Table 1

Types and sources of variation in delivery of healthcare

Caused by biological and/or patient influence variation (in anatomy, pathology and patient preference)Caused by suboptimal availability and/or use of service resourcesCaused by suboptimal availability and/or use of EVAR resources
  • The monitoring frequency may depend on aneurysm size and growth rate.

  • Patients having an aorta anatomically unsuited for EVAR.

  • Patients being unsuited for open surgery due to comorbidities.

  • Female patients being operated at a smaller aneurysm diameter than male patients.

  • Life expectancy was a contributing factor in surgical decision-making.

Delays due to
  • waiting lists at the radiological units

  • radiological report turnaround time

  • waiting lists for additional tests such as heart and lung exams.

  • The described delays differed (a) within each hospital and (b) across units/hospitals. The management of these delays was particularly evident in the university hospital's workflow.

  • Delays due to accessibility to the EVAR service: the local surgeon had to refer eligible candidates to the vascular surgery service at the university hospital. Delays in the subsequent patient trajectory depended on the latter's process time.

  • Delays due to lack of professional capacity—for example, when EVAR-skilled personnel were on vacation.

  • Patient in need of EVAR suitability assessment within a few days to complete the decision on whether to operate.

  • Non-planned, extra workload in information processing due to patients preferring to have their CT exam/tests at private institutes.

Delayed decision due to:
  • Patients seeking to coordinate their own healthcare—for example, when a patient rescheduled his CT exam to take place on the same day as the clinical consultation. As a consequence, the patient was not informed about the surgeon's decision before 2–3 days later (the surgeon had to see the CT result).

Delayed decision due to:
  • Patient not showing up at the scheduled appointment.

  • Health personnel failing to act: eg, (1) a CT exam–performed at outside units–was not routed to EVAR suitability assessment in timely advance of the clinical consultation; (2) one patient was not enrolled in the surveillance programme at the time of the discovery of aneurysm.

  • EVAR, endovascular repair.