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

Abstract

BackgroundThoracic 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 ResultsData 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.ConclusionsChanges 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.

Systematic Review of Studies That Have Evaluated Screening Tests in Relatives of Patients Affected by Nonsyndromic Thoracic Aortic Disease

“…Diseases of the thoracic aorta are increasing in prevalence, accounting for 1% to 2% of all deaths in Western countries 1, 2, 3, 4, 5. In the United States, diseases of the aorta account for more than 40 000 deaths per year 1, 4.…”

“…In the United States, diseases of the aorta account for more than 40 000 deaths per year 1, 4. Thoracic aortic diseases (TADs) are often silent entities with a mortality of almost 80% when presenting as life‐threatening emergencies 3, 6. Therefore, early diagnosis and treatment are likely to improve long‐term survival.…”

Addressing unwarranted clinical variation: A rapid review of current evidence

“…Two groups of studies reported approaches to determine UCV, with suggestions to address UCV. The first group of 4 studies applied a framework to determine UCV in population or hospital level data . The second group of 14 studies applied statistical models, most commonly regression analyses, to identify variation that was considered to be deviating at a statistically significant level from standard, appropriate or expected levels of variability …”

“…The final study utilized the Theoretical Domains Framework, widely used in determining health behaviours, to qualitatively identify factors perceived to influence practice. The Theoretical Domains Framework was used to explore factors thought to influence deviation from evidence‐based recommendations via interviews based on 12 theoretical domains rather than being used as a framework to understand UCV . Findings suggest that deviation from evidence‐based guidelines in the assessment of patients with mild traumatic brain injury was largely driven by beliefs about the impact on patient outcomes of using assessment or clinical‐decision tools, lack of skills and knowledge in the use of the tools, and lack of social norms in the specialty around the use of such tools .…”

“…The Theoretical Domains Framework was used to explore factors thought to influence deviation from evidence‐based recommendations via interviews based on 12 theoretical domains rather than being used as a framework to understand UCV . Findings suggest that deviation from evidence‐based guidelines in the assessment of patients with mild traumatic brain injury was largely driven by beliefs about the impact on patient outcomes of using assessment or clinical‐decision tools, lack of skills and knowledge in the use of the tools, and lack of social norms in the specialty around the use of such tools . Environmental pressures relating to high patient throughput were also influential in decision‐making about adherence to evidence‐based practice guidelines …”