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Commentary on ‘A Decision Aid Regarding Treatment Options for Patients with an Asymptomatic Abdominal Aortic Aneurysm: A Randomised Clinical Trial’
INVITED COMMENTARY
Commentary on ‘A Decision Aid Regarding Treatment Options for Patients with an Asymptomatic Abdominal Aortic Aneurysm: A Randomised Clinical Trial’ M. Björck Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
In this issue of European Journal of Vascular and Endovascular Surgery, Knops et al. report the results of a randomised trial.1 They address an important issue for everyday vascular surgery: how can we better inform patients with abdominal aortic aneurysm (AAA), and involve them actively in the surgical decision-making? The study was performed in six vascular centres in Amsterdam. Patients who were recently diagnosed with an AAA with a diameter of 4 cm or more were randomised between standard care and adding an interactive CD-ROM informing them of the pros and cons of elective surgery and watchful waiting. The results are quite interesting. The patients who received the extra standardised information had better knowledge, but anxiety, satisfaction, and decisional conflict scores did not differ between the groups. How should we interpret these findings? Having an AAA is a worrying situation, and being better informed does not necessarily reduce anxiety. To decide between two alternatives that both include a risk of death is a difficult existential conflict. A patient attitude that was quite common in the 1970s when I started to practise surgery, was that the patient placed his fate in the hands of the surgeon. “Doctor, you know best!”, was a frequent comment. Strangely enough, these patients gave the impression of having great confidence in the young surgeon who was to operate on them, and did not seek more information. We still meet these patients, although this is increasingly uncommon. The colleagues in Amsterdam are to be congratulated for having performed another important clinical study, and a randomised controlled trial, giving us the highest level of evidence. Yet there are, as always in research, some limitations. An outstanding issue, that may limit the generalisability of the investigation, is the quality of “standard care.” We know from other studies on interventions that standard care has the tendency to improve during the time that an investigation is carried out. It is possible that the surgeons participating in the study may have improved their practice, informing their patients better than at baseline, before the study was initiated. Unfortunately, there are no baseline data. We have investigated quality of life (QoL) with Short-Form 36 before and after screening for AAA, thus with true baseline data before the ultrasound investigation of the aorta was performed,2 and 12 months later.We found that among those who DOI of original article: http://dx.doi.org/10.1016/j.ejvs.2014.04.016 E-mail address: [email protected] (M. Björck). 1078-5884/$ e see front matter Ó 2014 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ejvs.2014.06.033
had an age-adjusted normal QoL prior to screening and who were found to have the disease, no negative effects were observed on QoL. Those who suffered a low QOL prior to screening, however, had their QoL further impaired by the diagnosis of an AAA. Thus, there seems to exist a small vulnerable subgroup of patients, which, among psychiatrists, is sometimes labelled “the orchids”, as opposed to the “the dandelions,” that grow through the concrete.To further explore the explanation for this negative reaction, we performed a qualitative investigation of some of those patients who had had their QoL further impaired 12 months after AAA screening, using thematic content analysis.3 The investigation showed that these patients all had multiple other physical and/or mental diseases that overshadowed the AAA. Maybe information given by a sensitive clinician is more appropriate than standardized information? This way the information can be individualised. In particular, patients with an AAA that is less than 5.5 cm need to be reassured that the risk of rupture is very small, and this reassurance is probably better delivered by a doctor than by a machine. The Amsterdam study highlights that we need to investigate further how to inform patients about AAA, in order not to have unnecessary negative effects on QoL. The fact that AAA screening is becoming part of routine health care in many countries4,5 makes this issue even more important.We need to address this field of research with a multidisciplinary approach, taking advantage of previous experiences in behavioural sciences and nursing. Most of the work is still ahead of us. REFERENCES 1 Knops AM, Goosens A, Ubbink DT, Balm R, Koelemay MJ, Vahl AC, et al. A decision aid regarding treatment options for patients with an asymptomatic abdominal aortic aneurysm: a randomised clinical trial. Eur J Vasc Endovasc Surg 2014 [in press]. 2 Wanhainen A, Rosén C, Rutegård J, Bergqvist D, Björck M. Low quality of life prior to screening for abdominal aortic aneurysm is a risk factor for negative mental effects. Ann Vasc Surg 2004;18:287e93. 3 Brännström M, Björck M, Strandberg G, Wanhainen A. Patients’ experiences of being informed about having an abdominal aortic aneurysm e a follow-up case study after screening. J Vasc Nurs 2009;27:70e4. 4 Stather PW, Dattani N, Bown MJ, Earnshaw JJ, Lees TA. International variations in AAA screening. Eur J Vasc Endovasc Surg 2013;45:231e4. 5 Svensjö S, Björck M, Gurtelschmid M, Djavani Gidlund K, Hellberg A, Wanhainen A. Low prevalence of abdominal aortic aneurysm among 65-year-old Swedish men indicates a change in the epidemiology of the disease. Circulation 2011;124:1118e23.
Commentary on ‘A Decision Aid Regarding Treatment Options for Patients with an Asymptomatic Abdominal Aortic Aneurysm: A Randomised Clinical Trial’ M. Björck Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
In this issue of European Journal of Vascular and Endovascular Surgery, Knops et al. report the results of a randomised trial.1 They address an important issue for everyday vascular surgery: how can we better inform patients with abdominal aortic aneurysm (AAA), and involve them actively in the surgical decision-making? The study was performed in six vascular centres in Amsterdam. Patients who were recently diagnosed with an AAA with a diameter of 4 cm or more were randomised between standard care and adding an interactive CD-ROM informing them of the pros and cons of elective surgery and watchful waiting. The results are quite interesting. The patients who received the extra standardised information had better knowledge, but anxiety, satisfaction, and decisional conflict scores did not differ between the groups. How should we interpret these findings? Having an AAA is a worrying situation, and being better informed does not necessarily reduce anxiety. To decide between two alternatives that both include a risk of death is a difficult existential conflict. A patient attitude that was quite common in the 1970s when I started to practise surgery, was that the patient placed his fate in the hands of the surgeon. “Doctor, you know best!”, was a frequent comment. Strangely enough, these patients gave the impression of having great confidence in the young surgeon who was to operate on them, and did not seek more information. We still meet these patients, although this is increasingly uncommon. The colleagues in Amsterdam are to be congratulated for having performed another important clinical study, and a randomised controlled trial, giving us the highest level of evidence. Yet there are, as always in research, some limitations. An outstanding issue, that may limit the generalisability of the investigation, is the quality of “standard care.” We know from other studies on interventions that standard care has the tendency to improve during the time that an investigation is carried out. It is possible that the surgeons participating in the study may have improved their practice, informing their patients better than at baseline, before the study was initiated. Unfortunately, there are no baseline data. We have investigated quality of life (QoL) with Short-Form 36 before and after screening for AAA, thus with true baseline data before the ultrasound investigation of the aorta was performed,2 and 12 months later.We found that among those who DOI of original article: http://dx.doi.org/10.1016/j.ejvs.2014.04.016 E-mail address: [email protected] (M. Björck). 1078-5884/$ e see front matter Ó 2014 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ejvs.2014.06.033
had an age-adjusted normal QoL prior to screening and who were found to have the disease, no negative effects were observed on QoL. Those who suffered a low QOL prior to screening, however, had their QoL further impaired by the diagnosis of an AAA. Thus, there seems to exist a small vulnerable subgroup of patients, which, among psychiatrists, is sometimes labelled “the orchids”, as opposed to the “the dandelions,” that grow through the concrete.To further explore the explanation for this negative reaction, we performed a qualitative investigation of some of those patients who had had their QoL further impaired 12 months after AAA screening, using thematic content analysis.3 The investigation showed that these patients all had multiple other physical and/or mental diseases that overshadowed the AAA. Maybe information given by a sensitive clinician is more appropriate than standardized information? This way the information can be individualised. In particular, patients with an AAA that is less than 5.5 cm need to be reassured that the risk of rupture is very small, and this reassurance is probably better delivered by a doctor than by a machine. The Amsterdam study highlights that we need to investigate further how to inform patients about AAA, in order not to have unnecessary negative effects on QoL. The fact that AAA screening is becoming part of routine health care in many countries4,5 makes this issue even more important.We need to address this field of research with a multidisciplinary approach, taking advantage of previous experiences in behavioural sciences and nursing. Most of the work is still ahead of us. REFERENCES 1 Knops AM, Goosens A, Ubbink DT, Balm R, Koelemay MJ, Vahl AC, et al. A decision aid regarding treatment options for patients with an asymptomatic abdominal aortic aneurysm: a randomised clinical trial. Eur J Vasc Endovasc Surg 2014 [in press]. 2 Wanhainen A, Rosén C, Rutegård J, Bergqvist D, Björck M. Low quality of life prior to screening for abdominal aortic aneurysm is a risk factor for negative mental effects. Ann Vasc Surg 2004;18:287e93. 3 Brännström M, Björck M, Strandberg G, Wanhainen A. Patients’ experiences of being informed about having an abdominal aortic aneurysm e a follow-up case study after screening. J Vasc Nurs 2009;27:70e4. 4 Stather PW, Dattani N, Bown MJ, Earnshaw JJ, Lees TA. International variations in AAA screening. Eur J Vasc Endovasc Surg 2013;45:231e4. 5 Svensjö S, Björck M, Gurtelschmid M, Djavani Gidlund K, Hellberg A, Wanhainen A. Low prevalence of abdominal aortic aneurysm among 65-year-old Swedish men indicates a change in the epidemiology of the disease. Circulation 2011;124:1118e23.