This House believes that coronary angioplasty should take place in a limited number of high volume centres: avoiding the American example.

Transcription

1 This House believes that coronary angioplasty should take place in a limited number of high volume centres: avoiding the American example.

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3 Volume vs outcome Primary PCI Surgical cover off site vs on site Equity of access Staffing What BCIS can do for you!

4 Institutional Volume vs Outcome 362,748 PCI s in in USA; ~ 80% stents Crude mortality (%) Low Medium High Very High > <0.001 Adjusted OR Low vs high: 1.21 ( ) Medium vs high: 1.02 ( ) Very high vs high: 0.94 ( ) Epstein et al. JACC 2004; 43: p

5 Institutional Volume vs Outcome in Primary PCI Low: n=112 ( 16 PPCI s/yr) Intermediate: n=223 (17-48 PPCI s/yr) High: n=111 ( 49 PPCI s/yr) In-hospital mortality for patients with AMI treated with thrombolysis vs PCI; interaction between reperfusion strategy and primary PCI volume was significant (p<.001). Magid et al: JAMA, 2000; 284:

6 Institutional PCI volume in the UK <200 <400 <600 <800 <1000 <1200 <1400 <1600 <1800 <2000 <2200 <2400 >2400

7 Operator Volume vs Outcome ~50% stents Adjusted Rates of 30-Day Mortality and CABG Following PCI Among 167,208 Medicare Beneficiaries During Adjusted for age, sex, race, AMI as primary diagnosis, comorbidity score, urgency of admission, and multivessel PCI. McGrath et al. JAMA, 2000; 284:

8 Operator Volume vs Outcome Beaumont Hospital ,293 PCI s 28 operators Annual operator volume <92, , >140 Career experience <8, 9-14, >14 End points: Mortality, MACE Stent rate ~ 80%

9 MI < 14 days: 7 Creat>1.5mg/dl: 4 MVD: 4 Age>65: 4 Relation of BRS to study outcomes. p < for death, MACE, MI after PCI, CVA, or CABG. p = 0.04 for MI after PCI. AJC 2004; 94:

10 Operator Volume vs Outcome BRS Mortality MACE Annual operator volume < % 2.52% % 2.93% > % 2.41% p value Career experience < % 2.79% % 2.54% > % 2.54% p value AJC 2004; 94:

11 Operator volume in the UK (NHS Centres) 2003 data from 54 of 56 centres No of Centres >250 No PCIs/Consultant

12 Higher mortality after PCI in hospitals without onsite surgery October 27, 2004 theheart.org 29% excess mortality among patients undergoing PCI at hospitals without onsite surgical backup.

13 Wennberg et al. JAMA 2004; 292:

14 Wennberg et al. JAMA 2004; 292:

15 Surgical cover in the UK On site Off site No of centres (% of total) No. of PCI (% of total) Procedures per centre (mean) Operator volume* (mean) (76%) (24%) (87%) (13%) * NHS Centres only

16 PCI volumes at centres with off 4 site surgical cover 3 No. of Centres >701 No. Procedures per Centre

17 GRACE ACS Registry hospitals in 14 countries n %PCI %CABG % 6/12 Lab (77%) No lab 6729 (23%) Jan 05

18 ISD Scotland Emergency admissions with Angina/MI No lab Dx only PCI No lab Dx only PCI

19 ISD Scotland Emergency admissions with Angina/MI %Cath %Revasc No lab Dx only PCI No lab Dx only PCI

20 NHS Lanarkshire - PCI. Age Standardised discharge rate/100k / / / / / / / / / /04p NHS Ayrshire & Arran - PCI. Age Standardised discharge rate/100k / / / / / / / / / /04p

21 ISD Scotland 2003 Revascularisation adjusted for IHD Mortality Ayrshire&Arran Lanarkshire PCI Male Female CABG Male Female Median delay (index admission) 10 days 2 days

22 BCIS Recommendations If potential new centres are likely to satisfy the recommendations... they should be encouraged to develop because the UK requires a considerable increase in PTCA activity. Heart 1996; 75:

23 Model PCI Network Population ~ 500, acute sites both with A&E/CCU one site acts as PCI centre Revascularisation target 2000/M/year PCI:CABG target 3:1 750 PCI s plus additional STEMI s 5 operators 150 each 1 in 4 with prospective cover 24/7 cover for STEMI Amsterdam model (partial shift) Fixed weeknight cover with next morning off

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25 PCI in the DGH YES But not every DGH can have on-site PCI Existing diagnostic sites with the potential to commence PCI should be identified Prioritise sites with operators already doing PCI off-site Critical mass of patients and staff essential

26 Coronary Angiography in DGH NO diagnostic only sites with no potential to develop PCI should be closed no ability to bail-out no ability to follow-on All patients should be investigated at the local PCI centre

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28 Potential Expansion of DGH-PCI in England Battle Hospital, Reading Mayday St Mary s Portsmouth Cheltenham/Glos RI Bath Northwich Park North Middlesex Royal Surrey Wirral Taunton Rochdale Shrewsbury North Hampshire Airedale St.Peters Norfolk&Norwich Northampton QEH, Gateshead West Cumberland Pinderfields Hastings Swindon Walsall Doncaster Torbay St. Albans Hereford York Dewsbury Huddersfield Bradford Bournemouth Wolverhampton

29 PCI Rates in the UK England Scotland N. Ireland Wales NB Assume 2.21 m population Rx in Wales

30 Wales

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33 Institutional Volume vs Outcome 44,276 PCI s in California in 1997 < > 400 p POBA (43%) Mortality 2.6% 1.9% 1.4% <0.001 EmCABG 2.4% 2.1% 1.2% <0.001 Stenting (57%) Mortality 1.6% 1.5% 1.1% 0.02 EmCABG 1.1% 1.2% 0.8% 0.01 AHJ 2003; 146: 932-4

34 Volume vs Outcome Patient Characteristics by Annual Physician and Hospital Medicare PCI Volume. McGrath: JAMA, 2000; 284:

35 Volume vs Outcome Adjusted Rates for the Combined End Point of CABG or 30-Day Mortality Following PCI by Physician and Hospital Annual Medicare PCI Volume. McGrath et al. JAMA, 2000; 284:

36 Operator Volume vs Outcome Operator experience vs (A) in-hospital death rate (R 2 =0.001, P=0.85) and (B) inhospital MACE (R 2 =0.004, p=0.75). Annual operator volume vs (A) in-hospital death rate (R 2 =0.001, P=0.89) and (B) inhospital MACE (R 2 =0.033, P=0.35).

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38 NHS Lanarkshire - Angiography. Age Standardised discharge rate/100k / / / / / / / / / /04p NHS Ayrshire & Arran - Angiography. Age Standardised discharge rate/100k / / / / / / / / / /04p

39 NHS Lanarkshire - Total Revascularisation Age Standardised discharge rate/100k / / / / / / / / / /04p NHS Ayrshire & Arran - Total Revascularisation Age Standardised discharge rate/100k / / / / / / / / / /04p

40 NHS Lanarkshire - CABG. Age Standardised discharge rate/100k / / / / / / / / / /04p NHS Ayrshire & Arran - CABG. Age Standardised discharge rate/100k / / / / / / / / / /04p

41 Wennberg et al. JAMA 2004; 292:

42 Volume vs Outcome in Primary PCI Association Between Reperfusion Strategy and Risk of Death During Hospitalization for 3 Volume Groups, and the Effect of Adding Covariates. Magid et al. JAMA 2000; 284:

43 V/Q and Coronary Stenting CABG in hospital 30 day mortality Overall 1.87% 3.30% OPERATOR < 30/year 2.25%* 3.25% > 60/year 1.55% 3.39% CENTRE <80/year 1.83% 4.29%** >160/year 1.83% 3.15% OVERALL Stent 1.2% 2.83% No stent 2.78% 3.94%

44 If appropriately funded, would you be prepared to commence PCI in your hospital? YES NO % Dedicated (n=17) Hybrid (n=16) 34

45 Would you be concerned about having no on-site cardiac surgery? YES NO % Dedicated (n=17) Hybrid (n=16)

46 Would you anticipate selecting low to medium risk cases only? YES NO % Dedicated (n=17) Hybrid (n=16)

47 Would you perform PCI in AMI? YES NO % Dedicated (n=17) 57 Hybrid (n=16) 43

48 C-PORT - Trial design ST-elevation MI < 12 hours (n = 451) Randomization (1:1) in 11 hospitals with CCU and diagnostic cath labs without preexisting PCI program or on-site surgical back-up Fibrinolysis Accelerated tpa (max. 100 mg) 1 PCI Stent / IIbIIIa at Physician Discretion Primary Endpoint: Death, Reinfarction, or Stroke through 6 months

49 % of Patients C-PORT - Primary 6/12 Intention to Treat p = p = NS Accel. t-pa (n=226) Median Door to Needle Time=46 min Median Door to Balloon Time=102 min p = PCI (n=225) p = NS Combined* Death Reinfarction Disabling Stroke *Primary Endpoint: Death, Reinfarction, or Stroke JAMA 2002; 287:

50 Surgical Cover for Primary PCI Cover (n=592) No cover (n=468) Age Prior MI (%) Success (%) Death-low risk (%) < 1 < 1 Death -high risk (%) D 8.8 1yr 14.3 D 6.4 1yr 8.5 Weaver at al. Circulation 1995; I-138