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“Tertiary Centres are Obsolete”

“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 DGH Mark Signy DGH

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“Tertiary Centres are Obsolete”

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  1. “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

  2. Acknowledgements • Will Orr DGH • Mark Signy DGH • Andrew Bishop DGH • Kevin Beatt DGH • Peter Ludman Tertiary/BCIS hit man Conflict of Interests: None

  3. “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’s-worth 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 big-name interventionist (when we can find him/her)…or even by the very guy who sent them in & needs an imposing bit on their letterhead…

  4. “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…..)

  5. 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

  6. “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?

  7. Nombres de PCI dans certains pays Européens Bernard De Bruyne, Aalst, Belgium GE Par 106 habitants BE UK High Tech 2007, Marseille

  8. On v Off Site SurgeryNHS Centres only 51% Form AB

  9. Surgical Cover(all 91 NHS and Private Centres) 2006 data: Ludman Form AB

  10. 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’

  11. Here is a DGH interventionist who is virtually indistinguishable from a “tertiary” interventionist except for where he works… DGH TIPSY…

  12. From Bishop, A. 2007, (his only data slide)

  13. All Cases at Tertiary-Centre • ‘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 (0.95%) From Audit Coordinator via Signy, M. 2007

  14. Non-elective ‘Hot’ 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 (0.9%) 3 (0.2%) 7 (0.5%) 23(1.5%)

  15. 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%)

  16. 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 ££ Not just to make a quick buck ££

  17. UK Inter-Hospital Transfer Times 2004

  18. 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

  19. `boutique angioplasty`

  20. 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

  21. CAPTIM 1 Year Results Sx > 2 hours Sx < 2 hours Death Death P=0.47 P=0.057 Primary PCI Pre Hospital Lysis Primary PCI Pre Hospital Lysis Steg Circulation 2003;108:2851-6

  22. 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

  23. 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

  24. Reading STEMI Data MINAP Jan 2008

  25. 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

  26. 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

  27. Evolution of the Non Surgical PCI Centre Interventionist:

  28. 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

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