Abdominal Aortic Aneurysm (AAA) Screening. Date: 7 March 2017 Version: 1.0

Transcription

1 Information Services Division/ National Specialist and Screening Services Directorate Abdominal Aortic Aneurysm (AAA) Screening Guidance and information on the key performance indicators (KPIs) for the Abdominal Aortic Aneurysm screening programme Date: 7 March 2017 Version: 1.0 Page 1 of 30

2 Contents Introduction 3 Background 3 Review 4 Reporting 4 Roles and responsibilities 4 Data collection and analysis 4 AAA Screening Programme: Key Performance Indicators (KPIs) 5 AAA Screening Programme: KPI definitions 6 Appendix 1: Glossary 28 Page 2 of 30

3 Introduction The Scottish Abdominal Aortic Aneurysm (AAA) screening programme aims to reduce deaths associated with the risk of aneurysm rupture in men aged 65 and over by identifying aneurysms early so that they can be monitored or treated. The screening test is a simple ultrasound scan of the abdomen which takes around 10 minutes. The programme invites men for screening during the year they turn 65, while men over 65 who have not previously been screened can self-refer. Most men have a normal result and are discharged from the screening programme. Men with detected small aneurysms are invited for annual surveillance screening and men with detected medium aneurysms are invited for quarterly surveillance screening, to check the size of the aneurysm. Men with large aneurysms are referred to vascular specialist services. Further information on the AAA screening programme in Scotland can be found on the NHS Inform website. This document presents the definitions for the Key Performance Indicators (KPIs) for the Scottish AAA Screening Programme, along with the criteria used for their calculation. KPI data will be published annually by Information Services Division (ISD) to provide a high level view of the quality and performance of the screening programme in Scotland. This is the first version of the KPI definitions. Background The Key Performance Indicators for the Scottish AAA screening programme are intended to offer a focus on aspects of the patient journey from invitation, through the delivery of the scan, to referral for clinical assessment, to outcome of surgical intervention if this is required. These KPIs are aligned to the Abdominal Aortic Aneurysm (AAA) Screening Programme Clinical Standards (Healthcare Improvement Scotland, April 2011). The KPIs are not intended to cover all aspects of the AAA Screening programme nor the detail of any subsequent surgical intervention. They are designed to assess critical achievement of aspects of the screening pathway: Invitation; Attendance; Quality of screening, Referral; Clinical Intervention; and Outcomes. The purpose of reporting achievement of the KPIs is to give a high level view of the performance of the AAA screening programme, act as a driver for continuous improvement, and to direct specific review of any areas that (from the KPIs) appear to be underperforming. Each KPI has two thresholds: Essential: the minimum level of performance which the screening programme is expected to attain. All services should be achieving the essential criteria set out in each KPI. Any concern should lead to immediate action by the host NHS Board with support from National Specialist and Screening Services Directorate (NSD) as required. Desirable: the screening programme should aspire towards attaining and maintaining performance at this level. Full achievement of the desirable threshold should indicate a high performing service. Page 3 of 30

4 Review The Scottish AAA screening programme Key Performance Indicators will be reviewed on an annual basis. Reporting The KPI data will be produced every six months. Data will be published annually to provide a high level view of the quality and performance of the screening programme in Scotland. Interim mid-year KPI data will be produced so that the programme can review progress. As these data will be provisional they will not be published in the public domain until data for the full financial year is available. Roles and responsibilities AAA Screening Governance & Quality Assurance Reference Group (SGQARG): responsible for agreeing, monitoring and signing off performance reports AAA Monitoring and Evaluation Group (MEG): responsible for reviewing data in the draft performance reports collated by ISD based on data supplied nationally. The MEG will provide advice on the KPI collection and submission process when required. National Specialist and Screening Services Directorate (NSD): responsible for reviewing KPI data in accordance with the standards and requirements of the programme Information Services Division (ISD): responsible for analysis and dissemination of KPI data, following submission, to inform governance and management of the programme NHS Board/Collaborative AAA programme: accountable and responsible for ensuring data and information is retained in-line with national guidance Data collection and analysis Data for the screening programme are derived from the Scottish AAA Call Recall System. This system facilitates the invitation of men for screening and records the results. It is used by all NHS Boards in Scotland. Some NHS Boards run the programme on a collaborative basis, for example NHS Fife and NHS Tayside operationally run the national programme as a collaborative. Information Services Division (ISD) receives data extracts from the system for the purpose of producing and publishing statistics on the AAA screening programme in Scotland. For queries relating to this document, please contact: nss.isdaaascreen@nhs.net Page 4 of 30

5 AAA Screening Programme: Key Performance Indicators (KPIs) Patient Journey Topic KPI Quality Measure Essential and Desirable criteria 1. Invitation and Attendance Completeness of offer 1.1 Percentage of eligible population who are sent an initial offer to screening before age 66 90% E 100% D 2.Minimising harm 3. Referral for assessment / Treatment Acceptance of Offer/ Uptake Quality of scan/ images/ samples/testing technique Timely treatment/ intervention by specialist, measured from first positive scan/referral 1.2 Percentage of men offered screening who are tested before age 66 and 3 months 1.3 Percentage of men offered screening who are tested before age 66 and 3 months by Scottish Index of Multiple Deprivation (SIMD) quintile 1.4a Percentage of annual surveillance appointments due where men are tested within 6 weeks of due date 1.4b Percentage of quarterly surveillance appointments due where men are tested within 4 weeks of due date 2.1a Percentage of screening encounters where aorta could not be visualised 70% E 85% D 70% E 85% D 90% E 100% D 90% E 100% D <3% E <1% D 2.1b Percentage of men screened where aorta could not be visualised <3% E <1% D 2.2 Percentage of images which failed the quality assurance audit and required immediate recall 3.1 Percentage of men with AAA 5.5cm seen by vascular specialist within two weeks of screening 3.2 Percentage of men with AAA 5.5cm deemed appropriate for intervention/operated on by vascular specialist within eight weeks <4% E <1% D 75% E 95%D 60% E 80% D of screening 4. Outcome Post-operative mortality day mortality rate following open elective AAA surgery <5% E <3.5% D day mortality rate following EVAR intervention <4% E <2% D Page 5 of 30

6 AAA Screening Programme: KPI definitions KPI 1.1 Objective Clinical Standard Patient Journey Thresholds Percentage of eligible population who are sent an initial offer to screening before age 66 Completeness of offer of initial screening among eligible population Standard 4: Participant eligibility Effective call arrangements are in place to ensure all men are invited for screening in the year following their 65 th birthday. Invitation and attendance Essential: 90% Desirable: 100% Denominator The number of men eligible for an initial screen. Men become eligible for screening when they reach 65 years of age and should be invited for screening before their 66 th birthday. As the measurement point for this KPI is men s 66 th birthday, the denominator is defined as men registered with a Community Health Index (CHI) number reaching age 66 in the financial year. Definitions In line with national guidance, the population of men eligible for initial screening does not include men: (i) Already on surveillance prior to roll-out of the screening programme (ii) Already screened with a negative discharge result (iii) Who have had an aneurysm repair (confirmed) (iv) Under surveillance at vascular services (confirmed) (v) Referred to vascular services (vi) Unfit for scanning (vii) Who are deceased (viii) Who are out of cohort. These men have ineligibility categories: (a) Transferred out of Scotland (b) Transferred out by CHI (c) Transferred out untraced (d) Deleted or marked for deletion (CHI) (e) Temporary residents (f) Gone Away, No Address Men who were sent an invite and then subsequently identified as ineligible will be excluded from the denominator, if this ineligibility commenced before Page 6 of 30

7 their 66 th birthday. Numerator The number of men sent a first invitation for an initial screen before their 66 th birthday. Equations Mitigations Equity impact Reporting Additional details for ISD/users of Scottish AAA Call Recall System Number of men sent a first invitation before their 66th birthday Number of men in eligible population reaching age 66 in the financial year An offer is assumed to be sent if an offer letter is printed from the Scottish AAA Call Recall System i.e. the date of invitation sent is the date the letter is printed. Some men can be added to the cohort shortly before they turned 66, for example because they moved in from outside Scotland. This may mean that it is not possible for the programme to achieve 100%. Hard to reach and vulnerable groups who may be most at risk of having an aneurysm may be the least likely to attend. Programmes should work to ensure that all men have equal opportunity to make an informed choice and have access to the service. Homeless populations difficult to invite. Reporting period: financial year of eligibility for initial screening Data presented by: NHS Board of residence Denominator: the number of men reaching age 66 in the financial year who are eligible for screening as defined above. Note men with any one of the above ineligibility categories will be excluded from the denominator if: The start date of ineligibility is before 66 th birthday The ineligibility category end date is null indicating the ineligibility is permanent. Men with temporary ineligibility categories, such as temporary deferment, are included in the denominator. Numerator: of the denominator cohort, the number of men sent a first invitation for an initial screen before their 66 th birthday i.e. date offer sent is before 66 th birthday. The date offer sent is the date the letter is printed from the Scottish AAA Call Recall System. Page 7 of 30

8 KPI 1.2 Objective Clinical Standard Patient Journey Thresholds Percentage of men offered screening who are tested before age 66 and 3 months To maximise uptake of initial screening in eligible population Standard 5: AAA screening uptake The uptake of AAA screening is maximised (within the principles of informed choice). Invitation and attendance Essential: 70% Desirable: 85% Denominator The number of men in the eligible population sent a first invitation for an initial screen before their 66 th birthday. Note: this denominator is equivalent to the numerator for KPI 1.1. Numerator The number of men who had an initial screen before they reached age 66 and 3 months. Definitions Men should be invited for screening before their 66th birthday however some men may reschedule their appointment or not attend their first screening appointment. Therefore the uptake of screening is measured at age 66 and 3 months, giving men a further 3 months to attend following their 66th birthday. Men are counted as having been tested if they have a screening result of positive, negative or nonvisualisation. Equation Mitigations Equity impact Reporting Number of eligible men tested before reaching 66 years and 3 months Number of eligible men sent an invite before their 66th birthday An offer is assumed to be sent if an offer letter is printed from the Scottish AAA Call Recall System i.e. the date of invitation sent is the date the letter is printed. Some men may choose to defer their initial screen which may lower the percentage screened before they reach 66 years and 3 months. Hard to reach and vulnerable groups who may be most at risk of having an aneurysm may be the least likely to attend. Programmes should work to ensure that all men have equal opportunity to make an informed choice and have access to the service. Reporting period: financial year of eligibility for initial screening Data presented by: NHS Board of residence Page 8 of 30

9 Additional details for ISD/users of Scottish AAA Call Recall System Denominator: the number of men eligible for screening sent a first invitation for an initial screen before their 66 th birthday i.e. date offer sent is before 66 th birthday. The date offer sent is the date the letter is printed from the Scottish AAA Call Recall System. Numerator: of the denominator cohort, the number of men who had an initial screen before reaching 66 years and 3 months of age. Men are included in the numerator if they have a final (or latest) initial screen result of positive, negative, or non-visualisation. This includes a small number of positive/negative results with a follow-up recommendation of immediate recall. Men who attended screening and have a result of technical failure are not included in the numerator. The technical failure result category covers attendances at clinics where, for example, screening could not take place due to equipment failure or the man declined screening during the attendance. Page 9 of 30

10 KPI 1.3 Objective Clinical Standard Patient Journey Thresholds Percentage of men offered screening who are tested before age 66 and 3 months, by Scottish Index of Multiple Deprivation (SIMD) quintile To maximise uptake of initial screening in eligible population Standard 5: AAA screening uptake The uptake of AAA screening is maximised (within the principles of informed choice). Invitation and attendance Essential: 70% Desirable: 85% Denominator The number of men in the eligible population in each SIMD quintile who were sent a first invitation for an initial screen before their 66 th birthday. Numerator The number of men in each SIMD quintile who had an initial screen before they reached age 66 and 3 months. Definitions Men should be invited for screening before their 66th birthday however some men may reschedule their appointment or not attend their first screening appointment. Therefore the uptake of screening is measured at age 66 and 3 months, giving men a further 3 months to attend following their 66th birthday. Men are counted as having been tested if they have a screening result of positive, negative or nonvisualisation. Equation Mitigations Equity impact Reporting Additional details for Number of eligible men in each SIMD quintile tested before reaching 66 years and 3 months Number of eligible men in each SIMD quintile sent an invite before their 66th birthday An offer is assumed to be sent if an offer letter is printed from the Scottish AAA Call Recall System i.e. the date of invitation sent is the date the letter is printed. Some men may choose to defer their initial screen which may lower the percentage screened before they reach 66 years and 3 months. Hard to reach and vulnerable groups who may be most at risk of having an aneurysm may be the least likely to attend. Programmes should work to ensure that all men have equal opportunity to make an informed choice and have access to the service. Reporting period: financial year of eligibility for initial screening Data presented by: NHS Board of residence Denominator: the number of men eligible for screening in each SIMD quintile sent a first invitation for an initial screen before their Page 10 of 30

11 ISD/users of Scottish AAA Call Recall System 66 th birthday i.e. date offer sent is before 66 th birthday. The date offer sent is the date the letter is printed from the Scottish AAA Call Recall System. Numerator: of the denominator cohort, the number of men in each SIMD quintile who had an initial screen before reaching 66 years and 3 months of age. Men are included in the numerator if they have a final (or latest) initial screen result of positive, negative, or nonvisualisation. This includes a small number of positive/negative results with a follow-up recommendation of immediate recall. Men who attended screening and had a result of technical failure are not included in the numerator. The technical failure result category covers attendances at clinics where, for example, screening could not take place due to equipment failure or the man declined screening during the attendance. Supplementary information The SIMD quintile used for this KPI is the 2016 SIMD Scotland level population-weighted quintile, which is derived by ISD from the postcode provided on the ISD data extract. This postcode data has some limitations as it relates to the man s home postcode on the CHI database at the time of the data extract and this was not necessarily the postcode where they lived at the time of invitation or screening. Page 11 of 30

12 KPI 1.4a Objective Clinical Standard Patient Journey Thresholds Definitions Equation Mitigations Equity impact Reporting Additional details for ISD/users of Scottish AAA Call Recall System Percentage of annual surveillance appointments due where men are tested within 6 weeks of due date To maximise uptake of surveillance screening Standard 4: Participant eligibility Effective recall arrangements are in place to ensure all men with screen-detected aneurysms are invited for surveillance. Invitation and attendance Essential: 90% Desirable: 100% Denominator The number of annual surveillance appointments due. Numerator The number of men tested within 12 months and 6 weeks of previous scan. Men are counted as having been tested if they have a screening result of positive, negative or nonvisualisation. Number of men tested within 12 months 6 weeks of previous scan Number of annual surveillance appointments due Men may choose to delay attendance Hard to reach and vulnerable groups who may be most at risk of having an aneurysm may be the least likely to attend. Programmes should work to ensure that all men have equal opportunity to make an informed choice and have access to the service. Reporting period: financial year of appointment(s) due date Data presented by: NHS Board of residence Denominator: the number of annual surveillance appointments due as derived from the date of the previous scan and the follow-up recommendation of the previous scan (i.e. recommendation of followup in 12 months). Men who have a relevant ineligibility category assigned with a start date between the time of their previous scan and before 12 months and 6 weeks later are not included in the denominator. The relevant ineligibility categories are: (i) AAA repaired (confirmed) (ii) AAA repaired (awaiting confirmation) (iii) Under surveillance at vascular services (confirmed) (iv) Under surveillance at vascular services (awaiting confirmation) (v) Referred to vascular services (vi) Unfit for scanning (vii) Deceased (viii) Out of cohort ineligibility categories: (a) Transferred out of Scotland (b) Transferred out by CHI (c) Transferred out untraced Page 12 of 30

13 (d) Deleted or marked for deletion (CHI) (e) Temporary residents (f) Gone Away, No Address (ix) Unsuitable for portable scanning (x) Negative result - discharge Men who are offered an invitation for screening but are found to be ineligible are removed from the numerator and denominator. Men with temporary ineligibility categories, such as temporary deferment, are included in the denominator. Numerator: of the denominator cohort, the number of men who were tested within 12 months and 6 weeks of previous scan. This is calculated as the number of men with date of screening minus date of previous screen 408 days. Note that tested is defined as men with a final (or latest) surveillance screen result of positive, negative, or nonvisualisation. This will include a small number of positive/negative results with a follow-up recommendation of immediate recall. Men who attended screening and had a result of technical failure are not included in the numerator. The technical failure result category covers attendances at clinics where, for example, screening could not take place due to equipment failure or the man declined screening during the attendance. Supplementary information Following each screen, the clock for the next screen is reset. There is no minimum date for the screen in the numerator, to allow for screens scheduled for the convenience of the man. For example, a man initially screened and added to the annual surveillance cohort on 2 June 2014 could have his next surveillance appointment early on 1 May 2015 for his convenience e.g. notified screening appointment office that he was going on an extended holiday. He would be counted in the denominator and numerator for this KPI for financial year 2015/16. The follow-up recommendation at his appointment on 1 May 2015 was to continue on annual surveillance so the clock is reset in the calculations. This means for the following financial year (2016/17), he will count in the denominator and if he is screened within 12 months and 6 weeks of 1 May 2015, he will be counted in the numerator. A few men will be counted more than once in the financial year. For example if a man had an initial scan on 3 April 2014 and a small aneurysm was detected he would be due for a follow-up surveillance appointment in 12 months. If his next scan was on 30 March 2015, he would be counted as being due for an annual surveillance appointment on 3 April 2015 (where he would have counted as having been tested due to the scan he received on 30 March 2015), and he would have a second appointment due on 30 March Both of these due dates fall within the financial year 2015/16. Page 13 of 30

14 KPI 1.4b Objective Clinical Standard Patient Journey Thresholds Definitions Equation Mitigations Equity impact Reporting Additional details for ISD/users of Scottish AAA Call Recall System Percentage of quarterly surveillance appointments due where men are tested within 4 weeks of due date To maximise uptake of surveillance screening Standard 4: Participant eligibility Effective recall arrangements are in place to ensure all men with screen-detected aneurysms are invited for surveillance. Invitation and attendance Essential: 90% Desirable: 100% Denominator The number of quarterly surveillance appointments due. Numerator The number of men tested within 3 months and 4 weeks of previous scan. Men are counted as having been tested if they have a screening result of positive, negative or nonvisualisation. Number of scans within 3 months 4 weeks of previous scan Number of quarterly surveillance appointments due Men may choose to delay attendance Hard to reach and vulnerable groups who may be most at risk of having an aneurysm may be the least likely to attend. Programmes should work to ensure that all men have equal opportunity to make an informed choice and have access to the service. Reporting period: financial year of appointment due date Data presented by: NHS Board of residence Denominator: the number of quarterly surveillance appointments due as derived from the date of the previous scan and the follow-up recommendation of the previous scan (i.e. recommendation of followup in 3 months). Men who have a relevant ineligibility category assigned with a start date between the time of their previous scan and before 3 months and 4 weeks later are not included in the denominator. The relevant ineligibility categories are: (i) AAA repaired (confirmed) (ii) AAA repaired (awaiting confirmation) (iii) Under surveillance at vascular services (confirmed) (iv) Under surveillance at vascular services (awaiting confirmation) (v) Referred to vascular services (vi) Unfit for scanning (vii) Deceased (viii) Out of cohort ineligibility categories : (a) Transferred out of Scotland (b) Transferred out by CHI Page 14 of 30

15 (c) Transferred out untraced (d) Deleted or marked for deletion (CHI) (e) Temporary residents (f) Gone Away, No Address (ix) Unsuitable for portable scanning (x) Negative result - discharge Men who are offered an invitation for screening but are found to be ineligible are removed from the numerator and denominator. Men with temporary ineligibility categories, such as temporary deferment, are included in the denominator. Numerator: of the denominator cohort, the number of scans within 3 months and 4 weeks of previous scan. This is calculated as the number of men with date of screening minus date of previous screen 120 days. Note: that tested is defined as men with a final (or latest) surveillance screen result of positive, negative, or non-visualisation. This will include a small number of positive/negative results with a follow-up recommendation of immediate recall. Men who attended screening and had a result of technical failure are not included in the numerator. The technical failure result category covers attendances at clinics where, for example, screening could not take place due to equipment failure or the man declined screening during the attendance. Supplementary information Following each screen, the clock for the next screen is reset. There is no minimum date for the screen in the numerator, to allow for screens scheduled for the convenience of the man. Each appointment due is counted and therefore most men are counted multiple times each financial year. For example if a man had an initial scan on 14 January 2015 and a medium aneurysm was detected, he would be due for a follow-up surveillance appointment in 3 months. This man would be expected to attend four surveillance appointments in the financial year 2015/16; his first surveillance appointment in April 2015, his second in July 2015, his third in October 2015 and his fourth in January His fifth surveillance appointment would be due in April 2016 and therefore falls in the following financial year 2016/17. Additionally a few men may be seen more than four times a year if, in the example used above, the man attends early for one of his appointments. For example if he attends his fourth appointment early on 29 December 2015 he would be due his fifth on 29 March In this example all five appointment due dates are counted in financial year 2015/16. Most men who enter or leave quarterly surveillance part way through the year will have less than four surveillance appointments due in the financial year. Page 15 of 30

16 KPI 2.1a Objective Clinical Standard Patient Journey Thresholds Definitions Equation Mitigations Equity impact Reporting Additional details for ISD/users of Scottish AAA Call Recall System Percentage of screening encounters where aorta could not be visualised Quality of scan/ images/samples/testing technique Standard 6: The AAA screening examination The quality of the AAA screening test analyses is continually assessed and monitored, and there is evidence of internal quality control, external quality assessment and quality assurance. Minimising harm Essential: <3% Desirable: <1% Denominator The total number of scans. This includes initial screens (cohort and self-referral) and surveillance scans. Numerator Screening results of positive, negative or nonvisualisation are included. The number of scans with a screening result of nonvisualisation. Number of scans where aorta could not be visualised Number of scans This KPI counts the number of scans and not the number of men scanned, and therefore some men will be counted more than once. If an aorta cannot be fully visualised at the first scan, men are offered a second scan. This means some of the men counted as a nonvisualisation in this KPI will have had a definitive negative or positive screening result at their second scan. Reporting period: financial year in which scan occurred Data presented by: NHS Board of screening Denominator: the number of scans with a screening result of: Positive Negative Non-visualisation Note there are a small number of positive or negative results with a follow-up recommendation of immediate recall. These are included in the denominator. Attendances at screening clinics with a result of technical failure are not included in the denominator. The technical failure result category indicates screening couldn t take place and the reasons include equipment failure or the man declined screening during the attendance. Numerator: of the denominator cohort, the number of scans with a result of non-visualisation. Page 16 of 30

17 KPI 2.1b Percentage of men screened where aorta could not be visualised Objective Clinical Standard Patient Journey Thresholds Quality of scan/ images/samples/testing technique Standard 6: The AAA screening examination The quality of the AAA screening test analyses is continually assessed and monitored, and there is evidence of internal quality control, external quality assessment and quality assurance. Minimising harm Essential: <3% Desirable: <1% Denominator The number of men screened. This includes initial screens (cohort and self-referral) and surveillance scans. Definitions Numerator Screening results of positive, negative or nonvisualisation are included. The number of men with at least one screen where the aorta could not be visualised. Equation Mitigations Equity impact Reporting Additional details for ISD/users of Scottish AAA Call Recall System Number of men with at least one scan result where aorta could not be visualised Number of men screened If an aorta cannot be fully visualised at the first scan, men are offered a second scan. This means some of the men counted as a nonvisualisation in this KPI will have had a definitive negative or positive screening result at their second scan. Reporting period: financial year in which scan occurred Data presented by: NHS Board of screening Denominator: the number of men with at least one screening result of: Positive Negative Non-visualisation Note there are a small number of positive or negative results with a follow-up recommendation of immediate recall. These are included in the denominator. Attendances at screening clinics with a result of technical failure are not included in the denominator. The technical failure result category indicates screening couldn t take place and the reasons include equipment failure or the man declined screening during the attendance. Numerator: of the denominator cohort, the number of men with at least one result of non-visualisation. Page 17 of 30

18 KPI 2.2 Objective Clinical Standard Patient Journey Thresholds Percentage of images which failed the quality assurance audit and required immediate recall Quality of scan/ images/samples/testing technique Standard 6: The AAA screening examination The quality of the AAA screening test analyses is continually assessed and monitored, and there is evidence of internal quality control, external quality assessment and quality assurance. Minimising harm Essential: <4% Desirable: <1% Denominator The number of scans that have been quality assured (audited). This includes initial screens (cohort and self-referral) and surveillance scans. Definitions Numerator The number of scans that failed the quality assurance audit and required immediate recall. Scans can fail the audit for a number of reasons: these are accuracy of calliper placement, image quality, angle and anatomy. Equation Mitigations Equity impact Reporting Additional details for ISD/users of Scottish AAA Call Recall System Number of scans with an audit result of "fail" and requiring immediate recall Number of scans with an audit result of "pass" or "fail" The data for this KPI should be interpreted with some caution due to data quality issues. The accuracy and comparability of the data on the quality assurance audit is dependent on the implementation of standardised approach to quality assurance. Some work has been undertaken by the screening programme to implement a standardised approach though further work is required is to review this and establish guidelines that will provide robust quality assurance data. This review may lead to a revision of the definition of this KPI. Reporting period: financial year in which scan occurred Data presented by: NHS Board of screening Denominator: number of scans with a quality assurance audit result i.e. pass or fail. Numerator: of the denominator cohort, the number of scans which failed the audit and required immediate recall. Supplementary information For a reporting period, there will be at a minimum lag of three months between the date the scan was selected for the audit and the date of reporting. For example, in any particular year, scans taken in the period 1 January to 31 March that are selected for audit on 1 April, Page 18 of 30

19 will not be included in this reporting period for this KPI until after 30 June to allow time for the images to be audited by lead screeners. After allowing for a minimum three month time-lag, any scans that were selected for the audit and have not been audited will not be included in this KPI. Page 19 of 30

20 KPI 3.1 Objective Clinical Standard Patient Journey Thresholds Definitions Percentage of men with AAA 5.5cm seen by vascular specialist within two weeks of screening To ensure high quality and timely intervention Standard 8: Referral and assessment Men with an AAA measuring 5.5cm are referred to a designated unit in accordance with the UK National Screening Committee Quality Standards and Service Objectives (2009). Referral for assessment / treatment Essential: 75% Desirable: 95% Denominator The number of men with AAA 5.5cm referred to vascular specialist services. This includes men in the eligible cohort and self-referrals from either initial screen or surveillance screen. Referrals made in error such that an appointment with vascular specialist services is not required are excluded from the denominator. All other referrals with AAA 5.5cm are included in the denominator, including men who were seen by vascular services and were determined to have been referred in error. Numerator The number of men where the number of days between the date of screening and the date first seen by vascular specialist services is 14 calendar days. Equation Mitigations Equity impact Reporting Additional details for ISD/users of Scottish AAA Call Recall System Number of men with AAA 5.5cm referred to vascular seen within 14 days of screening Number of men with AAA 5.5cm referred to vascular Men may choose to delay their appointments for longer than 14 days or decline the referral. Reporting period: financial year in which scan occurred Data presented by: NHS Board of residence Denominator: the number of men with AAA 5.5cm and the actual referral date is not null and the vascular referral outcome category is not referred in error: appointment with vascular service not required. Note: men who declined the referral or did not attend the outpatient appointment are included in the denominator. Numerator: of the denominator cohort, the number of men where date seen by vascular specialist services minus date of screening 14 calendar days (i.e. for the purposes of the calculation, date of Page 20 of 30

21 screening is day zero). Note: only men seen by vascular specialist services within 14 calendar days are included in the numerator. Men with planned appointments within 14 calendar days who did not attend the appointment are not included in the numerator. Supplementary information Only valid data is included i.e. where the date seen by vascular specialist services is recorded it must be date of screening. Data not meeting the criteria are excluded from the denominator and numerator. On the ISD data extract from the Scottish AAA Call Recall System there are two vascular referral outcome result variables which are (a) first outcome result and (b) final (latest) outcome result. This KPI is based on the final (latest) outcome result variable. In rare instances, a man could be referred to vascular services more than once in the time period being examined. In theory this could happen when a man is referred in error as determined by vascular services, is referred back to the screening programme for surveillance and then a later date is referred to vascular services with AAA 5.5cm. If this happens within the time period being examined for this KPI, then each referral will be included in the figures. Page 21 of 30

22 KPI 3.2 Objective Clinical Standard Patient Journey Thresholds Definitions Percentage of men with AAA 5.5cm deemed appropriate for intervention/operated on by vascular specialist within eight weeks of screening To ensure high quality and timely intervention Standard 9: Pre and post operative management All men assessed for an elective intervention will be managed in line with the UK National Screening Committee Quality Standards and Service Objectives (2009) Referral for assessment / treatment Essential: 60% Desirable: 80% Denominator The number of men with AAA 5.5cm referred to vascular specialist services and deemed appropriate for surgery. This includes men in the eligible cohort and self-referrals from either initial screen or surveillance screen. Men who were deemed appropriate for surgery and who deferred surgery, died before treatment, declined surgery or self-discharged are included in the denominator. Numerator The number of men where the number of days between the date of screening and the date of procedure 56 calendar days. Equation Mitigations Equity impact Reporting Additional details for ISD/users of Scottish AAA Call Recall System Number of men with AAA 5.5cm referred to vascular operated on within 56 days Number of men with AAA 5.5cm referred to vascular and deemed appropriate for surgery Reporting period: financial year in which scan occurred Data presented by: NHS Board of residence Denominator: the number of men with AAA 5.5cm and the vascular referral outcome category is one of the following: (i) Appropriate for surgery: declined surgery (ii) Appropriate for surgery: died before treatment (iii) Appropriate for surgery: self-discharge (iv) Appropriate for surgery: patient deferred surgery (v) Appropriate for surgery: AAA repaired and survived 30 days (vi) Appropriate for surgery: died within 30 days of treatment (vii) Appropriate for surgery: final outcome pending. (viii) Other final outcome, where a surgery type is recorded indicating the procedure was abandoned and the date of surgery has been recorded. Numerator: of the denominator cohort, the number of men where Page 22 of 30

23 date of procedure minus date of screening 56 calendar days (i.e. for the purposes of the calculation, date of screening is day zero). Where a date of procedure is not recorded it is assumed that the man did not have surgery within eight weeks. There will always be a sufficient time-lag in reporting to allow sufficient time for procedures within 56 days to be recorded. Supplementary information Only valid data is included i.e. where the date of procedure is recorded it must be date of screening. Data not meeting the criteria are excluded from the denominator and numerator. On the ISD data extract from the Scottish AAA Call Recall System there are two vascular referral outcome result variables which are (a) first outcome result and (b) final (latest) outcome result. This KPI is based on the final (latest) outcome result variable. This KPI is collated by date of screening so, as time progresses the number of men deemed appropriate for intervention, and therefore included in the denominator for a particular reporting period, will change slightly. For example, there will be some men with a large aneurysm who were screened in financial year 2015/16 that have a non-final vascular referral outcome of referred to other specialty and would therefore not included in the figures when this KPI is first reported. In time, if they are subsequently deemed appropriate for surgery by vascular services, these men would be included in this KPI in any subsequent update of the figures reported for financial year 2015/16. Page 23 of 30

24 KPI day mortality rate following open elective AAA surgery Objective Clinical Standard Patient Journey Thresholds Definitions Post-operative mortality Standard 10: Post operative outcomes Collaborative vascular centres receiving referrals from the AAA screening programme for assessment and possible treatment will meet national quality assurance standards Outcome Essential: <5% Desirable: <3.5% Denominator The number of men with AAA 5.5cm who had open elective AAA surgery following referral from screening programme. Includes men in the eligible cohort and self-referrals from either initial screen or surveillance screen. Numerator The number of men who died within 30 days of open elective surgery. Equation Mitigations Equity impact Reporting Number of men who died within 30 days of open elective AAA surgery Number of men who had open elective AAA surgery Includes all cause mortality so some deaths may not be as a result of complications following surgery or result from the man s AAA. Data are collated by financial year in which the scan occurred. Due to small numbers, for reporting purposes the data for several years are combined and presented at Scotland level only. Denominator: the number of men with AAA 5.5cm and surgery type is open and the vascular referral outcome category is one of the following: Appropriate for surgery: AAA repaired and survived 30 days Appropriate for surgery: died within 30 days of treatment Additional details for ISD/users of Scottish AAA Call Recall System Men with an outcome referral of Appropriate for surgery: final outcome pending at the time of reporting are not included in the denominator. Numerator: of the denominator cohort, the number of men with the vascular referral outcome category Appropriate for surgery: died within 30 days of treatment. Supplementary information Only valid data is included. The Appropriate for surgery: AAA repaired and survived 30 days and Appropriate for surgery: died within 30 days of treatment categories will be cross-validated with the date of procedure and date of death (where applicable). For the Page 24 of 30

25 purposes of the calculation, date of surgery is day zero. This KPI is collated by date of screening so, as time progresses the number of men who had open elective surgery, and are therefore included in the denominator for a particular reporting period, will change slightly. For example, there may be some men with a large aneurysm who were screened in financial year 2015/16 that have a non-final vascular referral outcome and would therefore not be included in the figures when this KPI is first reported. In time, some of these men may subsequently have open elective surgery and a final outcome recorded regarding 30 day mortality. These men will be included in this KPI in any subsequent update of the figures reported for financial year 2015/16. Page 25 of 30

26 KPI day mortality rate following EVAR intervention Objective Clinical Standard Patient Journey Thresholds Definitions Post-operative mortality Standard 10: Post operative outcomes Collaborative vascular centres receiving referrals from the AAA screening programme for assessment and possible treatment will meet national quality assurance standards Outcome Essential: <4% Desirable: <2% Denominator The number of men with AAA 5.5cm who had Endovascular Aneurysm Repair (EVAR) intervention following referral from the screening programme. Includes men in the eligible cohort and self-referrals from either initial screen or surveillance screen. Numerator The number of men who died within 30 days of EVAR intervention. Equation Mitigations Equity impact Reporting Additional details for ISD/users of Scottish AAA Call Recall System Number of men who died within 30 days of EVAR intervention Number of men who had EVAR intervention Includes all cause mortality so some deaths may not be as a result of complications following surgery or result from the man s AAA. Data are collated by financial year in which the scan occurred. Due to small numbers, for reporting purposes the data for several years are combined and presented at Scotland level only. Denominator: the number of men with AAA 5.5cm and surgery type is EVAR and the vascular referral outcome category is one of the following: Appropriate for surgery: AAA repaired and survived 30 days Appropriate for surgery: died within 30 days of treatment Men with an outcome referral of Appropriate for surgery: final outcome pending at the time of reporting are not included in the denominator. Numerator: of the denominator cohort, the number of men with the vascular referral outcome category Appropriate for surgery: died within 30 days of treatment. Supplementary information Only valid data is included. The Appropriate for surgery: AAA repaired and survived 30 days and Appropriate for surgery: died within 30 days of treatment categories will be cross-validated with the date of procedure and date of death (where applicable). For the Page 26 of 30

27 purposes of the calculation, date of surgery is day zero. This KPI is collated by date of screening so, as time progresses the number of men who had an EVAR intervention, and are therefore included in the denominator for a particular reporting period, will change slightly. For example, there may be some men with a large aneurysm who were screened in financial year 2015/16 that have a non-final vascular referral outcome and would therefore not be included in the figures when this KPI is first reported. In time, some of these men may subsequently have an EVAR intervention and a final outcome recorded regarding 30 day mortality. These men will be included in this KPI in any subsequent update of the figures reported for financial year 2015/16. Page 27 of 30

28 Appendix 1: Glossary Term Abdominal Aortic Aneurysm (AAA) Calliper placement Collaborative (of NHS Boards) Completeness of offer Communication Elective (surgery) Eligible Definition An abnormal expansion of the aorta, which if untreated it may enlarge further and rupture. A method used to calculate the size of an aneurysm. NHS Boards in different areas working together to provide health services. The proportion of those eligible for screening who are offered screening. Completeness of offer is a measure of how effectively a programme offers screening to the eligible population. An interchange that the individual is capable of understanding and acting upon. This may be in a variety of formats including verbal and/or written. Elective surgery is non-emergency surgery which has been planned in advance. The population that is entitled to an offer of screening. Men become eligible for screening when they reach 65 years of age. The eligible population does not include men who are excluded from screening in accordance with national guidance, such as men who have already had an aneurysm repair. Note that men on surveillance and men who self-referred fall outside this definition of eligible. Endovascular Aneurysm Repair (EVAR) Financial year Initial screen Negative result (from screening) Offer Open AAA surgery Population Positive result (from screening) A method of AAA repair by placing a graft within the aneurysm from a small cut in the groin. The year from 1 April to 31 March. The first screening(s) to detect an aneurysm. An indication following a test that the condition being screened for is low-risk / not suspected in a subject. A formal communication made by the screening service, giving a specific subject an opportunity to be tested. An operation to replace the swollen section of the aorta with an artificial piece of artery (graft). The overall population for which a screening service is responsible An indication following a test that the condition being screened is high-risk / suspected in a subject. A screen positive in AAA screening is a maximum anterio-posterior aortic diameter of greater than or equal to 3.0cm, measured across the interior lumen. Page 28 of 30

29 Quintile (SIMD/deprivation) Refer Reporting period Result Scan or screen (for AAA) Screener Screening Screening encounter Self-referral SIMD Deprivation quintiles each contain 20% of the total population in Scotland. Deprivation quintile 1 contains the 20% of the population living in the most deprived datazones (small geographical areas), while quintile 5 contains the 20% of the population living in the least deprived datazones. The process of securing further diagnosis / specialist assessment following a positive result from screening. The defined time period over which activities should be included in aggregate performance reporting. Most screening processes occur over a period of days or weeks, to allow a scan or sample to be assessed. In such cases, a single point in the process (such as the screening encounter) should be used to determine whether the process falls within a particular reporting period. A formal and completed assessment of the risk of a condition being screened for in a subject, following a screening encounter. There are five possible results from AAA screening: Normal (negative): Aortic diameter less than 3.0cm Small AAA (positive): Aortic diameter between 3.0 and 4.4cm Medium AAA (positive): Aortic diameter between 4.5 and 5.4cm Large AAA (positive): Aortic diameter of 5.5cm or greater Non-visualisation: Aorta cannot be fully visualised A screening encounter where the subject is tested for AAA (ultrasound scan of abdomen) A healthcare professional responsible for administering screening tests. Testing people who do not have or have not recognised the signs or symptoms of the condition being tested for, either with the aim of reducing risk of an adverse outcome, or with the aim of giving information about risk. The provision of screening to a screening subject, usually through a process such as a scan or the collection of a sample. A screening encounter is usually characterised by contact between the screening subject and a healthcare professional, but some screening may be self-administered. Man over the age of 65 who has not been screened previously, who contacts their local AAA screening centre directly to request screening. Scottish Index of Multiple Deprivation The Scottish Index of Multiple Deprivation (SIMD) is the Scottish Government's official tool for identifying those places in Scotland suffering from deprivation. It incorporates several different aspects of deprivation, combining them into a single index. It is used for a wide range of purposes including as a statistical classification for measuring and monitoring inequalities in health and healthcare activity. Page 29 of 30