Prof Peter F Ludman (BCIS Audit Lead, London, UK) presents the highlights from the BCIS National Audit: Adult Interventional Procedures.

Filmed in London at BCIS ACI 2020.

Videographer: Natacha Wienand | Dominic Woodruff | Tom Green

Transcript Below : 

So, I'm Peter Ludman. I'm the Audit Secretary for the British Cardiovascular Intervention Society. And I've been asked to provide some highlights for the National Audit, the data of which was presented today. This is the audit for procedures performed, adult interventional procedures, performed in the UK in the financial year 2018 to 2019. 

The contents of this presentation is quite extensive and I intend only to touch on some highlights to try and give you an idea of what was presented today. 

So, in this year, there were 118 PCI centres across the UK and you can see how they're distributed between the four countries of the United Kingdom, in the National Health Service and in the private sector. And interestingly, for the first time since we've been collecting these data, this number hasn't changed since the previous year. So, there's been no change in the number of centres. You'll also see that for the first time since we've been recording these data, back in 1991, there was actually a fall in the total number of PCI's performed, down to 100, 100,294, giving us a rate per million, of 1,510. That fall was about 2.5% but it was not evenly distributed between the UK countries. And you'll see that Wales had a rise in their rate of PCI per million population. But, there was a fall in the English population. Fairly level pegging in Scotland. And the biggest fall, actually, was from Northern Ireland, but they started at a much higher rate and they continue to operate at a much higher rate. 

There are recommendations that in the UK, all centres should perform at least 400 PCI procedures per year. And the percentage of centres that performed less than this recommendation, less than 400 cases a year, shown in this slide. And you can see that in this year, it's fallen to the lowest level, so far. So, that if you look at just NHS centres, it's fallen to about 16%. If you take all centres, including private centres, it's fallen to 30. And a lot of private centres perform fairly low volume activity. How many of us are doing percutaneous coronary intervention? Well, the number's risen by only 4% to 690 and you'll see that only 40 of our operators are female, amounting to slightly less than 6% and this is something that the society is trying to work on to increase, to get better representation for all the talent that's out there. If you look at the pattern of surgical centres, the dark lines represent, sorry, start again. If you look at the pattern of provision of PCI in either surgical or non surgical centres, the dark lines represent the surgical centres, and you can see that they dominate the high volume PCI centres whereas the centres with offsite surgery dominate the low volume. But, there are nevertheless some surgical centres that do relatively low volume activity and some offsite centres with very high volumes. This ends up meaning that about 60% of all PCIs are performed in centres with on site surgery and 42% without. Now, let's turn to primary PCI, which is the emergency treatment for ST-segment elevation myocardial infarction. And this is a map of the UK and it shows the network of primary PCI centres and in dark purple circles, are all those centres that offer 24/7, 365 days a year access. Ambulances, diagnose, ST-elevation infarction in people's homes. They recognise they're having heart attacks and they take patients any time of day or night to these centres for primary PCI. 

You can see there are four centres, two in Manchester, and two down on the South coast in the square boxes that offer hybrid service. And then, there are some centres in the South in pale blue which offer primary PCI during working hours but at night the patients are treated elsewhere. And you can see this pattern of movement of patients, for example from Swindon and Gloucester towards Bristol and from outskirts of London towards London and also from places like Poole and Dorset, across to Bournemouth and Southampton. What's going on? There we go. Now, in 2016, Phil MacCarthy, Dan Blackman, David Hildick-Smith and Adrian Banning put together a position statement to try and look at what the facilities and emergency medical staffing would be appropriate for delivering a primary PCI service that was sustainable and appropriate. And you can see that one of the recommendations was to do with compensatory rest when operators have been up all night working. And they split this into two groups, into hospitals that do more than or equal to 400 primary PCIs a year. In other words, very busy centres where operators are likely to be out most of the night working and suggested that there should be a full day after such a night on call of compensatory rest. And for less intensive and less busy centres, there should be at least half a day. How does it pan out? Well, on the left hand side of this chart, you can see centres that are busy and you can see that actually only eight fulfil that recommendation of no work the following day. 16 have reduced activity and two no change in work at all. If you go to the lower volume centres, then you can see that in purple and green, 32 of the centres do actually fulfil the requirement of at least some reduction in the following day's activity. The other question we asked this year was that if that activity is reduced, how is this covered? Is it covered by a reduction in how much people are paid, how much their programmed activities are reduced, or is the work just shuffled around. And you can see that in 11 centres, the operators who are not working the following day have their pay effectively docked and in other centres, the work is just moved around. One of the other questions that was, other recommendations that was made was that if there is a centre participating in primary PCI that all interventional cardiologists in that centre should participate. But, you'll see that from the survey, 21 centres have interventional cardiologists working in their centres who do not participate in that rota. Sorry, I'll go back again. So, I probably should say... And at that stage, there is a huge amount of additional information that will be available on the business website that looks at the way in which PCI is delivered and the treatments that are delivered and the coronary syndromes that are treated. But, for the purposes of this presentation, I'm now going to move on to structural heart disease and particularly, I'm going to talk about aortic valve intervention. The most important aortic valve intervention and activities really has taken off recently, is transcatheter aortic valve implantation. And I'm pleased to say there are three new centres, this audit year. So, Hull has joined all the other English centres and there are two Scottish centres. And that means that every English cardiothoracic surgical centre now has a transcatheter aortic valve implantation programme and it brings us to a total of 41 centres in the UK. This is a map that shows that distribution of centres. Now, there's been a big jump in activity and you can see that in 2017, the activity was about 4,000 cases. But, in the financial year 2018-19 there's been a jump to 5,197 cases, which is a big increase. It's been done without any change in the infrastructure of the delivery of care for patients. And it ends up resulting in a rate per million population of about 78. And as we've got use to seeing, this is different across the different UK countries. And you can see that topping the bill, as usual, is Northern Ireland with a rate of 120 per million population and Scotland is tailing at 57 but with their two new centres, I fully expect their activity, and indeed the activity all across the UK, to increase very rapidly. So, that's a very quick summary, a quick look at a very comprehensive audit. The details of which will be available on the BCIS website. I would summarise by saying, that there've been many unusual things about the PCI activity this year in that there's been no change in the centres delivering that activity and that activity's actually fallen by 2.5%. And the procedure specific data this year has been delayed. But, will be available later, on the website. In the full presentation I talked about some very interesting observational research which has come from the data sets we've been collecting, looking at changes in practise and anti-platelet therapy. And, I also, in the main presentation talked about the public reporting of outcomes following percutaneous coronary intervention, which is available in the public section of the BCIS website. In terms of structural intervention, there's been a big increase in the use of transcatheter aortic valve implantation. And the full presentation talks about many other aspects of structural heart fail, of structural heart treatment. And I'll end my presentation there.