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Poorthuis MHF, Brand EC, Halliday A, Bulbulia R, Schermerhorn ML, Bots ML, de Borst GJ. A systematic review and meta-analysis of complication rates after carotid procedures performed by different specialties. J Vasc Surg 2020; 72:335-343.e17. [PMID: 32139311 DOI: 10.1016/j.jvs.2019.11.061] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 11/28/2019] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Different competencies and skills are required and obtained during medical specialization. However, whether these have an impact on procedural outcomes of carotid endarterectomy (CEA) or carotid artery stenting (CAS) is unclear. We assessed the reported association between operator specialization and procedural outcomes after CEA or CAS to determine whether CEA and CAS should be performed by specific specialties. METHODS We systematically searched PubMed and Embase up to August 21, 2017, for randomized clinical trials and observational studies that compared two or more specialties performing CEA or CAS for symptomatic and asymptomatic carotid artery stenosis. The composite primary outcome was procedural stroke or death (ie, occurring within 30 days of the procedure or before discharge). Risk estimates were pooled with a generic inverse variance random effects model. RESULTS A total of 35 studies (26 providing data on CEA, 8 providing data on CAS, and 1 providing data on both CEA and CAS) were included, describing 256,033 CEA and 38,605 CAS procedures. For CEA, decreased risk of procedural stroke or death for operations performed by vascular surgeons was found with pooled unadjusted relative risk (RR) of 0.63 (95% confidence interval [CI], 0.46-0.86; seven studies) compared with neurosurgeons and RR of 0.81 (95% CI, 0.66-0.99; six studies) compared with general surgeons. An increased risk of procedural stroke or death for operations performed by neurosurgeons compared with cardiothoracic surgeons was found with a pooled unadjusted RR of 1.22 (95% CI, 1.02-1.46). No studies adjusted for potential confounding, and no significant unadjusted associations were found in other comparisons of operator specialty for the primary outcome. For CAS, no differences in procedural stroke or death were found by operator specialty. CONCLUSIONS Studies were at high risk of bias mainly because of potential confounding by patient selection for CEA and CAS. Current evidence is insufficient to restrict CEA or CAS to specific specialties.
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Affiliation(s)
- Michiel H F Poorthuis
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Eelco C Brand
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Alison Halliday
- Nuffield Department of Surgical Sciences, Level 6 John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - Richard Bulbulia
- Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom; Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Michiel L Bots
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Gert J de Borst
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
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The Relationship between Hospital or Surgeon Volume and Outcomes in Lower Limb Vascular Surgery in the United Kingdom and Europe. Ann Vasc Surg 2017; 45:271-286. [DOI: 10.1016/j.avsg.2017.04.031] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 04/25/2017] [Indexed: 11/22/2022]
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3
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Austvoll-Dahlgren A, Underland V, Straumann GH, Forsetlund L. [Patient volume and quality in surgery for abdominal aortic aneurysm]. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2017; 137:529-537. [PMID: 28383226 DOI: 10.4045/tidsskr.16.0718] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Patient volume is assumed to affect quality, whereby complex procedures are best performed by those who perform them frequently. We have conducted a systematic review of the research on the association between patient volume and quality of vascular surgery. In this article we describe the outcomes for abdominal aortic aneurysm surgery.MATERIAL AND METHOD We undertook systematic searches in relevant databases. We searched for systematic reviews, and randomised and observational studies. The search was concluded in December 2015. We have summarised the results descriptively and assessed the overall quality of the evidence.RESULTS Forty-six observational studies fulfilled our inclusion criteria. We found a possible association for both hospital and surgeon volume. Higher patient volume may possibly be associated with lower 30-day mortality and lower hospital mortality for both open and endovascular surgery. Although the association appears to apply to both elective and acute hospitalisations, there is greater uncertainty with regard to the most ill patients. For hospital volume there may also be fewer complications for open and endovascular surgery, as well as for all surgery assessed as a whole. We considered the evidence base to be medium to very low quality.INTERPRETATION We found a possible correlation between patient volume and quality indicators such as mortality and complications. It may be advantageous to allocate planned procedures to institutions and surgeons with high volume, while this is less certain with regard to acute hospitalisations.
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Saratzis A, Thatcher A, Bath MF, Sidloff DA, Bown MJ, Shakespeare J, Sayers RD, Imray C. Reporting individual surgeon outcomes does not lead to risk aversion in abdominal aortic aneurysm surgery. Ann R Coll Surg Engl 2017; 99:161-165. [PMID: 28071950 DOI: 10.1308/rcsann.2017.0005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Reporting surgeons' outcomes has recently been introduced in the UK. This has the potential to result in surgeons becoming risk averse. The aim of this study was to investigate whether reporting outcomes for abdominal aortic aneurysm (AAA) surgery impacts on the number and risk profile (level of fitness) of patients offered elective treatment. METHODS Publically available National Vascular Registry data were used to compare the number of AAAs treated in those centres across the UK that reported outcomes for the periods 2008-2012, 2009-2013 and 2010-2014. Furthermore, the number and characteristics of patients referred for consideration of elective AAA repair at a single tertiary unit were analysed yearly between 2010 and 2014. Clinic, casualty and theatre event codes were searched to obtain all AAAs treated. The results of cardiopulmonary exercise testing (CPET) were assessed. RESULTS For the 85 centres that reported outcomes in all three five-year periods, the median number of AAAs treated per unit increased between the periods 2008-2012 and 2010-2014 from 192 to 214 per year (p=0.006). In the single centre cohort study, the proportion of patients offered elective AAA repair increased from 74% in 2009-2010 to 81% in 2013-2014, with a maximum of 84% in 2012-2013. The age, aneurysm size and CPET results (anaerobic threshold levels) for those eventually offered elective treatment did not differ significantly between 2010 and 2014. CONCLUSIONS The results do not support the assumption that reporting individual surgeon outcomes is associated with a risk averse strategy regarding patient selection in aneurysm surgery at present.
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Affiliation(s)
| | | | | | | | | | - J Shakespeare
- University Hospitals Coventry and Warwickshire NHS Trust , UK
| | | | - C Imray
- University Hospitals Coventry and Warwickshire NHS Trust , UK
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Goode SD, Keltie K, Burn J, Patrick H, Cleveland TJ, Campbell B, Gaines P, Sims AJ. Effect of procedure volume on outcomes after iliac artery angioplasty and stenting. Br J Surg 2013; 100:1189-96. [DOI: 10.1002/bjs.9199] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2013] [Indexed: 12/22/2022]
Abstract
Abstract
Background
Service reorganization to concentrate complex vascular services in hospitals with high caseload volume aims to reduce mortality and complication rates. The present study assessed the relationship between caseload volume and outcome for iliac artery angioplasty and stenting in England using a routinely available national data set (Hospital Episode Statistics, HES).
Methods
Routine administrative data for iliac artery angioplasty and stent procedures performed in England between 2007 and 2011 were analysed. Associations between centre volume and outcomes (death, complications and duration of hospital stay) were tested and compared for two methods of stratification (quartiles and quintiles) and two statistical tests (odds ratios and the Cochran–Armitage test for trend). Multivariable analysis was also performed.
Results
There were 23 308 episodes of care recorded in HES with Office of Population Censuses and Surveys Classification of Surgical Operations and Procedures, fourth revision, codes L54.1 or L54.4 corresponding to iliac artery intervention. There was a gradual increase year by year in number of procedures performed. Univariable and multivariable analysis showed no association between centre volume and either death or complications (multivariable odds ratio, OR 1·00, 95 per cent confidence interval 1·00 to 1·00) for elective and non-elective procedures. Age was associated with higher mortality and complication rates in elective procedures, and with mortality in non-elective procedures. The risk of death after elective iliac angioplasty or stenting was significantly higher in women (multivariable OR 4·98, 2·09 to 13·26).
Conclusion
There was no association between the outcomes of endovascular iliac artery intervention and centre volume, but outcomes were significantly worse with increasing age and female sex.
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Affiliation(s)
- S D Goode
- Sheffield Vascular Institute, Northern General Hospital, Sheffield, UK
- National Institute for Health and Care Excellence, London, UK
| | - K Keltie
- Medical Physics Department, Freeman Hospital, Newcastle Upon Tyne, UK
| | - J Burn
- Medical Physics Department, Freeman Hospital, Newcastle Upon Tyne, UK
| | - H Patrick
- National Institute for Health and Care Excellence, London, UK
| | - T J Cleveland
- Sheffield Vascular Institute, Northern General Hospital, Sheffield, UK
| | - B Campbell
- National Institute for Health and Care Excellence, London, UK
| | - P Gaines
- Sheffield Vascular Institute, Northern General Hospital, Sheffield, UK
| | - A J Sims
- Medical Physics Department, Freeman Hospital, Newcastle Upon Tyne, UK
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Grewal P, Davis M, Hamilton G. Provision of vascular surgery in England in 2012. Eur J Vasc Endovasc Surg 2013; 45:65-75. [DOI: 10.1016/j.ejvs.2012.10.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Accepted: 10/23/2012] [Indexed: 10/27/2022]
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Agha R. Towards national surgical surveillance in the UK--a pilot study. PLoS One 2012; 7:e47969. [PMID: 23239962 PMCID: PMC3519825 DOI: 10.1371/journal.pone.0047969] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2012] [Accepted: 09/24/2012] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE The Bristol heart inquiry in the United Kingdom (UK) highlighted the lack of standards for evaluating surgical performance and quality. In 2009, the World Health Organisation (WHO) proposed six standardised metrics for surgical surveillance. This is the first study to collect and analyse such metrics from a cohort of National Health Service (NHS) Trusts in England, helping to determine their feasibility and utility in measuring surgical performance, its impact on public health and mortality, and for tracking surgical trends over time. METHODS Freedom of Information Act 2000 (FOI) requests for WHO standardised surgical metrics were made to 36 NHS Trusts in England during July to November 2010. Additional data on Hospital Standardised Mortality Ratio (HSMR), Patient Safety Score and Abdominal Aortic Aneurysm (AAA) volume and mortality was obtained from Dr Foster Health and The Guardian Newspaper. Analysis was performed using mixed-effect logistic regression. RESULTS 30/36 trusts responded (83%). During 2005-9, 5.4 million operations were performed with a 24.2% increase in annual number of operations. This rising volume within hospitals was associated with lower mortality ratios. A 10% increase in operative volume was associated with a lower day of surgery death rate (DDR OR = 0.94, p = 0.056) and post-operative inpatient 30-day mortality (PDR30 OR = 0.93, p = 0.001). For every 10,000 more operations that an NHS Trust does, a 4% drop in PDR30 mortality was achieved. A 10% increase in the volume of elective AAAs was associated with lower elective AAA (OR = 0.96, p = 0.032) and emergency AAA (OR = 0.95, p = 0.009) PDR30 mortality. Lower DDR mortality was noted for emergency AAA mortality (OR = 0.95, p = 0.025) but not elective AAAs (OR = 0.97, p = 0.116). CONCLUSION Standarised surgical metrics can provide policy makers and commissioners with valuable summary data on surgical performance allowing for statistical process control of a complex intervention. This study has shown their collection is feasible albeit using FOI and the first to show a statistically significant volume-outcome relationship for surgery as a whole within hospitals. It adds weight to the argument that patients are safer in larger hospitals or those that become larger by growing their patient base. Together with other measures, such metrics can help build a picture of surgical surveillance in the UK and potentially lead us to safer surgery.
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Affiliation(s)
- Riaz Agha
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom.
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8
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Moxey PW, Hofman D, Hinchliffe RJ, Poloniecki J, Loftus IM, Thompson MM, Holt PJ. Volume–Outcome Relationships in Lower Extremity Arterial Bypass Surgery. Ann Surg 2012; 256:1102-7. [DOI: 10.1097/sla.0b013e31825f01d1] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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9
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Beggs AD, McGlone ER, Thomas PRS. Impact of centralisation on vascular surgical services. ACTA ACUST UNITED AC 2012. [DOI: 10.12968/bjhc.2012.18.9.468] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Andrew D Beggs
- Department of Surgery Epsom & St Helier Hospital NHS Trust
| | | | - Paul RS Thomas
- Department of Surgery Epsom & St Helier Hospital NHS Trust
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10
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Clough RE, Mani K, Lyons OT, Bell RE, Zayed HA, Waltham M, Carrell TW, Taylor PR. Endovascular treatment of acute aortic syndrome. J Vasc Surg 2011; 54:1580-7. [DOI: 10.1016/j.jvs.2011.07.034] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2011] [Revised: 06/16/2011] [Accepted: 07/01/2011] [Indexed: 11/25/2022]
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Johal A, Mitchell D, Lees T, Cromwell D, van der Meulen J. Use of Hospital Episode Statistics to investigate abdominal aortic aneurysm surgery. Br J Surg 2011; 99:66-72. [PMID: 22105834 DOI: 10.1002/bjs.7772] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2011] [Indexed: 01/17/2023]
Abstract
BACKGROUND A coding framework was evaluated to study patients undergoing open surgical replacement of an abdominal aortic aneurysm (AAA) in the English Hospital Episode Statistics (HES) database. The objective was to create groups of patients who are homogeneous with respect to diagnosis, prognosis and treatment. METHODS The frequency and consistency of potentially relevant diagnosis (International Classification of Diseases, 10th revision) and procedure (Office of Population Censuses and Surveys Classification, 4th revision) codes were assessed in patients admitted to English National Health Service hospitals between April 2003 and March 2008. Administrative codes were compared with diagnosis and procedure codes to check that patients who had undergone emergency surgery for a ruptured AAA were admitted as an emergency. RESULTS Of 20 290 patients undergoing AAA replacement, 19 250 (94·9 per cent) had a consistent diagnosis (unruptured or ruptured AAA); 79·3 per cent of patients with an emergency replacement were coded as having a ruptured AAA and 95·7 per cent of those with a non-emergency replacement as having an unruptured AAA. Of patients who had undergone emergency replacement of a ruptured AAA, 93·3 per cent were coded as having been admitted as an emergency. CONCLUSION Coding consistency was high. The proposed framework could define homogeneous groups by combining diagnosis, procedure and administrative codes. It also allows an assessment of potential miscoding at national and hospital level.
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Affiliation(s)
- A Johal
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
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12
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Holt PJE, Poloniecki JD, Thompson MM. Multicentre study of the quality of a large administrative data set and implications for comparing death rates. Br J Surg 2011; 99:58-65. [DOI: 10.1002/bjs.7680] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/08/2011] [Indexed: 11/06/2022]
Abstract
Abstract
Background
The aim was to compare the completeness and accuracy of the English Hospital Episode Statistics (HES) with a ‘gold standard’ data set for a sample of hospitals and to determine the effect of data quality on comparisons of hospital death rates.
Methods
A multicentre audit of data quality was undertaken, based on a sample of all elective abdominal aortic aneurysm (AAA) repairs performed in England. All elective AAA repairs in nine collaborating hospital trusts were included over a 2-year interval. Cases were identified from HES, local databases, hospital administration systems and theatre records. The main outcome measures were the numbers of cases and deaths according to HES compared with case-note review. The recording of co-morbidities and the effect of data accuracy on mortality analyses and risk adjustment were quantified.
Results
A total of 1102 elective AAA repairs were identified from HES data. Of 962 procedures with case-note review, 827 (86·0 per cent, 95 per cent confidence interval 84·0 to 88·0 per cent) were confirmed as elective AAA repair. The survival status with HES was 99·8 per cent accurate on comparison with the Office for National Statistics death registry. There was no significant difference in mortality assessment between the HES data and the ‘gold standard’ data set (5·3 versus 5·0 per cent; P = 0·753). Smaller hospitals were more affected by data inaccuracies than larger hospitals.
Conclusion
This study confirmed that HES data can be used effectively to compare mortality between hospitals. Administrative data will be used increasingly for assessing performance and clinicians should accept responsibility to improve coding. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.
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Affiliation(s)
- P J E Holt
- Department of Outcomes Research, St George's Vascular Institute, London, UK
| | - J D Poloniecki
- Department of Outcomes Research, St George's Vascular Institute, London, UK
- Population Health Sciences and Education, St George's University of London, London, UK
| | - M M Thompson
- Department of Outcomes Research, St George's Vascular Institute, London, UK
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Part One: All Major Arterial Interventions Should Now be Performed in High Volume Centres – Abdominal Aortic Aneurysms. Eur J Vasc Endovasc Surg 2011; 42:411-4. [DOI: 10.1016/j.ejvs.2011.07.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Part Two: The Case Against Centralisation of Abdominal Aortic Aneurysm Surgery in Higher Volume Centers. Eur J Vasc Endovasc Surg 2011; 42:414-7. [DOI: 10.1016/j.ejvs.2011.07.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Debate: Whether abdominal aortic aneurysm surgery should be centralized at higher-volume centers. J Vasc Surg 2011; 54:1208-14. [DOI: 10.1016/j.jvs.2011.07.064] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Fulop N, Walters R, Perri, Spurgeon P. Implementing changes to hospital services: factors influencing the process and 'results' of reconfiguration. Health Policy 2011; 104:128-35. [PMID: 21719140 DOI: 10.1016/j.healthpol.2011.05.015] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2011] [Revised: 05/10/2011] [Accepted: 05/30/2011] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Acute hospital reconfiguration is often presented as a problem to be solved by calculations of optimal design, a rational process amenable to influence by open and responsive consultation. We aimed to analyse factors in the process and 'results' of hospital reconfiguration in three case study sites in the English NHS. METHODS In-depth semi-structured interviews were conducted with internal and external stakeholders at each site. Analysis within each case was complemented by cross-case analysis focusing on the relationships between the features of the origins and process of reconfiguration and progress in the implementation of plans. FINDINGS We identified a number of inter-related factors operating in the process of implementation which influenced the 'results': the drivers for change, the reconfiguration, its content (particularly the extent to which services are withdrawn or made less accessible), the influence of stakeholders, such as local politicians, financial pressures, and the role of the management team. CONCLUSIONS We argue that the differences in reconfiguration implementation between the three cases reflected the nature of the proposed changes and local politics, rather than the strength of the 'evidence' for change. National policy has tended to over-emphasise the importance of consultation using 'evidence' and underplays these influencing factors.
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Affiliation(s)
- Naomi Fulop
- King's College London, Division of Health and Social Care Research, School of Medicine, London, United Kingdom.
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Medical tourism services available to residents of the United States. J Gen Intern Med 2011; 26:492-7. [PMID: 21161425 PMCID: PMC3077479 DOI: 10.1007/s11606-010-1582-8] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2009] [Revised: 10/26/2010] [Accepted: 11/02/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND There are growing reports of United States (US) residents traveling overseas for medical care, but empirical data about medical tourism are limited. OBJECTIVE To characterize the businesses and business practices of entities promoting medical tourism and the types and costs of procedures being offered. DESIGN, PARTICIPANTS, AND OUTCOMES: Between June and August 2008, we conducted a telephone survey of all businesses engaged in facilitating overseas medical travel for US residents. We collected information from each company including: the number of employees; number of patients referred overseas; medical records security processes; destinations to which patients were referred; treatments offered; treatment costs; and whether patient outcomes were collected. RESULTS We identified 63 medical tourism companies and 45 completed our survey (71%). Companies had a mean of 9.8 employees and had referred an average of 285 patients overseas (a total of approximately 13,500 patients). 35 (79%) companies reported requiring accreditation of foreign providers, 22 (50%) collected patient outcome data, but only 17 (39%) described formal medical records security policies. The most common destinations were India (23 companies, 55%), Costa Rica (14, 33%), and Thailand (12, 29%). The most common types of care included orthopedics (32 companies, 73%), cardiac care (23, 52%), and cosmetic surgery (29, 66%). 20 companies (44%) offered treatments not approved for use in the US--most commonly stem cell therapy. Average costs for common procedures, CABG ($18,600) and knee arthroplasty ($10,800), were similar to previous reports. CONCLUSIONS The number of Americans traveling overseas for medical care with assistance from medical tourism companies is relatively small. Attention to medical records security and patient outcomes is variable and cost-savings are dependent on US prices. That said, overseas medical care can be a reasonable alternative for price sensitive patients in need of relatively common, elective medical procedures.
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Karthikesalingam A, Hinchliffe RJ, Loftus IM, Thompson MM, Holt PJ. Volume-outcome relationships in vascular surgery: the current status. J Endovasc Ther 2010; 17:356-65. [PMID: 20557176 DOI: 10.1583/10-3035.1] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Vascular surgery has been widely practiced in hospitals within a general surgical service, although the consequent workload of individual vascular units has been small. There is an increasing body of evidence in favor of a positive relationship between hospital and surgeon volumes and the outcome of arterial surgery. These relationships suggest that vascular surgical procedures might be best placed within a centralized model of care to increase volume and thereby attain best outcomes. This systematic review appraises the current evidence for volume-outcome relationships in vascular surgery from a number of healthcare systems to examine the basis for centralization of vascular surgical services. The index procedures addressed in this review are open or endovascular repair of abdominal aortic aneurysm (AAA), ruptured AAA, descending thoracic aortic aneurysm, and thoracoabdominal aortic aneurysm, along with carotid endarterectomy and lower extremity arterial bypass.
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Affiliation(s)
- Alan Karthikesalingam
- Department of Outcomes Research, St George's Vascular Institute, St George's Healthcare NHS Trust, London, UK
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Karthikesalingam A, Hinchliffe RJ, Poloniecki JD, Loftus IM, Thompson MM, Holt PJE. Centralization harnessing volume-outcome relationships in vascular surgery and aortic aneurysm care should not focus solely on threshold operative caseload. Vasc Endovascular Surg 2010; 44:556-9. [PMID: 20675332 DOI: 10.1177/1538574410375130] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
There has been great interest in the setting of threshold operative volumes for safety to guide centralisation of vascular surgical services by healthcare commissioners. This editorial examines the evidence for designing services around a numeric safety threshold in the relationship between volume and outcome in vascular surgery. Thresholds should be aimed at the best outcomes and equity of care. Equity means access to the most up-to-date technology and all the relevant support services for elective and emergency cases. The relationship of volume and outcome with quality is complex, and demands a shift in focus to infrastructural and procedural improvements that drive high-quality services rather than the concentration of planning exclusively around an operative volume threshold.
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Affiliation(s)
- A Karthikesalingam
- Department of Outcomes Research, St George's Vascular Institute, Room 4.007, St George's Healthcare NHS Trust, London SW17 0QT, UK
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Awopetu AI, Moxey P, Hinchliffe RJ, Jones KG, Thompson MM, Holt PJE. Systematic review and meta-analysis of the relationship between hospital volume and outcome for lower limb arterial surgery. Br J Surg 2010; 97:797-803. [DOI: 10.1002/bjs.7089] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Abstract
Background
The aim was to investigate whether a relationship existed between case volume and outcome for lower limb vascular surgical procedures.
Methods
PubMed, Embase, the Cochrane Library and Google Scholar were searched for all articles on population-based studies on the volume–outcome relationship for lower limb vascular surgery at hospital level. Outcomes were mortality and subsequent amputation after lower limb vascular surgery. The data were subjected to meta-analysis by outcome.
Results
Some 452 093 patients from ten studies were included in the systematic review and five studies were included in meta-analyses. Seven of these articles found a significant positive hospital–volume outcome relationship. The pooled effect estimate for mortality was odds ratio (OR) 0·81 (95 per cent confidence interval 0·71 to 0·91) and that for amputation was OR 0·88 (0·79 to 0·98), with better results being found after surgery at higher-volume hospitals. Significant heterogeneity was seen in the data.
Conclusion
Higher-volume hospitals were associated with reduced amputation and mortality rates after lower limb vascular surgery. These data were not as conclusive as those for other vascular surgical procedures owing to significant heterogeneity.
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Affiliation(s)
- A I Awopetu
- Department of Outcomes Research, St George's Vascular Institute, St George's Healthcare NHS Trust, London SW17 0QT, UK
| | - P Moxey
- Department of Outcomes Research, St George's Vascular Institute, St George's Healthcare NHS Trust, London SW17 0QT, UK
| | - R J Hinchliffe
- Department of Outcomes Research, St George's Vascular Institute, St George's Healthcare NHS Trust, London SW17 0QT, UK
| | - K G Jones
- Department of Outcomes Research, St George's Vascular Institute, St George's Healthcare NHS Trust, London SW17 0QT, UK
| | - M M Thompson
- Department of Outcomes Research, St George's Vascular Institute, St George's Healthcare NHS Trust, London SW17 0QT, UK
| | - P J E Holt
- Department of Outcomes Research, St George's Vascular Institute, St George's Healthcare NHS Trust, London SW17 0QT, UK
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Holt PJE, Gogalniceanu P, Murray S, Poloniecki JD, Loftus IM, Thompson MM. Screened individuals' preferences in the delivery of abdominal aortic aneurysm repair. Br J Surg 2010; 97:504-10. [DOI: 10.1002/bjs.6939] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Abstract
Background
This study aimed to determine preferences for service attributes in a population screened for abdominal aortic aneurysm.
Methods
A questionnaire was designed to encompass various aspects of service provision. Questions were calibrated against the time an individual was willing to travel to access specific attributes. Subjects attending an aneurysm screening programme were asked to complete a questionnaire before their screening ultrasound scan. Statistical analysis was through pairwise analysis of the median travel times with the signed rank test. The Wilcoxon rank sum, analysed by the Kruskal–Wallis test, was used to compare preference ratings.
Results
A total of 262 individuals were asked to complete the questionnaire; the response rate was 98·5 per cent. Approximately 92 per cent of individuals stated a willingness to travel for at least 1 h beyond their nearest hospital in order to access services with a 5 per cent lower perioperative mortality rate, a 2 per cent lower amputation or stroke rate, a high annual caseload of aneurysm repairs, and routine availability of endovascular repair.
Conclusion
Patients attending aneurysm screening were willing to travel beyond their nearest hospital to access a service with better outcomes, higher surgical volumes and endovascular surgery.
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Affiliation(s)
- P J E Holt
- St George's Vascular Institute, St George's Healthcare NHS Trust, London, UK
| | - P Gogalniceanu
- St George's Vascular Institute, St George's Healthcare NHS Trust, London, UK
| | - S Murray
- St George's Vascular Institute, St George's Healthcare NHS Trust, London, UK
| | - J D Poloniecki
- Community Health Sciences, St George's, University of London, London, UK
| | - I M Loftus
- St George's Vascular Institute, St George's Healthcare NHS Trust, London, UK
| | - M M Thompson
- St George's Vascular Institute, St George's Healthcare NHS Trust, London, UK
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Holt PJE, Karthikesalingam A, Poloniecki JD, Hinchliffe RJ, Loftus IM, Thompson MM. Propensity scored analysis of outcomes after ruptured abdominal aortic aneurysm. Br J Surg 2010; 97:496-503. [DOI: 10.1002/bjs.6911] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Abstract
Background
This study examined the population outcome of ruptured abdominal aortic aneurysm (rAAA) in England, the role of endovascular repair (EVAR), and the relationship between outcome and hospital workload.
Methods
Data were retrieved from Hospital Episode Statistics between 1 April 2003 and 31 March 2008. Propensity scoring was used to compare the outcomes of stratified patients undergoing EVAR and open repair. The relationship between workload and outcome was determined.
Results
Some 3725 urgent and 4414 rAAA repairs were included. Mortality rates were 21·3 per cent for urgent repair and 46·3 per cent for rAAA repair. EVAR was employed for 16·3 and 7·6 per cent of urgent and rAAA repairs respectively. EVAR was associated with significantly reduced mortality for urgent repair (odds ratio (OR) 0·531, 95 per cent confidence interval 0·415 to 0·680; P < 0·001) and rAAA repair (OR 0·527, 0·416 to 0·668; P < 0·001). A propensity scored analysis confirmed the benefit of EVAR for rAAA repair (P < 0·001). Repair of rAAA at hospitals with a higher elective aneurysm workload was associated with lower mortality rates irrespective of the mode of treatment (P < 0·001). Higher-volume hospitals were more likely to operate on rAAA (P = 0·033).
Conclusion
EVAR offered a survival advantage over open repair for non-elective aneurysm procedures. Services for the treatment of rAAA should incorporate access to EVAR and would benefit from being based in units with a high elective caseload.
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Affiliation(s)
- P J E Holt
- Department of Outcomes Research, St George's Vascular Institute, London, UK
| | - A Karthikesalingam
- Department of Outcomes Research, St George's Vascular Institute, London, UK
| | - J D Poloniecki
- Community Health Sciences, St George's University of London, London, UK
| | - R J Hinchliffe
- Department of Outcomes Research, St George's Vascular Institute, London, UK
| | - I M Loftus
- Department of Outcomes Research, St George's Vascular Institute, London, UK
| | - M M Thompson
- Department of Outcomes Research, St George's Vascular Institute, London, UK
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Karthikesalingam A, Thompson MM, Holt PJE. The link between volume and outcome in endovascular aneurysm repair. Interv Cardiol 2010. [DOI: 10.2217/ica.09.142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Vogel TR, Dombrovskiy VY, Carson JL, Haser PB, Lowry SF, Graham AM. Infectious complications after elective vascular surgical procedures. J Vasc Surg 2010; 51:122-9; discussion 129-30. [DOI: 10.1016/j.jvs.2009.08.006] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2009] [Revised: 08/03/2009] [Accepted: 08/03/2009] [Indexed: 10/20/2022]
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25
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Holt PJ, Poloniecki JD, Khalid U, Hinchliffe RJ, Loftus IM, Thompson MM. Effect of Endovascular Aneurysm Repair on the Volume–Outcome Relationship in Aneurysm Repair. Circ Cardiovasc Qual Outcomes 2009; 2:624-32. [PMID: 20031901 DOI: 10.1161/circoutcomes.109.848465] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Peter J.E. Holt
- From the Department of Outcomes Research (P.J.E.H., U.K., R.J.H., I.M.L., M.M.T.), St George’s Vascular Institute, London; and Community Health Sciences (J.D.P.), St George’s University of London, United Kingdom
| | - Jan D. Poloniecki
- From the Department of Outcomes Research (P.J.E.H., U.K., R.J.H., I.M.L., M.M.T.), St George’s Vascular Institute, London; and Community Health Sciences (J.D.P.), St George’s University of London, United Kingdom
| | - Usman Khalid
- From the Department of Outcomes Research (P.J.E.H., U.K., R.J.H., I.M.L., M.M.T.), St George’s Vascular Institute, London; and Community Health Sciences (J.D.P.), St George’s University of London, United Kingdom
| | - Robert J. Hinchliffe
- From the Department of Outcomes Research (P.J.E.H., U.K., R.J.H., I.M.L., M.M.T.), St George’s Vascular Institute, London; and Community Health Sciences (J.D.P.), St George’s University of London, United Kingdom
| | - Ian M. Loftus
- From the Department of Outcomes Research (P.J.E.H., U.K., R.J.H., I.M.L., M.M.T.), St George’s Vascular Institute, London; and Community Health Sciences (J.D.P.), St George’s University of London, United Kingdom
| | - Matt M. Thompson
- From the Department of Outcomes Research (P.J.E.H., U.K., R.J.H., I.M.L., M.M.T.), St George’s Vascular Institute, London; and Community Health Sciences (J.D.P.), St George’s University of London, United Kingdom
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26
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Abstract
Change based on evidence
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Affiliation(s)
- T A Lees
- Audit and Research Committee, Vascular Society of Great Britain and Ireland, Freeman Hospital, High Heaton, Newcastle upon Tyne NE77DN, UK.
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