Vascular Surgeons: Leading the Way in Global Quality Improvement
Authors: Ron Fairman
Journal: Circulation (2016)

he development of vascular registries and practice guidelines by the Society for Vascular Surgery (SVS) and the European Society for Vascular Society (ESVS) represent a major step forward in achieving the goals of best practice and quality outcomes for patients with major vascular diseases.The report in this issue of Circulation by Beck et al 1 analyzes international variation in the contemporary management of abdominal aortic aneurysms (AAAs) with registry data from 11 countries across 3 continents in relation to 2 recommended treatment guidelines from the SVS and the ESVS.This ambitious project represents a collaboration of national quality improvement registries participating in the International Consortium of Vascular Registries.The IVCR was founded in 2014 2 as a partnership of ˃12 national registries, including the SVS's Vascular Quality Initiative (VQI) and the Vascunet program of the ESVS.The US Food and Drug Administration, through its Medical Device Epidemiology Network, 3 also participates in the IVCR, along with manufacturers and other stakeholders, with a coordinating center housed at Cornell University.The International Consortium of Vascular Registries mission is to provide a collaborative platform through which "registries around the world can share data to improve vascular health care."The current article represents a retrospective International Variations in Vascular Surgery project to compare treatment type (open vs endovascular) and patient selection between and within countries.Analysis of 51 153 patients undergoing open and endovascular AAA repair (both intact and ruptured) during a contemporary 3-year period revealed significant variation in the management of AAA despite relatively homogenous guidelines from the SVS and the ESVS.The most notable variations existed for the diameter of intact AAAs at repair, the utilization of endovascular (EVAR) versus open repair, and the treatment of elderly (octogenarian) patients.Of note, in addition to the among-country variations observed, significant variations were present among centers in each country in terms of EVAR use and rate of small AAA repair.EVAR use was more frequent in those countries that more frequently treated small AAAs.In addition, in those countries with a fee-for-service reimbursement model, the proportion of small AAA and octogenarians undergoing repair of intact aneurysms was higher than in countries with population-based reimbursement.The authors provocatively suggest that this differential management may be based on positive financial incentives.Both the SVS and ESVS societal guidelines recommend a uniform size threshold of 5.5 cm for intact AAA repair in men and slightly lower in women (5.0 cm SVS, 5.2 cm ESVS). 4,5The authors provide referenced support for these parameters.Yet the guidelines of both the SVS and the ESVS include aneurysm growth of >1 cm/year as an indication for intact AAA repair, and in this regard registry data are lacking.Although it has been assumed that growth rate influences rupture risk irrespective of aneurysm diameter, this theory has not been definitely proven.The SVS guide-Vascular Surgeons leading the Way in Global Quality improvement