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DGH v Tertiary Intervention Is there really a conflict? “The BCIS Perspective”

Dr Martyn Thomas Kings College Hospital BCIS President. DGH v Tertiary Intervention Is there really a conflict? “The BCIS Perspective”. MY CONFLICTS OF INTEREST ARE: Research Support: Boston Scientific, Cordis and Medtronic Advisory Board for: Boston, Cordis, Abbott, Lilly and Nycomed.

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DGH v Tertiary Intervention Is there really a conflict? “The BCIS Perspective”

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  1. Dr Martyn Thomas Kings College Hospital BCIS President DGH v Tertiary InterventionIs there really a conflict?“The BCIS Perspective”

  2. MY CONFLICTS OF INTEREST ARE: Research Support: Boston Scientific, Cordis and Medtronic Advisory Board for: Boston, Cordis, Abbott, Lilly and Nycomed.

  3. DGH v Tertiary Intervention(p.s. surgical v non surgicalcentres!)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!!

  4. DGH v Tertiary InterventionIs there really a conflict?“The BCIS Perspective” Where does the UK stand in worldwide terms with regard to revascularisation??

  5. 2005 data: Ludman Total UK PCI Procedures

  6. A worldwide perspective.

  7. 2005 data: Ludman UK Centres - 2005

  8. What are the current guidelines:for a new PCI centre?

  9. What are the current guidelines:for an operator?

  10. 2005 data: Ludman Number of PCIs performed in 2005(per NHS Centre) Mean = 1028 Data from: all 65 NHS centres

  11. Surgical Cover

  12. Surgical cover

  13. 2005 data: Ludman MACE (2005) - All PCIsAll Data from CCAD + Form C

  14. 2005 data: Ludman Surgical Cover(all 83 NHS and Private Centres)

  15. Tertiary (Surgical) and DGH (Non-Surgical) centres receiving BCIS visits since 2004 (the “Truth!”. 1:20 is a Surgical centre!

  16. Tertiary (surgical centre) ParanoiaWhere is all the work?What will we do?

  17. 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.

  18. NB: BCS 2004 proposed 2200-3300 per million for PCI alone!!

  19. The Model

  20. Where will PCI take place in the future?

  21. Implications for cath lab capacity

  22. Potential growth areas? For the surgical centres • “Hole” closure: PFO, ASD etc. • Percutaneous Valve therapy. • Intramyocardial injection therapy • “Gene/cell” therapy.

  23. 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).

  24. Interventional ResearchConsequences 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.

  25. The TariffProblems 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

  26. Tertiary centre: year 1100 cases referred from DGH60% unstable and 40% stable25% 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

  27. Tertiary centre: year 225 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

  28. 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.

  29. 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.

  30. 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.

  31. 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.

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