26th January




SESSION XIV – DEBATE

DGH vs Tertiary intervention –

Is there really a conflict?


Department of Health ...
No conflict of interest
     to declare
Cardiac surgeons




DGH cardiologist   Tertiary centre cardiologist
Cardiology in the district hospital.
Report of a working group of the British Cardiac Society
Br Heart J. 1987; 537-546

“...
BCS Council Meeting circa 1994
Statement by the Council of the British Cardiac
Society. Strategic planning for cardiac services
and the internal market: ...
BCS Working Group:
The changing interface between district hospital
cardiology and the major cardiac centres
Heart 1997; 7...
Main conclusions
• The establishment of new cardiac catheterisation
  laboratories in DGHs remote from a major centre shou...
UK Centres - 2005
                                                                                                        ...
England - Revascularisation - Numbers - CABG & PCI
                 1999/2000-2004/05 (Source: DH Returns)
80000

70000

 ...
19




                 200
                 400
                        600
                        800
                 ...
5,000
                               10,000
                                        15,000
                               ...
PCI waiters by length of wait
                 April 2002 onwards
6,000

5,000

4,000
                                    ...
Southampton – November 2006
Ke
           ns
              ing
                  t  on
                          an
          So                d
    ...
2005


PCI centres

      83


Angiography only
    Centres

      87
‘A discussion of the drugs
administered in a case of coronary
thrombosis is not relevant here –
but for pain relief morphi...
Heart Attack:
       Progress Since the NSF

• Percentage of patients treated within 30 minutes
  of arrival at hospital r...
Reperfusion treatment 2003-6
100
90
80
70
60
                              14.4%       In hospital lysis
50
              ...
Access to PPCI
• 37/68 English & Welsh hospitals with interventional
  facilities on site perform primary angioplasty
• 14...
Manchester (2)
-North Mcr       James Cook
-Salford          - Friarage
-Stockport
-Tameside
-Trafford         Leeds
     ...
Trust Catchment Areas
                   Secondary - Acute MI   Tertiary - CABG

 No. of Trusts             153           ...
Conclusion
• District hospital angiography has improved access to
  care and the capacity is needed
• Still a great deal o...
26th January SESSION XIV – DEBATE
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26th January SESSION XIV – DEBATE

  1. 1. 26th January SESSION XIV – DEBATE DGH vs Tertiary intervention – Is there really a conflict? Department of Health Perspective Roger Boyle
  2. 2. No conflict of interest to declare
  3. 3. Cardiac surgeons DGH cardiologist Tertiary centre cardiologist
  4. 4. Cardiology in the district hospital. Report of a working group of the British Cardiac Society Br Heart J. 1987; 537-546 “The district cardiologist may wish to maintain skills by participating in catheter sessions….” A report of a working group of the British Cardiac Society: cardiology in the district hospital. Br Heart J. 1994; 72: 303-308 “It is becoming commonplace for district hospitals to develop their own catheterisation facilities…………..”
  5. 5. BCS Council Meeting circa 1994
  6. 6. Statement by the Council of the British Cardiac Society. Strategic planning for cardiac services and the internal market: role of catheterisation laboratories in district general hospitals. Br Heart J. 1994; 71: 110-112 DGH cardiologists should be offered specific sessions in tertiary labs Some DGHs that are geographically disadvantaged might develop their own labs Over time, DGH labs would become the norm!!!!!!!!!
  7. 7. BCS Working Group: The changing interface between district hospital cardiology and the major cardiac centres Heart 1997; 78: 519-523
  8. 8. Main conclusions • The establishment of new cardiac catheterisation laboratories in DGHs remote from a major centre should be encouraged provided the workload is adequate to ensure efficient use of the facility • Cardiologists working in districts close to a major centre should be encouraged to catheterise their patients at the centre
  9. 9. UK Centres - 2005 2005 data: Ludman PCI Angio only 100 77 83 80 73 66 64 64 87 58 61 63 83 54 54 53 60 52 52 53 68 No. 65 Centres 40 20 0 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
  10. 10. England - Revascularisation - Numbers - CABG & PCI 1999/2000-2004/05 (Source: DH Returns) 80000 70000 CABG 60000 PCI 50000 Total 40000 30000 20000 10000 0 1999-2000 2000-2001 2001-2002 2002-2003 2003-2004 2004-2005 estimate
  11. 11. 19 200 400 600 800 1000 1200 1400 1600 0 89 /9 19 0 90 /9 19 1 91 / 19 92 92 /9 19 3 93 /9 19 4 94 /9 19 5 95 / 19 96 96 /9 19 7 97 /9 19 8 98 / 19 99 99 /0 20 0 00 /0 20 1 01 /0 20 2 02 / 20 03 03 Rate per million in England /0 20 4 04 /0 20 5 05 /0 6 Revascularisation trends PCI Total CABG
  12. 12. 5,000 10,000 15,000 20,000 25,000 0 Ap ril M ay Ju ne Ju A ly S e ug pt ust em b O er c N t ob ov er e D mb ec e em r b Ja er n F e uar br y ua r M y ar ch 2005 Ap ril M ay Ju ne Ju Au ly Se g pt ust em b O er ct N ob ov er em be r Angiography waiters from April 9+ 0-1 06-Jul 03-Apr 01-Feb 05-Jun 02-Mar 08-Sep 07-Aug 04-May
  13. 13. PCI waiters by length of wait April 2002 onwards 6,000 5,000 4,000 9 to 12 3,000 6 to 9 3 to 5 2,000 0 to 3 1,000 0 ct ct ct ct ct l l l l l pr pr pr pr pr n n n n Ju Ju Ju Ju Ju Ja Ja Ja Ja O O O O O A A A A 2002/3 2003/4 2004/5 2005/6 A 2006/7
  14. 14. Southampton – November 2006
  15. 15. Ke ns ing t on an So d ut Ch h Ca G els 0 500 1000 1500 2000 2500 3000 3500 4000 4500 m ui ea br ld 5000 id for ge d sh So Th Bro ire ut re m h e ley No Ri rth ve am Ch rs pt ilte o rn He nsh So rts ire ut me h 2500 pmp 2200 pmp Ha Bu re 1900 pmp rb ck or s o Ch ug h Rate pmp 2003/4 Ru erw sh ell Te m st oo Rate pmp 2015 Model Sp Va r el lley th W orn ea e G re lde en n Po wic ol h Br e U Ne t ox A w ow W F e No est ore rth Do st W rse ilts t No h rth L ire El Ke eed le sm S Th ste s er out urr ve e h oc n Po Sh k Ba rt ro UA an ps rk d hir in g Ne e an s d Ch ton W D o es ag rle t L en y an ha ca m s Ry hire No ed rth Sh al e e Ea St ffie st oc ld Li kp nc o Ne ol W rt wa ns ir SEPHO Revascularisation Model - Version 5 - Rates pmp hi ral B rk C re Ki lac an ald U ng kb d e A st ur Ca Sh rda on n st er le up wit le M wo on h D o od Hu ar rpe ll, we th Ci n U ty of A Al UA nw Sa ick St T lfor ok K orri d e- n dg on ow e -T sl re ey nt UA
  16. 16. 2005 PCI centres 83 Angiography only Centres 87
  17. 17. ‘A discussion of the drugs administered in a case of coronary thrombosis is not relevant here – but for pain relief morphine is often given by an attending doctor or on arrival at hospital….the patient should not be questioned unduly or in any way alarmed.’ 1970
  18. 18. Heart Attack: Progress Since the NSF • Percentage of patients treated within 30 minutes of arrival at hospital rose from 38% to 83% • Paramedics trained to assess, diagnose and provide thrombolysis • Percentage of patients treated within 60 minutes of a call for help rose from 30% to 65% • Pilot schemes set up to test feasibility of primary angioplasty in the NHS
  19. 19. Reperfusion treatment 2003-6 100 90 80 70 60 14.4% In hospital lysis 50 Prehospital lysis 40 PPCI 30 % 12.6% 20 10 [plus patients in NIAP 0 not yet transferred 2003 2004 2005 2006 ~ 2.5%]
  20. 20. Access to PPCI • 37/68 English & Welsh hospitals with interventional facilities on site perform primary angioplasty • 14/37 provide an internal service only – Only 4 provide 24/7, the rest lab hours or „occasional‟ • 23/37 offered a service to other hospitals – Reporting that they provided this to 78 hospitals – NB only 42 non interventional hospitals said they received a routine PPCI service, suggesting that service to other hospitals might be irregular / occasional
  21. 21. Manchester (2) -North Mcr James Cook -Salford - Friarage -Stockport -Tameside -Trafford Leeds - SJUH NW London (3) - Bradford -Hammersmith -W Middlesex -Ealing East London -Charing X - R London -St Mary‟s - Whipps X -Northwick - King George -Hillingdon - Oldchurch -Harefield - Homerton -Brompton - Newham -Hemel SE London -Lewisham Exeter -Bromley -Sidcup -Mayday
  22. 22. Trust Catchment Areas Secondary - Acute MI Tertiary - CABG No. of Trusts 153 28 Ave Pop Served 321,000 1.7 million Largest 787,000 3.2 million Smallest 104,000 816,000 Acute MI Catchments Tertiary CABG Catchments
  23. 23. Conclusion • District hospital angiography has improved access to care and the capacity is needed • Still a great deal of unmet need particularly in the North • We are a long way from providing a comprehensive PPCI service at the present • Many places are „dabbling‟ • We need a comprehensive strategy within each network with formal involvement of the ambulance service • No reason to exclude DGHs from providing this but the rota requirements are onerous

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