Relevance of the Viborg Population Based Screening Programme (VISP) for Cardiovascular Conditions Among 67 Year Olds: Attendance Rate, Prevalence, and Proportion of Initiated Cardiovascular Medicines Stratified By Sex

OBJECTIVE

To report sex specific overall attendance rate, prevalence of screen detected cardiovascular conditions, proportion of unknown conditions before screening, and proportion initiating prophylactic medicine among 67 year olds in Denmark.

DESIGN

Cross sectional cohort study.

METHODS

Since 2014, all 67 year olds in Viborg, Denmark, have been invited to screening for abdominal aortic aneurysm (AAA), peripheral arterial disease (PAD), carotid plaque (CP), hypertension, cardiac disease, and type 2 diabetes. Individuals with AAA, PAD, and or CP are recommended cardiovascular prophylaxis. Combining data with registries has facilitated estimation of unknown screen detected conditions. Up to August 2019, 5 505 had been invited; registry data were available for the first 4 826 who were invited.

RESULTS

The attendance rate was 83.7%, without sex difference. Screen detected prevalence was significantly lower among women than men: AAA, 5 (0.3%) vs. 38 (1.9%) (p < .001); PAD, 90 (4.5%) vs. 134 (6.6%) (p = .011); CP, 641 (31.8%) vs. 907 (44.8%) (p < .001); arrhythmia, 26 (1.4%) vs. 77 (4.2%) (p < .001); blood pressure ≥ 160/100 mmHg, 277 (13.8%) vs. 346 (17.1%) (p = .004); and HbA1c ≥ 48 mmol/mol, 155 (7.7%) vs. 198 (9.8%) (p = .019), respectively. Pre-screening proportions of unknown conditions were particularly high for AAA (95.4%) and PAD (87.5%). AAA, PAD, and or CP were found in 1 623 (40.2%), of whom 470 (29.0%) received pre-screening antiplatelets and 743 (45.8%) lipid lowering therapy. Furthermore, 413 (25.5%) started antiplatelet therapy and 347 (21.4%) started lipid lowering therapy. Only smoking was significantly associated with all vascular conditions in multivariable analysis: odds ratios (ORs) for current smoking were AAA 8.11 (95% CI 2.27 - 28.97), PAD 5.60 (95% CI 3.61 - 8.67) and CP 3.64 (95% CI 2.95 - 4.47).

CONCLUSION

The attendance rate signals public acceptability for attending cardiovascular screening. Men had more screen detected conditions than women, but prophylactic medicine was started equally frequently in both sexes. Sex specific cost effectiveness follow up is warranted.

The impact of population screening for cardiovascular disease on quality of life

Aims

To examine the impact of population screening-generated events on quality of life: invitation, positive test result, initiation of preventive medication, enrolment in follow-up at the surgical department, and preventive surgical repair.

Methods and results

A difference-in-difference design based on data collected alongside two randomized controlled trials where general population men were randomized to screening for cardiovascular disease or to no screening. Repeated measurements of health-related quality of life (HRQoL) were conducted up to 3 years after inclusion using all relevant scales of the EuroQol instrument: the anxiety/depression dimension, the EuroQol 5-dimension profile index (using Danish preference weights), and the visual analogue scale for global health. We compare the mean change scores from before to after events for groups experiencing vs. not experiencing the events. Propensity score matching is additionally used to provide both unmatched and matched results. Invitees reported to be marginally better off than non-invitees on all scales of the EuroQol. For events of receiving the test result, initiating preventive medication, being enrolled in surveillance, and undergoing surgical repair, we observed no impact on overall HRQoL but a minor impact of being enrolled in surveillance on emotional distress, which did not persist after matching.

Conclusion

The often-claimed detrimental consequences of screening to HRQoL could not be generally confirmed. Amongst the screening events assessed, only two possible consequences were revealed: a reassurance effect after a negative screening test and a minor negative impact to emotional distress of being enrolled in surveillance that did not spill over to overall HRQoL.

Geographical Variation in the Management of Peripheral Arterial Occlusive Disease: A Nationwide Danish Cohort Study

OBJECTIVE

Equal access for equal needs is a key goal for many healthcare systems but geographical variation research has shown that this is often not the case in areas other than vascular surgery. This study assessed the variation across specialised vascular centres of an entire healthcare system in the costs and outcomes for patients having first time revascularisation for peripheral arterial occlusive disease.

METHODS

This was a national study of all first time revascularisations performed in the Danish healthcare system between 2009 and 2014. Episodes were identified in the Danish Vascular Registry (n = 10 300) and data on one year follow up in terms of the costs of specialised healthcare (€) and amputation status were acquired from national registers. Generalised gamma and logit regressions were used to predict margins between centres while adjusting for population heterogeneity (age, sex, education, smoking, hypertension, diabetes, use of prophylactic pharmacological therapy, indication and type of revascularisation). Cost effectiveness frontiers were used to identify efficient providers and to illustrate the cost of reducing the system level risk of amputation.

RESULTS

For each of the indications of chronic limb threatening and acute limb ischaemia, the one year amputation risks varied from 11% to 16% across centres (p = .003, p = .006) whereas for intermittent claudication there was no significant difference across centres. The corresponding costs of care varied across centres for all indications (p = .027, p = .028, p = .030). Linking costs and outcomes, three of seven centres were observed to provide poorer quality at higher costs. Exponentially increasing costs to obtain the maximum reduction of the amputation risk were observed.

CONCLUSION

The results suggest that there is substantial variation in the clinical management of peripheral arterial occlusive disease across the Danish healthcare system and that this results in very different levels of efficiency - on top of potentially unequal treatment for equal needs. Further research is warranted.

Facilitating participation in cardiovascular preventive initiatives among people with diabetes: a qualitative study

Background

Type 2 diabetes (T2D) is associated with a significantly increased risk of cardiovascular disease (CVD). The DIAbetic CArdioVAscular Screening and intervention trial (DIACAVAS) was designed to clarify whether advanced imaging for subclinical atherosclerosis combined with medical treatment is an effective strategy to develop individualised treatment algorithms for Danish men and women with T2D aged 40–60. But in the DIACAVAS pilot study, the uptake was only 41%. Consequently, we explored how people experienced living with T2D to understand how to improve the uptake in initiatives targeting the prevention of CVD.

Methods

We used semi-structured interviews to obtain information on how the respondents experienced having T2D. For supplementary information, we used structured interviews on e.g. socioeconomic factors. From April to October 2019, 17 participants aged 40–60 years were recruited from general practices and diabetes outpatient clinics in Denmark. Several levels of analysis were involved consistent with inductive content analysis.

Results

The participants’ experiences of living with T2D fell along two continuums, from an emotional to a cognitive expression and from reactive to proactive disease management. This led to identification of four archetypal characteristics: (I) powerlessness, (II) empowerment, (III) health literacy, and (IV) self-efficacy. These characteristics indicated the importance of using different approaches to facilitate participation in cardiovascular preventive initiatives. Additionally, findings inspired us to develop a model for facilitating participation in future preventive initiatives.

Conclusion

Encouraging people with T2D to participate in cardiovascular preventive initiatives may necessitate a tailored invitation strategy. We propose a model for an invitational process that takes into consideration invitees’ characteristics, including powerlessness, empowerment, health literacy and self-efficacy. This model may enhance participation in such initiatives. However, participation is a general concern, not only in relation to cardiovascular prevention. Our proposed model may be applicable in preventive services for people with T2D in general.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10172-6.

A population-based screening study for cardiovascular diseases and diabetes in Danish postmenopausal women: acceptability and prevalence

BACKGROUND

Reducing women's cardiovascular risk and the economic costs associated with cardiovascular diseases (CVD) and diabetes (DM) continues to be a challenge. Whether a multifaceted CVD screening programme is beneficial as a preventive strategy in women remains uncertain. The aim of this study was to investigate the prevalence of CVD and DM as well as the acceptability toward screening and preventive actions.

METHODS

An observational study was performed among all women born in 1936, 1941, 1946 and 1951 living in Viborg Municipality, Denmark, from October 2011. In total, 1984 were invited to screening for abdominal aortic aneurysm (AAA), peripheral arterial disease (PAD), carotid plaque (CP), hypertension (HT), atrial fibrillation (AF), DM and dyslipidaemia. Participants with positive tests were offered prophylactic intervention including follow-up consultations in case of AAA, PAD and/or CP. Participants with AAA ≥ 50 mm were referred to specialists in vascular surgery. Women with AF or potential familial hypercholesterolaemia (FH) were referred to cardiology work-up.

RESULTS

Among those invited, 1474 (74.3%) attended screening, but the attendees' share decreased with increasing age groups (p < 0.001). AAA was diagnosed in 10 (0.7%) women, PAD in 101 (6.9%) and CP in 602 (40.8%). The percentage of women with these conditions rose with increasing age group (p < 0.05). Unconfirmed potential HT was observed in 94 (6.4%), unknown AF in 6 (0.4%), DM in 14 (1%) and potential FH in 35 (2.4%). None of these findings differed across age groups. Among the 631 women diagnosed with AAA, PAD and/or CP, 182 (28.8%) were already in antiplatelet and 223 (35.3%) in lipid-lowering therapy prior to screening. Antiplatelet therapy was initiated in 215 (34.1%) and lipid-lowering therapy in 191 (30.3%) women. Initiation of antiplatelet and lipid-lowering therapy was further recommended to 134 (21.2%) and 141 (22.4%) women, respectively, who hesitated to follow the recommendation.

CONCLUSIONS

The study recorded an acceptable total attendance rate, even though a significantly lower attendance rate was observed in the eldest women. The identified hesitation towards prophylactic therapy may affect the rationale and effectiveness of CVD screening, and hesitation seems a critical issue that should be addressed in the design of future screening programmes.

An interview-based study of nonattendance at screening for cardiovascular diseases and diabetes in older women: Nonattendees' perspectives

AIMS AND OBJECTIVES

This study explored nonattendees' perspectives on a screening programme for cardiovascular disease and diabetes mellitus among women aged 60-77 years.

BACKGROUND

Nonattendance in screening is a common concern and has been associated with increased morbidity and mortality. Whether nonattendees need targeted information to participate in screening is unknown. Thus, it is important to explore the reasons for nonattendance, particularly as nonattendees' perspectives have not been fully explored.

DESIGN

An interview study.

METHODS

The data were obtained through semistructured interviews with 10 women sampled from a population who declined to participate in a women's screening programme for cardiovascular disease and diabetes mellitus. Additionally, reflective notes on the interview context were documented. The data were collected in 2013. Kvale and Brinkmann's method for data analysis was applied.

RESULTS

All informants found the screening offer personally irrelevant, but this belief was changeable. The informants' perceptions of screening were based on subjective health and risk beliefs, personal knowledge of diseases and the screening programme, and distrust in the healthcare system.

CONCLUSION

Personal experiences, beliefs and self-protective strategies influence individuals' subjective interpretations of a screening programme's relevance. The perception that screening is irrelevant seems to be rooted in nonattendees' personal health-related assessment and knowledge. Consequently, whether nonattendance is determined by an informed decision is questionable. Negative experiences with the healthcare system led to hesitation towards screening in general.

RELEVANCE TO CLINICAL PRACTICE

This study is relevant to healthcare workers as well as decision-makers from a screening and preventive perspective. The findings highlight important issues that should be addressed to encourage invitees to accept screening invitations and to facilitate informed decision-making about screening participation.

Excess mortality during the first year after arterial trauma

INTRODUCTION

Extant studies on arterial trauma originate from outside Denmark and their findings may therefore not apply to a Danish setting. The aim of the present study was to investigate the long-term mortality and clinical characteristics of patients with arterial trauma treated in Odense University Hospital (OUH).

METHODS

This study was based on a historical cohort comprising all arterial traumas treated at OUH between 1990 and 2012. The Personal Identification Numbers were drawn and cross-referenced between The Danish Vascular Registry and the Accident Analysis Group. Mortality was compared with the expected mortality from the entire Danish population, matched to age, sex and date of trauma.

RESULTS

A total of 231 patients were analysed. The median follow-up period was 6.9 years (range: 0-22.47). Traffic was the most common cause of arterial trauma, violence the least common. Patients were mainly men (69%) with a median age of 32 years. Women had a median age of 46 years. The mortality rate ratios were as follows: overall in the first year 15.34 (95% confidence interval (CI): 10.34-21.93). Overall mortality rate ratios for year 1-5 was 1.66 (95% CI: 0.82-2.98); but when stratified, the effect was only significant in the reconstructed subgroup (2.22 (95% CI: 1.01-4.24).

CONCLUSION

Excess mortality was observed in patients with arterial traumas in the first year. However, patients receiving reconstructive arterial surgery after traumas had an excess mortality, even after adjustment for the effect of the first year. Whether the observed mortality is due to surgery itself, patients' risk behaviour or other factors remains unclear. Further national investigation is needed.

FUNDING

not relevant.

TRIAL REGISTRATION

not relevant. The study was approved by the Danish Data Protection Agency on 14 June 2013.

Individual decision making in relation to participation in cardiovascular screening: a study of revealed and stated preferences

AIMS

The (cost-)effectiveness of a screening programme may be strongly influenced by the participation rate. The objective of this study was to compare participants' and non-participants' motives for the attendance decision as well as their overall preferences for participation in cardiovascular disease screening.

METHODS

This study sampled 1053 participants and 1006 non-participants from a screening trial and randomly allocated the participants to receive different levels of additional information about the screening programme. An ad hoc survey questionnaire about doubt and arguments in relation to the participation decision was given to participants and non-participants along with a contingent valuation task.

RESULTS

Among participants, 5% had doubt about participation and the most frequent argument was that they did not want the test result. Among non-participants, 40% would reconsider their non-participation decision after having received additional information while the remainder 60% stood by their decision and provided explicit arguments for it. After having received additional information the participants still valued the programme significantly higher than non-participants, but the difference was relatively small.

CONCLUSIONS

Participants and non-participants in cardiovascular screening programmes seem to have different strengths of preferences, which signals that their behavioural choice is founded in rational thinking. Furthermore, it appears that additional information and a second reflection about the participation decision may affect a substantial proportion of non-participants to reverse their decision, a finding that should receive policy interest.

Insensitivity to scope in contingent valuation studies: reason for dismissal of valuations?

BACKGROUND

The credibility of contingent valuation studies has been questioned because of the potential occurrence of scope insensitivity, i.e. that respondents do not react to higher quantities or qualities of a good.

OBJECTIVE

The aim of this study was to examine the extent of scope insensitivity and to assess the relevance of potential explanations that may help to shed light on how to appropriately handle this problem in contingent valuation studies.

METHODS

We surveyed a sample of 2004 men invited for cardiovascular disease screening. Each respondent had three contingent valuation tasks from which their sensitivity to larger risk reductions (test 1) and to change in travel costs associated with participation (test 2) could be assessed. Participants were surveyed while waiting for their screening session. Non-participants were surveyed by postal questionnaire.

RESULTS

The sample was overall found to be sensitive to scope, testing at the conventional sample-mean level. At the individual respondent level, however, more than half of the respondents failed the tests. Potential determinants for failing the tests were examined in alternative regression models but few consistent relationships were identified. One exception was the influence of more detailed information, which was positively associated with willingness to pay and negatively associated with scope sensitivity.

CONCLUSION

Possible explanations for scope insensitivity are discussed; if cognitive limitations, emotional load and mental budgeting explain scope insensitivity there are grounds for rejecting valuations, whereas other factors such as the alternative theoretical framework of regret theory may render insensitivity to scope a result of rational thinking. It is concluded that future contingent valuation studies should focus more on extracting the underlying motives for the stated preferences in order to appropriately deal with responses that are seemingly irrational, and which may lead to imprecise welfare estimates.

Evidence for the Credibility of Health Economic Models for Health Policy Decisionmaking: A Systematic Literature Review of Screening for Abdominal Aortic Aneurysms

Objective

To investigate whether the credibility of health economic models of screening for abdominal aortic aneurysms for health policy decisionmaking has improved since 2005 when a systematic review by Campbell et al. concluded that reporting standards were poor and there was divergence between the findings of studies that was hard to explain.

Methods

A systematic literature review was carried out following PRISMA reporting principles. Health economic models of the cost-effectiveness of screening for abdominal aortic aneurysms published between 2005-2010 were included. Key characteristics were extracted and the models were assessed for quality against guidelines for best practice by a multidisciplinary team.

Results

Seven models were identified and found to provide divergent guidance. Only three reports met 10 of the 15 quality criteria.

Conclusions

Researchers in the field seem to have benefited from general advances in health economic modelling and some improvements in reporting were noted. However, the low level of agreement between studies in model structures and assumptions, and difficulty in justifying these (convergent validity), remain a threat to the credibility of health economic models. Decision-makers should not accept the results of a modelling study if the methods are not fully transparent and justified. Modellers should, whenever relevant, supplement a primary report of results with a technical report detailing and discussing the methodological choices made.

Novel aspects of the pathogenesis of aneurysms of the abdominal aorta in humans

Aneurysm of the abdominal aorta (AAA) is a particular, specifically localized form of atherothrombosis, providing a unique human model of this disease. The pathogenesis of AAA is characterized by a breakdown of the extracellular matrix due to an excessive proteolytic activity, leading to potential arterial wall rupture. The roles of matrix metalloproteinases and plasmin generation in progression of AAA have been demonstrated both in animal models and in clinical studies. In the present review, we highlight recent studies addressing the role of the haemoglobin-rich, intraluminal thrombus and the adventitial response in the development of human AAA. The intraluminal thrombus exerts its pathogenic effect through platelet activation, fibrin formation, binding of plasminogen and its activators, and trapping of erythrocytes and neutrophils, leading to oxidative and proteolytic injury of the arterial wall. These events occur mainly at the intraluminal thrombus-circulating blood interface, and pathological mediators are conveyed outwards, where they promote matrix degradation of the arterial wall. In response, neo-angiogenesis, phagocytosis by mononuclear cells, and a shift from innate to adaptive immunity in the adventitia are observed. Abdominal aortic aneurysm thus represents an accessible spatiotemporal model of human atherothrombotic progression towards clinical events, the study of which should allow further understanding of its pathogenesis and the translation of pathogenic biological activities into diagnostic and therapeutic applications.

Risk of hospitalization for cardiovascular disease after use of macrolides and penicillins: a comparative prospective cohort study

Chlamydia pneumoniae has been associated with cardiovascular diseases, and C. pneumoniae infection is treatable with macrolides. In this comparative cohort study, 634 users of macrolides and 3827 users of penicillins were identified from the Danish Health Service Registry of Prescriptions and followed up for an average of 6 months. The patients were then linked to the Regional Hospital Discharge Registry to assess the outcome of hospitalization for cardiovascular disease. In the first 3 months, the relative risk (RR) of admission for a cardiovascular disease was 0.48 (95% confidence interval, 0.27-0.88) in users of macrolides compared with users of penicillins. No difference was seen after 3 months. Interaction analyses indicated that the lower risk seen in users of macrolides could be more pronounced in patients without versus those with a previous cardiovascular disease (RR, 0.39 vs. 0.52), in patients >or=60 versus <60 years old (RR, 0.39 vs. 0.64), and in men versus women (RR, 0.35 vs. 0.67).

A comparative study of iliac and abdominal aortic aneurysms

BACKGROUND

The aim of the paper is to compare the epidemiology, risk factors and manifestations of iliac and abdominal aortic aneurysms.

METHODS

Two studies were used: 1. 5,470 65-73-year-old men invited for screening for abdominal aortic aneurysms. 2. Review of all 350 patients operated on for central aneurysms in the county of Viborg, Denmark from 1989-1997.

RESULTS

4,176 attended for screening. One hundred and seventy (4.0%) had an abdominal aortic aneurysm. Twenty-one (0.56%) needed operation. The proportion of patients with common iliac aneurysms requiring surgery was 0.17%. The operative incidence of iliac aneurysm was 18.4 per million per year, and 92.4 per million per year were operated on for abdominal aortic aneurysm. The mean serum cholesterol level for isolated iliac aneurysm and combined aneurysms was significantly lower compared to isolated abdominal aortic aneurysm (p<0.05). Urological symptoms were present in 42% of cases with isolated iliac aneurysm, and 25% of combined aneurysms compared to 8% of isolated abdominal aortic aneurysms. Fifty-eight percent of the isolated iliac aneurysms were ruptured, as against 27% of the abdominal aortic aneurysms. The peri- and postoperative mortality was 57% in ruptured isolated iliac aneurysms, 47% in ruptured combined aneurysms, and 31% in ruptured isolated aortic aneurysms.

CONCLUSIONS

Iliac aneurysms seem to be more underdiagnosed than abdominal aortic aneurysms, and are often diagnosed because of clinical manifestations, especially urological, or rupture. Iliac aneurysms seem more lethal than those of the abdominal aorta in cases of rupture.

[Life-threatening postoperative rectal hemorrhage after appendectomy]

A case of life-threatening haemorrhage nine days after appendicectomy is described in a 51 year old previously healthy man. Coecotomy revealed a bleeding artery near the invaginated appendiceal stump. The bleeding artery was presumably an intramural branch to the appendix from the posterior coecal artery that had not been included in the primary appendiceal ligature. This artery was presumably electrocoagulated during the appendicectomy but bleeding ensued when the coagulated tissue sloughed.

Prostatic carcinoma: complications of megavoltage radiation therapy

Megavoltage radiation therapy and radical prostatectomy are at present the only curative treatments for prostatic carcinoma. Because a high complication rate appeared to follow radiotherapy, all patients with prostatic carcinoma presenting to a Danish provincial hospital between 1975 and 1980 were reviewed. Of 31 radiation-treated patients, 23 had serious complications. No recurrence was noted in eight patients. Twenty-three had a recurrence despite radiotherapy but 11 of these patients had no local recurrence. In view of the high level of complications following radiation therapy and the high incidence of latent carcinomas in the prostate gland, a cautious approach to radiotherapy is recommended.