Horizon Scanning

North of ScotlandPlanning Group

North of ScotlandPlanning GroupHorizon Scanning

North of Scotland Cardiac Services

Pam Lowbridge & Malcolm Metcalfe



Horizon Scanning

An overview of potential future issues and trends that may have an impact on policy and planning



Projected future need

• Change in population

• Projected rates pmp over 10 years

• Projected increase in procedures over 10 years



Population change to 2020

Based on GRO Projected Population of Scotland 2008-based (published 21/10/09)

Projected North of Scotland Population, proportional by age band

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Year

Prop

ortio

n of

tota

l pop

ulat

ion

0-44 45-54 55-64 65-74 75-84 85+




• Overall population projected to increase by 4.9% over the next 10 years

• Over 45 population projected to increase from 46.6% to 49.6% of total population

• Over 65 population projected to increase from 18.1% to 22.2% of total population






Projected annual population change, by age band

-4%

-3%

-2%

-1%

0%

1%

2%

3%

4%

5%

6%

2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

Perc

enta

ge c

hang

e

0-44 45-54 55-64 65-74 75-84 85+



Projected increase in procedures

Projected increase in procedures for North of Scotland

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

Revascularisation Valve Surgery New Pacemakers New ICD New CRT New EPS/Ablation

2010-2015

2015-2020

Based on Oxford Healthcare Associates Access to Cardiac Care in the UK report (June 2009)



Projected future need

• New EPS/ablation shows highest projected rise in the number of procedures over the next 10 years

• Revascularisation shows highest projected rate pmp over the next 10 years



Projected rates pmp

Projected rates pmp for North of Scotland

0

500

1000

1500

2000

2500

3000

3500

Revascularisation Valve Surgery New Pacemakers New ICD New CRT New EPS/Ablation

2015

2020

Based on Oxford Healthcare Associates Access to Cardiac Care in the UK report (June 2009)



Technologies & Treatments

• Optimal Reperfusion Therapy

• CT coronary angiography

• Device closure

• PAVR / TAVI

• PMVR

• Dabigatran



CT coronary angiography

• Could potentially replace up to 20% of catheter coronary angiograms

• This would equate to over 1250 cases across North of Scotland p.a.

• Suitable for selected patients only – e.g. the use of betablockers means the technique is unsuitable for asthmatics

• Technique being used in NHS Highland



CTCA NHS Highland

• Started CTCA in June 2007 with regular sessions every week from 2008

• 250 patients have undergone CTCA to date with 50% avoiding a catheter study

• Estimated that CTCA represents a 66-88% saving on the cost of a catheter angiography per patient

• CTCA takes 30 mins, with the scan lasting 30 seconds



CTCA NHS Highland

• Positive effect on performance of radiographic staff who are challenged by this work

• Requires training of technical and medical staff

• Catheter studies only show the lumen whereas CTCA shows the lumen and the wall (where the pathology is)

NHS Highland comments provided by Dr John Miller, Consultant Radiologist, Raigmore Hospital



Device closure

• All device closures currently performed outwith North of Scotland • PFO (Patent Foramen Ovale) closures could be performed in Aberdeen – estimated minimum of 12 per year

• More complex procedures would remain in Edinburgh/Glasgow



PAVR / TAVI

• Percutaneous Aortic Valve Replacement / Transcatheter Aortic Valve Implantation

• Emerging technology

• Long-term durability and efficacy unknown

• Procedure performed at a limited number of centres across the UK



TAVI

'evidence on TAVI for aortic stenosis is limited to small numbers of patients who were considered to be at high risk for conventional cardiac surgery. It shows good short-term efficacy but there is little evidence on long term outcomes.' NICE interventional procedure guidance IPG266



TAVIBritish Cardiovascular Intervention Society (BCIS) and the Society of Cardiothoracic Surgeons (SCTS) position statement: Any hospital wishing to set up a TAVI programme should have the following minimum infrastructure available:• The ability to set up an MDT drawn from a minimum of 2 interventional cardiologists, 2 cardiothoracic surgeons, cardiac anaesthetists and cardiac imaging specialists.• Immediate availability of trans-thoracic and transoesophageal echocardiography.• Availability of a dedicated cardiac catheter lab or hybrid theatre.

• A theatre with “C” arm screening facilities is generally not appropriate for TAVI procedures .

• CT scanning facilities

• Immediate availability of perfusion services in case of the need for emergency femoro- femoral bypass.• On-site availability of a surgical recovery area and intensive care with staff experienced in looking after patients following surgical aortic valve replacement.• Robust arrangements for immediate renal support if necessary.

• Immediate access to vascular surgeons and interventional radiologists to deal with major peripheral vascular complications.



TAVI

British Cardiovascular Intervention Society (BCIS) and the Society of Cardiothoracic Surgeons (SCTS) position statement: •occasional practice and small volume TAVI units should be actively discouraged

•difficult to stipulate a minimum number of cases per year for a TAVI programme

•a minimum annual number of 24 cases per TAVI unit may be reasonable, but given the learning curve and infrastructure needed somewhere in the order of > 50 cases per year to be optimal



Projected TAVI cases

prevalence estimate of around 16pmp as an acceptable target

Projected number of TAVI cases

0

10

20

30

40

50

60

70

80

90

100

Grampian Highland Orkney Shetland Tayside North ofScotland

Scotland

Nu

mb

er

of

ca

se

s

2010

2015

2020



PMVR

• Percutaneous Mitral Valve Repair

• Percutaneous repairs currently performed by the use of mitral valve clips – procedure carried out at a limited number of centres across the UK

• Percutaneous valve replacement still in experimental stages



Dabigatran

• Warfarin replacement which doesn’t require patient monitoring or dose adjustment

• Cost comparison – Dabigatran cost of £4.20 per patient per day; Warfarin cost of around 42p per patient per day

• Assuming a 1.1% prevalence rate, with 75% of these patients on Warfarin, comparative North of Scotland annual costs:

Warfarin £ 1.65mDabigatran £16.48m



In summary…

•Changing demographics

•Associated impact on demand

•Cost/benefit of incorporating new technologies/techniques

Documents

Horizon Scanning