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Campbell A, Waggett H, Armer M, Jacomelli J, Earnshaw JJ. OUP accepted manuscript. BJS Open 2022; 6:6526444. [PMID: 35143623 PMCID: PMC8830759 DOI: 10.1093/bjsopen/zrab148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 12/05/2021] [Accepted: 12/21/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction Methods Results Conclusion
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Affiliation(s)
- Abigail Campbell
- Department of Vascular Surgery, Gloucestershire Hospitals NHS Foundation Trust, Gloucestershire, UK
| | - Helena Waggett
- Department of Vascular Surgery, Gloucestershire Hospitals NHS Foundation Trust, Gloucestershire, UK
| | - Morag Armer
- NHS Abdominal Aortic Aneurysm Screening Programme (NAAASP), Public Health England, London, UK
| | - Jo Jacomelli
- NHS Abdominal Aortic Aneurysm Screening Programme (NAAASP), Public Health England, London, UK
| | - Jonothan J. Earnshaw
- Department of Vascular Surgery, Gloucestershire Hospitals NHS Foundation Trust, Gloucestershire, UK
- Correspondence to: Jonothan J. Earnshaw, Department of Vascular Surgery, Gloucestershire Hospitals NHS FT, Cheltenham General Hospital, Sandford Road, Cheltenham, Gloucestershire GL53 7AN, UK (e-mail ; ; @JJEarnshaw)
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Kim LG, Sweeting MJ, Armer M, Jacomelli J, Nasim A, Harrison SC. Modelling the impact of changes to abdominal aortic aneurysm screening and treatment services in England during the COVID-19 pandemic. PLoS One 2021; 16:e0253327. [PMID: 34129649 PMCID: PMC8205127 DOI: 10.1371/journal.pone.0253327] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 06/02/2021] [Indexed: 12/01/2022] Open
Abstract
Background The National Health Service (NHS) abdominal aortic aneurysm (AAA) screening programme (NAAASP) in England screens 65-year-old men. The programme monitors those with an aneurysm, and early intervention for large aneurysms reduces ruptures and AAA-related mortality. AAA screening services have been disrupted following COVID-19 but it is not known how this may impact AAA-related mortality, or where efforts should be focussed as services resume. Methods We repurposed a previously validated discrete event simulation model to investigate the impact of COVID-19-related service disruption on key outcomes. This model was used to explore the impact of delayed invitation and reduced attendance in men invited to screening. Additionally, we investigated the impact of temporarily suspending scans, increasing the threshold for elective surgery to 7cm and increasing drop-out in the AAA cohort under surveillance, using data from NAAASP to inform the population. Findings Delaying invitation to primary screening up to two years had little impact on key outcomes whereas a 10% reduction in attendance could lead to a 2% lifetime increase in AAA-related deaths. In surveillance patients, a 1-year suspension of surveillance or increase in the elective threshold resulted in a 0.4% increase in excess AAA-related deaths (8% in those 5–5.4cm at the start). Longer suspensions or a doubling of drop-out from surveillance would have a pronounced impact on outcomes. Interpretation Efforts should be directed towards encouraging men to attend AAA screening service appointments post-COVID-19. Those with AAAs on surveillance should be prioritised as the screening programme resumes, as changes to these services beyond one year are likely to have a larger impact on surgical burden and AAA-related mortality.
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Affiliation(s)
- Lois G. Kim
- Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, Strangeways Research Laboratory, University of Cambridge, Cambridge, United Kingdom
- * E-mail:
| | - Michael J. Sweeting
- Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, Strangeways Research Laboratory, University of Cambridge, Cambridge, United Kingdom
- Department of Health Sciences, University of Leicester, George Davies Centre, Leicester, United Kingdom
| | - Morag Armer
- Public Health England, Wellington House, London, United Kingdom
| | - Jo Jacomelli
- Public Health England, Wellington House, London, United Kingdom
| | - Akhtar Nasim
- Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Sheffield, United Kingdom
| | - Seamus C. Harrison
- Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, Strangeways Research Laboratory, University of Cambridge, Cambridge, United Kingdom
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Meecham L, Jacomelli J, Davis M, Pherwani A, Lees T, Earnshaw J. Outcomes in Men From the NHS Abdominal Aortic Aneurysm Screening Programme With a Large Aneurysm Referred for Intervention. J Vasc Surg 2021. [DOI: 10.1016/j.jvs.2021.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Meecham L, Jacomelli J, Davis M, Pherwani A, Lees T, Earnshaw JJ. Outcomes in Men From the NHS Abdominal Aortic Aneurysm Screening Programme With a Large Aneurysm Referred for Intervention. Eur J Vasc Endovasc Surg 2020; 61:192-199. [PMID: 33594980 DOI: 10.1016/j.ejvs.2020.09.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Revised: 08/24/2020] [Accepted: 09/17/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The NHS Abdominal Aortic Aneurysm Screening Programme (NAAASP) has been implemented since 2013. Men with a large aneurysm >54 mm, either at first screen or during surveillance, are referred for intervention. The aim of the present study was to explore outcomes in these men and to see whether there was any regional variation in treatment rates and type of repair. METHODS The study cohort included all men referred to a vascular network with a large abdominal aortic aneurysm (AAA). Basic demographic information, nurse assessment details, as well as outcome data were extracted from the national NAAASP IT system, AAA SMaRT, for analysis. RESULTS Some 3 026 men were referred for possible intervention (48% first screen, 52% surveillance). Some 448 men (13.3%) either declined (63, 2.1%), or were turned down for early intervention for various reasons (385, 12.7%). Some 8% were declined for medical reasons (true turn down rate). Men referred from surveillance were older, and more likely not to have had elective surgery within three months (16.0 vs. 11.2%; HR 1.37, 95% CI 1.07-1.75, p = .011). Turn down rates did not vary among local programmes, when surveillance men were taken into account. Some 2 624 (87%) men had planned AAA repair, with a peri-operative mortality of 1.3%. Thirty day surgical mortality was lower after EVAR: 0.4% compared with 2.1% after open repair. The method of repair remained consistent year on year, with roughly equal numbers undergoing endovascular (50%) and open surgical repair (48%); 2% unknown. There was regional variation in the proportion treated by endovascular repair: from 20% to 97%. CONCLUSION The turn down rate after referral for treatment with a screen detected AAA was low, but there remains considerable regional variation in the proportion undergoing endovascular repair. Procedures were undertaken with low peri-operative mortality.
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Affiliation(s)
- Lewis Meecham
- University Department of Vascular Surgery, Heart of England NHS Foundation Trust, UK
| | - Jo Jacomelli
- NHS Abdominal Aortic Aneurysm Screening Programme (NAAASP), Public Health England, UK
| | | | | | - Tim Lees
- NHS Abdominal Aortic Aneurysm Screening Programme (NAAASP), Public Health England, UK
| | - Jonothan J Earnshaw
- NHS Abdominal Aortic Aneurysm Screening Programme (NAAASP), Public Health England, UK.
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Meecham L, Jacomelli J, Davies M, Pherwani AD, Lees T, Earnshaw J. Outcomes in Men with Large AAA Referred for Intervention in the NHS AAA Screening Programme. Eur J Vasc Endovasc Surg 2019. [DOI: 10.1016/j.ejvs.2019.06.585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Oliver-Williams C, Sweeting M, Jacomelli J, Summers L, Stevenson A, Lees T. Safety of Men with Small and Medium Abdominal Aortic Aneurysms Under Surveillance in the National Health Service Screening Programme. J Vasc Surg 2019. [DOI: 10.1016/j.jvs.2019.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Oliver-Williams C, Sweeting MJ, Jacomelli J, Summers L, Stevenson A, Lees T, Earnshaw JJ. Safety of Men With Small and Medium Abdominal Aortic Aneurysms Under Surveillance in the NAAASP. Circulation 2019; 139:1371-1380. [PMID: 30636430 PMCID: PMC6415808 DOI: 10.1161/circulationaha.118.036966] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 11/09/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Population screening for abdominal aortic aneurysm (AAA) has commenced in several countries, and has been shown to reduce AAA-related mortality by up to 50%. Most men who screen positive have an AAA <5.5 cm in diameter, the referral threshold for treatment, and are entered into an ultrasound surveillance program. This study aimed to determine the risk of ruptured AAA (rAAA) in men under surveillance. METHODS Men in the National Health Service AAA Screening Programme who initially had a small (3-4.4 cm) or medium (4.5-5.4 cm) AAA were followed up. The screening program's database collected data on ultrasound AAA diameter measurements, dates of referral, and loss to follow-up. Local screening programs recorded adverse outcomes, including rAAA and death. Rupture and mortality rates were calculated by initial and final known AAA diameter. RESULTS A total of 18 652 men were included (50 103 person-years of surveillance). Thirty-one men had rAAA during surveillance, of whom 29 died. Some 952 men died of other causes during surveillance, mainly cardiovascular complications (26.3%) and cancer (31.2%). The overall mortality rate was 1.96% per annum, similar for men with small and medium AAAs. The rAAA risk was 0.03% per annum (95% CI, 0.02%-0.05%) for men with small AAAs and 0.28% (0.17%-0.44%) for medium AAAs. The rAAA risk for men with AAAs just below the referral threshold (5.0-5.4 cm) was 0.40% (0.22%-0.73%). CONCLUSIONS The risk of rAAA under surveillance is <0.5% per annum, even just below the present referral threshold of 5.5 cm, and only 0.4% of men under surveillance are estimated to rupture before referral. It can be concluded that men with small and medium screen-detected AAAs are safe provided they are enrolled in an intensive surveillance program, and that there is no evidence that the current referral threshold of 5.5 cm should be changed.
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Affiliation(s)
- Clare Oliver-Williams
- Cardiovascular Epidemiology Unit, Department of Public Health & Primary Care, University of Cambridge, UK (C.O.-W., M.S.)
- Homerton College, University of Cambridge, UK (C.O.-W.)
| | - Michael J Sweeting
- Cardiovascular Epidemiology Unit, Department of Public Health & Primary Care, University of Cambridge, UK (C.O.-W., M.S.)
- Department of Health Sciences, University of Leicester, UK (M.S.)
| | - Jo Jacomelli
- Public Health England, Vulcan House, Sheffield, UK (J.J., L.S., A.S.)
| | - Lisa Summers
- Public Health England, Vulcan House, Sheffield, UK (J.J., L.S., A.S.)
| | - Anne Stevenson
- Public Health England, Vulcan House, Sheffield, UK (J.J., L.S., A.S.)
| | - Tim Lees
- University Hospitals, Newcastle, Newcastle upon Tyne, UK (T.L.). Gloucestershire Hospitals National Health Service Foundation Trust, Cheltenham, UK
| | - Jonothan J Earnshaw
- University Hospitals, Newcastle, Newcastle upon Tyne, UK (T.L.). Gloucestershire Hospitals National Health Service Foundation Trust, Cheltenham, UK
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Jacomelli J, Summers L, Stevenson A, Lees T, Earnshaw J. Inequalities in Abdominal Aortic Aneurysm Screening in England: Effects of Social Deprivation and Ethnicity. J Vasc Surg 2017. [DOI: 10.1016/j.jvs.2017.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Jacomelli J, Summers L, Stevenson A, Lees T, Earnshaw JJ. Editor's Choice - Inequalities in Abdominal Aortic Aneurysm Screening in England: Effects of Social Deprivation and Ethnicity. Eur J Vasc Endovasc Surg 2017; 53:837-843. [PMID: 28416264 DOI: 10.1016/j.ejvs.2017.03.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 03/07/2017] [Indexed: 10/19/2022]
Abstract
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.
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Affiliation(s)
| | | | | | - T Lees
- University Hospitals, Newcastle, UK
| | - J J Earnshaw
- Gloucestershire Hospitals NHS Foundation Trust, UK.
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Jacomelli J, Summers L, Stevenson A. Impact of the First 5 Years of a National Abdominal Aortic Aneurysm Screening Programme. J Vasc Surg 2016. [DOI: 10.1016/j.jvs.2016.10.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Abstract
Objectives To monitor the early effect of a national population screening programme for abdominal aortic aneurysm in 65-year-old men. Setting The study used national statistics for death rates from abdominal aortic aneurysm (Office of National Statistics) and hospital admission data in England (Hospital Episode Statistics). Methods Information concerning deaths from abdominal aortic aneurysm (ruptured and non-ruptured) (1999-2014) and hospital admissions for ruptured abdominal aortic aneurysm (2000-2015) was examined. Results The absolute number of deaths from abdominal aortic aneurysm in men and women aged 65 and over has decreased by around 30% from 2001 to 2014, but as the population has increased, the relative reduction was 45.6% and 40.0%, respectively. Some 65% of all abdominal aortic aneurysm deaths are in men aged over 65; women aged 65 and over account for around 31%. Deaths from ruptured abdominal aortic aneurysm in men aged 60-74 (the screened group) appear to be declining at the same rate as in men aged 75 and over. The relative decline in admissions to hospital with ruptured abdominal aortic aneurysm may be greater in men and women aged 60-74 (which contains the screened group of men), than those older, giving the first possible evidence that abdominal aortic aneurysm screening is having an effect. Conclusion The death rate from abdominal aortic aneurysm is declining rapidly in England. There is the first evidence that screening may be contributing to this reduction.
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Affiliation(s)
| | | | | | - Tim Lees
- 2 University Hospitals, Newcastle Upon Tyne, UK
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Meecham L, Jacomelli J, Pherwani A, Earnshaw J. Self-referral to the NHS Abdominal Aortic Aneurysm Screening Programme. J Vasc Surg 2016. [DOI: 10.1016/j.jvs.2016.08.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Meecham L, Jacomelli J, Pherwani AD, Earnshaw J. Re: 'Re: Self-referral to the NHS Abdominal Aortic Screening Programme'. Eur J Vasc Endovasc Surg 2016; 52:271. [PMID: 27346444 DOI: 10.1016/j.ejvs.2016.05.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Accepted: 05/23/2016] [Indexed: 11/26/2022]
Affiliation(s)
- L Meecham
- University Hospital of North Staffordshire, Stoke on Trent, Staffordshire ST4 6QG, United Kingdom.
| | - J Jacomelli
- University Hospital of North Staffordshire, Stoke on Trent, Staffordshire ST4 6QG, United Kingdom
| | - A D Pherwani
- University Hospital of North Staffordshire, Stoke on Trent, Staffordshire ST4 6QG, United Kingdom
| | - J Earnshaw
- University Hospital of North Staffordshire, Stoke on Trent, Staffordshire ST4 6QG, United Kingdom
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Jacomelli J, Summers L, Stevenson A, Lees T, Earnshaw JJ. Impact of the first 5 years of a national abdominal aortic aneurysm screening programme. Br J Surg 2016; 103:1125-31. [DOI: 10.1002/bjs.10173] [Citation(s) in RCA: 93] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Revised: 11/06/2015] [Accepted: 02/18/2016] [Indexed: 11/07/2022]
Abstract
Abstract
Background
The Abdominal Aortic Aneurysm (AAA) Screening Programme was introduced by the National Health Service (NHS) in England to reduce the rate of death from ruptured AAA in men. The programme commenced in 2009 and was implemented completely across the country in April 2013. The aim was to review the first 5 years of the programme, looking specifically at compliance and early outcome.
Methods
Men aged 65 years were invited for a single abdominal ultrasound scan. Data were entered into a bespoke database (AAA SMaRT). This was a planned analysis after the first 5 years of the programme.
Results
The summation analysis involved the first 700 000 men screened, and the first 1000 men with a large AAA referred for possible treatment. The prevalence of AAA (aortic diameter larger than 2·9 cm) in 65-year-old men was 1·34 per cent. Mean uptake was 78·1 per cent, but varied from 61·7 to 85·8 per cent across the country. Based on the Index of Multiple Deprivation, uptake was 65·1 per cent in the most deprived versus 84·1 per cent in the least deprived areas. Of the first 1000 men referred for possible treatment of a large AAA (greater than 5·4 cm), the false-positive rate was 3·2 per cent. Some 870 men underwent a planned AAA intervention (non-intervention rate 9·2 per cent), with seven deaths (perioperative mortality rate 0·8 per cent).
Conclusion
The processes in the NHS AAA Screening Programme are effective in detecting and treating men with AAA.
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Affiliation(s)
| | | | | | - T Lees
- Department of Vascular Surgery, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - J J Earnshaw
- Department of Vascular Surgery, Gloucestershire Hospitals NHS Foundation Trust, Cheltenham, UK
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Earnshaw J, Williams CO, Lees T, Jacomelli J, Summers LJ, Stevenson A, Sweeting M, Thompson S. IF01. First Million Men Screened in the NHS Abdominal Aortic Aneurysm Screening Programme in England. J Vasc Surg 2016. [DOI: 10.1016/j.jvs.2016.03.219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Meecham L, Jacomelli J, Pherwani AD, Earnshaw J. Editor's Choice - Self-referral to the NHS Abdominal Aortic Aneurysm Screening Programme. Eur J Vasc Endovasc Surg 2016; 52:317-21. [PMID: 27142191 DOI: 10.1016/j.ejvs.2016.04.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Accepted: 04/03/2016] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The NHS Abdominal Aortic Screening Programme (NAAASP) invites men in their 65th year for screening, men over 65 may self-refer into the programme. Most studies have concentrated on those invited for screening, little is known about the self-referral group. Our aim was to provide a descriptive analysis of the men who self refer to NAAASP for screening. METHOD Information concerning basic demographic details and ultrasound results were recorded on the AAA SMaRT database. During nurse assessment data collected included smoking status, blood pressure, height, weight, and aspirin and statin therapy. Statistical analysis was performed using SPSS(®)20. RESULTS A total of 58,999 men have self-referred to the NAAASP since its inception. The mean age at self-referral was 73 (47-100). The mean aortic diameter was 1.9 cm (0.8-12.1). Increased self-referral rates were observed following organised publicity. The incidence of AAA was 4.1% (n = 2438) compared with 1.4% in the invited cohort (age 65 years), of these 7.6% (n = 186) were >5.5 cm. Of the 186, 152 (81.7%) underwent surgery, of which 55.3% (n = 84) underwent EVAR. The 30-day mortality in the men treated electively was 0%. The mean time from referral to surgery was 69 (2-361) days, with 57.9% (n = 88) being treated within 8 weeks of detection. CONCLUSION Self-referral has yielded higher detection rates than the invited cohort, more than justifying its cost. Now that NAAASP is fully operational it is important to continue media campaigns and publicity to target the "at-risk" men over 65 who would otherwise miss the benefits of AAA screening. Some key areas still need to be addressed.
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Affiliation(s)
- L Meecham
- University Hospitals North Midlands NHS Trust, Stoke on Trent, UK.
| | - J Jacomelli
- NHS Abdominal Aortic Aneurysm Screening Programme (NAAASP), Public Health England, Zone B, Floor 2, Skipton House, 80 London Road, London SE1 6LH, UK
| | - A D Pherwani
- University Hospitals North Midlands NHS Trust, Stoke on Trent, UK
| | - J Earnshaw
- NHS Abdominal Aortic Aneurysm Screening Programme (NAAASP), Public Health England, Zone B, Floor 2, Skipton House, 80 London Road, London SE1 6LH, UK
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