Clinical Excellence Queensland · 2019. 12. 8. · cardiac and thoracic surgery, cardiac rehabilitation, cardiac catheter interventions, electrophysiology and pacing, and heart failure

Clinical Excellence Queensland

Queensland Health

Improvement | Transparency | Patient Safety | Clinician Leadership | Innovation

Statewide Cardiac Clinical NetworkQueensland Cardiac Outcomes Registry

2018 Annual Report Electrophysiology and Pacing Audit

Queensland Cardiac Outcomes Registry 2018 Annual Report

Published by the State of Queensland (Queensland Health), November 2019

This document is licensed under a Creative Commons Attribution 3.0 Australia licence. To view a copy of this licence, visit creativecommons.org/licenses/by/3.0/au

© State of Queensland (Queensland Health) 2019

You are free to copy, communicate and adapt the work, as long as you attribute the State of Queensland (Queensland Health).

For more information contact:Statewide Cardiac Clinical Network, Queensland Health, GPO Box 48, Brisbane Qld 4001, email [email protected], 15 Butterfield St, Herston Qld 4006, phone 3328 9771 for Statewide Cardiac Clinical Network.

An electronic version of this document is available at: clinicalexcellence.qld.gov.au/priority-areas/ clinician-engagement/statewide-clinical-networks/cardiac

Disclaimer:The content presented in this publication is distrib-uted by the Queensland Government as an informa-tion source only. The State of Queensland makes no statements, representations or warranties about the accuracy, completeness or reliability of any information contained in this publication. The State of Queensland disclaims all responsibility and all liability (including without limitation for liability in negligence) for all expenses, losses, damages and costs you might incur as a result of the information being inaccurate or incomplete in any way, and for any reason reliance was placed on such information.

QCORAnnualReport2018

QCORAnnualReport2018

Contents1 Foreword 1

2 Message from the SCCN Chair 2

3 Introduction 3

4 Executive summary 6

5 Acknowledgements and authors 7

6 Future plans 9

7 Facility profiles 107.1 CairnsHospital 10

7.2 TheTownsvilleHospital 10

7.3 MackayBaseHospital 11

7.4 SunshineCoastUniversityHospital 11

7.5 ThePrinceCharlesHospital 12

7.6 RoyalBrisbaneandWomen’sHospital 12

7.7 PrincessAlexandraHospital 13

7.8 GoldCoastUniversityHospital 13

Electrophysiology and Pacing Audit

1 Message from the QCOR Electrophysiology and Pacing Committee Chair EP 3

2 Key findings EP 4

3 Participating sites EP 5

4 Case totals EP 84.1 Casevolume EP8

4.2 Casesbycategory EP9

5 Patient characteristics EP 105.1 Ageandgender EP10

5.2 Bodymassindex EP12

5.3 AboriginalandTorresStraitIslanderstatus EP12

6 Risk factors and comorbidities EP 136.1 Coronaryarterydisease EP13

6.2 Familyhistoryofsuddencardiacdeath EP13

6.3 Smokinghistory EP13

6.4 Diabetes EP14

6.5 Hypertension EP14

6.6 Dyslipidaemia EP14

6.7 Atrialarrhythmiahistory EP15

6.8 Heartfailure EP15

6.9 Valvularheartdisease EP16

6.10 Othercardiovasculardiseaseandco-morbidities EP16

6.11 Anticoagulation EP16

7 Care and treatment of patients EP 177.1 Urgencycategory EP17

7.2 Admissionsource EP18

7.3 Admissionsourceandurgencycategory EP19

7.4 Deviceprocedures EP20

7.5 Electrophysiologystudies/ablations EP22

7.6 Ablationtype EP24

7.7 Otherprocedures EP27

8 Procedural complications EP 28

9 Clinical indicators EP 309.1 Waitingtimefromreferraldateto

procedurebycasecategory EP31

9.2 Proceduraltamponaderates EP32

9.3 Reinterventionwithinoneyearofproceduredateduetocardiacdeviceleaddislodgement EP33

9.4 Rehospitalisationwithinoneyearofprocedureduetoinfectionresultinginlossofthedevicesystem EP33

9.5 12monthall-causemortalityforcardiacdeviceprocedures EP34

10 Conclusions EP 35

References i

Glossary ii

Ongoing initiatives iii

Part B: Thoracic SurgeryCardiothoracic Surgery Audit

Part A: Cardiac Surgery

FiguresElectrophysiology and Pacing AuditFigure1: Electrophysiologyandpacingcasesby

residentialpostcode EP5Figure2: CairnsHospital EP6Figure3: TheTownsvilleHospital EP6Figure4: MackayBaseHospital EP6Figure5: SunshineCoastUniversityHospital EP6Figure6: ThePrinceCharlesHospital EP7Figure7: RoyalBrisbaneandWomen’sHospital EP7Figure8: PrincessAlexandraHospital EP7Figure9: GoldCoastUniversityHospital EP7Figure10: ProportionofcasesbysiteandcategoryEP9Figure11: Proportionofallcasesbyagegroup

andgender EP10Figure12: Proportionofcasesbygenderand

category EP11Figure13: ProportionofcasesbyBMIandcase

category EP12Figure14: Proportionofcasesbyidentified

AboriginalandTorresStraitIslanderstatusandsite EP12

Figure15: Proportionofcasesbycoronaryarterydiseasehistoryandcasecategory EP13

Figure16: Proportionofcasesbysuddencardiacdeathhistoryandcasecategory EP13

Figure17: Proportionofcasesbysmokingstatusandcasecategory EP13

Figure18: Proportionofcasesbydiabetesstatusandcasecategory EP14

Figure19: Proportionofcasesbyhypertensionstatusandcasecategory EP14

Figure20: Proportionofcasesbydyslipidaemiastatusandcasecategory EP14

Figure21: Proportionofcasesbyatrialarrhythmiastatusandcasecategory EP15

Figure22:Proportionofcasesbyheartfailurestatusandcasecategory EP15

Figure23: Proportionofcasesbyvalvularheartdiseaseandcasecategory EP16

Figure24: ProportionofcasesbyCVdiseasehistoryandco-morbidityandcasecategory EP16

Figure25: Proportionofcasesbyanticoagulationstatusandcasecategory EP16

Figure26: Proportionofallcasesbyurgencycategory,procedurecategoryandsite EP17

Figure27: Admissionsourcebysite EP18Figure28: Admissionsourcebycasecategory EP18Figure29: Complexityofelectrophysiology

proceduresbysite EP22Figure30: Ablationtypebysite EP24Figure31: Proportionofarrhythmiasablated EP25

FigureA: Operationalstructure 3FigureB: QCOR2018infographic 4Figure1: CairnsHospital 10Figure2: TheTownsvilleHospital 10Figure3: MackayBaseHospital 11Figure4: SunshineCoastUniversityHospital 11Figure5: ThePrinceCharlesHospital 12Figure6: RoyalBrisbaneandWomen’sHospital 12Figure7: PrincessAlexandraHospital 13Figure8: GoldCoastUniversityHospital 13

Electrophysiology and Pacing AuditTable1: Participatingsites EP5Table2: Totalcasesbycategory EP8Table3: Casesbycasecategory EP9Table4: Medianagebygenderandcase

category EP10Table5: Proportionofcasesbygenderand

category EP11Table6: Proportionofallcasesbyurgency

categoryandsite EP17Table7: Admissionsourcebysite EP18Table8: Outpatientcasesbyurgencycategory EP19Table9: Inpatientcasesbyurgencycategory EP19Table10: Cardiacdevicecasetypesbysite EP20Table11: Electrophysiologystudy/ablationtypes

bysite EP22Table12: Proportionofstandardandcomplex

electrophysiologyproceduresbysite EP23Table13: Threedimensionalmappingsystem

typebysite EP24Table14: Ablationtypebysite EP24Table15: Medianageandgenderbyablation

type EP25Table16: Arrhythmiatypebysite EP26Table17: Otherprocedures EP27Table18: Cardiacdeviceprocedurecomplications EP28Table19: Electrophysiologyprocedure

complicationsbystudytypeandcomplexity EP29

Table20: Electrophysiologyandpacingclinicalindicators EP30

Table21: Electivepacemakerwaittimeanalysis EP31Table22: ElectiveICDwaittimeanalysis EP31Table23: Electivestandardablationwaittime

analysis EP31Table24: Electivecomplexablationwaittime

analysis EP32Table25: Proceduraltamponadeanalysis EP32Table26: Reinterventionduetolead

dislodgementanalysis EP33Table27: Rehospitalisationwithdeviceloss

analysis EP33Table28: 12monthall-causeunadjusted

mortalityforcardiacdeviceprocedures EP34

Tables

Supplement: Structural heart disease

QCORAnnualReport2018 Page1

1 ForewordAsDirectorGeneralofQueenslandHealth,Iampleasedto

presenttheQueensland Cardiac Outcomes Registry (QCOR) 2018

Annual Report.TheAnnualReportprovidesdetailedinformation

ontheperformanceofourclinicalcarefor,andoutcomesof,

peoplewithcardiacdisorders.

TheAnnualReportexaminesarangeofclinicalareasincluding

cardiacandthoracicsurgery,cardiacrehabilitation,cardiac

catheterinterventions,electrophysiologyandpacing,andheart

failuresupportservices.Thisyear’sAnnualReportincludes

additionalanalysisofspecificareasofinteresttoenable

examinationofclinicalissuesfacedbypractitionersattheface

ofpatientcare.

TheAnnualReportexemplifieshowQueenslandHealthis

meetingitsobjectivetoenable safe, high quality services.The

resultsshowthatQueenslandersarereceivingsomeofthebest

cardiaccareinthecountry,andoftentheworld.Queensland

Healthiscommittedtoempoweringourpeopletoprovidethe

bestpossiblehealthcare,tobetransparentinourworkand

importantlyuseinformationtoinformandimprovethehealth

outcomesofourpatients.

Thehighlevelofclinicalengagementextendsbeyondclinical

practicetoworkingcollaborativelywithQueenslandHealth

administratorstoimprovetheefficiencyofourorganisation.

Recently,cardiaccliniciansandadministratorscollaboratedand

usedQCORdatatoimprovethepurchasingprocessofclinical

productsresultinginsavingsof$5million.Thesefundswill

nowbeavailableintherelevantHospitalandHealthServicesto

reinvestintopatientcare.

QCORdataallowsustoberesponsivetotheneedsofour

patientsandcommunity.Itisactivelyusedtoinformhowwe

improvetheaccess,equity,safety,efficiencyandeffectiveness

ofourcardiachealthcare.

IwouldliketoacknowledgetheongoingeffortoftheStatewide

CardiacClinicalNetworkanditsmanycliniciansandcolleagues,

whohavecollaboratedtoproducethisAnnualReport.

Dr John Wakefield PSM Director-General Queensland Health

Page2 QCORAnnualReport2018

2 Message from the SCCN Chair Itismypleasuretointroducethe4thQueenslandCardiacOutcomeRegistry(QCOR)AnnualReport.The

activitiesofQCORcontinuetomature,andthisreportgivesusyetanotheropportunitytore-examinethe

reasonsforcontinuingthiswork,aswellasformingastimulustoreinvigorateourefforts.Thechancetoask,

“Whyarewedoingthis?”–alotofeffort,repeatedcommitteemeetings,somelatenights,andoccasional

irritationwithcolleagues,asacounterpoisetotheingrainedcliniciandesiretodotheabsolutebestforevery

patientwecareforandtohavedatatoproveit.Theledgerisstronglytiltedintheaffirmative.

Queenslandisnowacknowledgedashavingsomeofthemostcomprehensivecardiacdatainthecountry,

andthesuccessofthisprogramabsolutelyrestsonthesustainedclinicianparticipationonwhichthe

programmeisbuilt.Everystepfrompatientcare,throughrecordingofdata,tosubmission,reverification

andanalysisisheavilyinvestedbytheclinicians.Thisintensiveparticipationtowardsacommongoalhas

certainlydrawnthecardiaccommunitytogetherandwecanberightlyproudofthecohesivenessofthe

effortstoimprovecareacrossthestate.

Thereportthisyearfurtherextendsimportantelementsofpatientcare–wehaveastrongcollaboration

withQueenslandAmbulanceService(QAS),andnowhaveaccesstoquitecomprehensiveprehospitalcare

includingQASadministeredthrombolysisandoutcomes.InastateaslargeasQueenslanditiscriticalthat

wetracktheseimportantaspectsofcare.Thedocumentationofposthospitalcardiacrehabilitationand

heartfailuremanagementcontinuestoprovideamorecomprehensivepictureextendingthewindowofacute

admissionandwithoutdoubtaddingtothesafetyofouracuteinterventions.

Itisgratifyingtoseethatproceduraloutcomesacrossalloftheparticipatinginstitutionsremainstableand

ofhighquality.

Finally,oneoftheimportantreasonswhichcliniciansoriginallyidentifiedsupportingparticipationinthe

programhascometofruition–thecardiacdataderivedfromQCORhasnowledtospecificinvestmentby

thestategovernmentintheprocessesofcardiaccare.Inthecomingyear,inaninitialinvestmentrollout,

hospitalsinCairnsandTownsvillewillsignificantlyexpandtheiroutreachintoruralandremotecentresin

TorresandCapeandacrosstotheNorthWestHospitalandHealthService.QCORdatahasclearlyprofiled

boththeneedandtheshortfallofcardiacservicesintheseareasandhasledtoarecognitionofour

responsibilitiesfordeliveringsafeandefficacioustreatmentbothforpatientswholiveclosetomajorcentres,

butalsoespeciallyforthosefarremoved.ThisprogrammewillextendtotheremainingHospitalandHealth

Servicesinamulti-yearinvestment.

Again,Igivethankstoalloftheclinicianswhocontinuetoparticipateinthisimportantwork.Inthecoming

year,QCORwillhavethecapacitytoinviteprivatecardiacprovidersinthestatetosubmitdatatoQCOR,so

thatwecanobtainamorecompletepicturebothpublicandprivate,ofcardiacservicesacrossthestate.

AspecialthanksisgiventotheStatewideCardiacClinicalInformaticsUnittechnicalandadministrativestaff

whocontinuetosupplysuperbassistancetotheprogramandwhoaretrulyintegraltothequalityofthe

attachedreport.

Dr Paul Garrahy

Chair

Statewide Cardiac Clinical Network


3 IntroductionTheQueenslandCardiacOutcomesRegistry(QCOR)isanever-evolvingclinicalinformationcollectionwhichenablescliniciansandotherkeystakeholdersaccesstoquality,contextualisedclinicalandproceduraldata.OnthebackgroundofsignificantinvestmentanddirectionfromtheStatewideCardiacClinicalNetwork(SCCN)andundertheauspicesofClinicalExcellenceQueensland,QCORprovidesanalyticsandoverviewforseveralclinicalinformationsystemsanddatabases.Byutilisingextensiveancillarycomplementaryadministrativedatasets,asophisticatedlevelofmulti-purposereportingandinsighthasbeengained.

QCORdatacollectionsaregovernedbybespokeclinicalcommitteeswhichprovideoversightanddirectiontoreportingcontentandanalysisaswellasinformingdecision-makingforfutureendeavours.ThesecommitteesaresupportedbyStatewideCardiacClinicalInformaticsUnit(SCCIU)whoformthebusinessunitofQCOR.AllprocessesandgroupsreporttotheSCCN,whichisfacilitatedbyClinicalExcellenceQueensland.

ThestrengthoftheRegistrywouldnotbepossiblewithoutsignificantclinicianinput.Assistingtomaintainquality,relevanceandcontextthroughQCORcommittees,cliniciansarecontinuallydevelopingandevolvingtheanalysisandfocusofeachspecificgroup.TheSCCIUperformstheroleofcoordinatingtheseindividualQCORcommitteeswhicheachhavetheirindividualdirectionanduniquerequirements.

TheSCCIUprovidethereporting,analysis,anddevelopmentofthemanyclinicalcardiologyandcardiothoracicsurgicalapplicationsandsystemsinuseacrossQueenslandHealth.TheSCCIUalsoprovidesdataqualityandauditfunctionsaswellasexperttechnicalandinformaticsresourcesfordevelopment,maintenanceandcontinualimprovementofspecialisedclinicalapplicationsandrelevantsecondaryuses.

TheSCCIUteamconsistsof:

•MrGrahamBrowne–DatabaseAdministrator • DrIanSmith,PhD–Biostatistician•MrMichaelMallouhi–ClinicalAnalyst • MrWilliamVollbon–Manager

•MrMarcusPrior–InformaticsAnalyst • MrKarlWortmann–ApplicationDeveloper

This2018QCORreportnowincludesatotalof6clinicalaudits.TheadditionofthethoracicsurgeryauditreportcomplementstheexistingcardiacsurgeryreporttoenableaclearerpictureoftheworkundertakenbycardiacandthoracicsurgeonsinQueensland.Thisworkreflectseffortsinthisspaceandthehighlightsthevastpatientcohortthatareencounteredbycliniciansworkinginthisspecialty.ItiswiththiscontinualdevelopmentandevolutionofclinicalreportingmaturitythatQCORhopestofurthersupportcardiothoracicclinicalinformaticsintothefuture.

Tier 4: Steering CommitteeStatewide Cardiac Clinical Network

Tier 3: Executive DirectorHealthcare Improvement Unit

Tier 2: Deputy Director GeneralClinical Excellence Division

Tier 1: Director General

QCOR Business UnitSCCIU

QCORAdvisory Committee

QCORElectrophysiology

and PacingCommittee

QCORInterventional

CardiologyCommittee

QCORCardiac

RehabilitationCommittee

QCORHeart Failure

Committee

QCORCardiac Imaging

Committee

QCORCardiothoracic

SurgeryCommittee

Figure A: Operational structure


11% Hospital spending on cardiovascular disease

1 in 5admitted to hospital†

766,000 aged 65 years or older†

15% of total disease burden

is caused bycardiovascular disease†

16%Coronary heart diseaseis the leading cause of

death

>5 millionpopulation*

2018 Activity at a GlanceQueensland Cardiac Outcomes Registry

Thoracic Surgery Audit Interhospital transfer for coronary intervention review

What’s new?

Continuing our work

Clinical indicator progress

Case and patient volumesThe health of Queenslanders

Electrophysiology and pacing clinical indicators Cardiac rehabilitation patient outcome measures

Thrombolysis for STEMI analysis Body mass index in cardiac surgery investigation

Data linkage opportunities Structural heart disease application

National registry alignment Cardiac outreach application

Clinical indicator review ECG Flash project

Reference 1” please use an asterisk glyph.Reference 2 = dagger glyph,Reference 3 = double dagger

Reference 4 = paragraph symbol

4,867percutaneous coronary

interventions

11,723cardiac rehabilitation

referrals

850adult thoracic surgeries

2,384adult cardiac surgeries

4,878new heart failure support

services referrals

148transcatheter aortic valve replacement procedures

95%of cardiac

rehabilitation referrals within 3 days of

discharge

0.3%procedural tamponade rate for cardiac device and electrophysiology

procedures

85 minsmedian first

diagnostic ECG to reperfusion time for

primary PCI

0.9%mortality rate for

coronary artery bypass surgery at 30 days

92% of patients referred to a heart failure support service on an ACEI or

ARB at discharge

3,136cardiac electronic

implantable device procedures

401structural heart disease

interventions

4,474electrophysiology and

pacing procedures

23% have untreated

high blood pressure

11% smoke daily†

4.6% Aboriginal and Torres Strait

Islander population‡

31% have untreated

high total cholesterol

28%of all deaths due

to cardiovascular disease

4.8% have diabetes§

2 in 3 are overweight

or obese†

63% are sufficiently active†

Figure B: QCOR 2018 infographic


11% Hospital spending on cardiovascular disease

1 in 5admitted to hospital†

766,000 aged 65 years or older†

15% of total disease burden

is caused bycardiovascular disease†

16%Coronary heart diseaseis the leading cause of

death

>5 millionpopulation*

2018 Activity at a GlanceQueensland Cardiac Outcomes Registry

Thoracic Surgery Audit Interhospital transfer for coronary intervention review

What’s new?

Continuing our work

Clinical indicator progress

Case and patient volumesThe health of Queenslanders

Electrophysiology and pacing clinical indicators Cardiac rehabilitation patient outcome measures

Thrombolysis for STEMI analysis Body mass index in cardiac surgery investigation

Data linkage opportunities Structural heart disease application

National registry alignment Cardiac outreach application

Clinical indicator review ECG Flash project

Reference 1” please use an asterisk glyph.Reference 2 = dagger glyph,Reference 3 = double dagger

Reference 4 = paragraph symbol

4,867percutaneous coronary

interventions

11,723cardiac rehabilitation

referrals

850adult thoracic surgeries

2,384adult cardiac surgeries

4,878new heart failure support

services referrals

148transcatheter aortic valve replacement procedures

95%of cardiac

rehabilitation referrals within 3 days of

discharge

0.3%procedural tamponade rate for cardiac device and electrophysiology

procedures

85 minsmedian first

diagnostic ECG to reperfusion time for

primary PCI

0.9%mortality rate for

coronary artery bypass surgery at 30 days

92% of patients referred to a heart failure support service on an ACEI or

ARB at discharge

3,136cardiac electronic

implantable device procedures

401structural heart disease

interventions

4,474electrophysiology and

pacing procedures

23% have untreated

high blood pressure

11% smoke daily†

4.6% Aboriginal and Torres Strait

Islander population‡

31% have untreated

high total cholesterol

28%of all deaths due

to cardiovascular disease

4.8% have diabetes§

2 in 3 are overweight

or obese†

63% are sufficiently active†

* AustralianBureauofStatistics.Regionalpopulationgrowth,Australia,2017-2018.Cat.no.3218.0.ABS:Canberra;2019

† QueenslandHealth(2018).ThehealthofQueenslanders2018.ReportoftheChiefHealthOfficerQueensland.Brisbane.QueenslandGovernment

‡ AustralianBureauofStatistics.EstimatesofAboriginalandTorresStraitIslanderAustralians,June2016.Cat.no3238.055001.ABS:Canberra;2018

§ DiabetesAustralia.Statestatisticalsnapshot:Queensland.Asat30June2018;2018


4 Executive summaryThisreportencompassesproceduresandcasesfor8cardiaccatheterisationlaboratories(CCL)andelectrophysiologyandpacing(EP)facilitiesand5cardiothoracicsurgeryunitsoperatingacrossQueenslandpublichospitals.Italsoincludesreferralstoclinicalsupportandrehabilitationservicesforthemanagementofheartdiseaseincluding22heartfailuresupportservicesand55cardiacrehabilitationoutpatientfacilities.

•15,436diagnosticorinterventionalcaseswereperformedacrossthe8publiccardiaccatheterisationlaboratoryfacilitiesinQueenslandhospitals.Ofthese,4,867involvedpercutaneouscoronaryintervention(PCI).

•PatientoutcomesfollowingPCIremainencouraging.The30daymortalityratefollowingPCIwas1.9%,andofthe94deathsobserved,74%wereclassedaseithersalvageoremergencyPCI.

•InanalysisforpatientswithSTEMI,themediantimefromFdECGtoreperfusionandarrivalatPCIfacilitytoreperfusionwasobservedat85minutesand42minutes.Thiscomparesfavourablytoresultsforpreviousyearsandinternationally.

•Acrossthefoursiteswithacardiacsurgeryunit,atotalof2,384caseswereperformedincluding1,414CABGand1,005valveprocedures.

•Asinpreviousyears,observedratesforcardiacsurgerymortalityandmorbidityareeitherwithintheexpectedrangeorbetterthanexpected,dependingontheriskmodelusedtoevaluatetheseoutcomes.Onceagaintheexceptionwastherateofdeepsternalwoundinfection.

•TheCardiacSurgeryAuditincludesafocusedsupplementonobesityincardiacsurgery.Thisreporthighlightstheincreasedrateofpost-operativemorbidityandmortalityforpatientswithahigherBMI(>30kg/m2).

•Thefivepublichospitalsprovidingthoracicsurgeryservicesin2018performedatotalof850cases.Almostone-third(30%)ofsurgeriesfollowedapreoperativediagnosisofprimarylungcancerorpleuraldisease(33%).ThisisthefirstQCORAnnualReporttoexaminethoracicsurgery,andthiswillbeexpandedinfutureyears.

•Atthe8publicEPsites,atotalof4,474caseswereperformed,whichincluded3,136cardiacdeviceproceduresand1,061electrophysiologyprocedures.ThisauditincludesexpandedreportingaroundclinicalindicatorsforEPcases.

•ThisElectrophysiologyandPacingAuditidentifiedamedianwaittimeof81daysforcomplexablationprocedures,and33daysforelectiveICDimplants.

•Therewereatotalof11,723referralstooneofthe55publiccardiacrehabilitationservicesin2018.Mostreferrals(77%)followedanadmissionatapublichospitalinQueensland.

•ThevastmajorityofreferralstoCRwerecreatedwithinthreedaysofthepatientbeingdischargedfromhospital(95%),whileoverhalfofpatientswentontocompleteaninitialassessmentbyCRwithin28daysofdischarge(59%).

•Therewere4,878newreferralstoaheartfailuresupportservicein2018.Clinicalindicatorbenchmarkswereachievedfortimelyfollow-upofreferrals,andprescriptionofangiotensin-converting-enzymeinhibitor(ACEI)orangiotensinIIreceptorblockers(ARB)andappropriatebetablockersasperclinicalguidelines.


5 Acknowledgements and authorsThiscollaborativereportwasproducedbytheSCCIU,auditleadforQCORforandonbehalfoftheStatewideCardiacClinicalNetwork.

TheworkofQCORwouldnotbepossiblewithoutthecontinuedsupportandfundingfromClinicalExcellenceQueensland.Thispublicationdrawsontheexpertiseofmanyteamsandindividuals.Inparticular,theassistanceoftheStatisticalServicesBranch,HealthcareImprovementUnitandQueenslandAmbulanceServiceeachmakesignificantcontributionstoensurethesuccessoftheprogram.MetroNorthHospitalandHealthServicearealsorecognisedthroughtheirstakeinsupportingandhostingtheSCCIUoperationalteam.

Furthermore,thetirelessworkofclinicianswhocontributeandcollatequalitydata,aspartofprovidingqualitypatientcare,ensurescredibleanalysisandmonitoringofthestandardofcardiacservicesinQueensland.Thefollowingprovidedwritingassistancewiththisyear’sreport:

Interventional CardiologyDr Sugeet Baveja •TheTownsvilleHospitalDr Niranjan Gaikwad•ThePrinceCharlesHospitalDr Christopher Hammett•RoyalBrisbaneandWomen’sHospitalA/Prof Richard Lim•PrincessAlexandraHospitalDr Rohan Poulter•SunshineCoastUniversityHospitalA/Prof Atifur Rahman•GoldCoastUniversityHospitalDr Shantisagar Vaidya•MackayBaseHospitalDr Gregory Starmer (Chair)•CairnsHospital

Queensland Ambulance ServiceDr Tan Doan, PhDMr Brett Rogers

Cardiothoracic SurgeryDr Anil Prabhu•ThePrinceCharlesHospitalDr Andrie Stroebel•GoldCoastUniversityHospitalDr Morgan Windsor•RoyalBrisbaneandWomen’sHospital•ThePrinceCharlesHospitalDr Sumit Yadav•TheTownsvilleHospitalDr Christopher Cole (Chair)•PrincessAlexandraHospital

Electrophysiology and PacingMr John Betts•ThePrinceCharlesHospitalMr Anthony Brown•SunshineCoastUniversityHospitalMr Andrew Claughton•PrincessAlexandraHospitalDr Naresh Dayananda•SunshineCoastUniversityHospitalDr Russell Denman•ThePrinceCharlesHospitalMr Braden Dinham•GoldCoastUniversityHospitalMs Sanja Doneva•PrincessAlexandraHospitalMr Nathan Engstrom•TheTownsvilleHospitalMs Kellie Foder•RoyalBrisbaneandWomen’sHospitalDr Bobby John•TheTownsvilleHospitalDr Paul Martin•RoyalBrisbaneandWomen’sHospitalMs Sonya Naumann•RoyalBrisbaneandWomen’sHospitalDr Kevin Ng•CairnsHospitalDr Robert Park•GoldCoastUniversityHospitalA/Prof John Hill (Chair)•PrincessAlexandraHospital


Cardiac RehabilitationMs Michelle Aust•SunshineCoastUniversityHospitalMs Maura Barnden •MetroNorthHospitalandHealthServiceMr Gary Bennett•HealthContactCentreMs Jacqueline Cairns•CairnsHospitalMs Yvonne Martin•ChronicDiseaseBrisbaneSouthDr Johanne Neill•IpswichHospitalMs Samara Phillips•StatewideCardiacRehabilitationCoordinatorMs Deborah Snow•GoldCoastHospitalandHealthServiceMs Natalie Thomas•SouthWestHospitalandHealthServiceMr Stephen Woodruffe (Chair)•WestMoretonHospitalandHealthService

Heart Failure Support ServicesMs Kimberley Bardsley•QueenElizabethIIHospitalMs Tina Ha •PrincessAlexandraHospitalMs Helen Hannan•RockhamptonHospitalMs Annabel Hickey•StatewideHeartFailureServicesCoordinatorDr Rita Hwang, PhD•PrincessAlexandraHospitalMs Alicia McClurg•WestMoretonHospitalandHealthServiceDr Kevin Ng•CairnsHospitalMs Robyn Peters•PrincessAlexandraHospitalMs Serena Rofail •RoyalBrisbaneandWomen’sHospitalDr Yee Weng Wong•ThePrinceCharlesHospitalA/Prof John Atherton (Chair)•RoyalBrisbaneandWomen’sHospital

Statewide Cardiac Clinical Informatics UnitMr Michael MallouhiMr Marcus Prior Dr Ian Smith, PhDMr William Vollbon


6 Future plansContinualprogresswithexpandedanalysesandusesofclinicaldatahasbeenafocusforQCORin2018.Thisisevidentthroughnewreportelementsencompassingthoracicsurgeryandextendedexaminationofpatientsundergoingthrombolysisformyocardialinfarction.Similarly,obesityandcardiacsurgeryhavebeenexaminedandhaveunveiledkeyfindingsthatarehighlyrelevantgiventheincreasingincidenceofobesitywithinthegeneralpopulation.Intendingtoprovideclinicallyrelevantanalysis,thefutureworkofQCORisexciting.

TheutilisationoflinkagedataprovidedbyadministrativedatasetscontinuestoenableandassistQCORdatacollections.Thesedataenableinformationfromdifferentsourcestobebroughttogethertocreateanew,richerdataset.ExamplesoffutureopportunitiesfortheuseofsupplementarydatasetsaremedicationdetailfromdischargesummariesandpathologyinvestigationsundertakenwithinpublicQueenslandfacilities.Withaccesstotheseexpandeddatacollections,thereareopportunitiestobeseizedacrossmanyfrontsincludingenhancedriskadjustmentoptions,expandedclinicalindicatorprogramsandstreamlinedparticipationinnationalregistryactivities.Furthermore,thiswillenableefficienciesindatacollectionswhereelementsareeithernotavailableorpracticalforcollectionatthepoint-of-care,andtherebyreduceduplicationofentryacrossclinicalsystems.

OpportunitiesexisttobetterintegrateQCORclinicalapplicationswithenterprisesystemssuchastheacclaimedQueenslandHealthapplication,TheViewer.Itisenvisagedthatcardiacrehabilitationreferralsandassessmentformswillbeincorporatedwithinthepatientrecord,alongwithprocedurereportsgeneratedbytheupcomingQCORstructuralheartdiseaseapplication.ThesedevelopmentsaresettocomplementtheexistingreportsharingfunctionalitypresentwithintheQCORelectrophysiologysystem.Furtheropportunitieshavebeenflaggedacrosstheheartfailuresupportservicesandcardiothoracicsurgeryspacetoenhancetheseapplicationstomeetthebespokerequirementsoftheclinicalspecialtyareas.ByembracingopportunitiestosharevaluableclinicaldatakeptinvariousQCORsystems,investmentinQCORapplicationswillbefurtherrealisedandvalued.

Continualdevelopment,revision,andoptimisationofclinicalindicatorprogramsisessentialtotheongoingrelevanceoftheRegistry.QCORwillcontinuetocollaboratewithexpertsinallclinicaldomainstoexpandthescopeofourexistinganalyses.Thiswillbeundertakenwithaviewtomaintainandenhancethequalityofreportingandimprovethetimelinessandrelevanceoftheinformationprovidedforclinicalleads.Suchareaswherereportingwillbeenhancedfornextyear’sAnnualReportinclude:

•Timetoangiographyforpatientsreceivingthrombolysis

•Expandedradiationsafetyanalysesfordiagnosticandinterventionalcardiology

•Reviewofriskadjustmentmodelsforinterventionalcardiology

•EuroSCOREIIriskadjustmentforcardiacsurgerypatients

•MRAprescriptionratesforHFrEFpatients

•CRreferralsratesfollowingcardiacintervention

QCORisactivelyinvestigatingopportunitieswithinseveralareasincludingtheimplementationofnewpatient-reportedoutcomesandquality-of-lifemeasuresandrealisingfurtherefficienciesconcerningstatewideprocurementofmedicaldevices.NewareasofresearchandresearchpartnersandopportunitiestocontributetoworksunderwayacrossQueenslandHealth,andatanationallevel,arecontinuallybeingpursuedandengaged.


7 Facility profiles

7.2 The Townsville Hospital

Figure 2: The Townsville Hospital

•ReferralhospitalforCairnsandHinterlandandTorresandCapeHospitalandHealthServices,servingapopulationofapproximately280,000

•PublictertiarylevelinvasivecardiacservicesprovidedatCairnsHospitalinclude:

•Coronaryangiography

•Percutaneouscoronaryintervention

•Structuralheartdiseaseintervention

•ICD,CRTandpacemakerimplantation

•ReferralhospitalforTownsvilleandNorthWestHospitalandHealthServices,servingapopulationofapproximately295,000

•PublictertiarylevelinvasivecardiacservicesprovidedatTheTownsvilleHospitalinclude:




•Electrophysiology


•Cardiothoracicsurgery

7.1 Cairns Hospital

Figure 1: Cairns Hospital


7.4 Sunshine Coast University Hospital

Figure 4: Sunshine Coast University Hospital

•ReferralhospitalforMackayandWhitsundayregions,servingapopulationofapproximately182,000

•PublictertiarylevelinvasivecardiacservicesprovidedatMackayBaseHospitalinclude:



•Pacemakeranddefibrillatorimplants

•ReferralhospitalforSunshineCoastandWideBayHospitalandHealthServices,servingapopulationofapproximately563,000

•PublictertiarylevelinvasivecardiacservicesprovidedatSunshineCoastUniversityHospitalinclude:






7.3 Mackay Base Hospital

Figure 3: Mackay Base Hospital


7.6 Royal Brisbane and Women’s Hospital

Figure 6: Royal Brisbane and Women’s Hospital

•ReferralhospitalforMetroNorth,WideBayandCentralQueenslandHospitalandHealthServices,servingapopulationofapproximately900,000(sharedreferralbasewiththeRoyalBrisbaneandWomen’sHospital)

•PublictertiarylevelinvasivecardiacservicesprovidedatThePrinceCharlesHospitalinclude:







•Heart/lungtransplantunit

•Adultcongenitalheartdiseaseunit

•ReferralhospitalforMetroNorth,WideBayandCentralQueenslandHospitalandHealthServices,servingapopulationofapproximately900,000(sharedreferralbasewithThePrinceCharlesHospital)

•PublictertiarylevelinvasivecardiacservicesprovidedatTheRoyalBrisbaneandWomen’sHospitalinclude:






•Thoracicsurgery

7.5 The Prince Charles Hospital

Figure 5: The Prince Charles Hospital


7.8 Gold Coast University Hospital

Figure 8: Gold Coast University Hospital

•ReferralhospitalforMetroSouthandSouthWestHospitalandHealthServices,servingapopulationofapproximately1,000,000

•PublictertiarylevelinvasivecardiacservicesprovidedatthePrincessAlexandraHospitalinclude:







•ReferralHospitalforGoldCoastandnorthernNewSouthWalesregions,servingapopulationofapproximately700,000

•PublictertiarylevelinvasivecardiacservicesprovidedattheGoldCoastUniversityHospitalinclude:







7.7 Princess Alexandra Hospital

Figure 7: Princess Alexandra Hospital


Electrophysiology and Pacing Audit

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QCORAnnualReport2018 PageEP3

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1 Message from the QCOR Electrophysiology and Pacing Committee Chair

The2018QCORreportincludesamorecompletedatasetthanitspredecessor,allowingsomeyear-to-year

comparisonsofdataforthefirsttime,aswellasdatadescribingproceduralsuccessovertimeandother

clinicalindicators.Importantlyinthisreport,unmetneedisnowreflectedbywaitingtimesforcardiac

electrophysiologyandpacingprocedures.Profilingcontinuesregardingdemographics,activityandquality

fortheseprocedureswhichprolonglife(implantablecardioverterdefibrillator,ICD),compensatepathology

ofslowheartrhythm(pacemakers)andheartfailure(cardiacresynchronisationtherapy),curemostfastheart

rhythmsorpalliateandreducehospitalisationstheremainder(ablationforatrialfibrillationandventricular

tachycardia).RecentlytheintroductionofanadditionalMedicareBenefitsScheduleitemnumberfor

implantableECGlooprecorders(ILRs)intheinvestigationofcryptogenicstrokehasresultedinaverylarge

increaseindemandforthesedevices,mandatingformulationofrational,evidence-based,multi-disciplinary

strategytoaddressthatdemand.

Alloftheseprocedurescanenhancequalityoflifeandreduceburdenofdiseaseforthecommunity.However,

theyrequireadequateinfrastructureandadequatespecialisedworkforce.Deficienciesherearelongstanding

andincreasing,aswecontinuetofacetheincreasing,mutually-exacerbatingepidemicsofatrialfibrillation

andheartfailure.Thereisnilscopefor‘increasedefficiency’whenstaffaretoofewandoverworked.Again

the2018reportcontainsauthoritativeactivityandqualitymapping,nowwithdocumentationofwaitingtimes

toreflectunmetneedwhichmustguideplanningtoaddressthesedeficienciesurgently.

Inthebackground,theincreasing,agingpopulationshowsimprovedsurvivalofothercardiovascular

procedures,continuestoexhibitadverselifestyletrendsanddemandstechnologicaladvances.Inthe

largercentres,capacitytoperformablationprocedurescontinuestobechokedbyever-increasingdemand

forpacemakerandICDdeviceprocedures.Whilethesedeviceproceduresshouldalwayshavepriority,in

QueenslandHealththeyareusuallyperformedbyoperatorswithexpertiseincardiacelectrophysiology

andablation,onpatientswhobenefitfromthatexpertise.Ifablationisimperilledtowitheronavineof

indifferenceandinaction,lossofthatexpertisewillcompromise:

•outcomesacrosstheservice,

•patientaccesstoablationwhichisalreadytenuousandembarrassinglymeagrewhencomparedtoaccesstoablationintheprivatehealthsystem,and

•specialisedtrainingincardiacelectrophysiology.

Analysisofthisandfuturereportswillyieldveryimportantlearningsaboutthejourneysofpublicpatients

whoundergoproceduresforheartrhythmdisorders.IwishtoacknowledgethehardworkofQCOR

administrativestaff,andallcontributorstothedatasetincludingcardiacscientistsandclinicalcolleagues

whoapplyintegrity,co-operationandpassiontotheirworkinheartrhythmmanagement.

Associate Professor John Hill

Chair

QCOR Electrophysiology and Pacing Committee

PageEP4 QCORAnnualReport2018

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2 Key findingsThisElectrophysiologyandPacingAuditdescribesbaselinedemographics,riskfactors,proceduresperformedandoutcomesfor2018.

Keyfindingsinclude:

•AcrossQueensland,8publicsitescontributedtotheregistrywith7sitescontributingacompleteyearofdata.GoldCoastUniversityHospitalbegandirectdataentryon29January2018.

•4,474electrophysiologyandpacingcaseswereincluding3,136deviceproceduresand1,061electrophysiologyprocedures.

•Themajorityofallpatientswereagedover60years(70%)withamedianageof69years.

•TheoverallproportionofAboriginalandTorresStraitIslanderpatientswas3.7%.

•Thevastmajorityofpatients(72%)wereclassedashavinganunhealthybodymassindex(BMI)ofgreaterthan30kg/m2.

•Themajorityofprocedures(61%)wereclassifiedashigh-urgencyproceduresthatareclinicallyindicatedwithin30days.

•Outpatientproceduresaccountedfor54%ofallcases.

•Therewere520standardelectrophysiologyproceduresperformedwithafurther568complexproceduresundertaken,whichutilisethree-dimensionalmappingtechnology,involvepulmonaryveinisolationorventriculararrhythmias.

•Radiofrequencyablationwastheenergysourceutilisedinthevastmajorityofablationcases(85%).

•Atrialflutter,pulmonaryveinisolation(atrialfibrillation)andatrioventricularnodere-entrytachycardiaablationsaccountedfor81%ofallablationcases.

•Thereportedcomplicationrateforalldeviceprocedureswas2.9%,whileelectrophysiologyprocedureshada3.2%complicationrate.

•Therewasa0.3%proceduraltamponaderatereportedforallcases.

•Thestatewidemedianwaittimeforcomplexablationwas81dayswith73%ofcasesmeetingthe180daybenchmark.

•The12monthdevicesystemlossrateduetoinfectionwas1.4%.


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3 Participating sitesIn2018,therewere8publicelectrophysiologyandpacingunitsspreadacrossmetropolitanandregionalQueensland.All8oftheseentereddatadirectlyintotheQueenslandCardiacOutcomesRegistry(QCOR)electrophysiologyandpacingapplication.Theeighthsite,GoldCoastUniversityHospitalbegandirectentryinearly2018.

Patientscamefromawidegeographicalarea,withthemajorityofpatientsresidingontheeasternseaboard.

Figure 1: Electrophysiology and pacing cases by residential postcode

Table 1: Participating sites

Acronym Site nameCH CairnsHospitalTTH TheTownsvilleHospitalMBH MackayBaseHospitalSCUH SunshineCoastUniversityHospitalTPCH ThePrinceCharlesHospitalRBWH RoyalBrisbaneandWomen’sHospitalPAH PrincessAlexandraHospitalGCUH GoldCoastUniversityHospital

GoldCoastUniversityHospitalcommenceddirectdataentry29January2018


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Figure 2: Cairns Hospital Figure 3: The Townsville Hospital

Figure 4: Mackay Base Hospital Figure 5: Sunshine Coast University Hospital


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Figure 6: The Prince Charles Hospital Figure 7: Royal Brisbane and Women’s Hospital

Figure 8: Princess Alexandra Hospital Figure 9: Gold Coast University Hospital


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4 Case totals

4.1 Case volumeIn2018,4,474electrophysiologyandpacingproceduresweredocumentedusingtheQCORelectrophysiologyandpacingapplication.Thisnumberdoesnotreflecttheoverallcasetotalsasstatewideuptakeconcludedinearly2018.

Table 2: Total cases by category

Procedure combination Total cases n (%)

Category

Cardiacdeviceprocedure 3,098(69.2) DeviceCardiacdeviceprocedure+EPstudy 22(0.5)Cardiacdeviceprocedure+otherprocedure 10(0.2)Cardiacdeviceprocedure+EPstudy+ablation 4(0.1)Cardiacdeviceprocedure+EPstudy+cardioversion 1(<0.1)Cardiacdeviceprocedure+cardioversion 1(<0.1)EPstudy+ablation 772(17.2) EPEPstudy 184(4.1)Ablation 50(1.1)EPstudy+ablation+cardioversion 38(0.8)EPstudy+cardioversion 11(0.2)EPstudy+drugchallenge 4(0.1)EPstudy+ablation+otherprocedure 1(<0.1)EPstudy+otherprocedure 1(<0.1)Cardioversion 198(4.4) OtherOtherprocedure 46(1.0)Drugchallenge 32(0.7)Cardioversion+otherprocedure 1(<0.1)ALL 4,474 (100.0) Casetotalsdonotreflectallactivityduetoincompleteyearofdataacquisition


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4.2 Cases by categoryThemajorityofcasesperformedwerecardiacdeviceproceduresaccountingforovertwo-thirds(70%)ofdocumentedprocedures.Theremainderofcaseswereelectrophysiologyandablationprocedures(24%)withtheremaindercategorisedasotherprocedures(6%).

Device EP Other

0% 25% 50% 75% 100% 0% 25% 50% 75% 100% 0% 25% 50% 75% 100%

CH

TTH

MBH

SCUH

TPCH

RBWH

PAH

GCUH

STATEWIDE

Figure 10: Proportion of cases by site and category

Table 3: Cases by case category

Site Device n (%)

EP n (%)

Other n (%)

Total n (%)

CH 213(6.8) – 53(19.1) 266(5.9)TTH 223(7.1) 103(9.7) 138(49.8) 464(10.4)MBH 95(3.0) – 1(0.4) 96(2.1)SCUH 275(8.8) 231(21.8) 12(4.3) 518(11.6)TPCH 821(26.2) 322(30.3) 12(4.3) 1,155(25.8)RBWH 352(11.2) 161(15.2) 22(7.9) 535(11.9)PAH 680(21.7) 174(16.4) 37(13.4) 891(19.9)GCUH 478(15.2) 69(6.5) 2(0.7) 549(12.3)STATEWIDE 3,136 (70.1) 1,061 (23.7) 277 (6.2) 4,474 (100.0)Casetotalsdonotreflectall2018activityforGCUH


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5 Patient characteristics

5.1 Age and genderAgeisanimportantriskfactorfordevelopingcardiovasculardisease.Themajorityofpatientswereaged60yearsandabove(70%).Themedianageoftheoverallelectrophysiologyandpacingpatientcohortwas69yearsofage.

Themedianageofmaleandfemalepatientswas69years.Patientagedifferedgreatlybyprocedurecategorywiththemedianageofpatientsundergoingelectrophysiologyproceduresbeing58yearscomparedto73yearsforcardiacdeviceprocedures.

Male

10% 5% 0%

<40

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

≥85

Years

Female

0% 5% 10%

%oftotal(n=4,474)

Figure 11: Proportion of all cases by age group and gender

Table 4: Median age by gender and case category

Total cases n

Male years

Female years

ALL years

Device 3,136 72 74 73EP 1,061 60 55 58Other 277 62 66 63Total 4,474 69 69 69Casetotalsdonotreflectallactivityduetoincompleteyearofdataacquisition


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Overall,62%ofpatientsweremalewithasimilardistributionacrossallprocedurecategories.Thelargestproportionoffemaleswasrepresentedintheelectrophysiologycategory(41%).

0% 25% 50% 75% 100% 0% 25% 50% 75% 100%

Device

EP

Other

ALL

FemaleMale

Figure 12: Proportion of cases by gender and category

Table 5: Proportion of cases by gender and category

Total cases n

Male n (%)

Female n (%)

Device 3,136 1,968(62.8) 1,168(37.2)EP 1,061 622(58.6) 439(41.4)Other 277 189(68.2) 88(31.8)ALL 4,474 2,779 (62.1) 1,695 (37.9)


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5.2 Body mass indexPatientsclassedashavingabodymassindex(BMI)categoryofoverweight(35%),obese(32%)ormorbidlyobese(5%)representedalmostthree-quartersofallelectrophysiologyandpacingpatients.Patientsclassedasunderweightrepresented2%ofallcases.

Normal range* Overweight† Obese‡ Morbidly obese§

0% 10% 20% 30% 40% 50% 0% 10% 20% 30% 40% 50% 0% 10% 20% 30% 40% 50% 0% 10% 20% 30% 40% 50%

Device

EP

Other

ALL

Underweightcategory(2%)notdisplayed

* BMI18.5–24.9kg/m2

† BMI25–29.9kg/m2

‡ BMI30–39.9kg/m2

§ BMI≥40kg/m2

Figure 13: Proportion of cases by BMI and case category

5.3 Aboriginal and Torres Strait Islander statusOverall,theproportionofidentifiedAboriginalandTorresStraitIslanderpatientsundergoingelectrophysiologyandpacingprocedureswas3.7%.ThiscorrelatescloselytotheestimatedproportionofAboriginalandTorresStraitIslanderpersonswithinQueensland(4.6%).2Therewaslargevariationbetweenunits,withtheNorthQueenslandsitesseeingalargerproportionofAboriginalandTorresStraitIslanderpatients(Figure14).

0% 1% 2% 3% 4% 5% 6% 7% 8% 9% 10%

CH

TTH

MBH

SCUH

TPCH

RBWH

PAH

GCUH

STATEWIDE

Figure 14: Proportion of cases by identified Aboriginal and Torres Strait Islander status and site


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6 Risk factors and comorbidities

6.1 Coronary artery diseaseAcrossthestate,26%ofdeviceprocedurepatientswerereportedtohaveahistoryofcoronaryarterydisease.Thisfigurewasfarloweramongtheelectrophysiologycohort(14%).

0% 10% 20% 30% 40% 50%

Device

EP

Other

ALL

Excludesmissingdata(27%)

Figure 15: Proportion of cases by coronary artery disease history and case category

6.2 Family history of sudden cardiac deathDuringthesurveyedperiod,3%ofpatientswhounderwentotherproceduressuchascardioversionanddrugchallengeshadadocumentedfamilyhistoryofsuddencardiacdeath.Similarly,3%ofdevicepatientsalsohadthisriskfactor.

0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50%

Device

EP

Other

ALL


Figure 16: Proportion of cases by sudden cardiac death history and case category

6.3 Smoking historyOverall,30%ofpatientshadahistoryofsmoking,including8%whoweredocumentedasbeingcurrentsmokersand22%formersmokers.Therewere31%ofpatientswhoreportedneverhavingsmokedand15%withanunknownsmokinghistory.

Current Former Never Unknown

0% 10% 20% 30% 40% 50% 0% 10% 20% 30% 40% 50% 0% 10% 20% 30% 40% 50% 0% 10% 20% 30% 40% 50%

Device

EP

Other

ALL


Figure 17: Proportion of cases by smoking status and case category


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6.4 DiabetesTheprevalenceofdiabeteswashighestinthecardiacdeviceproceduregroup,with21%ofpatientsknowntobediabetic.Overall,18%ofthecohorthadsomeformofdiabetesundertreatment.

0% 10% 20% 30% 40% 50%

Device

EP

Other

ALL


Figure 18: Proportion of cases by diabetes status and case category

6.5 HypertensionHypertension,definedasreceivingantihypertensivemedicationsatthetimeofcase,waspresentinover43%ofpatientsirrespectiveofcasetype.Patientsinthecardiacdeviceprocedurecategoryhadagreaterincidenceofhypertension(49%).

0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50%

Device

EP

Other

ALL


Figure 19: Proportion of cases by hypertension status and case category

6.6 DyslipidaemiaWithinthiscohort,32%ofpatientsweretreatedwithstatinsfordyslipidaemiaatthetimeofcase.Thisrangedfrom35%fordeviceproceduresto26%intheelectrophysiologycategory.

0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50%

Device

EP

Other

ALL


Figure 20: Proportion of cases by dyslipidaemia status and case category


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6.7 Atrial arrhythmia historyAlmostone-thirdofpatients(30%)hadahistoryofatrialarrhythmia(atrialfibrillation,flutterorotheratrialarrhythmia).Theprevalenceofatrialarrhythmiarangedfrom23%to43%acrossprocedurecategories.

0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50%

Device

EP

Other

ALL


Figure 21: Proportion of cases by atrial arrhythmia status and case category

6.8 Heart failureOverall,12%ofpatientshadaclassificationofheartfailureatthetimeofcase,rangingfrom14%fordeviceproceduresto5%intheelectrophysiologycategory.

0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50%

Device

EP

Other

ALL


Figure 22: Proportion of cases by heart failure status and case category


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6.9 Valvular heart diseaseValvularheartdiseasewasdocumentedfor18%ofpatients,rangingfrom20%fordeviceproceduresto13%intheelectrophysiologycategory.

0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50%

Device

EP

Other

ALL


Figure 23: Proportion of cases by valvular heart disease and case category

6.10 Other cardiovascular disease and co-morbiditiesOverall,5%ofpatientshadaformofothercardiovasculardiseaseorco-morbidityatthetimeofcase,withanevendistributionacrosscasecategories.

0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50%

Device

EP

Other

ALL


Figure 24: Proportion of cases by CV disease history and co-morbidity and case category

6.11 AnticoagulationPatientswereidentifiedasbeingonanticoagulanttherapyincludingeitherWarfarinornon-vitaminKantagonistoralanticoagulants(NOAC)atthetimeofcase.Anticoagulatedpatientscomprised27%ofthetotalcohortwithpatientsintheelectrophysiologycategoryhavingthehighestuseofanticoagulants(39%).

NOAC Warfarin

0% 10% 20% 30% 40% 50% 0% 10% 20% 30% 40% 50%

Device

EP

Other

ALL


Figure 25: Proportion of cases by anticoagulation status and case category


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7 Care and treatment of patients

7.1 Urgency categoryUrgencycategoriesarebasedonthetimeframewhichtheprocedureisclinicallyindicated.Categorisationisjudgedbytheindividualtreatingclinician.

Acrossthestate,categoryonecasesformedthemajorityofproceduresundertaken.Urgencycategoryrangedwidelybetweensiteswithcategoryonecasesvaryingfrom28%to90%.Furtherdisparitywasnotedwithincategorythree,withthesecasesaccountingfor1%to37%ofcasevolumesbysite.

Table 6: Proportion of all cases by urgency category and site

Total cases n

Category 1* n (%)

Category 2† n (%)

Category 3‡ n (%)

CH 266 217(81.6) 37(13.9) 7(2.6)TTH 464 246(53.0) 51(11.0) 13(2.8)MBH 96 59(61.5) 34(35.4) 2(2.1)SCUH 518 143(27.6) 195(37.6) 136(26.3)TPCH 1,155 791(68.5) 254(22.0) 110(9.5)RBWH 535 229(42.8) 107(20.0) 199(37.2)PAH 891 443(49.7) 263(29.5) 184(20.7)GCUH 549 496(90.3) 45(8.2) 5(0.9)STATEWIDE 4,474 2,624 (58.6) 986 (22.0) 656 (14.7)Includesmissingdata4.7%

Casetotalsdonotreflectall2018activityforGCUH

* Proceduresthatareclinicallyindicatedwithin30days

† Proceduresthatareclinicallyindicatedwithin90days

‡ Proceduresthatareclinicallyindicatedwithin365days

Device EP Other

0% 25% 50% 75% 100% 0% 25% 50% 75% 100% 0% 25% 50% 75% 100%

CH

TTH

MBH

SCUH

TPCH

RBWH

PAH

GCUH

STATEWIDE

Legend Category 1 Category 2 Category 3

Figure 26: Proportion of all cases by urgency category, procedure category and site


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7.2 Admission sourceThemajorityofallcaseswereperformedonpatientsclassedasoutpatients(54%).Non-admittedinter-hospitaltransfersaccountedforlessthan1%ofallcasevolume

Inpatient Outpatient

0% 25% 50% 75% 100% 0% 25% 50% 75% 100%

CH

TTH

MBH

SCUH

TPCH

RBWH

PAH

GCUH

STATEWIDE

Figure 27: Admission source by site

Table 7: Admission source by site

Total cases n*

Inpatient n (%)

Outpatient n (%)

Non-admitted inter-hospital transfer

n (%)CH 266 112(42.1) 153(57.5) –TTH 464 179(38.6) 175(37.7) –MBH 96 45(46.9) 49(51.0) 2(2.1)SCUH 518 192(37.1) 293(56.6) –TPCH 1,155 530(45.9) 624(54.0) 1(0.1)RBWH 535 213(39.8) 321(60.0) 1(0.2)PAH 891 402(45.1) 489(54.9) –GCUH 549 239(43.5) 305(55.6) 5(0.9)STATEWIDE 4,474 1,912 (42.7) 2,409 (53.8) 9 (0.2)

* Includesmissingdata3.2%


Inpatient Outpatient

0% 25% 50% 75% 100% 0% 25% 50% 75% 100%

Device

EP

Other

ALL

Figure 28: Admission source by case category


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7.3 Admission source and urgency categoryCategoryoneproceduresaccountedforthehighestproportionofinpatientandoutpatientcases.Therewasamarkedincreaseinproportionsforinpatientprocedureswithcategoryonecasesaccountingforoverthree-quartersofcases(86%).Outpatientproceduresdemonstratedmoreevendistributionacrossthethreecategories.

Table 8: Outpatient cases by urgency category

Outpatient site Total cases n*

Category 1 n (%)

Category 2 n (%)

Category 3 n (%)

CH 153 109(71.2) 32(20.9) 7(4.6)TTH 175 103(58.9) 40(22.9) 13(7.4)MBH 49 15(30.6) 32(65.3) 2(4.1)SCUH 293 42(14.3) 113(38.6) 128(43.7)TPCH 624 290(46.5) 229(36.7) 105(16.8)RBWH 321 32(10.0) 96(29.9) 193(60.1)PAH 489 114(23.3) 225(46.0) 150(30.7)GCUH 305 263(86.2) 36(11.8) 4(1.3)STATEWIDE 2,409 968 (40.2) 803 (33.3) 602 (25.0)* Includes1.5%missingdata


Table 9: Inpatient cases by urgency category

Inpatient site Total cases n*

Category 1 n (%)

Category 2 n (%)

Category 3 n (%)

CH 112 108(96.4) 4(3.6) –TTH 179 143(79.9) 10(5.6) –MBH 45 42(93.3) 2(4.4) –SCUH 192 100(52.1) 66(34.4) 8(4.2)TPCH 530 501(94.5) 25(4.7) 4(0.8)RBWH 213 196(92.0) 11(5.2) 6(2.8)PAH 402 329(81.8) 38(9.5) 34(8.5)GCUH 239 228(95.4) 9(3.8) 1(0.4)STATEWIDE 1,912 1,647 (86.1) 165 (8.6) 53 (2.8)Casetotalsdonotreflectall2018activityforGCUH


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7.4 Device proceduresCasetypesandprocedurecombinationsvariedacrossthestateandisdrivenprimarilybyservicesofferedatindividualsites.Singleanddualchamberpacemakerimplants/generatorchangesaccountedforthemajorityofcasesacrossthestate.Therewere7sitesacrossthestateofferingbiventricularpacemaker(BiV)/implantablecardioverterdefibrillatorinsertionwiththreesitesprovidingleadlesspacemakerimplants.

Table 10: Cardiac device case types by site

Site Procedure type Case n (%)

CH Pacemakerimplant/generatorchange 121(56.8)Looprecorderimplant/explant 59(27.7)ICDimplant/generatorchange/upgrade 18(8.5)Leadrevision/replacement/pocketrevision 5(2.3)BiVICDimplant/generatorchange/upgrade 4(1.9)BiVpacemakerimplant/generatorchange/upgrade 4(1.9)Deviceexplant 1(0.5)Insertionofepicardiallead 1(0.5)

TTH Pacemakerimplant/generatorchange 99(44.4)ICDimplant/generatorchange/upgrade 49(22.0)BiVICDimplant/generatorchange/upgrade 38(17.0)Looprecorderimplant/explant 16(7.2)Leadrevision/replacement/pocketrevision 10(4.5)BiVpacemakerimplant/generatorchange/upgrade 6(2.7)Deviceexplant 4(1.8)Temporarypacingsystem 1(0.4)

MBH Pacemakerimplant/generatorchange 51(53.7)Looprecorderimplant/explant 30(31.6)Temporarypacingsystem 12(12.6)ICDimplant/generatorchange/upgrade 2(2.1)

SCUH Pacemakerimplant/generatorchange 183(66.8)ICDimplant/generatorchange/upgrade 38(13.9)Looprecorderimplant/explant 22(8.0)BiVpacemakerimplant/generatorchange/upgrade 13(4.7)BiVICDimplant/generatorchange/upgrade 10(3.6)Leadrevision/replacement/pocketrevision 5(1.8)Deviceexplant 2(0.7)Temporarypacingsystem 1(0.4)

TPCH Pacemakerimplant/generatorchange 374(45.6)ICDimplant/generatorchange/upgrade 160(19.5)Deviceexplant 76(9.3)BiVICDimplant/generatorchange/upgrade 72(8.8)Looprecorderimplant/explant 60(7.3)BiVpacemakerimplant/generatorchange/upgrade 29(3.5)Leadrevision/replacement/pocketrevision 25(3.0)Leadlesspacemakerimplant 12(1.5)Temporarypacingsystem 10(1.2)Defibrillationthresholdtesting 2(0.2)Insertionofepicardiallead 1(0.1)

RBWH Pacemakerimplant/generatorchange 135(38.4)Looprecorderimplant/explant 93(26.4)ICDimplant/generatorchange/upgrade 62(17.6)BiVICDimplant/generatorchange/upgrade 24(6.8)BiVpacemakerimplant/generatorchange/upgrade 23(6.5)Leadrevision/replacement/pocketrevision 11(3.1)Temporarypacingsystem 2(0.6)Deviceexplant 1(0.3)Insertionofepicardiallead 1(0.3)


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PAH Pacemakerimplant/generatorchange 445(65.4)ICDimplant/generatorchange/upgrade 113(16.6)Looprecorderimplant/explant 44(6.5)BiVICDimplant/generatorchange/upgrade 31(4.6)Leadrevision/replacement/pocketrevision 14(2.1)BiVpacemakerimplant/generatorchange/upgrade 10(1.5)Temporarypacingsystem 8(1.2)Leadlesspacemakerimplant 6(0.9)Deviceexplant 5(0.7)Defibrillationthresholdtesting 4(0.6)

GCUH Pacemakerimplant/generatorchange 287(60.0)ICDimplant/generatorchange/upgrade 94(19.7)Looprecorderimplant/explant 38(7.9)Leadrevision/replacement/pocketrevision 29(6.1)BiVICDimplant/generatorchange/upgrade 13(2.7)Deviceexplant 6(1.3)BiVpacemakerimplant/generatorchange/upgrade 4(0.8)Leadlesspacemakerimplant 3(0.6)Defibrillationthresholdtesting 2(0.4)Insertionofepicardiallead 1(0.2)Temporarypacingsystem 1(0.2)

STATEWIDE 3,136



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7.5 Electrophysiology studies/ablationsElectrophysiologystudiesincludingradiofrequencyablationwerethemostcommonindividualprocedureperformedacrossallsites,rangingfrom60%ofcasevolumeatTTHto83%atPAH.

Table 11: Electrophysiology study/ablation types by site

Site Procedure type Case n (%)

TTH Radiofrequencyablation 62(59.6)Cryotherapyablation 22(21.2)Electrophysiologystudy 19(18.3)Radiofrequencyandcryotherapyablation 1(<1.0)

SCUH Radiofrequencyablation 141(60.5)Cryotherapyablation 48(20.6)Electrophysiologystudy 42(18.0)Electrophysiologystudywithdrugchallenge 2(0.9)

TPCH Radiofrequencyablation 228(67.9)Electrophysiologystudy 66(19.6)Cryotherapyablation 35(10.4)Electrophysiologystudywithdrugchallenge 4(1.2)Radiofrequencyandcryotherapyablation 3(0.9)

RBWH Radiofrequencyablation 103(61.7)Electrophysiologystudy 47(28.1)Cryotherapyablation 8(4.8)Radiofrequencyandcryotherapyablation 8(4.8)Electrophysiologystudywithdrugchallenge 1(0.6)

PAH Radiofrequencyablation 147(83.1)Electrophysiologystudy 24(13.6)Cryotherapyablation 6(3.4)

GCUH Radiofrequencyablation 54(76.1)Electrophysiologystudy 17(23.9)

STATEWIDE 1,088Casetotalsdonotreflectall2018activityforGCUH

7.5.1 Standard vs complex electrophysiology

Complexelectrophysiologycasesinvolvingthree-dimensionalmappingtechnology,ventriculararrhythmiasorpulmonaryveinisolationaccountedfor52%ofallelectrophysiologycases.

Complex EP Standard EP

0% 20% 40% 60% 80% 100% 0% 20% 40% 60% 80% 100%

TTH

SCUH

TPCH

RBWH

PAH

GCUH

STATEWIDE

Figure 29: Complexity of electrophysiology procedures by site


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Table 12: Proportion of standard and complex electrophysiology procedures by site

Site Procedure type Total n

Complex EP n

Standard EP n

TTH Radiofrequencyablation 62 28 34Cryotherapyablation 22 22 –Electrophysiologystudy 19 4 15Radiofrequencyandcryotherapyablation 1 1 –

SCUH Radiofrequencyablation 141 74 67Cryotherapyablation 48 45 3Electrophysiologystudy 42 19 23Electrophysiologystudywithdrugchallenge 2 1 1

TPCH Radiofrequencyablation 228 117 111Electrophysiologystudy 66 27 39Cryotherapyablation 35 35 –Electrophysiologystudywithdrugchallenge 4 1 3Radiofrequencyandcryotherapyablation 3 3 –

RBWH Radiofrequencyablation 103 63 40Electrophysiologystudy 47 14 33Cryotherapyablation 8 6 2Radiofrequencyandcryotherapyablation 8 3 5Electrophysiologystudywithdrugchallenge 1 – 1

PAH Radiofrequencyablation 147 64 83Electrophysiologystudy 24 4 20Cryotherapyablation 6 – 6

GCUH Radiofrequencyablation 54 33 21Electrophysiologystudy 17 4 13

STATEWIDE 1,088 568 520Casetotalsdonotreflectall2018activityforGCUH


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7.5.2 Three-dimensional mapping system

Thetotalproportionofelectrophysiologycasesutilisingthree-dimensionalmappingsystemsacrosssites,anddistributionacrossvendorsisshowninTable13.Twovendorsaccountedfor85%ofallthree-dimensionalmappingsystemsused.

Table 13: Three dimensional mapping system type by site

Total cases n

CARTO n (%)

ESI n (%)

Rhythmia n (%)

ESI + Rhythmia n (%)

Other n (%)

TTH 29 7(24.1) 22(75.9) – – –SCUH 81 – 35(43.2) 44(54.3) – 2(2.5)TPCH 131 41(31.3) 78(59.5) 11(8.4) 1(0.8) –RBWH 77 7(9.1) 65(84.4) – – 5(6.5)PAH 57 32(56.1) 25(43.9) – – –GCUH 32 21(65.6) 11(34.4) – – –STATEWIDE 407 108 (26.5) 236 (58.0) 55 (13.5) 1 (0.2) 7 (1.7)Casetotalsdonotreflectall2018activityforGCUH

7.6 Ablation typeRadiofrequencyablationistheprincipalmethodacrossallsiteswith85%ofallcasesutilisingthisenergy.Therewasvariationintheproportionateusebetweensiteswithsomemorelikelytousemultipletypeswhichispossiblyafunctionofequipmentavailability.Asmallproportionofcases(1%)utilisedtwoenergytypes.

Radiofrequency Cryotherapy Radiofrequency and cryotherapy

0% 20% 40% 60% 80% 100% 0% 20% 40% 60% 80% 100% 0% 20% 40% 60% 80% 100%

TTH

SCUH

TPCH

RBWH

PAH

GCUH

STATEWIDE

Figure 30: Ablation type by site

Table 14: Ablation type by site

Total cases n

Radiofrequency n (%)

Cryotherapy n (%)

Radiofrequency + Cryotherapy

n (%)TTH 85 62(72.9) 22(25.9) 1(1.2)SCUH 189 141(74.6) 48(25.4) –TPCH 265 227(85.7) 35(13.2) 3(1.1)RBWH 119 103(86.6) 8(6.7) 8(6.7)PAH 153 147(96.1) 6(3.9) –GCUH 54 54(100.0) – –STATEWIDE 865 734 (84.9) 119 (13.8) 12 (1.3)Casetotalsdonotreflectall2018activityforGCUH


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7.6.1 Ablation type/arrhythmia

Themostfrequentlyablatedclinicalarrhythmiawasatrialfibrillation(pulmonaryveinisolation),whichaccountedfor34%ofablationsacrossallsites.Thiswasfollowedbyatrialflutter(21%)andatrioventricularnodalre-entrytachycardias(AVNRT)(20%).

Ageandgendervarieddependingonthearrythmiaablated.PatientsundergoingaccessorypathwayablationhadalowermedianagethanthosewhounderwentpulmonaryveinisolationorAVnodeablation.ThesedetailsarefurtherexpandedinTable15.

0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50%

Pulmonary vein isolation

Atrial flutter

AVNRT

Ventricular arrhythmia / ectopy

Supraventricular tachycardia

Accessory pathway

AV Node

Figure 31: Proportion of arrhythmias ablated

Table 15: Median age and gender by ablation type

Ablation type Gender Total cases n (%)

Median age years

Pulmonaryveinisolation Male 189(64.1) 58Female 106(35.9) 62

Atrialflutter Male 138(75.0) 65Female 46(25.0) 62

AVNRT Male 66(38.2) 59Female 107(61.8) 46

Ventriculararrhythmia/ectopy Male 58(65.9) 66Female 30(34.1) 49

Supraventriculartachycardia Male 28(40.0) 44Female 42(60.0) 44

Accessorypathway Male 17(58.6) 30Female 12(41.4) 26

AVnode Male 13(50.0) 78Female 13(50.0) 76

ALL 865 (100.0) 59


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Table 16: Arrhythmia type by site

Site Ablation type Count n (%)

TTH Pulmonaryveinisolation 25(29.4)AVNRT 20(23.5)Atrialflutter 18(21.2)Ventriculararrhythmia/ectopy 9(10.6)Accessorypathway 6(7.1)Supraventriculartachycardia 5(5.9)

AVnode 2(2.4)SCUH Pulmonaryveinisolation 93(49.2)

Atrialflutter 57(30.2)AVNRT 16(8.5)AVnode 9(4.8)Ventriculararrhythmia/ectopy 6(3.2)Supraventriculartachycardia 6(3.2)

Accessorypathway 2(1.1)TPCH Pulmonaryveinisolation 79(29.8)

AVNRT 53(20.0)Atrialflutter 45(17.0)Ventriculararrhythmia/ectopy 45(17.0)Supraventriculartachycardia 29(10.9)Accessorypathway 8(3.0)

AVnode 6(2.3)RBWH Pulmonaryveinisolation 33(27.7)

AVNRT 33(27.7)Atrialflutter 26(21.8)Supraventriculartachycardia 11(9.2)Ventriculararrhythmia/ectopy 10(8.4)Accessorypathway 5(4.2)

AVnode 1(0.8)PAH Pulmonaryveinisolation 48(31.4)

AVNRT 47(30.7)Atrialflutter 25(16.3)Supraventriculartachycardia 12(7.8)Ventriculararrhythmia/ectopy 9(16.7)Accessorypathway 7(4.6)

AVnode 5(3.3)GCUH Pulmonaryveinisolation 17(31.5)

Atrialflutter 13(24.1)Ventriculararrhythmia/ectopy 9(16.7)Supraventriculartachycardia 7(13.0)AVNRT 4(7.4)AVnode 3(5.6)

Accessorypathway 1(1.9)STATEWIDE 865Casetotalsdonotreflectall2018activityforGCUH


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7.7 Other proceduresThemostcommonformsofotherprocedurewerecardioversions(72%).Variationsinclinicalpracticeacrosssitescanbeobservedhere,withnotallcardioversionsperformedbeingcarriedoutintheelectrophysiologylaboratoryenvironmentordocumentedusingtheQCORapplication.

Table 17: Other procedures

Total n

Cardioversion n (%)

Drug challenge n (%)

Other n (%)

CH 53 45(84.9) 2(3.8) 6(11.3)TTH 138 118(85.5) 5(2.9) 15(10.9)MBH 1 – – 1(100.0)SCUH 12 – 10(83.3) 2(16.7)TPCH 12 2(16.7) – 10(83.3)RBWH 22 1(4.5) 13(59.1) 8(36.4)PAH 37 33(89.2) 1(2.7) 3(8.1)GCUH 2 1(50.0) – 1(50.0)STATEWIDE 277 200 (72.2) 31 (11.2) 46 (16.6)

Casetotalsdonotreflectallactivityduetoincompleteyearofdataacquisition


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8 Procedural complicationsLeadcomplicationswerethemostfrequentlyencounteredcomplicationfordeviceproceduresandpericardialeffusionswerethemostcommonlyobservedcomplicationacrosselectrophysiologyprocedures.Thesummaryofcomplicationsbelowdenoteseventsobservedduringtheprocedureaswellaspost.TheQCORelectrophysiologyapplicationispredominantlyutilisedforproceduraldetailreporting,andassuchdocumentationofproceduralcomplicationsistheresponsibilityofsitepractitioners.

ThecomplicationratesforproceduresinTables18and19arereflectedastheproportionofthetotalnumberofdeviceandelectrophysiologyproceduresrespectively.Onsomerareoccasions,thedevelopmentofanintraproceduralcomplicationsuchascoronarysinusdissectionnecessitatedachangeofproceduretypefromBiVimplant/upgradetoanon-BiVdeviceprocedure.Intheseinstances,complicationsarereportedagainstthefinalproceduretype.

Theoveralldeviceprocedurecomplicationratewas2.9%,whileelectrophysiologyprocedureshada3.2%complicationrate.

Table 18: Cardiac device procedure complications

Procedure type Complication Total n (%)

Pacemakerimplant/generatorchange Leadcomplication 14(0.5)Other 11(0.4)Pneumothorax 7(0.2)Pericardialeffusionwithorwithouttamponade 5(0.2)Haematoma 4(0.1)Infection 4(0.1)Cardiacarrest 2(<0.1)

Looprecorderimplant/explant Devicemigration/erosion 2(<0.1)Drugreaction 2(<0.1)Other 1(<0.1)

ICDimplant/generatorchange/upgrade Leadcomplication 3(0.1)Other 3(0.1)Bleeding 2(<0.1)Haematoma 2(<0.1)Infection 2(<0.1)Cardiacarrest 1(<0.1)Drugreaction 1(<0.1)Pneumothorax 1(<0.1)

BiVICDimplant/generatorchange/upgrade Leaddislodgement 3(0.1)Conductionblock 2(<0.1)Coronarysinusdissection 2(<0.1)Pericardialeffusionwithouttamponade 2(<0.1)Bleeding 1(<0.1)

BiVpacemakerimplant/generatorchange/upgrade Coronarysinusdissection 3(0.1)Coronarysinusperforation 1(<0.1)Leadcomplication 1(<0.1)Pericardialeffusionwithouttamponade 1(<0.1)

Deviceexplant Leadcomplication 1(<0.1)Leadrevision/replacement/pocketrevision Leadcomplication 5(0.2)

Pericardialeffusionwithtamponade 1(<0.1)Pneumothorax 1(<0.1)Vascularinjury 1(<0.1)

ALL 90 (2.9)


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Table 19: Electrophysiology procedure complications by study type and complexity

Procedure type Complexity Complication Total n (%)

Electrophysiologystudy ComplexEP Conductionblock 1(<0.1)Pericardialeffusionwithtamponade 1(<0.1)

Cryotherapyablation StandardEP Arrhythmiareturned 2(0.2)Conductionblock 1(<0.1)

ComplexEP Pericardialeffusionwithtamponade 1(<0.1)Phrenicnerveinjury 1(<0.1)

Radiofrequencyablation StandardEP Conductionblock 2(0.2)AtrialarrhythmiarequiringDCCV 1(<0.1)Ventriculararrhythmia 1(<0.1)

ComplexEP Pericardialeffusionwithtamponade 8(0.8)Arrhythmiareturned 7(0.7)Pericardialeffusion 3(0.3)Infection 2(0.2)Other 2(0.2)Bleeding 1(<0.1)

ALL 34 (3.2)


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9 Clinical indicators

Clinicalindicatorsareimportantmeasuresoftheclinicalmanagementandoutcomesofpatientcare.Anindicatorthatisclinicallyrelevantandusefulshouldhighlightspecificissuesthatmayrequireattentionorsignalareasforimprovement.Usuallyrate-based,indicatorsidentifytherateofoccurrenceofanevent.Thereisemergingrecognitionthatacapacitytoevaluateandreportonqualityisacriticalbuildingblockforsystem-wideimprovementofhealthcaredeliveryandpatientoutcomes.

ThequalityandsafetyindicatorswhichhavebeennominatedbythestatewideelectrophysiologyworkinggroupareoutlinedinTable20.

Table 20: Electrophysiology and pacing clinical indicators

Clinical indicator

Description

1 Waitingtimefrombookingdatetoprocedurebycasecategory2 Proceduraltamponaderates3 Reinterventionwithinoneyearofproceduredateduetocardiacdeviceleaddislodgement4 Rehospitalisationwithinoneyearofprocedureduetoinfectionresultinginlossofthedevice5 12monthall-causemortalityforcardiacdeviceprocedures


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9.1 Waiting time from referral date to procedure by case categoryWaitingtimesforclinicalinterventionsandinvestigationsareanimportantmetricformonitoringserviceprovisionandidentifyingpotentialunmetneed.Thisclinicalindicatorexaminesthewaitingtimeforvariouscardiacdeviceproceduretypes.Specifically,themedianwaittimefromthedatetheprocedurewasreferredtothecasedate.Forthepurposeofthisindicator,proceduresperformedonpatientsclassedaselective(proceduresnotperformedaspartofanacuteadmission)areexamined.

Theadverseconsequencesoftreatmentdelayarewellknownandincludedeteriorationintheconditionforwhichtreatmentisawaited,thelossofutilityfromdelay(especiallyiftreatmentcanrelievesignificantdisability),ariseinthecostsoftotaltreatment,accumulationofanylossofincomefromworkandasanextremeoutcome,death.

Animportantdistinctionexistsbetweenthewaitingtimeofthepatientsbookedfortheirprocedureandthosewhoarereferredforspecialistopinionandsubsequenttreatment.Asthisindicatorexaminesthewaittimefrombookingdatetocasedate,itisreflectiveofsystemperformancethatisspecificallyfocusedonelectrophysiologyandpacingdemandandneed.

9.1.1 Elective pacemaker

Examinationofthewaitingtimeforelectivepacemakerproceduresisbelow.Ofthe227caseswithcompletedata,themedianwaittimewas17days.

Table 21: Elective pacemaker wait time analysis

Total cases n

Total cases analysed n

Median wait time days

Interquartile range days

Statewide 349 227 17 1–34

9.1.2 Elective ICD wait time and proportion within 28 days

ThisanalysisexaminesthewaitingtimeforelectiveICDproceduresandtheproportionadheringtothebenchmarkof28daysorless.

Table 22: Elective ICD wait time analysis

Total cases n

Total cases analysed

n



Met target %

Statewide 217 120 33 7–53 44

9.1.3 Standard ablation

Waitingtimesforstandardablationproceduresarepresentedbelow.Ofthe208caseseligibleforanalysis,themedianwaittimewas91days.One-quarterofpatientshadawaittimeof159daysormore.

Table 23: Elective standard ablation wait time analysis

Total cases n

Total cases analysed n



Statewide 297 208 91 47–159


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9.1.4 Complex ablation (with proportion within 180 days or less)

Complexablationsaredefinedascasesusingthree-dimensionalmappingtechnologyorinvolvingventriculararrhythmiaorpulmonaryveinisolation.Thisindicatorexaminesthewaitingtimefortheseproceduresandtheproportionadheringtothebenchmarkof180daysorless.Thisindicatorisreportedatasitelevelandinvestigatesthosesiteswith>20caseswithdataforanalysis.

Amedianwaittimeof81dayswasobservedwithalargeinterquartilerangedemonstratingthatthereareanumberofpatientswithconsiderablylongwaits.

Table 24: Elective complex ablation wait time analysis

Total cases n

Total cases analysed

n



Met target %

TTH 27 0 N/A N/A N/ASCUH 102 7 N/A N/A N/ATPCH 144 140 127 55–233 64RBWH 67 67 28 18–43 99PAH 43 42 121 50–354 60GCUH 28 1 N/A N/A N/ASTATEWIDE 411 225 81 35–193 73N/A:Notdisplayeddueto<20casesavailableforanalysis

9.2 Procedural tamponade ratesCardiactamponadeisaknowncomplicationofcardiacdeviceandelectrophysiologyprocedures.Thisindicatorexaminestherateofproceduralpericardialtamponade.Aspericardialtamponadeisaclinicaldiagnosis,thisindicatorexplicitlyreportsthosepatientswiththisspecificdiagnosisanddoesnotincludethosepatientswiththediagnosisorfindingofpericardialeffusion.

Table 25: Procedural tamponade analysis

Procedure category Total cases analysed n

Procedural tamponade observed n

Procedural tamponade rate %

Device 3,136 4 0.1EP 1,061 10 0.9ALL 4,197 14 0.3


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9.3 Reintervention within one year of procedure date due to cardiac device lead dislodgement

Thisindicatoridentifiesthenumberofcaseswhereleaddislodgementwasobservedwithinoneyearofleadinsertion.Thecasesincludedinthisindicatorwereallnewdeviceimplantsorupgradeswhereanewlead/shadbeenimplantedandaleadrevisionorreplacementwassubsequentlyrequiredduetodislodgement.IndeximplantprocedureswerecasesperformedwithinQueenslandHealthimplantingfacilitiesinthe2017calendaryear.

Theanalysisshowed26cases(1.8%)wherereinterventionwasrequiredwithin12monthsoftheindexprocedure.Higherratesofreinterventionwerenotedinthebiventriculardevicecategorywhichmayreflectthegreatercomplexityofthesesystems.

Ofthese26cases,9atrialand17ventricularleaddislodgementswerenoted.Septalandapicallypositionedventricularleadswerethemostcommonlyobservedleaddislodgementsites(7each)followedbyrightventricularoutflowtract(n=2)andHisbundlesites(n=1).

Theseresultscomparefavourablywithinternationalcohortswhereobserveddislodgementratesforpacemakersystemimplantsvaryfrom1.0to2.7%21.

Table 26: Reintervention due to lead dislodgement analysis

Cases analysed n

Atrial lead n

Ventricular lead n

12 month lead dislodgement

n

12 month lead dislodgement

rate %Pacemakerimplant 968 8 11 19 2.0ICDimplant 301 1 2 3 1.0AnyBiVimplant 155 0 4 4 2.6All 2017 device cases 1,424 9 17 26 1.8

9.4 Rehospitalisation within one year of procedure due to infection resulting in loss of the device system

Oneofthemostseriouslong-termcomplicationsrelatedtomortalityandmorbidityforpatientswithcardiacimplantableelectronicdevicesisinfection.Completeremovalofallhardwareistherecommendedtreatmentforpatientswithestablisheddeviceinfectionbecauseinfectionrelapseratesduetoretainedhardwarearehigh.

A1.4%systemlossratewasobservedat12monthswhichisreassuringwhencomparedtointernationalliteraturewhichsuggestsinfectionratesnecessitatingexplantofapproximately2.4%22.

Table 27: Rehospitalisation with device loss analysis

Cases analysed n

12 month system loss due to infection

n

12 month system loss rate %

2017devicecases 1,765 25 1.4


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9.5 12 month all-cause mortality for cardiac device procedures12monthall-causemortalityisexaminedforpatientswithcardiacdevicesproceduresin2017.Itisimportanttonotethatpatientsundergoingtheseproceduresareoftenofanadvancedage,haveadvancedsymptomatology(advancedheartfailureinpatientswithbiventricularpacing)andoftenhavemultiplecomorbiditiesandriskfactors.

Table 28: 12 month all-cause unadjusted mortality for cardiac device procedures

Cases analysed n

12 month mortality observed

n

12 month mortality rate %

Median age at procedure

years

Interquartile range years

AnyBiVprocedure 189 12 6.3 71 63–77ICDprocedure 422 15 3.6 62 53–71Pacemakerprocedures 1,154 85 7.4 77 69–84All 2017 device cases 1,765 112 6.3 74 64–81


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10 ConclusionsThe2018QCORAnnualReporthasdemonstratedsignificantadvancesinanalysisofactivityandoutcomesincardiacelectrophysiology.ReferencetoQCORdatahasimprovedthecost-effectivenessofprocurementofcardiacelectronicimplantabledevices.Thesavingsrealisedtherebyhavepermittedfundingtoberedirectedtootherareasofneed.Withcontinuedclinicalinputandfocus,QCORdataandreportingwillbeabletoinformcliniciansnotonlyofperformanceandqualitybutalsotoprovideunprecedentedinsightintoservicecapacityandthroughput.ItisunusualforsuchinsighttobeavailabletocliniciansbeyondQueenslandHealth,nationallyorinternationally.Indeed,thedetailandrigourofQCORdataexemplifieswhatispossiblewithanengagedclinicalgroup.

ItismandatorythatQCORdata,whichisaccurateandcontextualised,shouldinformplanningforsustainedandappropriategrowthofinfrastructureandspecialisedworkforceacrossthestate.Enhancementofreportingofclinicalqualityindicatorshashighlightedfurthertheunmetdemandforcardiacablationprocedures,expressedmostparticularlyasunacceptablewaittimesatTPCHandPAH.Whilethemedianstatewidewaittimein2018forcomplexablationprocedureswas81days,thecorrespondingmeanwaittimeforablationforatrialfibrillationatPAHwas336days,and171daysforcomplexablationatTPCH.Thisdisparityspeakstoissuesofprioritisationforlaboratorybuildingandworkforcerecruitmentnow,butalsounderlinestheneedtomitigate,withvisionguidedbyQCORdata,futureincreaseofunmetneedatnewersites.ThenatureofwaittimedataavailablefromsomesitesbeyondBrisbaneremainsheterogeneous,stillrequiringcollationandinterpretationtoensureconsistencyinmeasurementandpresentation.Itshouldberecognisedthatwaittimesrecordeddonotincludeoutpatientwaitingtimesforapatienttobeassessedby(thetoofew)heartrhythmspecialists.Nomeasureofunmetneedcanaccountforthereluctancetoreferpatientsforcomplexablationbygeneralpractitionersandevencolleaguecardiologistswhoareawareoflong,unsatisfactorywaittimes.

TrendsinQCORdatasupportthepremisethatwhenplansareconsideredforbuildingofanadditionallaboratoryforcoronaryangiography/PCI,provisionshouldbemadeforacardiacelectrophysiologylaboratorytobebuiltintandem–thismakessenseintermsofeconomyofscaleforbuildingandinviewofever-risingdemandforEP-pacingservices,itselfpartlyconsequentontheadditional,invasivecoronaryactivities.Itisaxiomaticthatplanningforinfrastructureshouldproceedinparallelwithplanningforexpansionofspecialisedworkforce.TheseconceptsarebeingexaminedbytheSystemsPlanningBranch.

Clinicalindicatorshighlightthatonly44%ofelectiveICDprocedureswereundertakenwithin30days.Thisrepresentsunsatisfactorydelaywhichmustbeaddressed.Issuesofinadequateworkforceanddeficientlaboratoryinfrastructurewillhavecontributed.Proceduraltamponaderatesaresatisfactoryat0.2%,whiledeviceleaddislodgmentsarelikelyunder-reported.Devicelossat1yearduetoinfectionisprobablysatisfactoryat1.2%,butthereisnoroomforcomplacencyhere.

Where12monthall-causemortalityafterdeviceprocedureexceededage-matchedpopulationbackgroundratesin2018,itwasnotedthatsmallnumberofdeathsinyoungerpatientswerestatisticallyinsignificant,whiledatacapturedforelderlypatientslikelyrepresenteddeathinspiteof,notbecauseof,theirprocedures.

TheQCORinitiativeshaveunderscoredtheimportanceofqualitydatacaptureandtheindispensablenatureofclinicalinputtoguideusefulandrelevantreporting.Withfurtherfocusondatacompletenessandintegrity,thepoweroftheQCORcardiacelectrophysiologyregistrywillcontinuetoinformimprovementofserviceprovisionanddeliveryofquality,timelyclinicalcareforQueenslandHealthpatientswhohavecardiacrhythmdisorders.Suchimprovementnecessitatesimmediaterepairofinfrastructureandworkforcedeficienciestocreateasustainable,adequatefoundationfromwhichtolaunchtheexcitingfutureofcardiacelectrophysiology.

Pagei QCORAnnualReport2018

ReferencesElectrophysiology and Pacing Audit

2. AustralianBureauofStatistics.Estimates of Aboriginal and Torres Strait Islander Australians, June 2016.Cat.no3238.055001.ABS:Canberra;2018.

21. Wang,Y.,Hou,W.,Zhou,C.,Yin,Y.,Lu,S.,Liu,G.,…Zhang,H.-J.(2018).Meta-analysisoftheincidenceofleaddislodgementwithconventionalandleadlesspacemakersystems.Pacing and Clinical Electrophysiology,41(10),1365–1371

22. Greenspon,A.J.,Patel,J.D.,Lau,E.,Ochoa,J.A.,Frisch,D.R.,Ho,R.T.,…Kurtz,S.M.(2011).16-YearTrendsintheInfectionBurdenforPacemakersandImplantableCardioverter-DefibrillatorsintheUnitedStates.Journal of the American College of Cardiology,58(10),1001–1006.

QCORAnnualReport2018 Pageii

Glossary6MWT SixMinuteWalkTestACC AmericanCollegeofCardiologyACEI AngiotensinConvertingEnzymeInhibitorACOR AustralasianCardiacOutcomesRegistryACS AcuteCoronarySyndromesANZSCTSAustralianandNewZealandSocietyofCardiac

andThoracicSurgeonsAQoL AssessmentofQualityofLifeARB AngiotensinIIReceptorBlockerARNI AngiotensinReceptor-NeprilysinInhibitorsASD AtrialSeptalDefectATSI AboriginalandTorresStraitAV AtrioventricularAVNRT AtrioventricularNodalRe-entryTachycardiaBCIS BritishCardiovascularInterventionSocietyBiV BiventricularBMI BodyMassIndexBMS BareMetalStentBNH BundabergHospitalBSSLTX BilateralSequentialSingleLungTransplantBVS BioresorbableVascularScaffoldCABG CoronaryArteryBypassGraftCAD CoronaryArteryDiseaseCBH CabooltureHospitalCCL CardiacCatheterLaboratoryCH CairnsHospitalCHF CongestiveHeartFailureCI ClinicalIndicatorCR CardiacRehabilitationCRT CardiacResynchronisationTherapyCS CardiacSurgeryCV CardiovascularCVA CerebrovascularAccidentDAOH DaysAliveandOutofHospitalDES DrugElutingStentDOSA DayOfSurgeryAdmissionDSWI DeepSternalWoundInfectionECG 12leadElectrocardiographECMO ExtracorporealMembraneOxygenationED EmergencyDepartmenteGFR EstimatedGlomerularFiltrationRateEP ElectrophysiologyFdECG FirstDiagnosticElectrocardiographFTR FailureToRescueGAD GeneralizedAnxietyDisorderGCCH GoldCoastCommunityHealthGCUH GoldCoastUniversityHospitalGLH GladstoneHospitalGP GeneralPractitionerGYH GympieHospitalHBH HerveyBayHospital(includesMaryborough)HF HeartFailureHFpEF HeartFailurewithPreservedEjectionFractionHFrEF HeartFailurewithReducedEjectionFractionHFSS HeartFailureSupportServiceHHS HospitalandHealthServiceHOCM HypertrophicObstructiveCardiomyopathyHSQ HealthSupportQueenslandIC InterventionalCardiology

ICD ImplantableCardioverterDefibrillatorIHT Inter-hospitalTransferIPCH IpswichCommunityHealthLAA LeftAtrialAppendageLAD LeftAnteriorDescendingArteryLCX CircumflexArteryLGH LoganHospitalLOS LengthOfStayLV LeftVentricleLVEF LeftVentricularEjectionFractionLVOT LeftVentricularOutflowTractMBH MackayBaseHospitalMI MyocardialInfarctionMIH MtIsaHospitalMRA MineralocorticoidReceptorAntagonistsMTHB MaterAdultHospital,BrisbaneNCDR TheNationalCardiovascularDataRegistryNOAC Non-VitaminKAntagonistOralAnticoagulantsNP NursePractitionerNRBC Non-RedBloodCellsNSTEMI NonST-ElevationMyocardialInfarctionOR OddsRatioPAH PrincessAlexandraHospitalPAPVD PartialAnomalousPulmonaryVenousDrainagePCI PercutaneousCoronaryInterventionPDA PatentDuctusArteriosusPFO PatentForamenOvalePHQ PatientHealthQuestionairreQAS QueenslandAmbulanceServiceQCOR QueenslandCardiacOutcomesRegistryQEII QueenElizabethIIHospitalQH QueenslandHealthQHAPDC QueenslandHospitalAdmittedPatientData

CollectionRBC RedBloodCellsRBWH RoyalBrisbaneandWomen’sHospitalRCA RightCoronaryArteryRDH RedcliffeHospitalRHD RheumaticHeartDiseaseRKH RockhamptonHospitalRLH RedlandHospitalSCCIU StatewideCardiacClinicalInformaticsUnitSCCN StatewideCardiacClinicalNetworkSCUH SunshineCoastUniversityHospitalSHD StructuralHeartDiseaseSTEMI ST-ElevationMyocardialInfarctionSTS SocietyofThoracicSurgeryTAVR TranscatheterAorticValveReplacementTMVR TranscatheterMitralValveReplacementTNM Tumour,LymphNode,MetastasesTPCH ThePrinceCharlesHospitalTPVR TranscatheterPulmonaryValveReplacementTTH TheTownsvilleHospitalTWH ToowoombaHospitalVAD VentricularAssistDeviceVATS Video-AssistedThoracicSurgeryVCOR VictorianCardiacOutcomesRegistryVF VentricularFibrillationVSD VentricularSeptalDefect

Pageiii QCORAnnualReport2018

Ongoing initiativesWhilstcontinuallyrefiningandimprovingdatacollectionandreportingpracticesforthebenefitofpublicfacilities,QCORisalsobeginningtheinvestigationofamethodtocollectandanalyseclinicaldataforprivatehealthcarefacilities.Followinginterestfromvariousprivateproviders,QCORislookingtoextenditsqualityandsafetyfocustoaccommodatetherequirementsofthesefacilities.ItisanticipatedthatQCORwillprovidearoleinthedeliveryofreportsandbenchmarkingactivitieswhilstalsoactingasaconduittothevariousnationalregistriesinexistenceanddevelopment.

CardiacoutreachcontinuestoexpandinQueenslandwithformalisedandnewlyfundedserviceshavingcommencedbetweenCairnsandHinterlandandTorresandCapeHospitalandHealthServiceintendingtoprovidecardiaccareinmanyofthesecommunitiesforthefirsttime.ServiceswillcommenceinJanuary2020betweenTownsvilleandNorthWest.Theforwardplanfortherolloutofthismodelacrossthestatehasbeendevelopedinpartnershipwithconsumersandclinicians.Anewsystem,theQCOROutreachapplicationhasbeendevelopedtotrackactivity,serviceprovisionandpatientoutcomes.Thisground-updevelopmentspecificallyforcardiacoutreachfinishedtestingandgoesliveforuseinlate2019.

TheQCORStructuralHeartDiseasemoduleiscurrentlyinadvancedstagesofdevelopmentwithwiderdeploymentexpectedin2020.ThisQCORmodulehasbeendevelopedtoprovidesuperiorprocedurereportingcapabilitiesforstructuralheartdiseaseinterventions,deviceclosure,andpercutaneousvalvereplacementandrepairprocedures.Itwillenableparticipationinnationalqualityandsafetyactivitiesfortranscatheteraorticvalvereplacementaswellasallowclinicianstoutilisetheapplicationforcollectingpreandpost-proceduraldatainunprecedenteddetail.Theapplicationhasbeenthroughrigoroustestingwithusertrainingandfurtherenhancementsplannedforthenearfuture.

TheECGFlashinitiativeoftheSCCNhascontinuedtobeimplementedatseveralsitesthroughout2018and2019.Deploymentofhardwaretospokesiteshasbeenviaastagedapproachwithuptakebeingvariedbasedonlocalsiteworkloadandworkforce.IntegrationofECGFlashwithworkflowwithinhubsitescontinuestoevolvewithsitesnowtakingtheinitiativetoembraceandfeedbacktositesregardingtheappropriateuseofthesystem.Analysisoftheutilityofthesystemisbeginningtotakeplacewithafocusonclinicalefficacyandbenefit.ItisanticipatedthatQCORwillbeabletosupportthisnewinitiativethroughprocedurallinkageandoutcomemonitoringforthesubsetofpatientswhoseclinicalpathutilisedECGFlashandwentontosubsequentinvestigationormanagement.

OpportunitiesforparticipationintheformativestagesofnationalregistriesandinitiativeshavebeenembracedbyQueenslandclinicians.TheseimportantinitiativeswhichareinvariousstageofdevelopmentwillbecriticaltothefutureofclinicalregistriesinAustralia.Itisanticipatedthatwithfurtherinvolvementfromlocalstakeholdersthattheseentitieswillevolveintorelevantandusefultoolsforpatient-centredreportingandoutcomes.

QCORAnnualReport2018 Pageiv

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Documents

Clinical Excellence Queensland · 2019. 12. 8. · cardiac and thoracic surgery, cardiac rehabilitation, cardiac catheter interventions, electrophysiology and pacing, and heart failure