Editor's Choice – Volume–Outcome Relationships in Elective Abdominal Aortic Aneurysm Surgery: Analysis of the UK Hospital Episodes Statistics Database for the Getting It Right First Time (GIRFT) Programme

Abstract

WHAT THIS PAPER ADDS Volumeeoutcome relationships in abdominal aortic aneurysm surgery in England were investigated in the light of the introduction of a screening programme for older males, recent initiatives to centralise services, and greater use of endovascular techniques. Following these changes, good evidence was found of a volume eoutcome relationship for open surgery but not for endovascular aneurysm repair. Objective: To investigate whether a volumeeoutcome relationship exists for elective abdominal aortic aneurysm (AAA) surgery conducted within the National Health Service (NHS) in England. Methods: This was an analysis of administrative data. Data were extracted from the Hospital Episodes Statistics database for England from April 2011 to March 2019 for all adult admissions for elective infrarenal AAA surgery. Data were extracted for the NHS trust and surgeon undertaking the procedure, the surgical technique used (open or endovascular), the financial year of admission, length of hospital and critical care stay during the procedure and subsequent emergency re-admissions (primary outcome) and deaths within 30 days. Multilevel modelling was used to adjust for hierarchy and confounding. Results: A dataset of 31 829 procedures (8867 open, 22 962 endovascular) was extracted. For open surgery, lower trust annual volume was associated with higher 30 day emergency re-admission rates and higher 30 day mortality. For open surgery, lower surgeon annual volume was associated with higher 30 day mortality and length of hospital stay greater than the median. For endovascular surgery, lower surgeon annual volume was associated with not having an overnight stay in critical care. None of the other volumeeoutcome relationships investigated was significant. Conclusion: For elective infrarenal AAA surgery in the UK NHS, there was strong evidence of a volumeeoutcome relationship for open surgery. However, evidence for a volumeeoutcome relationship is dependent on the specific procedure undertaken and the outcome of interest.

Editor's Choice – Optimal Threshold for the Volume–Outcome Relationship After Open AAA Repair in the Endovascular Era: Analysis of the International Consortium of Vascular Registries

“…3 Additionally, administrative data analyses, using different statistical methods, from the UK have previously confirmed that variations in AAA repair outcomes were partially attributed to volume. 24,27 Prior work confirmed the improved in hospital mortality associated with higher volume hospitals performing OAR of intact and ruptured AAA. 1 Although no relationship were found between volume and early post-operative mortality for EVAR, it is important to highlight that this does not preclude the presence of a volumeeoutcome relationship in EVAR when assessing other long term outcomes.…”

Editor's Choice – Systematic Review and Meta-Analysis of the Impact of Institutional and Surgeon Procedure Volume on Outcomes After Ruptured Abdominal Aortic Aneurysm Repair

“…39 A recent report examining the relationship between volumes and outcomes in elective AAA surgery in England showed a significant effect of both institutional and individual surgeon volumes on outcomes for open AAA repair but not for EVAR. 40 Meltzer et al found that the significant effect of individual surgeon volume on outcomes after elective open AAA repair was more pronounced than that of institutional volume. 31 In the same study, the opposite was found for ruptured cases, where centre, and not surgeon volume, significantly affected outcomes.…”

Treatment Outcome Trends for Non-Ruptured Abdominal Aortic Aneurysms: A Nationwide Prospective Cohort Study

“…Finally, the DSAA does not include information on surgeon volumes, and therefore, it was not possible to describe surgeon volume, in contrast to other countries. 34,35 In conclusion, since the establishment of this nationwide quality improvement initiative (DSAA), all iAAA repair outcomes following standard EVAR and OSR have improved except for peri-operative mortality following standard EVAR which remained unchanged, although the proportion of patients with cardiac comorbidity increased over time in this group. The number of major complications after both OSR and EVAR decreased, and the proportion of TbO increased.…”