DGH v Tertiary Intervention
Is there really a conflict?
“The BCIS Perspective”
Dr Martyn Thomas
Kings College Hospital
BCIS President
MY CONFLICTS
OF INTEREST ARE:
Research Support: Boston Scientific,
Cordis and Medtronic
Advisory Board for: Boston, Cordis,
Abbott, Lilly and Nycomed.
DGH v Tertiary Intervention
(p.s. surgical v non surgical
centres!)
Is there really a conflict?
“The BCIS Perspective”
• What “experience” do I have to give such
a talk?
- BCIS President
- Currently perform PCI at Kings College
Hospital (Teriary) AND the “Mayday
Hospital” (DGH). Gives some perspective!!
DGH v Tertiary Intervention
Is there really a conflict?
“The BCIS Perspective”
Where does the UK stand in
worldwide terms with regard to
revascularisation??
Total UK PCI Procedures
2005 data: Ludman
Year Centres Total Rate per million Increase
Procedures (%)
1991 52 9,933 174
1992 52 11,575 203 16.5
1993 53 12,937 227 11.8
1994 54 14,624 256 13.0
1995 54 17,344 304 18.6
1996 53 20,511 359 18.1
1997 58 22,902 402 11.7
1998 61 24,899 437 8.7
1999 63 28,133 494 13
2000 66 33,652 590 20
2001 64 38,992 664 12.5
2002 64 44,913 759 14.3
2003 73 53,261 894 17.8
2004 77 62,780 1050 17.4
2005 83 70,142 1165 11.0
A worldwide perspective.
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
What are the current guidelines:
for a new PCI centre?
What are the current guidelines:
for an operator?
Number of PCIs performed in 2005
(per NHS Centre)
Mean = 1028 2005 data: Ludman
3000
2500
Number of PCIs
2000
1500
1000
500
0
Individual Centres
Data from: all 65 NHS centres
Surgical Cover
Surgical cover
MACE (2005) - All PCIs 2005 data: Ludman
All Data from CCAD + Form C
%
% Re PCI for Mortality
Year Procedure % QMI % Em. CABG
acute closure (%)
Success
1995 89 1.4 1.9 0.69
1996 90 1.4 1.7 0.72
1997 92 1.2 1.1 0.89
1998 92 0.8 0.7 0.80
1999 90 0.57 0.48 0.61
2000 92 0.6 0.4 0.64
2001 94 0.5 0.4 0.75
0.57
92 0.33 0.28 0.54
2002 (49 of
(51 of 64) (50 of 64) (53 of 64) (53 of 64)
64)
0.36
92 0.17 0.29 0.53
2003 (56 of
(62 of 73) (62 of 73) (64 of 73) (64 of 73)
73)
0.30
93.5 0.30 0.21 0.56
2004 (57 of
(63 of 78) (61 of 78) (64 of 78) (66 of 78)
78)
2005 90.2 0.24 0.12 0.59
Surgical Cover
(all 83 NHS and Private Centres)
2005 data: Ludman
On site Off site
No of centres 54 29
(65%) (35%)
No. of PCI (% of total) 57,545 12,622
(82%) (18%)
Mean No. PCI per centre 1065.6 435.2
PCIs per interventionist
167.4 114.4
(all 65 NHS centres only):
Tertiary (Surgical) and DGH (Non-Surgical) centres
receiving BCIS visits since 2004 (the “Truth!”.
1:20 is a
Surgical centre!
Tertiary (surgical centre)
Paranoia
Where is all the work?
What will we do?
The Model (DOH)
• 3 levels of revascularisation tested; 1900,
2200 and 2500 per million, by 2015
• 7.2% increase in ICDs, reaching latest
NICE guidelines by 2015.
• A range of 5-15% increase in
interventions for EP/arrythmias.
•NB: BCS 2004 proposed
2200-3300 per million
for PCI alone!!
The Model
Revasc PCI:CABG ratio
rates by
2015
2008 2010 2015
1900/mill 2.9:1 3.1:1 3.5:1
2200/mill 3.2:1 3.4:1 4.2:1
2500/mill 3.4:1 3.8:1 4.9:1
Where will PCI take place in
the future?
Implications for cath lab capacity
Potential growth areas
? For the surgical centres
• “Hole” closure: PFO, ASD etc.
• Percutaneous Valve therapy.
• Intramyocardial injection therapy
• “Gene/cell” therapy.
Specific “issues” with a change
toward PCI in non-surgical centres
(not outcome related!)
• Changes needed in the organisation of
some interventional research.
• Case Mix (the Tariff).
Interventional Research
Consequences of a “devolved
service”
• Currently a “handful” of surgical centres have
the infra-structure, and perform international
multicentre randomised trials and registries.
• For FIM type cases this requires relatively
straightforward lesions………..these will be
increasingly rare in the surgical centres.
• A change of infra-structure/research staff etc will
therefore be necessary for this activity to
continue.
The Tariff
Problems of Case Mix
• E15: Percutaneous coronary intervention
• Elective £3660
• Non-elective £4758
• CABG elective £7195
• CABG non elective £8748
• Kings MFF 1.3
• +16% uplift
• Leads to PCI elective=£5519 and PCI non
elective=£7175
Tertiary centre: year 1
100 cases referred from DGH
60% unstable and 40% stable
25% multiple stents
• Simple elective: make £500, Complex elective: lose
£1000
• Simple non-elective: make £1,500, Complex non-
elective: lose 1,500
• Revenue:
• Simple non-elective: +£67,500
• Complex non-elective: -£22,500
• Simple elective: +£15,000
• Complex elective: -£10,000
• Net income= +£50,000
Tertiary centre: year 2
25 cases referred from DGH
(all complex), 75 cases done in non
surgical centre.
• Non-surgical centre:
• Simple non-elective: +£67,500
• Simple complex: +£15,000
• Revenue: +£82,500
• Tertiary centre:
• Complex non-elective: -£22,500
• Complex elective: -£10,000
• Revenue: -£32,500
Potential consequences of the
Tariff and non-surgical centre PCI.
• Potential diversion of revascularisation
toward surgery because of “skewed” case
mix leading to PCI being non-viable.
• Potential of “profiteering” of DGH at the
expense of Quality.
Personnel view!!
• Fully supportive of non-surgical centre
PCI, as long as volume and expertise are
maintained.
• Here are the last x2 cases at the
Mayday………….last Thursday.
Conclusions
Training and experience has more influence on
outcome of PCI than location.
As long as individual and institutional volumes
are maintained BCIS fully supports the
development of non-surgical centre PCI.
Strong links between the surgical centre and
non-surgical centre with exchange of personnel
and audit data in both directions is essential.
Achievement of “European” type rates of
revascularisation cannot be done without full use
of the non-surgical cath labs.
Conclusions
Development of research infrastructure
within the non-surgical centres should be
encouraged.
Surgical centre operators should be
encouraged to “support” non-surgical
centres, including performing PCI
sessions.
Some form of tariff sharing may be
required across Networks to make all units
viable and to avoid distortion of clinical
practice for financial reasons.