new implants, and the longer a centre has been implanting, the higher the percentage of replacements implants. The national average for replacement implants is 21.79% of the total workload. This should always be borne in mind when forecasting future workload Replacement implants Centre 18 New Implants Total Implants % of total GRL Glenfield Hospital % CHN Nottingham City Hospital % NTH Northampton General Hospital % LIN Lincoln County Hospital % KMH Kings Mill Hospital % DER Derby Royal Infirmary % KGH Kettering General Hospital % PAP Papworth Hospital % GGH Grimsby District General Hospital % BRT Burton Hospital % RAD John Radcliffe Hospital % PIL Pilgrim Hospital Boston % WAL University Hospital Coventry % SCU Scunthorpe General Hospital NUN George Eliot Hospital % CHH Castle Hill Hospital % NGS Northern General Hospital 5 5 CHE Chesterfield Royal 4 4 DID Doncaster Royal Infirmary 3 3 GEO St George's Hospital % NHB Royal Brompton Hospital 3 3 MKH Milton Keynes General Hospital % BCH Birmingham Childrens Hospital % BOU Royal Bournemouth General Hospital 2 2 UCL University College Hospital 2 2 LGI Yorkshire Heart Centre 2 2 LBP Spire Leicester Hospital %

19 SGH Wessex Cardiothoracic Centre 2 2 GOS The Hospital for Sick Children 1 1 CHG Cheltenham General Hospital 1 1 GWY Gwynedd Hospital 1 1 HH Harefield Hospital 1 1 SIC South Infirmary Hospital 1 STM St Marys Hospital 1 1 HBP Hull and East Riding BUPA Hospital 1 1 HSC Harley Street Clinic 1 1 WAR Warwick Hospital 1 WAT Watford General Hospital 1 1 WYT Wythenshawe Hospital

20 Pacemaker implant trends 600 Pacemaker New Implant Rate adjusted for age and sex of network population per million population East Midlands Cardiac and Stroke Network England year 800 Pacemaker All Implant Rate adjusted for age and sex of network population per million population East Midlands Cardiac and Stroke Network England year 20

21 Pacemaker new implant rate in context Is the PCT new implant rate too high or too low, compared to the national target of 700? The funnel plot below shows the national target (grey line) and the upper (green) and lower (red) control limits. PCTs are shown in light blue circles, and this network's PCTs are shown as larger blue circles. If a PCT's rate is above the green line, it may be excessively high. If it is below the red line, it may be too low PCT New Implant Rate National Target Upper Control Limit Low er Control Limit PCT in This Netw ork significantly above national target PCT pacemaker new implant rate consistent with national target 200 significantly below national target , , , ,000 1,000,000 1,200,000 1,400,000 PCT population Funnel plots are a way of displaying performance against a national average or target. Here, the national target of 700 is shown as a horizontal grey line. The small blue dots represent the new implant rate (yaxis) in each PCT in the country plotted against that PCTs population (x-axis). The individual PCTs in THIS NETWORK are plotted as larger blue circles. The CONTROL LIMITS determine whether a PCT's new implant rate is significantly greater than (green line) or less than (red line) the national target. The statistical significance level was chosen to ensure that the total risk of one or more PCTs being outside the control limits by random chance is no more than 5%. 21

22 Geographical location of pacemaker implants 22

23 New and Total PM and ICD Implants Implantable Cardioverter Defibrillators (ICDs) The following hospitals implanted ICDs in patients from this cardiac network in Replacement implants Centre New Implants Total Implants % of total GRL Glenfield Hospital % CHN Nottingham City Hospital % KGH Kettering General Hospital NTH Northampton General Hospital RAD John Radcliffe Hospital % PAP Papworth Hospital % UCL University College Hospital 2 HH Harefield Hospital % GEO St George's Hospital % WAL University Hospital Coventry 1 1 LGI Yorkshire Heart Centre 1 1 NGS Northern General Hospital 1 1 NHB Royal Brompton Hospital 1 FRE Freeman Hospital 1 1 BAS Essex Cardiothoracic Centre 1 1 LBH London Bridge Hospital 1 1 CHH Castle Hill Hospital

24 ICD implant trends 80 ICD New Implant Rate adjusted for age and sex of network population per million population England year 120 ICD All Implant Rate adjusted for age and sex of network population 100 per million population England year 24

25 CRT implants in this network Heart failure is a major and growing public health problem in all Western countries, and is associated with high morbidity and mortality despite optimal medical therapy. Clinical trials of high scientific quality published in recent years have consistently found that cardiac resynchronisation therapy (CRT) improves symptoms, quality of life, exercise tolerance and survival in appropriately chosen patients with advanced heart failure and evidence of left ventricular dyssynchrony who are refractory to optimal medical therapy. CRT involves simultaneous pacing of the left and right ventricles (CRT-P), and may be combined, in the same device, with a defibrillation function (CRT-D). Although CRT involves pacing the heart, it should not be confused with 'classical' pacing for bradycardia - the vast majority of CRT recipients do not require pacing for bradycardia. The function of pacing is to make the ventricles beat at the same time ('resynchronisation'). Within this report, data for CRT-P and CRT-D are quantified separately from pacing and ICD data respectively. In the UK, CRT is provided predominantly by tertiary centres with a special interest in cardiac device therapy. Despite the high prevalence of heart failure, uptake of CRT in the UK is amongst the lowest in Western Europe. NICE published guidelines on the cost effectiveness of CRT in 2007, and it is expected that clinical demand for CRT therapy will continue to rise significantly in coming years. CRT implanting hospitals in this network CRT-D CRT-P 2008 Glenfield Hospital Northampton General Hospital University Hospital Queens Medical Centre 13 5 John Radcliffe Hospital 13 5 Papworth Hospital 3 4 Nottingham City Hospital 5 2 Castle Hill Hospital 1 5 Royal Derby Hospital 4 Queen Elizabeth Hospital 2 1 Hull Royal Infirmary 2 1 Spire Leicester Hospital 2 Yorkshire Heart Centre 1 1 Pilgrim Hospital Boston 1 1 Wexham Park Hospital 1 Harefield Hospital 1 Milton Keynes General Hospital 1 Royal Brompton Hospital 1 Harley Street Clinic 1 University College Hospital 1 Northern General Hospital 1 CRT-D CRT-P 2009 Glenfield Hospital

26 2009 Nottingham City Hospital Papworth Hospital 6 11 Northampton General Hospital 7 9 Kettering General Hospital 5 5 John Radcliffe Hospital 4 Castle Hill Hospital 2 University Hospital Coventry 1 Harefield Hospital 1 Kings Mill Hospital 1 St Thomas Hospital 1 University College Hospital 1 University Hospital of Wales 1 CRT-D CRT-P 2010 Glenfield Hospital Kettering General Hospital Nottingham City Hospital Northampton General Hospital Papworth Hospital 7 13 John Radcliffe Hospital 6 Castle Hill Hospital 3 1 University College Hospital 2 Yorkshire Heart Centre 1 1 Northern General Hospital 1 1 Royal Brompton Hospital 1 1 Kings Mill Hospital 1 1 Queen Elizabeth Hospital 1 1 University Hospital Coventry 1 St George's Hospital 1 St Marys Hospital 1 Wellington Hospital North 1 26

27 CRT implant trends CRT New Implant Rate adjusted for age and sex of network population East Midlands Cardiac and Stroke Network England per million population year CRT All Implant Rate adjusted for age and sex of network population East Midlands Cardiac and Stroke Network England per million population year Note: Low voltage CRT devices ( CRT-P) pace both the left and right ventricles. High voltage CRT devices (CRT-D) combine this function with a defibrillation capability. 27

28 Geographical location of Complex Devices implants 28

29 The European Picture European data for 2010 shows that the UK has average CRT implant rates compared to the Western Europe implant rates, and far below the rate in the U.S.A.. Greece Spain Ireland Portugal Finland Norway Switzerland Sweden France Austria UK Belgium Denmark Netherlands Czech Republic Germany Italy Total CRT-P & CRT-D Implants

30 Which hospitals serve which PCTs/LHBs? all implants for this cardiac network in 2010 Pacemakers 5EM.Nottingham City Total Implants 2010 CHN Nottingham City Hospital 84 GRL Glenfield Hospital 3 DER Royal Derby Hospital 2 SGH Wessex Cardiothoracic Centre 1 KMH Kings Mill Hospital 1 5N6.Derbyshire County [5ED] Total Implants 2010 DER Royal Derby Hospital 24 KMH Kings Mill Hospital 12 CHN Nottingham City Hospital 2 CHE Chesterfield Royal 2 GRL Glenfield Hospital 2 NHB Royal Brompton Hospital 1 DID Doncaster Royal Infirmary 1 NGS Northern General Hospital 1 5N6.Derbyshire County [5ER] Total Implants 2010 DER Royal Derby Hospital 22 CHN Nottingham City Hospital 17 GRL Glenfield Hospital 3 5N6.Derbyshire County [5H7] Total Implants 2010 BRT Burton Hospital 31 DER Royal Derby Hospital 26 GRL Glenfield Hospital 7 CHN Nottingham City Hospital 1 CHE Chesterfield Royal 1 5N7.Derby City Total Implants 2010 DER Royal Derby Hospital 78 GRL Glenfield Hospital 7 CHN Nottingham City Hospital 2 BCH Birmingham Childrens Hospital 1 5N8.Nottinghamshire County Total Implants 2010 CHN Nottingham City Hospital 179 KMH Kings Mill Hospital 176 GRL Glenfield Hospital 7 LIN Lincoln County Hospital 4 DER Royal Derby Hospital 3 PAP Papworth Hospital 2 30

31 NGS Northern General Hospital 2 DID Doncaster Royal Infirmary 2 WAT Watford General Hospital 1 LGI Yorkshire Heart Centre 1 LBP Spire Leicester Hospital 1 CHH Castle Hill Hospital 1 5N9.Lincolnshire Total Implants 2010 LIN Lincoln County Hospital 186 GRL Glenfield Hospital 85 PAP Papworth Hospital 63 GGH Grimsby District General Hospital 48 PIL Pilgrim Hospital Boston 23 SCU Scunthorpe General Hospital 11 CHN Nottingham City Hospital 10 UCL University College Hospital 2 NGS Northern General Hospital 2 CHH Castle Hill Hospital 2 KMH Kings Mill Hospital 2 LGI Yorkshire Heart Centre 1 HSC Harley Street Clinic 1 NHB Royal Brompton Hospital 1 GEO St George's Hospital 1 RAD John Radcliffe Hospital 1 HBP Hull And East Riding Bupa Hospital 1 HH Harefield Hospital 1 WAL University Hospital Coventry 1 5PA.Leicestershire County and Rutland Total Implants 2010 GRL Glenfield Hospital 399 BRT Burton Hospital 12 WAL University Hospital Coventry 10 PAP Papworth Hospital 9 CHN Nottingham City Hospital 7 NUN George Eliot Hospital 7 KGH Kettering General Hospital 5 BCH Birmingham Childrens Hospital 1 LIN Lincoln County Hospital 1 NHB Royal Brompton Hospital 1 GWY Gwynedd Hospital 1 DER Royal Derby Hospital 1 5PC.Leicester City Total Implants 2010 GRL Glenfield Hospital 194 5PD.Northamptonshire Total Implants 2010 NTH Northampton General Hospital 222 KGH Kettering General Hospital 149 RAD John Radcliffe Hospital 33 PAP Papworth Hospital 16 31

32 GRL Glenfield Hospital 6 WAL University Hospital Coventry 3 MKH Milton Keynes General Hospital 3 CHH Castle Hill Hospital 2 GEO St George's Hospital 2 BOU Royal Bournemouth General Hospital 2 CHG Cheltenham General Hospital 1 LBP Spire Leicester Hospital 1 SGH Wessex Cardiothoracic Centre 1 SIC South Infirmary Hospital 1 STM St Marys Hospital 1 GOS The Hospital For Sick Children 1 WAR Warwick Hospital 1 Implantable Cardioverter Defibrillators (ICDs) 5EM.Nottingham City Total Implants 2010 CHN Nottingham City Hospital 25 UCL University College Hospital 1 GRL Glenfield Hospital 1 5N6.Derbyshire County [5ED] Total Implants 2010 CHN Nottingham City Hospital 4 GRL Glenfield Hospital 3 NGS Northern General Hospital 1 5N6.Derbyshire County [5ER] Total Implants 2010 GRL Glenfield Hospital 4 CHN Nottingham City Hospital 3 5N6.Derbyshire County [5H7] Total Implants 2010 GRL Glenfield Hospital 10 5N7.Derby City Total Implants 2010 GRL Glenfield Hospital 13 CHN Nottingham City Hospital 7 5N8.Nottinghamshire County Total Implants 2010 CHN Nottingham City Hospital 64 GRL Glenfield Hospital 8 PAP Papworth Hospital 1 LBH London Bridge Hospital 1 5N9.Lincolnshire Total Implants 2010 GRL Glenfield Hospital 35 PAP Papworth Hospital 8 CHN Nottingham City Hospital 5 UCL University College Hospital 1 CHH Castle Hill Hospital 1 32

33 LGI Yorkshire Heart Centre 1 GEO St George's Hospital 1 RAD John Radcliffe Hospital 1 5PA.Leicestershire County and Rutland Total Implants 2010 GRL Glenfield Hospital 60 CHN Nottingham City Hospital 2 WAL University Hospital Coventry 1 FRE Freeman Hospital 1 BAS Essex Cardiothoracic Centre 1 HH Harefield Hospital 1 PAP Papworth Hospital 1 5PC.Leicester City Total Implants 2010 GRL Glenfield Hospital 21 5PD.Northamptonshire Total Implants 2010 KGH Kettering General Hospital 28 NTH Northampton General Hospital 16 RAD John Radcliffe Hospital 13 GRL Glenfield Hospital 6 PAP Papworth Hospital 2 HH Harefield Hospital 1 GEO St George's Hospital 1 NHB Royal Brompton Hospital 1 Cardiac Resynchronisation Therapy (CRT) 5EM.Nottingham City Total Implants 2010 CHN Nottingham City Hospital 15 5N6.Derbyshire County [5ED] Total Implants 2010 CHN Nottingham City Hospital 2 GRL Glenfield Hospital 1 5N6.Derbyshire County [5ER] Total Implants 2010 CHN Nottingham City Hospital 2 NHB Royal Brompton Hospital 1 GRL Glenfield Hospital 1 5N6.Derbyshire County [5H7] Total Implants 2010 GRL Glenfield Hospital 3 QEB Queen Elizabeth Hospital 1 5N7.Derby City Total Implants 2010 GRL Glenfield Hospital 2 5N8.Nottinghamshire County Total Implants 2010 CHN Nottingham City Hospital 20 33

34 KMH Kings Mill Hospital 2 QEB Queen Elizabeth Hospital 1 HHW Wellington Hospital North 1 GRL Glenfield Hospital 1 NGS Northern General Hospital 1 5N9.Lincolnshire Total Implants 2010 GRL Glenfield Hospital 20 PAP Papworth Hospital 16 CHH Castle Hill Hospital 4 LGI Yorkshire Heart Centre 2 UCL University College Hospital 1 NGS Northern General Hospital 1 GEO St George's Hospital 1 5PA.Leicestershire County and Rutland Total Implants 2010 GRL Glenfield Hospital 59 PAP Papworth Hospital 2 WAL University Hospital Coventry 1 5PC.Leicester City Total Implants 2010 GRL Glenfield Hospital 25 5PD.Northamptonshire Total Implants 2010 KGH Kettering General Hospital 49 NTH Northampton General Hospital 30 RAD John Radcliffe Hospital 6 PAP Papworth Hospital 2 UCL University College Hospital 1 GRL Glenfield Hospital 1 NHB Royal Brompton Hospital 1 STM St Marys Hospital 1 34

35 Pacing Mode for New Implants for this cardiac network Pacemakers Mode % for this network England % Atrial based modes DDDR 50.90% 61.54% DDD 2.47% 4.53% AAIR 0.90% 0.52% AAI 0.00% 0.05% DDI 0.00% 0.06% DDIR 0.00% 0.02% Other 0.17% 0.15% Ventricular based modes VVIR 44.88% 31.28% VVI 0.67% 1.57% VDDR 0.00% 0.04% VDD 0.00% 0.25% Note: The Mode table percentage calculations do not include any records where the mode was blank or unknown. Network England Ventricular based 45% Blank/ Unknown 1% Atrial based 54% Ventricular based 33% Blank/ Unknown 1% Atrial based 66% Note: The Network and England charts percentage segments are calculated based on the records in the Mode table but also include all records where the mode was blank or unknown. 35

36 Pacing Mode for New Implants major implanting hospitals in this cardiac network VVI VVIR AAI AAIR DDD DDDR VDD VDDR Atrial Based Pacing NATIONAL 1.6% 31.4% 0.0% 0.5% 4.5% 61.7% 0.3% 0.0% 66.8% This Network 0.7% 45.0% 0.0% 0.9% 2.5% 51.0% 0.0% 0.0% 54.4% CHN.Nottingham City Hospital 0.0% 39.5% 0.0% 0.0% 0.4% 60.1% 0.0% 0.0% 60.5% DER.Derby Royal Infirmary 2.8% 71.0% 0.0% 0.0% 7.5% 18.7% 0.0% 0.0% 26.2% GRL.Glenfield Hospital 0.0% 47.4% 0.0% 0.7% 0.2% 51.7% 0.0% 0.0% 52.6% KGH.Kettering General Hospital 0.0% 43.7% 0.0% 3.2% 0.8% 52.4% 0.0% 0.0% 56.3% KMH.Kings Mill Hospital 6.7% 41.8% 0.0% 3.7% 6.0% 41.8% 0.0% 0.0% 51.5% LIN.Lincoln County Hospital 0.0% 42.3% 0.0% 0.6% 2.6% 54.5% 0.0% 0.0% 57.7% NTH.Northampton General Hospital 0.0% 39.9% 0.0% 0.6% 7.5% 52.0% 0.0% 0.0% 60.1% Note: Implant centres shown have contributed at least 5% of Pacemaker implant activity in the network. Note: The Mode table for major implanting hospitals percentage calculations do not include any records where the mode was blank or unknown. NB: As from 2007, mode is based on the maximum mode of which the device is capable and not the mode at the end of the procedure. 36

37 Pacing Mode for Sick Sinus Syndrome 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 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. NB: the % of atrial based pacing shown for a centre applies only to patients residing in THIS NETWORK and may differ overall. New Implants for Sick Sinus Syndrome in this network Atrial-based New Implants for SSS in this network Ventricular-based New Implants for SSS in this network CHN.Nottingham City Hospital % 27.9% DER.Royal Derby Hospital % 37.5% GRL.Glenfield Hospital % 7.6% KGH.Kettering General Hospital % 14.3% KMH.Kings Mill Hospital % 32.4% LIN.Lincoln County Hospital % 18.8% NTH.Northampton General Hospital % 17.5% PAP.Papworth Hospital % 13.6% Note: Any hospital in the network not in this list did not code at least 10 implants as SSS. Note: For this analysis only ECG codes E1-E5 are used NB: As from 2007, mode is based on the maximum mode of which the device is capable and not the mode at the end of the procedure. References 1. TA88 Bradycardia - dual chamber pacemakers: Information for the public. NICE 23 February

38 The European Picture Atrial based pacing in the UK is low compared to most of Europe. Spain Turkey Netherlands UK Norway LATVIA Belgium FR Yugoslavia France Austria Sweden Denmark % Atrial-based pacing for Sick Sinus Syndrome 2003 (most recent survey) 60% 65% 70% 75% 80% 85% 90% 95% NB: As from 2007, mode is based on the maximum mode of which the device is capable and not the mode at the end of the procedure. 38

39 ECG Indication for New Implants Complete HB Incomplete HB AF + HB/brady Sick sinus syndrome Other NATIONAL 22.7% 22.8% 23.5% 27.5% 6.2% This Network 22.9% 21.9% 23.1% 28.0% 4.1% 5EM.Nottingham City 23.4% 21.9% 21.9% 25.0% 7.8% 5N6.Derbyshire County [5ED] 22.9% 34.3% 25.7% 14.3% 2.9% 5N6.Derbyshire County [5ER] 33.3% 16.7% 26.7% 23.3% 0.0% 5N6.Derbyshire County [5H7] 37.5% 25.0% 14.6% 22.9% 0.0% 5N7.Derby City 47.4% 22.8% 14.0% 15.8% 0.0% 5N8.Nottinghamshire County 24.5% 21.1% 24.9% 21.5% 8.0% 5N9.Lincolnshire 22.7% 26.7% 19.8% 24.1% 6.7% 5PA.Leicestershire County and Rutland 19.9% 19.6% 20.4% 37.9% 2.2% 5PC.Leicester City 25.2% 13.2% 27.8% 32.5% 1.3% 5PD.Northamptonshire 17.4% 21.8% 28.2% 29.4% 3.2% AF: atrial fibrillation HB: heart block Brady: bradycardia 39

40 Corrected and Actual New Implant Rates Pacemakers Expected and Actual New Implant Rates Explanatory note: The "Raw" new implant rate is the actual implant rate of new pacemakers per million population in each PCT. The "corrected" rate is the raw rate, adjusted for relative need so if a PCT has an aging population, its relative need is > 100% and its corrected rate will be reduced to reflect that need. Comparisons between PCTs and with network and national averages should be made using corrected rate. England Average 528 Network average (unadjusted) 467 Network average (corrected for age and sex) 458 Population Relative need for PM New Implant Rate 2010 Raw Corrected 5EM Nottingham City 286, % N6 Derbyshire County [5ED] 117, % N6 Derbyshire County [5ER] 110, % N6 Derbyshire County [5H7] 112, % N7 Derby City 236, % N8 Nottinghamshire County 657, % N9 Lincolnshire 688, % PA Leicestershire County and Rutland 673, % PC Leicester City 289, % PD Northamptonshire 669, %

41 How much does the implant rate vary in this network? Of course there will always be some random variation in implant rate. This NORMAL CAUSE variation is not considered likely to exceed 5% of the total implant rate for pacing. Variation IN EXCESS of 10% may be considered due to another (SPECIAL) cause, such as referral patterns or varying implantation policies between trusts. Variability Index for this Cardiac Network 35.1% 1% RATING: high excess variation in implant rates between PCTs 41

42 New Pacemaker Implant Rates The Western European average new implant rate for 2003 and 2004 was 700 per million population. This figure is also now the HRUK target and will be used as the basis for comparison. England Average 528 Network average (unadjusted) 467 Network average (corrected for age and sex) 458 Population Corrected New Implant Rate 2010 Deficit/ Excess 2010 compared to rate of 700 5EM Nottingham City 286, % 5N6 Derbyshire County [5ED] 117, % 5N6 Derbyshire County [5ER] 110, % 5N6 Derbyshire County [5H7] 112, % 5N7 Derby City 236, % 5N8 Nottinghamshire County 657, % 5N9 Lincolnshire 688, % 5PA Leicestershire County and Rutland 673, % 5PC Leicester City 289, % 5PD Northamptonshire 669, % 42

43 Corrected and Actual New Implant Rates Implantable Cardioverter Defibrillators (ICDs) Explanatory note: The "Raw" new implant rate is the actual implant rate of new ICDs per million population in each PCT. The "Corrected" rate is the raw rate, adjusted for relative need - so if a PCT has an aging population, its relative need is > 100% and its corrected rate will be reduced to reflect that need. Comparisons between PCTs should be made using Corrected rate. England Average 72 Network average (unadjusted) 72 Network average (corrected for age and sex) 70 Population Relative need for ICD New Implant Rate 2010 Raw Corrected 5EM Nottingham City 286, % N6 Derbyshire County [5ED] 117, % N6 Derbyshire County [5ER] 110, % N6 Derbyshire County [5H7] 112, % N7 Derby City 236, % N8 Nottinghamshire County 657, % N9 Lincolnshire 688, % PA Leicestershire County and Rutland 673, % PC Leicester City 289, % PD Northamptonshire 669, %

44 New ICD Implant Rates A target figure of 100 implants per million is used as a basis for comparison, based on recent NICE guidance. England Average 72 Network average (unadjusted) 72 Network average (corrected for age and sex) 70 Population Corrected New Implant Rate 2010 Deficit/ Excess 2010 compared to rate of 100 5EM Nottingham City 286, % 5N6 Derbyshire County [5ED] 117, % 5N6 Derbyshire County [5ER] 110, % 5N6 Derbyshire County [5H7] 112, % 5N7 Derby City 236, % 5N8 Nottinghamshire County 657, % 5N9 Lincolnshire 688, % 5PA Leicestershire County and Rutland 673, % 5PC Leicester City 289, % 5PD Northamptonshire 669, % 44

45 New Implant rate maps for East Midlands Cardiac and Stroke Network 45

46 New pacing implant rate 2010 comparison with Heart Rhythm UK target (700) Pacemaker New Implants 2010 adjusted for age and sex compared to target figure of 700 per million Derby City Derbyshire County [5ER] Derbyshire County [5ED] Nottingham City Nottinghamshire County Lincolnshire Derbyshire County [5H7] Leicestershire County and Rutland Northamptonshire Leicester City -70% -60% -50% -40% -30% -20% -10% 0% 10% 46

47 ICD new implant rate 2010 ICD New Implants 2010 adjusted for age and sex compared to target figure of 100 per million Lincolnshire Derbyshire County [5ER] Derbyshire County [5H7] Derbyshire County [5ED] Nottinghamshire County Derby City Leicestershire County and Rutland Leicester City Northamptonshire Nottingham City -70% -60% -50% -40% -30% -20% -10% 0% 10% 20% 47

48 Pacing Implant Deficit in 2010 comparison with HRUK recommendations The graph shows the NUMBER of additional new pacemakers implants that each PCT needs to implant to bring them up to the HRUK target rate. Deficit in New Pacemaker Implants 2010 compared to Heart Rhythm UK target rate of Leicester City Derbyshire County [5H7] Derbyshire County [5ER] Derbyshire County [5ED] Nottingham City Northamptonshire Derby City Leicestershire County and Rutland Nottinghamshire County Lincolnshire

49 Conclusions The age structure of the Network is slightly older than the England average, resulting in a slightly higher need for pacemakers and ICDs than the rest of the country. (2% for pacemakers and 4% for ICDs) The Network Pacemaker implant rate is static. The rate continues to track below the national average and far below national target The Network ICD new implant rate decreased slightly and matches the national average. The Network total CRT implant rate increased and is well below the national average. The proportion of atrial based pacing (54%) is lower than the national average of 66%. The proportion of ventricular based implants is especially high at Derby Royal Infirmary (74%). Seven hospitals implanting for the Network have an excessively high utilization of ventricular based pacing for Sick Sinus Syndrome, contrary to NICE TAG 88 (2005). Data quality and completeness (p5) is commendably high, reaching or exceeding national targets, with the notable exception of Nottingham City Hospital in respect of ICD and CRT clinical data. The value of the audit will be enhanced if this deficit could be addressed in 2011 The catheter laboratory at Pilgrim Hospital Boston was shut for most of 2010 and most of their cases were being done at Lincoln. Only 23 unique pacemaker procedures are ascribed to Pilgrim which have not been registered elsewhere. 49