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Patient outcome alone does not justify the centralisation of vascular services
S J Cook1, M D Rocker, M R Jarvis
1Department of Vascular Surgery, Royal Surrey County Hospital, Guildford, UK.
Insights
Patient outcomes in a single-consultant vascular unit were found to be equivalent to those in larger centers. This study suggests that centralizing vascular services may not improve patient outcomes.
Area of Science:
- Vascular Surgery
- Health Services Research
- Surgical Outcomes
Background:
- The Vascular Surgical Society recommends centralizing vascular services into units with at least four consultants.
- This recommendation is based on presumed benefits in patient care, resource utilization, and consultant coverage.
- The Royal Surrey County Hospital (RSCH) has operated with a single vascular consultant since April 1998, supplemented by cross-district cover.
Purpose of the Study:
- To evaluate patient outcomes at the RSCH vascular unit using P-POSSUM analysis.
- To compare these outcomes with published P-POSSUM data from a major vascular unit in Leeds.
Main Methods:
- Analysis of all patients undergoing major vascular surgery or amputation between April and November 1998.
- Utilized P-POSSUM (Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity) for outcome prediction.
Main Results:
- 86 patients underwent 102 procedures across 92 admissions with 100% data retrieval.
- Observed to Expected (O:E) mortality ratio was 0.80 (predicted 16, observed 13).
- Observed to Expected (O:E) morbidity ratio was 0.73 (predicted 26, observed 19). The O:E mortality ratio from Leeds was 0.83.
Conclusions:
- Patient outcomes at a single-handed vascular unit with cross-district cover are comparable to those in major vascular centers.
- Centralization of vascular services is not demonstrably justified by improved patient outcomes based on this analysis.
Background:
The Provision of Vascular Services document from the Vascular Surgical Society of Great Britain and Ireland argues for the centralisation of vascular services into units served by a minimum of four vascular consultants. The rationale for this is the presumed advantages of improved patient care, better utilisation of resources and a more comprehensive arrangement of consultant vascular cover. Since April 1998, the Royal Surrey County Hospital (RSCH) has had a single-handed vascular consultant with out-of-hours cross-district consultant vascular cover.
Objectives:
To use P-POSSUM analysis to determine patient outcome from the RSCH vascular unit, and to compare these with previously published P-POSSUM analysis from a major vascular unit in Leeds.
Patients And Methods:
All patients undergoing major vascular surgery or amputation between April and November 1998 were analysed.
Results:
86 patients underwent 102 surgical procedures in 92 separate admissions. Data retrieval was 100%. Predicted (E) mortality 16 cases; observed (O) mortality 13 cases; O:E ratio 0.80. Predicted morbidity 26 cases; observed morbidity 19; O:E ratio 0.73. O:E ratio for mortality from Leeds = 0.83.
Conclusions:
Patient outcome in a single-handed vascular unit, with cross-district consultant cover, is equivalent to that found in a major vascular unit. Centralisation of vascular services cannot be justified on the basis of differences in patient outcome.