The importance of structures and processes in determining outcomes for abdominal aortic aneurysm repair: an...

Annual procedural mortality reports have become mandatory for vascular surgery in England, reflecting a more widespread appetite for transparency and accountability across the National Health Service (NHS) [BMJ 2013;346:f854]. The outcomes of abdominal aortic aneurysm (AAA) repair, in particular, have attracted considerable commentary: from 1999 to 2006, postoperative mortality was higher in England than in many other countries (7.9 vs. 1.9-4.5%) [European Society for Vascular Surgery. 2nd Vascunet Report. 2008]. This stimulated considerable service reconfiguration (centralization), quality improvement initiatives, the uptake of endovascular technology, and the examination of institution-level mortality data [http://www.vascularsociety.org.uk/library/quality-improvement.html], which resulted in a fall in elective AAA mortality to 1.8% by 2012 [http://www.hqip.org.uk/assets/NCAPOP-Library/NCAPOP-2013-2014/Outcomes-after-Elective-Repair-of-Infra-renal-Abdominal-Aortic-Aneurysm.pdf (February 2015)]. Despite improvements at a national level, the outcomes of AAA repair vary considerably between different hospitals in the NHS [Circ Cardiovasc Qual Outcomes 2014;7:131-141], analogous to interprovider variation that has been reported across a range of emergency medical and surgical conditions [BMC Health Serv Res 2014;14:270]. This suggests that underlying institution structures and processes contribute independently to patients' outcomes. There is also considerable evidence that the outcomes of AAA repair vary in different healthcare systems, both in the elective European Society for Vascular Surgery, 2008 and emergency settings. A consideration of the role of structures and processes in influencing outcomes for AAA repair can be conducted across different institutions or even different healthcare systems. This can help identify which factors are consistently associated with the best outcomes, informing efforts to better organize and deliver services for patients requiring vascular surgery.