Screening

 

1. Screening men for abdominal aortic aneurysm: 10 year mortality and cost effectiveness results from the randomised Multicentre Aneurysm Screening Study. BMJ, 2009

Citation:

BMJ, 2009, vol./is. 338/(b2307), 0959-535X;1468-5833 (2009)

Author(s):

Thompson SG,Ashton HA,Gao L,Scott RA,Multicentre Aneurysm Screening Study Group

Abstract:

OBJECTIVES: To assess whether the mortality benefit from screening men aged 65-74 for abdominal aortic aneurysm decreases over time, and to estimate the long term cost effectiveness of screening. DESIGN: Randomised trial with 10 years of follow-up. SETTING: Four centres in the UK. Screening and surveillance was delivered mainly in primary care settings, with follow-up and surgery offered in hospitals. PARTICIPANTS: Population based sample of 67 770 men aged 65-74. INTERVENTIONS: Participants were individually allocated to invitation to ultrasound screening (invited group) or to a control group not offered screening. Patients with an abdominal aortic aneurysm detected at screening underwent surveillance and were offered surgery if they met predefined criteria. MAIN OUTCOME MEASURES: Mortality and costs related to abdominal aortic aneurysm, and cost per life year gained. RESULTS: Over 10 years 155 deaths related to abdominal aortic aneurysm (absolute risk 0.46%) occurred in the invited group and 296 (0.87%) in the control group (relative risk reduction 48%, 95% confidence interval 37% to 57%). The degree of benefit seen in earlier years of follow-up was maintained in later years. Based on the 10 year trial data, the incremental cost per man invited to screening was pound100 (95% confidence interval pound82 to pound118), leading to an incremental cost effectiveness ratio of pound7600 ( pound5100 to pound13,000) per life year gained. However, the incidence of ruptured abdominal aortic aneurysms in those originally screened as normal increased noticeably after eight years. CONCLUSIONS: The mortality benefit of screening men aged 65-74 for abdominal aortic aneurysm is maintained up to 10 years and cost effectiveness becomes more favourable over time. To maximise the benefit from a screening programme, emphasis should be placed on achieving a high initial rate of attendance and good adherence to clinical follow-up, preventing delays in undertaking surgery, and maintaining a low operative mortality after elective surgery. On the basis of current evidence, rescreening of those originally screened as normal is not justified. Trial registration Current Controlled Trials ISRCTN37381646.

 

2. Should the frequency of surveillance for small abdominal aortic aneurysms be reduced? EJVES 2013

Citation:

European Journal of Vascular & Endovascular Surgery 2013; 46(2):171-2

Authors:

Powell JT, Thompson SG

Abstract:

Different national screening programmes use a variety of surveillance intervals for patients identified with small abdominal aortic aneurysm. An individual patient meta-analysis of >15000 persons with small aneurysm has provided a strong scientific basis for safe surveillance frequency. In many screening programmes the number of surveillance visits for men could be reduced by up to half. The higher rate of aneurysm rupture in women leads to different recommendation for women.

 

3. Ultrasonography Screening for Abdominal Aortic Aneurysms: A Systematic Evidence Review for the U.S. Preventive Services Task Force. Annals of Internal Medicine 2014

Citation: Annals of Internal Medicine 2014; Online First 28 January doi:10.7326/M13-1844

Authors: Guirguis-Blake JM, Beil TL, Senger CA, et al.

Abstract:

Background: Long-term follow-up of population-based randomized, controlled trials (RCTs) have demonstrated that screening for abdominal aortic aneurysms (AAAs) measuring 3cm or greater decreases AAA-related mortality rates in men aged 65 years or older.

Purpose: To systematically review evidence about the benefits and harms of ultrasonography screening for AAAs in asymptomatic primary care patients.

Data Sources: MEDLINE, the Database of Abstracts of Reviews of Effects, the Cochrane Central Registry of Controlled Trials (January 2004 through January 2013), clinical trial registries, reference lists, experts, and a targeted bridge search for population-based screening RCTs through September 2013.

Study Selection: English-language, population-based fair- to good-quality RCTs and large cohort studies for AAA screening benefits as well as RCTs and cohort and registry studies for harms in adults with AAA.

Data Extraction: Dual quality assessment and abstraction of study details and results.

Data Synthesis: Reviews of 4 RCTs involving 137 214 participants demonstrated that 1-time invitation for AAA screening in men aged 65 years or older reduced AAA rupture and AAA-related mortality rates for up to 10 and 15 years, respectively, but had no statistically significant effect on all-cause mortality rates up to 15 years. Screening was associated with more overall and elective surgeries but fewer emergency operations and lower 30-day operative mortality rates at up to 10- to 15-year follow-up. One RCT involving 9342 women showed that screening had no benefit on AAA-related or all-cause mortality rates.

Limitations: Trials included mostly white men outside of the United States. Information for subgroups and about rescreening was limited.

Conclusion: One-time invitation for AAA screening in men aged 65 years or older was associated with decreased AAA rupture and AAA-related mortality rates but had little or no effect on all-cause mortality rates.

 

4. The importance of socioeconomic factors for compliance and outcome at screening for abdominal aortic aneurysm in 65-year-old men, Journal of Vascular Surgery July 2013

Citation: Journal of Vascular Surgery Volume 58 Issue 1, Pages 50-55, July 2013

Authors: Moncef Zarrouk, Jan Holst, Martin Malina, Bengt Lindblad, Christine Wann-Hansson, Maria Rosvall, Anders Gottsater

Objective:

To evaluate compliance with screening and prevalence of abdominal aortic aneurysm (AAA) in relation to background data regarding area-based socioeconomic status.

Methods:

Our department annually invites 4300 65-year-old men from the city of Malmö and 15 neighboring municipalities to ultrasound AAA screening. In a cross-sectional cohort study, compliance and AAA prevalence among 8269 men were related to background socioeconomic data such as mean income, proportion of immigrants, percentage of subjects on welfare, smoking habits, and unemployment rate in the different municipalities. The 10 different administrative areas in Malmö were evaluated separately.

Results:

Compliance with screening in the entire area was 6630/8269 (80.2%) but varied between 64.4% and 89.3% in different municipalities (P <.001). In univariate analysis, compliance increased with increasing mean income (r = 0.873; P < .001) but decreased with increasing proportion of immigrants (r = −0.685; P =.005) and subjects on welfare (r = −0.698; P = .004). Compliance in 10 different administrative parts of Malmö (P = .002) also increased with increasing mean income (r = 0.948; P < .001), and decreased with increasing proportion of immigrants (r = −0.650; P = .042) and increasing unemployment rate (r = −0.796; P = .006). Altogether, 117 (1.8%) AAAs were found, the prevalence differing between both different municipalities (P =.003) and the 10 different administrative parts of Malmö (P =.02). The prevalence of AAA in the 10 administrative parts of Malmö increased with increasing percentage of smokers (r = 0.784; P = .007), percentage of immigrants (r = 0.644; P = .044), and unemployment rate (r = 0.783; P =.007) but decreased with increasing mean income (r = −0.754; P = .012).

Conclusions:

Compliance with ultrasound screening for AAA differed between different geographical areas. In areas with low socioeconomic status, compliance rates were lower, whereas AAA prevalence was higher. The identification of contextual factors associated with low compliance is important to be able to allow targeted actions to increase efficacy of ultrasound screening for AAA. Targeted actions to increase
compliance in those areas are being scientifically investigated and implemented.

 

5. International Variations in AAA Screening, European Journal of Vascular & Endovascular Surgery, January 2013

Citation: European Journal of Vascular & Endovascular Surgery, Vol 45, Issue 3, March 2013. Published online 21 January 2013.

Authors: PW Stather, N Dattani, MJ Bown, JJ Earnshaw, TA Lees

Introduction:

Abdominal aortic aneurysm (AAA) screening programmes reduce AAA-related mortality and are cost-effective. This study aims to assess the state and variability of AAA screening programmes worldwide.

Methods:

Data were obtained from an international expert group convened at the 34th Charing Cross Symposium as well as government websites and published reports on screening programmes.

Results:

Six countries are in the process of implementing national AAA screening programmes, with Italy still performing screening trials. There is wide variability in inclusion criteria between countries with the majority screening only men in their 65th year, however 3 programmes include women, 2 programmes only include patients with high cardiovascular risk, and 2 trials are also screening for hypertension and lower limb atherosclerosis. Surveillance intervals vary between screening programmes, with the most common regimen being to vary the surveillance interval depending upon aneurysm size, however the optimum surveillance interval in terms of decreasing mortality and cost effectiveness remains uncertain.

Discussion:

International dissemination of current AAA screening programme outcomes is required to inform developing programmes about optimum screening intervals, benefits of surveillance of the subaneurysmal aorta, and screening for other cardiovascular disease.

 

6. Surveillance Intervals for Small Abdominal Aortic Aneurysms: A Meta-analysis. The Journal of the American Medical Association, February 2013

Citation: The Journal of the American Medical Association. 2013;309(8):806-813. doi:10.1001/jama.2013.950.

Authors: The RESCAN Collaborators

Importance: Small abdominal aortic aneurysms (AAAs [3.0 cm-5.4 cm in diameter]) are monitored by ultrasound surveillance. The intervals between surveillance scans should be chosen to detect an expanding aneurysm prior to rupture.

Objective: To limit risk of aneurysm rupture or excessive growth by optimizing ultrasound surveillance intervals.

Data Sources and Study Selection: Individual patient data from studies of small AAA growth and rupture were assessed. Studies were identified for inclusion through a systematic literature search through December 2010. Study authors were contacted, which yielded 18 data sets providing repeated ultrasound measurements of AAA diameter over time in 15 471 patients.

Data Extraction: AAA diameters were analysed using a random-effects model that allowed for between-patient variability in size and growth rate. Rupture rates were analysed by proportional hazards regression using the modelled AAA diameter as a time-varying covariate. Predictions of the risks of exceeding 5.5-cm diameter and of rupture within given time intervals were estimated and pooled across studies by random effects meta-analysis.

Results: AAA growth and rupture rates varied considerably across studies. For each 0.5-cm increase in AAA diameter, growth rates increased on average by 0.59 mm per year (95% CI, 0.51-0.66) and rupture rates increased by a factor of 1.91 (95% CI, 1.61-2.25). For example, to control the AAA growth risk in men of exceeding 5.5 cm to below 10%, on average, a 7.4-year surveillance interval (95% CI, 6.7-8.1) is sufficient for a 3.0-cm AAA, while an 8-month interval (95% CI, 7-10) is necessary for a 5.0-cm AAA. To control the risk of rupture in men to below 1%, the corresponding estimated surveillance intervals are 8.5 years (95% CI, 7.0-10.5) and 17 months (95% CI, 14-22).

Conclusion and Relevance: In contrast to the commonly adopted surveillance intervals in current AAA screening programs, surveillance intervals of several years may be clinically acceptable for the majority of patients with small AAA.

 

7. Twenty-year review of abdominal aortic aneurysm screening in men in the county of Gloucestershire, United Kingdom, Journal of Vascular Surgery July 2012

Citation:

Journal of Vascular Surgery: July 2012 (Volume 56, Issue 1)

Authors:

Rosie Darwood, Jonothan Earnshaw, Glenda Turton, Elaine Shaw, Mark Whyman, Keith Poskitt, Caroline Rodd, Brian Heather (Gloucestershire Hospitals NHs Foundation Trust)

Objective:

An ultrasound screening program for abdominal aortic aneurysms (AAAs) in men began in Gloucestershire in 1990 and has been running for 20 years. This report examines the workload and results.

Methods:

We reviewed the screening database for attendance and outcome records from AAA surgery in Gloucestershire and postmortem and death certificate results looking for men who died from ruptured AAAs in the screening cohort. The setting was an AAA screening program in the county of Gloucestershire, UK. Men aged 65 were invited by year of birth to attend for an ultrasound screening for AAAs. Men with an aorta <2.6 cm were reassured and discharged; men with an aorta between 2.6 cm and 5.4 cm were offered follow-up surveillance; men with an aorta >5.4 cm were considered for intervention. We analyzed attendance rates, screening and surveillance outcomes, and intervention rates and outcomes over the 20 years of the study.

Results:

Some 61,982 men were invited, and 52,690 attended for screening (85% attendance). At first scan, 50,130 men (95.14%) had an aortic diameter <2.6 cm in diameter and were reassured and discharged; 148 men (0.28%) had an AAA >5.4 cm in diameter and were referred for possible treatment; 2412 (4.57%) had an aortic diameter between 2.6 and 5.4 cm and entered a program of ultrasound surveillance. The overall mean aortic diameter on initial scan fell from 2.1 cm to 1.7 cm during the study (reduction 0.015 cm/y, 95% confidence interval [CI], 0.0144-0.0156 cm/y; P < .0001). Some 631 patients with AAAs had intervention treatment with a perioperative mortality rate of 3.9%; during the same interval, 372 AAAs detected incidentally were treated, with a mortality rate of 6.7%. The number of ruptured AAAs treated annually in Gloucestershire fell during the study (χ2 for trend = 18.31, df = 1; P < .0001).

Conclusions:

Screening reduced the number of ruptured AAAs in Gloucestershire during the 20 years of the program. There has been a significant reduction of men with an abnormal aorta, as the mean aortic diameter of the 65-year-old male has reduced over 20 years.

 

8. Low prevalence of abdominal aortic aneurysm among 65-year-old Swedish men indicates a change in the epidemiology of the disease

Citation:

Circulation 2011, 124: 1118-1123

Authors:

Sverker Svensjo, MD; Martin Bjorck, MD, PhD; Mikael Gurtelschmid, MD; Khatereh Djavani Gidlund, MD; Anders Hellberg, MD, PhD; Anders Wanhainen, MD, PhD

Background:

Screening elderly men with ultrasound is an established method to reduce mortality from ruptured
abdominal aortic aneurysm (AAA; Evidence Level 1a). Such programs are being implemented and generally consist of a single scan at 65 years of age. We report the results from screening 65-year-old men for AAA in middle Sweden.

Methods and Results:

All 65-year-old men (n=26,256), identified through the National Population Registry, were invited to an ultrasound examination. An AAA was defined as a maximum infrarenal aortic diameter of >=30 mm. In total, 22,187 (85%) accepted, and 373 AAAs were detected (1.7%; 95% confidence interval, 1.5 to 1.9). With 127 previously known AAAs (repaired/under surveillance) included, the total prevalence of the disease in the population was 2.2% (95% confidence interval, 2.0 to 2.4). Self-reported smoking (odds ratio, 3.4; P=0.001), coronary artery disease (odds ratio, 2.0; P=0.001), and hypertension (odds ratio, 1.6; P=0.001) were independently associated with AAA in a multivariate logistic regression model. Thirteen perc ent of the entire population reported to be current smokers, one third of the frequency reported in the 1980s. The observed low prevalence of AAA was explained mainly by this change in smoking habits.

Conclusions:

On the basis of the observed reduced exposure to risk factors, lower-than-expected prevalence of AAA among 65-year-old men, unchanged AAA repair rate, and significantly improved longevity of the elderly population, the current generally agreed-on AAA screening model can be questioned. Important issues to address are the threshold diameter for follow-up, the possible need for rescreening at a higher age, and selective screening among smokers.

 

9. Cost effectiveness of abdominal aortic aneurysm screening and rescreening in men in a modern context: evaluation of a hypothetical cohort using a decision analytical model. BMJ July 2012

Citation:

BMJ 2012;345:e4276 doi: 10.1136/bmj.e4276

Authors:

Rikke Søgaard associate professor 1, Jesper Laustsen chief vascular surgeon 2, Jes S Lindholt professor 3 4 (1Centre for Applied Health Services Research and Technology Assessment (CAST), Institute for Public Health, University of Southern Denmark, 5000 Odense, Denmark; 2Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark; 3Vascular Research Unit, Viborg Hospital, Viborg, Denmark; 4Department of Cardiothoracic and Vascular Surgery, Odense University Hospital, Odense, Denmark)

Abstract:

Objective: To assess the cost effectiveness of different screening strategies for abdominal aortic aneurysm in men, from the perspective of a national health service.

Setting: Screening units at regional hospitals.

Participants: Hypothetical cohort of 65 year old men from the general population.

Main outcome measures: Costs (£ in 2010) and effect on health outcomes (quality adjusted life years (QALYs)).

Results: Screening seems to be highly cost effective compared with not screening. The model estimated a 92% probability that some form of screening would be cost effective at a threshold of £20 000 (€24 790; $31 460). If men with an aortic diameter of 25-29 mm at the initial screening were rescreened once after five years, 452 men per 100 000 initially screened would benefit from early detection, whereas lifetime rescreening every five years would detect 794 men per 100 000. We estimated the associated incremental cost effectiveness ratios for rescreening once and lifetime rescreening to be £10 013 and £29 680 per QALY, respectively. The individual probability of being the most cost effective strategy was higher for each rescreening strategy than for the screening once strategy (in view of the £20 000 threshold).

Conclusions: This study confirms the cost effectiveness of screening versus no screening and lends further support to considerations of rescreening men at least once for abdominal aortic aneurysm.

 

10. Doubts and dilemmas over abdominal aortic aneurysm, BJS 2011

Citation:

British Journal of Surgery, May 2011; 98: 607-608; Published online inWileyOnlineLibrary (www.bjs.co.uk). DOI: 10.1002/bjs.7495

Author:

J. J. Earnshaw, Department of Vascular Surgery, Gloucestershire Royal Hospital

Full text of paper in pdf at bottom of page.

 

11. The ethics of screening for abdominal aortic aneurysm in men

Citation:

J Med Ethics 2010 36: 827-830 doi: 10.1136/jme.2010.035519

http://jme.bmj.com/content/36/12/827.full.html

Author(s):

Roger Brownsword and Jonothan J Earnshaw

Abstract:

Approximately 6000 men die every year from ruptured abdominal aortic aneurysm in England and Wales. Randomised clinical trials and a large pilot study have shown that ultrasound screening of men aged 65 years can prevent about half of these deaths. However, there is a significant perioperative morbidity and mortality from interventions to repair the detected aneurysm. This paper explores the ethical issues of screening men for abdominal aortic aneurysm. It is concluded that a population screening programme for abdominal aortic aneurysm offers a clear balance of good over harm. It is therefore ethically justified, as long as men are given adequate information at every stage of the process. Each man has the right to be properly informed, regardless of whether he accepts the invitation to be screened and, if an aneurysm is detected, whether or not he accepts treatment.

 

12. Screening for abdominal aortic aneurysm. Cochrane Database of Systematic Reviews 2007

Cosford PA, Leng GC. Screening for abdominal aortic aneurysm. Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: CD002945. DOI: 10.1002/14651858. CD002945.pub2.

 

13. A further meta-analysis of population-based screening for abdominal aortic aneurysm

Citation:

Journal of Vascular Surgery, June 2010 http://www.jvascsurg.org/article/S0741-5214(10)00668-3/references

Authors:

H Takagi, S Goto, M Matsui, H Manabe, T Umemoto 2010

Purpose:

It remains unclear whether population-based screening for abdominal aortic aneurysm (AAA) in men reduces all-cause long-term mortality. We performed an updated meta-analysis of randomized controlled trials of AAA screening for prevention of long-term mortality in men.

Methods:

To identify all randomized controlled trials of population-based AAA screening with long-term (≥10 year) follow-up in men, MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials were searched through June 2009. Data regarding AAA-related and all-cause mortality (including Cox regression hazard ratios [HRs] and 95% confidence intervals [CIs]) were abstracted from each individual study. For each study, data regarding mortality in both the screening and control groups were used to generate odds ratios (ORs) and 95% CIs. Study-specific estimates were combined using inverse variance-weighted averages of logarithmic ORs or HRs (or risk ratios where no HR was reported) in both fixed- and random-effects models.

Results:

Our search identified four randomized controlled trials of population-based AAA screening with long-term follow-up in men aged ≥65 years. Pooled analysis demonstrated a statistically significant reduction in AAA-related mortality (random-effects OR, 0.55; 95% CI, 0.36 to 0.86; P = .008; P for heterogeneity = .01; absolute risk reduction [ARR], 4 per 1000; number needed to screen [NNS], 238; random-effects HR, 0.55; 95% CI, 0.35 to 0.86; P = .009; P for heterogeneity = .009) and revealed a statistically nonsignificant reduction (but a strong trend toward a significant reduction) in all-cause mortality (fixed-effects OR, 0.98; 95% CI, 0.95 to 1.00 [1.001]; P = .06; P for heterogeneity = .93; ARR, 5 per 1000; NNS, 217; fixed-effects HR, 0.98; 95% CI, 0.96 to 1.00 [1.0001]; P ≥ .05 [P = .052]; P for heterogeneity = .74) with AAA screening relative to control.

Conclusion:

The results of our analysis suggest that population-based screening for AAA reduces AAA-related long-term mortality by 4 per 1000 over control in men aged ≥65 years. Whereas, screening for AAA shows a strong trend toward a significant reduction in all-cause long-term mortality by 5 per 1000, which does not narrowly reach statistical significance.

 

14. The Viborg Vascular (VIVA) screening trial of 65-74 year old men in the central region of Denmark: study protocol. Trials [Electronic Resource], 2010

Citation:

Trials [Electronic Resource], 2010, vol./is. 11/(67), 1745-6215;1745-6215 (2010)

Author(s):

Grondal N,Sogaard R,Henneberg EW,Lindholt JS

Abstract:

BACKGROUND: Screening for abdominal aortic aneurysm (AAA) of men aged 65-74 years reduces the AAA-related mortality and is generally considered cost effective. Despite of this only a few national health care services have implemented permanent programs. Around 10% of men in this group have peripheral arterial disease (PAD) defined by an ankle brachial systolic blood pressure index (ABI) below 0.9 resulting in an increased mortality-rate of 25-30%. In addition well-documented health benefits may be achieved through primary prophylaxis by initiating systematic cholesterol-lowering, smoking cessation, low-dose acetylsalicylic acid (aspirins), exercise, a healthy diet and blood-pressure control altogether reducing the increased risks for cardiovascular disease by at least 20-25%. The benefits of combining screening for AAA and PAD seem evident; yet they remain to be established. The objective of this study is to assess the efficacy and the cost-effectiveness of a combined screening program for AAA, PAD and hypertension. METHODS: The Viborg Vascular (VIVA) screening trial is a randomized, clinically controlled study designed to evaluate the benefits of vascular screening and modern vascular prophylaxis in a population of 50,000 men aged 65-74 years. Enrolment started October 2008 and is expected to stop in October 2010. The primary outcome is all-cause mortality. The secondary outcomes are cardiovascular mortality, AAA-related mortality, hospital services related to cardiovascular conditions, prevalence of AAA, PAD and potentially undiagnosed hypertension, health-related quality of life and cost effectiveness. Data analysis by intention to treat. RESULTS: Major follow-up will be performed at 3, 5 and 10 years and final study result after 15 years. TRIAL REGISTRATION: ClinicalTrials.gov NCT00662480

 

15. Long-term benefit and cost-effectiveness analysis of screening for abdominal aortic aneurysms from a randomized controlled trial. British Journal of Surgery, Jun 2010

Citation:

British Journal of Surgery, Jun 2010, vol./is. 97/6(826-34), 0007-1323;1365-2168 (2010 Jun)

Author(s):

Lindholt JS,Sorensen J,Sogaard R,Henneberg EW

Abstract:

BACKGROUND: The aim was to estimate long-term mortality benefits and cost-effectiveness of screening for abdominal aortic aneurysm (AAA) in men aged 64-73 years. METHODS: All men aged 64-73 years living in Viborg County were randomized to be controls (n = 6306) or invited for abdominal ultrasonography at a regional hospital (n = 6333). Mortality and AAA-related interventions were recorded in national databases. The cost of initial screening was based on actual costs of the programme. Incremental cost-effectiveness ratios (ICERs) were calculated on gains in life years and Quality Adjusted Life Years (QALY). Discounting (3 per cent) was applied to both costs and effects, and all costs were adjusted to euros at 2007 prices. RESULTS: The relative risk reduction of the screening programme in AAA-related mortality was 66 per cent (hazard ratio 0.34, 95 per cent confidence interval (c.i.) 0.20 to 0.57). The corresponding risk reduction in all-cause mortality was 2 per cent (hazard ratio 0.98, 95 per cent c.i. 0.93 to 1.03). The ICER was estimated at euro157 (-3292 to 4401) per life year gained and euro179 (-4083 to 4682) per QALY gained. Screening was found to be cost effective at a probability above 0.97 for a willingness-to-pay threshold of only euro5000. One-way sensitivity analysis demonstrated that this result was robust to various alternative assumptions, as the probability did not drop below 0.90 for any scenario. CONCLUSION: The mortality benefit of screening for AAA in men aged 64-73 years was maintained in the longer term and screening was cost effective

 

16. Abdominal aortic aneurysms, increasing infrarenal aortic diameter, and risk of total mortality and incident cardiovascular disease events: 10-year follow-up data from the Cardiovascular Health Study. Circulation, Feb 2008

Citation:

Circulation, Feb 2008, vol./is. 117/8(1010-7), 0009-7322;1524-4539 (2008 Feb 26)

Author(s):

Freiberg MS,Arnold AM,Newman AB,Edwards MS,Kraemer KL,Kuller LH

Abstract:

BACKGROUND: Long-term data describing small abdominal aortic aneurysms (AAAs) and increasing infrarenal aortic diameters and their relationship to future surgical repair, total mortality, and incident cardiovascular disease (CVD) events, particularly among women, are sparse. METHODS AND RESULTS: In 1992 to 1993, 4734 Cardiovascular Health Study participants > or = 65 years old had an abdominal aortic ultrasound evaluation. Of those screened, 416 had an AAA (infrarenal aortic diameter > or = 3.0 cm or an infrarenal/suprarenal ratio > or = 1.2). By 2002, there were 56 surgical AAA repairs and 10 AAA-related deaths. A single ultrasound screening demonstrated that aneurysm dilation > or = 3 cm identified 68% of all AAA repairs over the next 10 years and 6 of the 10 AAA-related deaths in 4% of the total population and that a > or = 2.5-cm dilation identified 91% of all AAA repairs and 9 of the 10 deaths in 10% of the total population. With adjusted Cox proportional hazard models, AAAs were associated with a higher risk of total mortality (hazard ratio 1.44, 95% confidence interval 1.25 to 1.66) and incident CVD events (hazard ratio 1.52, 95% confidence interval 1.25 to 1.85). Compared with diameters < 2.0 cm, infrarenal aortic diameters 2.0 to < 3.0 cm were associated with increased risk of incident CVD events in women and total mortality in men. CONCLUSIONS: This study suggests that a 1-time screening of the abdominal aorta can acceptably identify individuals with a clinically significant AAA. Infrarenal aortic diameters > 2.0 cm are associated with a significantly increased risk of future CVD events and total mortality

 

17. Fifteen-year follow-up of a randomized clinical trial of ultrasonographic screening for abdominal aortic aneurysms. British Journal of Surgery, Jun 2007

Citation:

British Journal of Surgery, Jun 2007, vol./is. 94/6(696-701), 0007-1323;0007-1323 (2007 Jun)

Author(s):

Ashton HA,Gao L,Kim LG,Druce PS,Thompson SG,Scott RA

Abstract:

BACKGROUND: Long-term benefits of screening for abdominal aortic aneurysm (AAA) are uncertain. These are the final results of a randomized controlled screening trial for AAA in men, updating those reported previously. Benefit and compliance over a median 15-year interval were examined. METHODS: One group of men were invited for ultrasonographic AAA screening, and another group, who received standard care, acted as controls. A total of 6040 men aged 65-80 years were randomized to one of the two groups. Outcome was monitored in terms of AAA-related events (surgery or death). RESULTS: In the group invited for screening, AAA-related mortality was reduced by 11 per cent (from 1.8 to 1.6 per cent, hazard ratio 0.89) over the follow-up interval. Screening detected an AAA in 170 patients; 17 of these died from an AAA-related cause, seven of which might have been preventable. The incidence of AAA rupture after an initially normal scan increased after 10 years of follow-up, but was still low overall (0.56 per 1000 person-years). CONCLUSION: Screening with a single ultrasonography scan still conferred a benefit at 15 years, although the results were not significant for this population size. Fewer than half of the AAA-related deaths in those screened positive could be prevented. Registration number: ISRCTN 00079388 (http://www.controlled-trials.com). (c) 2007 British Journal of Surgery Society Ltd

 

18. A sustained mortality benefit from screening for abdominal aortic aneurysm. Annals of Internal Medicine, May 2007

Citation:

Annals of Internal Medicine, May 2007, vol./is. 146/10(699-706), 0003-4819;1539-3704 (2007 May 15)

Author(s):

Kim LG,P Scott RA,Ashton HA,Thompson SG,Multicentre Aneurysm Screening Study Group

Abstract:

BACKGROUND: Longer-term mortality benefit and cost-effectiveness for abdominal aortic aneurysm (AAA) screening are uncertain. OBJECTIVE: To estimate the benefits, in terms of AAA-related and all-cause mortality, and cost-effectiveness of ultrasonography screening for AAA in a group that was invited to screening compared with a group that was not invited at a mean 7-year follow-up. DESIGN: Randomized trial. SETTING: 4 centers in the United Kingdom. PATIENTS: Population-based sample of 67,770 men age 65 to 74 years. INTERVENTION: Patients with an AAA detected at screening had surveillance and were offered surgery after predefined criteria were met. MEASUREMENTS: Mortality data were obtained after flagging on the national database. Unit costs obtained from large samples were applied to individual event data for the cost analysis. RESULTS: The hazard ratio was 0.53 (95% CI, 0.42 to 0.68) for AAA-related mortality in the group invited for screening. The rupture rate in men with normal results on initial ultrasonography has remained low: 0.54 rupture (CI, 0.25 to 1.02 ruptures) per 10 000 person-years. In terms of all-cause mortality, the observed hazard ratio was 0.96 (CI, 0.93 to 1.00). At the 7-year follow-up, cost-effectiveness was estimated at $19 500 (CI, $12,400 to $39,800) per life-year gained based on AAA-related mortality and $7600 (CI, $3300 to infinity) per life-year gained based on all-cause death. (All values are reported in U.S. dollars [U.K. 1 pound sterling = U.S. $1.58]). LIMITATION: Inclusion of deaths from aortic aneurysm at an unspecified site, which may include some thoracic aortic aneurysms, may have underestimated the treatment effect. CONCLUSIONS: These results from a large, pragmatic randomized trial show that the early mortality benefit of screening ultrasonography for AAA is maintained in the longer term and that the cost-effectiveness of screening improves over time. International Standard Randomized Controlled Trial registration number: ISRCTN37381646.

 

19. Screening for abdominal aortic aneurysm in a geographically isolated area. British Journal of Surgery, Aug 2005

Citation:

British Journal of Surgery, Aug 2005, vol./is. 92/8(984-8), 0007-1323;0007-1323 (2005 Aug)

Author(s):

Duncan JL,Wolf B,Nichols DM,Lindsay SM,Cairns J,Godden DJ

Abstract:

BACKGROUND: Screening for abdominal aortic aneurysm has been shown to reduce aneurysm-related mortality, but the applicability of the results to the whole of the UK has been questioned. This study examined screening in a remote and rural area. METHODS: Over 3 years, men aged 65-74 years were offered screening in the community by ultrasonography, usually in general practitioner surgeries. Men with an aneurysm were rescanned at intervals or assessed for surgery. The screening and hospital costs of the programme were calculated. RESULTS: Some 9323 men were offered screening of whom 8355 (89.6 per cent) attended. Uptake was high in all areas. A total of 430 scans (5.1 per cent) were abnormal; 40 men had an aneurysm greater than 55 mm in diameter. Twenty further men had an aorta that enlarged to greater than 55 mm during follow-up. A total of 54 men had elective repair with one death (mortality rate 2 per cent). The cost of screening alone was 16 pound per invitation and the overall cost of the programme, including surgery, was 58 pound per invitation. CONCLUSION: Screening for abdominal aortic aneurysm can be carried out in a remote and rural area with high uptake, acceptable clinical results and at no greater cost than in more densely populated areas

 

20. Screening for abdominal aortic aneurysms: single centre randomised controlled trial. BMJ, Apr 2005

Citation:

BMJ, Apr 2005, vol./is. 330/7494(750), 0959-535X;1468-5833 (2005 Apr 2)

Author(s):

Lindholt JS,Juul S,Fasting H,Henneberg EW

Abstract:

OBJECTIVE: To determine whether screening Danish men aged 65 or more for abdominal aortic aneurysms reduces mortality. DESIGN: Single centre randomised controlled trial. SETTING: All five hospitals in Viborg County, Denmark. PARTICIPANTS: All 12,639 men born during 1921-33 and living in Viborg County. In 1994 we included men born 1921-9 (64-73 years). We also included men who became 65 during 1995-8. INTERVENTIONS: Men were randomised to the intervention group (screening by abdominal ultrasonography) or control group. Participants with an abdominal aortic aneurysm > 5 cm were referred for surgical evaluation, and those with smaller aneurysms were offered annual scans. OUTCOME MEASURES: Specific mortality due to abdominal aortic aneurysm, overall mortality, and number of planned and emergency operations for abdominal aortic aneurysms. RESULTS: 4860 of 6333 men were screened (attendance rate 76.6%). 191 (4.0% of those screened) had abdominal aortic aneurysms. The mean follow-up time was 52 months. The screened group underwent 75% (95% confidence interval 51% to 91%) fewer emergency operations than the control group. Deaths due to abdominal aortic aneurysms occurred in nine patients in the screened group and 27 in the control group. The number needed to screen to save one life was 352. Specific mortality was significantly reduced by 67% (29% to 84%). Mortality due to non-abdominal aortic aneurysms was non-significantly reduced by 8%. The benefits of screening may increase with time. CONCLUSION: Mass screening for abdominal aortic aneurysms in Danish men aged 65 or more reduces mortality.

 

21. Screening for abdominal aortic aneurysm: a best-evidence systematic review for the U.S. Preventive Services Task Force. Annals of Internal Medicine, Feb 2005

Citation:

Annals of Internal Medicine, Feb 2005, vol./is. 142/3(203-11), 0003-4819;1539-3704 (2005 Feb 1)

Author(s):

Fleming C,Whitlock EP,Beil TL,Lederle FA

Abstract:

BACKGROUND: While the prognosis for abdominal aortic aneurysm (AAA) rupture is poor, ultrasound imaging is an accurate and reliable test for detecting AAAs before rupture. PURPOSE: To examine the benefits and harms of population-based AAA screening. DATA SOURCES: MEDLINE (1994 to July 2004) supplemented by the Cochrane Library, a reference list of retrieved articles, and expert suggestions. STUDY SELECTION: Randomized trials of AAA population screening, population studies of AAA risk factors, and data on adverse screening and treatment events from randomized trials and cohort studies. DATA EXTRACTION: All studies were reviewed, abstracted, and rated for quality by using predefined criteria. DATA SYNTHESIS: The authors identified 4 population-based randomized, controlled trials of AAA screening in men 65 years of age and older. On the basis of meta-analysis, an invitation to attend screening was associated with a significant reduction in AAA-related mortality (odds ratio, 0.57 [95% CI, 0.45 to 0.74]). A meta-analysis of 3 trials revealed no significant difference in all-cause mortality (odds ratio, 0.98 [CI, 0.95 to 1.02]). No significant reduction in AAA-related mortality was found in 1 study of AAA screening in women. Screening does not appear to be associated with significant physical or psychological harms. Major treatment harms include an operative mortality rate of 2% to 6% and significant risk for major complications. LIMITATIONS: The population screening studies focused on men and provided no information on racial or ethnic groups. No information was available on uninvited control group characteristics, so the importance of risk factors such as tobacco use or family history could not be assessed. Since all trials were conducted in countries other than the United States, generalizability to the U.S. population is uncertain. CONCLUSION: For men age 65 to 75 years, an invitation to attend AAA screening reduces AAA-related mortality

 

22. Population based randomised controlled trial on impact of screening on mortality from abdominal aortic aneurysm. BMJ, Nov 2004

Citation:

BMJ, Nov 2004, vol./is. 329/7477(1259), 0959-535X;1468-5833 (2004 Nov 27)

Author(s):

Norman PE,Jamrozik K,Lawrence-Brown MM,Le MT,Spencer CA,Tuohy RJ,Parsons RW,Dickinson JA

Abstract:

OBJECTIVE: To assess whether screening for abdominal aortic aneurysms in men reduces mortality. DESIGN: Population based randomised controlled trial of ultrasound screening, with intention to treat analysis of age standardised mortality. SETTING: Community based screening programme in Western Australia. PARTICIPANTS: 41,000 men aged 65-83 years randomised to intervention and control groups. INTERVENTION: Invitation to ultrasound screening. MAIN OUTCOME MEASURE: Deaths from abdominal aortic aneurysm in the five years after the start of screening. RESULTS: The corrected response to invitation to screening was 70%. The crude prevalence was 7.2% for aortic diameter > or = 30 mm and 0.5% for diameter > or = 55 mm. Twice as many men in the intervention group than in the control group underwent elective surgery for abdominal aortic aneurysm (107 v 54, P = 0.002, chi2 test). Between scheduled screening and the end of follow up 18 men in the intervention group and 25 in the control group died from abdominal aortic aneurysm, yielding a mortality ratio of 0.61 (95% confidence interval 0.33 to 1.11). Any benefit was almost entirely in men aged between 65 and 75 years, where the ratio was reduced to 0.19 (0.04 to 0.89). CONCLUSIONS: At a whole population level screening for abdominal aortic aneurysms was not effective in men aged 65-83 years and did not reduce overall death rates. The success of screening depends on choice of target age group and the exclusion of ineligible men. It is also important to assess the current rate of elective surgery for abdominal aortic aneurysm as in some communities this may already approach a level that reduces the potential benefit of population based screening

 

23. The Multicentre Aneurysm Screening Study (MASS) into the effect of abdominal aortic aneurysm screening on mortality in men: a randomised controlled trial. Lancet, Nov 2002

Citation:

Lancet, Nov 2002, vol./is. 360/9345(1531-9), 0140-6736;0140-6736 (2002 Nov 16)

Author(s):

Ashton HA,Buxton MJ,Day NE,Kim LG,Marteau TM,Scott RA,Thompson SG,Walker NM,Multicentre Aneurysm Screening Study Group

Abstract:

BACKGROUND: Opposing views have been published on the importance of ultrasound screening for abdominal aortic aneurysms. The Multicentre Aneurysm Screening Study was designed to assess whether or not such screening is beneficial. METHODS: A population-based sample of men (n=67800) aged 65-74 years was enrolled, and each individual randomly allocated to either receive an invitation for an abdominal ultrasound scan (invited group, n=33839) or not (control group, n=33961). Men in whom abdominal aortic aneurysms (> or =3 cm in diameter) were detected were followed-up with repeat ultrasound scans for a mean of 4.1 years. Surgery was considered on specific criteria (diameter > or =5.5 cm, expansion > or =1 cm per year, symptoms). Mortality data were obtained from the Office of National Statistics, and an intention-to-treat analysis was based on cause of death. Quality of life was assessed with four standardised scales. The primary outcome measure was mortality related to abdominal aortic aneurysm. FINDINGS: 27147 of 33839 (80%) men in the invited group accepted the invitation to screening, and 1333 aneurysms were detected. There were 65 aneurysm-related deaths (absolute risk 0.19%) in the invited group, and 113 (0.33%) in the control group (risk reduction 42%, 95% CI 22-58; p=0.0002), with a 53% reduction (95% CI 30-64) in those who attended screening. 30-day mortality was 6% (24 of 414) after elective surgery for an aneurysm, and 37% (30 of 81) after emergency surgery. INTERPRETATION: Our results provide reliable evidence of benefit from screening for abdominal aortic aneurysms

 

24. Late results concerning feasibility and compliance from a randomized trial of ultrasonographic screening for abdominal aortic aneurysm. British Journal of Surgery, Jul 2002

Citation:

British Journal of Surgery, Jul 2002, vol./is. 89/7(861-4), 0007-1323;0007-1323 (2002 Jul)

Author(s):

Vardulaki KA,Walker NM,Couto E,Day NE,Thompson SG,Ashton HA,Scott RA

Abstract:

BACKGROUND: The study was an update at 10 years of a randomized trial of the efficacy of screening for abdominal aortic aneurysm (AAA). The extent of benefit, feasibility and compliance were examined, and reasons why this intervention may fail a proportion of those screened were identified. METHODS: A total of 6058 men aged 65 years and over were randomized to a group invited to attend ultrasonographic screening or to a control group. The mortality rate from AAA in the two arms of the trial was compared using a Poisson model. Analyses were by intention to treat. RESULTS: There was a 21 per cent reduction in mortality rate from AAA over the 10-year follow-up (relative risk 0.79 (95 per cent confidence interval 0.53 to 1.40)). The observed relative mortality reduction peaked at 4 years with a 52 per cent reduction in the study group. Eighteen of 24 AAA deaths in the study group were among those who did not attend the first screen, or failed to comply with the follow-up protocol. CONCLUSION: A greater awareness of the benefits of full participation in a screening programme could provide a larger and sustained mortality reduction

 

25. Clinical trial of screening for abdominal aortic aneurysm in women. British Journal of Surgery, Mar 2002

Citation:

British Journal of Surgery, Mar 2002, vol./is. 89/3(283-5), 0007-1323;0007-1323 (2002 Mar)

Author(s):

Scott RA,Bridgewater SG,Ashton HA

Abstract:

BACKGROUND: Screening for abdominal aortic aneurysm (AAA) is commonly restricted to men. Recent studies have indicated a possible increase in deaths due to ruptured AAA in women, and a higher rate of rupture in women than in men. The present report details results from a randomized controlled trial that assessed the effects of screening women for AAA. METHODS: Some 9342 women aged 65-80 years were entered into the trial and randomized to age-matched screen and control groups. A single ultrasonographic scan was offered to women in the screening arm of the study. Women with an AAA received follow-up scans, and were considered for elective surgery if certain criteria were met. RESULTS: The prevalence of AAA was six times lower in women (1.3 per cent) than in men (7.6 per cent). Over 5- and 10-year follow-up intervals, the incidence of rupture was the same in the screened and control groups of women. CONCLUSION: Screening women for AAA is neither clinically indicated nor economically viable

 

26. A single normal ultrasonographic scan at age 65 years rules out significant aneurysm disease for life in men. British Journal of Surgery, Jul 2001

Citation:

British Journal of Surgery, Jul 2001, vol./is. 88/7(941-4), 0007-1323;0007-1323 (2001 Jul)

Author(s):

Crow P,Shaw E,Earnshaw JJ,Poskitt KR,Whyman MR,Heather BP

Abstract:

BACKGROUND: Screening for abdominal aortic aneurysm (AAA) has been carried out in Gloucestershire since 1990. All men in the county are offered aortic ultrasonography in their 65th year. Men with an aortic diameter of less than 26 mm are considered 'normal' and no follow-up is arranged. The aim of this study was to ascertain if men with 'normal' aortic diameters at age 65 years ever develop a clinically significant aneurysm. METHODS: A cohort study was performed on 223 65-year-old men who had an aorta of less than 26 mm in diameter in 1988. These men had repeat ultrasonography in 1993 and 2000. The causes of death in men who died during this interval were investigated. RESULTS: Eight men were lost to follow-up. As far as it was possible to ascertain, none of the 86 men who died over the 12-year interval did so from ruptured AAA. There was no clinically significant increase in mean aortic diameter in the remaining 129 men who had three serial ultrasonographic scans over the 12-year interval. CONCLUSION: A single, 'normal' ultrasound scan at age 65 years effectively rules out the risk of clinically significant aneurysm disease for life in men

 

27. Population screening reduces mortality rate from aortic aneurysm in men. British Journal of Surgery, Jun 2000

Citation:

British Journal of Surgery, Jun 2000, vol./is. 87/6(750-3), 0007-1323;0007-1323 (2000 Jun)

Author(s):

Heather BP,Poskitt KR,Earnshaw JJ,Whyman M,Shaw E

Abstract:

BACKGROUND: Rupture of an unsuspected abdominal aortic aneurysm is a major cause of death in men over the age of 65 years. A significant reduction in deaths is likely to result only from higher rates of detection and increased numbers of elective aneurysm repairs. Screening of men reaching the age of 65 years has been taking place in the county of Gloucestershire, UK since 1990 and the aim of this study was to investigate any change in the mortality rate from aortic aneurysm in the screened portion of the population. METHODS: Total number of deaths from all aortic aneurysm-related causes in the county's population was calculated from hospital and post-mortem records, together with computerized death certificate records, for the years 1994-1998. The overall number of aneurysm-related deaths in men aged 65-73 years, who have been progressively influenced by the screening programme, was compared with that for men of all other ages. RESULTS: The total number of aneurysm-related deaths in men aged 65-73 years decreased progressively year by year between 1994 and 1998; this reduction is highly statistically significant (P < 0. 001). No such change was observed in the unscreened part of the population. CONCLUSION: Screening for asymptomatic abdominal aortic aneurysm results in a significant reduction in numbers of deaths from all aneurysm-related causes in the screened portion of the male population

 

28. Influence of screening on the incidence of ruptured abdominal aortic aneurysm: 5-year results of a randomized controlled study. British Journal of Surgery Aug 1995

Citation:

British Journal of Surgery, Aug 1995, vol./is. 82/8(1066-70), 0007-1323;0007-1323 (1995 Aug)

Author(s):

Scott RA,Wilson NM,Ashton HA,Kay DN

Abstract:

From family medical practices 15775 men and women aged 65-80 years were identified and randomized into two groups: one group was invited for ultrasonographic screening for abdominal aortic aneurysm (AAA), and the other acted as age- and sex-matched controls. Of the 7887 invited for screening 5394 (68.4 per cent) accepted. AAA was detected in 218 (4.0 per cent overall and 7.6 per cent of men). Aortic surgery was offered to the screened group if certain criteria were met and no patient died from rupture who was fit for operation and accepted elective treatment. The incidence of rupture was reduced by 55 per cent in men in the group invited for screening, compared with controls. The incidence of rupture in women was low in both groups.

 

29. Screening for abdominal aortic aneurysms in men. BMJ 2004

J J Earnshaw, E Shaw, M R Whyman, K R Poskitt, B P Heather. Screening for abdominal aortic aneurysms in men. BMJ 2004; 328:1122-1124 (8 May)

 

30. The Last Judgment upon abdominal aortic aneurysm screening. International Journal of Cardiology

Authors: Hisato Takagi, Masao Niwa, Yusuke Mizuno, Shin-nosuke Goto, Takuya Umemoto for the ALICE (All-Literature Investigation of Cardiovascular Evidence) Group. Department of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan

Citation: International Journal of Cardiology. 2012 Nov 19. pii: S0167-5273(12)01472-6. doi: 10.1016/j.ijcard.2012.11.011. [Epub ahead of print]

 
 
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