Abdominal Aortic Aneurysm (AAA) Screening

Transcription

1 Abdominal Aortic Aneurysm (AAA) Screening Guidance and information on the Key Performance Indicators (KPIs) for the Abdominal Aortic Aneurysm screening programme 6 March 2018 V1.1

2 Contents Introduction... 2 Background... 2 Review... 3 Reporting... 3 Planned revisions... 3 Roles and responsibilities... 3 Data collection and analysis... 3 Summary of main changes... 4 AAA Screening Programme: Key Performance Indicators (KPIs)... 5 AAA Screening Programme: KPI definitions... 6 Appendix 1: Glossary

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. Men aged 65 are sent an invitation to attend AAA screening. Men over 65 years of age, who have not been screened previously, can self-refer into the screening programme. 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 surveillance screening every three months, 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 updated definitions for the Key Performance Indicators (KPIs) for the Scottish AAA Screening Programme, along with the criteria used for their calculation. This document replaces the KPI definitions V1.0, dated 7 March A summary of the main changes is available on page 4. The KPI data are published annually by Information Services Division (ISD) to provide a high level view of the quality and performance of the screening programme in Scotland. 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. 2

4 Review The Scottish AAA screening programme Key Performance Indicators are reviewed on an annual basis. Reporting The KPI data are produced every six months. Data for the full financial year are published annually to provide a high level view of the quality and performance of the screening programme in Scotland. In addition, interim mid-year KPI data are produced so that the programme can review progress. As these data are incomplete and provisional they are not published. Planned revisions Following publication of the KPI data, the vascular referral KPIs 3.1, 3.2, 4.1 and 4.2 are subject to planned revisions in following annual publication(s) to reflect updated data. Any revisions are expected to be minor. Data revisions are due to data on vascular referrals for a reporting period being updated as a result of: The updated status of a vascular referral from the screening programme following extraction of the data for publication. For example, a man referred to other specialty at the time of publication may later be deemed by a vascular specialist to be appropriate for surgery and have surgery. In the next annual publication, the relevant vascular referral KPIs will be revised to include data for this surgery. Incomplete vascular referral data at the time of data extraction for publication, or amendments to the data recorded made by NHS Boards following data extraction. ISD conduct data quality assurance checks with NHS Boards to help ensure vascular referral data are complete and accurate, however in occasional instances NHS Boards may not have recorded all the required data by the date of the ISD data extract. 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 computer system facilitates the invitation of men for screening and records the results. It 3

5 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 Summary of main changes KPI 4.1: 30-day mortality rate following open elective AAA surgery 4.2: 30-day mortality rate following EVAR intervention Changes The 30-day mortality KPIs are now collated and reported by year of surgery rather than year of screening. The reason underlying this change is to avoid data revisions for previous screening years due to updated outcomes for vascular referrals. This change has a negligible impact on the reported rates (the impact on the rates is in the range 0 to 0.1 percentage points). 4

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

7 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% Definitions 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. In line with national guidance, the population of men eligible for initial screening does not include men: (i) (ii) (iii) (iv) (v) (vi) (vii) (viii) Already on surveillance prior to roll-out of the screening programme Already screened with a negative discharge result Who have had an aneurysm repair (confirmed) Under surveillance at vascular services (confirmed) Referred to vascular services Unfit for scanning Who are deceased 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 6

8 (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 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 umber of eli ible men sent a first in itation before their 66th birthday umber of men in eli ible population reachin a e 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 Additional details for ISD/users of Scottish AAA Call Recall System 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. 7

9 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% Definitions Denominator Numerator 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. The number of men who had an initial screen before they reached age 66 and 3 months. 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 non-visualisation. Equation Mitigations Equity impact umber of eli ible men tested before reachin 66 years and months umber of eli ible men sent an in ite 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. 8

10 Reporting Additional details for ISD/users of Scottish AAA Call Recall System Reporting period: financial year of eligibility for initial screening Data presented by: NHS Board of residence 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. 9

11 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% Definitions Denominator Numerator 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. The number of men in each SIMD quintile who had an initial screen before they reached age 66 and 3 months. 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 non-visualisation. Equation Mitigations Equity impact umber of eli ible men in each I D uintile tested before reachin 66 years and months umber of eli ible men in each I D uintile sent an in ite 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. 10

12 Reporting 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 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. Additional details for ISD/users of 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 non-visualisation. 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 he lived at the time of invitation or screening. 11

13 KPI 1.4a Objective Clinical Standard Patient Journey Thresholds 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 screendetected aneurysms are invited for surveillance. Invitation and attendance Essential: 90% Desirable: 100% Definitions Denominator Numerator The number of annual surveillance appointments due. 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 non-visualisation. Equation Mitigations Equity impact Reporting Additional details for ISD/users of Scottish AAA Call Recall System umber of men tested ithin months 6 ee s of pre ious scan umber of annual sur eillance 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 follow-up 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) (ii) (iii) (iv) (v) AAA repaired (confirmed) AAA repaired (awaiting confirmation) Under surveillance at vascular services (confirmed) Under surveillance at vascular services (awaiting confirmation) Referred to vascular services 12

14 (vi) (vii) (viii) (ix) (x) (a) (b) (c) (d) (e) (f) Unfit for scanning Deceased Out of cohort ineligibility categories: Transferred out of Scotland Transferred out by CHI Transferred out untraced Deleted or marked for deletion (CHI) Temporary residents Gone Away, No Address Unsuitable for portable scanning 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 ith date of screenin minus date of pre ious screen 408 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 Follo in each screen, the cloc 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 June 0 4 could ha e his next sur eillance 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 followup 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 13

15 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 (and would be counted as 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. 14

16 KPI 1.4b Objective Clinical Standard Patient Journey Thresholds 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 screendetected aneurysms are invited for surveillance. Invitation and attendance Essential: 90% Desirable: 100% Definitions Denominator Numerator The number of quarterly surveillance appointments due. 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 non-visualisation. Equation Mitigations Equity impact Reporting Additional details for ISD/users of Scottish AAA Call Recall System umber of scans ithin months 4 ee s of pre ious scan umber of uarterly sur eillance 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 follow-up 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) (ii) (iii) (iv) AAA repaired (confirmed) AAA repaired (awaiting confirmation) Under surveillance at vascular services (confirmed) Under surveillance at vascular services (awaiting confirmation) 15

17 (v) (vi) (vii) Referred to vascular services Unfit for scanning Deceased (viii) Out of cohort ineligibility categories : (ix) (x) (a) (b) (c) (d) (e) (f) Transferred out of Scotland Transferred out by CHI Transferred out untraced Deleted or marked for deletion (CHI) Temporary residents Gone Away, No Address Unsuitable for portable scanning 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 screenin minus date of pre ious screen 0 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 Follo in each screen, the cloc 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 16

18 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. 17

19 KPI 2.1a Percentage of screening encounters where aorta could not be visualised Objective Quality of scan/ images/samples/testing technique Standard 6: The AAA screening examination Clinical Standard Patient Journey Thresholds 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% Definitions Denominator Numerator The total number of scans. This includes initial screens (cohort and self-referral) and surveillance scans. Screening results of positive, negative or non-visualisation are included. The number of scans with a screening result of nonvisualisation. Equation Mitigations Equity impact Reporting Additional details for ISD/users of Scottish AAA Call Recall System umber of scans here aorta could not be isualised umber 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 non-visualisation 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 18

20 included in the denominator. The technical failure result category indicates screenin couldn t ta e place and the reasons include e uipment failure or the man declined screening during the attendance. Numerator: of the denominator cohort, the number of scans with a result of non-visualisation. 19

21 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% Definitions Denominator Numerator The number of men screened. This includes initial screens (cohort and self-referral) and surveillance scans. Screening results of positive, negative or non-visualisation 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 umber of men ith at least one scan result here aorta could not be isualised umber 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 non-visualisation 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 20

22 screenin couldn t ta e place and the reasons include e uipment 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. 21

23 KPI 2.2 Objective 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 Clinical Standard Patient Journey Thresholds 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% Definitions Equation Denominator Numerator The number of scans that have been quality assured (audited). This includes initial screens (cohort and selfreferral) and surveillance scans. 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. umber of scans ith an audit result of fail and re uirin immediate recall umber of scans ith an audit result of pass or fail Mitigations Equity impact Reporting Additional details for ISD/users of 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 22

24 Scottish AAA Call Recall System 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. This is to allow time for the images to be audited by lead screeners. For example, scans taken in the period 1 January to 31 March that were selected for the audit on 1 April, should have an audit result recorded by 30 June. After allowing for this time-lag, any scans that do not have an audit result recorded by the date of the ISD data extract will not be included in this KPI. 23

25 KPI 3.1 Objective 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 Clinical Standard Patient Journey Thresholds 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% Definitions Denominator Numerator 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. The number of men where the number of days between the date of screening and the date first seen by vascular specialist ser ices is 4 calendar days. Equation Mitigations Equity impact Reporting umber of men ith AAA 5.5cm referred to ascular seen ithin 4 days of screenin umber of men ith AAA 5.5cm referred to ascular 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 KPI 3.1 is subject to planned revisions due to incomplete vascular referral data at the time of data extraction for publication, or amendments to the data recorded made by NHS Boards following data extraction. Any revisions are expected to be minor. 24

26 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 ith ascular ser ice not re uired. 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 screenin 4 calendar days (i.e. for the purposes of the calculation, date of screening is day zero). Additional details for ISD/users of Scottish AAA Call Recall System 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 screenin. 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. 25

27 KPI 3.2 Objective Percentage of men with AAA 5.5cm deemed appropriate for intervention who were operated on by vascular specialist within eight weeks of screening To ensure high quality and timely intervention Standard 9: Pre and post operative management Clinical Standard Patient Journey Thresholds 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% Definitions Equation Denominator Numerator The number of men ith AAA 5.5cm referred to ascular 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. The number of men where the number of days between the date of screenin and the date of procedure 56 calendar days. umber of men ith AAA 5.5cm referred to ascular operated on ithin 56 days umber of men ith AAA 5.5cm referred to ascular and deemed appropriate for sur ery Mitigations Equity impact Reporting Reporting period: financial year in which scan occurred Data presented by: NHS Board of residence KPI 3.2 is subject to planned revisions as the status of a man screened and referred to vascular services in a particular screening year may change following extraction of the data. The revisions are expected to be minor. As data for this KPI is collated by date of screening, 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. Updated data for men referred in a previous screening year who were deemed appropriate for surgery after the data extract date will be included in the calculation of KPI 3.2 in the following annual publication, leading to a planned 26

28 revision. 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 ould 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. In addition, planned revisions of this KPI will also be made where data were incomplete or amendments to the data recorded were made by NHS Boards following extraction of the data for publication. Additional details for ISD/users of Scottish AAA Call Recall System Denominator: the number of men with AAA 5.5cm and the vascular referral outcome category is one of the following: (i) (ii) (iii) (iv) (v) (vi) (vii) (viii) Appropriate for surgery: declined surgery Appropriate for surgery: died before treatment Appropriate for surgery: self-discharge Appropriate for surgery: patient deferred surgery Appropriate for surgery: AAA repaired and survived 30 days Appropriate for surgery: died within 30 days of treatment Appropriate for surgery: final outcome pending. 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 date of procedure minus date of screenin 56 calendar days (i.e. for the purposes of the calculation, date of screening is day zero). Following a time-lag to allow sufficient time for data recording, where the date of procedure is not recorded it is assumed that the man did not have surgery within 56 days. Supplementary information Only valid data is included i.e. where the date of procedure is recorded it must be date of screenin. 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. 27

29 KPI day mortality rate following open elective AAA surgery Objective Post-operative mortality Standard 10: Post operative outcomes Clinical Standard Patient Journey Thresholds 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% Definitions Denominator Numerator 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. The number of men who died within 30 days of open elective surgery. Equation Mitigations Equity impact Reporting Additional details for ISD/users of Scottish AAA Call Recall System umber of men ho died ithin 0 days of open electi e AAA sur ery umber of men ho had open electi e AAA sur ery 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 surgery occurred. Due to small numbers, for reporting purposes the data for several years are combined and presented at Scotland level only. KPI 4.1 is subject to planned revisions due to incomplete vascular referral data at the time of data extraction for publication, or amendments to the data recorded made by NHS Boards following data extraction. Any revisions are expected to be minor. 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 Men with an outcome referral of Appropriate for surgery: final outcome pendin at the time of reporting are not included in the denominator. 28

30 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 sur ery: AAA repaired and sur i ed 0 days and Appropriate for sur ery: died ithin 0 days of treatment cate ories ill be cross-validated with the date of procedure and date of death (where applicable). For the purposes of the calculation, date of surgery is day zero. 29

31 KPI day mortality rate following EVAR intervention Objective Clinical Standard Patient Journey Thresholds 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% Definitions Denominator Numerator 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. The number of men who died within 30 days of EVAR intervention. Equation Mitigations umber of men ho died ithin 0 days of E A inter ention umber of men ho had E A inter ention Includes all cause mortality so some deaths may not be as a result of complications following surgery or result from the man s AAA. Equity impact Data are collated by financial year in which the surgery occurred. Due to small numbers, for reporting purposes the data for several years are combined and presented at Scotland level only. Reporting Additional details for ISD/users of Scottish AAA Call Recall System KPI 4.2 is subject to planned revisions due to incomplete vascular referral data at the time of data extraction for publication, or amendments to the data recorded made by NHS Boards following data extraction. Any revisions are expected to be minor. 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 pendin at the time of reporting are not included in the denominator. 30

32 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 sur ery: AAA repaired and sur i ed 0 days and Appropriate for sur ery: died within 30 days of treatment cate ories ill be cross-validated with the date of procedure and date of death (where applicable). For the purposes of the calculation, date of surgery is day zero. 31

33 Appendix 1: Glossary Term Definition Abdominal Aortic Aneurysm (AAA) Calliper placement Collaborative (of NHS Boards) Completeness of offer Elective (surgery) Eligible 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. 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 Lead screener (for AAA) Negative result (from screening) Offer Open AAA surgery 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. The professional lead for the screening workforce in an NHS Board and responsible for the ongoing quality assurance of the local AAA screening programme, including the quality assurance of images and the workforce. 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 AAA repair operation involving cutting open the abdomen to replace the swollen section of the aorta with an artificial piece of artery (graft). 32

34 Population Positive result (from screening) Quintile (SIMD/deprivation) Refer Reporting period Result The overall population for which a screening service is responsible An indication following a test that the condition being screened is highrisk / 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. Deprivation quintiles each contain approximately 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 Scan or screen (for AAA) Screener Screening Screening encounter (for AAA) Self-referral 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 AAA screening to a man by a healthcare professional through the process of a scan. Man over the age of 65 who has not been screened previously, who contacts their local AAA screening centre directly to request screening. 33