Centralization harnessing volume-outcome relationships in vascular surgery and aortic aneurysm care should not focus solely on threshold operative caseload.

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.

Screened individuals' preferences in the delivery of abdominal aortic aneurysm repair.

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.

Re-interventions, readmissions and discharge destination: modern metrics for the assessment of the quality of care.

AIM: To determine whether administrative data can be used to determine metrics to inform the quality agenda. To determine the relationship between these metrics and the method of abdominal aortic aneurysm (AAA) repair undertaken. METHODS: The Hospital Episode Statistics (HES) data were taken for a 5-year period (01.04.2003-31.03.2008). Cases of elective AAA repair were identified. Outcomes were determined in terms of mortality, discharge destination, re-intervention rates and emergency readmission rates. The results were interpreted in light of whether AAA repair was open or endovascular and whether patients were octogenarians or younger patients. RESULTS: There were 18,060 elective AAA repairs with a mean in-hospital mortality rate of 5.9%. Of these 14,141 were open repairs with a mean mortality of 6.5% and 3919 EVAR (22%) with a mean mortality of 3.8%. EVAR patients were less likely to be discharged to ongoing care (p < 0.001) but were associated with a higher rate of re-intervention (p = 0.001) than open repairs. No differences were seen in one-year readmission rates. Octogenarians were more likely to undergo EVAR (p = 0.001), to be readmitted within 30-days (p = 0.009), to require further interventions on their index admission (p < 0.001) and less likely to be discharged home (p < 0.001) than younger patients. CONCLUSION: Administrative data can be used to identify metrics other than mortality and length of stay. These metrics might be used to inform service provision. In particular for AAA repair, differences in these outcomes were identified between open repair and EVAR and between octogenarians and younger patients.