““Tertiary Centres are Obsolete”Tertiary Centres are Obsolete”

Dr Neil Sulke

or

‘‘The Patsy’The Patsy’

In possibly his last ever presentation to BCIS

Competing interests: What’s best for our patientsCompeting interests: What’s best for our patients

AcknowledgementsAcknowledgements

• Will Orr DGH

• Mark Signy DGH

• Andrew Bishop DGH

• Kevin Beatt DGH

• Peter Ludman Tertiary/BCIS hit man

Conflict of Interests: NoneConflict of Interests: None

““Tertiary Centres are Obsolete”Tertiary Centres are Obsolete”

Well of course they aren’t:Well of course they aren’t:• How the heck will we generate enough of a waiting list

without them?• ALL our diminishing Private Practice will completely

disappear without them• When will our angina patients & their terrified relatives

ever again get to the big city shops?• They just won’t feel as if they’re getting their money’s-

worth without visiting a massive, remote & disorganised institution without adequate parking facilities, with hundreds of poorly staffed & under-utilised Cath Labs…

• To have a PCI started by a Spotty yr 2/3 SpR, partially undertaken by a yr 4 SpR & helpfully completed by a big-name interventionist (when we can find him/her)…or even by the very guy who sent them in & needs an imposing bit on their letterhead…

““Tertiary Centres are far from Tertiary Centres are far from Obsolete”Obsolete”

(Actually, They are are for a few tiny, unimportant, usually non profit making, repetitive, now un-glamourous, cardiac procedures that are partially redundant in the tertiary centres…..)

ECGs should ONLY be done in a Tertiary Centre (1930-ECGs should ONLY be done in a Tertiary Centre (1930-60):60): ‘‘just too complex to be understood in a DGH’just too complex to be understood in a DGH’ ‘ ‘inadequate technical back-up’inadequate technical back-up’ ‘ ‘insufficient numbers to remain safe’insufficient numbers to remain safe’ ‘ ‘facilities not cost effective in a DGH’facilities not cost effective in a DGH’ ‘ ‘Shown to be dangerous in low volumeShown to be dangerous in low volume centres in the USA…’centres in the USA…’

CC. CC.

Cor. Angiography,Cor. Angiography,

ThrombolysisThrombolysis

Permanent PacingPermanent Pacing

TOETOE

ICDsICDs

““Tertiary Centres Tertiary Centres might becomemight become Obsolete if they keep leaking Obsolete if they keep leaking

procedures to DGHs”procedures to DGHs”

What is the next bastion to fall?What is the next bastion to fall?• New imaging stuff? New imaging stuff? • ‘‘Basic’ EP/Ablation?Basic’ EP/Ablation?• AF Ablation? Or… AF Ablation? Or…

• Will it be PCI in almost all its forms?Will it be PCI in almost all its forms?

High Tech 2007, MarseilleHigh Tech 2007, Marseille

Nombres de PCI dans certains pays EuropéensNombres de PCI dans certains pays Européens

0

500

1000

1500

2000

2500

3000

3500

4000

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Par 106

habitantsGEGE

BEBE

UKUK

Bernard De Bruyne, Aalst, Belgium

38 38

2637

0%

20%

40%

60%

80%

100%

2005 2006

Off SiteOn Site

On v Off Site SurgeryNHS Centres only

51%

Form AB

Surgical Cover(all 91 NHS and Private Centres)

On site Off siteNo of centres 53 38

No. of PCI (% of total) 58,153 15,539

Emergency CABG (number) 56 8

Emergency CABG (% of activity) 0.1% 0.05%

2006 data: Ludman

Form AB

What is a DGH interventionist?

• “I’ve had a camera put in to link the cath lab to my office so I can sit at my desk and watch the DGH blokes f**k things up”

• Mike Norell

• ‘tertiary interventionist’

Here is a DGH interventionist who is virtually indistinguishable from a “tertiary”

interventionist except for where he works…

DGHTIPSY…

From Bishop, A. 2007, (his only data slide)

All Cases at Tertiary-CentreAll Cases at Tertiary-Centre

‘‘TERTIARY’ TERTIARY’ OPERATOROPERATOR

• No: 4858

• Mortality: 55(1.13%)

• CABG: 5 (0.1%)

• Q wave MI: 8 (0.16%)

• MACE 68 (1.4%)

‘‘DGH’ OPERATORDGH’ OPERATOR

3363

15 (0.45%)

8 (0.24%)

12 (0.36%)

35 (0.95%)

From Audit Coordinator via Signy, M. 2007

Non-elective ‘Hot’ CasesNon-elective ‘Hot’ Cases

TERTIARY TERTIARY OPERATOROPERATOR

• No: 2948

• Vessels: 1.23

• Stents/vessel: 1.2

• Mortality: 53(1.8%)

• CABG: 3 (0.1%)

• Q wave MI: 6 (0.2%)

• MACE 62(2.1%)

DGH OPERATORDGH OPERATOR

1308

1.19

1.27

13 (0.9%)

3 (0.2%)

7 (0.5%)

23(1.5%)

All Cases: first calendar year All Cases: first calendar year at Worthing DGHat Worthing DGH

• ‘‘DGH’ OPERATORS ONLYDGH’ OPERATORS ONLY

• Total cases:Total cases: 280 – MACE 1 (0.36%)

• Elective:Elective: 141 (51%)– MACE 0

• Non elective:Non elective: 139 (49%)– MACE 1 (0.7%)

How did DGHs get their hands on PCI ?How did DGHs get their hands on PCI ?

• ↑ number of cath labs throughout UK

• ↑ number of interventionally-trained Cardiologists appointed to DGHs

• frustration at ACS transfer-times

• PCI becoming safer££ Not just to

make a quick buck ££

Average Wait In Days Per Patient By Trust For Angio +/- Proceed

0 5 10 15 20 25 30

709410114133555

6779292013972531028981

1081147810451741619121801111323858128368885903739759810511783113171

1064513112052138485492127103100648412515

13377115291631351191104

12485714821161213710750142182611

134129442297130341796307

253

624259118618712347131031219

12256432393352827731261406

496013676409510966

Tru

st C

od

e

Average Wait (Days) Per Patient

Admission to Referral Referral to Transfer Transfer to Procedure

UK Inter-Hospital Transfer Times

2004

Worthing DGH PCI effect on locals:Worthing DGH PCI effect on locals:

• Non-elective wait for PCI now max 2 days (previously 11 days, reduced to 10.5 by ‘treat and transfer’ of 2 cases per week to real PCI Centre)

• All ACS/STEMI patients cath +/- PCI during index admission, all within 72 hrs

• Daytime ‘in hours’ Primary PCI available if no prehospital thrombolysis: previously none

• Elective wait in 2005 = 3.5 months Elective wait in 2008 = 1 month

• NB Downside: Signy’s Private Practice is halvedNB Downside: Signy’s Private Practice is halved

`boutique angioplasty`

Reading Strategy for STEMIReading Strategy for STEMI

• thrombolysis-based

• increasing rates of pre-hospital lysis

• aggressive in-patient angiography/PCI

• mandatory rescue PCI called at 60 mins

• primary PCI when lysis contraindicated

2.2%

5.7%

0%

5%

2.2%

5.7%

0%

5%

Pre HospitalLysis

Pre HospitalLysis

PrimaryPCI

PrimaryPCI

P=0.057P=0.057

DeathDeath

CAPTIM 1 Year Results

5.9%

3.7%

0%

10%

5.9%

3.7%

0%

10% P=0.47P=0.47

DeathDeath

Pre HospitalLysis

Pre HospitalLysis

PrimaryPCI

PrimaryPCI

Sx < 2 hours Sx > 2 hours

Steg Circulation 2003;108:2851-6

De Luca, G. et al. Circulation 2004;109:1223-1225

Primary PCITime to treatment and 1-year mortality

every 30 min delay increases mortality by 7.5%

Composite Primary End Point among the Trial Groups(Death, Recurrent Myocardial Infarction, Severe Heart Failure, or Cerebrovascular Accident)

Gershlick A et al. N Engl J Med 2005;353:2758-2768

Rescue PCI - REACT

5-yr follow-up suggests c.50% reduction in mortality

Reading STEMI Data

STEMI 05-06 06-07 07-08

n 126 138 79*

P-H Thrombolysis - 20% 37%

Revascularisation - 45% 72%

In-Hosp Mortality 5.6% 3.6% 2.5%

30d Mortality 7.9% - -

MINAP Jan 2008

Why not 24/7 Primary PCI in Why not 24/7 Primary PCI in Reading & other Boutiques?Reading & other Boutiques?

• not enough interventional cardiologists (need a minimum of 6 per unit)

• not enough cath lab staff

• do we DGH jobbers want to change the way we work?

• will it deliver better outcomes?

• Are there enough STEMIs to fight over?

• Let’s not make the Tertiary Centres completely redundant for PCI

• If they want to practice ‘Service Cardiology’ this is a great way to let them do it

Conclusion:Conclusion: ‘DGH PCI is clearly an outdated concept’‘DGH PCI is clearly an outdated concept’

• It has transformed the access and availability of PCI and is the main reason that we are moving towards PCI numbers and outcomes seen in civilised countries.

• BCIS/CCAD data shows it is safe and effective

• The numbers do clearlydo clearly stack up (despite the Ludmanite ‘size-matters’ stories from the USA…)

The new concept is: ‘Non Surgical Centre’ PCIThe new concept is: ‘Non Surgical Centre’ PCI

Evolution of the Non Surgical PCI Centre Interventionist:Evolution of the Non Surgical PCI Centre Interventionist:

So is the Surgical Centre Cardiologist Redundant?So is the Surgical Centre Cardiologist Redundant?

• Cardiologists in surgical centres will remain opinion leaders & drive new developments

• provide super-specialist services:– Rotablation

– AV Valve Stents/M Valvuloplasty/M Annuloplasty

– ASD, VSD closure

– HCM EtOH Ablation

– Aortic/?carotid Stents

– Surgery

– New Imaging Techniques

– Chronic Device Electrode Extraction…+ AF Ablation (for now)

• Hub & Spoke activity to be encouraged: (Big names could keep their ‘basic’ numbers up by visiting boutiques & keeping innovations under close review)

• Nobody needs to feel threatened