RESUMEN
OBJECTIVE: Population screening for abdominal aortic aneurysm (AAA) in men is currently ongoing in several countries. The aim was to examine the effects of deprivation and ethnicity on uptake of screening for abdominal aortic aneurysm (AAA) and prevalence of AAA. METHODS: This was a review of outcomes from a population screening programme using data collected contemporaneously on a bespoke national database. Men aged 65 in two annual cohorts (2013/14 and 2014/15) were invited for AAA screening. Attendance and prevalence of AAA (aortic diameter >2.9 cm) were recorded. Results were compared according to measures of social deprivation and recorded ethnicity. RESULTS: Some 593,032 men were invited and 461,898 attended for ultrasound screening; uptake 77.9%. Uptake was related to social deprivation: 65.1% in the most deprived decile, 84.1% in the least deprived: OR for least deprived 2.84, 95% CI 2.76-2.92, p<.0001. Men in deprived areas were more likely to actively decline screening: 6% versus 3.8% in the least deprived decile. AAA were twice as common in the most deprived compared with the least deprived decile: OR 2.1, 95% CI 1.77-2.27, p<.0001. AAA were more common in white British men than in black (OR 0.46, 95% CI 0.31-0.71) or Asian (OR 0.18, 95% CI 0.13-0.26) men. There was considerable local variation in all findings. CONCLUSIONS: Social deprivation affects uptake of AAA screening in 65 year old men. Local factors are the most important determinants of uptake, so solutions to improve uptake must be designed at local, not national level.
Asunto(s)
Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/etnología , Pueblo Asiatico , Población Negra , Carencia Cultural , Disparidades en Atención de Salud/etnología , Tamizaje Masivo/métodos , Aceptación de la Atención de Salud/etnología , Pobreza , Ultrasonografía , Anciano , Aneurisma de la Aorta Abdominal/psicología , Pueblo Asiatico/psicología , Población Negra/psicología , Inglaterra/epidemiología , Conductas Relacionadas con la Salud/etnología , Humanos , Modelos Logísticos , Masculino , Oportunidad Relativa , Valor Predictivo de las Pruebas , Prevalencia , Factores de Riesgo , Factores de TiempoRESUMEN
BACKGROUND: The Abdominal Aortic Aneurysm (AAA) Screening Programme was introduced by the National Health Service (NHS) in England to reduce the rate of death from ruptured AAA in men. The programme commenced in 2009 and was implemented completely across the country in April 2013. The aim was to review the first 5 years of the programme, looking specifically at compliance and early outcome. METHODS: Men aged 65 years were invited for a single abdominal ultrasound scan. Data were entered into a bespoke database (AAA SMaRT). This was a planned analysis after the first 5 years of the programme. RESULTS: The summation analysis involved the first 700 000 men screened, and the first 1000 men with a large AAA referred for possible treatment. The prevalence of AAA (aortic diameter larger than 2·9 cm) in 65-year-old men was 1·34 per cent. Mean uptake was 78·1 per cent, but varied from 61·7 to 85·8 per cent across the country. Based on the Index of Multiple Deprivation, uptake was 65·1 per cent in the most deprived versus 84·1 per cent in the least deprived areas. Of the first 1000 men referred for possible treatment of a large AAA (greater than 5·4 cm), the false-positive rate was 3·2 per cent. Some 870 men underwent a planned AAA intervention (non-intervention rate 9·2 per cent), with seven deaths (perioperative mortality rate 0·8 per cent). CONCLUSION: The processes in the NHS AAA Screening Programme are effective in detecting and treating men with AAA.
Asunto(s)
Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Rotura de la Aorta/prevención & control , Tamizaje Masivo , Anciano , Aneurisma de la Aorta Abdominal/complicaciones , Aneurisma de la Aorta Abdominal/epidemiología , Aneurisma de la Aorta Abdominal/terapia , Rotura de la Aorta/mortalidad , Inglaterra/epidemiología , Reacciones Falso Positivas , Humanos , Masculino , Evaluación de Resultado en la Atención de Salud , Cooperación del Paciente/estadística & datos numéricos , Medicina Estatal , UltrasonografíaRESUMEN
BACKGROUND: International comparison of registry data within vascular surgery has previously been published by Vascunet. One of the limitations of such comparisons is data validity and completeness, and meaningful interpretation of differences between countries can only be made if the data are robust within each of the countries studied. The Vascunet collaboration has therefore embarked on a validation exercise of international vascular registry data. METHODS: Five out of 20 hospitals performing vascular surgery in Sweden were visited by two international validators. Independent evaluation of the procedures of carotid endarterectomy and infrarenal abdominal aortic aneurysm repair was performed, and local hospital administrative data were compared with Swedvasc registry data. External validation compared the numbers of cases in these two systems of data collection and internal validation compared data accuracy and completeness within individual patient records. RESULTS: Hospital records identified 335 carotid and 393 abdominal aortic aneurysm (AAA) procedures, whereas Swedvasc identified 331 carotid and 359 AAAs. Nine carotid procedures and 64 AAA procedures were found in hospital administrative data but not in Swedvasc, and 14 carotids and 30 AAAs were found in Swedvasc but not in hospital data. External validity was 100% (95% CI 98.8-100%) for carotids and 98.8% (95% CI 96.9-99.5%) for AAAs. In internal validation, 0.8% of variables were missing in hospital data compared with Swedvasc and 4.2% were missing in Swedvasc compared with hospital data. Data contained within the data fields of Swedvasc and hospital data were the same in 97.4% (95% CI 96.3-98.3%) for carotids and 96.2% (CI 94.9-97.2%) for AAAs. CONCLUSION: This study has provided a template for international validation of registry data and has demonstrated that Swedvasc is a highly accurate system of data collection for Swedish vascular surgery.
Asunto(s)
Aneurisma de la Aorta Abdominal/cirugía , Recolección de Datos , Endarterectomía Carotidea , Hospitales , Registros Médicos , Sistema de Registros , Procedimientos Quirúrgicos Vasculares , Aneurisma de la Aorta Abdominal/diagnóstico , Aneurisma de la Aorta Abdominal/mortalidad , Conducta Cooperativa , Recolección de Datos/estadística & datos numéricos , Endarterectomía Carotidea/efectos adversos , Endarterectomía Carotidea/mortalidad , Endarterectomía Carotidea/estadística & datos numéricos , Femenino , Hospitales/estadística & datos numéricos , Humanos , Cooperación Internacional , Masculino , Registros Médicos/estadística & datos numéricos , Indicadores de Calidad de la Atención de Salud , Sistema de Registros/estadística & datos numéricos , Reproducibilidad de los Resultados , Suecia , Resultado del Tratamiento , Procedimientos Quirúrgicos Vasculares/efectos adversos , Procedimientos Quirúrgicos Vasculares/mortalidad , Procedimientos Quirúrgicos Vasculares/estadística & datos numéricosRESUMEN
OBJECTIVES: To study contemporary popliteal artery aneurysm (PA) repair. METHODS: Vascunet is a collaboration of population-based registries in 10 countries: eight had data on PA repair (Australia, Finland, Hungary, Iceland, New Zealand, Norway, Sweden, and Switzerland). RESULTS: From January 2009 until June 2012, 1,471 PA repairs were registered. There were 9.59 operations per million person years, varying from 3.4 in Hungary to 17.6 in Sweden. Median age was 70 years, ranging from 66 years in Switzerland and Iceland to 74 years in Australia and New Zealand; 95.6% were men and 44% were active smokers. Elective surgery dominated, comprising 72% of all cases, but only 26.2% in Hungary and 39.7% in Finland, (p < .0001). The proportion of endovascular PA repair was 22.2%, varying from 34.7% in Australia, to zero in Switzerland, Finland, and Iceland (p < .0001). Endovascular repair was performed in 12.2% of patients with acute thrombosis and 24.1% of elective cases (p < .0001). A vein graft was used in 87.2% of open repairs, a synthetic or composite graft in 12.7%. Follow-up was until discharge or 30 days. Amputation rate was 2.0% overall: 6.5% after acute thrombosis, 1.0% after endovascular, 1.8% after open repair, and 26.3% after hybrid repair (p < .0001). Mortality was 0.7% overall: 0.1% after elective repair, 1.6% after acute thrombosis, and 11.1% after rupture. CONCLUSIONS: Great variability between countries in incidence of operations, indications for surgery, and choice of surgical technique was found, possibly a result of surgical tradition rather than differences in case mix. Comparative studies with longer follow-up data are warranted.
Asunto(s)
Aneurisma/cirugía , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Arteria Poplítea/cirugía , Pautas de la Práctica en Medicina , Anciano , Amputación Quirúrgica , Aneurisma/diagnóstico , Aneurisma/mortalidad , Australia , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/mortalidad , Implantación de Prótesis Vascular/tendencias , Distribución de Chi-Cuadrado , Conducta Cooperativa , Procedimientos Quirúrgicos Electivos , Urgencias Médicas , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/mortalidad , Procedimientos Endovasculares/tendencias , Europa (Continente) , Femenino , Humanos , Cooperación Internacional , Recuperación del Miembro , Masculino , Nueva Zelanda , Pautas de la Práctica en Medicina/tendencias , Sistema de Registros , Reoperación , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
INTRODUCTION: Abdominal aortic aneurysm (AAA) screening programmes reduce AAA-related mortality and are cost-effective. This study aims to assess the state and variability of AAA screening programmes worldwide. METHODS: Data were obtained from an international expert group convened at the 34th Charing Cross Symposium as well as government websites and published reports on screening programmes. RESULTS: Six countries are in the process of implementing national AAA screening programmes, with Italy still performing screening trials. There is wide variability in inclusion criteria between countries with the majority screening only men in their 65th year, however 3 programmes include women, 2 programmes only include patients with high cardiovascular risk, and 2 trials are also screening for hypertension and lower limb atherosclerosis. Surveillance intervals vary between screening programmes, with the most common regimen being to vary the surveillance interval depending upon aneurysm size, however the optimum surveillance interval in terms of decreasing mortality and cost effectiveness remains uncertain. DISCUSSION: International dissemination of current AAA screening programme outcomes is required to inform developing programmes about optimum screening intervals, benefits of surveillance of the subaneurysmal aorta, and screening for other cardiovascular disease.
Asunto(s)
Aneurisma de la Aorta Abdominal/diagnóstico , Aneurisma de la Aorta Abdominal/economía , Enfermedades Cardiovasculares/diagnóstico , Tamizaje Masivo/métodos , Adulto , Anciano , Aneurisma de la Aorta Abdominal/mortalidad , Aneurisma de la Aorta Abdominal/cirugía , Enfermedades Cardiovasculares/economía , Análisis Costo-Beneficio/economía , Femenino , Humanos , Masculino , Tamizaje Masivo/economía , Persona de Mediana Edad , Factores de RiesgoRESUMEN
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.
Asunto(s)
Aneurisma de la Aorta Abdominal/diagnóstico , Aneurisma de la Aorta Abdominal/cirugía , Rotura de la Aorta/diagnóstico , Rotura de la Aorta/cirugía , Codificación Clínica , Bases de Datos Factuales/estadística & datos numéricos , Tratamiento de Urgencia , Adulto , Anciano , Tratamiento de Urgencia/métodos , Tratamiento de Urgencia/estadística & datos numéricos , Inglaterra/epidemiología , Femenino , Mortalidad Hospitalaria , Humanos , Masculino , Auditoría Médica , Persona de Mediana Edad , Evaluación de Resultado en la Atención de Salud , Procedimientos Quirúrgicos Vasculares/estadística & datos numéricosRESUMEN
BACKGROUND: Carotid endarterectomy (CEA) reduces the risk of stroke in patients with internal carotid stenosis of 50-99 per cent. This study assessed national surgical practice through audit of CEA procedures and outcomes. METHODS: This was a prospective cohort study of UK surgeons performing CEA, using clinical audit data collected continuously and reported in two rounds, covering operations from December 2005 to December 2007, and January 2008 to September 2009. RESULTS: Some 352 (92·6 per cent) of 380 eligible surgeons contributed data. Of 19,935 CEAs recorded by Hospital Episode Statistics, 12,496 (62·7 per cent) were submitted to the audit. A total of 10,452 operations (83·6 per cent) were performed for symptomatic carotid stenosis; among these patients, the presenting symptoms were transient ischaemic attack in 4507 (43·1 per cent), stroke in 3572 (34·2 per cent) and amaurosis fugax in 1965 (18·8 per cent). The 30-day mortality rate was 1·0 per cent (48 of 4944) in round 1 and 0·8 per cent (50 of 6151) in round 2; the most common cause of death was stroke, followed by myocardial infarction. The rate of death or stroke within 30 days of surgery was 2·5 per cent (124 of 4918) in round 1 and 1·8 per cent (112 of 6135) in round 2. CONCLUSION: CEA is performed less commonly in the UK than in other European countries and probably remains underutilized in the prevention of stroke. Increasing the number of CEAs done in the UK, together with reducing surgical waiting times, could prevent more strokes.
Asunto(s)
Estenosis Carotídea/cirugía , Endarterectomía Carotidea/métodos , Práctica Profesional , Anciano , Amaurosis Fugax/etiología , Diagnóstico Tardío , Femenino , Humanos , Ataque Isquémico Transitorio/etiología , Masculino , Inhibidores de Agregación Plaquetaria/uso terapéutico , Cuidados Posoperatorios/métodos , Complicaciones Posoperatorias/etiología , Cuidados Preoperatorios/métodos , Estudios Prospectivos , Derivación y Consulta , Accidente Cerebrovascular/etiologíaAsunto(s)
Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Tamizaje Masivo/métodos , Factores de Edad , Anciano , Anciano de 80 o más Años , Aneurisma de la Aorta Abdominal/epidemiología , Aneurisma de la Aorta Abdominal/mortalidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Prevalencia , Medición de Riesgo , Factores de Riesgo , Factores Sexuales , Factores de TiempoRESUMEN
OBJECTIVES: To compare practice in lower limb bypass surgery in nine countries. DESIGN: A prospective study amalgamating and analysing data from national and regional vascular registries. METHODS: A table of data fields and definitions was agreed by all member countries of the Vascunet Collaboration. Data from January 2005 to December 2009 was submitted to a central database. RESULTS: 32,084 cases of infrainguinal bypass (IIB) in nine countries were analysed. Procedures per 100,000 population varied between 2.3 in the UK and 24.6 in Finland. The proportion of women varied from 25% to 43.5%. The median age for all countries was 70 for men and 76 for women. Hungary treated the youngest patients. IIB was performed for claudication for between 15.7% and 40.8% of all procedures. Vein grafts were used in patients operated on for claudication (52.9%), for rest pain (66.7%) and tissue loss (74.1%). Italy had the highest use of synthetic grafts. Among claudicants 45% of bypasses were performed to the below knee popliteal artery or more distally. Graft patency at 30 days varied between 86% and 99%. CONCLUSIONS: Significant variations in practice between countries were demonstrated. These results should be interpreted alongside the known limitations of such registry data with respect to quality and completeness of the data. Variation in data completeness and data validation between countries needs to be improved for useful international comparison of outcomes.
Asunto(s)
Extremidad Inferior/irrigación sanguínea , Enfermedad Arterial Periférica/cirugía , Pautas de la Práctica en Medicina/estadística & datos numéricos , Injerto Vascular/estadística & datos numéricos , Anciano , Análisis de Varianza , Implantación de Prótesis Vascular/estadística & datos numéricos , Distribución de Chi-Cuadrado , Europa (Continente) , Femenino , Adhesión a Directriz/estadística & datos numéricos , Humanos , Masculino , Enfermedad Arterial Periférica/mortalidad , Enfermedad Arterial Periférica/fisiopatología , Guías de Práctica Clínica como Asunto , Estudios Prospectivos , Sistema de Registros , Factores de Tiempo , Resultado del Tratamiento , Injerto Vascular/efectos adversos , Injerto Vascular/mortalidad , Grado de Desobstrucción Vascular , Venas/trasplanteRESUMEN
OBJECTIVES: The aim of the study was to analyse variation in carotid surgical practice, results and effectiveness in nine countries. PATIENTS AND METHODS: A total of 48,185 carotid endarterectomies (CEAs) and 4602 carotid artery stenting (CAS) procedures were included in the comparison. A theoretical effectiveness of CEA provision for each country was estimated. RESULTS: 92.6% of the CEAs were performed according to the inclusion criteria based on the current European recommendations and had a theoretical benefit for the patient. The indication for surgery was symptomatic stenosis in 60.1% and this proportion varied between 31.4% in Italy and 100% in Denmark. The overall combined stroke and death rate in symptomatic patients was 2.3%. This varied between rates of 0.9% in Italy and 3.8% in Norway. The overall combined stroke and death rate in asymptomatic patients was 0.9%. It was lowest in Italy at 0.5%, and highest in Sweden at 2.7%. We estimated that the stroke prevention rate per 1000 CEAs varied from 72.9 in Italy to 130.8 in Denmark. CONCLUSIONS: There is significant variation in clinical practice across the participating countries. The theoretical stroke prevention potential of CEA seems to vary between participating countries due to differences in the inclusion criteria.
Asunto(s)
Estenosis Carotídea/cirugía , Auditoría Clínica , Endarterectomía Carotidea/métodos , Endarterectomía Carotidea/normas , Guías de Práctica Clínica como Asunto , Anciano , Australia/epidemiología , Estenosis Carotídea/complicaciones , Europa (Continente)/epidemiología , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Masculino , Sistema de Registros , Estudios Retrospectivos , Factores de Riesgo , Accidente Cerebrovascular/epidemiología , Accidente Cerebrovascular/etiología , Tasa de Supervivencia/tendenciasAsunto(s)
Procedimientos Endovasculares/normas , Arterias Mesentéricas/cirugía , Venas Mesentéricas/cirugía , Enfermedades Vasculares/terapia , Procedimientos Quirúrgicos Vasculares/normas , Procedimientos Endovasculares/efectos adversos , Humanos , Arterias Mesentéricas/diagnóstico por imagen , Arterias Mesentéricas/fisiopatología , Venas Mesentéricas/diagnóstico por imagen , Venas Mesentéricas/fisiopatología , Valor Predictivo de las Pruebas , Factores de Riesgo , Circulación Esplácnica , Resultado del Tratamiento , Enfermedades Vasculares/diagnóstico por imagen , Enfermedades Vasculares/fisiopatología , Procedimientos Quirúrgicos Vasculares/efectos adversosRESUMEN
OBJECTIVES: The aim of the study was to assess if technical and patient-related factors are related to outcome after carotid surgery. DESIGN: Vascunet is a collaboration of national and regional registries with 10 contributing countries. PATIENTS AND METHODS: Data from 48,035 carotid endarterectomies (CEAs) performed in 383 centres, during 2003-2007, were merged into a common database. RESULTS: CEA was performed without patch (34%), with patch (40%) or with eversion (26%) in 74% for symptomatic and in 26% for asymptomatic disease. Overall (in-hospital and 30-day) mortality was 0.45%. Type of CEA or anaesthesia did not affect mortality, nor did contralateral occlusion. Mortality was higher in patients above the age of 75 years, for both genders (p < 0.05). The overall (in-hospital) stroke rate was 1.9%, the method of anaesthesia did not affect stroke rate. It was higher in patients with contralateral occlusion (4.6% vs. 2.5%, p = 0.002). Standard CEA without patch had a higher stroke rate than when a patch was used (2.3 vs. 1.7%, p = 0.015). Female patients >75 years had a higher stroke rate than younger women (2.0% vs. 1.6%, p = 0.078); this difference was not observed in men. CONCLUSIONS: Although there are limitations with registry data, the large number of cases involved provides useful information on outcomes, supplementing data from the randomised clinical trials (RCTs).
Asunto(s)
Estenosis Carotídea/cirugía , Endarterectomía Carotidea , Factores de Edad , Anciano , Anestesia , Australasia/epidemiología , Estenosis Carotídea/complicaciones , Estenosis Carotídea/mortalidad , Europa (Continente)/epidemiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Sistema de Registros , Factores Sexuales , Accidente Cerebrovascular/epidemiología , Accidente Cerebrovascular/prevención & control , Tasa de Supervivencia , Resultado del TratamientoRESUMEN
OBJECTIVES: To study contemporary treatment and outcome of abdominal aortic aneurysm (AAA) repair in nine countries. DESIGN AND METHODS: Data on primary AAA repairs 2005-2009 were amalgamated from national and regional vascular registries in Australia, Denmark, Finland, Hungary, Italy, Norway, Sweden, Switzerland and the UK. Primary outcome was in-hospital or 30-day mortality. Multivariate logistic regression was used to assess case-mix. RESULTS: 31,427 intact AAA repairs were identified, mean age 72.6 years (95% CI 72.5-72.7). The rate of octogenarians and use of endovascular repair (EVAR) increased over time (p < 0.001). EVAR varied between countries from 14.7% (Finland) to 56.0% (Australia). Overall perioperative mortality after intact AAA repair was 2.8% (2.6-3.0) and was stable over time. The perioperative mortality rate varied from 1.6% (1.3-1.8) in Italy to 4.1% (2.4-7.0) in Finland. Increasing age, open repair and presence of comorbidities were associated with outcome. 7040 ruptured AAA repairs were identified, mean age 73.8 (73.6-74.0). The overall perioperative mortality was 31.6% (30.6-32.8), and decreased over time (p = 0.004). CONCLUSIONS: The rate of AAA repair in octogenarians as well as EVAR increased over time. Perioperative outcome after intact AAA repair was stable over time, but improved after ruptured repair. Geographical differences in treatment of AAA remain.
Asunto(s)
Aneurisma de la Aorta Abdominal/terapia , Rotura de la Aorta/terapia , Anciano , Anciano de 80 o más Años , Aneurisma de la Aorta Abdominal/mortalidad , Rotura de la Aorta/mortalidad , Europa (Continente)/epidemiología , Femenino , Humanos , Modelos Logísticos , Masculino , Pautas de la Práctica en Medicina , Sistema de Registros , Estudios Retrospectivos , Tasa de Supervivencia , Factores de Tiempo , Resultado del TratamientoRESUMEN
Fibroepithelial polyps (FEPs) are common, benign intraoral lesions that tend to develop slowly at predictable sites, often in response to local irritation or trauma. Historical precedent often results in referral to oral and maxillofacial surgery (OMFS) departments for biopsy, often irrespective of symptoms, and histological assessment. OMFS and pathology services are struggling to cope with an increasing workload that will potentially lead to widespread delays to diagnosis and treatment. Over the past 20 years, clinical pathways and guidance have been developed to ensure that healthcare interventions, such as the removal of third molars, tonsils, skin tags, and benign moles, are evidence-based, have a net patient benefit, and ensure the best use of finite NHS resources. However, no such guidance exists for intraoral lesions and we regard this as an oversight. We analysed the removal of 682 FEPs over a seven-year period and report sensitivities of 92.4% for a "confirmed clinical suspicion of an FEP" and 99.7% for a "confirmed clinical suspicion of a benign diagnosis". The incidence of non-benign disease was 0.3%. Primary care dentists should be able to diagnose and monitor FEPs and refer only if symptoms are serious or in high-risk patients or sites. Adopting this practice across the UK could free up to 1825 four-hour OMFS clinics, 405hours of consultant histopathologists' time, and recurring savings to the NHS estimated to be in the region of £620 000/annum. We believe that the removal of FEPs should be reclassified as an "intervention not normally funded", and the time and resources put to better use treating patients with lesions of questionable pathology.
Asunto(s)
Carcinoma de Células Escamosas , Pólipos , Enfermedades de la Piel , Neoplasias Cutáneas , Humanos , Recurrencia Local de Neoplasia , Pólipos/diagnóstico , Pólipos/cirugíaRESUMEN
BACKGROUND: This randomized clinical trial compared early outcomes after radiofrequency ablation (RFA) and conventional surgery for varicose veins. METHODS: Consecutive patients with symptomatic varicose veins due to isolated great saphenous vein (GSV) incompetence and suitable for RFA were randomized to either RFA or conventional surgery (saphenofemoral disconnection and stripping). Clinical, radiological and patient-based outcomes were recorded at 1 and 5 weeks after intervention. RESULTS: RFA resulted in successful obliteration of the GSV in all 47 patients. Complete above-knee stripping was unsuccessful in seven of 41 patients. RFA took longer than conventional surgery: median interquartile range 76 (67-84) versus 48 (39-54) min; P < 0.001. Patients returned to their normal activities significantly earlier after RFA (median 3 (2-5) versus 12.5 (4-21) days; P < 0.001). Postoperative pain was significantly less after RFA (median score on visual analogue scale 1.70 (0.50-4.30) versus 4.0 (2.35-6.05); P = 0.001). Patient satisfaction, quality of life improvement and analgesic requirements significantly favoured RFA. CONCLUSION: RFA took longer to perform but resulted in a significantly better early outcome than conventional surgery in suitable patients with great saphenous varicose veins.
Asunto(s)
Ablación por Catéter/métodos , Vena Safena/cirugía , Várices/cirugía , Adulto , Femenino , Humanos , Ligadura , Masculino , Persona de Mediana Edad , Dolor Postoperatorio/etiología , Satisfacción del Paciente , Calidad de Vida , Várices/rehabilitaciónRESUMEN
OBJECTIVE: To compare the costs involved (from procedure to recovery) following radiofrequency ablation and conventional surgery for lower limb varicose veins in a selected population. DESIGN: Prospective randomised controlled trial. METHODS: Patients with symptomatic great saphenous varicose veins suitable for radiofrequency ablation were randomised to either RF ablation or surgery (sapheno-femoral ligation and stripping). The hospital, general practice and patient costs incurred until full recovery and the indirect cost to society, due to sickness leave after surgery, were calculated to indicate mean cost per patient under each category. RESULTS: Ninety three patients were randomised. Eighty eight patients (47 - RF ablation, 41 - surgery) underwent the allocated intervention. Ablation took longer to perform than surgery (mean 76.8 vs 47.0 min, p<.001). Ablation was more expensive (mean hospital cost per patient 1275.90 pounds vs 559.13 pounds) but enabled patients to return to work 1 week earlier than after surgery (mean 12.2 vs 19.8 days, p=0.006). Based on the Annual Survey of Hours and Earnings (Office of National Statistics, UK) for full time employees, the cost per working hour gained after ablation was 6.94 pounds (95% CI 6.26, 7.62). CONCLUSION: The increased cost of radiofrequency ablation is partly offset by a quicker return to work in the employed group (ISRCTN29015169http://www.controlled-trials.com).
Asunto(s)
Ablación por Catéter/economía , Vena Femoral/cirugía , Costos de la Atención en Salud , Vena Safena/cirugía , Várices/economía , Várices/cirugía , Procedimientos Quirúrgicos Vasculares/economía , Actividades Cotidianas , Adulto , Costo de Enfermedad , Análisis Costo-Beneficio , Eficiencia , Medicina Familiar y Comunitaria/economía , Femenino , Costos de Hospital , Humanos , Ligadura , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Recuperación de la Función , Ausencia por Enfermedad/economía , Factores de Tiempo , Resultado del Tratamiento , Várices/fisiopatologíaAsunto(s)
Aorta Abdominal/patología , Aneurisma de la Aorta Abdominal/diagnóstico , Tamizaje Masivo/métodos , Anciano , Aneurisma de la Aorta Abdominal/economía , Aneurisma de la Aorta Abdominal/epidemiología , Aneurisma de la Aorta Abdominal/terapia , Análisis Costo-Beneficio , Dilatación Patológica , Progresión de la Enfermedad , Femenino , Costos de la Atención en Salud , Humanos , Masculino , Tamizaje Masivo/economía , Selección de Paciente , Valor Predictivo de las Pruebas , Prevalencia , Pronóstico , Medición de Riesgo , Factores de Riesgo , Factores de TiempoRESUMEN
BACKGROUND: VBHOM (Vascular Biochemistry and Haematology Outcome Models) adopts the approach of using a minimum data set to model outcome and has been previously shown to be feasible after index arterial operations. This study attempts to model mortality following lower limb amputation for critical limb ischaemia using the VBHOM concept. METHODS: A binary logistic regression model of risk of mortality was built using National Vascular Database items that contained the complete data required by the model from 269 admissions for lower limb amputation. The subset of NVD data items used were urea, creatinine, sodium, potassium, haemoglobin, white cell count, age on and mode of admission. This model was applied prospectively to a test set of data (n=269), which were not part of the original training set to develop the predictor equation. RESULTS: Outcome following lower limb amputation could be described accurately using the same model. The overall mean predicted risk of mortality was 32%, predicting 86 deaths. Actual number of deaths was 86 (chi(2)=8.05, 8 d.f., p=0.429; no evidence of lack of fit). The model demonstrated adequate discrimination (c-index=0.704). CONCLUSIONS: VBHOM provides a single unified model that allows good prediction of surgical mortality in this high risk group of individuals. It uses a small, simple and objective clinical data set that may also simplify comparative audit within vascular surgery.
Asunto(s)
Amputación Quirúrgica/mortalidad , Isquemia/cirugía , Extremidad Inferior/irrigación sanguínea , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Modelos Cardiovasculares , Evaluación de Resultado en la Atención de Salud , Medición de RiesgoRESUMEN
National Confidential Enquiry into Patient Outcome and Death guidelines for urgent surgery recommend a fully staffed emergency operating theatre and restriction of 'after-midnight' operating to immediate life-, limb- or organ-threatening conditions. Audit performed in our institution demonstrated significant decreases in waiting times for urgent surgery and an increased seniority of medical care associated with overnight pre-operative assessment of patients by anaesthetic trainees. Nevertheless, urgent cases continued to be delayed unnecessarily. A classification of delays was developed from existing guidelines and their incidence was audited. The results were disseminated to involved directorates. A repeat of the audit demonstrated a significant decrease in delays (p = 0.001), a significant increase in the availability of surgeons (p = 0.001) and a significant decrease in the median waiting time for urgent surgery compared to the first audit cycle and a previous standard (p < 0.01). We conclude that auditing delays and disseminating the results of the audit significantly decreases delays and median waiting times for urgent surgery because of improved surgical availability.