SPECIALISED SERVICES NATIONAL DEFINITIONS SET (2nd EDITION)

Specialised Vascular Services (Adult) - Definition No. 30

Preface

36 specialised services are covered by the Specialised Services National Definitions Set (2nd edition).

The definitions were developed through national working groups (one for each service). Many clinicians, hospital managers, finance and information staff and commissioners were directly involved in working group meetings and many more provided comments during the consultation stages. Some of the definitions have been endorsed by the relevant national organisations.

The definitions identify the activity that should be regarded as specialised and therefore subject to collaborative commissioning arrangements. The definitions provide a helpful basis for service reviews and strategic planning and enable commissioners to establish a broad base-line position and make initial comparisons on activity and spend. It should be noted that, currently, many of the definitions have coding gaps and other information problems as well as a lack of agreed standard service currencies; further work is needed in these areas.

Production of the Specialised Services National Definitions Set is an iterative process. Over time new specialised services will be provided by the NHS whilst other services will become more commonplace and cease to be specialised.

Each definition is divided into two sections.

Section A provides descriptions of the various services covered. In most definitions, the existing pattern or model of service provision is described as well as the clinical service. Each definition includes a list of relevant national guidelines, such as DoH or Royal College of Publications, and identifies any national databases containing health outcomes information. Section A also includes sections on finance and information, examines the best way of identifying the relevant activity in information systems and acknowledges any coding gaps or difficulties. Most of the definitions include a recommended standard currency for the service (eg. banded bed days).

Section B includes specific issues considered to be important by the working group concerned. The views expressed in Section B are those of the particular working group and do not necessarily represent opinion within the DoH or the NHS. Resolving these issues is not within the remit of the definitions project.

It should be noted that the definitions are not service specifications nor do they prescribe service models or set service standards. Where national standards for a service already exist these may be referred to in the definition but specific decisions regarding the planning and procurement of a specialised service are matters for NHS commissioners themselves to address. Inclusion of a treatment or intervention in a definition should not be taken to mean that there is established evidence of clinical or cost effectiveness.

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Comments and suggested improvements to the definitions are very welcome and can be sent to the email address: specialised.services.defins@doh.gsi.gov.uk

SECTION A

1. General Description

Vascular services include emergency treatment of leaking or ruptured aneurysms, acute limb ischaemia, vascular trauma and iatrogenic vascular injury. Vascular services also include elective treatment for aneurysms and other abnormal blood vessels, limb ischaemia, carotid artery disease, peripheral and visceral arterial disease and venous disease including varicose veins. Vascular access work (e.g. for renal dialysis and for chemotherapy access) is also a part of vascular services.

Treatment may be by open surgery or endovascular techniques, in addition to the risk factor modification and medical treatment. On some occasions there are collaborative arrangements for emergency on-call rotas between hospitals for these services. Some highly specialised vascular treatments will be provided in only a limited number of hospitals, because they are especially complex and there are relatively small numbers of patients involved.

2. Rationale for the Service being included in the Specialised Services Definitions Set

The services require specialist clinical expertise, and may be provided in hospitals, which serve a number of neighbouring PCTs. There is published evidence showing better outcomes when vascular work is carried out by specialists who regularly undertake a certain minimum numbers of procedures.

Models of service provision have been proposed in the following documents:

The Provision of Vascular Services. Vascular Advisory Committee of the Vascular Surgical Society of Great Britain and Ireland, Revised Edition 1998 (due to be revised 2003)

The Provision of Emergency Vascular Services. Document prepared by the Vascular Surgical Society of Great Britain and Ireland, 2001 (due to be reviewed 2004)

Provision of Vascular Radiology Services. Document prepared by the Vascular Surgical Society of Great Britain and Ireland and the Royal College of Radiologists (currently draft document, 2002)

Michaels J, Brazier J, Palfreyman S, Shackley P and Slack R. Cost and outcome implications of the organisation of vascular services. Health Technology Assessment 2000; 4 (11)

3. Links to Other Services on the Specialised Definitions Set

There are links between specialised vascular services and the following other specialised services:

No.1, Specialised Cancer Services (Adult)

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No.4, Specialised Services for Women’s Health (Adult) (specialised gynaecology)

No.7, Complex Specialised Rehabilitation for Brain Injury and Complex Disability (Adult)

No.8, Specialised Neurosciences Services (Adult)

No.11, Renal Services (Adult)

No.13, Specialised Cardiology and Cardiac Surgery (Adult)

No.23, Specialised Services for Children

No. 24, Specialised Dermatology Services (Adult) (management of venous ulcer disease)

No.27, Specialised Endocrinology Services (Adult) (specifically the management of diabetic patients)

No.31, Specialised Pain Management Services (Adult)

No.34, Specialised Orthopaedic Services (Adult)

4. Detailed Description of Specialised Activity

The recommended provision of vascular services has been based on one surgeon per 150,000 population but additional vascular surgeons and radiologists will be required in future for acceptable on-call rotas (currently a minimum of four surgeons for a rota). In order to satisfy the requirements of clinical governance, training, effective on-call rotas, etc. The Vascular Surgical Society of Great Britain and Ireland has recommended that independent vascular units should serve populations of at least 500,000, while units serving smaller populations should develop collaborative arrangements (1).

It is acknowledged that much of the varicose vein surgery is carried out by non-vascular surgeons, but the inclusion of varicose veins may increase flexibility by justifying sufficient vascular specialists to allow a viable emergency on-call rota where one would not otherwise be possible. PCTs and their local providers will determine the most appropriate service model to meet local needs.

Increasingly, as a result of the changes in training, general surgeons are less likely to be conversant with vascular procedures.

There is evidence showing poorer outcomes across a range of specialised procedures related to low volume of procedures (2). There is a strong argument therefore that all specialised vascular procedures should be carried out in hospitals with fully staffed and equipped vascular departments. Vascular services require planning such that the proper delivery of the specialised element is permitted within clinical networks.

The specialised services, which encompass vascular surgery also include vascular radiology. The manpower requirements for vascular radiology are similar to those of

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vascular surgery and therefore the recommendations outlined above for surgery can also be taken to apply to endovascular specialists.

For optimal vascular surgical care: input from the following services is also required: cardiology, diabetology, neurology, critical care, renal medicine, dermatology and vascular anaesthesiology.

The procedures may include:

4.1 Emergency Procedures

treatment of ruptured or leaking aneurysms treatment of acute ischaemia treatment of vascular trauma including life threatening bleeding from any source treatment of iatrogenic vascular injury management of pulmonary emboli including IVC filter implantation surgery for critically ischaemic limbs

4.2 Elective Procedures

4.2.1 Vascular radiology encompasses a range of vascular procedures including the treatment of peripheral and visceral arterial and venous disease:

angioplasty and thrombolysis stenting and stent grafting diagnostic angiography, magnetic resonance imaging (MRI), computer

tomography (CT) and ultrasound embolisation transjugular intrahepatic portosystemic shunt (TIPS)

4.2.2 Surgical procedures

repair of abdominal aortic aneurysms including suprarenal aneurysms. surgery for intermittent claudication and limb threatening ischaemia surgery for peripheral arterial aneurysms amputation sympathectomy carotid artery procedures treatment of thoracic outlet syndrome vascular reconstruction after cancer resection venous surgery (including complex varicose veins) medical and surgical care of lymphoedema

There are a number of reasons for considering all varicose vein procedures with vascular services in the commissioning process. These are set out below:

There is a subgroup of recurrent and complex varicose veins that require specialised assessment and treatment.

Referring clinicians may not be able to readily identify those requiring specialised assessment.

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Varicose veins are the most common cause of litigation within general and vascular surgery in the UK. Complications and recurrence rate have been shown to be high, often through avoidable causes (3-5).

There is evidence of variability in practice (6-7). There is evidence that specialist assessment (e.g. the use of hand held Doppler

and/or vascular laboratory investigations) improves accuracy of diagnosis. There is evidence of considerable variation in the commissioning of services for

patients with varicose veins leading to geographical variation and lack of equity (8).

Vascular services have a high proportion of urgent and emergency workload, and the inclusion of varicose vein surgery balances this with a volume of elective work.

There are certain services, which, due to the low volume of procedures carried out, need to be planned for and provided in fewer specialised units. They include:

treatment of thoraco-abdominal aneurysms renal artery intervention and surgery mesenteric vessel intervention and surgery management of lymphatic disease. treatment of arterio-venous malformations paediatric vascular surgery (included in No. 23, Specialised Services for Children

for commissioning purposes)

4.2.3 Vascular access work

The involvement of vascular surgeons in access work is very variable. Renal access surgery is carried out by transplant surgeons in many hospitals. The role of interventional radiologists in vascular access work is increasing.

5. Recommended Units of Activity / Currency Measurement

Minimum data sets are available including diagnosis and procedure/operation codes for each inpatient episode. Current outpatient information will identify patient attendances as a minimum, but a minimum data set for all outpatients activity is available.

The recommended units of activity are:

inpatient episode (Finished Consultant Episode) outpatient attendance

It should be noted that in relation to inpatient treatment, many patients have a number of different procedures.

In addition many patients are seen by vascular specialists as a result of inpatient referrals; these patients are not coded as part of vascular work and the vascular input is not captured by the current systems.

There are problems relating to a number of vascular radiology procedures for which there are currently no OPCS codes. Examples include endovascular repair of thoracic

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aortic aneurysm, percutaneous aortic stent insertion and thrombolysis of any vein. The NHS Information Authority is currently investigating this.

The NHS Information Authority is proposing to have a new national specialty code for ‘vascular surgery’, which should also include all endovascular surgery.

Attached is an Appendix listing of vascular procedures with OPCS 4 codes that currently fall within specialised vascular procedures.

6. Elements of Service / Guidance for Costing

Detailed, accurate costs for specialised vascular procedures are important, based on Human Resource Groups (HRG) codes set out on page 25 of ‘The Provision of Vascular Services’ – Vascular Advisory Committee, Revised Edition, 1998. This will apply to both inpatient and outpatient costs, as some HRGs have also been developed for outpatients.

7. Recommended National Standards, Guidelines and Protocols

Evidence-Based Guidelines for the Configuration of Vascular Services. Michaels J et al, 2001. Journal of Clinical Excellence 3: 145-53

The Provision of Vascular Services. Vascular Advisory Committee of the Vascular Surgical Society of Great Britain and Ireland, Revised Edition 1998 (due to be revised 2003)

The Provision of Emergency Vascular Services. Document prepared for the Vascular Surgical Society of Great Britain and Ireland, 2001 (review date 2004)

Provision of Vascular Radiology Services. Document prepared for the Vascular Surgical Society of Great Britain and Ireland and the Royal College of Radiologists (currently draft document, 2002)

Structured Training in Clinical Radiology. Royal College of Radiology, 1999

Training in Interventional Radiology – Statement produced by the Vascular Surgical Society of Great Britain and Ireland and the Royal College of Radiology, 2002

Guidelines on the treatment of varicose veins. National Institute of Clinical Excellence, December 2001

SECTION B

Note: The views expressed in the following section are those of the Working Group and do not necessarily represent opinion in the Department of Health or the NHS.

8. Issues to be Noted Regarding this Service / Definition

8.1 Endovascular aneurysm repair (EVAR) and carotid stenting

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There will be significant implications for the commissioning of services if the studies, which are currently in progress, demonstrate benefit from these treatments. The procedures require specialist skills, particularly from both vascular radiologists and vascular surgeons, as well as specialist equipment. It may not be possible, or economically viable to provide these in every hospital currently undertaking surgical aneurysm repair or carotid endarterectomy.

8.2 Deep vein thrombosis and use of thrombolysis and caval filters Changes in the management of DVT, particularly for threatened limbs, may result in an increase in demand for specialist vascular radiology and transfer of significant additional workload to vascular services.

8.3 Thoracic dissections and thoracic aneurysms New endovascular radiology techniques are being developed for the treatment of these conditions using covered stents. This is likely to result in significant change in practice for conditions that are currently managed within cardiac or general medical services.

8.4 Current trials looking at the comparison of angioplasty and supervised exercise for treatment of claudication

8.5 The increasing involvement of vascular radiologists in cancer services both in treating and palliating cancers

8.6 Overlap of vascular services with other specialties e.g. use of vascular radiology in embolisation of uterine fibroids and the support required from other specialties, including vascular anaesthesia, critical care, cardiology, diabetology and renal medicine

8.7 Vascular surgeons and radiologists are being requested on an increasing basis to provide support to colleagues in other clinical specialties, both within hospitals where specialist vascular teams are based and at other general hospitals. The support required can be offered on a visiting basis and/or through the use of information technology links for both elective and emergency work.

8.8 Endovascular treatment may not always be recorded as a finished consultant episode. It is recommended that endovascular procedures should be designated as FCEs or outpatient procedures with OPCS codes identified in order that waiting times for treatment and costs of treatment can more easily be identified for vascular procedures.

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References

1. The Provision of Emergency Vascular Services. Document prepared by the Vascular Surgical Society of Great Britain and Ireland, 2001 (due to be reviewed 2004)

2. Shackley P, Slack R, Booth A, Michaels J. Is there a positive volume-outcome relationship in peripheral vascular surgery? Results of a systematic review. Eur J Vasc Endovasc Surg 2000; 20(4):326-35

3. Campbell WB, France F, Goodwin HM on behalf of the Research and Audit Committee of the Vascular Surgical Society of Great Britain and Ireland. Medicolegal claims in vascular surgery. Ann R Coll Surg Engl 2002; 84: 181-184

4. Miller GV, Lewis WG, Sainsbury JR, Macdonald RC. Morbidity of varicose vein surgery: auditing the benefit of changing clinical practice. Ann R Coll Surg Engl 1996; 78(4):345-9

5. Turton EP, McKenzie S, Weston MJ, Berridge DC, Scott DJ. Optimising a varicose vein services to reduce recurrence. Ann R Coll Surg Engl 1997; 79(6):451-4

6. O’Shaughnessy M, Rahall E, Walsh TN, Given HF. Surgery in the treatment of varicose veins. Ir Med J 1989; 82(2):54-5

7. Lees T, Singh S, Beard J, Spencer P, Rigby C. Prospective audit of surgery for varicose veins. Br J Surg 1997; 84(1):44-6

8. Galland RB, Whatling PJ, Crook TJ, Magee TR. Regional variation in varicose vein operations in England 1989-1996. Ann R Coll Surg Engl 2000; 82(4):275-9

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Appendix

SPECIALISED VASCULAR SERVICES (ADULT)

OPCS 4 Codes

L16 Extraanatomic bypass of aortaL18 Emergency replacement of aneurysmal segment of aortaL19 Other replacement of aneurysmal segment of aortaL20 Other emergency bypass of segment of aortaL21 Other bypass of segment of aortaL22 Attention to prosthesis of aortaL23 Plastic repair of aortaL25 Other open operations on aortaL26 Transluminal operations on aortaL29 Reconstruction of carotid arteryL30 Other open operations on carotid arteryL31 Transluminal operations on carotid arteryL33 Operations on aneurysm of cerebral arteryL34 Other open operations on cerebral arteryL35 Transluminal operations on cerebral arteryL37 Reconstruction of subclavian arteryL38 Other open operations on subclavian arteryL39 Transluminal operations on subclavian arteryL41 Reconstruction of renal arteryL42 Other open operations on renal arteryL43 Transluminal operations on renal arteryL45 Reconstruction of other visceral branch of abdominal aortaL46 Other open operations on the other visceral branch of abdominal aortaL47 Transluminal operations on other visceral branch of abdominal aortaL48 Emergency replacement of aneurysmal iliac arteryL49 Other replacement of aneurysmal iliac arteryL50 Other emergency bypass of iliac arteryL51 Other bypass of iliac arteryL52 Reconstruction of iliac arteryL53 Other open operations on iliac arteryL54 Transluminal operations on iliac arteryL56 Emergency replacement of aneurysmal femoral arteryL57 Other replacement of aneurysmal femoral arteryL58 Other emergency bypass of femoral arteryL59 Other bypass of femoral arteryL60 Reconstruction of femoral arteryL62 Other open operations on femoral arteryL63 Transluminal operations on femoral arteryL65 Revision of reconstruction of arteryL67 Excision of other arteryL68 Repair of other arteryL70 Other open operations on other arteryL71 Therapeutic transluminal operations on other arteryL72 Diagnostic transluminal operations on other arteryL74 Arteriovenous shuntL75 Other arteriovenous operations

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L77 Connection of vena cava or branch of vena cavaL79 Other operations on vena cavaL81 Other bypass operations on veinL82 Repair of valve of veinL83 Other operations for venous insufficiencyL84 Ligation of varicose vein of legL86 Injection into varicose vein of legL87 Other operations on varicose vein of legL90 Open removal of thrombus from veinL91 Other vein related operationsL93 Other open operations on vein

X12 Operations on amputation stump

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