The importance of structures and processes in determining outcomes for abdominal aortic aneurysm repair: an international perspective

Abstract

Annual procedural mortality reports have become mandatory for vascular surgery in England, reflecting a more widespread appetite for transparency and accountability across the National Health Service (NHS) [BMJ 2013;346:f854]. The outcomes of abdominal aortic aneurysm (AAA) repair, in particular, have attracted considerable commentary: from 1999 to 2006, postoperative mortality was higher in England than in many other countries (7.9 vs. 1.9-4.5%) [European Society for Vascular Surgery. 2nd Vascunet Report. 2008]. This stimulated considerable service reconfiguration (centralization), quality improvement initiatives, the uptake of endovascular technology, and the examination of institution-level mortality data [http://www.vascularsociety.org.uk/library/quality-improvement.html], which resulted in a fall in elective AAA mortality to 1.8% by 2012 [http://www.hqip.org.uk/assets/NCAPOP-Library/NCAPOP-2013-2014/Outcomes-after-Elective-Repair-of-Infra-renal-Abdominal-Aortic-Aneurysm.pdf (February 2015)]. Despite improvements at a national level, the outcomes of AAA repair vary considerably between different hospitals in the NHS [Circ Cardiovasc Qual Outcomes 2014;7:131-141], analogous to interprovider variation that has been reported across a range of emergency medical and surgical conditions [BMC Health Serv Res 2014;14:270]. This suggests that underlying institution structures and processes contribute independently to patients' outcomes. There is also considerable evidence that the outcomes of AAA repair vary in different healthcare systems, both in the elective European Society for Vascular Surgery, 2008 and emergency settings. A consideration of the role of structures and processes in influencing outcomes for AAA repair can be conducted across different institutions or even different healthcare systems. This can help identify which factors are consistently associated with the best outcomes, informing efforts to better organize and deliver services for patients requiring vascular surgery.

Editor's Choice – European Society for Vascular Surgery (ESVS) 2019 Clinical Practice Guidelines on the Management of Abdominal Aorto-iliac Artery Aneurysms

“…36 However, this is harder to interpret in the modern era, when AAA repair is performed by teams rather than individuals. 37 The associations between volume and outcome have also been shown in the emergency setting, for ruptured AAA (rAAA) repair [38][39][40][41] and recent studies document that it is safe to transfer most rAAA patients to the nearest high volume specialised vascular centre and that such a policy may, in fact, decrease mortality. [42][43][44] In a recent international registry study, including 9273 patients from 11 countries treated for rAAA, the peri-operative mortality was lower in centres with a primary EVAR approach or with high caseload volume; 23% in centres >22 repairs per year versus 30% in centres with a caseload <22, p < 0.001.…”

Infrarenalis aortaaneurysma-műtétek országos eredményeinek elemzése a Nemzeti Érsebészeti Regiszter alapján (2010–2019)

“…A prospektíven rögzített és retrospektíven feldolgozott adatok a Nemzeti Érsebészeti Regiszterből származnak, melyet korábban a MAÉT és a GYEMSZI/ÁEEK, majd 2019-től a GOKI gondoz. A regiszter adatait önkéntes alapon szolgáltatta 26 Elsődleges célunk a kórházon belüli perioperatív mortalitás elemzése volt, a műtéti technika (endovascularis aortareconstructio vs. nyitott aortareconstructio) és az intézeti betegforgalom (kis betegforgalmú érsebészeti ellátó vs. nagy betegforgalmú érsebészeti ellátó) alapján összehasonlítva a vizsgált időszak első (2010-2014) és második (2015-2019) ötéves periódusának adatait. Emellett célul tűztük ki a mortalitás független rizikófaktorainak azonosítását is.…”

“…Az elmúlt évtizedben számos országban kiemelt, nagy betegforgalmú aortacentrumokat hoztak létre a hatékonyabb nagyérellátás érdekében. Bár néhány szerző az érsebészeti ellátóintézetek betegforgalma és eredményei között nem talált egyértelmű összefüggést [12][13][14], a centralizáció előnyeit, főként az infrarenalis aortaaneurys-mák perioperatív mortalitásának csökkenését, egyre több tanulmány bizonyítja [15][16][17][18][19][20][21][22][23][24][25][26][27]. A legfrissebb szakmai irányelvek az eddigi eredményeket összegezve a nagy betegforgalmú centrumokban történő aortaaneurysma-ellátást javasolják [11,28].…”

“Turn downs” in aortic emergencies: Reassurance or uncertainty?

“…"Turn-down" rate has been reported to have a significant influence on outcomes, and being turned down for an operation is associated with a significant short-term mortality risk. 2,3 As a result, studies have suggested that "turn-down" rates should be reported alongside institutional series to qualify the apparent operative success. 4 Surgical "turndown" is also a difficult variable to ascertain reliably and is influenced by several factors including surgical volume.…”