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
Acknowledgments The implant registration data that allows the construction of reports such as this is contributed on a voluntary basis by all pacemaker implanting hospitals in the United Kingdom. The data is held in the National Pacemaker Database, established in 1977 by Dr Anthony Rickards, and now part of the Central Cardiac Audit Database (CCAD www.ccad.org.uk) which runs the national cardiac audits as part of the National Institute for Cardiovascular Outcomes Research (NICOR), which is part of University College London. Anonymised extracts from the National Pacemaker Database were used to generate this report, with the express permission of the owners of the data, Heart Rhythm UK and the full agreement of the Department of Health Heart Team and HQIP. This national audit is funded as part of the National Clinical Audit & Patient Outcome Programme (NCAPOP), which is managed by the Healthcare Quality Improvement Partnership (HQIP www.hqip.org.uk). The preparation of this report was supported by HQIP. Data collection was carried out by CCAD 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 Network Devices Survey Group. The report may be downloaded from www.devicesurvey.com British Cardiovascular Society 2
Contents Analysis of Provision of Heart Rhythm Devices for Acknowledgments... 2 Data Quality Statement... 4 Overview of Device Implants in the UK... 6 The Range of New Implant rate 2010... 8 PCTs/LHBs in the Network...11 Network Age and Sex Distribution...12 Correcting Implant Rates for Age and Sex...13 Relative need for Pacemakers and ICDs...15 New and Total PM and ICD Implants...16 Geographical location of pacemaker implants...19 New and Total PM and ICD Implants...20 CRT implants in this network...22 Geographical location of Complex Devices implants...25 Which hospitals serve which PCTs/LHBs?...27 Pacing Mode for New Implants...29 Pacing Mode for Sick Sinus Syndrome...31 ECG Indication for New Implants...33 Corrected and Actual New Implant Rates...34 New Implant rate maps for...38 New pacing implant rate 2010...39 ICD new implant rate 2010...40 Pacing Implant Deficit in 2010...41 Conclusions...42 3
Data Quality Statement The quality of the analyses in this report is only as good as the quality of the data that supports it. That data is originally submitted by hospitals to the National Pacemaker Database. If there is a deficit in registration, or if registrations do not contain a valid postcode, then analysis gaps are inevitable. Data is then anonymised and extracted to provide the basis of the analysis by the Survey Group. To minimise the risk of deficit errors, a threshold of 98% for registration and postcode completeness is sought for each hospital. Overall network completeness MUST reach 98% or a report will not be issued. Every effort is made to ensure this report is as accurate as possible - however please contact us if you identify any residual problem and we will try to correct the error promptly. Below is a list of important hospitals for this network and their completeness of VALID postcodes during the study period. Valid Postcodes Overall network average 100.00% Main implant Centres BOU.Royal Bournemouth General Hospital 100.00% PGH.Poole General Hospital 100.00% SAL.Salisbury District Hospital 100.00% SGH.Wessex Cardiothoracic Centre 99.87% WDH.Dorset County Hospital 100.00% YEO.Yeovil District Hospital 100.00% Note: Implant centres shown have implanted at least 10 devices in the network. 4
Data Quality and Completeness Listed below are important fields and their completion rates with valid entries. All Devices ICD, CRT- D & CRT-P Network / Implant Centre Valid Post Code Valid NHS No Valid Gender Valid DOB ECG Symptom Aetiology Target 98.0% 98.0% 98.0% 98.0% 90.0% 90.0% 90.0% England 99.4% 84.0% 99.9% 99.8% 94.5% 94.0% 94.6% This Network 100.0% 92.6% 100.0% 99.9% 96.1% 96.1% 93.6% Royal Bournemouth General Hospital 100.0% 100.0% 100.0% 100.0% 96.0% 96.0% 97.9% Poole General Hospital 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% - Dorset County Hospital 100.0% 81.9% 100.0% 100.0% 100.0% 100.0% 83.1% Network / Implant Centre NYHA Dyspnoea Status CRT-D & ICD LV Function ICD Indication CRT-D & CRT-P QRS duration Overall index of valid data completeness Target 90.0% 90.0% 90.0% 90.0% 90.0% England 63.5% 74.5% 57.5% 27.9% 84.4% This Network 54.9% 75.6% 0.0% 4.9% 78.6% Royal Bournemouth General Hospital 87.4% 93.3% 0.0% 0.0% 84.6% Poole General Hospital - - - - 105.1% Dorset County Hospital 0.0% 35.4% 0.0% 0.0% 67.6% 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
Overview of Device Implants in the UK New pacemakers Comments: The ten year average growth rate is 4.1% Implant rates decreased slightly in England and in Wales. The new PM implant rates decreased significantly in Northern Ireland. There is a substantial shortfall in data submission from Scotland, data has been suppressed post 2008. New pacing rate remains highest in England (528 new implants per million population in 2010). per million population 600 500 400 300 200 100 0 England Wales Scotland N Ireland 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 year New ICD implants Comments: The ten year average growth rate is 14.9% ICD implant rate remains highest in N Ireland. (There is a substantial shortfall in data submission from Scotland). ICD implant rate increased significantly in England and in Wales in 2010. per million population 140 120 100 80 60 40 20 0 England Wales Scotland N Ireland 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 year 6
New CRT implants Comments New CRT rate increased significantly in England and remained the highest rate. The new CRT rate also increased in N Ireland, Wales and Scotland in 2010. (There is a substantial shortfall in data submission from Scotland). per million population 120 100 80 60 40 20 0 England Wales Scotland N Ireland 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 year Total CRT implants Comments The total CRT rate rose significantly in England for the last three years. Total CRT implants Rate was highest in England (114 new implants per million population in 2010). The total CRT rate also increased in N Ireland, Wales and Scotland in 2010. (There is a substantial shortfall in data submission from Scotland). per million population 140 120 100 80 60 40 20 0 England Wales Scotland N Ireland 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 year 7
The Range of New Implant rate 2010 grey line represents national average Pacemaker New Implant rate 2010 adjusted for age and sex Bedfordshire and Hertfordshire Heart and Stroke Network Surrey Heart & Stroke Network North & East Yorkshire and Northern Lincolnshire Cardiac Network Kent Cardiovascular Network North West London Cardiac and Stroke Network Sussex Heart Network North of England Cardiovascular Network South West London Cardiac Network Cheshire & Merseyside Cardiac Network Cardiac and Stroke Networks in Cumbria and Lancashire Greater Manchester & Cheshire Cardiac Network South Central Cardiovascular Network West Yorkshire Cardiac Network Black Country Cardiovascular Network Essex Cardiac and Stroke Network North Central London Cardiac & Stroke Network Anglia Stroke and Heart Network North Trent Network of Cardiac Care South East London Cardiac & Stroke Network North East London Cardiac and Stroke Network Peninsula Heart and Stroke Network Birmingham, Sandwell and Solihull Cardiac and Stroke Network East Midlands Cardiac and Stroke Network Shropshire & Staffordshire Cardiac Network Avon, Gloucestershire, Wiltshire & Somerset Cardiac and Stroke Network Herefordshire and Worcestershire Cardiac Network Coventry & Warwickshire Cardiovascular Network 0 100 200 300 400 500 600 700 800 8
The Range of New Implant rate 2010 grey line represents national average ICD New Implant rate 2010 adjusted for age and sex North East London Cardiac and Stroke Network Kent Cardiovascular Network Bedfordshire and Hertfordshire Heart and Stroke Network North Central London Cardiac & Stroke Network South East London Cardiac & Stroke Network North West London Cardiac and Stroke Network South Central Cardiovascular Network Avon, Gloucestershire, Wiltshire & Somerset Cardiac and Stroke Network North of England Cardiovascular Network Sussex Heart Network East Midlands Cardiac and Stroke Network Cheshire & Merseyside Cardiac Network Surrey Heart & Stroke Network Black Country Cardiovascular Network West Yorkshire Cardiac Network North Trent Network of Cardiac Care South West London Cardiac Network Birmingham, Sandwell and Solihull Cardiac and Stroke Network Coventry & Warwickshire Cardiovascular Network Greater Manchester & Cheshire Cardiac Network Essex Cardiac and Stroke Network Shropshire & Staffordshire Cardiac Network Peninsula Heart and Stroke Network North & East Yorkshire and Northern Lincolnshire Cardiac Network Anglia Stroke and Heart Network Cardiac and Stroke Networks in Cumbria and Lancashire Herefordshire and Worcestershire Cardiac Network 0 20 40 60 80 100 120 140 9
The Range of Total Implant rate 2010 grey line represents national average All CRT Total Implant rate 2010 adjusted for age and sex includes CRTD and CRTP North West London Cardiac and Stroke Network Birmingham, Sandwell and Solihull Cardiac and Stroke Network Cheshire & Merseyside Cardiac Network Greater Manchester & Cheshire Cardiac Network South East London Cardiac & Stroke Network West Yorkshire Cardiac Network South West London Cardiac Network Bedfordshire and Hertfordshire Heart and Stroke Network Kent Cardiovascular Network North Central London Cardiac & Stroke Network Black Country Cardiovascular Network Surrey Heart & Stroke Network North & East Yorkshire and Northern Lincolnshire Cardiac Network Cardiac and Stroke Networks in Cumbria and Lancashire Sussex Heart Network Anglia Stroke and Heart Network South Central Cardiovascular Network Peninsula Heart and Stroke Network North East London Cardiac and Stroke Network Coventry & Warwickshire Cardiovascular Network Herefordshire and Worcestershire Cardiac Network Avon, Gloucestershire, Wiltshire & Somerset Cardiac and Stroke Network Shropshire & Staffordshire Cardiac Network Essex Cardiac and Stroke Network North of England Cardiovascular Network East Midlands Cardiac and Stroke Network North Trent Network of Cardiac Care 0 20 40 60 80 100 120 140 160 180 200 10
PCTs/LHBs in the Network Total population 0.7 million. Code PCT/LHB Population Old PCT (where relevant*) 5QM Dorset 403,046 5QN Bournemouth and Poole 298,038 * 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
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 5QM Population: 403,046 0-5: 9,378 8,914 46-50: 13,542 14,109 Average age: 45.3 6-10: 10,639 10,269 51-55: 12,707 13,375 % aged 70+: 17.7% 11-15: 12,796 12,141 56-60: 14,827 16,394 * Older than national average 5QN 16-20: 14,585 11,984 61-65: 14,010 15,251 21-25: 8,670 7,028 66-70: 11,570 12,580 26-30: 7,667 7,370 71-75: 10,446 11,766 31-35: 8,748 9,446 76-80: 8,908 11,064 36-40: 11,878 13,022 81-85: 6,301 9,114 41-45: 13,813 14,804 85+: 4,771 9,159 Population: 298,038 0-5: 7,501 7,341 46-50: 9,533 9,812 Average age: 42.6 6-10: 7,607 7,195 51-55: 8,443 8,712 % aged 70+: 15.6% 11-15: 8,363 8,036 56-60: 9,414 9,831 * Older than national average Dorset Bournemouth and Poole 16-20: 9,639 9,382 61-65: 8,379 8,363 21-25: 10,722 10,147 66-70: 6,681 7,225 26-30: 9,080 9,168 71-75: 5,913 7,347 31-35: 9,092 9,596 76-80: 5,404 7,380 36-40: 10,318 10,374 81-85: 4,164 6,365 41-45: 10,567 10,879 85+: 3,139 6,926 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%. 12
Correcting Implant Rates for Age and Sex Calculating Need Most pacemakers are implanted for conduction system disease, which is predominantly a disease of the elderly. The graph (right) shows the percentage of the population in 5 year age bands, and the percentage of pacemaker implants. Only 11% of the population are aged 70 or more, but they receive 76% of all pacemaker implants. Men also receive more pacemakers than women. Although the national average new implant rate is 528, it reaches more than 11,000 in men aged more than 90 (right). So the proportion of older people in a local population will strongly influence how many pacemakers need to be implanted. If we examine closely the age and sex distribution of the local population of a PCT (LHB in Wales) or Network, we can work out how many pacemakers we would EXPECT to see implanted, compared to the national average. The ratio of the local and national rate is called the Relative Need, and we calculate this for both pacemakers and ICDs. So, for example, in North East London the population is relatively young. Only 8% are aged 70 or more, compared to the national average of 11%. This means that this network doesn't need as many pacemaker implants relative to the nation as a whole. Their Relative Need for Pacing is calculated to be 80% of the national average. In contrast, Sussex has a more elderly population, with 16% aged 70 or over. Their Relative Need for Pacing is 140%. 13
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%. 14
Relative need for Pacemakers and ICDs Indicative new implant rate Pacemakers: 528 ICD: 72 (average for England 2010) Average age: 39.44 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 5QM Dorset 45.3 816 154.6% 95 133% Bournemouth and 5QN Poole 42.6 677 128.2% 77 108% Cardiac Network - Relative Need for New Implant Rate 756 143.38% 87 122.51% England (for comparison) England 528 100% 72 100% 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. 15
New and Total PM and ICD Implants Pacemakers The following hospitals implanted pacemakers in patients from this cardiac network in 2010. A new pacemaker centre will implant nearly 100% new implants, and the longer a centre has been implanting, the higher the percentage of replacements implants. The national average for replacement implants is 21.79% of the total workload. This should always be borne in mind when forecasting future workload. 2010 Replacement implants Centre New Implants Total Implants % of total BOU Royal Bournemouth General Hospital 284 402 29.35% WDH Dorset County Hospital 185 224 17.41% PGH Poole General Hospital 152 201 24.38% YEO Yeovil District Hospital 21 30 30.00% SGH Wessex Cardiothoracic Centre 17 22 22.73% SAL Salisbury District Hospital 14 17 17.65% RDE Royal Devon & Exeter Hospital 3 4 25.00% BRI Bristol Royal Infirmary 3 4 25.00% MPH Taunton & Somerset Hospital 2 3 33.33% STH St Thomas Hospital 2 2 QEG Queen Elizabeth Hospital 1 1 SCU Scunthorpe General Hospital 1 1 HSC Harley Street Clinic 1 NHB Royal Brompton Hospital 1 1 UCL University College Hospital 1 1 WAT Watford General Hospital 1 1 BAL Barts and the London 1 1 WRC Worcester Royal Hospital 1 1 HHW Wellington Hospital North 1 1 16
Pacemaker implant trends 1100 Pacemaker New Implant Rate adjusted for age and sex of network population 1000 900 per million population 800 700 600 500 400 300 200 England 100 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 year 1600 Pacemaker All Implant Rate adjusted for age and sex of network population 1400 1200 per million population 1000 800 600 400 200 England 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 year 17
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. 1200 1000 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 800 600 400 consistent with national target 200 significantly below national target 0 0 200,000 400,000 600,000 800,000 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%. 18
Geographical location of pacemaker implants 19
New and Total PM and ICD Implants Implantable Cardioverter Defibrillators (ICDs) The following hospitals implanted ICDs in patients from this cardiac network in 2010. 2010 Replacement implants Centre New Implants Total Implants % of total BOU Royal Bournemouth General Hospital 66 69 4.35% WDH Dorset County Hospital 30 30 SGH Wessex Cardiothoracic Centre 5 12 58.33% BHD Beaumont Hospital 1 1 STH St Thomas Hospital 1 1 UCL University College Hospital 1 20
ICD implant trends 140 ICD New Implant Rate adjusted for age and sex of network population 120 per million population 100 80 60 40 20 0 England 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 year 180 ICD All Implant Rate adjusted for age and sex of network population 160 140 per million population 120 100 80 60 40 20 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 year England 21
CRT implants in this network Heart failure is a major and growing public health problem in all Western countries, and is associated with high morbidity and mortality despite optimal medical therapy. Clinical trials of high scientific quality published in recent years have consistently found that cardiac resynchronisation therapy (CRT) improves symptoms, quality of life, exercise tolerance and survival in appropriately chosen patients with advanced heart failure and evidence of left ventricular dyssynchrony who are refractory to optimal medical therapy. CRT involves simultaneous pacing of the left and right ventricles (CRT-P), and may be combined, in the same device, with a defibrillation function (CRT-D). Although CRT involves pacing the heart, it should not be confused with 'classical' pacing for bradycardia - the vast majority of CRT recipients do not require pacing for bradycardia. The function of pacing is to make the ventricles beat at the same time ('resynchronisation'). Within this report, data for CRT-P and CRT-D are quantified separately from pacing and ICD data respectively. In the UK, CRT is provided predominantly by tertiary centres with a special interest in cardiac device therapy. Despite the high prevalence of heart failure, uptake of CRT in the UK is amongst the lowest in Western Europe. NICE published guidelines on the cost effectiveness of CRT in 2007, and it is expected that clinical demand for CRT therapy will continue to rise significantly in coming years. CRT implanting hospitals in this network CRT-D CRT-P 2001 Harefield Hospital 2 Wessex Cardiothoracic Centre 4 Yeovil District Hospital 1 Royal Bournemouth General Hospital 1 CRT-D CRT-P 2002 Wessex Cardiothoracic Centre 18 2 Taunton & Somerset Hospital 1 CRT-D CRT-P 2003 Wessex Cardiothoracic Centre 13 2 Yeovil District Hospital 1 Taunton & Somerset Hospital 1 King's College Hospital 1 CRT-D CRT-P 2004 Wessex Cardiothoracic Centre 39 4 University College Hospital 4 1 Harefield Hospital 1 Royal Bournemouth General Hospital 1 CRT-D CRT-P 2005 Wessex Cardiothoracic Centre 17 4 22
2005 Royal Devon & Exeter Hospital 1 1 Royal Bournemouth General Hospital 12 Taunton & Somerset Hospital 1 University College Hospital 2 Dorset County Hospital 16 Harefield Hospital 1 London Bridge Hospital 1 CRT-D CRT-P 2006 Royal Bournemouth General Hospital 23 15 Dorset County Hospital 1 16 Wessex Cardiothoracic Centre 11 1 Harefield Hospital 2 Royal Brompton Hospital 2 St Thomas Hospital 1 CRT-D CRT-P 2007 Royal Bournemouth General Hospital 52 14 Dorset County Hospital 14 8 Yeovil District Hospital 1 Royal Devon & Exeter Hospital 1 Wessex Cardiothoracic Centre 4 University College Hospital 1 St George's Hospital 1 CRT-D CRT-P 2008 Royal Bournemouth General Hospital 52 18 Dorset County Hospital 22 22 Wessex Cardiothoracic Centre 7 1 Royal Brompton Hospital 1 CRT-D CRT-P 2009 Royal Bournemouth General Hospital 93 37 Dorset County Hospital 25 10 Wessex Cardiothoracic Centre 4 1 Taunton & Somerset Hospital 2 1 Yeovil District Hospital 1 Royal Devon & Exeter Hospital 1 John Radcliffe Hospital 1 Harefield Hospital 1 CRT-D CRT-P 2010 Royal Bournemouth General Hospital 31 67 Dorset County Hospital 16 17 Wessex Cardiothoracic Centre 3 King's College Hospital 1 23
CRT implant trends 180 160 CRT New Implant Rate adjusted for age and sex of network population 140 England per million population 120 100 80 60 40 20 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 year 200 CRT All Implant Rate adjusted for age and sex of network population per million population 180 160 140 120 100 80 60 England 40 20 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 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. 24
Geographical location of Complex Devices implants 25
The European Picture European data for 2010 shows that the UK has average CRT implant rates compared to the Western Europe implant rates, and far below the rate in the U.S.A.. Greece Spain Ireland Portugal Finland Norway Switzerland Sweden France Austria UK Belgium Denmark Netherlands Czech Republic Germany Italy Total CRT-P & CRT-D Implants 2010 0 50 100 150 200 250 26
Which hospitals serve which PCTs/LHBs? all implants for this cardiac network in 2010 Pacemakers 5QM.Dorset Total Implants 2010 WDH Dorset County Hospital 224 BOU Royal Bournemouth General Hospital 174 PGH Poole General Hospital 71 YEO Yeovil District Hospital 30 SAL Salisbury District Hospital 17 SGH Wessex Cardiothoracic Centre 11 RDE Royal Devon & Exeter Hospital 4 MPH Taunton & Somerset Hospital 3 HHW Wellington Hospital North 1 QEG Queen Elizabeth Hospital 1 NHB Royal Brompton Hospital 1 HSC Harley Street Clinic 1 SCU Scunthorpe General Hospital 1 BRI Bristol Royal Infirmary 1 STH St Thomas Hospital 1 UCL University College Hospital 1 WAT Watford General Hospital 1 BAL Barts And The London 1 WRC Worcester Royal Hospital 1 5QN.Bournemouth and Poole Total Implants 2010 BOU Royal Bournemouth General Hospital 228 PGH Poole General Hospital 130 SGH Wessex Cardiothoracic Centre 11 BRI Bristol Royal Infirmary 3 STH St Thomas Hospital 1 Implantable Cardioverter Defibrillators (ICDs) 5QM.Dorset Total Implants 2010 WDH Dorset County Hospital 30 BOU Royal Bournemouth General Hospital 26 SGH Wessex Cardiothoracic Centre 5 STH St Thomas Hospital 1 27
5QN.Bournemouth and Poole Total Implants 2010 BOU Royal Bournemouth General Hospital 43 SGH Wessex Cardiothoracic Centre 7 UCL University College Hospital 1 BHD Beaumont Hospital 1 Cardiac Resynchronisation Therapy (CRT) 5QM.Dorset Total Implants 2010 BOU Royal Bournemouth General Hospital 34 WDH Dorset County Hospital 33 SGH Wessex Cardiothoracic Centre 3 KCH King's College Hospital 1 5QN.Bournemouth and Poole Total Implants 2010 BOU Royal Bournemouth General Hospital 64 28
Pacing Mode for New Implants for this cardiac network Pacemakers Mode % for this network England % Atrial based modes DDDR 65.36% 61.54% DDD 0.14% 4.53% AAIR 0.14% 0.52% AAI 0.00% 0.05% DDI 0.00% 0.06% DDIR 0.00% 0.02% Other 0.00% 0.15% Ventricular based modes VVIR 33.33% 31.28% VVI 1.01% 1.57% VDDR 0.00% 0.04% VDD 0.00% 0.25% Note: The Mode table percentage calculations do not include any records where the mode was blank or unknown. Network England Ventricular based 34% Blank/ Unknown 0.3% Ventricular based 33% Blank/ Unknown 1% Atrial based 66% Atrial based 66% Note: The Network and England charts percentage segments are calculated based on the records in the Mode table but also include all records where the mode was blank or unknown. 29
Pacing Mode for New Implants major implanting hospitals in this cardiac network VVI VVIR AAI AAIR DDD DDDR VDD VDDR Atrial Based Pacing NATIONAL 1.6% 31.4% 0.0% 0.5% 4.5% 61.7% 0.3% 0.0% 66.8% This Network 1.0% 33.3% 0.0% 0.1% 0.1% 65.4% 0.0% 0.0% 65.7% BOU.Royal Bournemouth General Hospital 0.0% 30.3% 0.0% 0.0% 0.0% 69.7% 0.0% 0.0% 69.7% PGH.Poole General Hospital 0.0% 33.6% 0.0% 0.0% 0.0% 66.4% 0.0% 0.0% 66.4% WDH.Dorset County Hospital 0.0% 36.8% 0.0% 0.0% 0.0% 63.2% 0.0% 0.0% 63.2% 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. 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 81% in 2009 and 84% in 2010. 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 BOU.Royal Bournemouth General Hospital 83 84.3% 15.7% PGH.Poole General Hospital 43 83.7% 16.3% WDH.Dorset County Hospital 45 91.1% 8.9% 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 2005. http://www.nice.org.uk/ta88 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. 32
ECG Indication for New Implants Complete HB Incomplete HB AF + HB/brady Sick sinus syndrome Other NATIONAL 22.7% 22.8% 23.5% 27.5% 6.2% This Network 19.0% 22.3% 25.3% 28.1% 5.2% 5QM.Dorset 20.4% 20.7% 25.5% 29.1% 4.3% 5QN.Bournemouth and Poole 17.0% 24.7% 25.1% 26.6% 6.6% AF: atrial fibrillation HB: heart block Brady: bradycardia 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. England Average 528 Network average (unadjusted) 988 Network average (corrected for age and sex) 687 Population Relative need for PM New Implant Rate 2010 Raw Corrected 5QM Dorset 403,046 154.6% 1058 685 5QN Bournemouth and Poole 298,038 128.2% 894 697 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 1.3% 1% RATING: small variation in implant rates between PCTs 34
New Pacemaker Implant Rates The Western European average new implant rate for 2003 and 2004 was 700 per million population. This figure is also now the HRUK target and will be used as the basis for comparison. England Average 528 Network average (unadjusted) 988 Network average (corrected for age and sex) 687 Population Corrected New Implant Rate 2010 Deficit/ Excess 2010 compared to rate of 700 5QM Dorset 403,046 685-2% 5QN Bournemouth and Poole 298,038 697-0.4% 35
Corrected and Actual New Implant Rates Implantable Cardioverter Defibrillators (ICDs) Explanatory note: The "Raw" new implant rate is the actual implant rate of new ICDs per million population in each PCT. The "Corrected" rate is the raw rate, adjusted for relative need - so if a PCT has an aging population, its relative need is > 100% and its corrected rate will be reduced to reflect that need. Comparisons between PCTs should be made using Corrected rate. England Average 72 Network average (unadjusted) 147 Network average (corrected for age and sex) 121 Population Relative need for ICD New Implant Rate 2010 Raw Corrected 5QM Dorset 403,046 133.1% 139 104 5QN Bournemouth and Poole 298,038 108.2% 158 146 36
New ICD Implant Rates A target figure of 100 implants per million is used as a basis for comparison, based on recent NICE guidance. England Average 72 Network average (unadjusted) 147 Network average (corrected for age and sex) 121 Population Corrected New Implant Rate 2010 Deficit/ Excess 2010 compared to rate of 100 5QM Dorset 403,046 104 4% 5QN Bournemouth and Poole 298,038 146 46% 37
New Implant rate maps for Dorset Cardiac Network 38
New pacing implant rate 2010 comparison with Heart Rhythm UK target (700) Pacemaker New Implants 2010 adjusted for age and sex compared to target figure of 700 per million Dorset Bournemouth and Poole -3% -2% -2% -1% -1% 0% 39
ICD new implant rate 2010 ICD New Implants 2010 adjusted for age and sex compared to target figure of 100 per million Dorset Bournemouth and Poole 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% 40
Pacing Implant Deficit in 2010 comparison with HRUK recommendations The graph shows the NUMBER of additional new pacemakers implants that each PCT needs to implant to bring them up to the HRUK target rate. Deficit in New Pacemaker Implants 2010 compared to Heart Rhythm UK target rate of 700 0-2 Bournemouth and Poole Dorset -4-6 -8-10 -12 41
Conclusions The age structure of the Network is significantly older than the national average, resulting in a much higher relative need for pacemakers (by 43%) and ICDs (by 23%). As one would expect rural Dorset has the oldest population, but the urban areas of Bournemouth/Poole are also relatively old. The network new pacemaker implant rate remained static and continues to track well above the national average and just below the national target. The pacemaker implantation rate is the highest in England and Wales. The network new ICD implant rate increased significantly and is well above the national target. The CRT total implant rate has decreased in 2010, the rate remains above the national target. The proportion of atrial based pacing (66%) matches the national average. Poole General Hospital (16%) and Royal Bournemouth General Hospital have higher than desirable rates of ventricular based pacemaker implants for sick sinus syndrome; this is not compliant with NICE TAG 88 (2005). There are significant data deficits (p5) at Royal Bournemouth and Dorset County Hospitals in respect of CRT-D/ICD data. It will enhance the value of the audit if these deficits can be addresses in 2011. 42