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BackgroundVascular services is changing rapidly, having emerged as a new specialty with its own training and specialised techniques. This has resulted in the need for reconfiguration of services to provide adequate specialist provision and accessible and equitable services.ObjectivesTo identify the effects of service configuration on practice, resource use and outcomes. To model potential changes in configuration. To identify and/or develop electronic data collection tools for collecting patient-reported outcome measures and other clinical information. To evaluate patient preferences for aspects of services other than health-related quality of life.DesignThis was a multiple methods study comprising multiple systematic literature reviews; the development of a new outcome measure for users of vascular services (the electronic Personal Assessment Questionnaire – Vascular) based on the reviews, qualitative studies and psychometric evaluation; a trade-off exercise to measure process utilities; Hospital Episode Statistics analysis; and the development of individual disease models and a metamodel of service configuration.SettingSpecialist vascular inpatient services in England.Data sourcesModelling and Hospital Episode Statistics analysis for all vascular inpatients in England from 2006 to 2018. Qualitative studies and electronic Personal Assessment Questionnaire – Vascular evaluation with vascular patients from the Sheffield area. The trade-off studies were based on a societal sample from across England.InterventionsThe data analysis, preference studies and modelling explored the effect of different potential arrangements for service provision on the resource use, workload and outcomes for all interventions in the three main areas of inpatient vascular treatment: peripheral arterial disease, abdominal aortic aneurysm and carotid artery disease. The electronic Personal Assessment Questionnaire – Vascular was evaluated as a potential tool for clinical data collection and outcome monitoring.Main outcome measuresSystematic reviews assessed quality and psychometric properties of published outcome measures for vascular disease and the relationship between volume and outcome in vascular services. The electronic Personal Assessment Questionnaire – Vascular development considered face and construct validity, test–retest reliability and responsiveness. Models were validated using case studies from previous reconfigurations and comparisons with Hospital Episode Statistics data. Preference studies resulted in estimates of process utilities for aneurysm treatment and for travelling distances to access services.ResultsSystematic reviews provided evidence of an association between increasing volume of activity and improved outcomes for peripheral arterial disease, abdominal aortic aneurysm and carotid artery disease. Reviews of existing patient-reported outcome measures did not identify suitable condition-specific tools for incorporation in the electronic Personal Assessment Questionnaire – Vascular. Reviews of qualitative evidence, primary qualitative studies and a Delphi exercise identified the issues to be incorporated into the electronic Personal Assessment Questionnaire – Vascular, resulting in a questionnaire with one generic and three disease-specific domains. After initial item reduction, the final version has 55 items in eight scales and has acceptable psychometric properties. The preference studies showed strong preference for endovascular abdominal aortic aneurysm treatment (willingness to trade up to 0.135 quality-adjusted life-years) and for local services (up to 0.631 quality-adjusted life-years). A simulation model with a web-based interface was developed, incorporating disease-specific models for abdominal aortic aneurysm, peripheral arterial disease and carotid artery disease. This predicts the effects of specified reconfigurations on workload, resource use, outcomes and cost-effectiveness. Initial exploration suggested that further reconfiguration of services in England to accomplish high-volume centres would result in improved outcomes, within the bounds of cost-effectiveness usually considered acceptable in the NHS.LimitationsThe major source of evidence to populate the models was Hospital Episode Statistics data, which have limitations owing to the complexity of the data, deficiencies in the coding systems and variations in coding practice. The studies were not able to address all of the potential barriers to change where vascular services are not compliant with current NHS recommendations.ConclusionsThere is evidence of potential for improvement in the clinical effectiveness and cost-effectiveness of vascular services through further centralisation of sites where major vascular procedures are undertaken. Preferences for local services are strong, and this may be addressed through more integrated services, with a range of services being provided more locally. The use of a web-based tool for the collection of clinical data and patient-reported outcome measures is feasible and can provide outcome data for clinical use and service evaluation.Future workFurther evaluation of the economic models in real-world situations where local vascular service reconfiguration is under consideration and of the barriers to change where vascular services do not meet NHS recommendations for service configuration is needed. Further work on the electronic Personal Assessment Questionnaire – Vascular is required to assess its acceptability and usefulness in clinical practice and to develop appropriate report formats for clinical use and service evaluation. Further studies to assess the implications of including non-health-related preferences for care processes, and location of services, in calculations of cost-effectiveness are required.Study registrationThis study is registered as PROSPERO CRD42016042570, CRD42016042573, CRD42016042574, CRD42016042576, CRD42016042575, CRD42014014850, CRD42015023877 and CRD42015024820.FundingThis project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 9, No. 5. See the NIHR Journals Library website for further project information.

Background: A variety of instruments have been used to assess outcomes for patients with venous leg ulcers. This study sought to identify, evaluate and recommend the most appropriate patient reported outcomes (PROMs) for English-speaking patients with venous leg ulcers (VLUs). Method: This systematic review used a two-staged approach. Electronic searches of major databases including MEDLINE were completed in October 2015 and then updated in July 2016. Additional studies were identified from citation checking. Study selection, data extraction and quality assessment were undertaken independently by at least two reviewers. Evaluation and summary of measurement properties of identified PROMs were undertaken using standard and adapted study-relevant criteria. Results: Ten studies with data for three generic PROMS and six condition-specific measures were identified. No generic PROM showed adequate content and criterion validity; however the EQ-5D, Nottingham Health Profile (NHP) and 12-item Health Survey Short-Form had good acceptability with scores ranging from 80% to 91%. In general, the EQ-5D showed poor responsiveness in patients with VLUs. Condition-specific PROMs demonstrated poor criterion and construct validity. Overall, good internal consistency was demonstrated for the Venous Leg Ulcer Quality of Life (VLU-QOL) and the Sheffield Preference-based Venous Ulcer questionnaire (SPVU-5D). Test re-test reliability was also satisfactory for SPVU-5D and VeLUSET measures. Conclusions: The NHP and VLU-QOL seemed the most suitable PROMs for use by clinicians. A valid condition-specific PROM is still required.

Background Varicose veins can affect quality of life. Patient-reported outcome measures (PROMs) provide a direct report from the patient about the impact of the disease without interpretation from clinicians or anyone else. The aim of this study was to examine the quality of the psychometric evidence for PROMs used in patients with varicose veins. Methods A systematic review was undertaken to identify studies that reported the psychometric properties of generic and disease-specific PROMs in patients with varicose veins. Literature searches were conducted in databases including MEDLINE, up to July 2016. The psychometric criteria used to assess these studies were adapted from published recommendations in accordance with US Food and Drug Administration guidance. Results Nine studies were included which reported on aspects of the development and/or validation of one generic (36-Item Short Form Health Survey, SF-36®) and three disease-specific (Aberdeen Varicose Vein Questionnaire, AVVQ; Varicose Veins Symptoms Questionnaire, VVSymQ®; Specific Quality-of-life and Outcome Response – Venous, SQOR-V) PROMs. The evidence from included studies provided data to support the construct validity, test–retest reliability and responsiveness of the AVVQ. However, its content validity, including weighting of the AVVQ questions, was biased and based on the opinion of clinicians, and the instrument had poor acceptability. VVSymQ® displayed good responsiveness and acceptability rates. SF-36® was considered to have satisfactory responsiveness and internal consistency. Conclusion There is a scarcity of psychometric evidence for PROMs used in patients with varicose veins. These data suggest that AVVQ and SF-36® are the most rigorously evaluated PROMs in patients with varicose veins.

Objective: To carry out the cultural adaptation of the Pieper-Zulkowski Pressure Ulcer Knowledge Test (PZ-PUKT) for use in Brazil and analyze the internal consistency of the adapted version. Method: This was a methodological study. The PZ-PUKT is a knowledge test consisting of 72 items, divided into: prevention, staging, and wound description. The present study was developed in two phases: (1) translation of the questionnaire from English to Brazilian Portuguese, back-translation, and assessment of equivalence between the original and back-translated version by an expert panel; (2) pre-testing with nurses. Results: The questionnaire showed face and content validity according to the opinions of the experts. Cronbach's alpha for the total test score was higher than 0.70. The adapted version presented satisfactory internal consistency for the studied sample. Conclusion: The adapted version of the instrument for Portuguese can be used in intervention studies as a tool to measure “nursing knowledge about pressure injury/ulcers” as a dependent variable. RESUMEN Objetivo: Realizar adaptación cultural del instrumento Pressure Ulcer Knowledge Test (PZ-PUKT) para uso en Brasil y analizar la consistencia interna de la versión adaptada. Método: Estudio metodológico. El PZ-PUKT es un test de conocimiento con 72 ítems divididos en: prevención, estadificación y descripción de la herida. El proyecto se desarrolló en dos fases: (1) traducción del instrumento del Inglés al Portugués brasileño, retrotraducción y evaluación de equivalencia de versiones por un Comité de especialistas; (2) prueba piloto con enfermeros. Resultados: El instrumento demostró validez de apariencia y contenido, según los especialistas. El valor del coeficiente Alfa de Cronbach para el puntaje total fue superior a 0,70. La versión adaptada demostró satisfactoria consistencia interna para la muestra estudiada. Conclusión: El instrumento validado para el Portugués podrá ser utilizado en estudios de intervenciones, como instrumento para mensurar la variable dependiente “Conocimientos del enfermero sobre lesión/úlcera por presión”. RESUMO Objetivo: Realizar adaptação cultural do instrumento Pressure Ulcer Knowledge Test (PZ-PUKT), para uso no Brasil e analisar a consistência interna da versão adaptada. Método: Estudo metodológico. O PZ-PUKT é um teste de conhecimento com 72 itens, distribuídos em: prevenção, estadiamento e descrição da ferida. O projeto foi desenvolvido em duas fases: (1) tradução do instrumento do inglês para o português do Brasil, retrotradução e avaliação de equivalência das versões por um comitê de especialistas; (2) pré-teste com enfermeiros. Resultados: O instrumento demonstrou validade de face e conteúdo na opinião de especialistas. O valor do coeficiente alfa de Cronbach, para o escore total, foi acima de 0,70. A versão adaptada apresentou consistência interna satisfatória para a amostra estudada. Conclusão: O instrumento validado para o português tem possibilidade de ser utilizado em estudos de intervenções como instrumento para mensurar a variável dependente: Conhecimento do enfermeiro sobre lesão/úlcera por pressão.

AIMS AND OBJECTIVES: To examine, from the perspective of staff, if obese patients have any additional care needs, and what the impact of these care requirements are on care provision. We have selected obese patients with venous leg ulceration as an example patient population to explore these questions. \ud \ud BACKGROUND: Anecdotal evidence indicates obesity can increase care requirements and have implications for obesity for care provision. However, little research exists nationally or internationally that provides evidence from a health care perspective. Obesity is a contributory causative factor of lower limb ulceration. In addition to affecting the development of venous leg ulceration, obesity may also impact on the care an obese patient may require and receive. \ud \ud DESIGN: Qualitative study using semi-structured in interviews and framework analysis. \ud \ud METHODS: Interviews were conducted with 18 health care professionals and one focus group with 12 health care professionals who cared for patients with venous ulceration. Data were analysed to identify recurring themes relating to the impact of obesity on care provision. \ud \ud RESULTS: This study found that the increasing numbers of obese patients with leg ulcers are currently presenting challenges to care delivery in many different ways. There was an impact of obesity on patient experience in terms of dignity, safety and quality. Data indicated that neither hospital nor community care services were adequately set up to meet the needs of obese patients in general. \ud \ud CONCLUSION: Health care providers need to recognise that increasing numbers of overweight and obese patients are presenting challenges to care delivery. The study also indicated the need for senior strategic leadership in planning for meeting the needs of obese patients. \ud \ud RELEVANCE TO CLINICAL PRACTICE: Nursing is well placed to provide specialist support to co-ordinate services for obese/oversize patients if a suitable strategic and leadership role is developed. Nurses are used to offering patients help in areas of health promotion such as smoking cessation. Lessons learnt from this area could be applied to help and encourage staff to support patients with weight management.

Objective: \ud Patient-reported outcome measures (PROMs) provide a way to measure the impact of a disease and its associated treatments on the quality of life from the patients’ perspective. The aim of this review was to identify PROMs that have been developed and/or validated in patients with carotid artery stenosis (CAS) undergoing revascularisation and to assess their psychometric properties and examine suitability for research and clinical use.\ud Methods: \ud Eight electronic databases including MEDLINE and CINAHL were searched using a two-stage search approach to identify studies reporting the development and/or validation of relevant PROMs in patients with CAS undergoing revascularisation. Supplementary citation searching and hand-searching reference lists of included studies were also undertaken. The COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) and Oxford criteria were used to assess the methodological quality of the included studies and the psychometric properties of the PROMs were evaluated using established assessment criteria.\ud Results: \ud Five studies reporting on six PROMs were included: 36-Item Short Form Health Survey (SF-36), Euro-QoL-5-Dimension Scale (EQ-5D), Hospital Anxiety and Depression Scale (HADS), Dizziness Handicap Inventory (DHI), Quality of life for carotid artery disease scale and a disease-specific PROM for CAS. The rigour of the psychometric assessment of the PROMs was variable with most only attempting to assess a single psychometric criterion. No study reported evidence on construct validity and test-retest reliability. Evidence for acceptability for the use of SF-36, EQ-5D and the disease-specific PROM were rated good in most studies. Only one study reported a Cronbach alpha score >0.70 as evidence of internal consistency. Overall, the psychometric evaluation of all included PROMs was rated as poor within the CAS population undergoing revascularisation.\ud Conclusions: \ud This review highlighted a lack of evidence in validated PROMs used for patients undergoing carotid artery revascularisation. As a result, the development and validation of a new PROM for this patient population is warranted in order to provide data which can supplement traditional clinical outcomes (stroke

Objectives To describe how qualitative methods can be used in the development of descriptive systems of preference-based measures (PBMs) of health-related quality of life. Methods The requirements of the National Institute for Health and Clinical Excellence and other agencies together with the increasing use of patient-reported outcome measures has led to an increase in the demand for PBMs. Recently, interest has grown in developing new PBMs and while previous research on PBMs has mainly focused on the methods of valuation, research into the methods of developing descriptive systems is an emerging field. Results Traditionally, descriptive systems of PBMs were developed by using top-down methods, where content was derived from existing measures, the literature, or health surveys. A contrasting approach is a bottom-up methodology, which takes the views of patients or laypeople on how their life is affected by their health. This approach generally requires the use of qualitative methods. Qualitative methods lend themselves well to the development of PBMs. They also ensure that the measure has appropriate language, content validity, and responsiveness to change. While the use of qualitative methods in the development of non-PBMs is fairly standard, their use in developing PBMs was until recently nonexistent. Conclusions In this article, we illustrate the use of qualitative methods by presenting two case studies of recently developed PBMs, one generic and one condition specific. We outline the stages involved, discuss the strengths and weaknesses of the approach, and compare with the top-down approach used in the majority of PBMs to date.

Background Peripheral arterial disease (PAD) is generally associated with considerable morbidity and reduced quality of life. Patient-reported outcome measures (PROMs) provide important information about the burden of disease and impact of treatment in affected patients. Objectives The objective of the review was to identify and appraise studies reporting the psychometric evaluation of PROMs administered to a specified population of patients with PAD with a view to recommending suitable PROMs. Methods A systematic review of peer-reviewed English language articles was undertaken to identify primary studies reporting psychometric properties of PROMs in English-speaking patients with various stages of PAD. Comprehensive searches were completed up until January 2015. Study selection, data extraction and quality assessment were undertaken independently by at least two researchers. Findings were presented as tabular and narrative summaries based on accepted guidance. Results Psychometric evaluation of 6 generic and 7 condition-specific PROMs reported in 14 studies contributed data to the review. The frequently reported measure was the SF-36 (n = 11 studies); others included the Walking Impairment Questionnaire (n = 8 studies), EQ-5D (n = 5 studies) and the Vascular Quality of Life Questionnaire (n = 3 studies). Studies included a diverse PAD population and varied in methodology, including approach to validation of PROMs. Conclusions Various PROMs have been validated in patients with PAD but no study provided evidence of a full psychometric evaluation in the patient population. Careful selection is required to identify reliable and valid PROMs to use in clinical and research settings. Electronic supplementary material The online version of this article (doi:10.1186/s12955-016-0563-y) contains supplementary material, which is available to authorized users.

THE TITLE of this book may give the impression that it concerns the collection and analysis of healthcare data, but it is actually about how to use Microsoft office 2007 software in healthcare settings.

INTRODUCTION:Patient-reported outcome measures (PROMs) provide a way to measure the impact of a disease and its associated treatments on the quality of life from the patients’ perspective. The aim of this review was to identify PROMs that have been developed and/or validated in patients with carotid artery disease (CAD) undergoing revascularization, and to assess their psychometric properties and examine suitability for research and clinical use.METHODS:Eight electronic databases including MEDLINE and CINAHL were searched from inception to May 2015 and updated in the MEDLINE database to February 2017. A two-stage search approach was used to identify studies reporting the development and/or validation of relevant PROMs in patients with CAD undergoing revascularization. Supplementary citation searching and hand-searching reference lists of included studies were also undertaken. The Consensus-based standards for the selection of health measurement instruments (COSMIN) and Oxford criteria were used to assess the methodological quality of the included studies, and the psychometric properties of the PROMs were evaluated using established assessment criteria.RESULTS:Six PROMs, reported in five studies, were identified: 36-Item Short Form Health Survey (SF-36), Euro-QoL-5-Dimension Scale (EQ-5D), Hospital Anxiety and Depression Scale (HADS), Dizziness Handicap Inventory (DHI), Quality of life for CAD scale by Ivanova 2015 and a disease-specific PROM designed by Stolker 2010. The rigour of the psychometric assessment of the PROMs were variable with most only attempting to assess a single psychometric criterion. No study reported evidence on criterion validity and test-retest reliability. The overall psychometric evaluation of all included PROMs was rated as poor.CONCLUSIONS:This review highlighted a lack of evidence in validated PROMs used for patients undergoing carotid artery revascularization. As a result, the development and validation of a new PROM for this patient population is warranted in order to provide data which can supplement traditional clinical outcomes (stroke >30 days post-procedural, myocardial infarction and death), and capture changes in health status and quality of life in patients to help inform treatment decisions.

Patient-reported outcome measures (PROMs) are increasingly being used in the NHS to inform clinical treatments and even the funding of individual healthcare providers. This article examines the background to their increasing use. It aims to provide nurses with information and advice about resources to increase their knowledge of PROMs. It outlines the importance of patient-centred outcomes, describes the different types of PROMs and their use in clinical practice.

Aims and objectives. To review the quality of life questionnaires used to measure the impact of venous ulceration and to evaluate their psychometric properties. Background. Venous leg ulcers have a negative impact on quality of life. Health-related quality of life can be measured using structured questionnaires. Nurses are the primary care providers for patients with venous ulceration and are ideally placed to assess and develop these types of questionnaires. There may also be an opportunity to use such quality of life instruments to measure the impact of nursing interventions in other areas where nurses are the key care providers. Design. Systematic review. Method. Studies were sought that used quality of life instruments to evaluate the impact of venous ulceration. Fourteen electronic bibliographical databases and 11 Internet-based health services research related resources were searched. In addition, grey literature was sought and the reference lists of relevant articles checked. Data were extracted regarding the type of instrument used, sample, number of items and domains and psychometric performance of the instrument. Results. The initial search identified a total of 338 potential citations. After review, a total of 31 studies were included: 17 used generic and 14 used disease-specific instruments. Five different types of generic and seven disease-specific instruments were identified. There was significant heterogeneity between the studies in terms of study design, aetiology of ulceration and times of assessment. The disease-specific instruments showed limitations in relation to their applicability to venous ulcer patients because of flaws in design or validation. Conclusions. The literature on quality of life related to venous ulceration failed to sufficiently distinguish between those with different causes of leg ulceration. There appeared to be problems with the ability of current quality of life instruments to detect changes in quality of life related to ulcer healing. Relevance to clinical practice. There appears to be an opportunity for nurses to develop a health-related quality of life health-related quality of life instruments to evaluate their impact on patient outcomes. Such instruments could potentially allow nursing interventions to be assessed more effectively than the recently proposed nursing metrics.

Background Surgical treatment of medically uncomplicated varicose veins is common, but its clinical effectiveness remains uncertain. Methods A randomized clinical trial was carried out at two large acute National Health Service hospitals in different parts of the UK (Sheffield and Exeter). Some 246 patients were recruited from 536 consecutive referrals to vascular outpatient clinics with uncomplicated varicose veins suitable for surgical treatment. Conservative management, consisting of lifestyle advice, was compared with surgical treatment (flush ligation of sites of reflux, stripping of the long saphenous vein and multiple phlebectomies, as appropriate). Changes in health status were measured using the Short Form (SF) 6D and EuroQol (EQ) 5D, quality of life instruments based on SF-36 and EuroQol, complications of treatment, symptomatic measures, anatomical extent of varicose veins and patient satisfaction. Results In the first 2 years after treatment there was a significant quality of life benefit for surgery of 0·083 (95 per cent confidence interval (c.i.) 0·005 to 0·16) quality-adjusted life years (QALYs) based on the SF-6D score and 0·13 (95 per cent c.i. 0·016 to 0·25) based on the EQ-5D score. Significant benefits were also seen in symptomatic and anatomical measures. Conclusion Surgical treatment provides symptomatic relief and significant improvements in quality of life in patients referred to secondary care with uncomplicated varicose veins.

Objective. To assess the accuracy of hand held Doppler (HHD) as a rapid screening test for selecting varicose vein patients for duplex imaging. Design. Prospective single blind study of consecutive patients in a randomised trial. Materials. Use of hand held Doppler and duplex ultrasound scanners. Methods. One thousand two hundred and eighteen legs (943 patients) were examined by HHD and then duplex. HHD examiners recorded whether they would normally have requested duplex. Results. HHD results of one Clinical Assistant (166 limbs) were significantly poorer than all others and his results were excluded from analysis. Duplex would not have been requested in 645 of 1052 (62%) limbs. Among these HHD missed significant reflux in the long saphenous vein in 18 (3%) and the short saphenous in 25 (4%). Reasons for requesting duplex were popliteal fossa reflux (202); recurrent (94) or atypical (86) varicose veins; and possible previous thrombosis (67). Differences were observed between staff and units in requests for duplex; and in thoroughness and style of duplex reporting. Conclusions. Selective use of HHD can avoid duplex imaging for many patients, with a low failure rate for detecting correctable venous reflux. Observed variations between individuals and units in results of HHD and duplex imaging have implications for the increasing use of duplex by clinicians.

An audit of 101 notes comparing patient outcomes and quality indicators before and after the introduction of a vascular nurse specialist claudication clinic was undertaken. The nurse-led clinics resulted in a reduction in median waiting time from referral to first appointments from 20 weeks to 2 weeks, and a significant reduction (p

BACKGROUND: Patients experience a wide range of symptoms from varicose veins and are seeking treatment from health care providers. However, there is little data on the relative effectiveness of the treatments available. Patients are therefore often confronted with a choice regarding treatment that they are ill-equipped to make. This lack of certainty and the resultant potential for variability in treatment decisions can mean that patients have expectations that are unrealistic or unfulfilled. AIMS AND OBJECTIVES: The aim of our study was to explore patients' expectations and reasons for seeking treatment for varicose veins. Additional aims included the exploration of symptoms associated with varicose veins and their impact on quality of life. DESIGN: Qualitative study conducted in a large NHS Trust. METHODS: A total of 16 patients, who had been referred to a specialist vascular service for the treatment of varicose veins, were recruited. Semi-structured interviews were used to explore the patients' reasons for seeking treatment. Framework analysis was used to analyse the data from the anonymized transcripts. RESULTS: Participants attributed a wide range of symptoms to their varicose veins, and were actively seeking treatment with the expectation that they would gain symptom relief. The symptoms attributed to their varicose veins had a significant negative impact on their quality of life and lifestyle. Improving the cosmetic appearance of their legs was seen as a secondary benefit. CONCLUSIONS: The perceived symptoms of varicose veins can impact on lifestyle and quality of life. Patients seek treatment with the expectation of treatment outcomes that are not supported by robust clinical evidence. Appropriate education and management of such expectations are an essential step in caring for this group of patients. RELEVANCE TO CLINICAL PRACTICE: Nurses are caring for patients with varicose veins in a range of clinical settings. When caring and providing information for this group of patients, nurses need to be aware of the impact of varicose vein symptoms and to understanding that patients may have unrealistic expectations or invalid reasons for seeking treatment.

The present article describes a project to establish an evidence-based council in a large acute teaching hospital as a tool for promoting evidence-based practice. The council aimed to give clinically active nurses ownership of research questions and an opportunity to develop confidence in their evidence-based practice skills. The development and implementation of the project are outlined and recommendations for encouraging capacity and the involvement of nurses with regard to evidence-based practice are provided.

Evidence-based practice has become an ubiquitous concept within nursing. However, there is little comparative data of nursing with other professions on attitudes to evidence-based practice. This article reports on a survey of nurses' and physiotherapists' sources of knowledge and perceived barriers to evidence-based practice within a large teaching hospital. A total of 324 questionnaires were sent to nurses and physiotherapists. The results showed that both physiotherapists and nurses accessed a wide variety of sources of knowledge. However, nurses were more likely to use policy and procedure manuals and discussions with medical staff than physiotherapists. Both professions have problems with overcoming the barrier of time. Nurses were more likely than physiotherapists to rate themselves as having poor evidence-based practice skills.

Aim: The objective of this systematic literature review was to gain insight into the effectiveness of off-loading devices to prevent heel pressure ulcers within the acute hospital setting. Background: Heels have been identified as the second most common site for pressure ulcers. Devices which off-load pressure can include pillows, wedges and boots. It is unclear as to which method or device is best at preventing pressure ulcers. Design and methods: A systematic review was carried out through the search of electronic databases and bibliographies of relevant publications. Randomised controlled trials (RCTs) and systematic reviews that compared devices which off-load heels to prevent pressure ulcers were identified. Results: A total of five studies were included in the review. The methodological quality of the studies was generally poor. The studies reported that heel-boot elevation devices appeared more beneficial. However, poor compliance with wearing the devices was identified, as well as a perceived increased risk of falls. There were little data on cost-effectiveness. Conclusions: There is little high-quality trial evidence to support the routine use of heel devices to prevent pressure ulcers. However, they may have a role to play within a multifaceted programme of pressure-ulcer prevention.

Background An abnormal dilatation of the abdominal aorta is referred to as an abdominal aortic aneurysm (AAA). Due to the risk of rupture, surgical repair is offered electively to individuals with aneurysms greater than 5.5 cm in size. Traditionally, conventional open surgical repair (OSR) was considered the first choice approach. However, over the past two decades endovascular aneurysm repair (EVAR) has gained popularity as a treatment option. This article intends to review the role of EVAR in the management of elective AAA. Objectives To assess the effectiveness of EVAR versus conventional OSR in individuals with AAA considered fit for surgery, and EVAR versus best medical care in those considered unfit for surgery. This was determined by the effect on short, intermediate and long-term mortality, endograft related complications, re-intervention rates and major complications. Search methods The Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator (TSC) searched the Specialised Register (January 2013) and the Cochrane Central Register of Controlled Trials (CENTRAL) (2012, Issue 12). The TSC also searched trial databases for details of ongoing or unpublished studies. Selection criteria Prospective randomised controlled trials (RCTs) comparing EVAR with OSR in individuals with AAA considered fit for surgery. and comparing EVAR with best medical care in individuals considered unfit for surgery. We excluded studies with inadequate data or using an inadequate randomisation technique. Data collection and analysis Three reviewers independently evaluated trials for appropriateness for inclusion and extracted data using pro forma designed by the Cochrane PVD Group. We assessed the quality of trials using The Cochrane Collaboration's 'Risk of bias' tool. We entered collected data in to Review Manager (version 5.2.3) for analysis. Where direct comparisons could be made, we determined odds ratios (OR). We tested studies for heterogeneity and, when present, we used a random-effects model; otherwise we used a fixed-effect model. We tabulated data that could not be collated. Main results Four high-quality trials comparing EVAR with OSR (n = 2790) and one high-quality trial comparing EVAR with no intervention (n = 404) fulfilled the inclusion criteria. In individuals considered fit for surgery, a pooled analysis, including 1362 individuals randomised to EVAR and 1361 randomised to OSR, found short-term mortality (including 30-day or inhospital mortality, excluding deaths prior to intervention) with EVAR to be significantly lower than with OSR (1.4% versus 4.2%, OR 0.33, 95% confidence interval (CI) 0.20 to 0.55; P < 0.0001). Using intention-to-treat analysis (ITT) there was no significant difference in mortality at intermediate follow-up (up to four years from randomisation), with 221 (15.8%) and 237 (17%) deaths in the EVAR (n = 1393) and OSR (n = 1390) groups, respectively (OR 0.92, 95% CI 0.75 to 1.12; P = 0.40). There was also no significant difference in long-term mortality (beyond four years), with 464 (37.3%) deaths in the EVAR and 470 (37.8%) deaths in the OSR group (OR 0.98, 95% CI 0.83 to 1.15; P = 0.78). Similarly, there was no significant difference in aneurysm-related mortality between groups, either at the intermediate- or long-term follow up. Studies showed that both EVAR and OSR were associated with similar incidences of cardiac deaths (OR 1.14, 95% CI 0.86 to 1.52; P = 0.36) and fatal stroke rate (OR 0.81, 95% CI 0.42 to 1.55; P = 0.52). The long-term reintervention rate was significantly higher in the EVAR group than in the OSR group (OR 1.98, 95% CI 1.12 to 3.51; P = 0.02; I2 = 85%). Results of the reintervention analysis should be interpreted with caution due to significant heterogeneity. Operative complications, health-related quality of life and sexual dysfunction were generally comparable between the EVAR and OSR groups. However, there was a slightly higher incidence of pulmonary complications in the OSR group compared with the EVAR group (OR 0.36, 95% CI 0.17 to 0.75; P = 0.006). In individuals considered unfit for conventional OSR, the one included trial found no difference between the EVAR and no-intervention groups with regard to all-cause mortality at final follow up, with 21.0 deaths per 100 person-years in the EVAR group and 22.1 deaths per 100 person years in the no-intervention group (adjusted hazard ratio (HR) with EVAR 0.99, 95% CI 0.78 to 1.27; P = 0.97). Aneurysm-related deaths were, however, significantly higher in the no-intervention group than in the EVAR group (adjusted HR 0.53, 95% CI 0.32 to 0.89; P = 0.02). There was no difference in myocardial events (HR 1.07, 95% CI 0.60 to 1.91) between the groups in this study. Authors' conclusions In individuals considered fit for conventional surgery, EVAR was associated with lower short-term mortality than OSR. However, this benefit from EVAR did not persist at the intermediate- and long-term follow ups. Individuals undergoing EVAR had a higher reintervention rate than those undergoing OSR. Most of the reinterventions undertaken following EVAR, however, were catheter-based interventions associated with low mortality. Operative complications, health-related quality of life and sexual dysfunction were generally comparable between EVAR and OSR. However, there was a slightly higher incidence of pulmonary complications in the OSR group than in the EVAR group. In individuals considered unfit for open surgery, the results of a single trial found no overall short- or long-term benefits of EVAR over no intervention with regard to all-cause mortality, but individuals may differ and individual preferences should always be taken into account.

Although the trend is to restrict access to treatment, patients will continue to seek treatment for varicose veins.

Objective To examine the effectiveness and cost-effectiveness of antimicrobial silver-donating dressings for venous leg ulcers compared with simple non-adherent (also known as low-adherent) dressings. Design A pragmatic, prospective randomised controlled trial (RCT) and cost-effectiveness analysis of silver-donating versus low-adherent dressings in the treatment of venous leg ulcers. A non-randomised observational group was also recruited. Setting Primary and secondary care services in the north and south of England (Sheffield and Exeter). Participants Consenting patients with active ulceration of the lower leg that had been present for a period of greater than 6 weeks. Interventions Patients were randomised to receive either a silver-donating or non-silver low-adherent dressing applied beneath compression bandages or hosiery. The choice of dressing within these groups was left to clinician preference. Evaluation was by clinical assessment, supplemented by evaluation of quality of life and cost-effectiveness. Main outcome measures The primary outcome measure was complete ulcer healing at 12 weeks in the index limb. Secondary measures were costs and quality-adjusted life-years (QALYs), cost-effectiveness, time to healing, and recurrence rate at 6 months and 1 year. Results In total, 304 participants were recruited to the clinical trial: 213 to the RCT and 91 to the observational arm. Within the RCT 107 were randomised to antimicrobial dressings and 106 to the control dressings. There were no significant differences (p > 0.05) between the two groups for the primary outcome measure of proportion of ulcers healed at 12 weeks (59.6% for silver and 56.7% for control dressings). The overall median time to healing was also not significantly different between the two groups (p = 0.408). A total of 24 patients had recurrent ulcers within 1 year; the recurrence rates of 11.6% (n = 11) for the antimicrobial and 14.4% (n = 13) for the control dressings were not significant. Mean utility valuations for both the EuroQol 5 dimensions (EQ-5D) quality of life questionnaire and Short Form 6 dimensions (SF-6D) utility index showed no differences for either group at 1, 3, 6 or 12 months. Compared with the control group, the antimicrobial group had an incremental cost of £97.85 and an incremental QALY gain of 0.0002, giving an incremental cost-effectiveness ratio for the antimicrobial dressings of £489,250. Cost-effectiveness modelling of the results of the RCT showed that antimicrobial dressings were not cost-effective. Conclusions No significant differences in either primary or secondary end points were found between the use of antimicrobial silver-donating dressings and the control group of low-adherent dressings. Modelling showed that antimicrobial silver dressings were not cost-effective. Trial registration Current Controlled Trials ISRCTN72485131.

Background Antimicrobial silver dressings are used beneath graduated compression in the treatment of venous ulceration. There is little information on whether their use is effective. This was a prospective randomized trial and cost-effectiveness analysis of silver-donating versus non-silver low-adherence dressings in the treatment of venous leg ulcers. Methods Patients were randomized between the two types of dressing. The primary outcome measure was complete ulcer healing at 12 weeks. Secondary outcomes included time to healing, quality of life and cost-effectiveness. Results A total of 213 patients were recruited. There was no difference between the dressings in the proportion of ulcers healed at 12 weeks (59·6 per cent for silver and 56·7 per cent for control dressings). Mean utility scores for the EuroQol 5D and Short Form 6D were similar in both groups at 1, 3, 6 and 12 months. Compared with the control group the antimicrobial group had an incremental cost of £97·85 and an incremental quality-adjusted life year gain of 0·0002, giving an incremental cost-effectiveness ratio of £489 250 for the antimicrobial dressings. Conclusion No significant differences were found in either primary or secondary endpoints. There was no evidence to support the routine use of silver-donating dressings beneath compression for venous ulceration. Registration number: ISRCTN 72485131 (http://www.controlled-trials.com).

Objective Compression hosiery is widely used in the prevention and management of symptoms related to varicose veins. However, there are still gaps and questions in relation to its benefit. This review seeks to examine the current evidence regarding the effectiveness of compression hosiery in the treatment of varicose veins. Method Prospective, randomized controlled trials (RCTs) evaluating compression hosiery in the treatment of varicose veins were sought. Where RCTs were unavailable other evidence was included. Studies were included if they evaluated the application of compression to patients with a diagnosis of varicose veins. Twelve electronic bibliographic databases and 18 internet-based research resources were searched. Inclusion or exclusion of trials was decided by two reviewers acting independently. Results The search strategy identified 25 studies. Eleven were RCTs or systematic reviews, 12 non-randomized studies and two guidelines. No consensus was found regarding the class of compression needed for the effective management of varicose veins. Wearing compression improved symptom management, but could be confounded by the exclusion of high number of non-compliant patients within the trials. Wearing compression to slow the progression, or prevent the reoccurrence of varicose veins could not be supported by the current published evidence. Conclusion The evidence for the benefit of compression hosiery for varicose veins was equivocal. The published literature was often contradictory and had methodological flaws.

There can be difficulties in measuring how quality of life is affected by having a leg ulcer.To assess the impact of venous ulceration on quality of life and to pilot a draft questionnaire for patients with venous ulcers.Questions on the impact of venous ulceration were identified through a literature review, semi-structured interviews and focus groups. A self-completed postal questionnaire containing 16 disease-specific items, EuroQol, SF-6 and life-satisfaction questions was sent to 266 people with a history of venous ulceration.A response rate of 61% (n = 152) was obtained. The most frequent symptoms reported were pain (80%), exudate (75%), and depression (65%). The presence of an ulcer resulted in statistically significant lower quality-of-life and life-satisfaction scores.Patients with venous ulcers experience reduced quality of life. Those with a healed ulcer also have a poorer quality of life compared with the general population.

Aclinician trying to examine the evidence about a particular treatment or intervention can be frustrated by phrases such as: ‘more evidence needed’ or ‘insufficient evidence of effectiveness’ or ‘the current evidence was of poor quality’. It can sometimes seem that researchers are not answering questions that have any relevance or use to clinical staff. As a nurse researcher within the area of tissue viability I would like to plead some extenuating circumstances. In conducting research you can encounter problems with money, bureaucracy, recruitment and dissemination.

Objective To review the evidence of effectiveness of dressings applied to venous leg ulcers. Design Systematic review and meta-analysis. Data sources Hand searches of journals and searches of electronic databases, conference proceedings, and bibliographies up to April 2006; contacts with dressing manufacturers for unpublished studies. Studies reviewed All randomised controlled trials that evaluated dressings applied to venous leg ulcers were eligible for inclusion. Data from eligible studies were extracted and summarised independently by two reviewers using a data extraction sheet. Methodological quality was assessed independently by two reviewers. Results The search strategy identified 254 studies; 42 of these fulfilled the inclusion criteria. Hydrocolloids were no more effective than simple low adherent dressings used beneath compression (eight trials; relative risk for healing with hydrocolloid 1.02, 95% confidence interval 0.83 to 1.28). For other comparisons, insufficient evidence was available to allow firm conclusions to be drawn. None of the dressing comparisons showed evidence that a particular class of dressing healed more ulcers. Some differences existed between dressings in terms of subjective outcome measures and ulcer healing rates. The results were not affected by the size or quality of trials or the unit of randomisation. Insufficient data were available to allow conclusions to be drawn about the relative cost effectiveness of different dressings. Conclusions The type of dressing applied beneath compression was not shown to affect ulcer healing. The results of the meta-analysis showed that applying hydrocolloid dressings beneath compression produced no benefit in terms of ulcer healing compared with applying simple low adherent dressings. No conclusive recommendations can be made as to which type of dressing is most cost effective. Decisions on which dressing to apply should be based on the local costs of dressings and the preferences of the practitioner or patient.

Venous ulcers, sometimes termed varicose or stasis ulcers, are a consequence of damage to the valves in the veins of the legs, leading to raised venous pressure. They are characterized by a cyclical pattern of healing and recurrence. There is a need to have a thorough assessment of patients with leg ulcers by an appropriately experienced clinician to maximize the chance of healing the ulcer. The main treatment is the application of compression, either in the form of compression bandages or hosiery. Dressings are applied beneath the compression with a view to controlling exudate, comfort and to aid healing. There are a large number of dressing products and types available but the evidence to justify their use is poor. The main treatment for venous ulcers should therefore be the application of compression therapy with a simple, low adherent dressing.

Venous leg ulcers are often colonised by microorganisms and, this can have an adverse effect on wound healing (Eriksson, 1984; Halbert et al, 1992). During the last 5 years many dressings that purport to have antimicrobial effects have become available (Chambers et al, 2007). These dressings have been promoted for use in the prevention and treatment of infection in wounds (Alcaraz and Kelly, 2003; Lansdown et al, 2003; Vanscheidt et al, 2003; Dowsett 2004). One type of antimicrobial dressing is those that donate silver to the wound bed. These are based on the ability of silver to kill or limit the growth of a wide variety of microbial organisms (Thomas and McCubbin, 2003).

AIM: This paper is a report of a study to examine, from the perspective of patients, the impact of venous leg ulcers on health-related quality of life in current and former intravenous drug users and the general population. BACKGROUND: Venous ulceration can be caused by intravenous drug use. There has been little examination on how this affects the quality of life of this group of patients and how they compare with other patients who have venous ulcers. METHOD: A qualitative approach was adopted, using framework analysis. Semi-structured interviews with 19 participants who had a venous leg ulcer were conducted between August 2005 and February 2006. Interview audiotapes were analysed to identify recurring themes relating to the impact of venous leg ulcers on overall quality of life. FINDINGS: A complex interaction between symptoms, social restriction and attribution of illness influenced the impact of venous leg ulcers. Smell and pain were the symptoms that had the most profound impacts. In addition to the physical and psychological consequences, participants' activities and social interactions were restricted. Intravenous drug users experienced more social isolation and difficulties in accessing treatment for their venous ulcers. CONCLUSION: While leg ulcer services remain focused on the needs of older people, services for young intravenous drug users are unlikely to improve. A more coherent and earlier intervention, when the ulcers are not as difficult to treat, would decrease time and costs to the health service. The challenge is to find new ways of providing effective and accessible care to this growing population.

Aim. To examine the potential role of the Clinical Librarian in facilitating evidence-based practice of nurses in acute hospital settings and develop a model for the role. Background. There is a growing policy and professional expectation that nurses will seek out and apply evidence in their clinical practice. Studies have demonstrated that nurses experience barriers in working with an evidence-based approach. The role of Clinical Librarian has been used in other countries and within medicine to overcome some of the barriers to evidence-based practice. There are limitations in the previous work in terms of rigour of evaluation, scope of the Clinical Librarian role and application to nursing in a UK setting. Design. A qualitative consultation of 72 nurses in acute care settings. Methods. Six consultation group interviews of between 4–19 participants. Written records were recorded by the scribe. Content analysis was undertaken to identify the range and frequency of comments. Results. Clinical questions currently go unanswered because of barriers of time, skills deficits and access to resources. Literature searching, skills training and evidence dissemination were the main areas of work the staff requested that a Clinical Librarian should undertake. It was anticipated that the Clinical Librarian could interact and work productively with nursing staff with a limited but regular presence on the ward. Interim communication could be via e-mail, phone and written suggestions and requests for work. It was seen to be vital that the Clinical Librarian worked in partnership with staff to build evidence-based practice capacity and ensure clinical relevance of the work. Conclusions. This study has generated the first model for the Clinical Librarian role with an emphasis on nursing. It is derived from the views of clinical nurses. Recommendations are made for the implementation and evaluation of such a role. Relevance to clinical practice. The Clinical Librarian could be an invaluable support to promoting evidence-based nursing.

Cost utility analyses typically incorporate preferences based upon the mean values for health states generated from a sample of the general population. The main argument for using general population values rests upon the premise that in a publicly funded health care system the main objective of the health care system is a societal one, namely to maximise health subject to equity concerns. Alternatively, it can be argued that patients themselves should be asked to value their own health state given that they have first hand experience of the state being valued. This paper investigates the relationship between patient and general population values within the context of a randomised controlled trial to compare alternative treatments for varicose veins. It was found that patients' own health valuations tended to be higher than those of the general population sample. The results from this study have important implications for economic evaluation. The incremental QALY gain for patients receiving treatment for moderate varicose veins would be almost halved if patients' own values were used to estimate QALYs in contrast to the general population values. The results also suggest that the variant of elicitation technique may be more important than the source of those values in revealing discrepancies. Copyright © 2006 John Wiley & Sons, Ltd.

Background Venous leg ulcers, sometimes called varicose or stasis ulcers, are a consequence of damage to the valves in the veins of the legs, leading to raised venous pressure. Venous ulcers are characterised by a cyclical pattern of healing and recurrence. The main treatment is the application of compression, either in the form of compression bandages or hosiery. Dressings are usually applied beneath the compression to aid healing, comfort and to control exudate. Wounds heal quicker in a moist environment and dressings are used to absorb excess fluid or retain fluid in an otherwise dry wound in order to achieve a 'moist wound environment'. There are a large number of dressing products and types available. It is unclear whether particular dressings aid healing of leg ulcers. Objectives To assess the effectiveness of wound dressings for the treatment of venous leg ulcers. Search methods We searched the Cochrane Wounds Group Specialised Register (April 2006) and CENTRAL (issue 1, 2006) and several other electronic databases (up to April 2005). Manufacturers of dressing products were contacted for unpublished studies. Selection criteria Randomised controlled trials that evaluated dressings for the treatment of venous leg ulcers. There was no restriction in terms of source, date of publication or language. Ulcer healing was the primary endpoint. Data collection and analysis Data from eligible studies were extracted and summarised using a data extraction sheet by two authors independently. Main results 42 randomised controlled studies were identified that met the inclusion criteria. The main dressing types that were evaluated were hydrocolloids (n = 23), foams (n = 6), alginates (n = 4), hydrogel dressings (n = 6) and a group of miscellaneous dressings (n = 3). In none of the comparisons was there evidence that any one dressing type was better than others in terms of number of ulcers healed. Current evidence does not suggest that hydrocolloids are more effective than simple low adherent dressings used beneath compression (9 trials; relative risk for healing with hydrocolloid 1.09 (95% CI 0.89 to 1.34)). For other comparisons there was insufficient evidence. Authors' conclusions The type of dressing applied beneath compression has not been shown to affect ulcer healing. For the majority of dressing types there was insufficient data to allow us to draw strong conclusions except for hydrocolloid compared with a low adherent dressing. The result of the meta-analysis indicate no significant difference in healing rates between hydrocolloid dressings and simple, low-adherent dressings when used beneath compression. Decisions regarding which dressing to apply should be based on local costs of dressings and practitioner or patient preferences.

BACKGROUND: Varicose veins are a relatively common condition and account for around 54,000 in‐patient hospital episodes per year. The two most common interventions for varicose veins are surgery and sclerotherapy. However, there is little comparative data regarding their effectiveness. OBJECTIVES: To identify whether the use of surgery or sclerotherapy should be recommended for the management of primary varicose veins. SEARCH METHODS: Thirteen electronic bibliographic databases were searched covering biomedical, science, social science, health economic and grey literature (including current research). In addition, the reference lists of relevant articles were checked and various health services research‐related resources were consulted via the internet. These included health economics and HTA organisations, guideline producing agencies, generic research and trials registers, and specialist sites. SELECTION CRITERIA: All studies that were described as randomised controlled trials comparing surgery with sclerotherapy for the treatment of primary varicose veins were identified. DATA COLLECTION AND ANALYSIS: Two authors independently extracted and summarised data from the eligible studies using a data extraction sheet for consistency. All studies were cross‐checked independently by the authors. MAIN RESULTS: A total of 2306 references were found from our searches, 61 of which were identified as potential trials comparing surgery and sclerotherapy. However, only nine randomised trials, described in a total of 14 separate papers, fulfilled the inclusion criteria. Fifty trials were excluded and one trial is ongoing and is due for completion in 2004. The trials used a variety of outcome measures and classification systems which made direct comparison between trials difficult. However, the trend was for sclerotherapy to be evaluated as significantly better than surgery at one year; after one year (sclerotherapy resulted in worse outcomes) the benefits with sclerotherapy were less, and by three to five years surgery had better outcomes. The data on cost‐effectiveness was not adequately reported. AUTHORS' CONCLUSIONS: There was insufficient evidence to preferentially recommend the use of sclerotherapy or surgery. There needs to be more research that specifically examines both costs and outcomes for surgery and sclerotherapy.

BACKGROUND Varicose vein surgery is a common surgical procedure but there is no consensus regarding the best surgical technique. The use of tourniquets during varicose vein surgery has been advocated as a means of reducing the potential for blood loss during the operation. OBJECTIVES To identify whether the use of a tourniquet should be recommended when undertaking surgery for the management of primary varicose veins. SEARCH STRATEGY The reviewers searched the Cochrane Peripheral Vascular Diseases Group trials register (last searched November 2001), thirteen electronic bibliographic databases, including the Cochrane Controlled Trials Register (CCTR) (last searched Issue 3, 2001), covering biomedical science, social science, health economic and grey literature (including current research). In addition, the reference lists of relevant articles were checked and various health services research related resources were consulted via the Internet. These included health economics and HTA organisations, guideline producing agencies, generic research and trials registers, and specialist sites. SELECTION CRITERIA All studies described as randomised controlled trials that examined the use of tourniquets during surgery for patients with primary varicose veins were included. DATA COLLECTION AND ANALYSIS Data from eligible studies were extracted and summarised independently by two reviewers. All studies were cross-checked independently by the reviewers. MAIN RESULTS A total of twenty published papers and nineteen studies were identified. Only three of these were randomised controlled trials and were included in the review. Sixteen studies were excluded as they were non-randomised and one was a duplicate study. All three trials had a small sample size and reported the trial design, outcome measures and analysis poorly. There were also variations in the outcome measures used between the trials. In addition, there was no consistency on the reporting of mean and medians for blood loss during the operation. It was therefore not possible to pool the data to perform meta-analysis. However, the reported blood loss when using a tourniquet was between 0 and 16mls compared to between 107 to 133mls when not using a tourniquet (p

Background There is increasing pressure to monitor surgical performance. In the UK, the Department of Health has produced clinical indicators based on routine data to monitor performance. This study analysed whether such data could measure performance in aortic surgery. Methods Routine hospital data on postoperative mortality were collected for 1995–1997 in the Trent region. Procedural and diagnostic codes, modes of admission, districts of residence, treatment and specialty data were compared with audit data and the Operating Theatre Information System. Results: Inaccuracies in the Health Resource Group (HRG) codes meant that 21·4 per cent of elective aortic cases (HRG Q02) were probably emergencies and 26 per cent of probable ruptured aneurysms were not coded as a vascular emergency. Case mix and patient selection introduced a bias, apparent between tertiary and district general hospitals. For patients aged over 80 years, two district hospitals undertook no elective aortic surgery; the rate for emergency aortic surgery varied between 16 and 25 per cent in the district hospitals, and was 77 per cent in the tertiary centre. Conclusion Crude mortality rates used as an indicator of performance are subject to bias and distortion owing to the collection of incorrect information, variation in patient selection between hospitals and case-mix differences. There was a considerable variation in selection and outcomes of patients undergoing aortic surgery in this study.