The NVR is commissioned by the Healthcare Quality Improvement Partnership (HQIP) as part of the National Clinical Audit and Patient Outcomes Programme and is designed to support quality improvement within NHS hospitals performing vascular surgery by providing information on their performance. The 2018 Annual Report is the sixth since the NVR was launched in 2013 and reports data primarily from 2017. In this summary we present of those data with direct relevance to vascular anaesthetists. The full report is available on the website.
1) Elective infra-renal AAA
There were 4208 elective infra-renal AAA repairs in 2017:
1338 (32%) by open repair (OR)
2870 (68%) by endovascular repair (EVAR)
Overall in-hospital mortality rates:
Patients having OR were more susceptible to respiratory complications and renal failure, and the rate of return to theatre was also higher
Postoperative admission to critical care:
OR 97.6%, median length of stay of 2 days
EVAR 35.1%, median length of stay 1 day
Readmission within 30 days:
Average length of stay:
OR 8 days
EVAR 2 days
Overall compliance with standards related to the elective AAA care pathway (Percentage of patients meeting standard)
|Elective patients were discussed at MDT meetings||83.0||78.3||74.4|
|Patients underwent a formal anaesthetic review||96.3||96.6||96.0|
|Patients whose anaesthetic review was done by a consultant vascular anaesthetist||91.6||91.9||92.2|
|Patients had their fitness measured||84.7||83.9||82.2|
|Most common assessment methods:|
Echo +/- pulmonary function tests
2) Ruptured AAA
Despite the national screening programme, the number of aneurysm ruptures remains high, with 2,682 cases from January 2015 to December 2017.
Over this period, the choice of EVAR has remained static for ruptured AAA (approximately 30% compared to 70% for elective repair).
Patients undergoing EVAR for ruptured AAA had a lower in-hospital postoperative mortality compared to OR (22.9% and 42.3%, respectively). Direct comparison of these figures is difficult and the open procedures may represent the more complex cases. All NHS trusts demonstrated postoperative in-hospital mortality rates within the expected range.
There has been some concern that outcomes are worse for patients having surgery at the weekend. The in-hospital mortality rates for ruptured AAA repairs performed on weekdays and at the weekend were 35.2% and 39.4%, but the difference was not statistically significant
Vascular units should evaluate how access to EVAR can be improved for emergency repair of ruptured aneurysms. This may require review of anaesthetic as well as surgical aspects of the care pathway.
A total of 4,148 carotid interventions were submitted to the NVR in 2017. The number of procedures recorded in the NVR has decreased significantly (a 15% drop in two years). This seems to reflect a fall in activity rather than a reduction in case-ascertainment.
The median time from symptoms to surgery decreased from 13 days in 2016 to 12 days in 2017. However, there remains significant variation between NHS trusts, with the median delay ranging from 4 days to 36 days.
93% of patients were on antiplatelet agents and 39% of these received local/regional anaesthesia block
54.6% of procedures involved the use of a shunt.
Medication for cardiovascular conditions was common among patients prior to surgery. Overall, 87.6% were taking statins. ACE inhibitors and beta-blockers were being taken by 37.9% and 24.1% of patients, respectively.
Surgical outcomes continue to be good and estimated rates of significant complication are low (see full report for more details).
Areas of improvement highlighted by the report were:
Time from symptoms to surgery. The benefit of surgery is much lower for most patients once 14 days have elapsed from the presenting symptoms. There was considerable variation in the median time to surgery during 2017. The median was 14 days or less for 58 of the 78 organisations and the median exceeded 20 days for 8 vascular units (half the number found in 2016).
Case volume. There is a documented volume-outcome relationship between case volume and clinical outcomes for CEA. The VSGBI provision of services document recommends that vascular units perform a minimum of 40 CEA per annum. In 2017, over 33 units did not meet this standard. Further reconfiguration of services may be required, given the decreasing national caseload.
1) Lower limb bypass
NHS hospitals submitted 17,475 open surgical bypass procedures to the NVR:
The report assessed whether the rate of in-hospital mortality differed for operations that occurred during the weekend compared with those performed on weekdays.
The in-hospital mortality rates for emergency admissions performed on weekdays and at the weekend were 5.0% and 7.8%, but the difference was not statistically significant
2) Major lower limb amputation
Over the three-year data collection period, 9,293 major lower limb amputations were entered into the NVR.
All the NHS trusts had a risk adjusted rate of in-hospital death that fell within the expected range.
The VASGBI Research & Audit Committee has been actively involved in negotiations to amend some of the Anaesthesia data fields on the NVR. These had finally been agreed and will be implemented in January 2019. This would enable us to produce reports with more information on aspects of practice relevant to vascular anaesthesia. The NVR is a rich data source that can be used for both audit and research and it allows reports that can be used for appraisals. We encourage our members to actively engage with the NVR.
Drs Elisa Dedola, Adam Pichel & Ronelle Mouton
Research and Audit Committee, VASGBI, November 2018