Reports shed light on cardiac care standards

There has been a wide range of national and regional programmes to modernise and improve cardiac services over the last decade, including extra funding to improve and extend the facilities of existing cardiothoracic centres to increase capacity, as well as additional funding to increase the number of catheter laboratories. There has also been a 62% increase in the number of consultant cardiologists in England, since 2000, and a 47% increase in the number of cardiothoracic surgeons. Programmes to reduce waiting list numbers and waiting times for cardiac interventions have also proved successful.1 However, one of the most impressive achievements within cardiac services, to date, has been the dramatic fall in mortality rates for patients undergoing surgery. A comprehensive study of over 400,000 operations, from the Society for Cardiothoracic Surgery of GB and Ireland (SCTS), showed that outcomes for adult cardiac patients have improved significantly over the past five years – even though more elderly and high-risk patients are now being treated. The report, entitled Demonstrating Quality: The Sixth National Adult Cardiac Surgical Database Report,2 conclusively proves wrong critics who suggested that publishing mortality data would lead to risk-averse behaviour from surgeons, with the most sick and elderly patients being turned down for surgery for fear of “blotting” statistics. In practice, the opposite has turned out to be true – the increase in reliable data has encouraged surgeons to take on more complicated cases. More people who would have been considered too sick to undergo an operation just five years ago are now routinely treated and doing well. The database findings provide compelling evidence that, since national publication of mortality rates in cardiac surgery began in 2001, the quality of care for patients has improved. Mortality rates for “coronary artery surgery” have fallen by 21% and for “isolated valves” by a third. For elective surgery in the under-70s mortality rate for “coronary artery surgery” is now less than 1%. The proportion of elderly patients being seen for surgery has also increased. One in five “coronary artery bypass” patients were over 75 and 5% over 80 years old. The average age of aortic valve replacement patients has increased from 61 in 1994 to 68 in 2008. The results also reveal that more diabetic, high blood pressure and overweight or obese patients are having cardiac surgery – all known risk factors, yet overall operation mortality rates continue to fall. In fact, between 2001 and 2008, there has been a 50% increase in the proportion of coronary surgery patients who are diabetic – while the proportion of coronary patients with hypertension (high blood pressure) has increased from less than 60% of cases to nearly 75%. “Re-do” operations (for bleeding or deep sternal wound infection) are rare and getting rarer. The re-do rate for bleeding fell from 3.8 to 3.2% between 2004 and 2008 and for infection from 0.8% to 0.6% over the same period and the time between first and second operations is increasing, indicating that the grafts are lasting longer. More than twice as many people are now having “aortic valve replacement” and “mitral valve operations”. Both these procedures are more commonly required for more elderly patients and this rise in demand reflects the increasing life expectancy for those with heart disease. The full analysis – published jointly by the SCTS and Dendrite Clinical Systems – gives a complete breakdown of how cardiac surgery is developing and highlights areas for future improvement including unequal access to cardiac surgery across the UK (www.e-dendrite.com). For example, while mortality rates across the board are improving there remains a persistent gap between the sexes with survival rates significantly worse for women than for men. With mortality rates for cardiac surgery so low – cardiac surgeons are now looking at extending outcome reporting to other areas which impact on recovery time and quality-of-life such as bleeding rates, post-operative stroke, kidney failure and the need to re-do operations. Report author and University Hospital of South Manchester consultant cardiac surgeon, Ben Bridgewater, said: “One of the benefits we are now seeing from public reporting of outcomes is not just about bringing poor performers ‘into the pack’ but improving the performance of the pack as a whole. The very act of auditing services brings about improvements as centres learn from one another.” The results of the surveillance prompted the Royal College of Surgeons of England to urge all surgical specialties to follow this lead as soon as possible. John Black, president of the Royal College of Surgeons, said: “This new report proves that open reporting works if well funded and led by the clinicians. All branches of surgery are following the trail on reporting outcomes that cardiac surgeons have blazed and this should spur those efforts on. All of medicine should take note of the findings that full audit has not resulted in risk-averse behaviour.”

Heart attack treatment

There was further cause for celebration earlier this year following the results of the Myocardial Ischaemia National Audit Project (MINAP),3 which highlighted steady improvement in the provision of heart attack treatment across England and Wales. Results from the Myocardial Ischaemia National Audit Project (MINAP) showed that nearly half of heart attack patients are receiving primary angioplasty rather than thrombolytic (clot-busting) drugs. This is an important step forward as primary angioplasty re-opens the blocked coronary artery causing the heart attack and has better outcomes than thrombolytic drugs. In October 2008, the Department of Health announced that primary angioplasty would take over from thrombolytic drugs as England’s first line of treatment of heart attacks. The number of hospitals that have performed primary angioplasty increased from 54 to 66 in the last year, although 14 of these hospitals performed less than 10 cases. In Wales two hospitals perform primary angioplasty. Results included the following: • In England in 2008/9 7,351 patients (47% of all receiving treatment) were treated with primary angioplasty compared with 4,035 (27%) in 2007/8, an increase of 82%. • In Wales in 2008/9 118 patients (12%) were treated with primary angioplasty compared to 42 in 2007/8, an increase of 181%. • In England 84% of patients were treated within 90 minutes of arrival at the interventional centre compared to 79% in 2007/8 and 79% of patients received primary angioplasty within 150 minutes of calling for help. • In Wales 74% of patients were treated within 90 minutes of arrival at the interventional centre compared to 57% in 2007/8, while 77% of patients received primary angioplasty within 150 minutes of calling for help. There is evidence that from about three hours after the onset of symptoms, primary angioplasty is significantly more effective than thrombolytic treatment in patients with heart attack. At present more than six out of ten patients with heart attack receive one or other form of treatment within three hours of the onset of symptoms. Those who take longer to be treated are mostly those who take a long time to call an ambulance or go to their GP or hospital. The 2009 report is the eighth report since the project began in 2001, and shows improvement in the following areas, year-on-year: • The speed with which patients receive thrombolytic treatment has been maintained. • In 2008/9, 71 % of English hospitals with their associated ambulance services, reached or exceeded the English national target (68%) for the delivery of thrombolysis within 60 minutes of calling for professional help, compared with 71% in 2007/8. • 82 % of hospitals in England provided thrombolytic treatment to 75% of eligible patients within 30 minutes of arrival at hospital compared to 90% in 2007/8. In Wales the percentage was 50% compared to 42% in 2007/8. • The high levels of prescription of secondary prevention medication has been maintained. Recommendations from the report to improve patient care included: • Improved access to primary angioplasty services where this is currently unavailable. • For the majority of English hospitals significant reduction in the delay before thrombolytic treatment within hospital is unlikely without compromising safety. There is still room for improvement in Wales. • Efforts should be directed to increase the number of patients in England and Wales who receive pre-hospital thrombolytic treatment, particularly where primary angioplasty is unavailable and long journeys to hospital are involved. Professor Roger Boyle, national director for heart disease and stroke, commented: “Primary angioplasty is the international gold standard of heart attack treatment. The report shows that the number of heart attack patients receiving this emergency care has increased rapidly by 80% over the past year – a fantastic achievement by the NHS. This means better outcomes for more patients and more lives saved.”