Anglia Stroke and Heart Network

David Cunningham Director, Central Cardiac Audit Database Richard Charles Chairman, Network Device Survey Group Morag Cunningham CRM Database Coordinator, Central Cardiac Audit Database Adél de Lange Data analyst, Central Cardiac Audit Database

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 133-155 Waterloo Road London SE1 8UG England Phone: 0207 972 2000 2

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 2009... 8 PCTs/LHBs in the Network...11 Network Age and Sex Distribution...12 Correcting Implant Rates for Age and Sex...14 Relative need for Pacemakers and ICDs...16 New and Total PM and ICD Implants...17 Geographical location of pacemaker implants...20 New and Total PM and ICD Implants...21 CRT implants in this network...23 Which hospitals serve which PCTs/LHBs?...27 Pacing Mode for New Implants...30 Pacing Mode for Sick Sinus Syndrome...32 ECG Indication for New Implants...34 Corrected and Actual New Implant Rates...35 New Implant rate maps for...40 New pacing implant rate 2009...41 ICD new implant rate 2009...42 Pacing Implant Deficit in 2009...43 Conclusions...44 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. 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 99.88% Main implant Centres ADD.Addenbrooke's Hospital 100.00% IPS.The Ipswich Hospital 100.00% NOR.Norfolk and Norwich Hospital 99.85% PAP.Papworth Hospital 99.66% 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 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% 75.7% 100.0% 95.0% 96.6% 95.9% 85.6% Addenbrooke's Hospital 100.0% 15.3% 100.0% 100.0% 99.1% 99.1% 100.0% The Ipswich Hospital 100.0% 94.8% 100.0% 100.0% 98.1% 97.1% - Norfolk and Norwich Hospital 99.8% 54.4% 99.8% 83.6% 97.9% 97.2% 75.7% Papworth Hospital 99.7% 96.5% 100.0% 100.0% 95.5% 95.3% 88.9% 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 66.2% 59.7% 15.7% 21.3% 77.2% Addenbrooke's Hospital 48.4% 67.7% 80.6% 86.8% 81.0% The Ipswich Hospital - - - - 103.3% Norfolk and Norwich Hospital 41.2% 17.6% 36.5% 13.1% 68.6% Papworth Hospital 86.0% 84.3% 0.0% 0.0% 82.2% 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 4.7% 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 600 500 400 300 200 100 0 England Wales Scotland N Ireland 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 year New ICD implants Comments: 120 100 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 80 60 40 20 ICD implant rate remained static in England and rose slightly in Wales in 2009. 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 year 6

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 2009. (There is a substantial shortfall in data submission from Scotland). per million population 100 90 80 70 60 50 40 30 20 10 0 England Wales Scotland N Ireland 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 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 120 100 80 60 40 20 England Wales Scotland N Ireland 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 year 7

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 Cardiac and Stroke Networks in Cumbria and Lancashire North of England Cardiovascular Network Black Country Cardiovascular Network Surrey Heart & Stroke Network South Central Cardiovascular Network North & East Yorkshire and Northern Lincolnshire Cardiac 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 0 100 200 300 400 500 600 700 800 8

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 North of England 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 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 0 20 40 60 80 100 120 9

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 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 of England Cardiovascular Network North Trent Network of Cardiac Care Herefordshire and Worcestershire Cardiac Network 0 50 100 150 200 250 10

PCTs/LHBs in the Network Total population 2.29 million. Code PCT/LHB Population Old PCT (where relevant*) 5PN Peterborough 163,265 5PP Cambridgeshire 589,605 5PQ Norfolk 739,043 5PR Great Yarmouth and Waveney 210,156 5PT Suffolk 585,281 * 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 5PN Population: 163,265 0-5: 5,729 5,439 46-50: 5,300 5,465 Average age: 38.3 6-10: 5,105 4,913 51-55: 4,620 4,929 % aged 70+: 10.1% 11-15: 5,428 5,212 56-60: 4,871 4,952 * Younger than national average 5PP 16-20: 5,602 5,355 61-65: 3,741 3,959 21-25: 5,271 5,227 66-70: 3,067 3,218 26-30: 5,936 5,799 71-75: 2,587 3,079 31-35: 6,413 5,953 76-80: 2,112 2,621 36-40: 6,725 6,401 81-85: 1,358 2,020 41-45: 6,052 6,150 85+: 835 1,821 Population: 589,605 0-5: 16,930 15,859 46-50: 20,123 19,983 Average age: 39.8 6-10: 16,951 16,640 51-55: 17,940 18,268 % aged 70+: 10.8% 11-15: 18,014 17,037 56-60: 19,072 19,545 5PQ 16-20: 20,215 18,667 61-65: 15,923 16,273 21-25: 22,095 20,620 66-70: 12,288 12,789 26-30: 19,753 18,141 71-75: 9,983 11,119 31-35: 20,228 20,372 76-80: 8,048 9,833 36-40: 23,167 23,159 81-85: 5,381 7,868 41-45: 22,880 22,791 85+: 3,638 8,012 Population: 739,043 0-5: 18,556 17,523 46-50: 24,068 24,378 Average age: 43.3 6-10: 19,675 18,972 51-55: 22,534 24,032 % aged 70+: 15.0% 11-15: 21,570 20,834 56-60: 26,500 27,850 * Older than national average Peterborough Cambridgeshire Norfolk 16-20: 22,515 21,351 61-65: 23,923 24,676 21-25: 22,419 21,306 66-70: 19,905 20,786 26-30: 20,028 19,423 71-75: 17,496 18,863 31-35: 20,886 21,580 76-80: 14,031 16,836 36-40: 25,499 25,197 81-85: 9,638 13,689 41-45: 26,086 26,433 85+: 6,449 13,536 12

Population PCT / LHB Age Male Female Age Male Female 5PR Population: 210,156 0-5: 5,409 5,208 46-50: 6,744 6,773 Average age: 43.5 6-10: 5,727 5,643 51-55: 6,396 6,763 % aged 70+: 15.5% 11-15: 6,656 6,326 56-60: 7,752 8,050 * Older than national average 5PT 16-20: 6,865 6,461 61-65: 6,984 7,377 21-25: 5,589 5,352 66-70: 5,956 6,055 26-30: 4,820 4,909 71-75: 4,910 5,659 31-35: 5,424 5,708 76-80: 3,935 5,099 36-40: 6,763 7,179 81-85: 2,851 3,971 41-45: 7,056 7,608 85+: 1,973 4,205 Population: 585,281 0-5: 16,945 16,309 46-50: 19,920 19,682 Average age: 41.6 6-10: 17,421 16,547 51-55: 17,824 18,454 % aged 70+: 13.1% 11-15: 18,825 17,645 56-60: 20,301 21,165 * Older than national average Great Yarmouth and Waveney Suffolk 16-20: 18,641 17,576 61-65: 17,237 18,070 21-25: 16,381 14,657 66-70: 14,108 14,472 26-30: 17,280 16,146 71-75: 12,033 12,929 31-35: 18,029 18,123 76-80: 9,765 11,669 36-40: 21,350 21,295 81-85: 6,425 9,677 41-45: 21,828 22,361 85+: 4,582 9,609 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%. 13

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%. 14

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%. 15

Relative need for Pacemakers and ICDs Indicative new implant rate Pacemakers: 534 ICD: 64 (average for England 2009) 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 5PN Peterborough 38.3 477 89.3% 61 95% 5PP Cambridgeshire 39.8 518 96.9% 63 99% 5PQ Norfolk 43.3 690 129.2% 77 121% Great Yarmouth and 5PR Waveney 43.5 698 130.7% 76 119% 5PT Suffolk 41.6 627 117.4% 72 112% Cardiac Network - Relative Need for New Implant Rate 615 115.13% 71 110.96% England (for comparison) England 534 100% 64 100% 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. 16

New and Total PM and ICD Implants Pacemakers The following hospitals implanted pacemakers in patients from this cardiac network in 2009. 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. 2009 Replacement implants Centre New Implants Total Implants % of total PAP Papworth Hospital 530 705 24.82% NOR Norfolk and Norwich Hospital 431 544 20.77% IPS The Ipswich Hospital 228 306 25.49% ADD Addenbrooke's Hospital 144 151 4.64% UCL University College Hospital 4 6 33.33% COL Colchester General Hospital 5 5 STH St Thomas Hospital 3 3 GOS The Hospital for Sick Children 2 3 33.33% MKH Milton Keynes General Hospital 3 YDH York District Hospital 2 SPH St Peter's Hospital 2 2 OAK Oaks Hospital Colchester 1 1 LIS Lister Hospital 1 1 HH Harefield Hospital 1 NHB Royal Brompton Hospital 1 BED Bedford Hospital 1 1 GUY Guy's Hospital 1 1 RCH Royal Cornwall Hospital 1 1 SCA Scarborough General Hospital 1 1 BOU Royal Bournemouth General Hospital 1 GRL Glenfield Hospital 1 GEO St George's Hospital 1 1 WAR Warwick Hospital 1 1 HSC Harley Street Clinic 1 1 17

Pacemaker implant trends 600 Pacemaker New Implant Rate adjusted for age and sex of network population 550 500 per million population 450 400 350 300 250 200 150 England 100 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 year 800 Pacemaker All Implant Rate adjusted for age and sex of network population 700 600 per million population 500 400 300 200 100 England 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 year 18

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%. 19

Geographical location of pacemaker implants 20

New and Total PM and ICD Implants Implantable Cardiac Defibrillators (ICDs) The following hospitals implanted ICDs in patients from this cardiac network in 2009. 2009 Replacement implants Centre New Implants Total Implants % of total PAP Papworth Hospital 64 95 32.63% NOR Norfolk and Norwich Hospital 42 43 2.33% ADD Addenbrooke's Hospital 8 8 BAS Essex Cardiothoracic Centre 2 2 UCL University College Hospital 1 1 LGI Yorkshire Heart Centre 1 1 LBH London Bridge Hospital 1 1 GEO St George's Hospital 1 1 RAD John Radcliffe Hospital 1 1 STM St Marys Hospital 1 1 21

ICD implant trends 70 ICD New Implant Rate adjusted for age and sex of network population 60 per million population 50 40 30 20 10 0 England 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 year 80 ICD All Implant Rate adjusted for age and sex of network population 70 60 per million population 50 40 30 20 10 0 England 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 year 22

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 1999 Harefield Hospital 1 CRT-P 2001 Papworth Hospital 1 CRT-D CRT-P CRT-D CRT-P 2003 Glenfield Hospital 1 Papworth Hospital 3 11 CRT-D CRT-P 2004 Guy's Hospital 1 Papworth Hospital 5 8 CRT-D CRT-P 2005 Hammersmith Hospital 1 King's College Hospital 1 Papworth Hospital 55 20 Royal Brompton Hospital 2 University College Hospital 1 CRT-D 2006 Barts and the London 1 Norfolk and Norwich Hospital 2 23 CRT-P

2006 Papworth Hospital 62 44 Royal Brompton Hospital 1 CRT-D CRT-P 2008 Papworth Hospital 35 102 Norfolk and Norwich Hospital 15 1 Glenfield Hospital 2 1 Barts and the London 1 1 Harefield Hospital 2 Royal Brompton Hospital 2 University College Hospital 1 The Ipswich Hospital 1 Hammersmith Hospital 1 Harley Street Clinic 1 John Radcliffe Hospital 1 Royal Devon & Exeter Hospital 1 St Thomas Hospital 1 CRT-D CRT-P 2009 Papworth Hospital 43 92 Norfolk and Norwich Hospital 39 22 Addenbrooke's Hospital 19 13 John Radcliffe Hospital 3 St Marys Hospital 1 Royal Brompton Hospital 1 Barts and the London 1 Essex Cardiothoracic Centre 1 Harley Street Clinic 1 24

CRT implant trends 100 CRT New Implant Rate adjusted for age and sex of network population 90 per million population 80 70 60 50 40 30 England 20 10 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 year 120 CRT All Implant Rate adjusted for age and sex of network population 100 England per million population 80 60 40 20 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 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. 25

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 2009 0 20 40 60 80 100 120 140 160 180 200 26

Which hospitals serve which PCTs/LHBs? all implants for this cardiac network in 2009 Pacemakers 5PN.Peterborough Total Implants 2009 PAP Papworth Hospital 76 UCL University College Hospital 2 GRL Glenfield Hospital 1 GOS The Hospital For Sick Children 1 RCH Royal Cornwall Hospital 1 5PP.Cambridgeshire Total Implants 2009 PAP Papworth Hospital 264 ADD Addenbrooke's Hospital 129 WAR Warwick Hospital 1 GOS The Hospital For Sick Children 1 HH Harefield Hospital 1 LIS Lister Hospital 1 BED Bedford Hospital 1 SCA Scarborough General Hospital 1 UCL University College Hospital 1 5PQ.Norfolk Total Implants 2009 NOR Norfolk And Norwich Hospital 410 PAP Papworth Hospital 178 ADD Addenbrooke's Hospital 2 UCL University College Hospital 1 GEO St George's Hospital 1 BOU Royal Bournemouth General Hospital 1 SPH St Peter's Hospital 1 5PR.Great Yarmouth and Waveney Total Implants 2009 NOR Norfolk And Norwich Hospital 121 PAP Papworth Hospital 16 IPS The Ipswich Hospital 2 GOS The Hospital For Sick Children 1 5PT.Suffolk Total Implants 2009 IPS The Ipswich Hospital 304 PAP Papworth Hospital 167 ADD Addenbrooke's Hospital 20 NOR Norfolk And Norwich Hospital 13 COL Colchester General Hospital 5 STH St Thomas Hospital 3 MKH Milton Keynes General Hospital 3 27

UCL University College Hospital 2 OAK Oaks Hospital Colchester 1 HSC Harley Street Clinic 1 SPH St Peter's Hospital 1 Implantable Cardioverter Defibrillators (ICDs) 5PN.Peterborough Total Implants 2009 PAP Papworth Hospital 12 UCL University College Hospital 1 ADD Addenbrooke's Hospital 1 5PP.Cambridgeshire Total Implants 2009 PAP Papworth Hospital 30 ADD Addenbrooke's Hospital 5 STM St Marys Hospital 1 GEO St George's Hospital 1 NOR Norfolk And Norwich Hospital 1 BAS Essex Cardiothoracic Centre 1 5PQ.Norfolk Total Implants 2009 NOR Norfolk And Norwich Hospital 35 PAP Papworth Hospital 8 LGI Yorkshire Heart Centre 1 LBH London Bridge Hospital 1 5PR.Great Yarmouth and Waveney Total Implants 2009 PAP Papworth Hospital 12 NOR Norfolk And Norwich Hospital 6 5PT.Suffolk Total Implants 2009 PAP Papworth Hospital 32 ADD Addenbrooke's Hospital 2 RAD John Radcliffe Hospital 1 NOR Norfolk And Norwich Hospital 1 BAS Essex Cardiothoracic Centre 1 Cardiac Resynchronisation Therapy (CRT) 5PN.Peterborough Total Implants 2009 PAP Papworth Hospital 17 5PP.Cambridgeshire Total Implants 2009 PAP Papworth Hospital 31 ADD Addenbrooke's Hospital 27 NOR Norfolk And Norwich Hospital 1 5PQ.Norfolk Total Implants 2009 NOR Norfolk And Norwich Hospital 51 28

PAP Papworth Hospital 19 ADD Addenbrooke's Hospital 2 5PR.Great Yarmouth and Waveney Total Implants 2009 PAP Papworth Hospital 10 NOR Norfolk And Norwich Hospital 9 5PT.Suffolk Total Implants 2009 PAP Papworth Hospital 40 RAD John Radcliffe Hospital 3 ADD Addenbrooke's Hospital 3 STM St Marys Hospital 1 HSC Harley Street Clinic 1 NHB Royal Brompton Hospital 1 BAS Essex Cardiothoracic Centre 1 BAL Barts And The London 1 29

Pacing Mode for New Implants for this cardiac network Pacemakers Mode % for this network England % Atrial based modes DDDR 62.65% 54.04% DDD 10.87% 11.39% AAIR 0.30% 0.50% AAI 0.00% 0.12% DDI 0.00% 0.13% DDIR 0.00% 0.08% Ventricular based modes VVIR 24.70% 29.94% VVI 1.48% 3.45% VDDR 0.00% 0.02% VDD 0.00% 0.33% Note: The Mode table percentage calculations do not include any records where the mode was blank or unknown. Network England Ventricular based 26% Blank/ Unknown 0.4% Ventricular based 33% Blank/ Unknown 2% Atrial based 74% 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. 30

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 1.5% 24.7% 0.0% 0.3% 10.9% 62.6% 0.0% 0.0% 73.8% ADD.Addenbrooke's Hospital 5.0% 11.4% 0.0% 0.0% 28.6% 55.0% 0.0% 0.0% 83.6% IPS.The Ipswich Hospital 0.0% 34.6% 0.0% 0.0% 17.1% 48.2% 0.0% 0.0% 65.4% NOR.Norfolk and Norwich Hospital 0.0% 21.4% 0.0% 0.2% 0.2% 78.1% 0.0% 0.0% 78.6% PAP.Papworth Hospital 2.5% 26.6% 0.0% 0.6% 11.7% 58.7% 0.0% 0.0% 70.9% 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. 31

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 2009. 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 ADD.Addenbrooke's Hospital 45 93.3% 6.7% IPS.The Ipswich Hospital 65 90.8% 9.2% NOR.Norfolk and Norwich Hospital 147 95.9% 4.1% PAP.Papworth Hospital 137 93.4% 6.6% 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 32

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. 33

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 21.8% 21.3% 23.9% 30.3% 2.8% 5PN.Peterborough 29.0% 22.6% 29.0% 16.1% 3.2% 5PP.Cambridgeshire 21.1% 25.0% 20.1% 31.2% 2.6% 5PQ.Norfolk 22.2% 20.9% 24.3% 30.7% 2.0% 5PR.Great Yarmouth and Waveney 22.9% 15.2% 18.1% 40.0% 3.8% 5PT.Suffolk 20.5% 20.2% 27.2% 28.6% 3.5% AF: atrial fibrillation HB: heart block Brady: bradycardia 34

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) 599 Network average (corrected for age and sex) 520 Population Relative need for PM New Implant Rate 2009 Raw Corrected 5PN Peterborough 163,265 89.3% 413 463 5PP Cambridgeshire 589,605 96.9% 549 566 5PQ Norfolk 739,043 129.2% 645 499 5PR Great Yarmouth and Waveney 210,156 130.7% 508 389 5PT Suffolk 585,281 117.4% 671 572 35

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 36

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) 599 Network average (corrected for age and sex) 520 Population Corrected New Implant Rate 2008 Deficit/ Excess 2009 compared to rate of 700 5PN Peterborough 163,265 463-34% 5PP Cambridgeshire 589,605 566-19% 5PQ Norfolk 739,043 499-29% 5PR Great Yarmouth and Waveney 210,156 389-44% 5PT Suffolk 585,281 572-18% 37

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) 54 Network average (corrected for age and sex) 49 Population Relative need for ICD New Implant Rate 2009 Raw Corrected 5PN Peterborough 163,265 94.6% 68 72 5PP Cambridgeshire 589,605 99.2% 50 50 5PQ Norfolk 739,043 120.9% 55 45 5PR Great Yarmouth and Waveney 210,156 119.3% 48 40 5PT Suffolk 585,281 111.8% 54 48 38

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) 54 Network average (corrected for age and sex) 49 Population Corrected New Implant Rate 2008 Deficit/ Excess 2009 compared to rate of 100 5PN Peterborough 163,265 72-28% 5PP Cambridgeshire 589,605 50-50% 5PQ Norfolk 739,043 45-55% 5PR Great Yarmouth and Waveney 210,156 40-60% 5PT Suffolk 585,281 48-52% 39

New Implant rate maps for Anglia Stroke and Heart Network 40

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 Great Yarmouth and Waveney Peterborough Norfolk Cambridgeshire Suffolk -50% -45% -40% -35% -30% -25% -20% -15% -10% -5% 0% 41

ICD new implant rate 2009 ICD New Implants 2009 adjusted for age and sex compared to target figure of 100 per million Great Yarmouth and Waveney Norfolk Suffolk Cambridgeshire Peterborough -70% -60% -50% -40% -30% -20% -10% 0% 42

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 700 0-20 -40 Peterborough Cambridgeshire Great Yarmouth and Waveney Suffolk Norfolk -60-80 -100-120 -140-160 -180-200 43

Conclusions The population is older than average, overall the network requires 15% more pacemakers than the national average, and 11% more ICDs. The Network pacemaker implantation rate has increased in 2009 and is now just below the national average. Three of the five PCTs experienced an increase. The Network ICD implant rate increased. Four of the five PCTs experienced an increase in rate, with only Great Yarmouth and Waveney PCT showing a slight decrease. Overall the Network ICD implant rate remains below the national average. The network Total CRT implant rate increased in 2009 and remains below the national average. The proportion of atrial based pacing (74%) is a lot higher than the national average of 65%. 44