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encompasses both outcomes and performance indicators such as timeliness of surgery and cranial nerve injury. Such reporting has driven improvement in quality of services by focussing clinicians on key components of high-quality pathways of care. Vascunet was formed in 1997 as a collaboration of national registries in Europe, New Zealand, and the state of Victoria in Australia, with its first report produced in 2007. Since then, the Vascunet group have published comparative data on carotid surgery, abdominal aortic aneurysm, One of the key features of these publications has been to describe the variation in clinical practice across neighbouring countries, notable examples being rates of surgery for asymptomatic stenosis and rates of lower limb bypass for intermittent claudication. Variation in outcomes is also reported at a national level. The value of such reporting was demonstrated by the 2008 Vascunet report. This demonstrated outlying mortality rates after elective repair of abdominal aortic aneurysm surgery in the UK. This was a stimulus to a quality improvement initiative that sought to standardise practice and improve outcomes. The transparent publication of standards led to their widespread adoption both by clinicians and service commissioners within the UK. Recent publications have demonstrated a marked improvement in UK outcomes. This cycle of audit, analysis, standard setting, and re-audit demonstrates the improvement in quality that can follow acknowledgement of poor outcomes. This experience mirrors those in other clinical specialities such as cardiothoracic surgery. Comparative audits suffer from a number of shortcomings, such as incomplete datasets with potential for bias and misleading interpretation. Most national registries rely on voluntary data contributions from practising clinicians who have varying levels of enthusiasm for audit. It is widely acknowledged that incomplete audit data is a source of bias and may give misleading messages. This has allowed some to ignore the messages from comparative audit, and may be the explanation behind some countries not wishing to participate in data analysis and publication. The recognition of this issue leads to the linking of Swedvasc (and the Helsinki datasets in Finland) data to national administrative datasets to improve accuracy. Similarly in the UK, data for carotid and aortic aneurysm procedures are now compared with national administrative datasets to demonstrate the quality of data. A secondary benefit has been an improvement in data quality, presumably as a result of peer pressure. Vascunet has recently taken this further with external validation of data subsets in Hungary 16 and Sweden (ongoing project). This pilot demonstrated that national datasets can be validated by expatriate experts, providing an independent and even more robust measure of data quality. It is planned to extend this throughout the Vascunet registries group, if funding can be found. Clinical audit data is one important source of information, about routine clinical practice, that can be used to highlight inconsistencies in clinical outcomes. The use of data, however incomplete, as an agent for change and as a guide for standard setting is established. We believe that the use of national audit data should be extended to drive quality improvement across geographical boundaries. There are significant challenges to achieving this, but Vascunet believes that the time is right to embrace this. With increasing financial constraints on healthcare, clinicians need to be seen to lead on issues of quality of care. Part of this requires an open approach to measuring the standards of care, with the aim of improvement, rather than criticism. We believe that we have the support of patients in this aim and that transparent publication of data serves to both inform and educate in the debate about allocation of limited resources. There is debate about what and how much data should be collected. Most enthusiasts approach clinical audit wishing to obtain a large amount of data to enable a detailed analysis of behaviour. The problem with this approach is that it inevitably relies on busy clinicians collecting the data, often after delivery of care. Unsurprisingly,
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