“Tertiary Centres are Obsolete”
Dr Neil Sulke
or
‘The Patsy’
In possibly his last ever presentation to BCIS
Competing interests: What’s best for our patients
Acknowledgements
•
•
•
•
•
Will Orr
Mark Signy
Andrew Bishop
Kevin Beatt
Peter Ludman
DGH
DGH
DGH
DGH
Tertiary/BCIS hit man
Conflict of Interests: None
“Tertiary Centres are Obsolete”
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’sworth 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 bigname 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
Obsolete”
(Actually, They 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 (1930-60):
‘just too complex to be understood in a DGH’
‘inadequate technical back-up’
‘insufficient numbers to remain safe’
‘facilities not cost effective in a DGH’
‘Shown to be dangerous in low volume
centres in the USA…’
CC.
Cor. Angiography,
Thrombolysis
Permanent Pacing
TOE
ICDs
“Tertiary Centres might become
Obsolete if they keep leaking
procedures to DGHs”
What is the next bastion to fall?
• New imaging stuff?
• ‘Basic’ EP/Ablation?
• AF Ablation?
Or…
• Will it be PCI in almost all its forms?
Nombres de PCI dans certains pays Européens
Bernard De Bruyne, Aalst, Belgium
4000
3500
Par 106
habitants
3000
GE
2500
2000
BE
1500
1000
500
0
UK
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
High Tech 2007, Marseille
On v Off Site Surgery
NHS Centres only
51%
100%
80%
26
37
60%
Off Site
On Site
40%
38
20%
38
0%
2005
2006
Form AB
Surgical Cover
(all 91 NHS and Private Centres)
2006 data: Ludman
No of centres
No. of PCI (% of total)
Emergency CABG (number)
Emergency CABG (% of activity)
On site
Off site
53
38
58,153
15,539
56
8
0.1%
0.05%
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…
DGH
TIPSY…
From Bishop, A. 2007, (his only data slide)
All Cases at Tertiary-Centre
• No:
‘TERTIARY’ OPERATOR ‘DGH’ OPERATOR
4858
3363
• Mortality:
• CABG:
• Q wave MI:
55(1.13%)
5 (0.1%)
8 (0.16%)
15 (0.45%)
8 (0.24%)
12 (0.36%)
• MACE
68 (1.4%)
35 (0.95%)
From Audit Coordinator via Signy, M. 2007
Non-elective ‘Hot’ Cases
•
•
•
•
•
•
TERTIARY OPERATOR DGH OPERATOR
No:
2948
1308
Vessels:
1.23
1.19
Stents/vessel:
1.2
1.27
Mortality:
53(1.8%)
13 (0.9%)
CABG:
3 (0.1%)
3 (0.2%)
Q wave MI:
6 (0.2%)
7 (0.5%)
• MACE
62(2.1%)
23(1.5%)
All Cases: first calendar year
at Worthing DGH
• ‘DGH’ OPERATORS ONLY
• Total cases: 280
– MACE 1 (0.36%)
• Elective: 141 (51%)
– MACE 0
• Non elective: 139 (49%)
– MACE 1 (0.7%)
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
Average Wait In Days Per Patient By Trust For Angio +/- Proceed
Trust Code
Admission to Ref erral
66
10 9
95
40
76
13 6
60
49
6
14 0
12 6
73
27
28
35
93
23
43
56
12 2
9
21
31
10
13
47
12 3
87
61
118
59
42
62
3
25
7
30
96
17
34
13 0
97
22
44
12 9
13 4
11
26
18
14 2
50
10 7
13 7
12
116
82
14
57
8
12 4
4
110
119
13 5
63
91
2
115
77
13 3
15
12 5
84
64
10 0
10 3
12 7
92
54
48
13 8
52
12 0
13 1
45
10 6
71
1
113
83
117
10 5
98
75
39
37
90
85
88
36
12 8
58
38
13 2
111
80
12 1
19
16
74
51
10 4
78
114
10 8
81
89
10 2
53
72
13 9
20
29
79
67
5
55
33
14 1
10 1
94
70
Ref erral to Transf er
Transf er to Procedure
UK Inter-Hospital
Transfer Times
2004
0
5
10
15
Ave r age Wait (Days ) Pe r Patie nt
20
25
30
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 halved
`boutique angioplasty`
Reading 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
CAPTIM 1 Year Results
Sx > 2 hours
Death
Sx < 2 hours
Death
P=0.47
10%
P=0.057
5.7%
5.9%
5%
3.7%
2.2%
0%
0%
Pre Hospital
Lysis
Primary
PCI
Pre Hospital
Lysis
Primary
PCI
Steg Circulation 2003;108:2851-6
Primary PCI
Time to treatment and 1-year mortality
every 30 min delay
increases mortality by 7.5%
De Luca, G. et al. Circulation 2004;109:1223-1225
Rescue PCI - REACT
5-yr follow-up suggests
c.50% reduction in mortality
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
Reading STEMI Data
STEMI
05-06
06-07
07-08
126
138
79*
P-H Thrombolysis
-
20%
37%
Revascularisation
-
45%
72%
In-Hosp Mortality
5.6%
3.6%
2.5%
30d Mortality
7.9%
-
-
n
MINAP Jan 2008
Why not 24/7 Primary PCI in
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:
‘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 clearly stack up (despite the
Ludmanite ‘size-matters’ stories from the
USA…)
The new concept is: ‘Non Surgical Centre’ PCI
Evolution of the Non Surgical PCI Centre Interventionist:
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