Wales North Cardiac Network

Transcription

1 Wales North Cardiac Network 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 This report was generated by the Network Device Survey Group and was commissioned by the Department of Health's Heart Services Team (Vascular Programme). If you wish further information please contact the Heart Services Team (Vascular Programme): 403 Wellington House Waterloo Road London SE1 8UG England Phone:

3 Contents Analysis of Provision of Heart Rhythm Devices for Wales North Cardiac Network Data Quality Statement... 4 Overview of Device Implants in the UK... 6 PCTs/LHBs in the Network... 8 Network Age and Sex Distribution... 9 Correcting Implant Rates for Age and Sex...11 Relative need for Pacemakers and ICDs...13 New and Total PM and ICD Implants...14 Geographical location of pacemaker implants...17 New and Total PM and ICD Implants...18 CRT implants in this network...20 Which hospitals serve which PCTs/LHBs?...25 Pacing Mode for New Implants...28 Pacing Mode for Sick Sinus Syndrome...30 ECG Indication for New Implants...32 Corrected and Actual New Implant Rates...33 New Implant rate maps for Wales North Cardiac Network...38 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. Permission to do so has been given by Heart Rhythm UK and by the Department of Health Vascular Team. 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 % CLW.Glan Clwyd District General Hospital 95.42% GWY.Gwynedd Hospital 96.11% MRI.Manchester Royal Infirmary % WRX.Maelor Hospital % 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% 72.7% 99.5% 99.5% 91.9% 90.8% 81.3% This Network 100.0% 88.8% 99.7% 100.0% 95.7% 96.0% 90.1% Liverpool Heart and Chest Hospital Glan Clwyd District General Hospital 100.0% 99.4% 100.0% 99.8% 99.7% 99.7% 99.0% 95.4% 76.5% 99.3% 99.3% 99.3% 99.3% - Gwynedd Hospital 96.1% 82.2% 100.0% 100.0% 87.2% 88.3% 35.7% Maelor Hospital 100.0% 99.0% 100.0% 100.0% 98.4% 98.4% 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 38.2% 46.8% 33.3% 12.6% 73.3% This Network 60.5% 67.5% 71.1% 1.4% 84.7% Liverpool Heart and Chest Hospital Glan Clwyd District General Hospital 85.5% 94.1% 97.2% 0.8% 95.2% % Gwynedd Hospital 0.0% 0.0% 0.0% 0.0% 56.4% Maelor Hospital 100.0% 0.0% 0.0% % 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 4.6% Implant rates rose in England, Wales and Northern Ireland. (There is a substantial shortfall in data submission from Scotland). New pacing rate remains highest in England (531 new implants per million population in 2009). 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 remained static in England and rose slightly 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 Wales. New CRT rate is the highest in England. The new CRT rate decreased significantly in N Ireland 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 and Wales. Total CRT implants Rate was highest in England (99 total implants per million population in 2009). per million population England Wales Scotland N Ireland year 7

8 PCTs/LHBs in the Network Wales North Cardiac Network Total population 0.67 million. Code PCT/LHB Population Old PCT (where relevant*) 6A2 Gwynedd 117,500 6A7 Conwy 110,900 6B1 Anglesey 68,400 6B4 Wrexham 129,700 6B5 Flintshire 149,400 6C1 Denbighshire 94,800 * 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. 8

9 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% Wales North Cardiac Network Population PCT / LHB Age Male Female Age Male Female 6A2 Population: 117, : 3,400 3, : 3,500 3,700 Average age: : 3,600 3, : 3,700 3,900 % aged 70+: 14.0% 11-15: 3,800 3, : 4,400 4,200 * Older than national average 6A : 3,700 3, : 3,400 3, : 3,800 4, : 3,000 3, : 3,000 2, : 2,500 3, : 3,500 3, : 1,900 2, : 3,700 3, : 1,300 2, : 3,700 3, : 700 2,000 Population: 110, : 2,700 2, : 3,300 3,500 Average age: : 3,200 3, : 3,500 3,700 % aged 70+: 17.0% 11-15: 3,700 3, : 3,900 4,100 * Older than national average 6B : 3,500 3, : 3,300 3, : 2,500 2, : 3,200 3, : 2,400 2, : 2,800 3, : 3,100 3, : 2,200 3, : 3,500 3, : 1,600 2, : 3,600 3, : 1,000 2,500 Population: 68, : 1,800 1, : 2,200 2,300 Average age: : 2,100 1, : 2,400 2,500 % aged 70+: 13.6% 11-15: 2,200 2, : 2,600 2,700 * Older than national average Gw ynedd Conwy Anglesey 16-20: 2,200 2, : 2,200 2, : 1,700 1, : 1,900 1, : 1,500 1, : 1,500 1, : 2,100 2, : 1,100 1, : 2,200 2, : 700 1, : 2,200 2, : 400 1,100 9

10 Population PCT / LHB Age Male Female Age Male Female 6B4 Population: 129, : 3,800 3, : 4,100 4,500 Average age: : 4,000 3, : 4,400 4,500 % aged 70+: 11.5% 11-15: 4,300 4, : 4,600 4,400 6B : 4,400 3, : 3,400 3, : 4,200 4, : 2,800 3, : 3,700 3, : 2,300 2, : 4,700 4, : 1,700 2, : 4,800 5, : 1,200 2, : 4,400 4, : 700 1,800 Population: 149, : 4,300 4, : 4,700 5,000 Average age: : 4,700 4, : 5,000 5,200 % aged 70+: 10.7% 11-15: 5,100 4, : 5,300 5,400 6C : 5,000 4, : 4,100 4, : 4,100 3, : 3,400 3, : 4,200 4, : 2,600 3, : 5,200 5, : 2,000 2, : 5,900 6, : 1,300 2, : 5,500 5, : 700 1,800 Population: 94, : 2,600 2, : 2,800 3,100 Average age: : 2,900 2, : 3,300 3,300 % aged 70+: 14.8% 11-15: 3,200 3, : 3,400 3,500 * Older than national average Wrexham Flintshire Denbighshire 16-20: 3,100 2, : 2,800 2, : 2,200 2, : 2,500 2, : 2,300 2, : 2,000 2, : 2,800 3, : 1,600 2, : 3,100 3, : 1,100 2, : 3,200 3, : 700 1,900 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%. 10

11 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 531, 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%. 11

12 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%. 12

13 Relative need for Pacemakers and ICDs Wales North Cardiac Network Indicative new implant rate Pacemakers: 531 ICD: 62 (average for England 2009) 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 6A2 Gwynedd % % 6A7 Conwy % % 6B1 Anglesey % % 6B4 Wrexham % % 6B5 Flintshire % % 6C1 Denbighshire % % Cardiac Network - Relative Need for New Implant Rate Wales North Cardiac 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. 13

14 New and Total PM and ICD Implants Wales North Cardiac Network 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 22.82% of the total workload. This should always be borne in mind when forecasting future workload Replacement implants Centre New Implants Total Implants % of total WRX Maelor Hospital % GWY Gwynedd Hospital % CLW Glan Clwyd District General Hospital % BHL Liverpool Heart and Chest Hospital % MRI Manchester Royal Infirmary % MOR Morriston Hospital % COC Countess of Chester Hospital 4 4 AHM The Alexandra Hospital % ACH Royal Liverpool Children's Hospital % RAD John Radcliffe Hospital 1 1 RSS Royal Shrewsbury Hospital 1 1 STO University Hospital North Staffs 1 1 VIC Victoria Hospital 1 1 WAR Warwick Hospital 1 14

15 Pacemaker implant trends 600 Pacemaker New Implant Rate adjusted for age and sex of network population per million population North Wales England year 800 Pacemaker All Implant Rate adjusted for age and sex of network population per million population North Wales England year 15

16 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 c 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%. 16

17 Geographical location of pacemaker implants Wales North Cardiac Network 17

18 New and Total PM and ICD Implants Wales North Cardiac Network 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 % MRI Manchester Royal Infirmary % GWY Gwynedd Hospital % UCL University College Hospital % ACH Royal Liverpool Children's Hospital % MCH Manchester Childrens Hospital 1 1 WRX Maelor Hospital 1 18

19 ICD implant trends 70 ICD New Implant Rate adjusted for age and sex of network population 60 per million population North Wales England year 80 ICD All Implant Rate adjusted for age and sex of network population per million population North Wales England year 19

20 CRT implants in this network Wales North Cardiac 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 1999 Gwynedd Hospital 1 Liverpool Heart and Chest Hospital Liverpool Heart and Chest Hospital 1 CRT-D CRT-P CRT-D CRT-P 2001 The Alexandra Hospital 3 Liverpool Heart and Chest Hospital 1 Gwynedd Hospital 1 Manchester Royal Infirmary 1 Wythenshawe Hospital 2 CRT-D CRT-P 2002 Liverpool Heart and Chest Hospital 5 4 Maelor Hospital 2 The Alexandra Hospital 2 Gwynedd Hospital 1 CRT-D CRT-P 2003 Liverpool Heart and Chest Hospital 8 9 The Alexandra Hospital 1 Gwynedd Hospital 1 20

21 2003 Manchester Royal Infirmary 1 Wythenshawe Hospital 1 CRT-D CRT-P 2004 Manchester Royal Infirmary 8 6 Liverpool Heart and Chest Hospital 7 6 Wythenshawe Hospital 5 The Alexandra Hospital 2 Wessex Cardiothoracic Centre 2 CRT-D CRT-P 2005 Liverpool Heart and Chest Hospital 8 14 Manchester Royal Infirmary 2 6 Wythenshawe Hospital 2 3 The Alexandra Hospital 2 Glan Clwyd District General Hospital 1 Gwynedd Hospital 1 CRT-D CRT-P 2006 Liverpool Heart and Chest Hospital Manchester Royal Infirmary 8 9 The Alexandra Hospital 1 9 Wythenshawe Hospital 2 1 Gwynedd Hospital 1 1 Glan Clwyd District General Hospital 1 CRT-D CRT-P 2007 Liverpool Heart and Chest Hospital Manchester Royal Infirmary 12 6 Wythenshawe Hospital 2 2 The Alexandra Hospital 1 Glan Clwyd District General Hospital 1 Gwynedd Hospital 3 CRT-D CRT-P 2008 Liverpool Heart and Chest Hospital Manchester Royal Infirmary 3 4 Wythenshawe Hospital 1 3 Gwynedd Hospital 2 Glan Clwyd District General Hospital 1 1 Maelor Hospital 1 CRT-D CRT-P 2009 Liverpool Heart and Chest Hospital Manchester Royal Infirmary

22 2009 Gwynedd Hospital 4 2 Wythenshawe Hospital 2 1 The Alexandra Hospital 1 2 Morriston Hospital 1 22

23 CRT implant trends CRT New Implant Rate adjusted for age and sex of network population North Wales 80 England per million population year 120 CRT All Implant Rate adjusted for age and sex of network population 100 North Wales 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. 23

24 The European Picture European data for 2009 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.. Finland Spain Norway Ireland Switzerland Belgium UK France Sweden Austria Denmark Netherlands Portugal Germany Italy Total CRT-P & CRT-D Implants

25 Which hospitals serve which PCTs/LHBs? all implants for this cardiac network in 2009 Wales North Cardiac Network Pacemakers 6A2.Gwynedd Total Implants 2009 GWY Gwynedd Hospital 64 WRX Maelor Hospital 12 BHL Liverpool Heart And Chest Hospital 7 MOR Morriston Hospital 5 MRI Manchester Royal Infirmary 4 CLW Glan Clwyd District General Hospital 3 COC Countess Of Chester Hospital 1 AHM The Alexandra Hospital 1 RAD John Radcliffe Hospital 1 RSS Royal Shrewsbury Hospital 1 WAR Warwick Hospital 1 6A7.Conwy Total Implants 2009 CLW Glan Clwyd District General Hospital 53 GWY Gwynedd Hospital 36 BHL Liverpool Heart And Chest Hospital 8 WRX Maelor Hospital 1 MRI Manchester Royal Infirmary 1 STO University Hospital North Staffs 1 6B1.Anglesey Total Implants 2009 GWY Gwynedd Hospital 59 MRI Manchester Royal Infirmary 4 AHM The Alexandra Hospital 2 BHL Liverpool Heart And Chest Hospital 2 ACH Royal Liverpool Children's Hospital 2 6B4.Wrexham Total Implants 2009 WRX Maelor Hospital 99 BHL Liverpool Heart And Chest Hospital 10 AHM The Alexandra Hospital 1 MOR Morriston Hospital 1 6B5.Flintshire Total Implants 2009 WRX Maelor Hospital 48 BHL Liverpool Heart And Chest Hospital 26 CLW Glan Clwyd District General Hospital 23 COC Countess Of Chester Hospital 2 ACH Royal Liverpool Children's Hospital 1 VIC Victoria Hospital 1 25

26 6C1.Denbighshire Total Implants 2009 CLW Glan Clwyd District General Hospital 64 WRX Maelor Hospital 10 BHL Liverpool Heart And Chest Hospital 7 COC Countess Of Chester Hospital 1 Implantable Cardioverter Defibrillators (ICDs) 6A2.Gwynedd Total Implants 2009 MRI Manchester Royal Infirmary 5 BHL Liverpool Heart And Chest Hospital 5 GWY Gwynedd Hospital 5 MCH Manchester Childrens Hospital 1 6A7.Conwy Total Implants 2009 BHL Liverpool Heart And Chest Hospital 6 MRI Manchester Royal Infirmary 2 ACH Royal Liverpool Children's Hospital 2 6B1.Anglesey Total Implants 2009 MRI Manchester Royal Infirmary 5 BHL Liverpool Heart And Chest Hospital 5 UCL University College Hospital 1 GWY Gwynedd Hospital 1 6B4.Wrexham Total Implants 2009 BHL Liverpool Heart And Chest Hospital 13 WRX Maelor Hospital 1 UCL University College Hospital 1 6B5.Flintshire Total Implants 2009 BHL Liverpool Heart And Chest Hospital 12 6C1.Denbighshire Total Implants 2009 BHL Liverpool Heart And Chest Hospital 5 GWY Gwynedd Hospital 1 Cardiac Resynchronisation Therapy (CRT) 6A2.Gwynedd Total Implants 2009 MRI Manchester Royal Infirmary 7 GWY Gwynedd Hospital 2 WYT Wythenshawe Hospital 1 MOR Morriston Hospital 1 BHL Liverpool Heart And Chest Hospital 1 26

27 6A7.Conwy Total Implants 2009 BHL Liverpool Heart And Chest Hospital 7 AHM The Alexandra Hospital 1 6B1.Anglesey Total Implants 2009 MRI Manchester Royal Infirmary 5 GWY Gwynedd Hospital 4 BHL Liverpool Heart And Chest Hospital 3 WYT Wythenshawe Hospital 2 AHM The Alexandra Hospital 1 6B4.Wrexham Total Implants 2009 BHL Liverpool Heart And Chest Hospital 10 6B5.Flintshire Total Implants 2009 BHL Liverpool Heart And Chest Hospital 20 AHM The Alexandra Hospital 1 6C1.Denbighshire Total Implants 2009 BHL Liverpool Heart And Chest Hospital 4 MRI Manchester Royal Infirmary 1 27

28 Pacing Mode for New Implants for this cardiac network Wales North Cardiac Network Pacemakers Mode % for this network England % Atrial based modes DDDR 46.13% 58.46% DDD 14.69% 5.90% AAIR 0.52% 0.50% AAI 0.00% 0.04% DDI 0.00% 0.02% DDIR 0.00% 0.03% Ventricular based modes VVIR 36.08% 32.02% VVI 2.58% 1.86% VDDR 0.00% 0.03% VDD 0.00% 0.29% Note: The Mode table percentage calculations do not include any records where the mode was blank or unknown. Network England Ventricular based 38% Blank/ Unknown 2.5% Atrial based 59% Ventricular based 34% Blank/ Unknown 1% Atrial based 65% 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. 28

29 Pacing Mode for New Implants major implanting hospitals in this cardiac network Wales North Cardiac Network VVI VVIR AAI AAIR DDD DDDR VDD VDDR Atrial Based Pacing NATIONAL 1.9% 32.3% 0.0% 0.5% 6.0% 59.0% 0.3% 0.0% 65.5% This Network 2.6% 36.1% 0.0% 0.5% 14.7% 46.1% 0.0% 0.0% 61.3% BHL.Liverpool Heart and Chest Hospital CLW.Glan Clwyd District General Hospital 4.2% 25.0% 0.0% 2.1% 12.5% 56.3% 0.0% 70.8% 4.9% 24.5% 0.0% 1.0% 26.5% 43.1% 0.0% 70.6% GWY.Gwynedd Hospital 0.0% 48.6% 0.0% 0.0% 10.3% 41.1% 0.0% 51.4% WRX.Maelor Hospital 0.9% 39.4% 0.0% 0.0% 11.9% 47.7% 0.0% 59.6% 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. 29

30 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 76% in 2008 and 81% 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 % 8.3% CLW.Glan Clwyd District General Hospital % 5.3% GWY.Gwynedd Hospital % 27.6% WRX.Maelor Hospital % 17.9% 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

31 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. 31

32 ECG Indication for New Implants Wales North Cardiac Network Complete HB Incomplete HB AF + HB/brady Sick sinus syndrome Other NATIONAL 22.1% 21.7% 23.4% 25.9% 6.8% This Network 18.3% 22.0% 24.3% 28.8% 6.5% 6A2.Gwynedd 18.6% 18.6% 12.9% 41.4% 8.6% 6A7.Conwy 24.6% 13.8% 24.6% 27.7% 9.2% 6B1.Anglesey 11.6% 32.6% 25.6% 18.6% 11.6% 6B4.Wrexham 14.1% 16.9% 39.4% 28.2% 1.4% 6B5.Flintshire 20.3% 27.0% 20.3% 28.4% 4.1% 6C1.Denbighshire 18.6% 27.1% 23.7% 23.7% 6.8% AF: atrial fibrillation HB: heart block Brady: bradycardia 32

33 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. Wales North Cardiac Network England Average 531 Network average (unadjusted) 439 Network average (corrected for age and sex) 370 Population Relative need for PM New Implant Rate 2009 Raw Corrected 6A2 Gwynedd 117, % A7 Conwy 110, % B1 Anglesey 68, % B4 Wrexham 129, % B5 Flintshire 149, % C1 Denbighshire 94, %

34 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 11.5% 1% RATING: small excess variation in implant rates between PCTs 34

35 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. Wales North Cardiac Network England Average 531 Network average (unadjusted) 439 Network average (corrected for age and sex) 370 Population Corrected New Implant Rate 2009 Deficit/ Excess 2009 compared to rate of 700 6A2 Gwynedd 117, % 6A7 Conwy 110, % 6B1 Anglesey 68, % 6B4 Wrexham 129, % 6B5 Flintshire 149, % 6C1 Denbighshire 94, % 35

36 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. Wales North Cardiac Network England Average 62 Network average (unadjusted) 49 Network average (corrected for age and sex) 44 Population Relative need for ICD New Implant Rate 2009 Raw Corrected 6A2 Gwynedd 117, % A7 Conwy 110, % B1 Anglesey 68, % B4 Wrexham 129, % B5 Flintshire 149, % C1 Denbighshire 94, %

37 New ICD Implant Rates A target figure of 100 implants per million is used as a basis for comparison, based on recent NICE guidance. Wales North Cardiac Network England Average 62 Network average (unadjusted) 49 Network average (corrected for age and sex) 44 Population Corrected New Implant Rate 2009 Deficit/ Excess 2009 compared to rate of 100 6A2 Gwynedd 117, % 6A7 Conwy 110, % 6B1 Anglesey 68, % 6B4 Wrexham 129, % 6B5 Flintshire 149, % 6C1 Denbighshire 94, % 37

38 New Implant rate maps for Wales North Cardiac Network 38

39 New pacing implant rate 2009 comparison with Heart Rhythm UK target (700) Wales North Cardiac Network Pacemaker New Implants 2009 adjusted for age and sex compared to target figure of 700 per million Conwy Denbighshire Flintshire Gwynedd Wrexham Anglesey -45% -40% -35% -30% -25% -20% -15% -10% -5% 0% 39

40 ICD new implant rate 2009 Wales North Cardiac Network ICD New Implants 2009 adjusted for age and sex compared to target figure of 100 per million Denbighshire Flintshire Conwy Wrexham Gwynedd Anglesey -80% -60% -40% -20% 0% 20% 40% 40

41 Pacing Implant Deficit in 2009 comparison with HRUK recommendations Wales North Cardiac Network 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 2009 compared to Heart Rhythm UK target rate of Anglesey Wrexham Gwynedd Flintshire Denbighshire Conwy

42 Conclusions Wales North Cardiac Network The age structure of the Network is considerably older than the England average, resulting in a 19% higher relative need for pacemakers and ICDs in this Network than the England average. The network pacemaker new implant rate is static and remained below the national average. The network ICD new implant rate decreased and is well below the national average. The CRT total implant rate is static and remained below the national average. The proportion of atrial based pacing (59%) is lower than the national average of 65%. Gwynedd Hospital (28%) has a higher rate of ventricular based pacemaker implants for sick sinus syndrome; this is not compliant with NICE TAG 88 (2005). 42