Clinical Audit of Heart Rhythm Devices Pacemaker, ICD and CRT Herefordshire and Worcestershire Cardiac Network

20 Clinical Audit of Heart Rhythm Devices Pacemaker, ICD and CRT Herefordshire and Worcestershire Cardiac Network David Cunningham Senior Strategist, NICOR Morag Cunningham CRM Database Coordinator, NICOR Richard Charles Chairman, Heart Rhythm UK Device Audit Group

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 977 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 clinical audit is funded as part of the National Clinical Audit & Patient Outcome Programme (NCAPOP), which is managed by the Healthcare Quality Improvement Partnership (HQIP www.hqip.org.uk). The preparation of this report was supported by HQIP. Data collection was carried out by NICOR with support provided from NHS Improvement (www.improvement.nhs.uk) 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 Heart Rhythm UK Audit Group. The report may be downloaded from www.devicesurvey.com. 2

Contents Acknowledgments...2 Contents...3 Introduction to the 20 Reports...4 The National Clinical Audit Report...5 Overview of Device Implants in the UK...7 How does the UK compare with Europe?...9 Data Quality Statement... 4 Data Completeness and Data Quality for Key Hospitals in this Network... 5 20 Implant Rates in the Cardiac Networks... 7 PCTs/LHBs in the Network... 20 Correcting Implant Rates for Age and Sex... 2 Relative Need for Pacemakers, ICDs and CRTs... 23 Centres providing Device Implants to this Network... 24 0 Year Implant Trends Network v National... 25 Provider Hospitals: which hospitals serve which PCTs/LHBs?... 26 Geographical Location of Implants... 28 Pacing Mode in this Network: Physiological vs NonPhysiological... 30 Pacing Mode for New Implants by Centre... 3 Physiological Pacing in Sick Sinus Syndrome... 32 ECG Indication for New Pacemaker Implants... 33 New Pacemaker Implant Rates corrected for Age and Sex... 34 New ICD Implant Rates corrected for Age and Sex... 35 New Implant Rate Maps... 37 Pacemaker Implant Deficit in 20... 38 Conclusions... 39 3

Introduction to the 20 Reports The Heart Rhythm UK Device Audit Group (formerly the Network Devices Survey Group), now in its ninth consecutive year of work, continues its audit of cardiac rhythm management, and particularly the level of provision of cardiac pacemakers, implantable defibrillators and cardiac resynchronisation therapy in England and Wales. This year the seventh consecutive annual national report has been published, covering clinical activity in 20, and it is a pleasure for me to welcome its publication. You will find the national report at www.devicesurvey.com. The report s principal focus remains the provision of data on the total volume and equity of provision of implantable cardiac devices, corrected for the demographic structure of the population. The methodology allows valid comparison of activity between and within different Network areas, and thus benchmarking of activity. This year the audit has used population data from the 20 census, rather than serial extrapolations from the 200 census, which should be borne in mind when comparing implant activity in this report with those from previous years. A summary account of cardiac arrhythmia ablation activity is now a fixed and valuable section of the report, and one which will be developed further in future reports. Work over the past two years has resulted in this being a full clinical audit of cardiac rhythm management, having evolved from the more simple past surveys of implantable device activity. Completion of an increased number of data fields has been encouraging, and I congratulate all those involved, particularly cardiac physiologists, arrhythmia nurses and clinicians who have worked so hard to ensure data collection. Clinical audit lies at the heart of understanding the quality and effectiveness of what we do for patients, and our performance compared to national and professional guidelines. The report provides an excellent contemporary picture of cardiac device and arrhythmia ablation activity in the NHS in England and Wales. Enormous progress has been made, driven by the advances in clinical science and technology and the hard work of NHS staff who translate these advances into practice. There is always scope for improvement, and this report highlights that volumes and equity of service provision of arrhythmia services in the NHS sometimes falls short by international comparison. However, the progress made to date is encouraging and I commend this report to all colleagues who plan, commission or deliver cardiac arrhythmia services for patients in England and Wales. Professor Huon Gray Interim National Clinical Director for Cardiovascular Disease, Dept of Health (England) & Consultant Cardiologist, University Hospital of Southampton 4

The National Clinical Audit Report The Heart Rhythm UK Device Audit Group (formerly the Network Device Survey Group) is pleased to present its seventh set of annual reports covering the calendar year 20. Our name change is not a mere rebranding; consistent with the aspirations set out in my Introduction to the 200 Report, it reflects our steady progress towards a full clinical audit, and our integral relationship with our national society. Furthermore, the transfer of the cardiac audits during 20, including this device audit, to the aegis of NICOR (the National Institute for Cardiovascular Outcomes Research based at University College, London) has been a wholly positive development which will greatly enhance the probability that the audit will indeed survive, develop and flourish in future. Whilst it is crucial for us to expand the clinical outcomes content of the Audit report, it remains a vital task of this Report to present data describing the total volume and equity of provision of the major cardiac implantable device therapies pacemakers for bradycardia (PM), implantable cardioverter defibrillators (ICDs) for cardiac arrest and cardiac resynchronisation therapy (CRT) for advanced heart failure across all Cardiac Networks in England and Wales. The core methodology of the survey remains unchanged, allowing valid direct comparison between Cardiac Networks, Primary Care Trusts (Local Health Boards in Wales) and between the national reports for 2009, 200, the current report for 20, and all previous annual reports. A full account of the methodology is presented within the National Report. This report continues to use the current professionally accepted targets for each device class, as in previous years 700 new implants/million(m) population for PM, 00 new implants/m for ICD and 30 total (new + replacement)/m for CRT, although there is a compelling case to revisit these targets in the light of current European trends. UK performance must be viewed in the context of our European neighbours; as we have previously emphasised, there is evidence neither of overprescribing of devices in Europe, nor is there evidence that the prevalence of the conditions for which a device is indicated, based on current professional guidelines, differs between the UK and Western Europe. What are the headline results for 20? In England, the PM new implant rate is 525/M, a small fall from 200 which establishes a disappointing flat line from 2009. The ICD new rate is 77/M, a 6.9% increase over 200, whilst the CRT total rate is 3/M, marking an abrupt halt to the consistent yearonyear rise since 200. The performance of the NHS in England continues to compare unfavourably with most of the developed European economies. Wales demonstrates striking and commendable increases in implant rates for PM and CRT, whilst falls in implant rates in Northern Ireland for ICD and CRT arrest its erstwhile progress, although the ICD implant rate there continues to far exceed the rest of the UK. Data returns from Scotland show signs of improvement for complex devices but remain sadly depleted, as in previous years. It can be emphasised with confidence that the overall provision of 5

cardiac implantable devices by the NHS remains inadequate to meet the needs of the population at risk. Inequity of provision of devices still afflicts the NHS but has noticeably decreased due to a general regression towards the (inadequate) mean implant rate. A regression towards the target would have been more welcome. To spell it out yet again, your chances of getting the life saving or life enhancing device you need depends critically on where you live. The 20 Reports continue our drive to present the clinical data which support the prescription of complex devices in particular. Finally, it is again a pleasure to recognise both the efforts of hard pressed clinical staff at implanting centres who submit their data and the continued input of constructive criticism from all who are charged with, and wish to see, the provision of a top class device service in the UK. To all colleagues we offer our thanks for their contribution to the resource we offer here. Dr Richard Charles Emeritus Consultant Cardiologist, Liverpool Heart and Chest Hospital Chairman, Heart Rhythm UK Audit Group The National Audit of Cardiac Rhythm Management 20 Report can be downloaded from www.devicesurvey.com. 6

Overview of Device Implants in the UK General note: up to 200, population estimates were yearonyear projections from ONS of the population, extrapolating from the 200 census. In general these projections tend to underestimate the true population. The 20 rates use the population from the 20 census, so a slight increase in actual implant rate might be masked by replacing a population underestimate with a true estimate. (Note: the rates in these graphs are NOT adjusted for age and sex). New Pacemakers Comments 600 500 England Wales Scotland N Ireland Pacemaker implant rate in England again remains static (524 per million population). per million population 400 300 200 Large increase in new pacemaker rate in Wales 00 No increase in pacing rate in N Ireland. 0 200 2002 2003 2004 2005 2006 2007 2008 2009 200 20 year Data submissions from Scotland have improved but are still incomplete. New ICDs Comments ICD rate fell slightly in N Ireland but is still well above the rest of the UK. England and Wales rates remain very similar, with a modest increase in 20. per million population 40 20 00 80 60 40 20 England Wales Scotland N Ireland Dramatic rise in Scottish rate actually reflects better data submission, but is still not 00% complete. 0 200 2002 2003 2004 2005 2006 2007 2008 2009 200 20 year 7

Total CRTs Comments The total CRT rate (all implants CRTP and CRT D) for England failed to increase for the first year since these devices were introduced. per million population 40 20 00 80 60 40 20 England Wales Scotland N Ireland There was a large increase in the CRT rate in Wales and a large drop in N Ireland. 0 200 2002 2003 2004 2005 2006 2007 2008 2009 200 20 year The CRT rate in Scotland remains very low and is one of the lowest in Europe. 8

How does the UK compare with Europe? Pacemaker New Implant Rate 20 per million population Germany Iceland France Italy Sweden Finland Estonia Malta Czech Republic Lithuania Denmark Belgium Switzerland Poland Norway Slovakia UK Greece Slovenia Croatia Portugal Latvia Netherlands Serbia San Marino Israel Bulgaria Montenegro Belarus Luxembourg Russia Macedonia Bosnia Herzegovina Armenia Ukraine Azerbaijan 0 00 200 300 400 500 600 700 800 900 000 00 200 9

ICD New Implant Rate 20 per million population San Marino Czech Republic Germany Denmark Italy Poland Belgium Norway Netherlands Slovakia Switzerland Finland France Israel Sweden Luxembourg Iceland Portugal UK Greece Spain Estonia Malta Montenegro Serbia Lithuania Latvia Belarus Bosnia Herzegovina Macedonia Bulgaria Armenia Russia Georgia Ukraine 0 50 00 50 200 250 300 0

CRT Total Implant Rate 20 per million population Italy Germany Denmark Czech Republic Netherlands France Austria UK San Marino Norway Sweden Hungary Switzerland Israel Poland Finland Slovakia Estonia Belgium Ireland Malta Spain Iceland Portugal Slovenia Serbia Luxembourg Greece Lithuania Latvia Montenegro Cyprus Bulgaria Croatia Romania Macedonia Tunisia Russia Bosnia Herzegovina Belarus Georgia Armenia Azerbaijan Egypt Ukraine Morocco 0 50 00 50 200 250

Comments and Analysis of UK Implant Rates compared to Europe UK device implant rates have lagged behind our European neighbours for decades. The situation is not improving, it is getting worse. It is clear from the graphs above that small countries with a low GDP cannot afford to implant cardiac devices. The UK is not in that situation. To compare like with like, we took an average of European countries with a population over 0 million and a GDP per capita of at least $0,000 in 20. The nine countries selected for comparison were Netherlands, Germany, France, Belgium, Italy, Spain, Portugal, Greece and the Czech Republic. The table below shows the UK implant rates and the populationweighted European average rates. UK 20 Europe 20 Pacemaker new implant rate 524 697 ICD new implant rate 76 46 CRT total implant rate 3 42 Clearly there remains an enormous deficit in new implant rates for pacemakers and ICDs. The target (set some years ago) of 700 new implants per million for pacemakers seems to be still valid in comparison with Europe. However, the target of 00 for new ICD implants appears low in comparison with Europe, although still much higher than the UK is currently achieving. The European average CRT rate is 0% higher than the Heart Rhythm UK/BSH target rate of 30 and so this target probably does not need to be reviewed at the moment. All data in this section was extracted from the EHRA White Book 202: The Current Status of Electrophysiology in ESC Member Countries. The book can be found at http://www.escardio.org/communities/ehra/publications/documents/ ehrawhitebook202.pdf 2

New Pacemaker Implant Rate Europe 20 3

Data Quality Statement The quality of the analyses in this report is only as good as the quality of the data on which it is based. 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 this analysis. 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. 4

Data Completeness and Data Quality for Key Hospitals in this Network Listed below are the most important data fields and their completion rates with CLINICALLY VALID entries. Note that any code which translates to Unknown or Uncoded is not considered to be clinically valid. 5

6

20 Implant Rates in the Cardiac Networks There has been a noticeable decrease in variability across networks in 20. This has resulted from a decrease in rate for the highest rate implanting networks and an increase in the lower rate networks. Unfortunately this means that none of the networks now implant up to the target rate of 700 for pacemakers. It would have been preferable to see regression towards the target rather than regression towards the mean. As it stands, it appears that a clinically inadequate national average is being sought as an acceptable level of performance, when the focus should be on improvement to the levels of our Western European neighbours. The grey line represents the national average rate. The blue line is the national target rate. new Pacemaker rate 20 adjusted for age and sex North West London Cardiac and Stroke Network Dorset Cardiac Network Sussex Heart Network North & East Yorkshire and Northern Lincolnshire Cardiac Network Bedfordshire and Hertfordshire Heart and Stroke Network North East London Cardiac and Stroke Network South West London Cardiac Network North Central London Cardiac & Stroke Network North of England Cardiovascular Network Kent Cardiovascular Network Cheshire & Merseyside Cardiac Network Anglia Stroke and Heart Network South Central Cardiovascular Network West Yorkshire Cardiac Network Greater Manchester & Cheshire Cardiac Network NB: North Wales and South Wales have a higher than average need for pacing so the adjusted rates shown here are lower than the unadjusted national rate for Wales shown on Page 7. North Trent Network of Cardiac Care Surrey Heart & Stroke Network Black Country Cardiovascular Network Birmingham, Sandwell and Solihull Cardiac and Stroke Network Peninsula Cardiac Managed Clinical Network East Midlands Cardiac & Stroke Network Cardiac and Stroke Networks in Lancashire and Cumbria Avon, Gloucestershire, Wiltshire & Somerset Cardiac and Stroke Network South East London Cardiac & Stroke Network Essex Cardiac and Stroke Network South Wales North Wales Shropshire & Staffordshire Cardiac Network Coventry & Warwickshire Cardiovascular Network Herefordshire and Worcestershire Cardiac Network 0 00 200 300 400 500 600 700 800 The national target rate is 700 implants per million population. No network reaches this level. 7

ICD The grey line represents the national average rate. The blue line is the national target rate. new ICD rate 20 adjusted for age and sex North East London Cardiac and Stroke Network Dorset Cardiac Network Sussex Heart Network South West London Cardiac Network North West London Cardiac and Stroke Network Cheshire & Merseyside Cardiac Network North Central London Cardiac & Stroke Network Bedfordshire and Hertfordshire Heart and Stroke Network Surrey Heart & Stroke Network Kent Cardiovascular Network Black Country Cardiovascular Network West Yorkshire Cardiac Network Birmingham, Sandwell and Solihull Cardiac and Stroke Network East Midlands Cardiac & Stroke Network North & East Yorkshire and Northern Lincolnshire Cardiac Network North of England Cardiovascular Network Essex Cardiac and Stroke Network South Central Cardiovascular Network Avon, Gloucestershire, Wiltshire & Somerset Cardiac and Stroke Network North Wales South Wales Peninsula Cardiac Managed Clinical Network Anglia Stroke and Heart Network Greater Manchester & Cheshire Cardiac Network Shropshire & Staffordshire Cardiac Network Herefordshire and Worcestershire Cardiac Network Coventry & Warwickshire Cardiovascular Network South East London Cardiac & Stroke Network North Trent Network of Cardiac Care Cardiac and Stroke Networks in Lancashire and Cumbria 0 20 40 60 80 00 Dorset and NE London are to be commended for maintaining their implant rates at or above the national target of 00. Sussex has seen a significant increase and has also reached the target, as has SW London. Hereford & Worcester has seen an improvement from an extremely low level (<40) to nearly 60. The rate in Lancs & Cumbria remains very low. For some reason the rate in SE London has fallen catastrophically, and this needs further examination. 8 20

CRT The grey line represents the national average rate. The blue line is the national target rate. total CRT rate 20 adjusted for age and sex Dorset Cardiac Network North West London Cardiac and Stroke Network Kent Cardiovascular Network Birmingham, Sandwell and Solihull Cardiac and Stroke Network South East London Cardiac & Stroke Network Sussex Heart Network North East London Cardiac and Stroke Network Cardiac and Stroke Networks in Lancashire and Cumbria Greater Manchester & Cheshire Cardiac Network South West London Cardiac Network Cheshire & Merseyside Cardiac Network North & East Yorkshire and Northern Lincolnshire Cardiac Network North Central London Cardiac & Stroke Network West Yorkshire Cardiac Network Anglia Stroke and Heart Network Peninsula Cardiac Managed Clinical Network South Central Cardiovascular Network Surrey Heart & Stroke Network Bedfordshire and Hertfordshire Heart and Stroke Network North Wales Black Country Cardiovascular Network Coventry & Warwickshire Cardiovascular Network Shropshire & Staffordshire Cardiac Network Essex Cardiac and Stroke Network North of England Cardiovascular Network Herefordshire and Worcestershire Cardiac Network South Wales Avon, Gloucestershire, Wiltshire & Somerset Cardiac and Stroke Network East Midlands Cardiac & Stroke Network North Trent Network of Cardiac Care 0 20 40 60 80 00 20 40 Eleven networks have achieved the Heart Rhythm UK/BSH target of 30 total CRT implants per million North Trent are implanting at only half of the target rate. A number of other networks are well below average and even further below the target rate. 9 60 80 200

PCTs/LHBs in the Network Code PCT/LHB Population Herefordshire and Worcestershire Cardiac Network 750,76 5CN 5PL 83,69 566,557 Herefordshire Worcestershire 20

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 shows the percentage of the population in 5 year age bands, and the percentage of pacemaker implants. Only % 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,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 %. 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 6% aged 70 or over. Their Relative Need for Pacing is 40%. 2

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 40% = 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 200 and 20 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 38%. 22

Relative Need for Pacemakers, ICDs and CRTs National new implant rates 20: Pacemaker:.524. ICD:.76. CRT:.3. new implants new implants total implants A PCT with a relatively OLD population will need relatively MORE implants compared to a PCT with a young population, because the incidence of indications for pacing and ICD is higher in older people. Relative Need for Pacing Required Rate to be comparable with national average Herefordshire and Worcestershire Cardiac Network 9% 5CN 5PL 29% 6% Code Note: PCT/LHB Herefordshire Worcestershire Relative Need for ICD Required Rate to be comparable with national average Relative Need for CRT Required Rate to be comparable with national average 626 6% 89 9% 35 675 60 2% 4% 92 87 27% 7% 43 32 "Required" implant rates are relative to the national average rate, but are corrected depending on the age and sex distribution of the local population. For Pacemakers, the required implant rate will be higher if the percentage of older people in the PCT is higher. For ICDs and CRTs, the same general rule applies, but the pattern is slightly different, because these devices have a different age/sex distribution. These relative rates will be used to correct the observed rates and produce a truer reflection of local implant rates vs. local need. 23

Centres providing Device Implants to this Network Centres that implanted at least 0 devices in this network in 20 Centre Pacemaker ICD CRT WRC Worcestershire Royal Hospital 98 0 0 QEB Queen Elizabeth Hospital Edgbaston 45 33 55 HCH County Hospital Hereford 89 0 CHG Cheltenham General Hospital 20 2 WAL University Hospital Coventry 3 4 8 24

0 Year Implant Trends Network v National Pacemakers New Pacemaker Implant Rate (national target: 700 new implants per million population) adjusted for age and sex of network population 550 rate per million population 500 A drastic fall in PM implant rate which was already well below the national average. 450 400 350 300 National 250 Herefordshire and Worcestershire Cardiac Network 200 200 2002 2003 2004 2005 2006 2007 2008 2009 200 20 year ICD (national target: 00 new implants per million population) New ICD Implant Rate adjusted for age and sex of network population 90 rate per million population 80 ICD rate increased significantly in 20 but remains below the national average. 70 60 50 40 30 20 National 0 Herefordshire and Worcestershire Cardiac Network 0 200 2002 2003 2004 2005 2006 2007 2008 2009 200 20 year CRT (national target: 30 total implants per million population) Total CRT Implant Rate adjusted for age and sex of network population 20 CRT implant rate fell slightly in 20 and is still below the national average. rate per million population 00 80 60 40 National 20 Herefordshire and Worcestershire Cardiac Network 0 200 2002 2003 2004 2005 2006 2007 2008 year 25 2009 200 20

Provider Hospitals: which hospitals serve which PCTs/LHBs? All implants in this cardiac network in 20 PACEMAKERS PCT/LHB Implanting Centre 5CN HCH County Hospital Hereford 86 Herefordshire QEB Queen Elizabeth Hospital Edgbaston 5 CHG Cheltenham General Hospital 5 WRC Worcestershire Royal Hospital 4 UCL University College Hospital 5PL WRC Worcestershire Royal Hospital 94 Worcestershire QEB Queen Elizabeth Hospital Edgbaston 30 CHG Cheltenham General Hospital 5 RUS Russells Hall Hospital 7 RAD John Radcliffe Hospital 4 HHW Wellington Hospital 3 WAL University Hospital Coventry 3 HCH County Hospital Hereford 3 BCH Diana Princes of Wales Childrens Hospital 2 NCR Wolverhampton Heart Centre 2 WAR Warwick Hospital 2 AHM BMI Alexandra Hospital HAM Hammersmith Hospital SDG Stafford Hospital SOL Solihull General Hospital WAT Watford General Hospital WMH Manor Hospital 26 Implants

ICDs Implantable Cardioverter Defibrillators PCT/LHB Implanting Centre Implants 5CN QEB Queen Elizabeth Hospital Edgbaston 6 Herefordshire UCL University College Hospital 2 PHB BMI Priory Hospital 5PL QEB Queen Elizabeth Hospital Edgbaston 7 Worcestershire NCR Wolverhampton Heart Centre 5 WAL University Hospital Coventry 4 UCL University College Hospital 2 CHG Cheltenham General Hospital 2 GOS Great Ormond Street Hospital for Children GHS Good Hope General Hospital SAN Sandwell District Hospital SCM James Cook University Hospital CRTs Cardiac Resynchronisation Therapy PCT/LHB Implanting Centre 5CN QEB Queen Elizabeth Hospital Edgbaston Herefordshire PAP Papworth Hospital GHS Good Hope General Hospital 5PL QEB Queen Elizabeth Hospital Edgbaston 44 Worcestershire WAL University Hospital Coventry 8 PHB BMI Priory Hospital 2 NHB Royal Brompton Hospital BRI Bristol Royal Infirmary CHG Cheltenham General Hospital GHS Good Hope General Hospital HCH County Hospital Hereford RUS Russells Hall Hospital 27 Implants

Geographical Location of Implants Pacemaker Implants 28

Complex Implants (ICD and CRT) 29

Pacing Mode in this Network: Physiological vs NonPhysiological There is ample evidence that atrialbased pacing modes (also known as physiological pacing modes) improve patients quality of life, and may also prolong survival. NICE Guidance (TA88, 2005) has confirmed the desirability of physiological pacing when appropriate. 30 years ago all pacemakers were ventricularbased, i.e. the only part of the heart which was stimulated was the lower chambers. Increasingly, atrialbased (mainly dual chamber) pacing has replaced the ventricular modes, a trend which is beneficial to patients. It is not possible, or desirable, to completely eradicate ventricular pacing. Patients in permanent atrial fibrillation cannot benefit from atrialbased pacing, and this is a significant subgroup in the elderly. % for this network % for England DDDR 70.% 66.9% DDD 2.9% 2.4% AAIR AAI 0.003% Other 0.03% Mode Atrial based pacing Ventricular based pacing VVIR 26.8% 29.9% VVI 0.3% 0.8% The proportion of physiological pacing in this network is slightly above the national average. 30

Pacing Mode for New Implants by Centre Only implants in this network Mode DDDR DDD AAIR AAI Other physiological All Physiological VVIR VVI National 66.9% 2.4% 0.03% 69.3% 29.9% 0.8% This network 70.% 2.9% 0.3% 73.2% 3.3% 7.2% 7.2% 28.8% 75.3% 2.2%.% 78.7% 2.3% 55.6% 2 75.6% 24.4% 6 6 4 Worcestershire Royal Hospital County Hospital Hereford Queen Elizabeth Hospital Edgbaston Cheltenham General Hospital All hospitals implant at least the national average of physiological devices, with the exception of Cheltenham, whose 40% ventricular based rate is much higher than average. Note: Pacing Mode is based on the maximum mode of which the device is capable, and not the programmed mode at the end of the procedure. 3

Physiological Pacing in Sick Sinus Syndrome Only implants in this network 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 8% in 2009, 84% in 200 and 84% in 20. Any percentage of ventricular based pacing greater than 0% 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. Number of implants for Sick Sinus Syndrome % Atrial Based Pacing % Ventricular Based Pacing England 83.7% 6.3% This network 77.0% 23.0% Worcestershire Royal Hospital 37 70.3% 29.7% County Hospital Hereford 8 94.4% 5.6% Hereford implants a high % of physiological pacemakers for SSS. Worcester's rate is similar to their overall rate of 7% and lower than average. The implantation of ventricular devices in 30% of SSS patients is contrary to NICE guidance. Note: Any hospital in the network but not in this list did not code at least 0 implants as SSS. Note: For this analysis only ECG codes EE5 are used for SSS. Code E6 is excluded. 32

ECG Indication for New Pacemaker Implants ECG Indication for all new implants in England 20 AF + HB/brady 22% Sick sinus syndrome 28% Other 6% Complete heart block 2% Incomplete heart block 23% AF: atrial fibrillation HB: heart block Brady: bradycardia 33

New Pacemaker Implant Rates corrected for Age and Sex Explanatory note: The "corrected rate (R), expressed as implants per million population, is calculated using the following formula: R A x06 B.C where A = number of new implants B = population C = relative need 20 New Pacemaker Implant Rates for PCTs in this Network Population Need for Pacing New PM Implants 00% ENGLAND Corrected New PM Implant Rate Deficit/ Excess compared to target rate of 700 524 This network 750,76 9% 300 335 52% 5CN Herefordshire 83,69 29% 85 360 49% 5PL Worcestershire 566,557 6% 25 326 53% 34

New ICD Implant Rates corrected for Age and Sex 20 New ICD Implant Rates for PCTs in this Network Population Need for ICD New ICD Implants 00% ENGLAND Corrected New ICD Implant Rate Deficit/ Excess compared to target rate of 00 76 This network 750,76 6% 326 56 44% 5CN Herefordshire 83,69 2% 6 72 28% 5PL Worcestershire 566,557 4% 33 5 49% Note: values between 95% and 05% are not considered significantly different from the target rate so are in black text. 35

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New Implant Rate Maps 37

Pacemaker Implant Deficit in 20 The table below shows how many extra pacemakers each PCT would need to commission to bring the implant rate up to the national recommended target rate for new pacemaker implants (700). If the value shown is zero, then the PCT is already commissioning enough devices to reach the target rate. Pacemaker Implant Deficit in 20 Population Deficit/ Excess compared to target rate of 700 New Pacemaker Implant Deficit (number of devices) 5CN Herefordshire 83,69 49% 62 5PL Worcestershire 566,557 53% 22 Herefordshire Worcestershire 0 50 implant deficit 62 00 50 200 22 250 38

Conclusions The Network population is older than average so there is an 9% greater need for pacemakers and 6% greater for ICDs than the national average. Implant rates for all device classes are seriously below the national average. The situation is particularly drastic for PM which fell sharply from an already low level; the rate is now only half the national target, and is far from the national average. This would suggest the need for a local pacing policy review. The ICD implant rate rose in both PCTs, but the overall rate is below the national average. For CRT, a substantial rise in 200 has been followed by a small fall in 20, so that this rate is also below the national average. Data quality and completeness are generally satisfactory for demographic and basic clinical fields except at QEB Edgbaston (NHS number) and County Hospital Hereford (aetiology). Physiological pacemaker prescription in the Network mirrors the national average overall, although at Cheltenham there is a high rate of ventricular pacing. For sick sinus syndrome specifically Worcestershire Royal Hospital uses a high rate of ventricular based pacing; this is not compliant with NICE guidance. 39