Public Health Perspective of Ventricular Arrhythmia Treatment. Dr Debbie Chase, Public Health Specialist Trainee, SCPCT

Transcription

1 Public Health Perspective of Ventricular Arrhythmia Treatment Dr Debbie Chase, Public Health Specialist Trainee, SCPCT

2 Outline of presentation Epidemiology of ventricular arrhythmias and use of ICDs Four public health research studies Local public health input into ICD commissioning Time limited assessment of current and future need

3 Public Health PhD research questions 1. What is the current knowledge on the incidence and prognosis of diagnosed ventricular arrhythmias? 2. What are the current and future patterns of ICD use? 3. What is the incidence and prognosis of diagnosed symptomatic ventricular arrhythmias in a defined population? 4. What is the scope for preventing sudden cardiac death from ventricular arrhythmias?

4 What is the current knowledge on the incidence and prognosis of diagnosed ventricular arrhythmias? Systematic review Methods Medline ( ), Embase ( ), Citation Index (searched in 2002) Reference lists Two reviewers Quality assessment Comparison of incidence rates and survival probabilities

5 What is the current knowledge on the incidence and prognosis of diagnosed ventricular arrhythmias? Systematic review Results 3 U.S. incidence studies based on routine data Incidence higher in males and older age groups 32 prognostic studies Prognosis heavily dependent on left ventricular function Good methodological quality but

6 What are the current and future patterns of ICD use? Analysis of national ICD data and survey of ICD centres Methods Descriptive data analysis ( data) Assessment relating regional ICD data to two proxy measures of need Survey of current practice and perceptions on future trends

7 Age-sex standardised ICD ratio by deprivation quintiles Standardised ICD ratio Quintile 1 Quintile 2 Quintile 3 Quintile 4 Quintile 5 Deprivation quintiles Parkes J, Chase D, Grace A, Cunningham D, Roderick P. British Medical Journal 2005; 330:

8 What is the incidence and prognosis of diagnosed symptomatic ventricular arrhythmias in a defined population? Prospective population based cohort study Methods Newly diagnosed patients with VT or VF Case identification over 11 months ( ) Hot pursuit method 12 months follow up Population of SSWH and Winchester City Cross boundary flow

9 Results Annual incidence rates Number of cases in 11 months Incidence rate per million population 95% confidence intervals All ventricular arrhythmia cases , 252 Males , 356 Females , 197 Life threatening ventricular arrhythmias , 90

10 Results - Annual ventricular arrhythmia incidence rate by age group 2000 Incidence rate per million population year age bands Chase, D; Roderick, P; Milne, R; Morgan J, Heart. 92 (Supplement 2):A64, May 2006

11 What is the scope for preventing sudden cardiac death from ventricular arrhythmias? Case series of SCD Methods Consecutive post-mortem cases of SCD presumed to be primarily caused by a VA Identified over 12 months in defined population ( ) Data collected on pathology and previous health service history Expert judgement on appropriateness of cases for an ICD

12 Results in Patients < 85 years No previous cardiac disease Appropriate for an ICD No need for further investigation Should have had further tests Further information required Total 58 (40%) 1 (< 1%) 11 (8%) 72 (49%) 4 (3%) 146 Chase D; Roderick P; Burnley H; Gallagher P; Roberts P; Morgan J Europace 2008; 10: , June

13 Conclusions from PhD research Incidence of ventricular arrhythmias is dependent on: case definition, referral patterns and availability of diagnostic testing ICD use does not appear to equate with need A large proportion of SCD victims could not have been identified through health service contact Future work should focus on developing care pathways for patients presenting with symptoms suggestive of ventricular arrhythmias and indications for ICDs.

14 Commissioning ICDs assessing need Timely healthcare needs assessment of ICDs in SCPCT (November 2007) - Epidemiological data - Demand - Health service use

15 30 BAND X ACTUAL ACTIVITY AT SUHT FOR 2007/ % Activity % % 80.00% 60.00% 40.00% 20.00% % Variance % % % Actual Activity Baseline % Variance % % % % Month

16 Number of ICDs implanted SCPCT rate was 50.4 pmp in Surrounding PCTs had much lower rates (ranging from 12.7 to 32.9 pmp) SCPCT rate in 2007 of 83.9 pmp

17 Justification for increased use Additional NICE guidance indication, need expected to rise to 300 pmp Local tertiary service expansion Implementation of a local hospital based initiative to identify more cases Local Commissioners purchasing predictions did not take account of these changes