An economic evaluation of an abdominal aortic aneurysm screening program in Italy

Point-of-care ultrasonography for cardiovascular conditions in family practice: between risk and opportunity

Several articles have appeared in the medical literature on the use of ultrasound in primary care. Point-of-care ultrasound refers to ultrasound protocols performed at the bedside to evaluate many conditions such as aortic aneurysm or assessment of left ventricular function by estimation of ejection fraction. Primary care physicians can play a key role in evaluating such conditions for their patients. It should be considered that the use of ultrasound in general practice can not only be an aid to diagnosis but also an active screening tool, accessible even to those with basic training in ultrasound; the left ventricle and large abdominal vessels are indeed clearly visible with this technique, which with little training can become accessible to many. In a working organization, so few trained physicians would be sufficient to screen the target population of the entire group and extend the assessment to a large number of participants.

Outcomes of a pilot abdominal aortic aneurysm screening program in a population of Central Greece

BACKGROUND

Abdominal aortic aneurysm (AAA) screening has contributed in the decrease of aneurysm related and all-cause mortality. The objective of our study is to present our experience from the only existing pilot AAA screening program in Greece.

METHODS

Men from both urban and rural areas in Central Greece, aged >60 years old without a previously known diagnosis of AAA were invited through the public primary health care units to participate to a screening program. Demographics, comorbidities, family history and anthropometric data were recorded. Aortic diameter values of >30 mm and common iliac artery (CIA) diameter values of >18 mm, were defined as aneurysmatic by ultrasound.

RESULTS

The screening program included 1256 individuals (1256/1814; response rate 69%). The incidence of AAA and CIA aneurysm was 2% (25/1256) and 2.3% (29/1256), respectively. Increased age (P<0.042), tobacco use (P<0.006) and its duration (P<0.008) were related to higher incidence of AAA, while diabetes mellitus to lower one (P<0.048). Multivariate analysis showed that AAA was associated to longer duration of smoking (1.05, CI: 0.02-6.6; P=0.01). Statin and antiplatelet therapy were administrated in 40% (10/25) and 44% (11/25), respectively of individuals with AAA. An additional analysis was provided between subjects with AD of 25-30 mm and AD <25 mm. In multivariate analysis, no factor was associated to AD of 25-30 mm.

CONCLUSIONS

The incidence of AAA and CIA aneurysm in Central Greece is 2% and 2.3%, respectively. Smoking duration was the strongest associated factor with AAA incidence. This provides to healthcare policy makers a strong valid point for the prevention strategies.

Priorities among effective clinical preventive services in British Columbia, Canada

BACKGROUND

Despite the long-standing experience of rating the evidence for clinical preventive services, the delivery of effective clinical preventive services in Canada and elsewhere is less than optimal. We outline an approach used in British Columbia to assist in determining which effective clinical preventive services are worth doing.

METHODS

We calculated the clinically preventable burden and cost-effectiveness for 28 clinical preventive services that received a 'strong or conditional (weak) recommendation for' by the Canadian Task Force on Preventive Health Care or an 'A' or 'B' rating by the United States Preventive Services Task Force. Clinically preventable burden is the total quality adjusted life years that could be gained if the clinical preventive services were delivered at recommended intervals to a British Columbia birth cohort of 40,000 individuals over the years of life that the service is recommended. Cost-effectiveness is the net cost per quality adjusted life year gained.

RESULTS

Clinical preventive services with the highest population impact and best value for money include services that address tobacco use in adolescents and adults, exclusive breastfeeding, and screening for hypertension and other cardiovascular disease risk factors followed by appropriate pharmaceutical treatment. In addition, alcohol misuse screening and brief counseling, one-time screening for hepatitis C virus infection in British Columbia adults born between 1945 and 1965, and screening for type 2 diabetes approach these high-value clinical preventive services.

CONCLUSIONS

These results enable policy makers to say with some confidence what preventive manoeuvres are worth doing but further work is required to determine the best way to deliver these services to all those eligible and to establish what supportive services are required. After all, if a clinical preventive service is worth doing, it is worth doing well.

Epidemiology of Abdominal Aortic Aneurysm Repair in Brazil from 2008 to 2019 and Comprehensive Review of Nationwide Statistics Across the World

INTRODUCTION

Studying epidemiology of abdominal aortic aneurysms repairs is essential to prevent related deaths. Although outcomes are influenced by socioeconomic factors, there are no nationwide studies on these statistics in low-and-middle income countries. Therefore, we designed this study to evaluate abdominal aortic aneurysms repair rates, trends, costs, and in-hospital mortality in the Brazilian Public Health System, which exclusively insures over 160 million Brazilians.

MATERIAL AND METHODS

Retrospective cross-sectional population-based analysis of publicly available data referring to all abdominal aortic aneurysm repairs performed between 2008 and 2019 in Brazilian public hospitals.

RESULTS

We observed a total of 13,506 abdominal aortic aneurysm repairs, of which 32% were emergency endovascular repairs, 20% emergency open repairs, 32% elective endovascular repairs and 16% elective open repairs. There has been a downward trend in total abdominal aortic aneurysms repairs and an increasing predominance of endovascular repair. Elective and endovascular repairs were significantly associated with lower in-hospital mortality. For ruptured abdominal aortic aneurysms, we observed mortality rates of 13.8% after endovascular repair and 52.1% after open repair. For intact abdominal aortic aneurysms, we observed mortalities of 3.8% after endovascular repair and 18.6% after open repair. Procedure and mortality rates varied significantly among the Brazilian regions.

CONCLUSIONS

We observed a low and decreasing rate of abdominal aortic aneurysm repair. Most repairs were emergency and endovascular and there was an increasing predominance of endovascular repair. Endovascular and elective repairs were associated with lower mortality.

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.

Prediction model of isolated iliac and abdominal aneurysms

OBJECTIVES

We analyse the cardiovascular risk factors in patients undergoing screening for Isolated Iliac Aneurysm (IIA) and Abdominal Aortic Aneurysm (AAA) and propose a logistic regression model to indicate patients at risk of IIA and/or AAA.

METHODS

A screening programme was carried out to identify the presence of aneurysm based on Duplex scan examination. Cardiovascular risk factors information was collected from each subject. A descriptive analysis for the incidence of IIA and AAA stratified by age and sex was carried out to evaluate factors incidence. A logistic regression model was developed to predict the probability of developing an aneurysm based on the observed risk factor levels. A threshold probability of aneurysm risk for a datum patient was also identified to effectively direct screening protocols to patients most at risk.

RESULTS

A cohort of 10 842 patients was evaluated: 1.52% affected by IIA, 2.69% by AAA and 3.90% by at least one. Risk factors analysis showed that: IIA was correlated with cardiological status, diabetes, cardiovascular disease family history, and dyslipidaemia; AAA was correlated with cardiological status, body mass index, hypertension, and dyslipidaemia; diabetes and dyslipidaemia were the most relevant factors with at least one aneurysm. The prediction tool based on the logistic regression and the threshold probability predict the presence of IIA and AAA in 69.7% and 83.8% of cases, under k-fold cross-validation.

CONCLUSIONS

The proposed regression model can represent a valid aid to predict IIA and AAA presence and to select patients to be screened.

Optimising intervals for abdominal aortic aneurysm surveillance: A pilot study analysing patient opinion

Introduction

Optimising abdominal aortic aneurysm surveillance intervals will improve current surveillance programmes. To the author's knowledge, no known study has exclusively asked patient opinion with regards to their surveillance interval. The aim of this study was to therefore determine a patient's perspective of their optimal intervals, encouraging shared decision-making and creating a patient-focused service.

Methods

Fifty patients, currently under abdominal aortic aneurysm surveillance, were interviewed. Patients were asked their opinions before and after seeing a patient decision aid. A patient decision aid presents information of risk in an easy-to-understand format. This specific patient decision aid, designed and created for this study, informed patients of the 'risk of exceeding the 5.5 cm surgical threshold' with regards to various surveillance intervals. The chosen optimal surveillance interval was recorded for each patient, and a median interval was calculated for each abdominal aortic aneurysm group. Groups were categorised based upon maximum aortic diameter (3.0-3.4 cm, 3.5-3.9 cm, 4.0-4.4 cm and 4.5-4.9 cm).

Results

After assessing the patient decision aid, the median surveillance interval calculated for each abdominal aortic aneurysm group was 24 months (3.0-3.4 cm), 12 months (3.5-3.9 cm), 12 months (4.0-4.4 cm) and 6 months (4.5-4.9 cm), respectively. The majority of patients (78%, n = 39) agreed that the patient decision aid was a useful tool to help make an informed choice.

Conclusion

Overall, patients in abdominal aortic aneurysm groups 3.0-3.4 cm and 4.5-4.9 cm would choose to lengthen abdominal aortic aneurysm surveillance intervals. Lengthening the current surveillance intervals to 24 months (currently 12 months) for abdominal aortic aneurysm group 3.0-3.4 cm and to 6 months (currently 3 months) for abdominal aortic aneurysm group 4.5-4.9 cm would not only increase capacity but also reflect the needs and wishes of those using the National Health Service. The use of a patient decision aid is an effective way of communicating, to the patient, the risk of the proposed changes and thus alleviating potential anxiety.

Empirical Monetary Valuation of a Quality-Adjusted Life-Year in the Kingdom of Saudi Arabia: A Willingness-to-Pay Analysis

BACKGROUND

No willingness-to-pay (WTP) per quality-adjusted life-year (QALY) value exists for the Kingdom of Saudi Arabia (KSA).

OBJECTIVE

The primary objective of this study was to determine the WTP for a QALY in the KSA.

METHODS

Adult citizens of the KSA, patients with cancer, or members of the general public (MGP) were recruited to participate in a time trade-off survey to elicit health utilities. Cancer was chosen as the disease of interest for patients and the MGP, with a scenario describing stage 3 colorectal cancer, because it is a disease condition that impacts on both quality of life and survival time. In a second step, respondents were asked about their WTP to move from the estimated health state to a state of perfect health for 1 year (QALY). Finally, that amount was processed to generate the WTP for a full QALY. The second step was repeated with a 5-year horizon. Sensitivity analyses were performed without outliers.

RESULTS

From 400 participants, data from 378 subjects were obtained and usable: 177 patients, 201 MGP; 278 male, 100 female subjects; 231 aged 26-65 years. Demographic distribution varied widely between the two subgroups for age, education level, and employment status, but with less variation in sex and income. Elicited health utilities were 0.413 (0.472 after adjustment) for the overall group, 0.316 (0.416) for patients, and 0.499 (0.508) for MGP. Overall WTP for a QALY was $US25,600 (adjusted $US32,000) for the 1-year horizon and $US19,200 (adjusted $US22,720) for the 5-year horizon.

CONCLUSION

This was the first empirical attempt to estimate the WTP per QALY for the KSA. Results are comparable to those in some other countries and to gross domestic product figures for the KSA. Further research in a country-wide sample is warranted.

Systematic review on abdominal aortic aneurysm screening cost-efficiency and methodological quality assessment

INTRODUCTION

Abdominal aortic aneurysm (AAA) is a silent, progressive disease that can lead to death. It is easily diagnosed with noninvasive methods and its routine treatment has excellent results. This creates an optimal situation for population screening programs. The aim of this paper was to assess results and methodological quality of cost-utility studies on screening versus no screening scenarios for AAA to assess future establishment of new AAA screening programs.

EVIDENCE ACQUISITON

A systematic review of efficiency (cost-effectiveness and cost-utility) studies was performed, finally selecting cost-utility studies on AAA screening versus no screening. Papers were selected that dealt with efficiency of screening for AAA according to PICOTS framework and the methodological quality assessed according to the economic evaluation analyses described by Drummond and Caro. Two independent reviewers were involved in the procedure.

EVIDENCE SYNTHESIS

Research retrieved 88 studies. From those, 26 showed cost-effectiveness and cost-utility results. Finally, 10 studies had cost-utility results and suited criteria (published in the last 10 years; time-horizon: 10 years or more) for exhaustive analysis. All publications, except one, showed adequate incremental cost-utility ratios according to different national perspectives. Methodological assessment showed some quality limitations, but the majority of items analyzed were favorably answered after applying the questionnaires.

CONCLUSIONS

Confirmation of the cost-utility results in this revision at a national/regional level should be the basis for the implantation of new national screening programs worldwide. The methodological evaluation applied in this revision is crucial for the corresponding future piggy-back trials to assess routine application of national AAA screening programs.

ACR Appropriateness Criteria® Abdominal Aortic Aneurysm Follow-up (Without Repair)

Abdominal aortic aneurysm (AAA) is defined as aneurysmal dilation of the abdominal aorta to 3 cm or greater. A high degree of morbidity and mortality is associated with AAA rupture, and imaging surveillance plays an essential role in mitigating the risk of rupture. Aneurysm size and growth rate are factors associated with the risk of rupture, thus surveillance imaging studies must be accurate and reproducible to characterize aneurysm size. Ultrasound, CT angiography, and MR angiography provide an accurate and reproducible assessment of size, while radiographs and aortography provide limited evaluation. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

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

BACKGROUND

Abdominal aortic aneurysm (AAA) rupture carries a high fatality rate. AAAs can be detected before rupture by abdominal ultrasound imaging, allowing elective repair. Population-based screening for AAA in older men reduces AAA-related mortality by about 40 per cent. The UK began an AAA screening programme offering one-off scans to men aged 65 years in 2009. Sweden has a similar programme. Currently, there is no AAA screening programme in New Zealand. This cost-utility analysis aimed to assess the cost-effectiveness of a UK-style screening programme in the New Zealand setting.

METHODS

The analysis compared a formal AAA screening programme (one-off abdominal ultrasound imaging for about 20 000 men aged 65 years in 2011) with no systematic screening. A Markov macrosimulation model was adapted to estimate the health gains (in quality-adjusted life-years, QALYs), health system costs and cost-effectiveness in New Zealand. A health system perspective and lifetime horizon was adopted.

RESULTS

With New Zealand-specific inputs, the adapted model produced an estimate of about NZ $15 300 (€7746) per QALY gained, with a 95 per cent uncertainty interval (UI) of NZ $8700 to 31 000 (€4405 to 15 694) per QALY gained. Health gains were estimated at 117 (95 per cent UI 53 to 212) QALYs. Health system costs were NZ $1·68 million (€850 535), with a 95 per cent UI of NZ $820 200 to 3·24 million (€415 243 to €1·65 million).

CONCLUSION

Using New Zealand's gross domestic product per capita (about NZ $45 000 or €22 100) as a cost-effectiveness threshold, a UK-style AAA screening programme would be cost-effective in New Zealand.

Analysis of clinical benefit, harms, and cost-effectiveness of screening women for abdominal aortic aneurysm

BACKGROUND

A third of deaths in the UK from ruptured abdominal aortic aneurysm (AAA) are in women. In men, national screening programmes reduce deaths from AAA and are cost-effective. The benefits, harms, and cost-effectiveness in offering a similar programme to women have not been formally assessed, and this was the aim of this study.

METHODS

We developed a decision model to assess predefined outcomes of death caused by AAA, life years, quality-adjusted life years, costs, and the incremental cost-effectiveness ratio for a population of women invited to AAA screening versus a population who were not invited to screening. A discrete event simulation model was set up for AAA screening, surveillance, and intervention. Relevant women-specific parameters were obtained from sources including systematic literature reviews, national registry or administrative databases, major AAA surgery trials, and UK National Health Service reference costs.

FINDINGS

AAA screening for women, as currently offered to UK men (at age 65 years, with an AAA diagnosis at an aortic diameter of ≥3·0 cm, and elective repair considered at ≥5·5cm) gave, over 30 years, an estimated incremental cost-effectiveness ratio of £30 000 (95% CI 12 000-87 000) per quality-adjusted life year gained, with 3900 invitations to screening required to prevent one AAA-related death and an overdiagnosis rate of 33%. A modified option for women (screening at age 70 years, diagnosis at 2·5 cm and repair at 5·0 cm) was estimated to have an incremental cost-effectiveness ratio of £23 000 (9500-71 000) per quality-adjusted life year and 1800 invitations to screening required to prevent one AAA-death, but an overdiagnosis rate of 55%. There was considerable uncertainty in the cost-effectiveness ratio, largely driven by uncertainty about AAA prevalence, the distribution of aortic sizes for women at different ages, and the effect of screening on quality of life.

INTERPRETATION

By UK standards, an AAA screening programme for women, designed to be similar to that used to screen men, is unlikely to be cost-effective. Further research on the aortic diameter distribution in women and potential quality of life decrements associated with screening are needed to assess the full benefits and harms of modified options.

FUNDING

UK National Institute for Health Research Health Technology Assessment programme.

[Identifying barriers to screening for abdominal aortic aneurysm in general practice: Qualitative study of 14 general practitioners in Paris]

INTRODUCTION

Abdominal aortic aneurysm (AAA) is a silent pathology with often fatal consequences in case of rupture. AAA screening, recommended in France and many other countries, has shown its effectiveness in reducing specific mortality. However, AAA screening rate remains insufficient.

OBJECTIVE

To identify barriers to AAA screening in general practice.

MATERIAL AND METHOD

Qualitative study carried out during 2016 among general practitioners based in Paris.

RESULTS

Fourteen physicians were included. Most of the barriers were related to the physician: unawareness about AAA and screening recommendations, considering AAA as a secondary question not discussed with the patient, abdominal aorta not included in cardiovascular assessment, no search for a familial history of AAA, AAA considered a question for the specialist, lack of time, lack of training, numerous screenings to propose, oversight. Some barriers are related to the patient: unawareness of the pathology and family history of AAA, refusal, questioning the pertinence of the doctor's comments, failure to respect the care pathway. Others are related to AAA: source of anxiety, low prevalence, rarity of complications. The remaining barriers are related to screening: cost-benefit and risk-benefit ratios, sonographer unavailability, constraint for the patient, overmedicalization.

CONCLUSION

Information and training of general practitioners about AAA must be strengthened in order to optimize AAA screening and reduce specific mortality.

What are the Prevalence of Abdominal Aortic Aneurysm in Patients with Chronic Obstructive Pulmonary Diseases and the Characteristics of These Patients?

OBJECTIVE

To determine the prevalence of abdominal aortic aneurysm (AAA) in patients with chronic obstructive pulmonary disease (COPD) and to assess the characteristics of these patients.

MATERIALS AND METHODS

Stable COPD patients (age, >40 years) were included in the study between January 2014 and June 2014. Patients with acute exacerbations and a previous lung resection were excluded. Data regarding demographic characteristics were recorded. The modified Medical Research Council (mMRC) dyspnea scale was used to assess the severity of breathlessness. The COPD Assessment Test (CAT) was performed. Abdominal aortic diameter was measured using abdominal ultrasonography (AUS), and AAA was diagnosed as an aortic diameter of ≥30 mm at the renal artery level.

RESULTS

In total, 82 patients were examined. AAA was detected in five (6.1%) patients. Diabetes mellitus, hypertension, and coronary artery disease were present in four patients with AAA. The average mMRC score was 3.2±0.4, and the mean CAT score was 18.4±6.0. Aneurysmal diameter was >50 mm in four patients and 37 mm in one patient. Statistically significant differences were found between patient with AAA and those without AAA with respect to the mean abdominal aortic diameters at the renal artery and iliac artery levels (p=0.012 and 0.002, respectively).

CONCLUSION

Our findings suggest that AAA is associated with COPD, with a prevalence rate of 6.1%. AAA is usually asymptomatic until a clinical status of rupture, which is associated with a higher mortality risk. Early diagnosis of AAA is lifesaving. In COPD patients, AAA might be easily determined using AUS, which is a noninvasive and relatively cheap procedure.

Cost-effectiveness of Screening for Abdominal Aortic Aneurysm in Combination with Medical Intervention in Patients with Small Aneurysms

OBJECTIVES

Screening for abdominal aortic aneurysm (AAA) among 65 year old men has been proven cost-effective, but nowadays is conducted partly under new conditions. The prevalence of AAA has decreased, and endovascular aneurysm repair (EVAR) has become the predominant surgical method for AAA repair in many centers. At the Malmö Vascular Center pharmacological secondary prevention with statins, antiplatelet therapy, and blood pressure reduction is initiated and given to all patients with AAA. This study evaluates the cost-effectiveness of AAA screening under the above mentioned conditions.

METHODS

This was a Markov cohort simulation. A total of 4,300 65 year old men were invited to annual AAA screening; the attendance rate was 78.3% and AAA prevalence was 1.8%. A Markov model with 11 health states was used to evaluate cost-effectiveness of AAA screening. Background data on rupture risks, costs, and effectiveness of surgical interventions were obtained from the participating unit, the national Swedvasc Registry, and from the scientific literature.

RESULTS

The additional costs of the screening strategy compared with no screening were €169 per person and year. The incremental health gain per subject in the screened cohort was 0.011 additional quality adjusted life years (QALYs), corresponding to an incremental cost-effectiveness ratio (ICER) of €15710 per QALY. Assuming a 10% reduction of all cause mortality, the incremental cost of screening was €175 per person and year. The gain per subject in the screened cohort was 0.013 additional QALYs, corresponding to an ICER of €13922 per QALY CONCLUSIONS: AAA screening remains cost-effective according to both the Swedish recommendations and the UK National Institute for Health and Care Excellence recommendations in the new era of lower AAA prevalence, EVAR as the predominant surgical method, and secondary prevention for all AAA patients.

[Economic evaluation studies in diagnostic imaging: justification and critical reading]

First, this article describes the concepts and tools most widely used for economic evaluation in healthcare. Second, it discusses some elements that must be taken into account in the social decision about how much we are willing to spend to prolong a person's life by one year. Third, it describes the criteria recommended for the critical analysis of publications that evaluate the economic aspects of health interventions. Finally, several studies about ultrasound screening for aneurysms of the abdominal aorta are used as illustrative examples to show how these elements and criteria can be applied.

[Ultrasound screening of abdominal aortic aneurysm: Lessons from Vesale 2013]

Although aneurysm of the abdominal infra-renal aorta (AAA) meets criteria warranting B mode ultrasound screening, the advantages of mass screening versus selective targeted opportunistic screening remain a subject of debate. In France, the French Society of Vascular Medicine (SFMV) and the Health Authority (HAS) published recommendations for targeted opportunistic screening in 2006 and 2013 respectively. The SFMV held a mainstream communication day on November 21, 2013 in France involving participants from metropolitan France and overseas departments that led to a proposal for free AAA ultrasound screening: the Vesalius operation. Being a consumer operation, the selection criteria were limited to age (men and women between 60 and 75 years); the age limit was lowered to 50 years in case of direct family history of AAA. More than 7000 people (as many women as men) were screened in 83 centers with a 1.70% prevalence of AAA in the age-based target population (3.12% for men, 0.27% for women). The median diameter of detected AAA was 33 mm (range 20 to 74 mm). The prevalence of AAA was 1.7% in this population. Vesalius data are consistent with those of the literature both in terms of prevalence and for cardiovascular risk factors with the important role of smoking. Lessons from Vesalius to take into consideration are: screening is warranted in men 60 years and over, especially smokers, and in female smokers. Screening beyond 75 years should be discussed. Given the importance of screening, the SFMV set up a year of national screening for AAA (Vesalius operation 2014/2015) in order to increase public and physician awareness about AAA detection, therapeutic management, and monitoring. AAA is a serious, common, disease that kills 6000 people each year. The goal of screening is cost-effective reduction in the death toll.

Incremental Cost of Emergency Versus Elective Surgery

OBJECTIVE

To determine hospital costs and the adjusted risk of death associated with emergent versus elective surgery.

BACKGROUND

Emergency surgery has a higher cost and worse outcomes compared with elective surgery. However, no national estimates of the excess burden of emergency surgery exist.

METHODS

Nationwide Inpatient Sample (NIS) data from 2001 to 2010 were analyzed. Patients aged 18 years or older who underwent abdominal aortic aneurysm repair, coronary artery bypass graft, or colon resection for neoplasm were included. Using generalized linear models with propensity scores, cost differences for emergent versus elective admission were calculated for each procedure. Multivariable logistic regression was performed to investigate the adjusted odds of mortality comparing elective and emergent cases. Discharge-level weights were applied to analyses.

RESULTS

A total of 621,925 patients, representing a weighted population of 3,057,443, were included. The adjusted mean cost difference for emergent versus elective care was $8741.22 (30% increase) for abdominal aortic aneurysm repair, $5309.78 (17% increase) for coronary artery bypass graft, and $7813.53 (53% increase) for colon resection. If 10% of the weighted estimates of emergency procedures had been performed electively, the cost benefit would have been nearly $1 billion, at $996,169,160 (95% confidence interval [CI], $985,505,565-$1,006,834,104). Elective surgery patients had significantly lower adjusted odds of mortality for all procedures.

CONCLUSIONS

Even a modest reduction in the proportion of emergent procedures for 3 conditions is estimated to save nearly $1 billion over 10 years. Preventing emergency surgery through improved care coordination and screening offers a tremendous opportunity to save lives and decrease costs.

Investigating the Generalizability of Economic Evaluations Conducted in Italy: A Critical Review

OBJECTIVES

To assess the methodological quality of Italian health economic evaluations and their generalizability or transferability to different settings.

METHODS

A literature search was performed on the PubMed search engine to identify trial-based, nonexperimental prospective studies or model-based full economic evaluations carried out in Italy from 1995 to 2013. The studies were randomly assigned to four reviewers who applied a detailed checklist to assess the generalizability and quality of reporting. The review process followed a three-step blinded procedure. The reviewers who carried out the data extraction were blind as to the name of the author(s) of each study. Second, after the first review, articles were reassigned through a second blind randomization to a second reviewer. Finally, any disagreement between the first two reviewers was solved by a senior researcher.

RESULTS

One hundred fifty-one economic evaluations eventually met the inclusion criteria. Over time, we observed an increasing transparency in methods and a greater generalizability of results, along with a wider and more representative sample in trials and a larger adoption of transition-Markov models. However, often context-specific economic evaluations are carried out and not enough effort is made to ensure the transferability of their results to other contexts. In recent studies, cost-effectiveness analyses and the use of incremental cost-effectiveness ratio were preferred.

CONCLUSIONS

Despite a quite positive temporal trend, generalizability of results still appears as an unsolved question, even if some indication of improvement within Italian studies has been observed.

Baseline prevalence of abdominal aortic aneurysm, peripheral arterial disease and hypertension in men aged 65–74 years from a population screening study (VIVA trial)

Background

Abdominal aortic aneurysm (AAA) screening has been introduced into some health systems and could easily be supplemented with broader vascular screening. The aim of this study was to evaluate the screening set-up and investigate combined screening for AAA, peripheral arterial disease (PAD) and possible hypertension (HT), and detection rates.

Methods

This observational study was based on the intervention arm of a screening trial in 25 083 Danish men aged 65–74 years. A combined screening programme for AAA, PAD and HT was offered at local hospitals. Participants with positive test results were offered secondary prophylaxis and/or referred to their general practitioner. The programme set-up included decentralized screening by three mobile teams at 14 venues. Diagnostic criteria were: aortic diameter at least 30 mm for AAA, ankle : brachial pressure index below 0·9 or above 1·4 for PAD, and BP exceeding 160/100 mmHg for HT.

Results

Overall, 18 749 men (uptake 74·7 per cent) attended the screening. An AAA was diagnosed in 3·3 (95 per cent c.i. 3·0 to 3·6) per cent, PAD in 10·9 (10·5 to 11·4) per cent and HT in 10·5 (10·0 to 10·9) per cent. Lipid-lowering and/or antiplatelet treatment was initiated in 34·8 per cent of the participants.

Conclusion

Preventive actions were started in one-third of the attenders. The long-term effect of this on morbidity and mortality is an important part of future analysis. The trial confirms that the prevalence of AAA in Denmark has decreased only slightly in the past decade, from 4·0 to 3·3 per cent, in contrast to other nations.

Abdominal aortic aneurysm screening: how many life years lost from underuse of the medicare screening benefit?

BACKGROUND

Since 2007, Medicare has provided one-time abdominal aortic aneurysm (AAA) screening for men with smoking history, and men and women with a family history of AAA as part of its Welcome to Medicare visit.

OBJECTIVE

We examined utilization of the new AAA screening benefit and estimated how increased utilization could influence population health as measured by life years gained. Additionally, we explored the impact of expanding screening to women with smoking history.

DESIGN

Analysis of Medicare claims and a simulation model to estimate the effects of screening, using published data for parameter estimates.

SETTING

AAA screening in the primary care setting.

PATIENTS

Newly-enrolled Medicare beneficiaries aged 65 years, with smoking history or family history of AAA.

MAIN MEASURES

Life expectancy, 10-year survival rates.

KEY RESULTS

Medicare data revealed low utilization of AAA screening, under 1% among those eligible. We estimate that screening could increase life expectancy per individual invited to screening for men with smoking history (0.11 years), with family history of AAA (0.17 years), and women with family history (0.08 years), and smoking history (0.09 years). Average gains of 131 life years per 1,000 persons screened for AAA compare favorably with the grade B United States Preventive Services Task Force (USPSTF) recommendation for breast cancer screening, which yields 95-128 life years per 1,000 women screened. These findings were robust over a range of scenarios.

LIMITATIONS

The simulation results reflect assumptions regarding AAA prevalence, treatment, and outcomes in specific populations based on published research and US survey data. Published data on women were limited.

CONCLUSIONS

The Welcome to Medicare and AAA screening benefits have been underutilized. Increasing utilization of AAA screening would yield substantial gains in life expectancy. Expanding screening to women with smoking history also has the potential for substantial health benefits.

Cost-effectiveness of the National Health Service Abdominal Aortic Aneurysm Screening Programme in England

BACKGROUND

Implementation of the National Health Service abdominal aortic aneurysm (AAA) screening programme (NAAASP) for men aged 65 years began in England in 2009. An important element of the evidence base supporting its introduction was the economic modelling of the long-term cost-effectiveness of screening, which was based mainly on 4-year follow-up data from the Multicentre Aneurysm Screening Study (MASS) randomized trial. Concern has been expressed about whether this conclusion of cost-effectiveness still holds, given the early performance parameters, particularly the lower prevalence of AAA observed in NAAASP.

METHODS

The existing published model was adjusted and updated to reflect the current best evidence. It was recalibrated to mirror the 10-year follow-up data from MASS; the main cost parameters were re-estimated to reflect current practice; and more robust estimates of AAA growth and rupture rates from recent meta-analyses were incorporated, as were key parameters as observed in NAAASP (attendance rates, AAA prevalence and size distributions).

RESULTS

The revised and updated model produced estimates of the long-term incremental cost-effectiveness of £5758 (95 per cent confidence interval £4285 to £7410) per life-year gained, or £7370 (£5467 to £9443) per quality-adjusted life-year (QALY) gained.

CONCLUSION

Although the updated parameters, particularly the increased costs and lower AAA prevalence, have increased the cost per QALY, the latest modelling provides evidence that AAA screening as now being implemented in England is still highly cost-effective.

Novel biomarkers of abdominal aortic aneurysm disease: identifying gaps and dispelling misperceptions

Abdominal aortic aneurysm (AAA) is a prevalent and potentially life-threatening disease. Early detection by screening programs and subsequent surveillance has been shown to be effective at reducing the risk of mortality due to aneurysm rupture. The aim of this review is to summarize the developments in the literature concerning the latest biomarkers (from 2008 to date) and their potential screening and therapeutic values. Our search included human studies in English and found numerous novel biomarkers under research, which were categorized in 6 groups. Most of these studies are either experimental or hampered by their low numbers of patients. We concluded that currently no specific laboratory markers allow screeing for the disease and monitoring its progression or the results of treatment. Further studies and studies in larger patient groups are required in order to validate biomarkers as cost-effective tools in the AAA disease.

Hospitalization rates and post-operative mortality for abdominal aortic aneurysm in Italy over the period 2000-2011

Background

Recent studies have reported declines in incidence, prevalence and mortality for abdominal aortic aneurysms (AAAs) in various countries, but evidence from Mediterranean countries is lacking. The aim of this study is to examine the trend of hospitalization and post-operative mortality rates for AAAs in Italy during the period 2000–2011, taking into account the introduction of endovascular aneurysm repair (EVAR) in 1990s.

Methods

This retrospective cohort study was carried out in Emilia-Romagna, an Italian region with 4.5 million inhabitants. A total of 19,673 patients hospitalized for AAAs between 2000 and 2011, were identified from the hospital discharge records (HDR) database. Hospitalization rates, percentage of OSR and EVAR and 30-day mortality rates were calculated for unruptured (uAAAs) and ruptured AAAs (rAAAs).

Results

Adjusted hospitalization rates decreased on average by 2.9% per year for uAAAs and 3.2% for rAAAs (p<0.001). The temporal trend of 30-day mortality rates remained stable for both groups. The percentage of EVAR for uAAAs increased significantly from 2006 to 2011 (42.7 versus 60.9% respectively, mean change of 3.9% per year, p<0.001). No significant difference in mortality was found between OSR and EVAR for uAAAs and rAAAs.

Conclusions

The incidence and trend of hospitalization rates for rAAAs and uAAAs decreased significantly in the last decade, while 30-day mortality rates in operated patients remained stable. OSR continued to be the most common surgery in rAAAs, although the gap between OSR and EVAR recently declined. The EVAR technique became the preferred surgery for uAAAs since 2008.

The Cost Effectiveness of Hand Held Ultrasound Scanning for Abdominal Aortic Aneurysm in Older Males with a History of Smoking

Objective: Abdominal aortic aneurysm (AAA) is a serious illness occurring in 1 of 20 older men. Guidelines emphasize the role of ultrasound scanning for patients at risk of AAA, yet the cost effectiveness of such scanning remains uncertain. New pocket mobile echocardiography (PME) devices may enhance the cost effectiveness of such scanning due to its low cost, ability to be used in primary care settings, and high degree of accuracy. This study performs cost utility analyses (CUAs) comparing opportunistic scanning for AAA using a PME to usual care for a hypothetical cohort of 10,000 male smokers age 65+. Methods: The study compares the incremental cost per quality-adjusted life year (QALY) gained for three alternative strategies over a 5-year time horizon. The study used a decision analytic simulation model to calculate the incremental cost utility for the different strategies. Three alternative criteria for surgical intervention were considered via scanning according to aneurysm size. These treatment strategies were compared to a control group that received no scanning. Model input values are taken from the literature. Sensitivity analysis was performed to gauge the robustness of the results. Results: Opportunistic scanning is cost effective. Indeed, when surgical intervention is limited to medium (5.0-5.4 cm) or large (≥5.5 cm) aneurysms, such scanning is dominant; that is, it costs less and increases QALYs compared to usual care. When surgical intervention is extended to small (4.0-4.9 cm) aneurysms, scanning remains cost effective ($64,156 per QALY vs. $100,000 threshold). The results are robust to alternative plausible model input values. Conclusion: These findings suggest that primary care physicians with proper training should consider PMEs as a cost effective method to opportunistically scan and manage AAA patients among older males who have a history of smoking.

Italian population-based values of EQ-5D health states

OBJECTIVE

To estimate a value set for the calculation of Italian-specific quality-adjusted life years (QALYs), based on preferences elicited on EuroQol five-dimensional (EQ-5D) questionnaire health states using the time trade-off technique.

METHODS

The revised standard Measurement and Valuation of Health protocol was followed. Twenty-five health states, divided into three groups and given to 450 subjects, were selected to obtain 300 observations per state. Subjects aged 18 to 75 years were recruited to be representative of the Italian general adult population for age, sex, and geographical distribution. To improve efficiency, face-to-face interviews were conducted by using the Computer Assisted Personal Interviewing approach. Several random effects regression models were tested to predict the full set of EQ-5D questionnaire health states. Model selection was based on logical consistency of the estimates, sign and magnitude of the regression coefficients, goodness of fit, and parsimony.

RESULTS

The model that satisfied the criteria of logical consistency and was more efficient includes 10 main effect dummy variables for the EQ-5D questionnaire domain levels and the D1 interaction term, which accounts for the number of dimensions at levels 2 or 3 beyond the first. This model has an R(2) of 0.389 and a mean absolute error of 0.03, which are comparable to or better than those of models used in other countries. The utility estimates after state 11111 range from 0.92 (21111) to -0.38 (33333). Italian utility estimates are higher than those estimated in the United Kingdom and Spain and used so far to assess QALYs and conduct cost-utility evaluations in Italy.

CONCLUSIONS

A specific value set is now available to calculate QALYs for the conduction of health economic studies targeted at the Italian health care system.