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Coronary Revascularisation: the DoH View

Coronary Revascularisation: the DoH View. Dr Roger Boyle National Director for Heart Disease. NSF Standards. Standard nine “People with angina that is increasing in frequency or severity should be referred to a cardiologist urgently or, for those at greatest risk, as an emergency”

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Coronary Revascularisation: the DoH View

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  1. Coronary Revascularisation: the DoH View Dr Roger Boyle National Director for Heart Disease

  2. NSF Standards Standard nine “People with angina that is increasing in frequency or severity should be referred to a cardiologist urgently or, for those at greatest risk, as an emergency” Standard ten “ NHS Trusts should put in place hospital-wide systems of care so that patients with suspected or confirmed coronary heart disease receive timely and appropriate investigation and treatment to relieve their symptoms and reduce their risk of subsequent events”

  3. National Service Framework • Accepted • effectiveness of revascularisation • low rates in UK • inequity of access • history of under-investment

  4. NSF and NHS Plan Targets • Initial NSF target (March 2000) 3000 additional revascularisations by April 2002 • Second NHS Plan target (July 2000) 6000 additional procedures by April 2003 • “Further targets will be set”!

  5. NSF waiting time goals • Referral by GP to specialist assessment/consultant appointment: two weeks maximum • Prompt investigation and revascularisation within three months of the decision to treat

  6. Priorities and Planning Framework 2003-6 Improve access to services across the patient pathway and increase patient choice: • by achieving the two week wait standard for Rapid Access Chest Pain Clinics; • by setting local targets to make progress to the NSF goal of a 3 month maximum wait for angiography; • by delivering maximum waits of 3 months for revascularisation by March 2005 or sooner.

  7. Strategies for delivery • RACPC’s • Target 150, 186 achieved • 71% seen within 2 weeks, Target 100% • Catheter lab investment programme • National capacity reviews • based on SMR adjusted targets • Immediate revenue injection • Workforce development programme

  8. Revenue invested in revascularisation

  9. Capital schemes • Over £300m for expansion • Expansion at James Cook, Bristol and Papworth complete • Entirely new centre at Wolverhampton • Expansion at Blackpool, Liverpool, Manchester (South and Central), Southampton, Sheffield, Leeds and Plymouth • £80m for new catheter labs • plans for 86 new or replacement labs in train

  10. Extending Patient Choice • Total eligible since 1st July 2002 • 4621 • Clinically eligible • 3298 • Exercised choice • 3183 • Opting for treatment elsewhere • 1531 have now been treated elsewhere

  11. CABG waiting times in England

  12. CABG waiters in England (over 6 months)

  13. Trends in waits for CABG Actual Projected

  14. Revascularisation waits(more than 6 months)

  15. Revascularisation waits(all waiters)

  16. NSF and NHS Plan Targets • Initial NSF target (March 2000) 3000 additional revascularisations by April 2002 achieved by April 2001 • Second NHS Plan target 6000 additional procedures by April 2003 achieved by April 2002

  17. NSF waiting time goals(for 2008) • Referral by GP to specialist assessment/consultant appointment: two weeks maximum -achieved for 71% • Prompt investigation and revascularisation within three months of the decision to treat - angio waits to be monitored from April - 3 month wait for revascularisation in sight

  18. Remaining challenges for PCI • Equity of access • Ratio of PCI to CABG • Revising the activity target • Primary PCI • Eluting stents • Staffing requirements to handle growth

  19. CAGB rate versus SMR for CHD by StHA in 2000/1 Y=3.732x+73.312 Correlation coefficient 0.6, p=0.0004 (Aggregated up from DHA data)

  20. PCI rate versus SMR for CHD by DHA in 2000/1 p=NS

  21. Data from HES (FCEs in England only) Ratio 1.3 : 1

  22. 19% Efficiency gains 17% Data from HES (FCEs in England only) Ratio 1.3 : 1

  23. Primary PCI - how, where and when? • Better than pre-hospital thrombolysis? • Volume affects outcome • Ambulance triage? • Rescue and thrombolysis-ineligible cases only or all? • Is it really cost-effective? • How does it rank with other priorities?

  24. Expansion of PCI - one scenario • Current activity (England) • 30,000 • Additional activity to achieve 1000 pmp • 20,000 • Incidence of STEMI (MINAP) • 24,000 • Total activity needed (?) • 74,000 or an increase of 147%

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