Wales – Mid and South West Cardiac Network - BHRSbhrs.com/files/files/Audit Reports/2009-Mid and South West Wales.pdf · Wales – Mid and South West Cardiac Network David Cunningham

Wales – Mid and South West Cardiac 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

2

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

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Contents

Analysis of Provision of Heart Rhythm Devices for


Data Quality Statement ............................................................................................... 4 Overview of Device Implants in the UK ............................................................................. 6 PCTs/LHBs in the Network ............................................................................................ 8 Network Age and Sex Distribution ................................................................................... 9 Correcting Implant Rates for Age and Sex.........................................................................11 Relative need for Pacemakers and ICDs ...........................................................................13 New and Total PM and ICD Implants...............................................................................14 Geographical location of pacemaker implants .....................................................................17 New and Total PM and ICD Implants...............................................................................18 CRT implants in this network ........................................................................................20 Which hospitals serve which PCTs/LHBs? ..........................................................................24 Pacing Mode for New Implants......................................................................................27 Pacing Mode for Sick Sinus Syndrome..............................................................................29 ECG Indication for New Implants ...................................................................................31 Corrected and Actual New Implant Rates ..........................................................................32 New Implant rate maps for Wales – Mid and South West Cardiac Network ...................................37 New pacing implant rate 2009.......................................................................................38 ICD new implant rate 2009 ..........................................................................................39 Pacing Implant Deficit in 2009 ......................................................................................40 Conclusions ............................................................................................................41

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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 100.00%

Main implant Centres

MOR.Morriston Hospital 100.00%

NEV.Nevill Hall Hospital 87.67%

POW.Princess Of Wales Hospital 100.00%

RSS.Royal Shrewsbury Hospital 100.00%

UHW.University Hospital of Wales 99.68% Note: Implant centres shown have implanted at least 10 devices in the network.

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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% 72.7% 99.5% 99.5% 91.9% 90.8% 81.3%

This Network 100.0% 86.0% 100.0% 100.0% 95.5% 95.9% 91.0%

Morriston Hospital 100.0% 98.5% 100.0% 100.0% 97.9% 98.1% 92.5%

Princess Of Wales Hospital 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% -

University Hospital of Wales 99.7% 9.4% 100.0% 100.0% 99.0% 99.2% 96.2%

CRT-D & ICD CRT-D & CRT-P

Network / Implant Centre NYHA

Dyspnoea Status

LV Function

ICD Indication

QRS duration

Overall index of valid data

completeness

Target 90.0% 90.0% 90.0% 90.0% 90.0%

England 38.2% 46.8% 33.3% 12.6% 73.3%

This Network 83.7% 86.5% 81.7% 50.9% 90.8%

Morriston Hospital 94.9% 96.2% 97.4% 81.8% 96.9%

Princess Of Wales Hospital - - - - 105.1%

University Hospital of Wales 63.9% 73.5% 39.2% 14.6% 76.5%

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%.

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Overview of Device Implants in the UK

New pacemakers Comments:

• The ten year average growth rate is 4.6%

• 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 (531 new implants per million population in 2009).

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 remained static in England and rose slightly in Wales in 2009.

0

100

200

300

400

500

600

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

year

per million population

England

Wales

Scotland

N Ireland

0

20

40

60

80

100

120

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

year


England

Wales

Scotland

N Ireland

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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).

Total CRT implants

Comments

• The total CRT rate rose significantly in England and Wales.

• Total CRT implants Rate was highest in England (99 total implants per million population in 2009).

0

10

20

30

40

50

60

70

80

90

100

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

year


England

Wales

Scotland

N Ireland

0

20

40

60

80

100

120

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

year


England

Wales

Scotland

N Ireland

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PCTs/LHBs in the Network

Wales – Mid and South West Cardiac Network Total population 0.99 million.

Code PCT/LHB Population Old PCT (where relevant*)

6A3 Pembrokeshire 116,300

6A4 Ceredigion 77,200

6A5 Neath Port Talbot 135,300

6A6 Swansea 224,700

6B3 Bridgend 129,900

6B7 Carmarthenshire 176,000

6C4 Powys 129,200 * 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.

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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

6A3Population: 116,800 0-5: 3,400 3,000 46-50: 3,600 3,700

Average age: 42.5 6-10: 3,800 3,600 51-55: 4,000 4,300

% aged 70+: 14.0% 11-15: 4,000 4,100 56-60: 4,300 4,600

16-20: 3,700 3,500 61-65: 3,600 3,800

21-25: 2,800 2,700 66-70: 3,300 3,300

26-30: 2,500 2,700 71-75: 2,800 3,000

31-35: 3,000 3,500 76-80: 2,000 2,600

36-40: 3,700 4,000 81-85: 1,300 2,100

41-45: 3,900 4,100 85+: 700 1,800

6A4Population: 77,300 0-5: 1,700 1,600 46-50: 2,400 2,500

Average age: 41.8 6-10: 2,100 1,900 51-55: 2,600 2,700

% aged 70+: 13.5% 11-15: 2,300 2,100 56-60: 2,900 2,900

16-20: 2,900 3,000 61-65: 2,300 2,300

21-25: 3,900 4,100 66-70: 2,000 2,000

26-30: 1,600 1,700 71-75: 1,600 1,800

31-35: 2,000 1,900 76-80: 1,300 1,700

36-40: 2,300 2,400 81-85: 1,000 1,300

41-45: 2,400 2,400 85+: 500 1,200

6A5Population: 135,400 0-5: 3,600 3,400 46-50: 4,600 4,700

Average age: 41.6 6-10: 4,100 4,000 51-55: 4,600 4,700

% aged 70+: 13.3% 11-15: 4,700 4,400 56-60: 4,500 4,700

16-20: 4,500 4,400 61-65: 3,700 3,800

21-25: 3,700 3,400 66-70: 3,300 3,400

26-30: 3,300 3,500 71-75: 2,700 3,300

31-35: 4,100 4,400 76-80: 2,200 3,100

36-40: 4,800 5,000 81-85: 1,400 2,500

41-45: 4,900 5,200 85+: 700 2,100

Pembrokeshire

* Older than national average

Ceredigion


Neath Port Talbot


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Population

PCT / LHB Age Male Female Age Male Female

6A6Population: 224,600 0-5: 6,000 5,900 46-50: 7,100 7,500

Average age: 41.1 6-10: 6,500 6,200 51-55: 7,000 7,300

% aged 70+: 13.4% 11-15: 7,300 6,700 56-60: 7,100 7,800

16-20: 7,900 7,600 61-65: 5,800 6,100

21-25: 8,700 8,000 66-70: 5,400 5,700

26-30: 5,900 5,900 71-75: 4,700 5,500

31-35: 6,800 7,200 76-80: 3,700 4,700

36-40: 7,700 7,900 81-85: 2,500 4,100

41-45: 7,700 7,800 85+: 1,400 3,500

6B3 Population: 129,900 0-5: 3,700 3,600 46-50: 4,200 4,200

Average age: 40.6 6-10: 4,100 3,900 51-55: 4,200 4,400

% aged 70+: 12.0% 11-15: 4,500 4,300 56-60: 4,300 4,500

16-20: 4,300 4,100 61-65: 3,500 3,700

21-25: 3,300 3,200 66-70: 3,000 3,300

26-30: 3,500 3,500 71-75: 2,500 3,000

31-35: 4,400 4,800 76-80: 1,900 2,500

36-40: 5,000 5,100 81-85: 1,300 2,200

41-45: 4,800 4,900 85+: 600 1,600

6B7Population: 175,900 0-5: 4,800 4,400 46-50: 5,700 6,100

Average age: 42.4 6-10: 5,500 5,200 51-55: 6,000 6,200

% aged 70+: 14.3% 11-15: 5,900 5,500 56-60: 6,500 6,600

16-20: 5,700 5,500 61-65: 5,300 5,300

21-25: 4,400 4,500 66-70: 4,600 4,700

26-30: 4,000 4,200 71-75: 3,900 4,400

31-35: 4,900 5,400 76-80: 3,200 4,100

36-40: 5,700 6,200 81-85: 2,000 3,500

41-45: 5,700 6,300 85+: 1,100 2,900

6C4Population: 129,300 0-5: 3,300 3,100 46-50: 4,200 4,400

Average age: 43.2 6-10: 4,100 3,700 51-55: 4,700 4,700

% aged 70+: 14.7% 11-15: 4,500 4,100 56-60: 5,000 5,200

16-20: 4,100 3,600 61-65: 4,000 4,100

21-25: 2,800 2,500 66-70: 3,500 3,500

26-30: 2,900 2,700 71-75: 3,100 3,300

31-35: 3,700 3,800 76-80: 2,400 3,000

36-40: 4,400 4,600 81-85: 1,700 2,400

41-45: 4,500 4,600 85+: 1,000 2,100

Powys


Bridgend

Carmarthenshire


Swansea


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%.

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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 531, 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%.

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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%.

13

Relative need for Pacemakers and ICDs Wales – Mid and South West Cardiac Network

Indicative new implant rate Pacemakers: 531 ICD: 62

(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

6A3 Pembrokeshire 42.5 660 124.3% 76 122%

6A4 Ceredigion 41.8 640 120.7% 72 115%

6A5 Neath Port Talbot 41.6 615 116.0% 69 112%

6A6 Swansea 41.1 622 117.2% 68 110%

6B7 Carmarthenshire 42.4 667 125.8% 74 119%

6C4 Powys 43.2 684 129.0% 75 121%

6B3 Bridgend 40.6 563 106.2% 67 107%

Cardiac Network - Relative Need for New Implant Rate

Wales – Mid and South West Cardiac Network 635 119.77% 71 114.54%

England (for comparison)

England 531 100% 62 100%

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.

14

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 22.82% 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

MOR Morriston Hospital 316 417 24.22%

POW Princess Of Wales Hospital 56 56

UHW University Hospital of Wales 7 34 79.41%

RSS Royal Shrewsbury Hospital 20 25 20.00%

NEV Nevill Hall Hospital 10 13 23.08%

HCH Hereford County Hospital 3 6 50.00%

BRC Bristol Children's Hospital 2 3 33.33%

BRI Bristol Royal Infirmary 2 3 33.33%

RGH Royal Glamorgan Hospital 2 3 33.33%

QEB Queen Elizabeth Hospital 2 3 33.33%

STO University Hospital North Staffs 2 2

GWE Royal Gwent Hospital 2 2

WWG West Wales General 1 1

BOL Bolton Royal Infirmary 1 1

DGE Eastbourne DGH 1 1

RDE Royal Devon & Exeter Hospital 1 1

BHL Liverpool Heart and Chest Hospital 1

PHB Priory Hospital 1 1

NHB Royal Brompton Hospital 1 1

UCL University College Hospital 1 1

HAM Hammersmith Hospital 1 1

WAT Watford General Hospital 1

WRX Maelor Hospital 1 1

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Pacemaker implant trends

Pacemaker New Implant Rate

adjusted for age and sex of network population

100

150

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250

300

350

400

450

500

550

600

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

year


Mid and South West Wales

England

Pacemaker All Implant Rate


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600

700

800

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

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England

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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.

0

200

400

600

800

1000

1200

0 200,000 400,000 600,000 800,000 1,000,000 1,200,000 1,400,000

PCT population

PCT pacemaker new implant rate

PCT New Implant Rate

National Target

Upper Control Limit

Low er Control Limit

PCT in This Netw ork

significantly above national target

consistent w ith national target

significantly below national target

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 (y-axis) 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%.

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Geographical location of pacemaker implants


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New and Total PM and ICD Implants


Implantable Cardioverter 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

MOR Morriston Hospital 46 57 19.30%

UHW University Hospital of Wales 5 7 28.57%

STO University Hospital North Staffs 5 5

QEB Queen Elizabeth Hospital 2 3 33.33%

STM St Marys Hospital 2 2

BHL Liverpool Heart and Chest Hospital 1 1

MRI Manchester Royal Infirmary 1

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ICD implant trends

ICD New Implant Rate


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60

70

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

year



England

ICD All Implant Rate


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80

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

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England

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CRT implants in this network Wales – Mid and South West Cardiac 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

1999 Harefield Hospital 1

CRT-D CRT-P

2000 Bristol Royal Infirmary 1

Morriston Hospital 1

University Hospital of Wales 1

CRT-D CRT-P

2001 Morriston Hospital 1 2

CRT-D CRT-P

2002 Morriston Hospital 1

Royal Shrewsbury Hospital 1

University Hospital of Wales 4

CRT-D CRT-P

2003 University Hospital of Wales 4 1

Morriston Hospital 2 2

Royal Brompton Hospital 1

Queen Elizabeth Hospital 1

CRT-D CRT-P


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Bristol Royal Infirmary 2


St George's Hospital 1

CRT-D CRT-P


University Hospital of Wales 1 2

Wellington Hospital North 1


CRT-D CRT-P




University Hospital North Staffs 2

CRT-D CRT-P


Morriston Hospital 8 9



University College Hospital 1

CRT-D CRT-P



Queen Elizabeth Hospital 2 1

St Thomas Hospital 2


CRT-D CRT-P



University College Hospital 3

Royal Brompton Hospital 2 1

Bristol Royal Infirmary 2


Royal Glamorgan Hospital 1


Good Hope General Hospital 1

St George's Hospital 1

22

CRT implant trends

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.

CRT New Implant Rate


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2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

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England

CRT All Implant Rate


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England

23

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..

Total CRT-P & CRT-D Implants 2009

0 20 40 60 80 100 120 140 160 180 200

Italy

Germany

Portugal

Netherlands

Denmark

Austria

Sweden

France

UK

Belgium

Switzerland

Ireland

Norway

Spain

Finland

24

Which hospitals serve which PCTs/LHBs? all implants for this cardiac network in 2009


Pacemakers

6A3.Pembrokeshire Total Implants 2009

MOR Morriston Hospital 64

UHW University Hospital Of Wales 5

BRC Bristol Children's Hospital 2

BRI Bristol Royal Infirmary 1

HAM Hammersmith Hospital 1

6A4.Ceredigion Total Implants 2009



WWG West Wales General 1

RSS Royal Shrewsbury Hospital 1

QEB Queen Elizabeth Hospital 1

WAT Watford General Hospital 1

6A5.Neath Port Talbot Total Implants 2009


POW Princess Of Wales Hospital 24



RGH Royal Glamorgan Hospital 1

6A6.Swansea Total Implants 2009


GWE Royal Gwent Hospital 2



WRX Maelor Hospital 1

6B3.Bridgend Total Implants 2009





BRC Bristol Children's Hospital 1

6B7.Carmarthenshire Total Implants 2009



NHB Royal Brompton Hospital 1

UCL University College Hospital 1

25

6C4.Powys Total Implants 2009

RSS Royal Shrewsbury Hospital 24

NEV Nevill Hall Hospital 13



HCH Hereford County Hospital 6

STO University Hospital North Staffs 2


DGE Eastbourne DGH 1

PHB Priory Hospital 1

RDE Royal Devon & Exeter Hospital 1

BHL Liverpool Heart And Chest Hospital 1

BOL Bolton Royal Infirmary 1














STM St Marys Hospital 2









MRI Manchester Royal Infirmary 1

BHL Liverpool Heart And Chest Hospital 1

26

Cardiac Resynchronisation Therapy (CRT)
























GEO St George's Hospital 1



GHS Good Hope General Hospital 1



27

Pacing Mode for New Implants for this cardiac network


Pacemakers

Mode % for this network England %

Atrial based modes

DDDR 31.99% 58.46%

DDD 25.83% 5.90%

AAIR 0.24% 0.50%

AAI 0.00% 0.04%

DDI 0.00% 0.02%

DDIR 0.00% 0.03%

Ventricular based modes

VVIR 28.20% 32.02%

VVI 13.74% 1.86%

VDDR 0.00% 0.03%

VDD 0.00% 0.29%

Note: The Mode table percentage calculations do not include any records where the mode was blank or unknown.

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.

England

Atrial

based

65%

Ventricular

based

34%

Blank/

Unknown

1%

Network

Ventricular

based

38%Atrial

based

59%

Blank/

Unknown

2.5%

28

Pacing Mode for New Implants major implanting hospitals in this cardiac network


VVI VVIR AAI AAIR DDD DDDR VDD VDDR Atrial Based Pacing

NATIONAL 1.9% 32.3% 0.0% 0.5% 6.0% 59.0% 0.3% 0.0% 65.5%

This Network 2.6% 36.1% 0.0% 0.5% 14.7% 46.1% 0.0% 0.0% 61.3%

MOR.Morriston Hospital 16.7% 28.9% 0.0% 0.0% 28.2% 26.2% 0.0% 54.4%

POW.Princess Of Wales Hospital 10.7% 30.4% 0.0% 0.0% 32.1% 26.8% 0.0% 58.9%

UHW.University Hospital of Wales

0.0% 0.0% 0.0% 0.0% 14.3% 85.7% 0.0% 100.0%

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.

29

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

MOR.Morriston Hospital 73 69.9% 30.1%

POW.Princess Of Wales Hospital 16 68.8% 31.3%

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


References 1. TA88 Bradycardia - dual chamber pacemakers: Information for the public. NICE 23 February 2005. http://www.nice.org.uk/TA88

30

The European Picture Atrial based pacing in the UK is low compared to most of Europe.

% Atrial-based pacing for Sick Sinus Syndrome2003 (most recent survey)

60% 65% 70% 75% 80% 85% 90% 95%

Denmark

Sweden

Austria

France

FR Yugoslavia

Belgium

LATVIA

Norway

UK

Netherlands

Turkey

Spain


31

ECG Indication for New Implants


Complete

HB Incomplete

HB AF +

HB/brady Sick sinus syndrome

Other

NATIONAL 22.1% 21.7% 23.4% 25.9% 6.8%

This Network 38.7% 16.1% 18.6% 23.6% 3.0%

6A3.Pembrokeshire 39.6% 16.7% 14.6% 25.0% 4.2%

6A4.Ceredigion 25.9% 18.5% 29.6% 25.9% 0.0%

6A5.Neath Port Talbot 43.1% 6.2% 15.4% 32.3% 3.1%

6A6.Swansea 43.3% 15.6% 17.8% 21.1% 2.2%

6B3 .Bridgend 35.8% 15.1% 28.3% 17.0% 3.8%

6B7.Carmarthenshire 35.7% 16.7% 20.2% 25.0% 2.4%

6C4.Powys 38.9% 33.3% 5.6% 16.7% 5.6%

AF: atrial fibrillation HB: heart block Brady: bradycardia

32

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 531

Network average (unadjusted) 445

Network average (corrected for age and sex) 372

New Implant Rate 2009

Population

Relative need for PM

Raw Corrected

6A3 Pembrokeshire

116,300 124.3% 481 387

6A4 Ceredigion

77,200 120.7% 382 316

6A5 Neath Port Talbot

135,300 116.0% 488 421

6A6 Swansea

224,700 117.2% 430 367

6B7 Carmarthenshire

176,000 125.8% 497 395

6C4 Powys

129,200 129.0% 378 293

6B3 Bridgend

129,900 106.2% 430 405

33

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

12.9%

1% RATING: small excess 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 531



Population Corrected New Implant Rate

2009

Deficit/ Excess 2009

compared to rate of 700

6A3 Pembrokeshire

116,300 387 -45%

6A4 Ceredigion

77,200 316 -55%


135,300 421 -40%

6A6 Swansea

224,700 367 -48%

6B3 Bridgend

129,900 405 -42%

6B7 Carmarthenshire

176,000 395 -44%

6C4 Powys

129,200 293 -58%

35

Corrected and Actual New Implant Rates


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 62



New Implant Rate 2009

Population

Relative need for ICD

Raw Corrected

6A3 Pembrokeshire

116,300 121.8% 60 49

6A4 Ceredigion

77,200 115.0% 65 56


135,300 111.5% 22 20

6A6 Swansea

224,700 109.7% 58 53

6B3 Bridgend

129,900 106.8% 38 36

6B7 Carmarthenshire

176,000 119.0% 97 81

6C4 Powys

129,200 121.0% 85 70

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 62



Population Corrected New Implant Rate

2009

Deficit/ Excess 2009

compared to rate of 100

6A3 Pembrokeshire

116,300 49 -51%

6A4 Ceredigion

77,200 56 -44%


135,300 20 -80%

6A6 Swansea

224,700 53 -47%

6B3 Bridgend

129,900 36 -64%

6B7 Carmarthenshire

176,000 81 -19%

6C4 Powys

129,200 70 -30%

37

New Implant rate maps for Wales – Mid and South West Cardiac Network

38

New pacing implant rate 2009 comparison with Heart Rhythm UK target (700)


Pacemaker New Implants 2009adjusted for age and sex

compared to target figure of 700 per million

-70% -60% -50% -40% -30% -20% -10% 0%

Neath Port Talbot

Bridgend

Carmarthenshire

Pembrokeshire

Swansea

Ceredigion

Powys

39

ICD new implant rate 2009


ICD New Implants 2009adjusted for age and sex

compared to target figure of 100 per million

-90% -80% -70% -60% -50% -40% -30% -20% -10% 0%

Carmarthenshire

Powys

Ceredigion

Swansea

Pembrokeshire

Bridgend

Neath Port Talbot

40

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 2009compared to Heart Rhythm UK target rate of 700

-100

-90

-80

-70

-60

-50

-40

-30

-20

-10

0

Ceredigion

Bridgend

Neath Port Talbot

Pembrokeshire

Carmarthenshire

Powys

Swansea

41

Conclusions

Wales – Mid and South West Cardiac Network � The population is much older than the average for England and Wales. Because of

this there is a 20% extra need for pacemakers and a 15% extra need for ICDs compared to average.

� The network pacemaker new implant rate increased slightly and remained below the

national average. � The network ICD new implant rate increased notably and remained below the

national average. � The CRT total implant rate is static and remained below the national average. � The proportion of atrial based pacing (59%) is lower than the national average of

65%. � Princess Of Wales Hospital (31%) and Morriston Hospital (30%) have higher rates of

ventricular based pacemaker implants for sick sinus syndrome; this is not compliant with NICE TAG 88 (2005).

Documents

Wales – Mid and South West Cardiac Network - BHRSbhrs.com/files/files/Audit Reports/2009-Mid and South West Wales.pdf · Wales – Mid and South West Cardiac Network David Cunningham