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A MODEL FOR CO-OPERATION - some inconvenient truths

A MODEL FOR CO-OPERATION - some inconvenient truths. Mark Signy Worthing and Brighton. Declaration of Interests. DGH interventional cardiologist Tertiary centre interventional cardiologist Personal experience of PCI as patient BCIS council member

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A MODEL FOR CO-OPERATION - some inconvenient truths

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  1. A MODEL FOR CO-OPERATION- some inconvenient truths Mark Signy Worthing and Brighton

  2. Declaration of Interests DGH interventional cardiologist Tertiary centre interventional cardiologist Personal experience of PCI as patient BCIS council member Lecturing /ad boards /educational sponsorship from device and pharma companies

  3. Firstly: Thanks for coming on board… • Dave Smith and many other ‘DGH’ cardiologists have campaigned for years for primary PCI in the UK : Dave and John Dean did the first proper UK pilot of PPCI in a DGH at Exeter • This meeting has up to now been a forum for regular debate as to whether we should do PPCI at all in UK… • Sadly, having decided at last to support it, the powers-that-be appear to be suggesting limiting PPCI to large centres, rather than to where the patients are…

  4. déjà vu? Type A/Type B cardiologists Limit catheterisation to tertiary centres Limit PCI to tertiary centres Limit PPCI to ‘heart attack’ centres or large volume centres ie mostly tertiary centres…

  5. Why? • Some publications suggest better PCI outcomes in large volume centres • Well yes, but several have in fact shown this in centres doing more than about 300 PCIs (which is well below the minimum number of PCIs per approved centre in the UK) and others have shown no difference at all… • A low–volume centre in US literature may perform less than 150 cases a year

  6. Are the Tertiary centres simply better? Better operators? Better outcomes? Closer to patients?

  7. Are the tertiary centres simply better? 1999 interventional post at Worthing: approx 20 applications some are now ‘tertiary’ interventional cardiologists (including one in Rod Stables’ own unit…) Did not being shortlisted or appointed make them better interventionists than if they had been appointed? Are they necessarily better interventionists than the appointed candidate? Or vice versa?

  8. Are the tertiary centres simply better? Barry Kneale was appointed to the first post he applied for Keith Dawkins (for example) wasn’t or the second… Would Barry have been a better interventionist if he had applied for (and not got) several less competitive posts?

  9. Do you become a worse interventionist if you move from a tertiary centre to a DGH?

  10. Are you a worse interventionist until they change your unit from a DGH to a tertiary centre?

  11. Are you a worse interventionist at the non-surgical centre if you work equally at both types of hospital

  12. Or is the tertiary centres’ outcome data simply better? Data presented at this meeting over the last few years (Reading, Eastbourne, Worthing etc) has shown DGH outcomes at least comparable to many tertiary centres…

  13. Are the tertiary centres simply better? Robust stats from Brighton back to the very beginning of the unit Data from1999 till summer 2007 Figures supplied by Gaynor Dixon (audit Co-ordinator RSCH)

  14. All Cases • ‘TERTIARY’ OPERATOR • No: 4858 • Mortality: 55(1.13%) • CABG: 5 (0.1%) • Q wave MI: 8 (0.16%) • MACE 68 (1.4%) • ‘DGH’ OPERATOR • 3363 • 15 (0.45%) • 8 (0.24%) • 12 (0.36%) • 35 (1%)

  15. Non-elective Cases TERTIARY OPERATOR No: 2948 Vessels: 1.23 Stents/vessel: 1.2 Mortality: 53(1.8%) CABG: 3 (0.1%) Q wave MI: 6 (0.2%) MACE 62(2.1%) DGH OPERATOR 1308 1.19 1.27 13 (1%) 3 (0.2%) 7 (0.5%) 23(1.7%)

  16. Worthingdata to 31st December 2008 All ‘DGH’ OPERATORS of course… Total cases: 819 MACE 6 (0.73%) Elective: 415 MACE 1 (0.24%) Non elective: 404 MACE 5 (1.2%)

  17. Here’s a conundrum: how well do our experts design services? SE coast SHA: 4.9 million population

  18. One tertiary centre for 4.9 million: where would YOU putit?

  19. In the middle?

  20. THE VISION (apparently…) 55 year old male Acute MI at 8AM on a busy Monday morning Rye (10 miles east of Hastings) Ambulance arrives in 10 minutes (if lucky) Thrombolysis could be given within 20-30 mins of onset of pain

  21. THE VISION (apparently) RYE +30 mins pain to thrombolysis

  22. THE VISION (apparently) HASTINGS PCI lab +60 mins DTN ?30 mins Possible 90 mins pain to balloon RYE +30 mins

  23. THE VISION (apparently) EASTBOURNE PCI Lab +105 mins DTB 60 mins Possible pain to balloon time 165 mins HASTINGS PCI lab +60 mins DTB ?30 mins RYE +30 mins

  24. THE VISION (apparently) RYE +30 mins BRIGHTON ‘Heart Attack centre’ +150 mins DTN 60 mins Possible DTB time 210 mins EASTBOURNE PCI Lab +105 mins DTN 60 mins HASTINGS PCI lab +60 mins DTN ?30 mins

  25. THE VISION (apparently) BRIGHTON ‘Heart Attack centre’ +150 mins DTN 60 mins Possible DTB time 210 mins EXCESS TIME FROM THROMBOLYSIS up to 180 mins EXCESS TIME OVER PCI at HASTINGS up to 120 mins Where’s the benefit for the patient? Does ANYONE (outside secure accommodation…) really think this is the way forward? HASTINGS PCI lab +60 mins DTN ?30 mins Possible DTB 90 mins RYE +30 mins to thrombolysis

  26. Non surgical centres contribute to the problems though: Several centres still doing less than 200 PCIs per year Some operators still consistently below 75 PCIs per year Some centres neither provide 24hr on-site PCI nor contribute to 24hr on-call for the network/centre (ie expect others to pick up their emergency work)

  27. West Sussex/Brighton Model for co-operation PCI done at Brighton (approx1200 cases) and Worthing (350-450 cases plus 150-200 taken to Brighton) ‘Niche’ intervention all done at Brighton (including rotablation, hole closure percutaneous AVR etc) All interventionists now work at both sites On-call for intervention shared between 7 interventionists (4 Worthing, 3 Brighton - out of hours on Brighton site)

  28. West Sussex/Brighton Model for co-operation Primary PCI done at both sites during weekdays Out of Hours primary PCI done at Brighton (shared on-call between 7 operators) The ambulance service much prefer this to 24 hr long distance transfer Thrombolysis not yet completely abandoned…

  29. Model for co-operation All PCI centres should do 400 cases and all operators 75 cases annually All centres must either provide 24 hr PCI or participate in a central 24hr PCI on-call service Non-surgical centre operators should have sessions at the surgical centre, participate in the network PCI audit, and should take/refer ‘niche’ cases and surgery to the centre

  30. Model for co-operation • Primary PCI should be performed as close to the patients as possible, and as early after onset of symptoms as possible • STEMI Patients should never, ever, be driven past an open, staffed and appropriate PCI centre simply for the sake of theoretical policy or maintenance of central numbers

  31. Model for co-operation • Don’t yet throw away high quality established prehospital thrombolysis in the bathwater of weak statistics: • even in the highly populated south east there are areas where it clearly remains an appropriate therapy

  32. A MODEL FOR CO-OPERATION TERTIARY-Burrell… SKI GUIDE… DGH - Signy… MIXED -Hogan…

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