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Coronary Revascularisation:
the DoH View
Dr Roger Boyle
National Director for Heart Disease
NSF StandardsStandard nine
“People with angina that is increasing in frequency or severity should be referred to a cardiologist urgently or, for those at greatest risk, as an emergency”
Standard ten
“ NHS Trusts should put in place hospital-wide systems of care so that patients with suspected or confirmed coronary heart disease receive timely and appropriate investigation and treatment to relieve their symptoms and reduce their risk of subsequent events”
National Service Framework
• Accepted– effectiveness of revascularisation– low rates in UK– inequity of access– history of under-investment
NSF and NHS Plan Targets
• Initial NSF target (March 2000) 3000 additional revascularisations by April 2002
• Second NHS Plan target (July 2000)6000 additional procedures by April 2003
• “Further targets will be set”!
NSF waiting time goals
• Referral by GP to specialist
assessment/consultant appointment:
two weeks maximum
• Prompt investigation and revascularisation
within three months of the decision to treat
Priorities and Planning Framework 2003-6
Improve access to services across the patient pathway and increase patient choice:– by achieving the two week wait standard for
Rapid Access Chest Pain Clinics; – by setting local targets to make progress to the
NSF goal of a 3 month maximum wait for angiography;
– by delivering maximum waits of 3 months for revascularisation by March 2005 or sooner.
Strategies for delivery• RACPC’s
– Target 150, 186 achieved– 71% seen within 2 weeks, Target 100%
• Catheter lab investment programme• National capacity reviews
– based on SMR adjusted targets
• Immediate revenue injection• Workforce development programme
Revenue invested in revascularisation
Year Non-recurrent
£m
Recurrent£m
Total£m
2000/2001 31 0 312001/2002 15 50 652002/2003 0 110.8 160.8
Capital schemes
• Over £300m for expansion– Expansion at James Cook, Bristol and Papworth
complete– Entirely new centre at Wolverhampton– Expansion at Blackpool, Liverpool, Manchester
(South and Central), Southampton, Sheffield, Leeds and Plymouth
• £80m for new catheter labs– plans for 86 new or replacement labs in train
Extending Patient Choice
• Total eligible since 1st July 2002– 4621
• Clinically eligible– 3298
• Exercised choice– 3183
• Opting for treatment elsewhere– 1531 have now been treated elsewhere
CABG waiting times in England
0
500
1000
1500
2000
2500
3000
Jun-9
8A
ug-98
Oct
-98
Dec
-98
Feb-
99A
pr-9
9Ju
n-99
Aug-
99O
ct-9
9D
ec-9
9Fe
b-00
Apr
-00
Jun-0
0A
ug-00
Oct
-00
Dec
-00
Feb-
01A
pr-0
1Ju
n-01
Aug-
01O
ct-0
1D
ec-0
1Fe
b-02
Apr
-02
Jun-0
2A
ug-02
Oct
-02
Num
ber
of p
atie
nts
wai
ting
12 month +9-11 month
CABG waiters in England (over 6 months)
0
500
1000
1500
2000
2500
April May June July Aug Sept Oct Nov
LeicesterWalsgraveBirminghamPapworthNottinghamN StaffsBristolSotonPlymouthOxfordBrightonSouth TeesS McrSheffieldFreemanLeedsHullCentral McrLiverpoolBlackpoolUCLHSt Mary'sSt George'sRoyal FreeRBHKingsHammersmithGuys' & St Thomas'BLT
Trends in waits for CABG
0
500
1000
1500
2000
2500
3000
April
May
June Ju
lyAug
Sept
OctNov Dec Ja
nFeb
Mar Apr Ju
n Jul
2002/3
Num
ber
of 6
mon
th w
aite
rs
Actual
Projected
Revascularisation waits(more than 6 months)
0
500
1000
1500
2000
2500
3000
April May June July Aug Sept Oct Nov
2002/3
Pat
ient
s w
aiti
ng m
ore
than
6
mon
ths
PCICABG
Revascularisation waits(all waiters)
0
2000
4000
6000
8000
10000
12000
April May June July Aug Sept Oct Nov
2002/3
Tot
al n
umbe
rs w
aiti
ng
PCICABG
NSF and NHS Plan Targets
• Initial NSF target (March 2000)3000 additional revascularisations by April 2002
achieved by April 2001
• Second NHS Plan target6000 additional procedures by April 2003
achieved by April 2002
NSF waiting time goals(for 2008)
• Referral by GP to specialist assessment/consultant appointment: two weeks maximum - achieved for 71%
• Prompt investigation and revascularisation
within three months of the decision to treat
- angio waits to be monitored from April
- 3 month wait for revascularisation in sight
Remaining challenges for PCI
• Equity of access
• Ratio of PCI to CABG
• Revising the activity target
• Primary PCI
• Eluting stents
• Staffing requirements to handle growth
CAGB rate versus SMR for CHD by StHA in 2000/1
100
200
300
400
500
600
700
800
900
80 90 100 110 120 130SMR
Ra
te p
er m
illi
on
(Aggregated up from DHA data)
Correlation coefficient 0.6, p=0.0004
Y=3.732x+73.312
PCI rate versus SMR for CHD by DHA in 2000/1
0
200
400
600
800
1000
1200
50 70 90 110 130 150
SMR
Rat
e pe
r m
illi
on
p=NS
Data from HES (FCEs in England only)
15,00017,00019,00021,00023,00025,00027,00029,00031,000
PCICABG
Ratio 1.3 : 1
Data from HES (FCEs in England only)
15,000
17,000
19,000
21,000
23,000
25,000
27,000
29,000
31,000
1998/1999 1999/2000 2000/2001 2001/2002
PCICABG
Ratio 1.3 : 1Efficiency gains
17%
19%
Primary PCI - how, where and when?
• Better than pre-hospital thrombolysis?
• Volume affects outcome
• Ambulance triage?
• Rescue and thrombolysis-ineligible cases only or all?
• Is it really cost-effective?
• How does it rank with other priorities?
Expansion of PCI - one scenario
• Current activity (England)– 30,000
• Additional activity to achieve 1000 pmp– 20,000
• Incidence of STEMI (MINAP)– 24,000
• Total activity needed (?)– 74,000 or an increase of 147%
Recommended