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Commentary on ‘Self Referral to the NHS Abdominal Aortic Aneurysm Screening Programme’
Eur J Vasc Endovasc Surg (2016) 52, 322
INVITED COMMENTARY
Commentary on ‘Self Referral to the NHS Abdominal Aortic Aneurysm Screening Programme’ S. Lepidi
*
Division of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Italy
The interesting study by Meecham et al. highlights the importance of a well conducted national screening programme for AAA that should also be implemented in other European countries.1 The results of four large randomized controlled trials (RCTs) demonstrated a 40% reduction in abdominal aortic aneurysm (AAA) related deaths in ultrasound screened versus unscreened cohorts of men aged 65e74 years of age.2 These results were the basis for initiating national screening programmes in different countries like the UK, Sweden, and the USA. In England, the National Health Service AAA screening programme (NAAASP) began in 2009.3 The NAAASP protocol consists of an invitation for ultrasound AAA screening sent to all men in the year they are 65 years of age. 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 follow up data from RCTs.4 The cost effectiveness of AAA screening has not been established in women. Although RCTs analysed cohorts of men aged 65e74 years, the NAAASP protocol only offers an invitation to 65 year old men. This choice was most probably based on a balance between the cost effectiveness and the availability of resources for the programme. However, what about men >65 years of age, who have never had ultrasound screening for AAA? The NAAASP allows men >65 years of age to enter the programme by self referring for an ultrasound scan. Local screening providers usually publicise this facility through media campaigns. The authors focused on the results of the “self referral” cohort. From April 2009 to 14 August 2014, a total of 58,999 men referred themselves to the NAAASP for screening; 700,816 invited men were screened during the same period. Among the 2,438 (4.1%) AAAs detected, 186 (7.6%) were >5.5 cm and 152 (81.7%) patients underwent DOI of original article: http://dx.doi.org/10.1016/j.ejvs.2016.04.002 * Division of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Via Giustiniani, 2, 35128, Padova, Italy. E-mail address: [email protected] (S. Lepidi). 1078-5884/Ó 2016 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ejvs.2016.05.012
surgery (endovascular aneurysm repair in 55.3%). The incidence of AAA in the self referral group (4.1%) was much higher than the 1.4% in the invited cohort. The authors conclude that these results more than justify the costs of sustaining a self referral option. There could be several reasons for the increased AAA detection rate in the self referral cohort, such as increased age, comorbidities, and pathology self awareness. These results are of interest, especially considering national or local screening programmes that are based only on self referral protocols. Although AAA diagnosis would probably be higher, a purely self referral driven programme would not prevent enough aneurysm related deaths in the general population to label the programme truly effective. However, the design of a self referral option should be considered a good choice when economic resources limit a more extended national AAA screening programme based on invitation protocols only. With the extension of the NAAASP throughout the years, an increased proportion of men >65 years of age will have been screened by a single ultrasound scan at the age of 65 years, and the need for a self referral option will be reduced. Finally, national screening programmes like the NAAASP should consider a re-evaluation protocol after several years, given the evidence from longterm follow up studies of AAA ruptures in those with an aorta originally screened as normal.5 REFERENCES 1 Meecham L, Jacomelli J, Pherwani AD, Earnshaw J. Self referral to the NHS Abdominal Aortic Aneurysm Screening Programme. Eur J Vasc Endovasc Surg 2016;52:317e21. 2 Cosford PA, Leng GC, Thomas J. Screening for abdominal aortic aneurysm. Cochrane Database Syst Rev 2007;2:CD002945. 3 Davis M, Harris M, Earnshaw JJ. Implementation of the National Health Service Abdominal Aortic Aneurysm Screening Program in England. J Vasc Surg 2013;57:1440e5. 4 Kim LG, P Scott RA, Ashton HA, Thompson SG. Multicentre Aneurysm Screening Study Group. A sustained mortality benefit from screening for abdominal aortic aneurysm. Ann Intern Med 2007;146:699e706. 5 Thompson SG, Ashton HA, Gao L, Buxton MJ, Scott RA. Multicentre Aneurysm Screening Study (MASS) Group. Final follow up of the Multicentre Aneurysm Screening Study (MASS) randomized trial of abdominal aortic aneurysm screening. Br J Surg 2012;99:1649e56.
INVITED COMMENTARY
Commentary on ‘Self Referral to the NHS Abdominal Aortic Aneurysm Screening Programme’ S. Lepidi
*
Division of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Italy
The interesting study by Meecham et al. highlights the importance of a well conducted national screening programme for AAA that should also be implemented in other European countries.1 The results of four large randomized controlled trials (RCTs) demonstrated a 40% reduction in abdominal aortic aneurysm (AAA) related deaths in ultrasound screened versus unscreened cohorts of men aged 65e74 years of age.2 These results were the basis for initiating national screening programmes in different countries like the UK, Sweden, and the USA. In England, the National Health Service AAA screening programme (NAAASP) began in 2009.3 The NAAASP protocol consists of an invitation for ultrasound AAA screening sent to all men in the year they are 65 years of age. 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 follow up data from RCTs.4 The cost effectiveness of AAA screening has not been established in women. Although RCTs analysed cohorts of men aged 65e74 years, the NAAASP protocol only offers an invitation to 65 year old men. This choice was most probably based on a balance between the cost effectiveness and the availability of resources for the programme. However, what about men >65 years of age, who have never had ultrasound screening for AAA? The NAAASP allows men >65 years of age to enter the programme by self referring for an ultrasound scan. Local screening providers usually publicise this facility through media campaigns. The authors focused on the results of the “self referral” cohort. From April 2009 to 14 August 2014, a total of 58,999 men referred themselves to the NAAASP for screening; 700,816 invited men were screened during the same period. Among the 2,438 (4.1%) AAAs detected, 186 (7.6%) were >5.5 cm and 152 (81.7%) patients underwent DOI of original article: http://dx.doi.org/10.1016/j.ejvs.2016.04.002 * Division of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Via Giustiniani, 2, 35128, Padova, Italy. E-mail address: [email protected] (S. Lepidi). 1078-5884/Ó 2016 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ejvs.2016.05.012
surgery (endovascular aneurysm repair in 55.3%). The incidence of AAA in the self referral group (4.1%) was much higher than the 1.4% in the invited cohort. The authors conclude that these results more than justify the costs of sustaining a self referral option. There could be several reasons for the increased AAA detection rate in the self referral cohort, such as increased age, comorbidities, and pathology self awareness. These results are of interest, especially considering national or local screening programmes that are based only on self referral protocols. Although AAA diagnosis would probably be higher, a purely self referral driven programme would not prevent enough aneurysm related deaths in the general population to label the programme truly effective. However, the design of a self referral option should be considered a good choice when economic resources limit a more extended national AAA screening programme based on invitation protocols only. With the extension of the NAAASP throughout the years, an increased proportion of men >65 years of age will have been screened by a single ultrasound scan at the age of 65 years, and the need for a self referral option will be reduced. Finally, national screening programmes like the NAAASP should consider a re-evaluation protocol after several years, given the evidence from longterm follow up studies of AAA ruptures in those with an aorta originally screened as normal.5 REFERENCES 1 Meecham L, Jacomelli J, Pherwani AD, Earnshaw J. Self referral to the NHS Abdominal Aortic Aneurysm Screening Programme. Eur J Vasc Endovasc Surg 2016;52:317e21. 2 Cosford PA, Leng GC, Thomas J. Screening for abdominal aortic aneurysm. Cochrane Database Syst Rev 2007;2:CD002945. 3 Davis M, Harris M, Earnshaw JJ. Implementation of the National Health Service Abdominal Aortic Aneurysm Screening Program in England. J Vasc Surg 2013;57:1440e5. 4 Kim LG, P Scott RA, Ashton HA, Thompson SG. Multicentre Aneurysm Screening Study Group. A sustained mortality benefit from screening for abdominal aortic aneurysm. Ann Intern Med 2007;146:699e706. 5 Thompson SG, Ashton HA, Gao L, Buxton MJ, Scott RA. Multicentre Aneurysm Screening Study (MASS) Group. Final follow up of the Multicentre Aneurysm Screening Study (MASS) randomized trial of abdominal aortic aneurysm screening. Br J Surg 2012;99:1649e56.