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Abdominal Aortic Aneurysm: Aspects on how to affect mortality from rupture
Östergötlands Läns Landsting, Heart and Medicine Center, Department of Thoracic and Vascular Surgery. Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Health Sciences.
2014 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Abdominal Aortic Aneurysm (AAA) is a disease that mainly affects elderly men, and ruptured AAA (rAAA) is associated with a mortality of > 80%. AAA seldom gives any symptoms prior to rupture.

The aims of this thesis were to investigate different aspects of how to affect mortality from rAAA.

In Study I, we identified 849 patients treated for rAAA during 1987-2004, and studied the 30-day survival after surgery, depending on whether they came directly to the treating hospital (one-stop) or were transferred via another hospital (two-stop). A two-stop referral pattern resulted in a 27% lower population-based survival rate for patients 65-74 years of age. However, the consequences would be small even if a one-stop referral pattern could be generally accomplished, due to the huge over-all mortality related to rAAA, hence an argument to find and treat AAA before rupture, e.g. by screening.

In Study II, we examined the AAA-prevalence and the risk factors for AAA among 70-year-old men. The screening-detected AAA-prevalence was 2.3%, thus less than half the predicted. The most important risk factor was smoking.

In Study III, we compared the screening-detected AAA-prevalence, the attendance rate, and the rate of opportunistic detection of AAA, between almost 8000 65- and 6000 70-year-old men. There was no difference in the screening-detected prevalence; probably due to the fact that almost 40% of the AAAs among the 70-year-old were already known prior to screening, compared to roughly 25% in the 65-year-old. The attendance rate was higher among the 65-year-old men, 85.7% compared 84.0% in the 70-year-old. Thus, there is no benefit of screening for AAA among 70- instead of 65-year-old men.

In Study IV, a cost-effectiveness analysis, we found that screening for AAA still appears to be cost-effective, despite profound changes in disease pattern and AAA-management.

In conclusion, we found that mortality from rAAA is not affected in any substantial way by different referral patterns and hence centralisation of services for AAA/rAAA is not a solution. A better alternative is to prevent rupture through early detection by screening. Screening 65-year-old men for AAA still appears to be cost-effective, despite profound changes in disease pattern and AAA-management during the last decade. Screening 70- instead of 65-year-old men will not increase the efficacy of screening.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2014. , 113 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1381
Keyword [en]
abdominal aortic aneurysm rupture AAA rAAA screening one-stop two stop prevalence risk factor cost-effectiveness
National Category
Surgery
Identifiers
URN: urn:nbn:se:liu:diva-102482DOI: 10.3384/diss.diva-102482ISBN: 978-91-7519-503-2 (print)OAI: oai:DiVA.org:liu-102482DiVA: diva2:678451
Public defence
2014-01-31, Berzeliussalen, Campus US, Linköpings universitet, Linköping, 13:00 (Swedish)
Opponent
Supervisors
Funder
Swedish Heart Lung FoundationCounty Council of Östergötland
Available from: 2014-01-08 Created: 2013-12-12 Last updated: 2017-03-27Bibliographically approved
List of papers
1. Population-based survival rate with a one- or two-stop referral pattern for patients with ruptured abdominal aortic aneurysms
Open this publication in new window or tab >>Population-based survival rate with a one- or two-stop referral pattern for patients with ruptured abdominal aortic aneurysms
2013 (English)In: International Journal of Angiology, ISSN 0392-9590, E-ISSN 1827-1839, Vol. 32, no 5, 492-500 p.Article in journal (Refereed) Published
Abstract [en]

AIM:

Is there a difference in the population-based survival rate for patients with ruptured abdominal aortic aneurysms (rAAA), handled by a "one-stop" or a "two-stop" referral pattern?

METHODS:

Ten regions in Sweden were identified where clear-cut "one-stop" or "two-stop" referral-patterns prevailed. From the Swedvasc Registry we identified 849 patients operated on for rAAA, 1987 to 2004, living in any of these ten regions, and related the number of survivors to the whole population served by each hospital.

RESULTS:

The population-based survival rate was 14% lower for patients following a "two-stop" compared to a "one-stop" referral pattern (P=0.084). For the group 65-74 years-of-age the difference was significant (P=0.021), but no corresponding effect was seen regarding operative mortality rate or sex.

CONCLUSION:

Compared to a "one-stop" referral pattern for rAAA, a "two-stop" referral pattern results in a lower population-based survival rate for patients 65-74 years old, but the consequences would be small even if a "one-stop" referral pattern could be generally accomplished.

Place, publisher, year, edition, pages
Turin, Italy: Edizioni Minerva Medica, 2013
Keyword
Abdominal aortic aneurysm ruptured one-stop two-stop
National Category
Surgery
Identifiers
urn:nbn:se:liu:diva-102480 (URN)23903308 (PubMedID)
Available from: 2013-12-12 Created: 2013-12-12 Last updated: 2017-12-06
2. Lower Prevalence than Expected when Screening 70-year-old Men for Abdominal Aortic Aneurysm
Open this publication in new window or tab >>Lower Prevalence than Expected when Screening 70-year-old Men for Abdominal Aortic Aneurysm
2013 (English)In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 46, no 4, 453-459 p.Article in journal (Refereed) Published
Abstract [en]

Background

Screening 65-year-old men for abdominal aortic aneurysms (AAA) is a cost-effective method to reduce the mortality from ruptured AAA. However, contemporary results show a lower than expected prevalence of AAA, thus questioning the benefit of screening. Since the prevalence increases with age, a possible way to enhance the benefit of screening might be to screen older men. Our aim was to determine the contemporary screening-detected prevalence among 70-year-old men.

Methods

A total of 5,623 unscreened 70-year-old men were invited to ultrasound screening. Uni- and multivariable analyses were used to assess the risk factors for AAA.

Results

The attendance rate was 84.0%. The prevalence of previously unknown AAAs was 2.3%. When adding the 64 men with an already known AAA to the screening-detected ones, the total prevalence in the population was at least 3.0%, and the previously discovered AAAs constituted 37.4% of the total prevalence. “Ex smoker” and “Current smoker” were the most important risk factors.

Conclusions

When screening 70-year-old men for AAA, the prevalence was less than half that expected, despite a high attendance rate. Smoking was the strongest risk factor. Almost 40% of the men with AAAs were already known from other means than screening.

Keyword
Abdominal aortic aneurysm, Screening, Prevalence, Attendance rate, Swedvasc
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-102089 (URN)10.1016/j.ejvs.2013.07.014 (DOI)000326408400012 ()
Note

Funding Agencies|Swedish Heart-Lung Foundation||King Gustav V and Queen Victorias foundation||

Available from: 2013-12-02 Created: 2013-11-29 Last updated: 2017-12-06
3. No benefit of screening for abdominal aortic aneurysm among 70- instead of 65-year-old men
Open this publication in new window or tab >>No benefit of screening for abdominal aortic aneurysm among 70- instead of 65-year-old men
2014 (English)In: International Angiology, ISSN 0392-9590, Vol. 33, no 5, 474-479 p.Article in journal (Refereed) Published
Abstract [en]

Objectives: Screening 65-year-old men for abdominal aortic aneurysm (AAA) reduces mortality from ruptured AAA (rAAA). Lower than expected prevalence of AAA is now found, why screening at a higher age and rescreening has been discussed. Our aim was to determine if screening at 70 years of age, instead of 65, increases clinical effectiveness.

Methods: 7951 and 5623 previously un-screened 65- and 70-year old men were invited to ultrasound screening.

Results: The attendance rate was 85.7% and 84.0%, p<0.01, for the 65- and 70-year old men respectively. The screening-detected prevalence did not differ, being 1.9% and 2.3%, p=0.15, respectively, probably due to the fact that 23.5% and 37.4% of all known AAA among 65- and 70-year-old men, were detected by other means prior to screening, p<0.01. However, the total known prevalence differed between the age-groups, being at least 2.1% and 3.0% respectively, p<0.001.

Conclusion: The screening-detected AAA-prevalence did not differ between 65- and 70-yearold men, due to the greater number of AAA known prior to screening among 70- compared to 65-year-old men. Screening men at 70 instead of 65 years of age would not result in detection of substantially more previously unknown AAA, thus not preventing rAAA and consequently not more saved life-years. Further, data also indicates that it is questionable if re-screening the 65-year-old male population after five years would generate any important clinical effect.

Place, publisher, year, edition, pages
EDIZIONI MINERVA MEDICA, 2014
National Category
Clinical Medicine
Identifiers
urn:nbn:se:liu:diva-102927 (URN)000345727000010 ()
Available from: 2014-01-08 Created: 2014-01-08 Last updated: 2017-03-27Bibliographically approved
4. Changing Conditions - the same Conclusion: Cost-effective to Screen for Abdominal Aortic Aneurysm among 65-year-old Men, based on Data from an Implemented Screening Programme
Open this publication in new window or tab >>Changing Conditions - the same Conclusion: Cost-effective to Screen for Abdominal Aortic Aneurysm among 65-year-old Men, based on Data from an Implemented Screening Programme
Show others...
2014 (English)Manuscript (preprint) (Other academic)
Abstract [en]

Background: Health economic analyses based on randomized trials have shown that screening for abdominal aortic aneurysm (AAA) cost-effectively decreases AAA-related as well as allcause mortality. However, results from running screening programmes now reveal substantially changed conditions in terms of prevalence, attendance rate, costs and mortality after intervention. Our aim was to evaluate whether screening for AAA among 65-year-old men on a general basis is cost-effective under current clinical practice.

Methods: A decision-analytic model, previously used to show the cost-effectiveness of an AAA-screening programme before decision to introduce screening in practice, was updated using results from implemented screening-programmes as well as data from contemporary published data and the Swedvasc registry.

Results: The base-case analysis showed that the cost per life-year gained and quality-adjusted life year (QALY) gained were 3252 € and 4231 €, respectively. The probability of screening being cost-effective was high.

Conclusion: Despite profound changes in disease pattern and AAA-management, the current results are similar to those reported almost 10 years ago, and thus screening 65-year-old men for AAA still appears to be cost-effective.

National Category
Clinical Medicine
Identifiers
urn:nbn:se:liu:diva-102928 (URN)
Available from: 2014-01-08 Created: 2014-01-08 Last updated: 2017-03-27Bibliographically approved

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