Screening for Abdominal Aortic Aneurysms: The Effects of Age and Social Deprivation on Screening Uptake, Prevalence and Attendance at Follow-Up in the MASS Trial

Socioeconomic disparities in abdominal aortic aneurysm repair rates and survival

BACKGROUND

Abdominal aortic aneurysm (AAA) is more prevalent in socioeconomically disadvantaged areas. This study investigated socioeconomic disparities in AAA repair rates and survival.

METHODS

The study used ecological and cohort study designs, from 31 672 census areas in England (April 2006 to March 2018), the Index of Multiple Deprivation 2010 as the area-level deprivation indicator, and Poisson, logistic and Cox regression.

RESULTS

Some 77 606 patients (83.4 per cent men) in four age categories (55-64, 65-74, 75-84, 85 or more years) were admitted with AAA from a population aged at least 55 years of 14.7 million. Elective open and endovascular repair rates were 41 (95 per cent c.i. 23 to 61) and 60 (36 to 89) per cent higher respectively among men aged 55-64 years in the most versus least deprived areas by quintile. This differences diminished and appeared to reverse with increasing age, with 26 (-1 to 45) and 25 (13 to 35) per cent lower rates respectively in men aged 85 years or more in the most deprived areas. Men admitted from more deprived areas were more likely to die in hospital without aneurysm repair. Among those who had aneurysm repair, this was more likely to be for a ruptured aneurysm than among men from less deprived areas. For intact aneurysm repair, they were relatively more likely to have this during an emergency admission. The mortality rate after repair was higher for men from more deprived areas, although the hazard diminished with age. Patterns were unclear for women.

CONCLUSION

There were clear socioeconomic disparities in operation rates, mode of presentation, and outcome for AAA surgery. Policies are needed to address these disparities.

Abdominal Aortic Aneurysm Formation with a Focus on Vascular Smooth Muscle Cells

Abdominal aortic aneurysm (AAA) is a lethal degenerative vascular disease that affects, mostly, the elder population, with a high mortality rate (>80%) upon rupture. It features a dilation of the aortic diameter to larger than 30 mm or more than 50%. Diverse pathological processes are involved in the development of AAA, including aortic wall inflammation, elastin breakdown, oxidative stress, smooth muscle cell (SMC) phenotypic switching and dysfunction, and extracellular matrix degradation. With open surgery being the only therapeutic option up to date, the lack of pharmaceutical treatment approach calls for identifying novel and effective targets and further understanding the pathological process of AAA. Both lifestyle and genetic predisposition have an important role in increasing the risk of AAA. Several cell types are closely related to the pathogenesis of AAA. Among them, vascular SMCs (VSMCs) are gaining much attention as a critical contributor for AAA initiation and/or progression. In this review, we summarize what is known about AAA, including the risk factors, the pathophysiology, and the established animal models of AAA. In particular, we focus on the VSMC phenotypic switching and dysfunction in AAA formation. Further understanding the regulation of VSMC phenotypic changes may provide novel therapeutic targets for the treatment or prevention of AAA.

Underutilization of Guideline-based Abdominal Aortic Aneurysm Screening in an Academic Health System

OBJECTIVES

The US Preventive Services Task Force (USPSTF) recommends a 1-time screening for AAA with ultrasonography in men aged 65-75 who have ever smoked. Our objectives were to identify the AAA screening rates in a large academic health system and assess factors associated with receipt of screening.

METHODS

Data were extracted from electronic health record data from the Duke University Health System and the US Census Bureau. Index screening eligibility date was defined as the 65^th birthdate for male patients with a history of smoking. Patients with an index screening eligibility date between 1/1/2016 and 12/31/2018 were included in the study population and followed through 12/31/2019. Screened patients were identified by procedure codes for ultrasonography, CT or MRI.

RESULTS

Among 6,682 eligible patients who turned 65 years old between 1/1/2016 and 12/31/2018 with at least 1 year of follow-up, only 463 (6.9%) received AAA screening during the study period. The odds of receiving AAA screening within 1 year of index eligibility were 27% lower for Black patients compared to whites [OR=0.73, 95% CI (0.58,0.93)]. Patients who visited a PCP or had hypertension had 75% and 41% greater odds of receiving screening, respectively [OR 1.75, 95% CI (1.36,2.25)] and [OR 1.41 95% CI (1.11,1.80)] compared with patients who did not. Among 4,580 men with 2 years of follow-up, AAA screening rate increased to 13.0%. Patients who visited a PCP had 64% greater odds of receiving screening within 2 years of index eligibility compared to those who did not [OR=1.64, 95% CI (1.30,2.06)].

CONCLUSION

Screening for AAA per USPSTF guidelines is underutilized with evidence of a racial disparity. Although PCP visit is the most consistent predictor of screening, provider screening rates are low.

Income Deprivation and Groin Wound Surgical Site Infection: Cross-Sectional Analysis from the Groin Wound Infection after Vascular Exposure Multicenter Cohort Study

Background: Living in deprived areas is associated with poorer outcomes after certain vascular procedures and surgical site infection in other specialties. Our primary objective was to determine whether living in more income-deprived areas was associated with groin wound surgical site infection after arterial intervention. Secondary objectives were to determine whether living in more income-deprived areas was associated with mortality and clinical consequences of surgical site infection. Methods: Postal code data for patients from the United Kingdom who were included in the Groin Wound Infection after Vascular Exposure (GIVE) multicenter cohort study was used to determine income deprivation, based on index of multiple deprivation (IMD) data. Patients were divided into three IMD groups for descriptive analysis. Income deprivation score was integrated into the final multivariable model for predicting surgical site infection. Results: Only patients from England had sufficient postal code data, analysis included 772 groin incisions (624 patients from 22 centers). Surgical site infection occurred in 9.7% incisions (10.3% of patients). Surgical site infection was equivalent between income deprivation tertiles (tertile 1 = 9.5%; tertile 2 = 10.3%; tertile 3 = 8.6%; p = 0.828) as were the clinical consequences of surgical site infection and mortality. Income deprivation was not associated with surgical site infection in multivariable regression analysis (odds ratio [OR], 0.574; 95% confidence interval [CI], 0.038-8.747; p = 0.689). Median age at time of procedure was lower for patients living in more income-deprived areas (tertile 1 = 68 years; tertile 2 = 72 years; tertile 3 = 74 years; p < 0.001). Conclusions: We found no association between living in an income-deprived area and groin wound surgical site infection, clinical consequences of surgical site infection and mortality after arterial intervention. Patients living in more income-deprived areas presented for operative intervention at a younger age, with similar rates of comorbidities to patients living in less income-deprived areas.

Cost-effectiveness of a population-based AAA screening program for men over 65 years old in Iran

BACKGROUND

Screening program tend to recognized patients in their early stage and consequently improve health outcomes. Cost-effectiveness of the abdominal aortic aneurysm (AAA) screening program has been scarcely studied in developing countries. We sought to evaluate the cost-effectiveness of a screening program for the abdominal aortic aneurysm (AAA) in men aged over 65 years in Iran.

METHODS

A Markov cohort model with 11 mutually exclusive health statuses was used to evaluate the cost-effectiveness of a population-based AAA screening program compared with a no-screening strategy. Transitions between the health statuses were simulated by using 3-month cycles. Data for disease transition probabilities and quality of life outcomes were obtained from published literature, and costs were calculated based on the price of medical services in Iran and the examination of the patients' medical records. The outcomes were life-years gained, the quality-adjusted life-year (QALY), costs, and the incremental cost-effectiveness ratio (ICER). The analysis was conducted for a lifetime horizon from the payer's perspective. Costs and effects were discounted at an annual rate of 3%. Uncertainty surrounding the model inputs was tested with deterministic and probabilistic sensitivity analyses.

RESULTS

The mean incremental cost of the AAA screening strategy compared with the no-screening strategy was $140 and the mean incremental QALY gain was 0.025 QALY, resulting in an ICER of $5566 ($14,656 PPP) per QALY gained. At a willingness-to-pay of 1 gross domestic product (GDP) per capita ($5628) per QALY gained, the probability of the cost-effectiveness of AAA screening was about 50%. However, at a willingness-to-pay of twice the GDP per capita per QALY gained, there was about a 95% probability for the AAA screening program to be cost-effective in Iran.

CONCLUSIONS

The results of this study showed that at a willingness-to-pay of 1 GDP per capita per QALY gained, a 1-time AAA screening program for men aged over 65 years could not be cost-effective. Nevertheless, at a willingness-to-pay of twice the GDP per capita per QALY gained, the AAA screening program could be cost-effective in Iran. Further, AAA screening in high-risk groups could be cost-effective at a willingness-to-pay of 1 GDP per capita per QALY gained.

Improving Abdominal Aortic Aneurysm (AAA) Screening Uptake through Patient Engagement-Analysis and Outcomes of Strategies to Improve Uptake at a Regional Program Level

BACKGROUND

To identify areas of health inequality that adversely affect patient engagement at a regional level within the National Abdominal Aortic Aneurysm Screening Program (NAAASP). Patient-reported improvements to services were implemented and analysis of subsequent uptake undertaken.

METHODS

A prospective study of 390 men who failed to attend their AAA screening invitation. Nonattendees were contacted by post and telephone. Patients were analyzed as per ethnicity, working status, and Index of Multiple Deprivation quintile. Patient-suggested improvements to the service were recorded, analyzed, and implemented. Uptake data were then collected for the subsequent two years.

RESULTS

The Screening Management and Referral Tracking system used by NAAASP is 97% accurate in holding patient contact details, and nonattenders are four times more likely to respond to telephone contact. Reasons for failing to attend screening invitations include factors that can be addressed at a regional level such as: inconvenient timings/locations of screening clinics and a lack of awareness or understanding of what AAA screening means as well as language/literacy barriers. The incidence of AAAs in the nonattendee group was almost 3 times that of our general (attending) population. Afro-Caribbean men were disproportionately less likely to attend for screening. After implementing patient-suggested improvements to the service, screening uptake increased from 75.2% (2015-16 screening year) to 81.3% (2017-2018).

CONCLUSIONS

To date, no other studies have gone on to assess the effectiveness of interventions targeted at reducing inequalities in NAAASP attendance, but we show an increase in local screening uptake of 6% in a 2-year period after implementing improvement strategies. This article adds to existing literature by confirming external factors such as social deprivation adversely influence screening uptake and that AAAs are more prevalent in socially deprived groups. It reinforces the importance of regional attempts to contact and engage nonattenders as they may be most at risk of developing AAAs.

Pharmacological Preventive Potential Among Attenders at Vascular Screening: Findings from the VIVA Trial

OBJECTIVE

Findings from the Viborg Vascular (VIVA) trial show a mortality benefit of multi-faceted vascular screening which was mainly ascribed to the initiation of prophylactic medication. However, the pharmacological preventive potential, which exists when individuals have a positive screening test result and do not already use statins and anti-platelet agents, has not been analysed. The aim of this study was to investigate factors associated with a pharmacological preventive potential of statins and anti-platelet agents among attenders vascular screening for abdominal aortic aneurysm (AAA) and peripheral arterial disease (PAD).

METHODS

This cross-sectional study used data from the VIVA trial screening arm including 25 074 men aged 64-75 years recruited between October 2008 and January 2011. Explanatory variables comprised socio-demographic- and socio-economic characteristics, comorbidities, medication use, and travel distance derived from nationwide registries. Outcomes included a positive screening test result, a pharmacological preventive potential, and attendance. Associations between the explanatory variables and the outcomes were investigated using the chi-square test and multivariate logistic regression.

RESULTS

The factors most likely to be associated with a pharmacological preventive potential for positive AAA screening comprised age >70 years (odds ratio (OR) 1.23, 95% confidence interval 1.00-1.51), existing chronic obstructive pulmonary disease (COPD) (OR 2.22, 95% CI 1.38-3.57), and use of anti-hypertensives (OR 1.37, 95% CI 1.09-1.71). For positive PAD screening age >70 years (OR 1.41, 95% CI 1.25-1.60), living alone (OR 1.34, 95% CI 1.14-1.56), low income, COPD (OR 2.13, 95% CI 159-283), use of anti-hypertensives (OR 1.14, 95% CI 1.00-1.29) or anti-diabetics (OR 1.12, 95% CI 1.01-1.28), and short travel distance were associated with a pharmacological preventive potential. For combined vascular screening, age >70 years, living alone, low income, COPD, and use of anti-hypertensives were associated with a pharmacological preventive potential. Among these subgroups, lower attendance was associated with age >70 years, living alone, low income, COPD, and use of anti-diabetics.

CONCLUSION

Future vascular screening programmes might benefit from tailoring information to subgroups who are more likely to benefit from screening but less likely to accept an offer.

Screening women aged 65 years or over for abdominal aortic aneurysm: a modelling study and health economic evaluation

BACKGROUND

Abdominal aortic aneurysm (AAA) screening programmes have been established for men in the UK to reduce deaths from AAA rupture. Whether or not screening should be extended to women is uncertain.

OBJECTIVE

To evaluate the cost-effectiveness of population screening for AAAs in women and compare a range of screening options.

DESIGN

A discrete event simulation (DES) model was developed to provide a clinically realistic model of screening, surveillance, and elective and emergency AAA repair operations. Input parameters specifically for women were employed. The model was run for 10 million women, with parameter uncertainty addressed by probabilistic and deterministic sensitivity analyses.

SETTING

Population screening in the UK.

PARTICIPANTS

Women aged ≥ 65 years, followed up to the age of 95 years.

INTERVENTIONS

Invitation to ultrasound screening, followed by surveillance for small AAAs and elective surgical repair for large AAAs.

MAIN OUTCOME MEASURES

Number of operations undertaken, AAA-related mortality, quality-adjusted life-years (QALYs), NHS costs and cost-effectiveness with annual discounting.

DATA SOURCES

AAA surveillance data, National Vascular Registry, Hospital Episode Statistics, trials of elective and emergency AAA surgery, and the NHS Abdominal Aortic Aneurysm Screening Programme (NAAASP).

REVIEW METHODS

Systematic reviews of AAA prevalence and, for elective operations, suitability for endovascular aneurysm repair, non-intervention rates, operative mortality and literature reviews for other parameters.

RESULTS

The prevalence of AAAs (aortic diameter of ≥ 3.0 cm) was estimated as 0.43% in women aged 65 years and 1.15% at age 75 years. The corresponding attendance rates following invitation to screening were estimated as 73% and 62%, respectively. The base-case model adopted the same age at screening (65 years), definition of an AAA (diameter of ≥ 3.0 cm), surveillance intervals (1 year for AAAs with diameter of 3.0-4.4 cm, 3 months for AAAs with diameter of 4.5-5.4 cm) and AAA diameter for consideration of surgery (5.5 cm) as in NAAASP for men. Per woman invited to screening, the estimated gain in QALYs was 0.00110, and the incremental cost was £33.99. This gave an incremental cost-effectiveness ratio (ICER) of £31,000 per QALY gained. The corresponding incremental net monetary benefit at a threshold of £20,000 per QALY gained was -£12.03 (95% uncertainty interval -£27.88 to £22.12). Almost no sensitivity analyses brought the ICER below £20,000 per QALY gained; an exception was doubling the AAA prevalence to 0.86%, which resulted in an ICER of £13,000. Alternative screening options (increasing the screening age to 70 years, lowering the threshold for considering surgery to diameters of 5.0 cm or 4.5 cm, lowering the diameter defining an AAA in women to 2.5 cm and lengthening the surveillance intervals for the smallest AAAs) did not bring the ICER below £20,000 per QALY gained when considered either singly or in combination.

LIMITATIONS

The model for women was not directly validated against empirical data. Some parameters were poorly estimated, potentially lacking relevance or unavailable for women.

CONCLUSION

The accepted criteria for a population-based AAA screening programme in women are not currently met.

FUTURE WORK

A large-scale study is needed of the exact aortic size distribution for women screened at relevant ages. The DES model can be adapted to evaluate screening options in men.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42015020444 and CRD42016043227.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Editor's Choice - Inequalities in Abdominal Aortic Aneurysm Screening in England: Effects of Social Deprivation and Ethnicity

OBJECTIVE

Population screening for abdominal aortic aneurysm (AAA) in men is currently ongoing in several countries. The aim was to examine the effects of deprivation and ethnicity on uptake of screening for abdominal aortic aneurysm (AAA) and prevalence of AAA.

METHODS

This was a review of outcomes from a population screening programme using data collected contemporaneously on a bespoke national database. Men aged 65 in two annual cohorts (2013/14 and 2014/15) were invited for AAA screening. Attendance and prevalence of AAA (aortic diameter >2.9 cm) were recorded. Results were compared according to measures of social deprivation and recorded ethnicity.

RESULTS

Some 593,032 men were invited and 461,898 attended for ultrasound screening; uptake 77.9%. Uptake was related to social deprivation: 65.1% in the most deprived decile, 84.1% in the least deprived: OR for least deprived 2.84, 95% CI 2.76-2.92, p<.0001. Men in deprived areas were more likely to actively decline screening: 6% versus 3.8% in the least deprived decile. AAA were twice as common in the most deprived compared with the least deprived decile: OR 2.1, 95% CI 1.77-2.27, p<.0001. AAA were more common in white British men than in black (OR 0.46, 95% CI 0.31-0.71) or Asian (OR 0.18, 95% CI 0.13-0.26) men. There was considerable local variation in all findings.

CONCLUSIONS

Social deprivation affects uptake of AAA screening in 65 year old men. Local factors are the most important determinants of uptake, so solutions to improve uptake must be designed at local, not national level.

Influence of rurality, deprivation and distance from clinic on uptake in men invited for abdominal aortic aneurysm screening

BACKGROUND

Effective abdominal aortic aneurysm (AAA) screening requires high uptake. The aim was to assess the independent association of screening uptake with rurality, social deprivation, clinic type, distance to clinic and season.

METHODS

Screening across Grampian was undertaken by trained nurses in six community and three hospital clinics. Men aged 65 years were invited for screening by post (with 2 further reminders for non-responders). AAA screening data are stored on a national call-recall database. The Scottish postcode directory was used to allocate to all invited men a deprivation index (Scottish Index of Multiple Deprivation), a Scottish urban/rural category and distance to clinic. Multivariable analysis was undertaken.

RESULTS

The cohort included 5645 men invited for screening over 12 months (October 2012 to October 2013); 42·6 per cent lived in urban areas, 38·9 per cent in rural areas and 18·5 per cent in small towns (uptake 87·0, 89·3 and 90·8 per cent respectively). Overall uptake was 88·6 per cent with 76 new AAAs detected: 15·2 (95 per cent c.i. 11·8 to 18·6) per 1000 men screened. Aberdeen city (large urban area) had the lowest uptake (86·1 per cent). Uptake declined with increasing deprivation, with the steepest decline in urban areas. On multivariable analysis, a 1-point increase in deprivation deciles was associated with a 0·08 (95 per cent c.i. 0·06 to 0·11) reduction in the odds of being screened (P < 0·001). Clinic type (community versus hospital), distance to clinic and season were not associated independently with uptake.

CONCLUSION

Both urban residence and social deprivation were associated independently with uptake among men invited for AAA screening.

Socioeconomic influence on orofacial cleft patient care

Background

Cleft lip and palate is the most common craniofacial birth defect in the UK. Orofacial clefts have functional and aesthetic implications requiring intensive multi-disciplinary follow-up to optimise development. Failure to attend follow-up is likely to have a negative impact on patient outcomes. The aim of this retrospective audit is to establish if socioeconomic status influences attendance, DNA and cancellation rates in cleft patients.

Methods and results

A retrospective audit of 74 orofacial cleft patients born and operated on at the Royal Hospital for Sick Children Glasgow between 2006 and 2007. There was higher rate of DNA in more deprived social groups−21% (SIMD 1) against 10% (SIMD 5). A higher rate of DNA in cleft lip and palate patients was noted. This group of patients showed a marked difference in attendance between SIMD 1 (38%) and SIMD 5 (78%).

Conclusion

More deprived areas have a higher outpatient DNA rate for cleft patients resulting in suboptimal follow-up. Ultimately, causation of poorer outcomes in this group is likely to be multi-factorial but the financial implication of travelling to multiple clinics should be considered and it may be that resource reallocation is the answer to address the current inequality of health care provision.

The anti-angiogenic role of discoidin domain receptor 2 (DDR2) in laser-induced choroidal neovascularization

Choroidal neovascularization (CNV), an aberrant growth of blood vessels in the choroid layer of the eye, is a major cause of vision loss. In view of our recent finding that discoidin domain receptor 2 (DDR2), a collagen-binding receptor tyrosine kinase, is involved in control of vascular endothelial activity and tumor angiogenesis, the present study aims to investigate whether and how DDR2 affects the pathogenesis of CNV. We initially found that a spontaneous DDR2 mutant mouse colony (slie) exhibited enhanced amplitude of laser-induced CNV. The inhibitory role of DDR2 in CNV development was further confirmed by experiments through intravitreous injection of DDR2 small interference RNA (siRNA) or DDR2-expressing adenovirus. Quantitative real-time polymerase chain reaction (qPCR) and immunoblot analysis showed that DDR2 regulates the expression of several major pro-angiogenic factors in the laser-injured choroid as well as in retinal pigment epithelium (RPE) cells. In addition, it was demonstrated that the CNV-induced increases in the phosphorylation levels of Akt and mTOR were affected by the upregulation or downregulation of DDR2. Thus, the data from this study for the first time revealed that DDR2 negatively regulates the development of experimental CNV in vivo, which may provide a novel target for preventing human pathological ocular neovascularization. Key messages: DDR2 does not affect retinal development. DDR2 inhibits laser-induced CNV. DDR2 regulates angiogenic factor expression in CNV lesion as well as in RPE cells. DDR2 is involved in modulation of CNV-induced activation of PI3K pathway.

Final follow-up of the Multicentre Aneurysm Screening Study (MASS) randomized trial of abdominal aortic aneurysm screening

BACKGROUND

The long-term effects of abdominal aortic aneurysm (AAA) screening were investigated in extended follow-up from the UK Multicentre Aneurysm Screening Study (MASS) randomized trial.

METHODS

A population-based sample of men aged 65-74 years were randomized individually to invitation to ultrasound screening (invited group) or to a control group not offered screening. Patients with an AAA (3·0 cm or larger) detected at screening underwent surveillance and were offered surgery after predefined criteria had been met. Cause-specific mortality data were analysed using Cox regression.

RESULTS

Some 67 770 men were enrolled in the study. Over 13 years, there were 224 AAA-related deaths in the invited group and 381 in the control group, a 42 (95 per cent confidence interval 31 to 51) per cent reduction. There was no evidence of effect on other causes of death, but there was an overall reduction in all-cause mortality of 3 (1 to 5) per cent. The degree of benefit seen in earlier years of follow-up was slightly diminished by the occurrence of AAA ruptures in those with an aorta originally screened normal. About half of these ruptures had a baseline aortic diameter in the range 2·5-2·9 cm. It was estimated that 216 men need to be invited to screening to save one death over the next 13 years.

CONCLUSION

Screening resulted in a reduction in all-cause mortality, and the benefit in AAA-related mortality continued to accumulate throughout follow-up.

REGISTRATION NUMBER

ISRCTN37381646 (http://www.controlled-trials.com).

Assessing individual breast cancer risk within the U.K. National Health Service Breast Screening Program: a new paradigm for cancer prevention

The aim of this study is to determine breast cancer risk at mammographic screening episodes and integrate standard risk factors with mammographic density and genetic data to assess changing the screening interval based on risk and offer women at high risk preventive strategies. We report our experience of assessing breast cancer risk within the U.K. National Health Service Breast Screening Program using results from the first 10,000 women entered into the "Predicting Risk Of breast Cancer At Screening" study. Of the first 28,849 women attending for screening at fifteen sites in Manchester 10,000 (35%) consented to study entry and completed the questionnaire. The median 10-year Tyrer-Cuzick breast cancer risk was 2.65% (interquartile range, 2.10-3.45). A total of 107 women (1.07%) had 10-year risks 8% or higher (high breast cancer risk), with a further 8.20% having moderately increased risk (5%-8%). Mammographic density (percent dense area) was 60% or more in 8.3% of women. We collected saliva samples from 478 women for genetic analysis and will extend this to 18% of participants. At time of consent to the study, 95.0% of women indicated they wished to know their risk. Women with a 10-year risk of 8% or more or 5% to 8% and mammographic density of 60% or higher were invited to attend or be telephoned to receive risk counseling; 81.9% of those wishing to know their risk have received risk counseling and 85.7% of these were found to be eligible for a risk-reducing intervention. These results confirm the feasibility of determining breast cancer risk and acting on the information in the context of population-based mammographic screening.

Time orientation and health-related behaviour: measurement in general population samples

Research on health behaviour and time orientation has been hindered by a lack of consensus about appropriate measurement. Study 1 assessed the reliability of the Consideration of Future Consequences Scale (CFC) and the Zimbardo Time Perspective Inventory (ZTPI) in a general population sample (n = 300). Although more reliable, the CFC was less readable. Study 2 assessed the validity of a shortened ZTPI, measuring future and present orientation, and the full CFC. The measures had good discrimination to distinguish interpersonal differences. Construct validity of present, but not future, orientation as measured by the ZTPI, was evidenced by its mediation of the association between socioeconomic status and expectations of participating in diabetes screening. The CFC mediated this relationship more weakly. Further investigation of present orientation in understanding health-related behaviour is warranted.

Impact of an informed choice invitation on uptake of screening for diabetes in primary care (DICISION): randomised trial

OBJECTIVE

To compare the effect of an invitation promoting informed choice for screening with a standard invitation on attendance and motivation to engage in preventive action.

DESIGN

Randomised controlled trial.

SETTING

Four English general practices.

PARTICIPANTS

1272 people aged 40-69 years, at risk for diabetes, identified from practice registers using a validated risk score and invited to attend for screening.

INTERVENTION

Intervention was a previously validated invitation to inform the decision to attend screening, presenting diabetes as a serious potential problem, and providing details of possible costs and benefits of screening and treatment in text and pie charts. This was compared with a brief, standard invitation simply describing diabetes as a serious potential problem.

MAIN OUTCOME MEASURES

The primary end point was attendance for screening. The secondary outcome measures were intention to make changes to lifestyle and satisfaction with decisions made among attenders.

RESULTS

The primary end point was analysed for all 1272 participants. 55.8% (353/633) of those in the informed choice group attended for screening, compared with 57.6% (368/639) in the standard invitation group (mean difference -1.8%, 95% confidence interval -7.3% to 3.6%; P=0.51). Attendance was lower among the more deprived group (most deprived third 47.5% v least deprived third 64.3%; P<0.001). Interaction between deprivation and effect of invitation type on attendance was not significant. Among attenders, intention to change behaviour was strong and unaffected by invitation type.

CONCLUSIONS

Providing information to support choice did not adversely affect attendance for screening for diabetes. Those from more socially deprived groups were, however, less likely to attend, regardless of the type of invitation received. Further attention to invitation content alone is unlikely to achieve equity in uptake of preventive services.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN 73125647.

Uncertainty and validation of health economic decision models

Health economic decision models are based on specific assumptions relating to model structure and parameter estimation. Validation of these models is recommended as an indicator of reliability, but is not commonly reported. Furthermore, models derived from different data and employing different assumptions may produce a variety of results.A Markov model for evaluating the long-term cost-effectiveness of screening for abdominal aortic aneurysm is described. Internal, prospective and external validations are carried out using individual participant data from two randomised trials. Validation is assessed in terms of total numbers and timings of key events, and total costs and life-years. Since the initial model validates well only internally, two further models are developed that better fit the prospective and external validation data. All three models are then extrapolated to a life-time horizon, producing cost-effectiveness estimates ranging from pound1600 to pound4200 per life-year gained.Parameter uncertainty is now commonly addressed in health economic decision modelling. However, the derivation of models from different data sources adds another level of uncertainty. This extra uncertainty should be recognised in practical decision-making and, where possible, specifically investigated through independent model validation.

Risk Factors for Abdominal Aortic Aneurysm and the Influence of Social Deprivation

Introduction: the objective of this abdominal aortic aneurysm (AAA) screening study was to determine attendance and disease prevalence patterns in Northern Ireland and the role of deprivation and other risk factors. Patients and methods: patients from primary care practices from Belfast, Lisburn, and Saintfield were screened. Past medical history and deprivation details were determined. Results: 2264 men from Belfast, 1104 men in Lisburn, and 284 in Saintfield were invited to attend. Overall, 1659 (45.3%) men attended, with 40.6% from Belfast, 55.0% from Lisburn, and 45.8% from Saintfield ( P < .0001). Ninety-two (5.5%) new AAAs were diagnosed, with 6.5%, 3.8%, and 6.2% in the 3 areas ( P = .055). As deprivation decreased, attendance increased and prevalence decreased. Smoking, peripheral arterial disease, number of medications prescribed, and geographical origin were independent risk factors for AAAs. Conclusion: aneurysm prevalence is influenced by geographical origin and deprivation, which should, therefore, be important factors in health care planning and screening provision.

Ultrasound screening for abdominal aortic aneurysm in medicare beneficiaries

Ultrasound screening for abdominal aortic aneurysm (AAA) has been shown to be beneficial and cost-effective for men aged 65-74. However, most screening studies have been conducted in Europe and Australia, where attendance for screening was higher than the single large U.S. study involving only veterans. The prevalence of AAA in the U.S. general population is not well defined, nor is the best method of recruitment for screening. Letters of invitation for a free screening ultrasound for AAA were sent to 30,000 randomly selected Medicare beneficiaries from the hospital referral region of three university-affiliated hospitals without restriction by age, gender, or comorbidity. Attendance for screening was calculated by age, gender, and travel distance to the screening center. Telephone calls to a random sample of nonresponders were made to determine the reason for failure to attend. Prevalence of AAA by ultrasound and known risk factors for AAA (e.g., age, gender, smoking status) were determined. The attendance rate was 7% (2,005). Attendance was greater with male gender (p < 0.01), younger age (p < 0.05), and decreased travel distance to the screening center (p < 0.05). The primary reasons for failure to attend included incorrect address or vital status, poor health, and lack of interest. Prevalence of previously undetected AAA was 2.8% in men and 0.2% in women. AAA was predicted by smoking status and male gender (p < 0.01 for each). Unselected invitation of Medicare beneficiaries for ultrasound screening for AAA results in a low attendance and low yield of AAA. The prevalence estimates from this study may not reflect the entire Medicare population given the low attendance and may reflect the healthy habits of those most interested in screening. Patients should be selected for screening based on their suitability for repair if an AAA is found as well as their risk factors for AAA. The best method of recruitment for screening of those most at risk for AAA in the United States remains to be determined.

Social patterning of screening uptake and the impact of facilitating informed choices: psychological and ethical analyses

Screening for unsuspected disease has both possible benefits and harms for those who participate. Historically the benefits of participation have been emphasized to maximize uptake reflecting a public health approach to policy; currently policy is moving towards an informed choice approach involving giving information about both benefits and harms of participation. However, no research has been conducted to evaluate the impact on health of an informed choice policy. Using psychological models, the first aim of this study was to describe an explanatory framework for variation in screening uptake and to apply this framework to assess the impact of informed choices in screening. The second aim was to evaluate ethically that impact. Data from a general population survey (n = 300) of beliefs and attitudes towards participation in diabetes screening indicated that greater orientation to the present is associated with greater social deprivation and lower expectation of participation in screening. The results inform an explanatory framework of social patterning of screening in which greater orientation to the present focuses attention on the disadvantages of screening, which tend to be immediate, thereby reducing participation. This framework suggests that an informed choice policy, by increasing the salience of possible harms of screening, might reduce uptake of screening more in those who are more deprived and orientated to the present. This possibility gives rise to an apparent dilemma where an ethical decision must be made between greater choice and avoiding health inequality. Philosophical perspectives on choice and inequality are used to point to some of the complexities in assessing whether there really is such a dilemma and if so how it should be resolved. The paper concludes with a discussion of the ethics of paternalism.

Fifteen-year follow-up of a randomized clinical trial of ultrasonographic screening for abdominal aortic aneurysms

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).

Geography, private costs and uptake of screening for abdominal aortic aneurysm in a remote rural area

Background

The relationship between geographical location, private costs, health provider costs and uptake of health screening is unclear. This paper examines these relationships in a screening programme for abdominal aortic aneurysm in the Highlands and Western Isles of Scotland, a rural and remote area of over 10,000 square miles.

Methods

Men aged 65–74 (n = 9323) were invited to attend screening at 51 locations in 50 settlements. Effects of geography, deprivation and age on uptake were examined. Among 8,355 attendees, 8,292 completed a questionnaire detailing mode of travel and costs incurred, time travelled, whether accompanied, whether dependants were cared for, and what they would have been doing if not attending screening, thus allowing private costs to be calculated. Health provider (NHS) costs were also determined. Data were analysed by deprivation categories, using the Scottish Indices of Deprivation (2003), and by settlement type ranging from urban to very remote rural.

Results

Uptake of screening was high in all settlement types (mean 89.6%, range 87.4 – 92.6%). Non-attendees were more deprived in terms of income, employment, education and health but there was no significant difference between non-attendees and attendees in terms of geographical access to services. Age was similar in both groups. The highest private costs (median £7.29 per man) and NHS screening costs (£18.27 per man invited) were observed in very remote rural areas. Corresponding values for all subjects were: private cost £4.34 and NHS cost £15.72 per man invited.

Conclusion

Uptake of screening for abdominal aortic aneurysm in this remote and rural setting was high in comparison with previous studies, and this applied across all settlement types. Geographical location did not affect uptake, most likely due to the outreach approach adopted. Private and NHS costs were highest in very remote settings but still compared favourably with other published studies.

Systematic review of recent evidence for the safety and efficacy of elective endovascular repair in the management of infrarenal abdominal aortic aneurysm

Background

Conventional management of abdominal aortic aneurysm (AAA) is by open repair and is associated with a mortality rate of 2–6 per cent. Endovascular aneurysm repair (EVAR) is an alternative technique first introduced in 1991. A systematic review was undertaken of the evidence for the safety and efficacy of elective EVAR in the management of asymptomatic infrarenal AAA.

Methods

Thirteen electronic bibliographical databases were searched, covering biomedical, health-related, science and social science literature. Outcomes were assessed with respect to efficacy (successful deployment, technical success, conversion rates and secondary intervention rates) and safety (30-day mortality rate, procedure morbidity rates and technical issues—endoleaks, graft thrombosis, stenosis and migration).

Results

Of 606 reports identified, 61 met the inclusion criteria (three randomized and 15 non-randomized controlled trials, and 43 uncontrolled studies). There were 29 059 participants in total; 19 804 underwent EVAR. Deployment was successful in 97·6 per cent of cases. Technical success (complete aneurysm exclusion) was 81·9 per cent at discharge and 88·8 per cent at 30 days. Secondary intervention to treat endoleak or maintain graft patency was required in 16·2 per cent of patients. Mean stay in the intensive care unit and mean hospital stay were significantly shorter following EVAR. The 30-day mortality rate for EVAR was 1·6 per cent (randomized controlled trials) and 2·0 per cent in nonrandomized trials and case series. Technical complications comprised stent migration (4·0 per cent), graft limb thrombosis (3·9 per cent), endoleak (type I, 6·8 per cent; type II, 10·3 per cent; type III, 4·2 per cent) and access artery injury (4·8 per cent).

Discussion

EVAR is technically effective and safe, with lower short-term morbidity and mortality rates than open surgery. However, there is a need for extended follow-up as the long-term success of EVAR in preventing aneurysm-related deaths is not yet known.