Cheshire & Merseyside Cardiac 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 Network Age and Sex Distribution Correcting Implant Rates for Age and Sex Relative need for Pacemakers and ICDs New and Total PM and ICD Implants Geographical location of pacemaker implants New and Total PM and ICD Implants CRT implants in this network Geographical location of Complex Devices implants Which hospitals serve which PCTs/LHBs? Pacing Mode for New Implants Pacing Mode for Sick Sinus Syndrome ECG Indication for New Implants Corrected and Actual New Implant Rates New Implant rate maps for 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 BHL.Liverpool Heart and Chest Hospital 99.92% COC.Countess of Chester Hospital % FAZ.University Hospital Aintree 99.12% RLU.Royal Liverpool University Hospital % WDG.Warrington District General Hospital % WHI.Whiston Hospital 99.15% WIR.Arrowe Park Hospital % WYT.Wythenshawe Hospital 99.76% 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 Gender Valid DOB ECG Symptom Aetiology Target 98.0% 98.0% 98.0% 98.0% 90.0% 90.0% 90.0% England 99.4% 84.0% 99.9% 99.8% 94.5% 94.0% 94.6% This Network 100.0% 75.0% 100.0% 99.8% 96.9% 97.0% 98.8% Liverpool Heart and Chest Hospital 99.9% 99.4% 100.0% 99.7% 98.3% 98.9% 98.9% Countess of Chester Hospital 100.0% 100.0% 100.0% 100.0% 97.2% 97.2% - University Hospital Aintree 99.1% 2.2% 100.0% 99.6% 95.6% 95.6% - Royal Liverpool University Hospital 100.0% 99.3% 100.0% 100.0% 97.1% 97.1% - Warrington District General Hospital 100.0% 91.2% 100.0% 100.0% 96.7% 96.7% 100.0% Arrowe Park Hospital 100.0% 9.0% 100.0% 99.6% 99.1% 97.3% - Whiston Hospital 99.2% 87.3% 100.0% 100.0% 93.2% 93.2% - 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 63.5% 74.5% 57.5% 27.9% 84.4% This Network 95.7% 97.0% 0.0% 93.8% 85.7% Liverpool Heart and Chest Hospital 98.4% 99.1% 96.3% 0.0% 96.6% Countess of Chester Hospital % University Hospital Aintree % Royal Liverpool University Hospital Warrington District General Hospital % 0.0% 0.0% 0.0% 0.0% 65.9% Arrowe Park Hospital % Whiston Hospital % 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 Peninsula Heart and Stroke Network East Midlands Cardiac 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 East Midlands 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 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 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 East Midlands Cardiac and Stroke Network North Trent Network of Cardiac Care

11 PCTs/LHBs in the Network Total population 1.9 million. Code PCT/LHB Population Old PCT (where relevant*) 5J2 Warrington 194,043 5J4 Knowsley 151,302 5NJ Sefton 277,421 5NK Wirral 311,210 5NL Liverpool 436,072 5NM Halton and St Helens 297,099 5NN Western Cheshire 235,197 * 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 5J2 Population: 194, : 5,754 5, : 7,134 6,884 Average age: : 5,955 5, : 6,223 6,053 % aged 70+: 10.4% 11-15: 6,487 6, : 6,371 6,505 5J : 6,513 6, : 5,222 5, : 5,764 5, : 4,385 4, : 5,283 5, : 3,353 3, : 6,293 6, : 2,455 3, : 7,640 7, : 1,558 2, : 8,265 8, : 992 2,353 Population: 151, : 4,656 4, : 5,241 5,999 Average age: : 4,860 4, : 4,407 4,757 % aged 70+: 10.8% 11-15: 5,230 5, : 4,192 4,575 5NJ 16-20: 5,810 5, : 3,188 3, : 5,420 5, : 3,246 3, : 3,949 4, : 2,690 3, : 4,199 4, : 2,111 2, : 5,559 6, : 1,052 1, : 5,503 6, : 572 1,436 Population: 277, : 6,941 6, : 9,811 10,651 Average age: : 7,798 7, : 8,874 9,507 % aged 70+: 14.3% 11-15: 9,375 9, : 9,174 9,546 * Older than national average Warrington Knowsley Sefton 16-20: 9,888 9, : 7,365 8, : 8,467 7, : 6,713 8, : 6,253 6, : 6,310 7, : 6,371 7, : 4,767 6, : 8,560 10, : 3,001 4, : 10,199 11, : 1,884 4,742 12

13 Population PCT / LHB Age Male Female Age Male Female 5NK Population: 311, : 9,029 8, : 10,414 11,583 Average age: : 9,218 8, : 9,618 10,579 % aged 70+: 13.6% 11-15: 10,524 9, : 10,942 11,102 * Older than national average 5NL 16-20: 11,030 10, : 8,772 9, : 9,385 8, : 7,153 8, : 6,996 7, : 6,219 7, : 7,939 8, : 4,960 7, : 10,013 11, : 3,246 5, : 10,577 12, : 2,180 5,468 Population: 436, : 12,247 11, : 14,242 15,732 Average age: : 11,756 11, : 12,249 13,259 % aged 70+: 10.7% 11-15: 12,973 12, : 12,388 12,938 5NM 16-20: 16,655 16, : 9,156 9, : 22,939 23, : 8,766 9, : 16,243 15, : 7,740 8, : 13,409 13, : 6,007 7, : 15,350 14, : 3,197 5, : 14,888 16, : 2,016 4,931 Population: 297, : 8,902 8, : 10,076 10,613 Average age: : 8,938 8, : 9,433 9,940 % aged 70+: 10.6% 11-15: 10,056 9, : 10,536 10,790 5NN Wirral Liverpool Halton and St Helens 16-20: 10,628 10, : 8,010 8, : 9,292 9, : 6,650 7, : 8,197 8, : 5,397 6, : 9,174 9, : 3,970 5, : 10,612 11, : 2,333 3, : 10,946 11, : 1,279 3,422 Western Cheshire Population: 235, : 6,091 5, : 8,199 8,338 Average age: : 6,776 6, : 7,442 7,706 % aged 70+: 12.9% 11-15: 7,479 6, : 8,211 8, : 7,799 7, : 6,932 7, : 7,080 7, : 5,790 6, : 6,033 5, : 4,747 5, : 6,879 7, : 3,795 4, : 8,217 8, : 2,354 3, : 9,068 9, : 1,664 3,545 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%. 13

14 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%. 14

15 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%. 15

16 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 5J2 Warrington % % 5J4 Knowsley % 69 95% 5NJ Sefton % % 5NK Wirral % % 5NL Liverpool % 66 91% 5NM Halton and St Helens % % 5NN Western Cheshire % % Cardiac Network - Relative Need for New Implant Rate % % 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. 16

17 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 New Implants Total Implants % of total BHL Liverpool Heart and Chest Hospital % WIR Arrowe Park Hospital % FAZ University Hospital Aintree % COC Countess of Chester Hospital % RLU Royal Liverpool University Hospital % WHI Whiston Hospital % WDG Warrington District General Hospital % WYT Wythenshawe Hospital % AHM The Alexandra Hospital % ACH Royal Liverpool Children's Hospital % MRI Manchester Royal Infirmary 3 3 FRE Freeman Hospital 2 WRX Maelor Hospital % AEI Royal Albert Edward Infirmary % LGH Leighton Hospital 1 1 STO University Hospital North Staffs 1 1 BCH Birmingham Childrens Hospital 1 1 RPH Royal Preston Hospital 1 1 HH Harefield Hospital 1 RAD John Radcliffe Hospital 1 1 YDH York District Hospital 1 1 BRD Bradford Royal Infirmary

18 Pacemaker implant trends 600 Pacemaker New Implant Rate adjusted for age and sex of network population per million population Cheshire & Merseyside Cardiac Network England year 800 Pacemaker All Implant Rate adjusted for age and sex of network population per million population Cheshire & Merseyside Cardiac Network England year 18

19 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 w ith 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%. 19

20 Geographical location of pacemaker implants 20

21 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 BHL Liverpool Heart and Chest Hospital % BHF British Heart Foundation 1 1 MRI Manchester Royal Infirmary 1 1 VIC Victoria Hospital

22 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 22

23 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 1999 Harefield Hospital 1 CRT-P CRT-D CRT-P 2000 Cardiothoracic Centre 3 12 The Alexandra Hospital 3 Wythenshawe Hospital 2 CRT-D CRT-P 2001 Cardiothoracic Centre Wythenshawe Hospital 2 Belfast City Hospital 2 South Infirmary Hospital 1 CRT-D CRT-P 2002 Cardiothoracic Centre 9 16 The Alexandra Hospital 2 2 CRT-D CRT-P 2003 Cardiothoracic Centre The Alexandra Hospital 1 2 Wythenshawe Hospital 1 2 Royal Victoria Hospital, Belfast 1 23

24 CRT-D CRT-P 2004 Cardiothoracic Centre Manchester Royal Infirmary 1 1 Wythenshawe Hospital 6 King's College Hospital 1 CRT-D CRT-P 2005 Cardiothoracic Centre The Alexandra Hospital 2 2 Wythenshawe Hospital 2 2 Manchester Royal Infirmary 2 1 CRT-D CRT-P 2006 Cardiothoracic Centre Wythenshawe Hospital 1 1 Belfast City Hospital 1 The Alexandra Hospital 1 Manchester Royal Infirmary 3 CRT-D CRT-P 2007 Cardiothoracic Centre Wythenshawe Hospital 2 2 Royal Liverpool University Hospital 2 1 The Alexandra Hospital 1 Yorkshire Heart Centre 1 Manchester Royal Infirmary 2 CRT-D CRT-P 2008 Liverpool Heart and Chest Hospital Wythenshawe Hospital 2 2 Manchester Royal Infirmary 2 The Alexandra Hospital 1 University Hospital North Staffs 1 Victoria Hospital 1 CRT-D CRT-P 2009 Liverpool Heart and Chest Hospital Wythenshawe Hospital 6 2 Manchester Royal Infirmary 2 2 Harefield Hospital 1 Royal Brompton Hospital 1 CRT-D CRT-P 2010 Liverpool Heart and Chest Hospital

25 2010 Wythenshawe Hospital 2 2 Manchester Royal Infirmary 1 John Radcliffe Hospital 1 St Thomas Hospital 1 Warrington District General Hospital 1 Royal Liverpool Children's Hospital 1 25

26 CRT implant trends CRT New Implant Rate adjusted for age and sex of network population Cheshire & Merseyside Cardiac Network England per million population year CRT All Implant Rate adjusted for age and sex of network population Cheshire & Merseyside Cardiac 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. 26

27 Geographical location of Complex Devices implants 27

28 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 Aus tria UK Belgium Denmark Netherlands Czech Republic Germany Italy Total CRT-P & CRT-D Implants

29 Which hospitals serve which PCTs/LHBs? all implants for this cardiac network in 2010 Pacemakers 5J2.Warrington Total Implants 2010 WDG Warrington District General Hospital 59 BHL Liverpool Heart And Chest Hospital 27 AHM The Alexandra Hospital 6 WYT Wythenshawe Hospital 4 WHI Whiston Hospital 1 RLU Royal Liverpool University Hospital 1 BRD Bradford Royal Infirmary 1 FAZ University Hospital Aintree 1 5J4.Knowsley Total Implants 2010 BHL Liverpool Heart And Chest Hospital 47 WHI Whiston Hospital 30 FAZ University Hospital Aintree 24 RLU Royal Liverpool University Hospital 6 ACH Royal Liverpool Children's Hospital 1 RAD John Radcliffe Hospital 1 WYT Wythenshawe Hospital 1 5NJ.Sefton Total Implants 2010 FAZ University Hospital Aintree 118 BHL Liverpool Heart And Chest Hospital 91 RLU Royal Liverpool University Hospital 5 RPH Royal Preston Hospital 1 AHM The Alexandra Hospital 1 5NK.Wirral Total Implants 2010 WIR Arrowe Park Hospital 206 BHL Liverpool Heart And Chest Hospital 33 RLU Royal Liverpool University Hospital 2 COC Countess Of Chester Hospital 1 5NL.Liverpool Total Implants 2010 RLU Royal Liverpool University Hospital 115 BHL Liverpool Heart And Chest Hospital 92 FAZ University Hospital Aintree 72 WHI Whiston Hospital 5 ACH Royal Liverpool Children's Hospital 3 MRI Manchester Royal Infirmary 1 5NM.Halton and St Helens Total Implants 2010 WHI Whiston Hospital 79 29

30 BHL Liverpool Heart And Chest Hospital 57 WDG Warrington District General Hospital 25 AEI Royal Albert Edward Infirmary 2 FRE Freeman Hospital 2 MRI Manchester Royal Infirmary 2 FAZ University Hospital Aintree 1 RLU Royal Liverpool University Hospital 1 ACH Royal Liverpool Children's Hospital 1 5NN.Western Cheshire Total Implants 2010 COC Countess Of Chester Hospital 134 BHL Liverpool Heart And Chest Hospital 40 WIR Arrowe Park Hospital 15 WYT Wythenshawe Hospital 3 RLU Royal Liverpool University Hospital 3 WRX Maelor Hospital 2 WDG Warrington District General Hospital 2 YDH York District Hospital 1 STO University Hospital North Staffs 1 HH Harefield Hospital 1 BCH Birmingham Childrens Hospital 1 LGH Leighton Hospital 1 AHM The Alexandra Hospital 1 Implantable Cardioverter Defibrillators (ICDs) 5J2.Warrington Total Implants 2010 BHL Liverpool Heart And Chest Hospital 13 5J4.Knowsley Total Implants 2010 BHL Liverpool Heart And Chest Hospital 20 VIC Victoria Hospital 1 5NJ.Sefton Total Implants 2010 BHL Liverpool Heart And Chest Hospital 19 5NK.Wirral Total Implants 2010 BHL Liverpool Heart And Chest Hospital 29 5NL.Liverpool Total Implants 2010 BHL Liverpool Heart And Chest Hospital 42 5NM.Halton and St Helens Total Implants 2010 BHL Liverpool Heart And Chest Hospital 24 BHF British Heart Foundation 1 MRI Manchester Royal Infirmary 1 5NN.Western Cheshire Total Implants 2010 BHL Liverpool Heart And Chest Hospital 22 30

31 Cardiac Resynchronisation Therapy (CRT) 5J2.Warrington Total Implants 2010 BHL Liverpool Heart And Chest Hospital 12 WYT Wythenshawe Hospital 1 WDG Warrington District General Hospital 1 5J4.Knowsley Total Implants 2010 BHL Liverpool Heart And Chest Hospital 28 RAD John Radcliffe Hospital 1 MRI Manchester Royal Infirmary 1 5NJ.Sefton Total Implants 2010 BHL Liverpool Heart And Chest Hospital 47 STH St Thomas Hospital 1 5NK.Wirral Total Implants 2010 BHL Liverpool Heart And Chest Hospital 61 5NL.Liverpool Total Implants 2010 BHL Liverpool Heart And Chest Hospital 97 ACH Royal Liverpool Children's Hospital 1 5NM.Halton and St Helens Total Implants 2010 BHL Liverpool Heart And Chest Hospital 40 WYT Wythenshawe Hospital 3 5NN.Western Cheshire Total Implants 2010 BHL Liverpool Heart And Chest Hospital 36 31

32 Pacing Mode for New Implants for this cardiac network Pacemakers Mode % for this network England % Atrial based modes DDDR 49.47% 61.53% DDD 16.65% 4.53% AAIR 0.35% 0.52% AAI 0.23% 0.05% DDI 0.12% 0.06% DDIR 0.00% 0.02% Other 0.12% 0.15% Ventricular based modes VVIR 26.85% 31.28% VVI 5.28% 1.57% VDDR 0.00% 0.04% VDD 0.94% 0.25% Note: The Mode table percentage calculations do not include any records where the mode was blank or unknown. Network England Blank/ Unknown 16% Ventricular based 28% Atrial based 56% 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. 32

33 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 5.3% 26.9% 0.2% 0.4% 16.7% 49.6% 0.9% 0.0% 66.9% BHL.Liverpool Heart and Chest Hospital 9.5% 24.6% 0.0% 0.5% 24.1% 41.2% 0.0% 0.0% 65.8% COC.Countess of Chester Hospital 0.0% 39.1% 0.0% 0.0% 0.0% 60.9% 0.0% 0.0% 60.9% FAZ.University Hospital Aintree 8.7% 22.1% 1.2% 1.2% 37.8% 24.4% 4.7% 0.0% 64.5% RLU.Royal Liverpool University Hospital WDG.Warrington District General Hospital 2.4% 17.1% 0.0% 0.0% 8.9% 71.5% 0.0% 0.0% 80.5% 1.3% 32.1% 0.0% 0.0% 7.7% 59.0% 0.0% 0.0% 66.7% WIR.Arrowe Park Hospital 0.0% 38.1% 0.0% 0.0% 28.6% 33.3% 0.0% 0.0% 61.9% 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. 33

34 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 BHL.Liverpool Heart and Chest Centre % 14.6% COC.Countess of Chester Hospital % 23.7% FAZ.University Hospital Aintree % 20.0% RLU.Royal Liverpool University Hospital % 7.7% WDG.Warrington District General Hospital % 9.1% WHI.Whiston Hospital % 31.3% 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

35 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. 35

36 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 18.4% 26.6% 23.2% 25.4% 6.4% 5J2.Warrington 24.7% 27.4% 15.1% 27.4% 5.5% 5J4.Knowsley 21.3% 26.2% 21.3% 24.6% 6.6% 5NJ.Sefton 14.7% 24.4% 31.4% 23.1% 6.4% 5NK.Wirral 15.6% 32.2% 23.1% 23.6% 5.5% 5NL.Liverpool 18.4% 24.9% 21.7% 25.8% 9.2% 5NM.Halton and St Helens 27.0% 25.2% 20.9% 20.9% 6.1% 5NN.Western Cheshire 14.9% 25.0% 23.6% 32.4% 4.1% AF: atrial fibrillation HB: heart block Brady: bradycardia 36

37 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) 508 Network average (corrected for age and sex) 501 Population Relative need for PM New Implant Rate 2010 Raw Corrected 5J2 Warrington 194, % J4 Knowsley 151, % NJ Sefton 277, % NK Wirral 311, % NL Liverpool 436, % NM Halton and St Helens 297, % NN Western Cheshire 235, %

38 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 15.8% 1% RATING: small excess variation in implant rates between PCTs 38

39 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) 508 Network average (corrected for age and sex) 501 Population Corrected New Implant Rate 2010 Deficit/ Excess 2010 compared to rate of 700 5J2 Warrington 194, % 5J4 Knowsley 151, % 5NJ Sefton 277, % 5NK Wirral 311, % 5NL Liverpool 436, % 5NM Halton and St Helens 297, % 5NN Western Cheshire 235, % 39

40 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) 66 Network average (corrected for age and sex) 64 Population Relative need for ICD New Implant Rate 2010 Raw Corrected 5J2 Warrington 194, % J4 Knowsley 151, % NJ Sefton 277, % NK Wirral 311, % NL Liverpool 436, % NM Halton and St Helens 297, % NN Western Cheshire 235, %

41 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) 66 Network average (corrected for age and sex) 64 Population Corrected New Implant Rate 2010 Deficit/ Excess 2010 compared to rate of 100 5J2 Warrington 194, % 5J4 Knowsley 151, % 5NJ Sefton 277, % 5NK Wirral 311, % 5NL Liverpool 436, % 5NM Halton and St Helens 297, % 5NN Western Cheshire 235, % 41

42 New Implant rate maps for Cheshire & Merseyside Cardiac Network 42

43 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 Warrington Halton and St Helens Knowsley Sefton Wirral Western Cheshire Liverpool -45% -40% -35% -30% -25% -20% -15% -10% -5% 0% 43

44 ICD new implant rate 2010 ICD New Implants 2010 adjusted for age and sex compared to target figure of 100 per million Warrington Sefton Wirral Western Cheshire Halton and St Helens Liverpool Knowsley -60% -50% -40% -30% -20% -10% 0% 10% 20% 44

45 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 Liverpool Western Cheshire Knowsley Wirral Warrington Halton and St Helens Sefton

46 Conclusions The population is slightly older than the average, overall the network requires 1% more pacemakers than the national average, and 3% more for ICDs. Both the network new pacemaker implant rate and the new ICD implant rate decreased, both track closely to the national average, and below the national target. The CRT implant rate is significantly above, and growing faster than, the national average. Six of the seven PCTs exceeded the national target. The proportion of atrial based pacing (56%) is lower than the national average of 66%. Two hospitals, namely Whiston Hospital (31%) and Countess of Chester Hospital (24%) have high rates of ventricular based pacemaker implants for sick sinus syndrome; this is not compliant with NICE TAG 88 (2005). Significant data quality issues (p5) exist variously at University Hospital Aintree, Arrowe Park, Liverpool Heart and Chest and Warrington Hospitals. Similarly, there is a significant proportion of 'unknown' pacemaker mode registrations (p32), principally from Arrowe Park Hospital. The value of the audit will be enhanced if these deficits can be addressed in