North of England Cardiovascular 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 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 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...16 Relative need for Pacemakers and ICDs...18 New and Total PM and ICD Implants...20 Geographical location of pacemaker implants...23 New and Total PM and ICD Implants...24 CRT implants in this network...26 Which hospitals serve which PCTs/LHBs?...30 Pacing Mode for New Implants...34 Pacing Mode for Sick Sinus Syndrome...36 ECG Indication for New Implants...38 Corrected and Actual New Implant Rates...39 New Implant rate maps for...44 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 98.91% Main implant Centres ASH.Wansbeck General Hospital % DAR.Darlington Memorial Hospital % DRY.Dryburn Hospital % FRE.Freeman Hospital 99.79% HGH.Hartlepool General % QEG.Queen Elizabeth Hospital 99.12% SCM.James Cook Hospital 99.84% STD.South Tyneside District Hospital 91.43% SUN.Sunderland District 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% 73.2% 99.5% 99.5% 85.6% 84.4% 69.6% This Network 100.0% 69.1% 99.8% 99.7% 88.8% 81.9% 47.4% Sunderland District Hospital 100.0% 97.1% 100.0% 100.0% 97.1% 92.9% - Wansbeck General Hospital 100.0% 79.5% 100.0% 100.0% 99.1% 99.5% 100.0% Darlington Memorial Hospital 100.0% 81.9% 100.0% 100.0% 94.9% 94.9% - Dryburn Hospital 100.0% 15.2% 100.0% 100.0% 98.8% 17.0% - Freeman Hospital 99.8% 71.1% 99.8% 99.9% 87.9% 87.1% 62.0% James Cook Hospital 99.8% 92.3% 99.5% 99.0% 70.2% 68.8% 10.3% Queen Elizabeth Hospital 99.1% 17.5% 100.0% 100.0% 100.0% 94.7% 75.0% 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 36.1% 46.7% 33.8% 11.9% 70.7% This Network 56.3% 62.1% 0.7% 64.3% 69.5% Sunderland District Hospital % Wansbeck General Hospital % 91.6% Darlington Memorial Hospital % Dryburn Hospital % Freeman Hospital 84.9% 91.9% 96.1% 0.0% 85.9% James Cook Hospital 0.0% 0.0% 0.0% 0.0% 51.3% Queen Elizabeth Hospital 0.0% 0.0% 0.0% 0.0% 56.6% 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 4.7% 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 (534 new implants per million population in 2009). per million population England Wales Scotland N Ireland year New ICD implants Comments: England Wales Scotland N Ireland The ten year average growth rate is 15.9% ICD implant rate remains highest in N Ireland. (There is a substantial shortfall in data submission from Scotland). per million population ICD implant rate remained static in England and rose slightly in Wales in 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 (101 total implants per million population in 2009). per million population England Wales Scotland N Ireland year 7

8 The Range of New Implant rate 2009 grey line represents national average Pacemaker New Implant rate 2009 adjusted for age and sex Dorset Cardiac Network Bedfordshire and Hertfordshire Heart and Stroke Network Kent Cardiovascular Network North West London Cardiac and Stroke Network Cheshire & Merseyside Cardiac Network North Central London Cardiac & Stroke Network South East London Cardiac & Stroke Network Black Country Cardiovascular Network Surrey Heart & Stroke Network South Central Cardiovascular Network North & East Yorkshire and Northern Lincolnshire Cardiac Network Cardiac and Stroke Networks in Cumbria and Lancashire Anglia Stroke and Heart Network Peninsula Heart and Stroke Network Avon, Gloucestershire, Wiltshire & Somerset Cardiac and Stroke Network Greater Manchester & Cheshire Cardiac Network West Yorkshire Cardiac Network North Trent Network of Cardiac Care East Midlands Cardiac and Stroke Network South West London Cardiac Network Sussex Heart Network North East London Cardiac and Stroke Network Essex Cardiac and Stroke Network Birmingham, Sandwell and Solihull Cardiac and Stroke Network Shropshire & Staffordshire Cardiac Network Coventry & Warwickshire Cardiovascular Network Herefordshire and Worcestershire Cardiac Network

9 The Range of New Implant rate 2009 grey line represents national average ICD New Implant rate 2009 adjusted for age and sex North East London Cardiac and Stroke Network Dorset Cardiac Network Black Country Cardiovascular Network North Central London Cardiac & Stroke Network Kent Cardiovascular Network Bedfordshire and Hertfordshire Heart and Stroke Network South East London Cardiac & Stroke Network Essex Cardiac and Stroke Network Avon, Gloucestershire, Wiltshire & Somerset Cardiac and Stroke Network East Midlands Cardiac and Stroke Network Cheshire & Merseyside Cardiac Network Sussex Heart Network North West London Cardiac and Stroke Network Surrey Heart & Stroke Network Coventry & Warwickshire Cardiovascular Network South Central Cardiovascular Network Greater Manchester & Cheshire Cardiac Network Peninsula Heart and Stroke Network South West London Cardiac Network North Trent Network of Cardiac Care Anglia Stroke and Heart Network West Yorkshire Cardiac Network Cardiac and Stroke Networks in Cumbria and Lancashire Shropshire & Staffordshire Cardiac Network Birmingham, Sandwell and Solihull Cardiac and Stroke Network Herefordshire and Worcestershire Cardiac Network North & East Yorkshire and Northern Lincolnshire Cardiac Network

10 The Range of Total Implant rate 2009 grey line represents national average All CRT Total Implant rate 2009 adjusted for age and sex includes CRTD and CRTP Dorset Cardiac Network Cheshire & Merseyside Cardiac Network South East London Cardiac & Stroke Network Greater Manchester & Cheshire Cardiac Network Cardiac and Stroke Networks in Cumbria and Lancashire North West London Cardiac and Stroke Network South West London Cardiac Network West Yorkshire Cardiac Network Birmingham, Sandwell and Solihull Cardiac and Stroke Network Kent Cardiovascular Network North Central London Cardiac & Stroke Network Bedfordshire and Hertfordshire Heart and Stroke Network Surrey Heart & Stroke Network Peninsula Heart and Stroke Network South Central Cardiovascular Network Sussex Heart Network Anglia Stroke and Heart Network Black Country Cardiovascular Network Avon, Gloucestershire, Wiltshire & Somerset Cardiac and Stroke Network North East London Cardiac and Stroke Network Shropshire & Staffordshire Cardiac Network Coventry & Warwickshire Cardiovascular Network North & East Yorkshire and Northern Lincolnshire Cardiac Network Essex Cardiac and Stroke Network East Midlands Cardiac and Stroke Network North Trent Network of Cardiac Care Herefordshire and Worcestershire Cardiac Network

11 PCTs/LHBs in the Network Total population 2.68 million. Code PCT/LHB Population Old PCT (where relevant*) 5D7 Newcastle 270,462 5D8 North Tyneside 195,045 5D9 Hartlepool 91,137 5E1 North Tees 189,141 5J9 Darlington 99,344 5KF Gateshead 190,461 5KG South Tyneside 151,020 5KL Sunderland 280,593 5KM Middlesbrough 138,434 5ND County Durham 500,711 5NV North Yorkshire and York 120,400 5KH.Hambleton and Richmondshire 5QR Redcar and Cleveland 139,494 TAC Northumberland Care Trust 309,866 * 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 5D7 Population: 270, : 7,382 6, : 8,592 9,206 Average age: : 7,008 6, : 7,631 7,737 % aged 70+: 11.4% 11-15: 7,805 7, : 7,567 7,363 5D : 10,067 9, : 5,764 5, : 16,584 16, : 4,844 5, : 11,193 9, : 4,632 5, : 7,761 8, : 3,682 5, : 8,850 8, : 2,343 4, : 9,503 9, : 1,724 3,744 Population: 195, : 5,441 5, : 6,975 7,135 Average age: : 5,358 5, : 6,486 6,684 % aged 70+: 12.9% 11-15: 5,808 5, : 6,585 6,741 5D9 New castle North Tyneside 16-20: 6,372 5, : 5,025 5, : 5,485 5, : 4,232 4, : 5,690 6, : 3,851 4, : 6,049 6, : 2,968 4, : 6,895 7, : 2,078 3, : 7,665 7, : 1,226 2,888 Hartlepool Population: 91, : 2,710 2, : 3,189 3,271 Average age: : 2,827 2, : 2,897 2,917 % aged 70+: 11.5% 11-15: 3,224 3, : 2,973 2, : 3,318 3, : 2,199 2, : 2,872 2, : 2,041 2, : 2,485 2, : 1,854 2, : 2,650 2, : 1,283 1, : 2,974 3, : 811 1, : 3,531 3, : 427 1,042 12

13 Population PCT / LHB Age Male Female Age Male Female 5E1 Population: 189, : 5,493 5, : 6,718 7,130 Average age: : 5,952 5, : 6,093 6,073 % aged 70+: 10.6% 11-15: 6,554 6, : 6,270 6,346 5J : 6,879 6, : 4,834 4, : 6,298 6, : 3,871 4, : 5,431 5, : 3,352 3, : 6,037 6, : 2,496 3, : 6,758 7, : 1,539 2, : 7,247 7, : 923 2,067 Population: 99, : 3,175 2, : 3,521 3,659 Average age: : 2,885 2, : 3,196 3,200 % aged 70+: 12.3% 11-15: 3,211 3, : 3,378 3,431 5KF 16-20: 3,299 3, : 2,704 2, : 2,814 2, : 2,212 2, : 2,599 2, : 1,878 2, : 2,900 3, : 1,438 1, : 3,515 3, : 1,012 1, : 3,839 3, : 571 1,535 Population: 190, : 5,045 5, : 6,687 7,057 Average age: : 5,456 5, : 5,835 5,816 % aged 70+: 12.6% 11-15: 5,782 5, : 6,289 6,318 5KG 16-20: 6,661 5, : 4,898 5, : 5,991 5, : 4,573 5, : 5,693 5, : 3,943 4, : 5,711 6, : 3,022 3, : 6,903 7, : 1,872 2, : 7,386 7, : 1,055 2,585 Population: 151, : 3,856 3, : 5,376 5,711 Average age: : 4,278 4, : 4,909 4,863 % aged 70+: 13.2% 11-15: 5,039 4, : 5,001 4,874 * Older than national average North Tees Darlington Gateshead South Tyneside 16-20: 5,428 5, : 3,630 3, : 4,975 4, : 3,518 3, : 4,364 4, : 3,053 3, : 4,426 4, : 2,403 3, : 5,105 5, : 1,531 2, : 5,636 6, : 990 2,169 13

14 Population PCT / LHB Age Male Female Age Male Female 5KL Population: 280, : 7,497 7, : 10,025 10,323 Average age: : 7,814 7, : 9,033 9,162 % aged 70+: 11.5% 11-15: 8,929 8, : 9,164 9,591 5KM 16-20: 9,884 9, : 6,966 7, : 10,192 9, : 6,408 6, : 9,067 8, : 5,394 6, : 8,182 8, : 4,169 5, : 10,038 10, : 2,315 4, : 10,275 11, : 1,299 3,109 Population: 138, : 4,393 4, : 4,790 5,006 Average age: : 4,173 4, : 4,078 4,343 % aged 70+: 10.9% 11-15: 4,629 4, : 4,098 4,089 5ND 16-20: 5,453 5, : 3,040 3, : 6,164 5, : 2,677 3, : 4,560 4, : 2,399 2, : 4,096 4, : 1,992 2, : 4,450 4, : 1,137 1, : 5,004 5, : 710 1,677 Population: 500, : 13,233 12, : 17,433 17,984 Average age: : 13,630 13, : 16,547 16,439 % aged 70+: 12.1% 11-15: 15,605 14, : 17,345 17,899 5NV [5KH] Sunderland Middlesbrough County Durham 16-20: 17,334 16, : 14,440 14, : 19,159 17, : 12,188 12, : 12,906 13, : 9,996 11, : 13,542 14, : 7,395 9, : 17,498 18, : 4,817 7, : 19,285 19, : 2,617 6,772 North Yorkshire and York [Hambleton and Richmondshire] Population: 120, : 3,300 3, : 3,900 4,000 Average age: : 3,700 3, : 4,000 4,100 % aged 70+: 12.0% 11-15: 3,900 3, : 4,400 4, : 4,700 3, : 3,400 3, : 4,400 2, : 2,900 3, : 3,400 2, : 2,400 2, : 3,900 4, : 1,800 2, : 4,500 4, : 1,100 1, : 4,300 4, : 700 1,700 14

15 Population PCT / LHB Age Male Female Age Male Female 5QR Redcar and Cleveland Population: 139, : 4,001 3, : 4,824 4,876 Average age: : 4,054 3, : 4,433 4,569 % aged 70+: 12.5% 11-15: 4,746 4, : 5,050 5, : 4,889 4, : 4,138 4, : 4,288 4, : 3,661 3, : 3,324 3, : 2,835 3, : 3,506 3, : 2,162 2, : 4,556 5, : 1,372 2, : 5,042 5, : 808 2,008 TAC Population: 309, : 7,953 7, : 11,663 11,889 Average age: : 8,532 8, : 11,117 11,241 % aged 70+: 13.2% 11-15: 9,496 9, : 12,017 12,502 * Older than national average Northumberland Care Trust 16-20: 10,027 9, : 9,942 10, : 8,679 7, : 7,942 8, : 7,305 7, : 6,694 7, : 7,828 8, : 4,976 6, : 10,167 10, : 3,400 5, : 11,795 12, : 2,119 4,658 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%. 15

16 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 534, 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%. 16

17 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%. 17

18 Relative need for Pacemakers and ICDs Indicative new implant rate Pacemakers: 534 ICD: 64 (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 5D7 Newcastle % 61 95% 5D8 North Tyneside % % 5D9 Hartlepool % % 5E1 North Tees % 63 99% 5J9 Darlington % % 5KF Gateshead % % 5KG South Tyneside % % 5KL Sunderland % % 5KM Middlesbrough % 62 98% 5ND County Durham % % North Yorkshire and 5NV York [5KH] % % 5QR Redcar and Cleveland % % Northumberland Care TAC Trust % % 18

19 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. 19

20 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 23.10% of the total workload. This should always be borne in mind when forecasting future workload Replacement implants Centre New Implants Total Implants % of total FRE Freeman Hospital % SCM James Cook Hospital % ASH Wansbeck General Hospital % DAR Darlington Memorial Hospital % DRY Dryburn Hospital % SUN Sunderland District Hospital % QEG Queen Elizabeth Hospital % STD South Tyneside District Hospital % HGH Hartlepool General % ERI Edinburgh Royal Infirmary % HAR Harrogate District Hospital 3 3 CMI Cumberland Infirmary % HAG Harrogate General Hospital 1 1 BAT Royal United Hospital Bath 1 1 RHC Royal Hampshire County Hospital 1 1 SCA Scarborough General Hospital 1 1 AEI Royal Albert Edward Infirmary 1 1 SMP St Marys Hospital 1 BFH Broomfield Hospital 1 1 STO University Hospital North Staffs 1 1 WEX Wexham Park Hospital 1 1 YDH York District Hospital 1 1 NPH Northwick Park Hospital

21 Pacemaker implant trends 700 Pacemaker New Implant Rate adjusted for age and sex of network population 600 per million population England year 900 Pacemaker All Implant Rate adjusted for age and sex of network population per million population England year 21

22 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%. 22

23 Geographical location of pacemaker implants 23

24 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 FRE Freeman Hospital % SCM James Cook Hospital % WYT Wythenshawe Hospital 1 1 GUY Guy's Hospital 1 1 STH St Thomas Hospital

25 ICD implant trends 90 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 25

26 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 2000 Freeman Hospital 3 CRT-D CRT-P CRT-D CRT-P 2001 Freeman Hospital 7 22 Wansbeck General Hospital 1 CRT-D CRT-P 2002 Freeman Hospital James Cook University Hospital 3 CRT-D CRT-P 2003 Freeman Hospital James Cook University Hospital 7 1 CRT-D CRT-P 2004 Freeman Hospital James Cook University Hospital 8 12 Wansbeck General Hospital 3 West Cumberland Infirmary 1 Blackpool Victoria Hospital 1 CRT-D CRT-P 2005 Freeman Hospital

27 2005 James Cook University Hospital 9 18 Wansbeck General Hospital 2 CRT-D CRT-P 2006 Freeman Hospital James Cook University Hospital Wansbeck General Hospital 3 CRT-D CRT-P 2007 Freeman Hospital James Cook University Hospital Blackpool Victoria Hospital 1 Wansbeck General Hospital 3 CRT-D CRT-P 2008 Freeman Hospital James Cook Hospital Wansbeck General Hospital 3 University College Hospital 2 Victoria Hospital 1 South Tyneside District Hospital 1 CRT-D CRT-P 2009 Freeman Hospital James Cook Hospital Wansbeck General Hospital 4 Yorkshire Heart Centre 2 Royal Brompton Hospital 1 27

28 CRT implant trends CRT New Implant Rate adjusted for age and sex of network population 80 England per million population year 120 CRT All Implant Rate adjusted for age and sex of network population 100 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. 28

29 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

30 Which hospitals serve which PCTs/LHBs? all implants for this cardiac network in 2009 Pacemakers 5D7.Newcastle Total Implants 2009 FRE Freeman Hospital 218 ASH Wansbeck General Hospital 3 RHC Royal Hampshire County Hospital 1 NPH Northwick Park Hospital 1 5D8.North Tyneside Total Implants 2009 FRE Freeman Hospital 85 ASH Wansbeck General Hospital 80 5D9.Hartlepool Total Implants 2009 SCM James Cook Hospital 42 HGH Hartlepool General 10 FRE Freeman Hospital 3 5E1.North Tees Total Implants 2009 SCM James Cook Hospital 69 HGH Hartlepool General 37 FRE Freeman Hospital 3 5J9.Darlington Total Implants 2009 DAR Darlington Memorial Hospital 70 SCM James Cook Hospital 8 FRE Freeman Hospital 1 5KF.Gateshead Total Implants 2009 QEG Queen Elizabeth Hospital 96 FRE Freeman Hospital 48 ASH Wansbeck General Hospital 2 DRY Dryburn Hospital 2 5KG.South Tyneside Total Implants 2009 STD South Tyneside District Hospital 64 FRE Freeman Hospital 64 SUN Sunderland District Hospital 4 QEG Queen Elizabeth Hospital 3 SMP St Marys Hospital 1 5KL.Sunderland Total Implants 2009 SUN Sunderland District Hospital 112 FRE Freeman Hospital 38 QEG Queen Elizabeth Hospital 9 DRY Dryburn Hospital 3 STO University Hospital North Staffs 1 30

31 SCM James Cook Hospital 1 5KM.Middlesbrough Total Implants 2009 SCM James Cook Hospital 99 5ND.County Durham Total Implants 2009 DRY Dryburn Hospital 160 DAR Darlington Memorial Hospital 94 SCM James Cook Hospital 47 FRE Freeman Hospital 46 SUN Sunderland District Hospital 24 HGH Hartlepool General 8 QEG Queen Elizabeth Hospital 2 CMI Cumberland Infirmary 1 WEX Wexham Park Hospital 1 5NV.North Yorkshire and York [5KH] Total Implants 2009 SCM James Cook Hospital 91 DAR Darlington Memorial Hospital 13 FRE Freeman Hospital 2 HAR Harrogate District Hospital 1 SCA Scarborough General Hospital 1 BFH Broomfield Hospital 1 5QR.Redcar and Cleveland Total Implants 2009 SCM James Cook Hospital 106 FRE Freeman Hospital 2 HAG Harrogate General Hospital 1 HAR Harrogate District Hospital 1 TAC.Northumberland Care Trust Total Implants 2009 ASH Wansbeck General Hospital 128 FRE Freeman Hospital 90 ERI Edinburgh Royal Infirmary 4 YDH York District Hospital 1 CMI Cumberland Infirmary 1 BAT Royal United Hospital Bath 1 AEI Royal Albert Edward Infirmary 1 Implantable Cardioverter Defibrillators (ICDs) 5D7.Newcastle Total Implants 2009 FRE Freeman Hospital 21 GUY Guy's Hospital 1 5D8.North Tyneside Total Implants 2009 FRE Freeman Hospital 22 5D9.Hartlepool Total Implants 2009 SCM James Cook Hospital 8 31

32 FRE Freeman Hospital 1 5E1.North Tees Total Implants 2009 SCM James Cook Hospital 11 FRE Freeman Hospital 2 WYT Wythenshawe Hospital 1 5J9.Darlington Total Implants 2009 SCM James Cook Hospital 5 FRE Freeman Hospital 3 5KF.Gateshead Total Implants 2009 FRE Freeman Hospital 14 SCM James Cook Hospital 1 5KG.South Tyneside Total Implants 2009 FRE Freeman Hospital 12 5KL.Sunderland Total Implants 2009 FRE Freeman Hospital 16 SCM James Cook Hospital 2 STH St Thomas Hospital 1 5KM.Middlesbrough Total Implants 2009 SCM James Cook Hospital 10 5ND.County Durham Total Implants 2009 SCM James Cook Hospital 22 FRE Freeman Hospital 18 5NV.North Yorkshire and York [5KH] Total Implants 2009 SCM James Cook Hospital 10 5QR.Redcar and Cleveland Total Implants 2009 SCM James Cook Hospital 12 TAC.Northumberland Care Trust Total Implants 2009 FRE Freeman Hospital 25 Cardiac Resynchronisation Therapy (CRT) 5D7.Newcastle Total Implants 2009 FRE Freeman Hospital 8 5D8.North Tyneside Total Implants 2009 FRE Freeman Hospital 12 ASH Wansbeck General Hospital 1 5D9.Hartlepool Total Implants 2009 SCM James Cook Hospital 1 5E1.North Tees Total Implants 2009 SCM James Cook Hospital 4 FRE Freeman Hospital 2 5J9.Darlington Total Implants 2009 SCM James Cook Hospital 2 32

33 FRE Freeman Hospital 1 5KF.Gateshead Total Implants 2009 FRE Freeman Hospital 13 5KG.South Tyneside Total Implants 2009 FRE Freeman Hospital 15 5KL.Sunderland Total Implants 2009 FRE Freeman Hospital 25 5KM.Middlesbrough Total Implants 2009 SCM James Cook Hospital 7 FRE Freeman Hospital 1 5ND.County Durham Total Implants 2009 FRE Freeman Hospital 14 SCM James Cook Hospital 6 5NV.North Yorkshire and York [5KH] Total Implants 2009 SCM James Cook Hospital 8 LGI Yorkshire Heart Centre 2 5QR.Redcar and Cleveland Total Implants 2009 SCM James Cook Hospital 4 TAC.Northumberland Care Trust Total Implants 2009 FRE Freeman Hospital 15 ASH Wansbeck General Hospital 3 NHB Royal Brompton Hospital 1 33

34 Pacing Mode for New Implants for this cardiac network Pacemakers Mode % for this network England % Atrial based modes DDDR 55.44% 54.04% DDD 13.29% 11.39% AAIR 0.34% 0.50% AAI 0.00% 0.12% DDI 0.07% 0.13% DDIR 0.00% 0.08% Ventricular based modes VVIR 28.39% 29.94% VVI 2.35% 3.45% VDDR 0.00% 0.02% VDD 0.07% 0.33% Note: The Mode table percentage calculations do not include any records where the mode was blank or unknown. Network England Ventricular based 30% Blank/ Unknown 3.6% Ventricular based 33% Blank/ Unknown 2% Atrial based 66% 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. 34

35 Pacing Mode for New Implants major implanting hospitals in this cardiac network VVI VVIR AAI AAIR DDD DDDR VDD VDDR Atrial Based Pacing NATIONAL 3.5% 30.0% 0.1% 0.5% 11.4% 54.2% 0.3% 0.0% 66.2% This Network 2.4% 28.4% 0.0% 0.3% 13.3% 55.5% 0.1% 0.0% 69.2% ASH.Wansbeck General Hospital 0.0% 35.1% 0.0% 1.0% 8.8% 55.2% 0.0% 0.0% 64.9% DAR.Darlington Memorial Hospital 0.0% 31.2% 0.0% 0.6% 16.8% 51.4% 0.0% 0.0% 68.8% DRY.Dryburn Hospital 0.8% 18.5% 0.0% 0.0% 23.4% 57.3% 0.0% 0.0% 80.6% FRE.Freeman Hospital 0.0% 25.5% 0.0% 0.3% 2.2% 72.0% 0.0% 0.0% 74.5% QEG.Queen Elizabeth Hospital 0.0% 21.8% 0.0% 0.0% 32.1% 46.2% 0.0% 0.0% 78.2% SCM.James Cook Hospital 9.2% 30.0% 0.0% 0.3% 19.9% 40.4% 0.3% 0.0% 60.5% SUN.Sunderland District Hospital 1.8% 22.7% 0.0% 0.0% 9.1% 66.4% 0.0% 0.0% 75.5% 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. 35

36 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 SUN.Sunderland District Hospital % 5.3% ASH.Wansbeck General Hospital % 20.0% DAR.Darlington Memorial Hospital % 3.4% DRY.Dryburn Hospital % 10.4% FRE.Freeman Hospital % 3.8% QEG.Queen Elizabeth Hospital % 5.3% SCM.James Cook Hospital % 21.8% STD.South Tyneside District Hospital % 0.0% HGH.Hartlepool General % 0.0% 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

37 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. 37

38 ECG Indication for New Implants Complete HB Incomplete HB AF + HB/brady Sick sinus syndrome Other NATIONAL 22.1% 21.7% 23.4% 26.1% 6.7% This Network 21.7% 18.4% 23.7% 33.4% 2.8% 5D7.Newcastle 19.0% 14.4% 20.3% 45.1% 1.3% 5D8.North Tyneside 19.8% 24.0% 24.8% 24.8% 6.6% 5D9.Hartlepool 14.3% 7.1% 40.5% 38.1% 0.0% 5E1.North Tees 21.5% 13.9% 32.9% 30.4% 1.3% 5J9.Darlington 17.8% 13.7% 34.2% 32.9% 1.4% 5KF.Gateshead 17.1% 27.6% 20.0% 34.3% 1.0% 5KG.South Tyneside 27.7% 18.8% 20.8% 30.7% 2.0% 5KL.Sunderland 16.1% 22.3% 23.2% 33.9% 4.5% 5KM.Middlesbrough 26.1% 29.0% 20.3% 18.8% 5.8% 5ND.County Durham 25.2% 12.6% 21.1% 39.1% 2.0% 5NV.North Yorkshire and York [5KH] 26.5% 27.7% 20.5% 25.3% 0.0% 5QR.Redcar and Cleveland 23.4% 19.5% 28.6% 24.7% 3.9% TAC.Northumberland Care Trust 23.5% 20.5% 22.9% 28.3% 4.8% AF: atrial fibrillation HB: heart block Brady: bradycardia 38

39 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 534 Network average (unadjusted) 582 Network average (corrected for age and sex) 580 Population Relative need for PM New Implant Rate 2009 Raw Corrected 5D7 Newcastle 270, % D8 North Tyneside 195, % D9 Hartlepool 91, % E1 North Tees 189, % J9 Darlington 99, % KF Gateshead 190, % KG South Tyneside 151, % KL Sunderland 280, % KM Middlesbrough 138, % ND County Durham 500, % NV North Yorkshire and York [5KH] 120, % QR Redcar and Cleveland 139, % TAC Northumberland Care Trust 309, %

40 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 15.3% 1% RATING: slight excess variation in implant rates between PCTs 40

41 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 534 Network average (unadjusted) 582 Network average (corrected for age and sex) 580 Population Corrected New Implant Rate 2008 Deficit/ Excess 2009 compared to rate of 700 5D7 Newcastle 270, % 5D8 North Tyneside 195, % 5D9 Hartlepool 91, % 5E1 North Tees 189, % 5J9 Darlington 99, % 5KF Gateshead 190, % 5KG South Tyneside 151, % 5KL Sunderland 280, % 5KM Middlesbrough 138, % 5ND County Durham 500, % 5NV North Yorkshire and York [5KH] 120, % 5QR Redcar and Cleveland 139, % TAC Northumberland Care Trust 309, % 41

42 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 64 Network average (unadjusted) 64 Network average (corrected for age and sex) 61 Population Relative need for ICD New Implant Rate 2009 Raw Corrected 5D7 Newcastle 270, % D8 North Tyneside 195, % D9 Hartlepool 91, % E1 North Tees 189, % J9 Darlington 99, % KF Gateshead 190, % KG South Tyneside 151, % KL Sunderland 280, % KM Middlesbrough 138, % ND County Durham 500, % NV North Yorkshire and York [5KH] 120, % QR Redcar and Cleveland 139, % TAC Northumberland Care Trust 309, %

43 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 64 Network average (unadjusted) 64 Network average (corrected for age and sex) 61 Population Corrected New Implant Rate 2008 Deficit/ Excess 2009 compared to rate of 100 5D7 Newcastle 270, % 5D8 North Tyneside 195, % 5D9 Hartlepool 91, % 5E1 North Tees 189, % 5J9 Darlington 99, % 5KF Gateshead 190, % 5KG South Tyneside 151, % 5KL Sunderland 280, % 5KM Middlesbrough 138, % 5ND County Durham 500, % 5NV North Yorkshire and York [5KH] 120, % 5QR Redcar and Cleveland 139, % TAC Northumberland Care Trust 309, % 43

44 New Implant rate maps for North of England Cardiovascular Network 44

45 New pacing implant rate 2009 comparison with Heart Rhythm UK target (700) Pacemaker New Implants 2009 adjusted for age and sex compared to target figure of 700 per million Sunderland Northumberland Care Trust North Tees Hartlepool Gateshead North Tyneside Newcastle County Durham Middlesbrough Redcar and Cleveland South Tyneside North Yorkshire and York [5KH] Darlington -40% -35% -30% -25% -20% -15% -10% -5% 0% 5% 10% 45

46 ICD new implant rate 2009 ICD New Implants 2009 adjusted for age and sex compared to target figure of 100 per million Middlesbrough North Yorkshire and York [5KH] Redcar and Cleveland Northumberland Care Trust Darlington Gateshead South Tyneside County Durham Sunderland Hartlepool North Tees Newcastle North Tyneside -90% -80% -70% -60% -50% -40% -30% -20% -10% 0% 46

47 Pacing Implant Deficit in 2009 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 2009 compared to Heart Rhythm UK target rate of Darlington North Yorkshire and York [5KH] Middlesbrough Redcar and Cleveland South Tyneside Hartlepool North Tyneside Newcastle Gateshead North Tees

48 Conclusions This network serves a population which is slightly older than average. There is a 0.5% higher need for pacemakers and 5% higher need for ICDs compared to the national average. The Network new implant rate for pacemakers decreased and is just above the national average. The Network new implant rate for ICDs decreased and tracks close to the national average. The CRT total implant rate is static, although eight of the 13 PCTs showed an increase. The network total implant rate is well below the national average. The proportion of atrial based pacing (66%) is slightly higher than the national average of 65%. James Cook Hospital (22%) has a high rate of ventricular based pacemaker implants for sick sinus syndrome; this is not compliant with NICE TAG 88 (2005) 48