National Vascular Registry 2019 Annual Report

National Vascular Registry 2019 Annual Report
Vascular Services Quality Improvement Programme 13 December 2019

• This report contains information on the process and outcomes of care provided by NHS vascular units during the three-years from 2016 to 2018 for patients undergoing:
• Lower limb bypass
• Lower limb angioplasty/stenting
• Major lower limb amputation
• Carotid endarterectomy
• Repair of aortic aneurysms, including elective infra-renal, ruptured infra-renal, and more complex aneurysms
• Also available on HQIP

TAVR for low-risk severe aortic stenosis: is this the end of surgical valve replacement?

TAVR for low-risk severe aortic stenosis: is this the end of surgical valve replacement?
BMJ Evidence-Based Medicine 1 November 2019. doi: 10.1136/bmjebm-2019-111259 [NHS OpenAthens required]

• New trials, PARTNER 3 and Evolut Low Risk, showed promising results for transcatheter aortic valve replacement for low-risk surgical patients with severe aortic stenosis. However, there remain caveats to its use in this population in clinical practice.

MRI for patients with CIEDs: simplifying complexity with a ‘one-stop’ service model

MRI for patients with cardiac implantable electronic devices: simplifying complexity with a ‘one-stop’ service model
BMJ Quality & Safety 2019;28:853-858, 19 September 2019

• MRI scanning for patients with cardiac implantable electronic devices (CIEDs) requires some additional steps to be taken both prior to imaging and on attendance. 
• A one stop service model [Barts Hospital NHS Trust, London] whereby CIEDs could be reprogrammed and scans acquired at a single location on a single visit is described, including workforce impact, and development of a standard booking protocol. No additional equipment or other fixed costs were needed. After 2 years, scan volume was over 20 times the national average with a lower waiting time, and while maintaining total departmental activity.

National Cardiac Audit Programme – Annual Report 2019

National Cardiac Audit Programme – Annual Report 2019
HQIP 12 September 2019

• The National Cardiac Audit Programme 2019 Annual Report covers over 300,000 records across five clinical areas: 
• Adult Cardiac Surgery
• Myocardial Ischaemia (MINAP)
• Percutaneous Coronary Intervention (PCI)
• Heart Failure
• Congenital Heart Disease
• The report focuses on three broad quality improvement themes: timely care, specialist care and evidence-based care delivered to a uniformly high standard.
• It highlights four areas of interest where improvements have been made but some hospitals have been slow to adopt innovation.
• Use of day-case elective PCI
• Use of disease-modifying medicines in heart failure with reduced ejection fraction
• Deep wound infections after cardiac surgery requiring additional surgery
• Use of radial access for PCI procedures

May 2019 Specialised services prioritisation decisions

May 2019 prioritisation decisions
NHS England 18 July 2019

• New treatments which should be included for routine commissioning based on recommendations from the Clinical Priorities Advisory Group (CPAG) include:
• Percutaneous patent foraman ovale closure for the prevention of recurrent cerebral embolic stroke in adults (around the age 60 years and under)
• Percutaneous mitral valve leaflet repair for primary degenerative mitral regurgitation (adults)

TAVI for the treatment of patients with severe symptomatic aortic stenosis who are at intermediate surgical risk

Transcatheter aortic valve implantation (TAVI) for the treatment of patients with severe symptomatic aortic stenosis who are at intermediate surgical risk
SHTG advice Statement and Evidence Note, 1 May 2019

• Based on commonly accepted UK cost-effectiveness thresholds, TAVI at list prices is unlikely to be cost-effective in patients with severe symptomatic aortic stenosis who are at intermediate surgical risk.

Advice for NHS Scotland

Heart valve disease - HSJ Guide

Heart Valve Disease
HSJ Guide April 2019 [subscription required]

• An HSJ supplement which looks at where we are with heart valve disease today - treatments, TAVI its commissioning and how to reduce variation.
• [Lots of data cited but no references.]

MRI for patients with cardiac implantable electronic devices: simplifying complexity with a ‘one-stop’ service model

MRI for patients with cardiac implantable electronic devices: simplifying complexity with a ‘one-stop’ service model.
BMJ Qual Saf Published Online First: 13 February 2019. doi: 10.1136/bmjqs-2018-009079

• Evaluation of a streamlined sustainable service that provides timely MRI scans to patients with cardiac implantable electronic devices (CIEDs) whereby devices could be reprogrammed and scans acquired at a single location and visit. Over 2 years MRI provision increased 6 to 20 times the national average with reduced waiting time from 60 to 15 days and no adverse events.
• Location - Barts Health Trust, London

Abstract

Impact of Prolonged ICU Stay in Cardiac Surgical Patients: A Systematic Review

Survival, Quality of Life, and Functional Status Following Prolonged ICU Stay in Cardiac Surgical Patients: A Systematic Review.
Crit Care Med. 47(1):e52-e63 January 2019

• A systematic review of the outcomes of cardiac surgical patients requiring prolonged intensive care with respect to survival, residential status, functional recovery, and quality of life in both hospital and long-term follow-up.
• The review found consistent evidence that patients with increases in ICU length of stay beyond 48 hours have significantly increasing risk of hospital and long-term mortality.

Scoping review of frailty in vascular surgery.

Scoping review of frailty in vascular surgery.
J Vasc Surg. 24 Dec 2018 Dec 24. pii: S0741-5214(18)32465-0. doi: 10.1016/j.jvs.2018.10.053.

• Discussion of the variety of tools available to measure frailty in patients undergoing vascular surgery interventions

Abstract

Early Discharge From Intensive Care After Cardiac Surgery

Early Discharge From Intensive Care After Cardiac Surgery is Feasible With an Adequate Fast Track, Stepdown Unit: Waikato Experience.
Heart, Lung and Circulation DOI: https://doi.org/10.1016/j.hlc.2018.11.002, 13 November 2018

• Experience of an Australian day zero discharge enhanced recovery unit from the Cardiothoracic intensive care department.
• Survival analysis demonstrated that the patients who were discharged early from ICU had significantly better follow-up survival compared to those who were discharged after 24 hours (p < 0.05).

Abstract

National Vascular Registry: Annual Report 2018

National Vascular Registry: Annual Report 2018
HQIP  28 November 2018

• Comparative information on five major interventions for vascular disease plus the findings of an organisational audit which evaluated the current arrangement of hospital vascular services, which are in the process of being re-organised into vascular networks in England.
• Interventions are:
• Carotid endarterectomy
• Repair of aortic aneurysms, including elective infra-renal, ruptured infra-renal, and more complex aneurysms
• Lower limb bypass
• Lower limb angioplasty/stenting
• Major lower limb amputation

National Cardiac Audit Programme (NCAP) Annual Report 2018

National Cardiac Audit Programme (NCAP) Annual Report 2018
HQIP 22 November 2018

• Aggregate report on six major national clinical audits of care of patients treated in the UK for heart disease. The six audits are: Congenital audit, Heart Attack audit, Angioplasty audit, Adult Surgery audit, Heart Failure audit and Arrhythmia audit. 
• Includes highlights of best practice.

Frailty and Clinical Outcomes in Heart Failure: A Systematic Review and Meta-analysis.

Frailty and Clinical Outcomes in Heart Failure: A Systematic Review and Meta-analysis.

J Am Med Dir Assoc. 2018 Jul 31. pii: S1525-8610(18)30329-3.

• Frailty is a significant predictor of all-cause mortality and hospital readmissions in HF. Assessment and close monitoring of frailty status of heart failure patients can potentially better guide clinical management of this population.

Abstract

Specialised commissioning prioritisation results – June 2018

Specialised commissioning prioritisation results – June 2018
NHS England 7 July 2018

• A list of the latest innovative new treatments approved by NHS England. Non drug innovations include:
• Left Atrial Appendage Occlusion for patients with atrial fibrillation and relative or absolute contraindications to anticoagulation (adults)
• Selective dorsal rhizotomy
• Total pancreatectomy with islet transplantation for chronic pancreatitis

The incremental predictive value of frailty measures in elderly patients undergoing cardiac surgery: A systematic review.

The incremental predictive value of frailty measures in elderly patients undergoing cardiac surgery: A systematic review.
Clin Cardiol. 5 Jul 2018,  doi: 10.1002/clc.23021

• Analysis of 12 studies concludes that addition of frailty measures to existing preioperative risk models improved the prediction performance for mortality, but the incorporation of frailty assessment into the perioperative risk assessment needs further evidence before making health policy recommendations.

Abstract

A Pragmatic Preoperative Prediction Score for Nonhome Discharge After Cardiac Operations

A Pragmatic Preoperative Prediction Score for Nonhome Discharge After Cardiac Operations. [Abstract]
Ann Thorac Surg. 2018 May;105(5):1384-1391. doi: 10.1016/j.athoracsur.2017.11.060.

• Using records of patients undergoing cardiac operations 2012 – 2016 (n=5253) the researchers identified preoperative risk factors for non home discharge after cardiac operations and developed a pragmatic non home discharge prediction score with high accuracy. 
• Non home discharge does not decrease the readmission rate after cardiac operations.

Are Angioplasty Waiting Time Inequalities Growing Again?

Are Angioplasty Waiting Time Inequalities Growing Again?
CHE Policy & Research Briefing April 2018

• This report examines angioplasty, a common heart revascularization procedure performed more than 20,000 times a year in England. 
• In the early 2000s, when waiting times were long, patients in the most income deprived fifth of neighbourhoods waited about 50% longer for non-emergency angioplasty than those in the least income deprived fifth. This gap occurred within hospitals, and was not primarily due to richer patients choosing to travel further to hospitals with shorter waiting times. 
• The gap fell to 10% by 2008 when waiting times were shortest, but started rising thereafter to around 20% by 2015 as waiting times started to grow again.

HeartFlow Analysis technology to be fast tracked

The HeartFlow Analysis

• HeatFlow Analysis is one of the technologies to be fast-tracked into use through NHS England’s Innovation and Technology Payment programme. (See NHS England News 9 April 2018)
• Using data from a standard CT scan, the non-invasive HeartFlow Analysis creates a personalised 3D model of the coronary arteries and analyses the impact that blockages have on blood flow. 
• NICE estimate up to 35,000 people per year could be eligible.

Cardiothoracic surgery - GIRFT report

Cardiothoracic Surgery: GIRFT Programme National Specialty Report
GIRFT March 2018

• Examination of the 31 units providing cardiothoracic surgery in England suggests that smarter bed management and using designated specialist teams for key cardiothoracic surgery procedures will deliver better outcomes.
• The report found variation across the units in patient flow, clinical outcomes and risk management, lung cancer, video-assisted thoracoscopic surgery (VATS), aortovascular surgery and mitral valve repair.
• Appendix 2 highlights some of the processes, practices and measures that have led to positive patient outcomes matched with greater cost efficiencies at University Hospitals Bristol and University Hospital Southampton.

FICM comments on the GIRFT Cardiothoracic Surgery Report here.

The report makes 20 recommendations and identify owners and a timeline for each one -