1. Heart disease: Getting international collaboration right Chris Gale c.p.gale@leeds.ac.uk Associate Professor, Honorary Consultant Cardiologist University of Leeds, UK

2. Risk of in-hspital all-cause mortality, odds ratio Year of admission to hospital Gale CP. Eur Heart J. 2012 Mar;33(5):630-9

3. Global cardiovascular care WesternisedRapid westernisationDeveloping North AmericaChinaAfrica Western EuropeIndiaSouth America High survivalResistant mortalityHigh mortality Guideline adherence Brisk implementation Primary prevention Medication adherenceOrganisational cultureSecondary care Novel technologiesSystemsEcological saturation Care deficits Premature cardiovascular death Lancet. 2012 Dec 15;380(9859):2095-128

4. Smith FG. Eur Heart J Acute Cardiovasc Care. 2014 Sep 11

5. Myocardial Iscahemia National Audit Project 1.2M Transcatheter Aortic Valve Implantation 7k National Heart Failure Audit 0.25M British Cardiovascular Intervention Society 0.8M Cardiothoracic Surgery 0.5M Cardiac Rhythm Management 1M National Institute for Cardiovascular Outcomes Research Gale CP. Heart. 2012 Jul;98(14):1040-3

6. DTN times approximately constant throughout the day PCI peak DTB at 0800 and trough at 1800 Eur Heart J. 2011 Mar;32(6):706-11 Door to treatment times, over 24 hrs

7. Use of coronary angiography, NSTEMI Age Hospital facilities Temporal trends Heart. 2009 Oct;95(19):1593-9

8. Prescription of medication for the secondary prevention of coronary events % STEMINSTEMI

9. Old and new Eur Heart J. 2011 Mar;32(6):706-11

10. More is less….. Eur Heart J. 2011 Mar;32(6):706-11

11. ……..is better Eur Heart J. 2011 Mar;32(6):706-11

12. Reduced inequalities? In-hospital risk of death, odds ratio Year 30-day risk of death, odds ratio West RM. Eur Heart J. 2012 Mar;33(5):630-9 Gale CP. Heart. 2014 Apr;100(7):582-9 Alabas O. Age Ageing. 2014 Nov;43(6):779-85 Gale CP. Int J Cardiol. 2013 Sep 30;168(2):881-7

13. Phenotype independent mortality ? System dependent mortality Gale CP. Heart. 2011 Dec;97(23):1926-31

14. Cumulative missed opportunities Profile of each missed opportunities along the pathway of STEMI care, by CMOC group for patients eligible for all nine care opportunities. Simms A. Eur Heart J Acute Cardiovasc Care. 2014 Sep 16.

15. ….are associated with premature death Kaplan-Meier unadjusted survival estimates for patients with STEMI, stratified by CMOC group for patients eligible for all nine care opportunities. Simms A. Eur Heart J Acute Cardiovasc Care. 2014 Sep 16.

16. International missed opportunities Gale CP EuroIntervention. 2013 Aug 22;9(4):469-76 Gale CP Int J Cardiol. 2013 Apr 19

17. ….are associated with avoidable death

18. Start (and finish) with the data Lilford. Lancet 2004;363:1147

19. Missing by choice and chance

20. Choice? Smith F. EHJ ACC 2014 Sep 11

21. Chance? Complete case analysis may bias estimates Spatial variation in missing data Gale CP. Heart. 2011 Dec;97(23):1926-31 % missing data in key fields

22. So, what can we do? Cases Countries Quality Care Facilities Outcomes Observational data Retrospective – registries Prospective – snap shots Randomised data RCT RRCT

23. Big Data MINAP HFA CRM BCIS CTS NACR Others Gale CP. Heart. 2012 Jul;98(14):1040-3

24. Big Data

34. EMMACE: data resolution Electronic Health Record Linkage: Acure coronary syndrome: MINAP Status and cause of death: ONS Hospital data: facilities questionanire Health data: HES Primary Care: The Phoenix Partnership EMMACE-3 Admission One m Six mOne year Consent into studies Death One year Questionnaires: Admission / One month / Six months/ One year Drug adherence/compliance: Morisky Medication Adherence, Single Question Medicine Adherence, Beliefs about Medicine, The Adherence Estimator and Problems with Taking medications, Satisfaction with Information about Medicines Scale (SIMS), List of Medications Health Related Quality of Life: EQ-5D Questionnaires: Admission / One month / Six months/ One year Drug adherence/compliance: Satisfaction with Information about Medicines Scale (SIMS), List of Medications Patient reported experience measure: Care Quality Commission Picker Inpatient -15 Health Related Quality of Life: Brief Illness Perception (BIP), EQ-5D Questionnaires: Annual Drug adherence: MacNew Health Related Quality of Life: EQ-5D Six monthsOne month Annual EMMACE-3X EMMACE-4 Alabas O. BMJ Open 2014 in press

35. Pyramid of evidence validitybias -to determine the optimal approaches to healthcare interventions and delivery cmRCT High validity Low bias

36. Cohort multiple RCT Regular outcome measurement Large observational cohort Eligible patients identified Remaining patients Randomised to intervention Usual care Relton C. BMJ. 2010;19:340

37. GRACE RRCT Data collection: MINAP, survey survey, NICOR, ONS

38. Acknowledgements Funders: – British Heart Foundation – National Institute for Health Research Institutions: – University of Leeds – National Institute for Cardiovascular Outcomes Research, UCL Team: c.p.gale@leeds.ac.uk