Implementing NICE guidance

NICE medical technology guidance 8

November 2011

The VeriQ system for assessing graft flow during coronary artery bypass graft surgery

What this presentation covers

Background

Guidance

Using the device

Costs and savings

Discussion

Accessing the guidance and implementation tools

All images in this presentation reproduced with kind permission of MediStim ASA

Background: medical technologies guidance

NICE medical technology guidance addresses specific technologies notified to NICE by manufacturers

The case for adopting the technology is supported if the technology has been found to offer advantages to patients and the NHS

The specific recommendations on individual technologies are not intended to limit use of other relevant technologies that may offer similar advantages

Background: current clinical practice

• Coronary artery disease:– atherosclerosis occluding coronary arteries– common cause of symptoms, disability and death

• Coronary artery bypass graft (CABG) surgery uses grafts to bypass narrowed or blocked arteries

• Graft dysfunction is a major determinant of perioperative morbidity and mortality after CABG

• Graft flow assessment usually subjective

• Objective methods (such as transoesophageal echocardiography, ECG, angiography) also used to give indirect information about technical success

Background: VeriQ

• For non-invasive assessment of graft blood flow during CABG

• Probe and microcomputer with touch screen, on a moveable trolley

• Two probe types (PS and PQ); guidance focuses on PS probes (compatible with common NHS sterilisation techniques)

• Probes deliver bidirectional ultrasound across target vessel; analysis of returning signal gives real time flow curve, mean blood flow, pulsatility index and diastolic filling percentage

Guidance

• The case for adopting the VeriQ system in the NHS for assessing graft flow during CABG is supported by the evidence

• Intraoperative transit time flow measurement detects imperfections that may be corrected by graft revision

• May reduce graft occlusion, perioperative morbidity and mortality

Click here for further information about evidence reviewed

Committee considerations

Perioperative adverse cardiac events resulting from graft failure cause serious complications which require

• subsequent interventions• prolonged intensive care stays• readmission

VeriQ, added to other methods of assessment, is likely to detect technical graft problems and has the potential to reduce graft occlusion rates

The ESC and EACTS revascularisation guidelines (2010) recommend graft evaluation by objective methods

Using the device

• Easy to use

• Does not increase operative time

• Two people to operate: cardiac surgeon and another (can be a member of the surgical team)

• Probe must be sterilised according to manufacturer’s instructions to achieve maximum repeat uses

Costs and savings for the NHS

Net cost of implementation for England (population 51.2 million)

Recurrent annual  cost/−saving (£)

Additional cost of equipment and surgery time from using VeriQ

1,203,723

Savings from reduction in adverse events −2,578,270

Total annual cost/-saving −1,374,547

Total annual cost/-savings per procedure −147

Savings from reduction in adverse events

Costs and savings due to reduction in adverse events

Costs/−savings per 1,000,000 population (£)

Current cost of perioperative myocardial infarction and associated rehabilitation

33,901

Current cost of intra-aortic balloon pumping 84,081

Current costs 117,982

Future cost of perioperative myocardial infarction and associated rehabilitation

17,843

Future cost of intra-aortic balloon pumping 50,198

Future costs 68,041

Net savings from reduced adverse events from guidance implementation −49,941

Additional costs of equipment and surgery time

Costs of equipment and surgery time

Costs/-savings per 1,000,000 population (£)

Total current costs of equipment and surgery time including cost of performing revisions 2,591

Total future costs of equipment and surgery time including costs of performing revisions 25,907

Net additional equipment and surgery time costs from guidance implementation 23,316

Net resource impact from guidance implementation [net additional costs – net savings (slide 10)] -26,625

Discussion

• What is our current approach to quality assuring graft patency?

• How can we encourage our colleagues to use this technology?

• What can we do to facilitate use of VeriQ in our organisation?

Accessing the guidance and implementation tools online

Visit www.nice.org.uk/guidance/MTG8 for

•guidance

•costing tools

•podcast

What do you think?

Did the implementation tool you accessed today meet your requirements, and will it help you to put the NICE guidance into practice?We value your opinion and are looking for ways to improve our tools. Please complete a short evaluation form.If you have problems accessing or using this tool, please email implementation@nice.org.uk

To open the links in this slide set right click over the link and choose ‘open link’

References – additional slide

The following slide is an additional slide containing references and details of the studies reviewed in this guidance.

If you used the hyperlinks on slide 6 during the presentation you will have already visited this slide

Evidence

• Keiser et al. (2010) Major adverse cardiac events occurred significantly more often in patients with pulsatility index grater than 5

• Becit et al. (2007) Lower incidence of intra-aortic balloon pump insertion and myocardial infarction in the study group (those who had transient time flow measurement during surgery and graft revision if needed based on measurement)

• Nordgaard et al. (2010) The VeriQ system provided systematically higher pulsatility index values than the transonic device

• NICE’s external assessment centre reviewed 26 studies on predecessor devices of the VeriQ; the predecessor devices predicted short-term graft failure following CABG surgery and were easier to carry out than other methods Return to slide 6 containing

recommendation