Volume-outcome relationships in vascular surgery: the current status

The impact of simulator training of vascular anastomosis and video assessment for surgical residents

INTRODUCTION

The rapid increase of minimally invasive surgery and the shortened training period for surgical residents has resulted in limited opportunities to acquire proficiency in open surgical techniques, such as vascular anastomosis. However, vascular anastomosis remains an essential skill in every surgery for bleeding control. This study aimed to validate the effectiveness of surgical education model for vascular anastomosis and assess the impact on the comprehension, skill, and confidence of surgical residents in performing vascular anastomosis.

METHODS

A total of 21 surgical residents with 1st to 3rd years of experience at Seoul National University Hospital participated in a four-week vascular anastomosis training program. The program included an educational lecture and the performance of an end-to-side anastomosis on a procedural model, with evaluations being conducted using the Objective Structured Assessment of Technical Skills (OSATS) and the End Product Rating Score (EPRS) in pre- and post-training surveys.

RESULTS

Significant improvement was observed in the OSATS score (from 9.22 ± 2.4 in week 1 to 12.87 ± 3.1 in week 4; P < 0.001) and the EPRS score (from 12.47 ± 4.1 in week 1 to 17.57 ± 2.2 in week 4; P < 0.001). Additionally, the surgical performance time significantly decreased from 20.99 ± 4.6 minutes to 16.33 ± 4.2 minutes (P = 0.019) CONCLUSIONS: Simulator training of in vitro vascular anastomosis, when accompanied by expert-led instruction, can effectively enhance the surgical proficiency, confidence, and overall surgical outcomes of residents, as inferred from the observed improvements in OSATS and EPRS scores. The results suggest that integration of this training model into surgical curricula could be a promising strategy for enhancing vascular surgical training.

The Impact of Travel Distance in Patient Outcomes Following Revascularization for Chronic Limb-Threatening Ischemia

INTRODUCTION

Patient travel distance to the hospital is a key metric of individual and social disadvantage and its impact on the management and outcomes following intervention for chronic limb-threatening ischemia is likely underestimated. We sought to evaluate the effect of travel distance on outcomes in patients undergoing first time lower extremity revascularization at our institution.

METHODS

We retrospectively reviewed all consecutive patients undergoing first-time lower extremity revascularization, both endovascular and open, for CLTI from 2005 to 2014. Patients were stratified into 2 groups based on travel distance from home to hospital greater than or less than 30 miles. Outcomes included reintervention, major amputation, restenosis, primary patency, wound healing, length of stay, length of follow-up and mortality. Kaplan-Meier estimates were used to determine event rates. Logistic and cox regression was used to evaluate for an independent association between travel distance and these outcomes.

RESULTS

Of the 1,293 patients were identified, 38% traveled more than 30 miles. Patients with longer travel distances were younger (70 vs 73 years, P=0.001), more likely to undergo open revascularization (65% vs 41%, P<0.001), and had similar WifI stages (P=0.404). Longer distance travelled was associated with an increase in total hospital length of stay (9.6 vs 8.6 days, P=0.031) and lower total length of post-operative follow-up (2.1 vs 3.0 years, P=0.001). At 5-years, there was no definitive difference in the rate of restenosis (HR 1.3[0.91-1.9, P=0.155) or reintervention (HR 1.4[0.96-2.1, P=0.065), but longer travel distance was associated with an increased rate of major amputation (HR 2.1[1.2-3.7], P=0.011), and death (HR 1.6[1.2-2.2], P=0.002). Longer travel distance was also associated with higher rate of non-healing wounds (HR 2.3[1.5-3.5], P=0.001).

CONCLUSIONS

Longer patient travel distance was found to be associated with a lower likelihood of limb salvage and survival in patients undergoing first-time lower extremity revascularization for chronic limb-threatening ischemia. Understanding and addressing the barriers to discharge, need for multidisciplinary follow-up, and appropriate post-operative wound care management will be key in improving outcomes at tertiary care regional specialty centers.

The Relationship Between Hospital Procedure Volume and Outcomes After Endovascular or Open Surgical Revascularisation for Peripheral Arterial Disease: An Analysis of Health Insurance Claims Data

OBJECTIVE

There is a paucity of data on the relationship between hospital procedure volume and outcomes after inpatient treatment of symptomatic peripheral arterial disease (PAD). This study aimed to generate meaningful hypotheses to support the ongoing discussion.

METHODS

Data derived from BARMER, Germany's second largest insurance provider, were linked with nationwide hospital procedure volumes from mandatory hospital quality reports. All endovascular (EVR) and open surgical revascularisations (OSR) provided to patients (≥ 40 years) with symptomatic PAD between 1 January 2013 and 31 December 2018 were included. Hospital volume was defined as the number of procedures performed by a hospital in the previous calendar year (in quartiles). Freedom from re-intervention, amputation, and overall mortality rate within 12 months after discharge were analysed using multivariable Cox proportional hazards models. In hospital mortality was determined by generalised estimating equations logistic regression models.

RESULTS

There were 88 187 revascularisations (72.4% EVR; EVR: 72.7 years and 45.2% females; OSR: 71.9 years and 41.9% females) registered by 668 hospitals. No statistically significant association was found between 12 month freedom from re-intervention and hospital volume (EVR: 4; quartile HR 1.05; 95% CI 0.94 - 1.16. OSR: 4; quartile HR 1.05; 95% CI 0.92 - 1.21). Patients with OSR had a decreased hazard of 12 month mortality in a high volume hospital compared with a low volume hospital (HR 0.85; 95% CI 0.73 - 0.98), but not with EVR (HR 1.03; 95% CI 0.91 - 1.16). Patients who were treated in hospitals with highest volumes showed decreased hazards of 12 month freedom from amputation when compared with low volume hospitals (EVR: HR 0.72; 95% CI 0.52 - 0.99. OSR: HR 0.61; 95% CI 0.44 - 0.85).

CONCLUSION

This large retrospective analysis of insurance claims suggests that higher procedure volume is associated with lower major amputation rates, although there is a need for standardisation of the definition of volume stratification. Future studies should address the impact of subsequent outpatient care and surveillance to further examine the complex interaction between treatment and outcomes.

Is there value in volume? An assessment of liver transplant practices in the United States since the inception of MELD

BACKGROUND

Liver transplantation has increased in volume and provides substantial survival benefit. However, there remains a need for value-based assessment of this costly procedure.

METHODS

Model for end stage liver disease era adult recipients were identified using United Network for Organ Sharing Standard Transplant Analysis file data (n = 75,988) and compared across time periods (period A: February 2002 to January 2007; B: February 2007 to January 2013; C: February 2013 to January 2019). Liver centers were divided into volume tertiles for each period (small, medium, large). Value for the index transplant episode was defined as percentage graft survival ≥1 year divided by mean posttransplant duration of stay.

RESULTS

All centers increased value over time due to ubiquitous improvement in 1-year graft survival. However, large centers demonstrated the most significant value change (large +17% vs small +7.0%, P < .001) due to a -8.5% reduction in large centers duration of stay from period A to C, while small centers duration of stay remained unchanged (-0.1%). Large centers delivered higher value despite more complex care: older recipients (54.8 ± 10.3 vs 53.0 ± 11.4 years P < .001), fewer model for end stage liver disease exceptions (34.0% vs 38.2%, P < .001), higher rates of candidate portal vein thrombosis (10.1% vs 8.5%, P < .001) and prior abdominal surgery (43.4% vs 37.4%, P < .001), and more marginal donor utilization (donor risk index 1.45 ± 0.38 vs 1.36 ± 0.33, P < .001). Mahalanobis metric matching demonstrated that compared with small centers, large centers progressively shortened recipient duration of stay per transplant in each period (A: -0.36 days, P = .437; B: -2.14 days, P < .001; C: -2.49 days, P < .001).

CONCLUSION

There is value in liver transplant volume. Adoption of value-based practices from large centers may allow optimization of health care delivery for this costly procedure.

Managing Vascular Trauma: Trauma Surgeons versus Vascular Surgeons

Objectives

Changes in vascular trauma care and trainee exposure to vascular surgery have raised questions regarding who should take care of vascular trauma patients. This study aimed to determine nationwide trends and perceptions regarding the management of vascular trauma amongst vascular and trauma surgeons.

Material and Methods

Online surveys were administered to trauma surgeons through the American Association for the Surgery of Trauma (AAST) and to vascular surgeons through the Vascular and Endovascular Surgery Society (VESS) and Western Vascular Society (WVS) in February 2021. Demographics, practice-related information, and interest in, experience and comfort level with vascular trauma were queried. Trainees and those practicing outside the United States were excluded. Results were analyzed using Stata/BE v16.1.

Results

247 surgeons were included in the final study population, of which 163 (66%) were trauma surgeons (T) and 84 (34%) were vascular surgeons (V). Vascular surgeons were younger (46 v 51y, P < .001) and had fewer years in practice (10 v 17y, P < .001). Vascular surgeons had greater experience and comfort with managing vascular trauma, but less interest in both vascular and endovascular trauma care when compared to trauma surgeons. Inability to maintain skillset (27%) and unfamiliarity with techniques (32%) were the most common barriers to practicing vascular trauma cited by trauma surgeons.

Discussion

Despite significant interest in practicing vascular trauma amongst trauma surgeons compared to vascular surgeons, most feel unprepared to do so. Collaboration between vascular and trauma surgeons could close the experience gap and appeal to the interests of both groups.

Centralization of pediatric surgical care in the Netherlands: Lessons learned

Centralization of care is a difficult process, as there are several stakeholders that are involved and should be heard. What can be the best option for a small group of patients may be detrimental to a larger group of patients that cannot be adequately treated close to home. The weighing of these factors is different in every environment. One universal rule however is: if you don't do it yourselves, others will do it for you. In the Netherlands, pediatric oncology, including surgery, is centralized in one center (Utrecht) with the help of several shared care centers scattered throughout the country for things that can be managed close to home.

Midterm outcomes of 455 patients receiving the AFX2 endovascular graft for the treatment of abdominal aortic aneurysm: A retrospective multi-center analysis

Since being introduced into clinical practice the AFX family of endografts has undergone labelling updates, design and manufacturing changes to address a Type III failure mode. The published literature on the performance of the current endograft-AFX2 -is limited to small series with limited follow up. The present study reports the largest series of patients implanted with AFX2 for the treatment of abdominal aortic aneurysms. The study was a retrospective, 5 center study of patients receiving an AFX2 endograft from January 2016 until Dec 2020. Electronic case report forms were provided to four of the centers, with one additional site providing relevant outcomes in an independent dataset. Relevant outcomes were reported via Kaplan-Meier analysis and included all-cause mortality, aneurysm-related mortality, post EVAR aortic rupture, open conversion, device related reinterventions and endoleaks. Among a cohort of 460 patients, 405 underwent elective repair of an AAA, 50 were treated for a ruptured AAA, and 5 were aorto-iliac occlusive disease cases. For the elective cohort (mean age 73.7y, 77% male, mean AAA diameter 5.4cm), the peri-operative mortality was 1.7%. Freedom from aneurysm-related mortality was 98.2% at 1,2,3 and 4 years post-operatively, there were no post-operative aortic ruptures, and 2 patients required open conversion. Freedom from Type Ia endoleaks was 99.4% at 1, 2, 3 and 4 years. Freedom from Type IIIa and Type IIIb endoleaks were 100% and 100% (year 1), 100% and 99.6% (year 2), 99.4% and 99.6% (year 3), 99.4% and 99.6% (year 4) respectively. Freedom from all device-related reintervention (including Type II endoleaks) at 4 y was 86.8%. The AFX2 endograft appears to perform to a satisfactory standard in terms of patient centric outcomes in mid-term follow up. The Type Ia and Type III endoleaks rates at 4y appear to be within acceptable limits. Further follow up studies are warranted.

Endovascular stent grafting and open surgical replacement for chronic thoracic aortic aneurysms: a systematic review and prospective cohort study

Background

The management of chronic thoracic aortic aneurysms includes conservative management, watchful waiting, endovascular stent grafting and open surgical replacement. The Effective Treatments for Thoracic Aortic Aneurysms (ETTAA) study investigates timing and intervention choice.

Objective

To describe pre- and post-intervention management of and outcomes for chronic thoracic aortic aneurysms.

Design

A systematic review of intervention effects; a Delphi study of 360 case scenarios based on aneurysm size, location, age, operative risk and connective tissue disorders; and a prospective cohort study of growth, clinical outcomes, costs and quality of life.

Setting

Thirty NHS vascular/cardiothoracic units.

Participants

Patients aged > 17 years who had existing or new aneurysms of ≥ 4 cm in diameter in the arch, descending or thoracoabdominal aorta.

Interventions

Endovascular stent grafting and open surgical replacement.

Main outcomes

Pre-intervention aneurysm growth, pre-/post-intervention survival, clinical events, readmissions and quality of life; and descriptive statistics for costs and quality-adjusted life-years over 12 months and value of information using a propensity score-matched subsample.

Results

The review identified five comparative cohort studies (endovascular stent grafting patients, n = 3955; open surgical replacement patients, n = 21,197). Pooled short-term all-cause mortality favoured endovascular stent grafting (odds ratio 0.71, 95% confidence interval 0.51 to 0.98; no heterogeneity). Data on survival beyond 30 days were mixed. Fewer short-term complications were reported with endovascular stent grafting. The Delphi study included 20 experts (13 centres). For patients with aneurysms of ≤ 6.0 cm in diameter, watchful waiting was preferred. For patients with aneurysms of > 6.0 cm, open surgical replacement was preferred in the arch, except for elderly or high-risk patients, and in the descending aorta if patients had connective tissue disorders. Otherwise endovascular stent grafting was preferred. Between 2014 and 2018, 886 patients were recruited (watchful waiting, n = 489; conservative management, n = 112; endovascular stent grafting, n = 150; open surgical replacement, n = 135). Pre-intervention death rate was 8.6% per patient-year; 49.6% of deaths were aneurysm related. Death rates were higher for women (hazard ratio 1.79, 95% confidence interval 1.25 to 2.57; p = 0.001) and older patients (age 61–70 years: hazard ratio 2.50, 95% confidence interval 0.76 to 5.43; age 71–80 years: hazard ratio 3.49, 95% confidence interval 1.26 to 9.66; age > 80 years: hazard ratio 7.01, 95% confidence interval 2.50 to 19.62; all compared with age < 60 years, p < 0.001) and per 1-cm increase in diameter (hazard ratio 1.90, 95% confidence interval 1.65 to 2.18; p = 0.001). The results were similar for aneurysm-related deaths. Decline per year in quality of life was greater for older patients (additional change –0.013 per decade increase in age, 95% confidence interval –0.019 to –0.007; p < 0.001) and smokers (additional change for ex-smokers compared with non-smokers 0.003, 95% confidence interval –0.026 to 0.032; additional change for current smokers compared with non-smokers –0.034, 95% confidence interval –0.057 to –0.01; p = 0.004). At the time of intervention, endovascular stent grafting patients were older (age difference 7.1 years; 95% confidence interval 4.7 to 9.5 years; p < 0.001) and more likely to be smokers (75.8% vs. 66.4%; p = 0.080), have valve disease (89.9% vs. 71.6%; p < 0.0001), have chronic obstructive pulmonary disease (21.3% vs. 13.3%; p = 0.087), be at New York Heart Association stage III/IV (22.3% vs. 16.0%; p = 0.217), have lower levels of haemoglobin (difference –6.8 g/l, 95% confidence interval –11.2 to –2.4 g/l; p = 0.003) and take statins (69.3% vs. 42.2%; p < 0.0001). Ten (6.7%) endovascular stent grafting and 15 (11.1%) open surgical replacement patients died within 30 days of the procedure (p = 0.2107). One-year overall survival was 82.5% (95% confidence interval 75.2% to 87.8%) after endovascular stent grafting and 79.3% (95% confidence interval 71.1% to 85.4%) after open surgical replacement. Variables affecting survival were aneurysm site, age, New York Heart Association stage and time waiting for procedure. For endovascular stent grafting, utility decreased slightly, by –0.017 (95% confidence interval –0.062 to 0.027), in the first 6 weeks. For open surgical replacement, there was a substantial decrease of –0.160 (95% confidence interval –0.199 to –0.121; p < 0.001) up to 6 weeks after the procedure. Over 12 months endovascular stent grafting was less costly, with higher quality-adjusted life-years. Formal economic analysis was unfeasible.

Limitations

The study was limited by small numbers of patients receiving interventions and because only 53% of patients were suitable for both interventions.

Conclusions

Small (4–6 cm) aneurysms require close observation. Larger (> 6 cm) aneurysms require intervention without delay. Endovascular stent grafting and open surgical replacement were successful for carefully selected patients, but cost comparisons were unfeasible. The choice of intervention is well established, but the timing of intervention remains challenging.

Future work

Further research should include an analysis of the risk factors for growth/rupture and long-term outcomes.

Trial registration

Current Controlled Trials ISRCTN04044627 and NCT02010892.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 6. See the NIHR Journals Library website for further project information.

Surgeon experience versus volume differentially affects lower extremity bypass outcomes in contemporary practice

BACKGROUND

Calls for minimum case thresholds to guide surgeon credentialing paradigms are increasing in contemporary practice. To date, the volume-outcome relationship and the role of surgeon experience as a proxy for quality have remained primarily focused on nonvascular extirpative surgery and aneurysm repair. However, it is unclear whether these data can be rightly extrapolated to predict lower extremity bypass (LEB) outcomes. Thus, the purpose of the present study was to examine whether the annualized case volume vs surgeon experience is more consequential in predicting for successful LEB reconstruction.

METHODS

A total of 25,852 procedures with sufficient 1-year follow-up data from the Society for Vascular Surgery Vascular Quality Initiative infrainguinal bypass registry (2003-2019) were reviewed for chronic limb threatening ischemia among patients undergoing infrageniculate reconstruction. The procedures were categorized according to surgeon years of practice experience at surgery (ie, 0-5, 6-10, 11-15, >15 years) and the number of LEB procedures performed by the surgeon during the year of surgery (volume quartiles: 1-8, 9-14, 15-21, and >21). Mixed effects logistic and Cox regression models were used to assess the effects of experience, volume, and their interaction on outcomes.

RESULTS

Increasing practice experience was more significantly associated with a reduction of in-hospital complications (odds ratio, 0.97; 95% confidence interval [CI], 0.96-0.99; P = .002) and the risk of major adverse limb events (odds ratio, 0.94; 95% CI, 0.92-0.97; P < .0001) compared with the volume. Increasing experience and volume were both associated with increased freedom from thrombosis (hazard ratio, 0.95; 95% CI, 0.93-0.98; P = .001). In contrast, neither experience nor volume had any significant association with early mortality. However, a higher volume was associated with diminished long-term survival (hazard ratio, 1.04; 95% CI, 1.0-1.1; P = .01). The most experienced surgeons (>15 years' experience) were significantly more likely to perform LEB for rest pain (P < .0001). No significant differences were found in the bypass rates among patients with tissue loss. The most experienced and highest volume surgeons were more likely to use an autogenous and/or composite conduit, in situ reconstruction, and/or pedal targets (P < .05). Similarly, more experienced and higher volume surgeons had less blood loss and shorter procedure times (P < .0001). Overall, the most experienced surgeons (>15 years' experience) were significantly more likely to have a higher volume with a diminished risk for all LEB outcomes.

CONCLUSIONS

Surgeon experience appears to have the most important role in predicting for overall LEB performance with improved in-hospital outcomes and major adverse limb events. The more experienced surgeons performed more complex reconstructions with fewer complications. These findings have significant clinical and educational implications as our most experienced surgeons approach retirement. Mentorship strategies to facilitate ongoing technical development among less experienced surgeons are imperative to sustain optimal limb salvage outcomes and have significant ramifications regarding expectations for regulatory and credentialing paradigms.

Acute aortic dissection type A: Impact of aortic specialists on short and long term outcomes

OBJECTIVES

Acute aortic dissection type-A (AADA) is a life threatening condition which requires emergency surgery. Surgery is usually performed by cardiac surgeons with various levels of aortic surgical experience. We compared the short-term perioperative outcome and long-term survival of patients operated by specialist aortic surgeons (SASs)and those who were operated by surgeons without specialist expertise.

METHODS

A single center retrospective review of 232 patients who underwent acute surgery for AADA was conducted between 2005 and 2020. The cohort was divided into those operated on by SASs (Group A, n = 186) and those operated on by nonaortic surgeons (Group B, n = 46). Statistical comparison was done using regression modelling and groups were propensity matched. Kaplan-Meier comparison was undertaken using STATA14.

RESULTS

Of 232 patients, 186 were operated on by an aortic specialist and 46 were operated by a nonaortic specialist. Overall 30-day mortality was 10% in Group A compared to 26.0% in Group B (unadjusted: p = .01, multivariate: p = .02, and propensity matched p = .05). Long-term mortality at 14 years was 26% in Group A compared to 52.0% in Group B (unadjusted: p = .001, multivariate: p = .001, and propensity matched: p = .01). Aortic surgeons performed a significantly higher number of aortic root procedures (43.0% vs. 17.3%, p = .001). The cross-clamp time and bypass time was significantly shorter in Group A patients (89 vs. 105 min, p < .01 and 153 vs. 185, p = < .001). Postoperative requirement for renal filtration was (19% vs. 37%, unadjusted p = .01, multivariate p = .03 and propensity matched p = .04). Although postoperative bleeding was less in Group A (4.0% vs. 11.0%, unadjusted p = .05) after propensity matching it was not statistically significant.

CONCLUSIONS

In patients with AADA, surgery performed by aortic specialist's results in improved outcomes. Aortic specialists replaced more of dissected aorta, resulting in an increased number of complex procedures, which may explain improved long-term survival after AADA in this cohort. This study adds further support in establishing a specialist aortic surgical service in cardiac centers.

Simulation Based Training and Assessment in Open Vascular Surgery: A Systematic Review

OBJECTIVE

The aim of this study was to systematically review the literature and give evidence based recommendations for future initiatives for simulation based training (SBT) and assessment in open vascular surgery.

DATA SOURCES

PubMed, Embase, and the Cochrane Library.

REVIEW METHODS

A systematic review of PubMed, Embase, and the Cochrane Library was performed, with the last search on 31 March 2020, to identify studies describing SBT and assessment in open vascular surgery. Kirkpatrick's levels for efficacy of training were evaluated. Validity evidence for assessment tools was evaluated according to the recommended contemporary framework by Messick.

RESULTS

Of 2 844 studies, 51 were included for data extraction. A high degree of heterogeneity in reporting standards and varying types of simulation was found. Vascular anastomosis was the most frequently simulated technical skill (43%). Assessment was mostly carried out using the Objective Structured Assessment of Technical Skills (55%). Validity evidence for assessment tools was found using outdated frameworks, and only one study used Messick's framework. Self directed training is valuable, the low trainer to trainee ratio is important to maximise efficiency, and experienced vascular surgeons are the most effective trainers.

CONCLUSION

Carefully designed and structured SBT is effective and can improve technical skills, especially in less experienced trainees. However, the supporting evidence lacks homogeneity in the reporting standards and types of simulations. Pass/fail standards that support proficiency based learning and studies investigating skills transfer should be the focus in future studies. Validity evidence of assessment tools needs to be addressed using contemporary frameworks.

The Effects of Minimum Caseload Requirements on Management and Outcome in Abdominal Aortic Aneurysm Repair

BACKGROUND

The German quality assurance guideline on abdominal aortic aneurysm (AAA) was implemented by the Joint Federal Committee (Gemeinsamer Bundesausschuss, G-BA) in 2008. The aims of this study were to verify the association between hospital case volume and outcome and to assess the hypothetical effect of minimum caseload requirements.

METHODS

The German diagnosis-related groups statistics for the years 2012 to 2016 were scrutinized for AAA (ICD-10 GM I71.3/4) with procedure codes for endo - vascular or open surgical treatment. The primary endpoint was in-hospital mortality. Logistic regression models were used for risk adjustment, and odds ratios (OR) were calculated as a function of the annual hospital-level case volume of AAA. In a hypo - thetical approach, the linear distances for various minimum caseloads (MC) were evaluated to assess accessibility.

RESULTS

The mortality of intact AAA (iAAA) was 2.7% (men [M] 2.4%, women [W] 4.2%); ruptured AAA (rAAA), 36.9% (M 36.9%, F 37.5%). An inverse relationship between annual hospital case volume of AAA and mortality was confirmed (iAAA/rAAA: from 3.9%/51% [<10 cases/year] through 3.3%/37% [30-39 cases/year] to 1.9%/28% [≥ 75 cases/year]). For a reference category of 30 AAA procedures/year, the following significant OR were found: 10 AAA cases/year, OR 1.21 (95% confidence interval [1.20; 1.21]); 20 cases, OR 1.09 [1.09; 1.09]; 50 cases, OR 0.89 [0.89; 0.89]; 75 cases, OR 0.82 [0.82; 0.82]. In a hypothetical centralization scenario with assumed MC of 30/year, 86% of the population would have to travel less than 100 km to the nearest hospital; with an MC of 40, this would apply to only 50% (without redistribution effects).

CONCLUSION

In the observed period, a significant correlation was confirmed between high annual case volume and low in-hospital mortality. A minimum caseload requirement of 30 AAA operations/year seems reasonable in view of the accessibility of hospitals. Cite this.

Vascular surgery: taking the next steps toward autonomy

The recognition of vascular surgery as an independent surgical specialty is inevitable, but the pathway to full autonomy remains uncertain. Vascular surgery emerged from general surgery in the mid-1950s with the advent of synthetic grafts and microvascular techniques. By the early 1980s, Accreditation Council for Graduate Medical Education-approved fellowships were established in most large academic medical centers. The American Board of Surgery recognized this additional specialty training by awarding vascular graduates a Certificate of Special Qualifications distinguishing them from general surgeons. The emergence of endovascular surgery radically changed the face of vascular surgery from a general surgery subspecialty to a unique surgical specialty with a growing array of minimally invasive tools. With the establishment of a primary Certificate in Vascular Surgery and the subsequent development of integrated residencies, vascular surgery moved ever closer to recognition as an independent surgical specialty. Despite the remarkable progress that has been observed over the past 50 years, there is a desire in the vascular community for formal recognition of the unique body of knowledge and surgical skills that serve as the foundation of contemporary vascular care.

Unplanned 30-day readmissions after endovascular aneurysm repair: An analysis using the Nationwide Readmissions Database

BACKGROUND

Endovascular aneurysm repair (EVAR) is the preferred method for addressing abdominal aortic aneurysms (AAAs), with proven reduction in perioperative morbidity and mortality. There are, however limited data examining the readmissions after EVAR that are associated with increased patient morbidity and cost. As EVAR use continues its dominance in the management of AAAs, it becomes imperative to identify and mitigate risk factors associated with unplanned hospital readmissions.

METHODS

The Nationwide Readmissions Database (NRD) was queried for all 30-day readmissions after an index EVAR procedure from 2012 to 2014. Preoperative patient demographics, hospital characteristics, readmission diagnosis, and costs were compared between those who were and were not readmitted within 30 days of the index operation. Multivariable logistic regression was used to identify potential risk factors associated with unplanned readmissions within 30 days.

RESULTS

We identified 120,646 patients who underwent an EVAR from 2012 to 2014 in the United States. The overall unplanned readmission rate during this period was 11.6% (n = 14,073) within 30 days of the index EVAR procedure. The readmission rate was the highest in 2012, with a rate of 12.3% (P = .02). Multivariate regression analysis showed that EVAR readmissions were significantly higher in patients who were of younger age (18 to 49 years) compared with other age groups (odds ratio [OR], 1.9-2.17; P < .001), female sex (OR, 1.367; P < .001), had Medicare (OR, 1.39) or Medicaid (OR, 1.25) insurance, or a combination of these. Underlying patient comorbidities significantly associated with readmissions included congestive heart failure (OR, 2.4), peripheral vascular disease (OR, 1.1), chronic pulmonary disease (OR, 1.2), cancer with no metastasis (OR, 1.5), metastatic cancer (OR, 2.2), renal failure (OR, 1.8), and diabetes (OR, 1.5).

CONCLUSIONS

The trend in 30-day readmission rates after EVAR has decreased slightly since 2012, but overall rates are at 11.6%, which is not insubstantial. Patient factors strongly associated with hospital readmission were younger age and patient comorbidities, including congestive heart failure, concurrent cancer diagnosis, renal failure, and diabetes.

Use of an Assistant Surgeon Does not Mitigate the Effect of Lead Surgeon Volume on Outcomes Following Open Repair of Intact Abdominal Aortic Aneurysms

OBJECTIVE/BACKGROUND

While higher lead surgeon volume has been associated with lower mortality following open abdominal aortic aneurysm (AAA) repair, little is known about the impact of using an attending surgeon as assistant surgeon. The aim of this study was to determine whether the presence of an assistant surgeon, particularly a high volume assistant, mitigates the relationship between lead surgeon volume and outcomes.

METHODS

All Medicare beneficiaries who underwent intact, open AAA repair between 2003 and 2008 were evaluated and nested regression models were constructed to evaluate the relationship between surgeon and assistant volume and peri-operative mortality, adjusting for comorbid conditions and hospital volume.

RESULTS

In total 28,590 repairs were studied, of which 19,284 (67.5%) were performed by a single surgeon and 9306 (32.5%) included an assistant surgeon. Of cases with an assistant, 12.3% included a high volume assistant surgeon. Lower volume surgeons more frequently used an assistant (lead surgeon Q1 volume: 40%; Q2: 36%; Q3: 34%; Q4: 29%; Q5: 27% [p < .01]). In cases with no assistant, adjusted peri-operative mortality varied monotonically with surgeon volume (Q1: 4.7%; Q2: 4.4%; Q3: 4.1%; Q4: 3.3%; Q5: 3.2%). However, the use of a high or a low volume assistant surgeon, compared with no attending surgeon as assistant, was not associated with lower peri-operative mortality in any lead surgeon volume quintile, even among those operations performed by the lowest volume lead surgeons.

CONCLUSION

Employing an assistant surgeon does not improve outcomes amongst any quintile of volume of the lead surgeon. As surgeons perform fewer open AAA repairs in the modern era, these data imply that even the help of a high volume assistant surgeon may not mitigate the detrimental effect of a lower volume surgeon.

Comparative analysis of the outcomes of elective abdominal aortic aneurysm repair in England and Sweden

Background

There is substantial international variation in mortality after abdominal aortic aneurysm (AAA) repair; many non‐operative factors influence risk‐adjusted outcomes. This study compared 90‐day and 5‐year mortality for patients undergoing elective AAA repair in England and Sweden.

Methods

Patients were identified from English Hospital Episode Statistics and the Swedish Vascular Registry between 2003 and 2012. Ninety‐day mortality and 5‐year survival were compared after adjustment for age and sex. Separate within‐country analyses were performed to examine the impact of co‐morbidity, hospital teaching status and hospital annual caseload.

Results

The study included 36 249 patients who had AAA treatment in England, with a median age of 74 (i.q.r. 69–79) years, of whom 87·2 per cent were men. There were 7806 patients treated for AAA in Sweden, with a median of age 73 (68–78) years, of whom 82·9 per cent were men. Ninety‐day mortality rates were poorer in England than in Sweden (5·0 versus 3·9 per cent respectively; P < 0·001), but were not significantly different after 2007. Five‐year survival was poorer in England (70·5 versus 72·8 per cent; P < 0·001). Use of EVAR was initially lower in England, but surpassed that in Sweden after 2010. In both countries, poor outcome was associated with increased age. In England, institutions with higher operative annual volume had lower mortality rates.

Conclusion

Mortality for elective AAA repair was initially poorer in England than Sweden, but improved over time alongside greater uptake of EVAR, and now there is no difference. Centres performing a greater proportion of EVAR procedures achieved better results in England.

Improving in England

The effect of negative randomized trials and surgeon volume on the rates of arthroscopy for patients with knee OA

Publication of 2 (negative) randomized clinical trials (RCTs) in 2002 and 2008 demonstrating inefficacy of arthroscopic debridement of the knee (ADK) for osteoarthritis, and a 2004 national non-coverage Medicare determination, have decreased overall ADK utilization. However, because of potentially favorable outcomes associated with high volume, surgeons performing high arthroscopy volume may be slower to abandon performing ADK than would low volume surgeons. We examined the trends in ADKs performed by high and low volume surgeons before and after these 2 trials and the Medicare determination. New York state residents 40 years and older undergoing outpatient ADK from 1997 to 2010 were identified from a statewide database, and monthly population-based age and sex-adjusted ADK rates were calculated. We estimated the change in utilization trends over time, stratified by surgeon annual arthroscopy volume, for Medicare and non-Medicare patients. 1386 surgeons performed 29,658 ADKs during the study period, with the proportion performed by high volume surgeons increasing from 22% in 1997 to 66% in 2010. Overall monthly ADK rates declined from 2.4 to 1.3 per 100,000 population (45%) over the study period. Rates of ADK performed by high volume surgeons increased after the first RCT in the non-Medicare population and after the CMS decision in the Medicare population, and decreased after the second RCT. With more definitive evidence from the second negative trial, high volume surgeons performed less ADKs, suggesting that multiple RCTs with consistently negative results are needed to change practice of high volume surgeons.

Surgeons' Perceptions of the Causes of Preventable Harm in Arterial Surgery: A Mixed-Methods Study

BACKGROUND

System factors contributing to preventable harm in vascular patients have not been previously reported in detail. The aim of this exploratory mixed-methods study was to describe vascular surgeons' perceptions of factors contributing to adverse events (AEs) in arterial surgery. A secondary aim was to report recommendations to improve patient safety.

METHODS

Vascular consultants/registrars working in the British National Health Service were questioned about the causes of preventable AEs through survey and semi-structured interview (response rates 77% and 83%, respectively). Survey respondents considered a recent AE, indicating on a 5 point Likert scale the extent to which various factors from a validated framework contributed toward the incident. Semi-structured interviews were conducted to obtain detailed accounts of contributory factors, and to elicit recommendations to improve safety.

RESULTS

Seventy-seven surgeons completed the survey on 77 separate AEs occurring during open surgery (n = 41) and in endovascular procedures (n = 36). Ten interviewees described 15 AEs. The causes of AEs were multifactorial (median number of factors/AE = 5, IQR 3-9, range 0-25). Factors frequently reported by survey respondents were communication failures (36.4%; n = 28/77); inadequate staffing levels/skill mix (32.5%; n = 25/77); lack of knowledge/skill (37.3%; n = 28/75). Themes emerging from interviews were team factors (communication failure, lack of team continuity, lack of clarity over roles/responsibilities); work environment factors (poor staffing levels, equipment problems, distractions); inadequate training/supervision. Knowledge/skill (p = .034) and competence (p = .018) appeared to be more prominent in causing AEs in open procedures compared with endovascular procedures; organisational structure was more frequently implicated in AEs occurring in endovascular procedures (p = .017). To improve safety, interviewees proposed team training programmes (5/10 interviewees); additional protocols/checklists (4/10); improved escalation procedures (3/10).

CONCLUSION

Vascular surgeons believe that AEs in arterial operations are caused by multiple, modifiable system factors. Larger studies are needed to establish the relative importance of these factors and to determine strategies that can effectively address system failures.

Surgeon, not institution, case volume is associated with limb outcomes after lower extremity bypass for critical limb ischemia in the Vascular Quality Initiative

OBJECTIVE

Studies from large administrative databases have demonstrated associations between institutional case volume and outcomes after lower extremity bypass (LEB). We hypothesized that increased institutional and surgeon volume would be associated with improved outcomes after LEB. Using a national, prospectively collected clinical database, the objective of this study was to determine the effects of both surgeon and institutional volume on outcomes after LEB.

METHODS

The Vascular Quality Initiative (VQI) was queried to identify all LEBs for critical limb ischemia or claudication between 2004 and 2014. Average annual case volume was calculated by dividing an institution's or surgeon's total LEB volume by the number of years they reported to the VQI. Institutional and surgeon volumes were analyzed as continuous variables to determine the impact of volume on major adverse cardiac events (MACEs), major adverse limb events (MALEs), graft patency, and amputation-free survival. Hierarchical regression models were used with cases clustered by surgeon and center. Time-dependent outcomes were evaluated with multivariable shared frailty Cox proportional hazards models.

RESULTS

From 2004 to 2014, there were 14,678 LEB operations performed at 114 institutions by 587 surgeons. Average annual institutional volume ranged from 1.0 to 137.5 LEBs per year, with a median of 26.9 (interquartile range, 14-45.3). Average annual surgeon volume ranged from 1 to 52 LEBs per year with a median of 5.7 (interquartile range, 2.5-9.3). Institutional LEB volume was not associated with MACEs or MALEs or with loss of patency. However, average annual surgeon volume was independently associated with reduced MALEs and improved primary patency. Institutional and surgeon volume did not predict MACEs.

CONCLUSIONS

In contradistinction to previous studies, there was no relationship in this study between institutional LEB volume and outcomes after LEB. However, greater average annual surgeon volume was associated with improved primary patency and decreased risk of MALEs. Open LEB remains a safe and effective procedure for limb salvage. Limb-related outcomes in critical limb ischemia and claudication will be optimized if surgeons maintain adequate volume of LEB.

The Impact of System Factors on Quality and Safety in Arterial Surgery: A Systematic Review

OBJECTIVE

A systems approach to patient safety proposes that a wide range of factors contribute to surgical outcome, yet the impact of team, work environment, and organisational factors, is not fully understood in arterial surgery. The aim of this systematic review is to summarize and discuss what is already known about the impact of system factors on quality and safety in arterial surgery.

DATA SOURCES

A systematic review of original research papers in English using MEDLINE, Embase, PsycINFO, and Cochrane databases, was performed according to PRISMA guidelines.

REVIEW METHODS

Independent reviewers selected papers according to strict inclusion and exclusion criteria, and using predefined data fields, extracted relevant data on team, work environment, and organisational factors, and measures of quality and/or safety, in arterial procedures.

RESULTS

Twelve papers met the selection criteria. Study endpoints were not consistent between papers, and most failed to report their clinical significance. A variety of tools were used to measure team skills in five papers; only one paper measured the relationship between team factors and patient outcomes. Two papers reported that equipment failures were common and had a significant impact on operating room efficiency. The influence of hospital characteristics on failure-to-rescue rates was tested in one large study, although their conclusions were limited to the American Medicare population. Five papers implemented changes in the patient pathway, but most studies failed to account for potential confounding variables.

CONCLUSIONS

A small number of heterogenous studies have evaluated the relationship between system factors and quality or safety in arterial surgery. There is some evidence of an association between system factors and patient outcomes, but there is more work to be done to fully understand this relationship. Future research would benefit from consistency in definitions, the use of validated assessment tools, measurement of clinically relevant endpoints, and adherence to national reporting guidelines.

[Patient volume and quality in surgery for abdominal aortic aneurysm]

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.

Unwarranted Variation in the Quality of Care for Patients With Diseases of the Thoracic Aorta

BACKGROUND

Thoracic aortic disease has a high mortality. We sought to establish the contribution of unwarranted variation in care to regional differences in outcomes observed in patients with thoracic aortic disease in England.

METHODS AND RESULTS

Data from the Hospital Episode Statistics (HES) and the National Adult Cardiac Surgery Audit (NACSA) were extracted. A parallel systematic review/meta-analysis through December 2015, and structure and process questionnaire of English cardiac surgery units were also accomplished. Treatment and mortality rates were investigated. A total of 24 548 adult patients in the HES study, 8058 in the NACSA study, and 103 543 from a total of 33 studies in the systematic review were obtained. Treatment rates for thoracic aortic disease within 6 months of index admission ranged from 7.6% to 31.5% between English counties. Risk-adjusted 6-month mortality in untreated patients ranged from 19.4% to 36.3%. Regional variation persisted after adjustment for disease or patient factors. Regional cardiac units with higher case volumes treated more-complex patients and had significantly lower risk-adjusted mortality relative to low-volume units. The results of the systematic review indicated that the delivery of care by multidisciplinary teams in high-volume units resulted in better outcomes. The observational analyses and the online survey indicated that this is not how services are configured in most units in England.

CONCLUSIONS

Changes in the organization of services that address unwarranted variation in the provision of care for patients with thoracic aortic disease in England may result in more-equitable access to treatment and improved outcomes.

Characterizing the role of a high-volume cancer resection ecosystem on low-volume, high-quality surgical care

BACKGROUND

Our objective was to determine the hospital resources required for low-volume, high-quality care at high-volume cancer resection centers.

METHODS

Patients who underwent esophageal, pancreatic, and rectal resection for malignancy were identified using Healthcare Cost and Utilization Project State Inpatient Database (Florida and California) between 2007 and 2011. Annual case volume by procedure was used to identify high- and low-volume centers. Hospital data were obtained from the American Hospital Association Annual Survey Database. Procedure risk-adjusted mortality was calculated for each hospital using multilevel, mixed-effects models.

RESULTS

A total of 24,784 patients from 302 hospitals met the inclusion criteria. Of these, 13 hospitals were classified as having a high-volume, oncologic resection ecosystem by being a high-volume hospital for ≥2 studied procedures. A total of 11 of 31 studied hospital factors were strongly associated with hospitals that performed a high volume of cancer resections and were used to develop the High Volume Ecosystem for Oncologic Resections (HIVE-OR) score. At low-volume centers, increasing HIVE-OR score resulted in decreased mortality for rectal cancer resection (P = .038). HIVE-OR was not related to risk-adjusted mortality for esophagectomy (P = .421) or pancreatectomy (P = .413) at low-volume centers.

CONCLUSION

Our study found that in some settings, low-volume, high-quality cancer surgical care can be explained by having a high-volume ecosystem.

Repair of type A dissection-benefits of dissection rota

BACKGROUND

Acute type A aortic dissection repair is a surgical emergency associated with high mortality. In 2007, Liverpool Heart & Chest Hospital was the first institution in the United Kingdom to implement a thoracic aortic on-call dissection rota. We set out to investigate whether the dissection rota improved hospital quality outcomes and long-term survival.

METHODS

Data from a prospectively collected database was analysed following case note validation. Two hundred patients underwent acute type A aortic dissection repair between October 1998 and November 2015. To assess the effect of the post-dissection rota on operative and postoperative outcomes, propensity matching of pre- and post-dissection rota patients was used.

RESULTS

Eighty patients were identified from the pre-dissection rota era and 120 from the post-dissection rota era. Sixty patients from each era were then propensity matched. Comparative analyses showed that patients who underwent acute type A dissection repair in the post-dissection rota period were less likely to suffer in-hospital mortality in both the matched and unmatched groups (30% vs. 13.3%; P=0.004 and 28.3% vs. 11.7%; P=0.055, respectively). A similar improvement was shown in acute renal failure (26.3% vs. 14.2%; P=0.033 and 31.7% vs. 15.0%; P=0.044, respectively). However, cardiopulmonary bypass times and aortic cross clamp times were still significantly longer in the matched post-dissection rota cohort. There was a significant improvement in 5-year survival for the pre- and post-dissection rota in both the matched and unmatched patients (P=0.004 and P=0.034).

CONCLUSIONS

Reorganization of surgical expertise, activity and implementation of a dissection rota within our hospital have resulted in lower in-hospital mortality and better survival outcomes in this group of patients.

Current treatment strategies for ruptured abdominal aortic aneurysm

BACKGROUND

Ruptured abdominal aortic aneurysm (rAAA) represents one of the most challenging emergencies in surgery. Open repair (OR) is associated with relevant morbidity and mortality and has not been reduced significantly over the last decade. The introduction of endovascular aneurysm repair (EVAR) and its meanwhile common use in the treatment of rAAA has raised the demand for randomised controlled trials (RCTs) in order to resolve a potential superiority of either OR or EVAR.

PURPOSE

This review discusses the current treatment strategies in rAAA repair including diagnostics, peri-operative management and results of OR and EVAR, focussing on RCTs comparing both modalities.

RESULTS

Thirty-day mortality after OR and EVAR shows no significant difference in published RCTs. In particular with respect to OR, 30-day mortality was much lower than anticipated throughout all RCTs ranging from 18 to 37 %. EVAR for rAAA resulted in reduced in-hospital stay. Limitations of all except one RCT are low patient recruitment and exclusion of haemodynamically unstable patients.

CONCLUSIONS

OR and EVAR need to be provided for rAAA. Despite lacking evidence, EVAR is the first choice treatment in experienced high-volume vascular centres. Low mortality rates in all RCTs raise the question if aortic surgery should be centralised.

Predicted shortage of vascular surgeons in the United Kingdom: A matter for debate?

BACKGROUND

Vascular surgery became a new independent surgical specialty in the United Kingdom (UK) in 2013. In this matter for debate we discuss the question, is there a "shortage of vascular surgeons in the United Kingdom?"

MATERIALS AND METHODS

We used data derived from the "Vascular Surgery United Kingdom Workforce Survey 2014", NHS Employers Electronic Staff Records (ESR), and the National Vascular Registry (NVR) surgeon-level public report to estimate current and predict future workforce requirements.

RESULTS

We estimate there are approximately 458 Consultant Vascular Surgeons for the current UK population of 63 million, or 1 per 137,000 population. In several UK Regions there are a large number of relatively small teams (3 or less) of vascular surgeons working in separate NHS Trusts in close geographical proximity. In developed countries, both the number and complexity of vascular surgery procedures (open and endovascular) per capita population is increasing, and concerns have been raised that demand cannot be met without a significant expansion in numbers of vascular surgeons. Additional workforce demand arises from the impact of population growth and changes in surgical work-patterns with respect to gender, working-life-balance and 7-day services.

CONCLUSIONS

We predict a future shortage of Consultant Vascular Surgeons in the UK and recommend an increase in training numbers and an expansion in the UK Consultant Vascular Surgeon workforce to accommodate population growth, facilitate changes in work-patterns and to create safe sustainable services.

Minimum volume standards in German hospitals: do they get along with procedure centralization? A retrospective longitudinal data analysis

BACKGROUND

Compliance with minimum volume standards for specific procedures serves as a criterion for high-quality patient care. International experiences report a centralization of the respective procedures. In Germany, minimum volume standards for hospitals were introduced in 2004 for 5 procedures (complex esophageal and pancreatic interventions; liver, kidney and stem cell transplantations), in 2006 total knee replacement was added. This study explores whether any centralization is discernible for these procedures in Germany.

METHODS

A retrospective longitudinal analysis of secondary data serves to determine a possible centralization of procedures from the system perspective. Centralization means that over time, fewer hospitals perform the respective procedure, the case volume in high-volume hospitals increases together with their percentage of the annual total case volume, and the case volume in low-volume hospitals decreases together with their percentage of the annual total case volume. Using data from the mandatory hospital quality reports for the years 2006, 2008 and 2010 we performed Kruskal Wallis and chi-square tests to evaluate potential centralization effects.

RESULTS

No centralization was found for any of the six types of interventions over the period from 2006 to 2010. The annual case volume and the number of hospitals performing interventions rose at differing rates over the 5-year period depending on the type of intervention. Seven percent of esophagectomies and 14% of pancreatectomies are still performed in hospitals with less than 10 interventions per year.

CONCLUSIONS

For the purpose of further centralization of interventions it will be necessary to first analyze and then appropriately address the reasons for non-compliance from the hospital and patient perspective.

Standards for heart valve surgery in a 'Heart Valve Centre of Excellence'

Surgical centres of excellence should include multidisciplinary teams with specialist expertise in imaging, clinical assessment and surgery for patients with heart valve disease. There should be structured training programmes for the staff involved in the periprocedural care of the patient and these should be overseen by national or international professional societies. Good results are usually associated with high individual and centre volumes, but this relationship is complex. Results of surgery should be published by centre and should include rates of residual regurgitation for mitral repairs and reoperation rates matched to the preoperative pathology and risk.

Misdiagnosis of ruptured abdominal aortic aneurysm: systematic review and meta-analysis

PURPOSE

To quantitatively summarize the incidence of misdiagnosis of ruptured abdominal aortic aneurysms (rAAA), the most common presenting features, and the commonest incorrect differential diagnoses.

METHODS

A systematic search according to PRISMA guidelines was performed using EMBASE and MEDLINE databases to identify studies reporting the initial rate of misdiagnosis of patients with rAAA. Random-effects meta-analyses were performed to estimate the rate of misdiagnosis, presenting features, and commonest differential diagnoses. A sensitivity analysis was performed for studies reporting after 1990.

RESULTS

Nine studies comprising 1109 patients contributed to the pooled analysis, which found a 42% incidence of rAAA misdiagnosis (95% CI 29% to 55%). In studies reporting after 1990, misdiagnosis was seen in 32% (95% CI 16% to 49%). The most common erroneous differential diagnoses were ureteric colic and myocardial infarction. Abdominal pain, shock, and a pulsatile mass were presenting features in 61% (49%-72%), 46% (32%-61%), and 45% (29%-62%) of rAAAs, respectively.

CONCLUSION

The rate of misdiagnosis of rAAA has remained consistent over time and is concerning. There is a need for an effective clinical decision tool to enable accurate diagnosis and triage at the scene of the emergency.

Insights from the clinical assurance of service reconfiguration in the NHS: the drivers of reconfiguration and the evidence that underpins it – a mixed-methods study

Background

Over the life of the NHS, hospital services have been subject to continued reconfiguration. Yet it is rare for the reconfiguration of clinical services to be evaluated, leaving a deficit in the evidence to guide local reconfiguration of services.

Objectives

The objectives of this research are to determine the current pressures for reconfiguration within the NHS in England and the solutions proposed. We also investigate the quality of evidence used in making the case for change, any key evidence gaps, and the opportunities to strengthen the clinical case for change and how it is made.

Methods

We have drawn on two key sources of evidence. First, we reviewed the reports produced by the National Clinical Advisory Team (NCAT) documenting its reviews of reconfiguration proposals. An in-depth multilevel qualitative analysis was conducted of 123 NCAT reviews published between 2007 and 2012. Second, we carried out a search and synthesis of the literature to identify the key evidence available to support reconfiguration decisions. The findings from this literature search were integrated with the analysis of the reviews to develop a narrative for each specialty and the process of reconfiguration as a whole.

Results

The evidence from the NCAT reviews shows significant pressure to reconfigure services within the NHS in England. We found that the majority of reconfiguration proposals are driving an increasing concentration of hospital services, with some accompanying decentralisation and, for some specialist services, the development of supporting clinical networks. The primary drivers of reconfiguration have been workforce (in particular the medical workforce) and finance. Improving outcomes and safety issues have been subsidiary drivers, though many make the link between staffing and clinical safety. Policy has also been a notable driver. Access has been notable by its absence as a driver. Despite significant pressures to reconfigure services, many proposals fail to be implemented owing to public and/or clinical opposition. We found strong evidence that some specialist service reconfiguration including vascular surgery and major trauma can significantly improve clinical outcomes. However, there are notable evidence gaps. The most significant is the absence of evidence that service reconfiguration can deliver significant savings. There is also an absence of evidence about safe staffing models and the interplay between staff numbers, skill mix and outcomes. We found that the advice provided by the NCAT reflects the current evidence, but one of the NCAT’s most valuable contributions has been to encourage greater clinical engagement in service change.

Conclusions

The NHS is continuing to concentrate many district general hospital services to resolve financial and workforce pressures. However, many proposals are not implemented owing to public opposition. We also found no evidence to suggest that this will deliver the savings anticipated. There is a significant gap in the evidence about safe staffing models and the appropriate balance of junior and senior medical as well as other clinical staff. There is an urgent need to carry out research that will help to fill the current evidence gap. There is also a need to retain some national clinical expertise to work alongside Clinical Senates in supporting local service reconfiguration.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.