Health gains, costs and cost-effectiveness of a population-based screening programme for abdominal aortic aneurysms

The value of lives in New Zealand

There is currently a pronounced lack of uniformity in the values placed on a life or a QALY by different New Zealand government entities taking actions designed to save lives or QALYs. With some limited exceptions, equity suggests that all QALYs be equally valued, and therefore likewise for all lives with the same residual life expectancy and quality of life. Prima facie, this is attainable by adopting the best (and only credible) New Zealand estimate of the value of life (the NZTA's $12.5 m value of the life of a median age person in good health), and using that or its QALY equivalent as a cutoff figure to determine interventions throughout the public sector. This provides opportunities for large welfare gains, from curtailing existing interventions that currently use much larger cutoff values (such as earthquake strengthening regulations) and expanding interventions that currently use much smaller cutoff values (such as public health spending). However, the NZTA's figure is only applicable to small increases in lives saved, and must decline as the number of additional lives saved increases. This relationship should be estimated.

Tea polyphenol nanoparticles enable targeted siRNA delivery and multi-bioactive therapy for abdominal aortic aneurysms

Abdominal aortic aneurysm (AAA) is a life-threatening vascular disease, while there is a lack of pharmaceutical interventions to halt AAA progression presently. To address the multifaceted pathology of AAA, this work develops a novel multifunctional gene delivery system to simultaneously deliver two siRNAs targeting MMP-2 and MMP-9. The system (TPNs-siRNA), formed through the oxidative polymerization and self-assembly of epigallocatechin gallate (EGCG), efficiently encapsulates siRNAs during self-assembly. TPNs-siRNA safeguards siRNAs from biological degradation, facilitates intracellular siRNA transfection, promotes lysosomal escape, and releases siRNAs to silence MMP-2 and MMP-9. Additionally, TPNs, serving as a multi-bioactive material, mitigates oxidative stress and inflammation, fosters M1-to-M2 repolarization of macrophages, and inhibits cell calcification and apoptosis. In experiments with AAA mice, TPNs-siRNA accumulated and persisted in aneurysmal tissue after intravenous delivery, demonstrating that TPNs-siRNA can be significantly distributed in macrophages and VSMCs relevant to AAA pathogenesis. Leveraging the carrier's intrinsic multi-bioactive properties, the targeted siRNA delivery by TPNs exhibits a synergistic effect for enhanced AAA therapy. Furthermore, TPNs-siRNA is gradually metabolized and excreted from the body, resulting in excellent biocompatibility. Consequently, TPNs emerges as a promising multi-bioactive nanotherapy and a targeted delivery nanocarrier for effective AAA therapy.

Health Economic Research Assessing the Value of Early Detection of Cardiovascular Disease: A Systematic Review

INTRODUCTION

Cardiovascular disease (CVD) is the most prominent cause of death worldwide and has a major impact on healthcare budgets. While early detection strategies may reduce the overall CVD burden through earlier treatment, it is unclear which strategies are (most) efficient.

AIM

This systematic review reports on the cost effectiveness of recent early detection strategies for CVD in adult populations at risk.

METHODS

PubMed and Scopus were searched to identify scientific articles published between January 2016 and May 2022. The first reviewer screened all articles, a second reviewer independently assessed a random 10% sample of the articles for validation. Discrepancies were solved through discussion, involving a third reviewer if necessary. All costs were converted to 2021 euros. Reporting quality of all studies was assessed using the CHEERS 2022 checklist.

RESULTS

In total, 49 out of 5552 articles were included for data extraction and assessment of reporting quality, reporting on 48 unique early detection strategies. Early detection of atrial fibrillation in asymptomatic patients was most frequently studied (n = 15) followed by abdominal aortic aneurysm (n = 8), hypertension (n = 7) and predicted 10-year CVD risk (n = 5). Overall, 43 strategies (87.8%) were reported as cost effective and 11 (22.5%) CVD-related strategies reported cost reductions. Reporting quality ranged between 25 and 86%.

CONCLUSIONS

Current evidence suggests that early CVD detection strategies are predominantly cost effective and may reduce CVD-related costs compared with no early detection. However, the lack of standardisation complicates the comparison of cost-effectiveness outcomes between studies. Real-world cost effectiveness of early CVD detection strategies will depend on the target country and local context.

REGISTRATION OF SYSTEMATIC REVIEW

CRD42022321585 in International Prospective Registry of Ongoing Systematic Reviews (PROSPERO) submitted at 10 May 2022.

Incidence and Outcomes of Abdominal Aortic Aneurysm Repair in New Zealand from 2001 to 2021

Purpose: The burden of abdominal aortic aneurysms (AAA) has changed in the last 20 years but is still considered to be a major cause of cardiovascular mortality. The introduction of endovascular aortic repair (EVAR) and improved peri-operative care has resulted in a steady improvement in both outcomes and long-term survival. The objective of this study was to identify the burden of AAA disease by analysing AAA-related hospitalisations and deaths. Methodology: All AAA-related hospitalisations in NZ from January 2001 to December 2021 were identified from the National Minimum Dataset, and mortality data were obtained from the NZ Mortality Collection dataset from January 2001 to December 2018. Data was analysed for patient characteristics including deprivation index, repair methods and 30-day outcomes. Results: From 2001 to 2021, 14,436 patients with an intact AAA were identified with a mean age of 75.1 years (SD 9.7 years), and 4100 (28%) were females. From 2001 to 2018, there were 5000 ruptured AAA with a mean age of 77.8 (SD 9.4), and 1676 (33%) were females. The rate of hospitalisations related to AAA has decreased from 43.7 per 100,000 in 2001 to 15.4 per 100,000 in 2018. There was a higher proportion of rupture AAA in patients living in more deprived areas. The use of EVAR for intact AAA repair has increased from 18.1% in 2001 to 64.3% in 2021. The proportion of octogenarians undergoing intact AAA repair has increased from 16.2% in 2001 to 28.4% in 2021. The 30-day mortality for intact AAA repair has declined from 5.8% in 2001 to 1.7% in 2021; however, it has remained unchanged for ruptured AAA repair at 31.6% across the same period. Conclusions: This study highlights that the incidence of AAA has declined in the last two decades. The mortality has improved for patients who had a planned repair. Understanding the contemporary burden of AAA is paramount to improve access to health, reduce variation in outcomes and promote surgical quality improvement.

Abdominal Aortic Screening Is a Priority for Health in Smoker Males: A Study on Central Italian Population

Abdominal aortic aneurysm (AAA) is a major public health problem. In the last decade, in some European countries, abdominal aortic screening (AAS) is emerging as a potential prevention for the rupture of AAA. The goals of our study were to estimate AAA prevalence and risk factors in males and females in a central Italian population, also defining the cost-effectiveness of AAS programs. A pilot study screening was conducted between 1 January 2015 and 31 December 2019 in the municipality of Teramo (Abruzzo Region, Italy) in a group of men and women, ranging from the age of 65 to 79, who were not previously operated on for AAA. The ultrasound was performed by means of Acuson sequoia 512 Simens with a Convex probe. The anterior posterior of the infra-renal aorta was evaluated. The odds ratio values (ORs) were used to evaluate the risk of AAA, and the following determinants were taken into consideration: gender, smoke use, hypertension, and ischemic heart disease. We also estimated the direct costs coming from aneurysmectomy (surgical repair or endovascular aneurysms repair-EVAR). A total of 62 AAA (2.7%, mean age 73.8 ± 4.0) were diagnosed, of which 57 were in men (3.7%, mean age 73.6 ± 4.0) and 5 were in women (0.7%, mean age 74.3 ± 4.1). Male gender and smoke use are more important risk factors for AAA ≥ 3 cm, respectively: OR = 5.94 (2.37-14.99, p < 0.001) and OR = 5.21 (2.63-10.30, p < 0.000). A significant increase in OR was noted for AAA ≥ 3 cm and cardiac arrhythmia and ischemic heart disease, respectively: OR = 2.81 (1.53-5.15, p < 0.000) and OR = 2.76 (1.40-5.43, p = 0.006). Regarding the cost analysis, it appears that screening has contributed to the reduction in costs related to urgency. In fact, the synthetic indicator given by the ratio between the DRGs (disease related group) relating to the emergency and those of the elective activity went from 1.69 in the year prior to the activation of the screening to a median of 0.39 for the five-year period of activation of the screening. It is important to underline that the results of our work confirm that the screening activated in our territory has led to a reduction in the expenditure for AAA emergency interventions, having increased the planned interventions. This must be a warning for local stakeholders, especially in the post-pandemic period, in order to strengthen prevention.

Screening Older Adult Men for Abdominal Aortic Aneurysm: A Scoping Review

Abdominal aortic aneurysm (AAA) is a potentially fatal condition predominantly affecting older adult men (60 years or over). Based on evidence, preventative health-care guidelines recommend screening older males for AAA using ultrasound. In attempts to reduce AAA mortality among men, screening has been utilized for early detection in some Western countries including the UK and Sweden. The current scoping review includes 19 empirical studies focusing on AAA screening in men. The findings from these studies highlight benefits and potential harms of male AAA screening. The benefits of AAA screening for men include decreased incidence of AAA rupture, decreased AAA mortality, increased effectiveness of elective AAA repair surgery, and cost-effectiveness. The potential harms of AAA screening included lack of AAA mortality reduction, negative impacts on quality of life, and inconsistent screening eligibility criteria being applied by primary care practitioners. The current scoping review findings are discussed to suggest changes to AAA screening guidelines and improve policy and practice.