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Meta-Analysis
. 2017 Mar 14;6(3):e004913.
doi: 10.1161/JAHA.116.004913.

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

Alex Bottle  1 , Giovanni Mariscalco  2 , Matthew A Shaw  3 , Umberto Benedetto  4 , Athanasios Saratzis  5 , Silvia Mariani  5 , Mohamad Bashir  6 , Paul Aylin  1 , David Jenkins  7 , Aung Y Oo  8 , Gavin J Murphy  5 ; UK Aortic Forum
Collaborators, Affiliations
Meta-Analysis

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

Alex Bottle et al. J Am Heart Assoc. .

Abstract

Background: Thoracic 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 results: Data 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.

Conclusions: Changes 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.

Keywords: aortic disease; aortic dissection; cardiac surgery; quality of care.

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Figures

Figure 1
Figure 1
Geographical variation by county across England with reference to treatment rates in patients diagnosed with thoracic aortic disease (left panel), 6‐month mortality in treated (mid panel) and untreated (right panel) patients. From HES (Hospital Episodes Statistics) cohort data.
Figure 2
Figure 2
Percentage of patients affected by thoracic aortic disease (TAD) by county and urgency of the operation received (elective vs emergent). From HES (Hospital Episodes Statistics) cohort data.
Figure 3
Figure 3
Activity (total number of procedures) (A) and in‐hospital mortality rate (B) by center, by most distal aortic segment; patient risk profile by center expressed by EuroSCORE II (C). From NACSA (National Adult Cardiac Surgery Audit) cohort data. Results of the national survey assessing current service organization for thoracic aortic disease in cardiac surgery centers across England; surgeons were queried on the presence of a dedicated aortic team, a specific on‐call rota for thoracic aortic disease, a hybrid theater, and an aortic multidisciplinary team (MDT) recognized in the consultant job plan (D): The presence of a vertical bar for a given center means that that center had the particular feature given in the chart key.
Figure 4
Figure 4
Forest plot with unadjusted (top) and adjusted (bottom) risk estimates for in‐hospital/30‐day mortality in high‐ versus low‐volume hospitals. OR indicates odds ratio.
See this image and copyright information in PMC

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