Background The association between hospital caseload and surgical mortality, including in vascular surgery, remains debated. Randomized trials have reported lower postoperative mortality after endovascular aneurysm repair (EVAR) than after open repair for intact abdominal aortic aneurysm (IAAA), although this has not been independently demonstrated across studies. We therefore investigated whether higher hospital abdominal aortic aneurysm (AAA) caseload or greater use of EVAR was associated with lower 90-day mortality in an unselected nationwide cohort of IAAA (unruptured aneurysm involving the abdominal aorta) undergoing repair. Methods This retrospective observational cohort study included 4,868 patients who underwent IAAA repair over 5 years, identified from a prospective vascular registry covering all vascular units in Sweden. Data on age, sex, heart disease, prior heart failure, pulmonary disease, kidney disease, frailty, and operative urgency were obtained from multiple sources and analyzed in relation to 90-day mortality using logistic regression. Each patient was assigned a hospital caseload value (HCV), defined as the annual number of ruptured and unruptured AAA repairs performed at the treating hospital, and a hospital EVAR proportion value (HEV), defined as the proportion of IAAA repairs performed with EVAR. Results Across vascular units, HCV ranged from 8.4 to 101 and HEV from 0 to 0.97. Overall, 90-day mortality was 2.4% (95% confidence interval [CI], 2.0%–2.9%). In adjusted analyses, neither HCV nor HEV was associated with 90-day mortality (odds ratio [OR], 1.04; 95% CI, 0.89–1.21; P = .63 and OR, 1.06; 95% CI, 0.76–1.49; P = .73, respectively), and no threshold effect was identified for either caseload or EVAR proportion with respect to 90-day mortality. Male sex was associated with lower 90-day mortality (OR, 0.56; 95% CI, 0.37–0.85; P = .007), whereas heart disease (OR, 1.47; 95% CI, 1.00–2.18; P = .05), pulmonary disease (OR, 1.69; 95% CI, 1.14–2.50; P = .009), and unplanned repair of symptomatic aneurysm (OR, 2.28; 95% CI, 1.12–4.64; P = .023) or emergency repair (OR, 2.52; 95% CI, 1.41–4.49; P = .002) were associated with higher 90-day mortality. Conclusion In this nationwide cohort, neither higher hospital AAA caseload (roughly more than 10 annual cases) nor greater use of EVAR for IAAA repair was associated with lower postoperative 90-day mortality.

OBJECTIVE:The aim of this study was to compare all cause mortality across three time periods with a focus on sex differences after revascularisation for chronic limb threatening ischaemia between 1994 and 2013 in Sweden. METHODS:In this observational registry study, patients registered in the Swedish vascular registry (Swedvasc), revascularised between 1994 and 2013 with open or endovascular infra-inguinal procedures, were divided into three time periods: 1994 - 1999, 2000 - 2006, and 2007 - 2013. Patients were followed for five years. Poisson regression was used to compare 30 day mortality, presented as adjusted relative risk ratio (aRR). Adjusted restricted mean survival time (aRMST) differences at five years were compared with a generalised linear model. The analyses were adjusted for age, comorbidities, and endovascular or open surgery. Comparison with the general Swedish population was also conducted with age adjusted standardised mortality ratios. Results are presented with the 95% confidence interval (CI). RESULTS:The study showed increasing 30 day mortality, with an aRR of 1.47 (95% CI 1.31 - 1.65) for women and aRR of 1.20 (95% CI 1.06 - 1.35) for men, per time period. In women, the five year RMST decreased from the first to the third period, with an aRMST of -45 (95% CI -59 - -32) days per period. In men, the aRMST increased 32 (95% CI 18 - 47) days per period. When comparing sexes, women showed lower 30 day mortality and higher five year survival than men in the first time period, but a significantly worse development over time periods than for men. Corresponding findings were observed in comparison with the general Swedish population. CONCLUSION:This study showed an increased 30 day mortality in women and men across the periods, most evident in women. Men showed an increased five year survival across the periods, whereas opposite findings were recorded for women. The dismal trend over time for women could not be explained by increased age or a higher prevalence of comorbidities.

The causal connection between hospital caseload and short-term mortality after complex surgery is controversial. Does a small minimum, say 10 cases yearly, suffice to secure good results or are substantially larger numbers necessary? Randomized studies are difficult, if not impossible, so these questions must be determined by observational studies which also can eliminate confounding. We analysed intact abdominal aortic aneurysms (iAAA) from these aspects with patients from the Swedish vascular registry (Swedvasc). As endovascular abdominal aortic aneurysm repair (EVAR) was connected to caseload, this was also considered, simultaneously. Swedvasc comprised 4 868 iAAA 2013–2017 and age, sex, risk factors, and mortality were procured. Swedheart supplied information of previous cardiac insufficiency. Information of municipal homecare was available from the National Board of Health and Welfare and was coded as patient frailty. Mortality at 90-days was evaluated with Cox regression versus caseload of all AAA, proportion of EVAR, age, sex, heart disease, previous cardiac insufficiency, pulmonary disease, kidney disease, frailty, and urgency (no-urgency, unplanned-with-symptoms, emergency). Additionally, caseload and proportion of EVAR were plotted and analysed against unadjusted institutional mortality. Neither caseload, nor more EVAR reduced patient's 90-day mortality (HR 1.04 P=0.650 and 1.06 P=0.739, respectively). Male sex decreased 90-day mortality (0.56 P=0.006) while heart disease, pulmonary disease, and urgency (either unplanned-with-symptoms or emergency) increased mortality (1.47 P=0.049, 1.66 P=0.010, 2.23 P=0.022, 2.45 P=0.002, respectively). Caseload or proportion of EVAR were not connected to individual hospital mortality. We failed to show any causal relationship between caseload or proportion of EVAR versus 90-day mortality.

Background There is a lack of knowledge regarding the epidemiology of severe trauma assessed by Swedish emergency medical services (EMS). Aim To investigate the prevalence of trauma in Sweden assessed by EMS from a national perspective and describe patient demography, aetiology, trauma type, prehospital triage and clinical outcomes. Methods Data from two national quality registries, the Swedish Ambulance Registry and the Swedish Trauma Registry (SweTrau) were collected from January 1 to December 31, 2019. Inclusion criteria were an Emergency Symptoms and Signs code equivalent to trauma in the Swedish Ambulance Registry and criteria fulfilled for SweTrau inclusion. Exclusion criteria were patients < 18 years old, those not transported to a hospital and those without a personal identification number. Results In total, 53,120 patients with trauma were included (14% of primary EMS missions involving a personal identification number). Of those, 2,278 (4.3%) patients (median age: 45 years; 32% women) were reported in SweTrau to have severe or potentially severe trauma (penetrating: 7%, blunt: 93%). In terms of including all causes of trauma, the code for ‘trauma alert activation’ was most frequent (55%). The most frequent injury mechanism was an injury caused by a car (34%). Most (89%) cases were assigned Priority 1 (life-threatening condition) at the dispatch centre. 62% were regarded as potentially life threatening upon EMS arrival, whereas 29% were assessed as non-life-threatening. Overall, 25% of the patients had new injury severity scores > 15. 12% required invasive treatment, 11% were discharged with severe disability and the 30-day mortality rate was 3.6%. Conclusion In this cross-sectional study, 14% of the primary EMS missions for one year were caused by trauma. However, only a small proportion of these cases are severe injuries, and the risk of severe disabilities and death appears to be limited. The most frequent aetiology of a severe trauma is injury caused by a car, and most severe traumas are blunt. Severe traumas are given the highest priority at the dispatch centre in the vast majority of cases, but nearly one-third of these cases are considered a low priority by the EMS nurse. The latter leaves room for improvement.

Abstract Background Risk-adjusted mortality (RAM) analysis and comparisons of clinically relevant subsets of trauma patients allow hospitals to assess performance in different processes of care. The aim of the study was to develop a RAM model and compare RAM ratio (RAMR) in subsets of severely injured adult patients treated in university hospitals (UHs) and emergency hospitals (EHs) in Sweden. Methods This was a retrospective study of the Swedish trauma registry data (2013 to 2017) comparing RAMR in patients (aged 15 years or older and New Injury Severity Score (NISS) of more than 15) in the total population (TP) and in multisystem blunt (MB), truncal penetrating (PEN), and severe traumatic brain injury (STBI) subsets treated in UHs and EHs. The RAM model included the variables age, NISS, ASA Physical Status Classification System Score, and physiology on arrival. Results In total, 6690 patients were included in the study (4485 from UHs and 2205 from EHs). The logistic regression model showed a good fit. RAMR was 4.0, 3.8, 7.4, and 8.5 percentage points lower in UH versus EH for TP (P < 0.001), MB (P < 0.001), PEN (P = 0.096), and STBI (P = 0.005), respectively. The TP and MB subsets were subgrouped in with (+) and without (−) traumatic brain injury (TBI). RAMR was 7.5 and 7.0, respectively, percentage points lower in UHs than in EHs in TP + TBI and MB + TBI (both P < 0.001). In the TP–TBI (P = 0.027) and MB–TBI (P = 0.107) subsets the RAMR was 1.6 and 1.8 percentage points lower, respectively. Conclusion The lower RAMR in UHs versus EH were due to differences in TBI-related mortality. No evidence supported that Swedish EHs provide inferior quality of care for trauma patients without TBI or for patients with penetrating injuries.

OBJECTIVES:Invasive treatment of infrainguinal intermittent claudication is controversial, and long-term outcomes are scarce. The study aim was to evaluate 8 years results regarding new vascular interventions on index and contralateral limb, hospitalization, mortality, and amputation in 775 patients revascularized for infrainguinal intermittent claudication in 2009. METHODS:Data on new vascular interventions retrieved from the Swedish vascular register (Swedvasc) were linked to the Inpatient Register and Cause of Death Register with information on hospitalizations, primary discharge diagnoses according to the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10), deaths, causes of death, and amputations. RESULTS:During 8 years of follow-up, 486 new vascular interventions were performed. Patients were admitted for a total of 4662 hospitalizations and spent 25,970 days in hospital. Between 79% and 99% of surviving subjects were hospitalized each year. During follow-up, 311 (40.1%) patients died. The most common causes of hospitalization and death were cerebrovascular disease, ischemic heart disease, or other diseases of the circulatory system, causing 47.5% of hospitalizations and 42.4% of deaths. Seventy-seven major lower limb amputations were performed in 52 patients. CONCLUSION:As patients undergoing invasive treatment of infrainguinal intermittent claudication have high morbidity and mortality, during 8 years of follow-up, the indication for invasive treatment should be carefully weighed against concomitant comorbidities and the timing of this treatment optimized with regard to the patient's possibilities to enjoy positive treatment effects on quality of life.

Objective: The objective of this study was to clarify whether the findings of the randomized studies of repair method (open aortic repair [OAR] vs endovascular aneurysm repair [EVAR]) concerning short-term and midterm survival for ruptured abdominal aortic aneurysms (RAAAs) could be confirmed in a contemporary, nationwide, and unselected population. Methods: This cohort study is based on prospectively collected data from Swedvasc, a nationwide vascular registry, including all 29 hospitals performing surgery for RAAA in Sweden (3 district, 19 county, and 7 university hospitals) during 2013 to 2015. All 702 patients operated on for RAAA during this time were included. Open surgery and endovascular repair, analyzed on the basis of individual patient repair (OAR vs EVAR) and hospital repair practice (OAR-only vs OAR/EVAR), were compared for short-term and midterm adjusted survival (0-90 days and 3 months-3 years). Results: Endovascular repair was used for 37% (260/702) of the aneurysms. The adjusted hazard ratio after OAR was 1.30 (0.95-1.77; P = .098; n = 702) for 0 to 90 days and 0.63 (0.43-0.93; P = .021; n = 491) for 3 months to 3 years of follow-up compared with EVAR. The adjusted hazard ratio for a practice of OAR-only was 0.73 (0.54-1.00; P = .047; n = 702) for 0 to 90 days and 0.68 (0.45-1.05; P = .080; n = 491) for 3 months to 3 years of follow-up compared with a practice of OAR/EVAR. No interaction between repair practice and short-term survival could be shown for either sex or age. Conclusions: An OAR/EVAR practice for RAAA is not superior to an OAR-only practice with respect to survival at short-term or midterm follow-up. The results are even compatible with an advantage of OAR-only practice vs OAR/EVAR practice for both follow-up periods. There is no extra benefit for either female or elderly patients with an OAR/EVAR practice.

BACKGROUND:Trauma survival prediction models can be used for quality assessment in trauma populations. The Norwegian survival prediction model in trauma (NORMIT) has been updated recently and validated internally (NORMIT 2). The aim of this observational study was to compare the accuracy of NORMIT 1 and 2 in two Swedish trauma populations.METHODS:Adult patients registered in the national trauma registry during 2014-2016 were eligible for inclusion. The study populations comprised the total national trauma (NT) population, and a subpopulation of patients admitted to a single level I trauma centre (TC). The primary outcome was 30-day mortality. Model validation included receiver operating characteristic (ROC) curve analysis and GiViTI calibration belts. The calibration was also assessed in subgroups of severely injured patients (New Injury Severity Score (NISS) over 15).RESULTS:A total of 26 504 patients were included. Some 18·7 per cent of patients in the NT population and 2·6 per cent in the TC subpopulation were excluded owing to missing data, leaving 21 554 and 3972 respectively for analysis. NORMIT 1 and 2 showed excellent ability to distinguish between survivors and non-survivors in both populations, but poor agreement between predicted and observed outcome in the NT population with overestimation of survival, including in the subgroup with NISS over 15. In the TC subpopulation, NORMIT 1 underestimated survival irrespective of injury severity, but NORMIT 2 showed good calibration both in the total subpopulation and the subgroup with NISS over 15.CONCLUSION:NORMIT 2 is well suited to predict survival in a Swedish trauma centre population, irrespective of injury severity. Both NORMIT 1 and 2 performed poorly in a more heterogeneous national population of injured patients.

Trauma patients often suffer for long time after their injury with physical and psychological problems. Patient-reported outcome measurements (PROM) help us to understand outcomes beyond mortality. The aim of the study was to describe a sample of Swedish trauma patients, regarding their physical function, psychological morbidity, and quality of life after trauma. The study population was sourced from the Swedish Trauma Register: taking 1 month of data from five hospitals, over three consecutive years. 218 patients met the inclusion criteria, 147 data sets were used. Inclusion criteria included: age ≥ 18; New Injury Severity Scale (NISS) ≥ 9; and discharged alive. Data were collected at 3, 6, and 12 months after the trauma. EuroQol-5D (EQ-5D), Posttraumatic Symptom Scale-10 (PTSS-10) questionnaires and Glasgow Outcome Score (GOS) instrument were used with additional questions about pain and return to work. 12 months after the trauma: full functional recovery (GOS 5) was seen in 68% of the patients; 59% reported difficult or moderate pain or discomfort; and 44.5% of the patients had returned to work. In EQ-5D mobility dimension, no recovery was evident between 6 and 12 months. Twenty percent of the patients had significant symptoms for PTSD after 6 months and 16% after 3 months and 12 months. Trauma patients had decreased physical function and psychological morbidity up to 1 year after the initial injury. Incorporating PROM in the follow-up after trauma is important to understand the patient’s perspective of care and treatment.

Key Clinical Message Neonatal aortic bifurcation thrombosis can cause occlusion of iliac arteries causing abnormal pelvic vasculature and claudication in childhood. A bifurcation graft normalizes the perfusion of the legs but not of the pelvis. In a girl, this does not preclude successful pregnancies in adult life. It has not been reported before.

Swedvasc is a registry for vascular surgical procedures, both open and endovascular. It was started in 1987 and since 1994 the whole population of Sweden is covered, at present around 10 million inhabitants. In a recent external validation, it was found to be highly accurate with abdominal aortic aneurysm surgery correctly reported in >96%. In this paper various factors explaining the almost 100% coverage are discussed, one important being that the registry has been developed and maintained within the profession of vascular surgery and not dictated by authorities. Another factor of importance is the possibility to use data in various research projects and so far 15 PhD theses have used Swedvasc data. To exemplify the practical use of the registry, the treatment of abdominal aortic aneurysms is scrutinized and among the various complications abdominal compartment syndrome is analyzed. Several significant temporal changes have been observed over the almost 25 years of Swedvasc: increasing use of endovascular surgery, treatment of aneurysms detected by screening , decreasing treatment for rupture, improved outcome, increasing treatment of older patients and patients with comorbid conditions. In conclusion, a high quality national vascular registry can be valid with high compliance and can be used to study population-based development of treatment and outcome. It can also be used to perform international comparisons with other registries, thereby getting an indication of the quality of care.

Background: Arm lymphedema is a well-recognized complication after breast cancer surgery that negatively impacts patients’ quality of life, both physiologically and psychologically. Lymph stasis and inflammation result in excess formation of adipose tissue, which makes removal of the deposited subcutaneous fat necessary to eliminate the excess volume. Liposuction, combined with postoperative controlled compression therapy (CCT), is the only treatment that gives complete reduction of the excess volume. The aim of this study was to evaluate the 5-year results after liposuction in combination with CCT. Methods: Patients consecutively operated on between 1993 and 2012 were identified from the lymphedema registry, comprising all patients with nonpitting lymphedema treated with liposuction and CCT in our department. Standardized forms were used to collect pre-, peri-, and postoperative data. Results: One hundred five women with nonpitting edema were treated. The mean interval between the breast cancer operation and lymphedema start was 2.9 ± 5.0 years, the mean duration of lymphedema was 10 ± 7.4 years, and the preoperative mean excess volume was 1,573 ± 645 ml. The mean volume aspirated was 1,831 ± 599 ml. Postoperative mean reduction 5 years postoperatively was 117% ± 26% as compared with the healthy arm. Conclusion: Liposuction is an effective method for the treatment of chronic, nonpitting, arm lymphedema resistant to conservative treatment. The volume reduction remains complete after 5 years.

Swedvasc is a registry for vascular surgical procedures, both open and endovascular. It was started in 1987 and since 1994 the whole population of Sweden is covered, at present around 10 million inhabitants. In a recent external validation, it was found to be highly accurate with abdominal aortic aneurysm surgery correctly reported in >96%. In this paper various factors explaining the almost 100% coverage are discussed, one important being that the registry has been developed and maintained within the profession of vascular surgery and not dictated by authorities. Another factor of importance is the possibility to use data in various research projects and so far 15 PhD theses have used Swedvasc data. To exemplify the practical use of the registry, the treatment of abdominal aortic aneurysms is scrutinized and among the various complications abdominal compartment syndrome is analyzed. Several significant temporal changes have been observed over the almost 25 years of Swedvasc: increasing use of endovascular surgery, treatment of aneurysms detected by screening , decreasing treatment for rupture, improved outcome, increasing treatment of older patients and patients with comorbid conditions. In conclusion, a high quality national vascular registry can be valid with high compliance and can be used to study population-based development of treatment and outcome. It can also be used to perform international comparisons with other registries, thereby getting an indication of the quality of care.

Abstracts Background: Arm lymphedema after breast cancer surgery affects women both from physical and psychological points of view. Lymphedema leads to adipose tissue deposition. Liposuction and controlled compression therapy (CCT) reduces the lymphedema completely. Methods and Results: Sixty female patients with arm lymphedema were followed for a 1-year period after surgery. The 36-item short-form health survey (SF-36) was used to assess health-related quality of life (HRQoL). Patients completed the SF-36 questionnaire before liposuction, and after 1, 3, 6, and 12 months. Preoperative excess arm volume was 1365 ± 73 mL. Complete reduction was achieved after 3 months and was sustained during follow-up. The adipose tissue volume removed at surgery was 1373 ± 56 mL. One month after liposuction, better scores were found in mental health. After 3 months, an increase in physical functioning, bodily pain, and vitality was detected. After 1 year, an increase was also seen for social functioning. The physical component score was higher at 3 months and thereafter, while the mental component score was improved at 3 and 12 months. Compared with SF-36 norm data for the Swedish population, only physical functioning showed lower values than the norm at baseline. After liposuction, general health, bodily pain, vitality, mental health, and social functioning showed higher values at various time points. Conclusions: Liposuction of arm lymphedema in combination with CCT improves patients HRQoL as measured with SF-36. The treatment seems to target and improve both the physical and mental health domains.

Objectives: Screening for abdominal aortic aneurysm (AAA) among 65 year old men has been proven costeffective, but nowadays is conducted partly under new conditions. The prevalence of AAA has decreased, and endovascular aneurysm repair (EVAR) has become the predominant surgical method for AAA repair in many centers. At the Malmo Vascular Center pharmacological secondary prevention with statins, antiplatelet therapy, and blood pressure reduction is initiated and given to all patients with AAA. This study evaluates the costeffectiveness of AAA screening under the above mentioned conditions.Methods: This was a Markov cohort simulation. A total of 4,300 65 year old men were invited to annual AAA screening; the attendance rate was 78.3% and AAA prevalence was 1.8%. A Markov model with 11 health states was used to evaluate cost-effectiveness of AAA screening. Background data on rupture risks, costs, and effectiveness of surgical interventions were obtained from the participating unit, the national Swedvasc Registry, and from the scientific literature.Results: The additional costs of the screening strategy compared with no screening were 169 per person and year. The incremental health gain per subject in the screened cohort was 0.011 additional quality adjusted life years (QALYs), corresponding to an incremental cost-effectiveness ratio (ICER) of 15710 per QALY. Assuming a 10% reduction of all cause mortality, the incremental cost of screening was 175 per person and year. The gain per subject in the screened cohort was 0.013 additional QALYs, corresponding to an ICER of 13922 per QALYConclusions: AAA screening remains cost-effective according to both the Swedish recommendations and the UK National Institute for Health and Care Excellence recommendations in the new era of lower AAA prevalence, EVAR as the predominant surgical method, and secondary prevention for all AAA patients. (C) 2016 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

Most nations with developed healthcare systems have a strong interest in audit, both for financial and clinical quality control. Whereas financial control has been a key political requirement for managing healthcare, the use of clinical outcome data has, until recently, taken more of a back seat. Clinical audit has a long history of describing outcomes and challenging established attitudes or practice.1Bridson E.Y. Iatrogenic epidemics of puerperal fever in the 18th and 19th centuries.Br J Biomed Sci. 1996; 53: 134-139PubMed Google Scholar Responses to published audits vary. Some clinicians voice criticism of bias as a result of selective reporting, either from a few units, or because of incomplete datasets.2Wyatt J. Acquisition and use of clinical data for audit and research.J Eval Clin Pract. 1995; 1: 15-27Crossref PubMed Scopus (29) Google Scholar Attitudes have gradually changed with improved understanding of the role of audit as a tool to examine and refine standards of practice.3Fowkes F.G. Medical audit cycle. A review of methods and research in clinical practice.Med Educ. 1982; 16: 228-238Crossref PubMed Scopus (35) Google Scholar This has been accompanied by a growth in clinical audit across all branches of medicine. The turn of the century marked a shift towards more widespread clinical audit, with development of political interest in using quality to justify or contain costs. The advent of organisations such as the National Institute for Clinical Excellence (NICE) in the UK saw a growth in the use of research and audit to set standards both for outcomes and processes of care. A good example of this in vascular surgery is the NICE clinical guideline 68, which sets out clear standards for assessment, referral, and treatment of patients with TIA and minor stroke.4Stroke: diagnosis and initial management of acute stroke and transient ischaemic attack (TIA). https://www.nice.org.uk/guidance/CG68.Google Scholar These standards are incorporated into national audits in Europe and reporting now encompasses both outcomes and performance indicators such as timeliness of surgery and cranial nerve injury.5http://www.vascularsociety.org.uk/wp-content/uploads/2014/04/UK-Carotid-Endarterectomy-Audit-Round-5-Report.pdf.Google Scholar Such reporting has driven improvement in quality of services by focussing clinicians on key components of high-quality pathways of care. Vascunet was formed in 1997 as a collaboration of national registries in Europe, New Zealand, and the state of Victoria in Australia, with its first report produced in 2007.6The first Vascular Surgery Database report 2007. www.esvs.org/committees/vascunet.Google Scholar, 7Björck M. Gibbons C.P. Jensen L.P. Laustsen J. Lees T. Moreno-Carilles R. et al.Vascular registries join to create a common international dataset on AAA surgery.Eur J Vasc Endovasc Surg. 2007; 34: 257-259Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar Since then, the Vascunet group have published comparative data on carotid surgery,8Menyhei G. Björck M. Beiles B. Halbakken E. Jensen L.P. Lees T. et al.Outcome following carotid endarterectomy: lessons learned from a large international vascular registry.Eur J Vasc Endovasc Surg. 2011; 41: 735-740Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar, 9Vikatmaa P. Mitchell D. Jensen L.P. Beiles B. Björck M. Halbakken E. et al.Variation in clinical practice in carotid surgery in nine countries 2005–2010. Lessons from VASCUNET and recommendations for the future of national clinical audit.Eur J Vasc Endovasc Surg. 2012; 44: 11-17Abstract Full Text Full Text PDF PubMed Scopus (74) Google Scholar abdominal aortic aneurysm,10Mani K. Lees T. Beiles B. Jensen L.P. Venermo M. Simo G. et al.Treatment of abdominal aortic aneurysm in nine countries 2005–2009: a Vascunet report.Eur J Vasc Endovasc Surg. 2011; 42: 598-607Abstract Full Text Full Text PDF PubMed Scopus (161) Google Scholar lower limb bypass,11Björck M. Beiles B. Menyhei G. Thomson I. Wigger P. Venermo M. et al.Editor's choice: contemporary treatment of popliteal artery aneurysm in eight countries – a report from the VASCUNET collaboration of registries.Eur J Vasc Endovasc Surg. 2014; 47: 164-171Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar and popliteal artery aneurysm.12Lees T. Troeng T. Thomson I.A. Menyhei G. Simo G. Beiles B. et al.International variations in infrainguinal bypass surgery – a VASCUNET report.Eur J Vasc Endovasc Surg. 2012; 44: 185-192Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar One of the key features of these publications has been to describe the variation in clinical practice across neighbouring countries, notable examples being rates of surgery for asymptomatic stenosis and rates of lower limb bypass for intermittent claudication. Variation in outcomes is also reported at a national level. The value of such reporting was demonstrated by the 2008 Vascunet report. This demonstrated outlying mortality rates after elective repair of abdominal aortic aneurysm surgery in the UK.13Second Vascunet database report 2008. http://www.esvs.org/journal/vascunet.Google Scholar This was a stimulus to a quality improvement initiative14Abdominal aortic aneurysm, improving outcomes for patients. http://www.health.org.uk/areas-of-work/programmes/closing-the-gap-through-clinical-communities/related-projects/abdominal-aortic-aneurysm-improving-outcomes-for-patients/.Google Scholar that sought to standardise practice and improve outcomes. The transparent publication of standards led to their widespread adoption both by clinicians and service commissioners within the UK. Recent publications have demonstrated a marked improvement in UK outcomes.15Outcomes after elective repair of infra-renal abdominal aortic aneurysm. http://www.vsqip.org.uk/wp/wp-content/uploads/2013/12/Outcomes-after-Elective-Repair-of-Infra-renal-Abdominal-Aortic-Aneurysm.pdf.Google Scholar This cycle of audit, analysis, standard setting, and re-audit demonstrates the improvement in quality that can follow acknowledgement of poor outcomes. This experience mirrors those in other clinical specialities such as cardiothoracic surgery. Comparative audits suffer from a number of shortcomings, such as incomplete datasets with potential for bias and misleading interpretation. Most national registries rely on voluntary data contributions from practising clinicians who have varying levels of enthusiasm for audit. It is widely acknowledged that incomplete audit data is a source of bias and may give misleading messages. This has allowed some to ignore the messages from comparative audit, and may be the explanation behind some countries not wishing to participate in data analysis and publication. The recognition of this issue leads to the linking of Swedvasc (and the Helsinki datasets in Finland) data to national administrative datasets to improve accuracy. Similarly in the UK, data for carotid and aortic aneurysm procedures are now compared with national administrative datasets to demonstrate the quality of data. A secondary benefit has been an improvement in data quality, presumably as a result of peer pressure. Vascunet has recently taken this further with external validation of data subsets in Hungary 16Bergqvist D. Bjorck M. Lees T. Menyhei G. Validation of the VASCUNET registry-pilot study.Vasa. 2014; 43: 141-144Crossref PubMed Scopus (25) Google Scholar and Sweden (ongoing project). This pilot demonstrated that national datasets can be validated by expatriate experts, providing an independent and even more robust measure of data quality. It is planned to extend this throughout the Vascunet registries group, if funding can be found. Clinical audit data is one important source of information, about routine clinical practice, that can be used to highlight inconsistencies in clinical outcomes. The use of data, however incomplete, as an agent for change and as a guide for standard setting is established. We believe that the use of national audit data should be extended to drive quality improvement across geographical boundaries. There are significant challenges to achieving this, but Vascunet believes that the time is right to embrace this. With increasing financial constraints on healthcare, clinicians need to be seen to lead on issues of quality of care. Part of this requires an open approach to measuring the standards of care, with the aim of improvement, rather than criticism. We believe that we have the support of patients in this aim and that transparent publication of data serves to both inform and educate in the debate about allocation of limited resources. There is debate about what and how much data should be collected. Most enthusiasts approach clinical audit wishing to obtain a large amount of data to enable a detailed analysis of behaviour. The problem with this approach is that it inevitably relies on busy clinicians collecting the data, often after delivery of care. Unsurprisingly, the levels of enthusiasm for this vary hugely, with some seeing it as an intrusion on their relationship with the patient. The end result is incomplete and unreliable datasets and limited reporting. An alternative is to collect small amounts of data about critical steps in the patient pathway of care. Such “key performance indicators” (KPI) can be linked to nationally collected administrative data to provide a moderately detailed account of the process of care. An example of this is seeking both outcome data (stroke and death) following carotid endarterectomy and collecting data on symptom to treatment time, to provide a more balanced picture of the quality of care. The resultant “less is more” approach allows for small datasets to provide important information to clinicians. A number of factors determine how effective clinical audit is at changing clinician behaviours and patient outcomes. There is now a growing science around audit and feedback.17Ivers N. Jamtvedt G. Flottorp S. Young J.M. Odgaard-Jensen J. French S.D. et al.Audit and feedback: effects on professional practice and healthcare outcomes.Cochrane Database Syst Rev. 2012 Jun 13; 6: CD000259https://doi.org/10.1002/14651858.CD000259.pub3Crossref PubMed Scopus (906) Google Scholar, 18Ivers N.M. Sales A. Colquhoun H. Michie S. Foy R. Francis J.J. et al.No more ‘business as usual’ with audit and feedback interventions: towards an agenda for a reinvigorated intervention.Implement Sci. 2014; 9: 14Crossref PubMed Scopus (216) Google Scholar This states some factors that seem self-evident. For example there is evidence that audit and feedback can be made more effective by setting explicit goals and having a clear and realistic action plan, based on evidence about best practice. There needs to be clarity about the changes required and a commitment to multiple feedback cycles, with availability of peer group data for comparison. Repeated feedback delivered in both written and verbal format by people perceived to be part of the clinical team (i.e. part of the professional group) is much more effective in bringing about change than delivery by outside agencies (e.g. departments of health, commissioners of care). We believe that Vascunet can fill this role as it is made up of representatives from all participating audits. Open reporting of data in a manner designed to support and encourage change, can be used to drive quality improvement by focussing on a small number of measures associated with a quality service. This has now been happening in many countries for some years. This approach has been used successfully for some years in Sweden, the UK and parts of the USA to demonstrate the quality of service and drive up standards by placing this in the public domain. The focus has been on care delivery within each country. We believe that the next step is for outcomes data analysis and quality improvement in vascular surgery to cross national boundaries, by common reporting of KPI for core vascular procedures. This is why Vascunet has begun validating national registries and has formed links with the North American Society of Vascular Surgery Quality Initiative (SVS-QI). What is now required is clinical support to agree that it is in both our and our patients' best interests to support a broadening of clinical audit to provide quality feedback across Europe. This will involve defining agreed datasets and seeking financial support to set up a data centre for analysis and reporting. Data collection should remain a local activity, owned by units and national societies, each committed to collaboration within the Vascunet group. We believe that the time is ripe to use the European registry experience to develop quality improvement initiatives throughout the European society nations and share our experiences openly to the benefit of our patients and clinical practices.

Objective: Few studies have been published on the safety of carotid endarterectomy (CEA) after intravenous thrombolysis (IVT). Registry reports have been recommended in order to gather large study groups.Design: A retrospective, registry based, case controlled study on prospectively gathered data from Sweden, the capital region of Finland, and from Denmark, including 30 days of follow up.Methods: The study group was a consecutive series of 5526 patients who had CEA for symptomatic carotid artery stenosis during a 4.5 year period. Among these, 202 (4%) had IVT prior to surgery, including 117 having CEA within 14 days, and 59 within 7 days of thrombolysis. IVT as well as CEA were performed following established guidelines. The median time from index symptom to CEA was 12 days (range 0-130, IQR 7-21).Results: The 30 day combined stroke and death rate was 3.5% (95% Cl 1.69-6.99) for those having IVT + CEA, 4.1% (95% Cl 3.46-4.39) for those having CEA without previous IVT (odds ratio 0.84 [95% CI 0.39-1.81]), 3.4% (95% Cl 1.33-8.39) for those having IVT + CEA within 14 days, and 5.1% (95% Cl 1.74-13.91) for those having IVT + CEA within 7 days.Conclusion: Data on the time from symptoms to CEA in patients not having IVT, Rankin score, degree of stenosis, and cerebral imaging were not available. Despite its weaknesses, this study reasserts that CEA can be performed within the recommended 2 weeks of the onset of symptoms and IVT without increasing the risk of pen-operative stroke or death. Centres and vascular registries are recommended to continue monitoring changes in patient characteristics, lead times, and major complications after CEA in general, with a special focus on those who have undergone a prior thrombolysis. (C) 2014 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

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.