- Email: [email protected]
Editor's Choice – Self-referral to the NHS Abdominal Aortic Aneurysm Screening Programme
Eur J Vasc Endovasc Surg (2016)
-,
1e5
Self-referral to the NHS Abdominal Aortic Aneurysm Screening Programme L. Meecham a b
a,*
, J. Jacomelli b, A.D. Pherwani a, J. Earnshaw
b
University Hospitals North Midlands NHS Trust, Stoke on Trent, UK NHS Abdominal Aortic Aneurysm Screening Programme (NAAASP), Public Health England, Zone B, Floor 2, Skipton House, 80 London Road, London SE1 6LH, UK
WHAT THIS STUDY ADDS This study outlines self-referral trends in the NHS abdominal aortic aneurysm screening programme. It also highlights the high detection rate of AAA (4.1%) in men who would not have otherwise undergone screening compared to their screened counterparts.
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 SPSSÒ20. Results: A total of 58,999 men have self-referred to the NAAASP since its inception. The mean age at self-referral was 73 (47e100). The mean aortic diameter was 1.9 cm (0.8e12.1). Increased self-referral rates were observed following organised publicity. The incidence of AAA was 4.1% (n ¼ 2438) compared with 1.4% in the invited cohort (age 65 years), of these 7.6% (n ¼ 186) were >5.5 cm. Of the 186, 152 (81.7%) underwent surgery, of which 55.3% (n ¼ 84) underwent EVAR. The 30-day mortality in the men treated electively was 0%. The mean time from referral to surgery was 69 (2e361) days, with 57.9% (n ¼ 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 “atrisk” men over 65 who would otherwise miss the benefits of AAA screening. Some key areas still need to be addressed. Ó 2016 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved. Article history: Received 27 October 2015, Accepted 3 April 2016, Available online XXX Keywords: Screening, Abdominal aortic aneurysm
INTRODUCTION The NHS Abdominal Aortic Screening Programme (NAAASP) was introduced in England in 2009. This followed review of randomized controlled trials of screening which suggested a single ultrasound scan of the aorta in men aged 65e74 years reduced the risk of subsequent aneurysm rupture by around 50%.1 The largest trial was the Multicentre Aneurysm Screening Study (MASS), which included 70,000 people and showed a significant reduction in death from abdominal aortic aneurysm (AAA) rupture over the next decade.2 A similar trial, the Danish Viborg trial, confirmed * Corresponding author. University Hospital of North Staffordshire, Stoke-on-Trent, UK. E-mail address: [email protected] (L. Meecham). 1078-5884/Ó 2016 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ejvs.2016.04.002
these findings and supported the cost-efficiency conclusions of MASS.3 The protocol for NAAASP is that all men in England are sent an invitation for ultrasound screening in the year they are 65. This includes almost 300,000 men every year. It is acknowledged that men over the age of 65 will never be invited for screening, and therefore the programme allows men over 65 to self-refer for an ultrasound scan. Local screening providers usually publicise this facility. Women are not invited for screening, nor can they currently selfrefer, since the cost-effectiveness of AAA screening in women is not established. Most studies have analysed potential benefits and costeffectiveness to individuals invited for screening, but have not included men who have self-referred. The aim of the present study was to provide a descriptive analysis of the group of men over the age of 65 years who have selfreferred into NAAASP since its inception in 2009, using data collected prospectively on AAA SMaRT (Screening
Please cite this article in press as: Meecham L, et al., Self-referral to the NHS Abdominal Aortic Aneurysm Screening Programme, European Journal of Vascular and Endovascular Surgery (2016), http://dx.doi.org/10.1016/j.ejvs.2016.04.002
2
Management and Referral Tracking), a bespoke database. Like all elements of this screening programme, it is important to ensure the self-referral mechanism is a useful component. METHOD The method of invitation to AAA screening and inclusion into surveillance has been published in detail elsewhere.4,5 Men aged 65 invited for AAA screening, and men over 65 who self-refer undergo abdominal ultrasound measurement of aortic diameter using a standard inner wall to inner wall measurement method.4 All men found to have a maximum aortic diameter of less than 3.0 cm are reassured and discharged. Men with an aortic diameter between 3.0 cm and 5.4 cm are enrolled into a surveillance programme and offered regular ultrasound follow-up. They are also offered an appointment for nurse assessment. Men with a large AAA over 5.4 cm are referred to their local accredited vascular surgical service for investigation and management. Although NAAASP commenced in 2009, for the first 4 years it was implemented through an expanding number of local programmes based on population sizes around 800,000. Implementation completed in 2013, and 41 local programmes now conduct ultrasound screening as close as possible to men’s homes. The present study examines the first 5 years of NAAASP data, including the first full year cohort of 65-year-old men in England (April 2013 to April 2014). For the purposes of the present study, information concerning men who referred themselves for AAA screening was collected. Information concerning basic demographic details and ultrasound results were recorded on AAA SMaRT. During nurse assessment of men with small and medium-sized AAA (3.0e5.4 cm), data collection included smoking status, blood pressure, height, weight, and aspirin and statin therapy. The results from this were compared with outcomes for 65-year-old men invited for screening. Statistical analysis Statistical analysis was performed using SPSSÒ version 20 software. Means were compared with t tests and analysis of variances performed on the variables studied. A p value <.05 was considered to be statistically significant.
L. Meecham et al.
The mean ages of those diagnosed with and those without AAA were similar at 72.6 and 72.1 respectively (p, not significant). There were no significant regional or geographic variations in the age of men who self-referred; the mean age was similar among all local screening programmes, ranging from 71.1 to 73.4 years. Annual self-referral data The number of men who refer themselves for AAA screening has increased each year (Fig. 1). This is mainly due to the enrolment of more local programmes, but also an increasing public awareness. There were several noticeable peaks in self-referrals, some of which can be related directly to national publicity. In 2010, attendance rates in February, March, and November were double those in the other months of the year. In November 2011, increased attendance followed publication of an article on AAA screening in the Daily Mail.6 A spike of self-referrals in May 2012 corresponded to successful completion of the largest phase of NAAASP’s national implementation. A threefold increase in self-referrals occurred in July 2013 after the inclusion of the Welsh and South Yorkshire programmes, which were covered on the ITV news. Self-referral in 2014 remained steady at more than 1,500 patients per month; there was a deliberate national policy not to conduct major publicity events while new local programmes were becoming established. Screen positive scans Of 2,438 (4.1%) men found to have an aortic diameter of more than 2.9 cm, 1,927 had a small AAA (3.0e4.4 cm) and 325 had a medium-sized AAA (4.5e5.4 cm). The mean aneurysm diameter was 3.8 cm (3.0e12.1 cm). Of potential interest to NAAASP for the future, it was found that 1,074 (1.6%) men with a mean age of 74 years (range, 64e96 years) had an aortic diameter of 2.6e2.9 cm (sub-aneurysmal aorta). The nurse assessment provided some data on men with an aortic diameter of 3 cm or more. Their mean height was 175.3 cm (109.0e201.0 cm). A significant majority, 1,687 (69.3%) were ex-smokers and 307 (12.6%) men were current smokers. The mean systolic and diastolic blood pressures recorded were 140.2 mmHg (range, 80.0e
RESULTS Since its inception in April 2009 to 14 August 2014, a total of 58,999 men referred themselves to NAAASP for screening (compared to 700,816 invited men who had been screened in the same time period, an uptake rate of 78.1%) and a total of 61,089 ultrasound scans were performed on these men. The mean age at self-referral was 73 years (range 47e 100 years). The mean aortic diameter noted was 1.9 cm (0.8e12.1 cm). An AAA (aortic diameter > 2.9 cm) was present in 2,438 (4.1%) men, in contrast to 1.4% in the invited cohort (aged 65 years). Most were small or mediumsized AAA, but 7.6% of these (n ¼ 186) were 5.5 cm or greater, the threshold for treatment referral.
Figure 1. Total number of annual self-referrals.
Please cite this article in press as: Meecham L, et al., Self-referral to the NHS Abdominal Aortic Aneurysm Screening Programme, European Journal of Vascular and Endovascular Surgery (2016), http://dx.doi.org/10.1016/j.ejvs.2016.04.002
NHS AAA Screening
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220.0 mmHg) and 79.5 mmHg (range, 30.0e128.0 mmHg) respectively. There was no significant difference in Aspirin and Statin therapy between small and large AAA (Table 1). Subgroup analysis was performed on the various descriptive factors. There was no significant difference between the mean aortic sizes in the different ethnicities of men found with AAA on self-referral (p ¼ .571) (Table 2), but only seven aneurysms were detected in non-white patients. Increasing height was not associated with increasing mean aortic diameter (p ¼ .057) (Table 3). There was no significant difference between the mean aortic diameter in current smokers, ex-smokers, and non-smokers (p ¼ .171). Neither systolic hypertension (>140 mmHg) nor diastolic hypertension (>80 mmHg) predisposed to a higher mean aortic diameter (p ¼ .723). Referrals for surgery Of the 186 self-referred men with a large AAA on initial scanning, 152 (81.7%) underwent surgery. Ten (5.4%) men declined surgery, nine (4.8%) were deemed unfit, 13 (6.9%) were put back into a surveillance programme at their local hospital, and two (1.0%) died while in the referral pathway. The mean age of the cohort undergoing surgery was 75.2 years (67.0e89.0 years) with a mean aortic diameter of 6.2 cm (5.5e12.1 cm). The mean systolic and diastolic blood pressures were 140 mmHg (105e187 mmHg) and 79 mmHg (53e117 mmHg), respectively. In all, 15.1% of patients were current smokers and 64.5% were ex-smokers. Of the 152 men who underwent surgery, 84 (55.3%) had endovascular repair, 59 (38.8%) had open repair, and the method of repair was unknown in nine (5.9%) men with a 30-day mortality at 0%. A small number of emergency procedures (n ¼ 8, 5.3%) were performed for symptomatic or ruptured AAA (sizes 3.5e7.7 cm), and mortality in these eight patients was 0%. The mean time from referral to the vascular service and outpatient assessment was 12.5 days (0e365 days), and from referral to surgery was 69 days (2e361 days). In all, 88 (57.9%) men were treated within 8 weeks of detection. The mean postoperative inpatient stay was 7.3 days (0e132 days) with no significant difference between mode of admission (p ¼ .990) and type of repair (p ¼ .605). There was no significant difference in aortic diameter (p ¼ .728) or mean age (p ¼ .54) in patients undergoing elective or emergency repair. There was a significant difference in diameter between AAA treated by EVAR (6.0 cm) compared with open repair (6.4 cm) (p ¼ .027). To date in this entire cohort of men over 65 self-referring into the programme, there have been 122 deaths (0.2%), but only four (0.007%) have been attributed to a ruptured AAA. Two of these patients had subtreatment threshold Table 1. Patients receiving aspirin and statin therapy when diagnosed with AAA after self-referral. Aspirin Statin
Small AAA (3e5.4 cm) 41.7% 64.9%
Large AAA (5.5 cm) 43.0% 61.3%
p .416 .681
Table 2. Mean aortic diameters by ethnicity among self-referral men who aortas measured 3 cm. Ethnicity
Total self-referrals
White Asian Black Chinese Unknown
50,037 513 157 33 8,034
Number with AAA 2,101 6 1 0 238
Mean aortic diameter (cm) 3.71 4.21 3.3 N/A 3.87
aneurysms (4.8 cm and 5.1 cm) and were being surveyed appropriately at 3-monthly intervals. One patient, a 67year-old man, found to have a 7.1-cm AAA at screening and referred to a surgeon’s clinic, died 2 days after detection from a ruptured AAA. The final patient was 79 with a 6.4-cm AAA. He was referred to a surgeon’s clinic and was undergoing preoperative tests before a decision for surgery. Unfortunately, he had a ruptured AAA and died before a decision on elective surgery was made. DISCUSSION It was recognised that implementing NAAASP to 65-year-old men only meant that men aged over 65 would never be screened. Therefore, funding was agreed so that approximately 2% of scans in the programme would be available for men to self-refer. The present analysis suggests that the prevalence of AAA among men who self refer is higher at 4.1% than those invited at age 65 (1.4%), and that a number of men with large AAA have been identified and treated, thus justifying the cost. The mean age of men who referred themselves was 73 years, and consistent across the various regions, and similar to the age range in MASS.2 There were, however, some exceptions, notably a man aged 100 who asked to be screened. This introduces the question of whether there should be any limits, such as an upper age for self-referral. Presently there are no limits on age or general fitness for self-referral. This issue is not unique to AAA screening. The US preventive services task force (USPSTF) issued guidance on screening for colorectal cancer (CRC). It recommended targeted screening for CRC in high-risk fit individuals between ages 76 and 85 and against CRC screening in those aged over 85 years.7e9 The majority of men self-referring for screening were white. It has been reported that the incidence of AAA in Table 3. Patient height and mean aortic diameter among selfreferral men who aortas measured 3 cm. Height (cm)
Number
<160 160e169 170e179 180e189 190e199 >199 Unknown
21 360 1,273 557 30 5 191
Mean aortic diameter (cm) 4.03 3.77 3.79 3.82 3.84 4.98 4.04
Please cite this article in press as: Meecham L, et al., Self-referral to the NHS Abdominal Aortic Aneurysm Screening Programme, European Journal of Vascular and Endovascular Surgery (2016), http://dx.doi.org/10.1016/j.ejvs.2016.04.002
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other ethnic groups is significantly less.10 In the invited cohort, men of non-white ethnic origin make up a far larger proportion of the screened individuals (4.3%) compared with the self-referral group (1.4%), and this may contribute to the difference in incidence of AAA noted between the two cohorts in the varying ethnic groups. Some individuals were screened despite being below the agreed inclusion age (65), the youngest being 47 years. This was during a publicity event for a regional programme launch and was certainly an exception. The number of self-referrals has increased annually, an expected trend as NAAASP was rolled out. Spikes in activity correlate with publicity in national and local press.6,11 Getting the balance right between the amount of national and local publicity, and corresponding self-referral rates, is a challenge for the programme. Some new local programmes were fragile, and there was the possibility of overwhelming them with self-referrals. Now that NAAASP is fully implemented, a cautious and planned increase in communications is possible. The value of self-referral has been questioned, yet the prevalence of AAA was 4.1%, more than twice the detection rate in 65 year olds (1.4%), and similar to MASS.12 This higher incidence along with the smaller number of men screened implies that the self-referral element to the NAAASP is more than cost-effective.13 Although this is partly explained by the fact that men who referred themselves were older, there is also the possibility that these men have a higher risk profile (smokers, family history of AAA) that encourages them to attend. It is known that men with a small aortic aneurysm often continue to progress with dilatation as time goes by.14e16 The present rate was obtained without any specific advice to men who may wish to refer themselves. It raises the possibility that a future communications policy could encourage men in higher risk groups to refer themselves, thus increasing AAA detection still further. This approach has been adopted by the US Veterans AAA Screening Programme, which uses criteria including aged between 65 and 75 years, a history of hypertension, and smoking a minimum of 100 cigarettes to encourage referral for screening. This approach yielded an incidence of 7.2%.17,18 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 “high-risk” men over 65 who would otherwise miss the benefits of AAA screening. Some key areas still need to be addressed such as whether there should be a maximum age of self-referral. ACKNOWLEDGEMENTS We would like to thank NAAASP and Public Health England for their committed help and support by providing data on self-referrals and help with its analysis. We would also like to thank the Staffordshire and South Cheshire AAA
L. Meecham et al.
screening programme for its specific contribution and all of the enrolled local programmes for their comprehensive data collection and compliance with data entry into AAA SMaRT. CONFLICT OF INTEREST J. Earnshaw is the Clinical Lead of the NHS Abdominal Aortic Aneurysm Screening Programme. A. Pherwani is the Clinical Lead for the Staffordshire and South Cheshire AAA Screening Programme & Vascular Network. FUNDING None. REFERENCES 1 Takagi H, Goto SN, Matsui M, Manabe H, Umemoto T. A further meta-analysis of population based screening for abdominal aortic aneurysm. J Vasc Surg 2010;52:1103e8. 2 The Multicentre Aneurysm Screening Study (MASS) into the effect of abdominal aortic aneurysm screening on mortality in men: a randomised controlled trial. Lancet 2002;360(9345): 1531e9. 3 Lindholt JS, Sørensen J, Søgaard R, Henneberg EW. Long-term benefit and cost-effectiveness analysis of screening for abdominal aortic aneurysms from a randomized controlled trial. Br J Surg 2010;97:826e34. 4 Davis M, Harris M, Earnshaw JJ. Implementation of the National Health Service Abdominal Aortic Aneurysm Screening Programme in England. J Vasc Surg 2013;57(5):1440e5. 5 NHS AAA Screening Programme. Essential elements in developing an abdominal aortic aneurysm screening and surveillance programme. Retrieved November 26, 2012 from: http:// aaa.screening.nhs.uk. 6 Jones B. Radio presenter saved my life: the 15-minute test that can save men from a hidden assassin. Daily Mail 15 November 2011. 7 Screening for colorectal cancer: U.S. Preventive Service Task Force recommendation statement. Ann Intern Med 2008;149(9):627e37. 8 Kahi CJ, van Ryn M, Juliar B, Stuart JS, Imeriale T. Provider recommendations for colorectal cancer screening in elderly veterans. J Gen Intern Med 2009;24(12):1263e8. 9 Hoffman RM, Walter LC. Colorectal cancer screening in the elderly: the need for informed decision making. J Gen Intern Med 2009;24(12):1336e7. 10 Benson RA, Poole R, Murray S, Moxey P, Loftus IM. Screening results from a large United Kingdom abdominal aortic aneurysm screening centre in the context of optimizing United Kingdom National Abdominal Aortic Aneurysm Screening Programme protocols. J Vasc Surg 2016;63(2):301e4. 11 http://webarchive.nationalarchives.gov.uk/20150408175925 12 Thompson SG, Ashton HA, Gao L, Scott RAP. Screening men for abdominal aortic aneurysm: 10 year mortality and cost effectiveness results from the randomised Multicentre Aneurysm Screening Study. BMJ 2009;38:b2307. 13 Glover MJ, Kim LG, Sweeting MJ, Thompson SG, Buxton MJ. Cost-effectiveness of the National Health Service Abdominal Aortic Aneurysm Screening Programme in England. Br J Surg 2014;101(8):976e82.
Please cite this article in press as: Meecham L, et al., Self-referral to the NHS Abdominal Aortic Aneurysm Screening Programme, European Journal of Vascular and Endovascular Surgery (2016), http://dx.doi.org/10.1016/j.ejvs.2016.04.002
NHS AAA Screening 14 Wild JB, Stather PW, Biancari F, Choke EC, Earnshaw JJ, Bown MJ. A multicentre observational study of the outcomes of screening detected sub-aneurysmal aortic dilatation. Eur J Vasc Endovasc Surg 2013;45(2):128e34. 15 Hafez H, Druce PS, Ashton HA. Abdominal aortic aneurysm development in men following a ‘normal’ aortic ultrasound scan. Eur J Vasc Endovasc Surg 2008;36:553e8. 16 Meecham L, Evans R, Buxton P, Allingham K, Hughes M, Pherwani AD. Abdominal aortic aneurysm diameters: a study
5 on the discrepancy between inner to inner and outer to outer measurements. Eur J Vasc Endovasc Surg 2015;49(1):28e32. 17 Chun KC, Teng KY, van Spyk EV, Carson JG, Lee ES. Outcomes of an abdominal aortic aneurysm screening program. J Vasc Surg 2013;57(2):376e81. 18 Bird AM, Davis AM. Screening for abdominal aortic aneurysm. JAMA 2015;313(11):1156e7.
Please cite this article in press as: Meecham L, et al., Self-referral to the NHS Abdominal Aortic Aneurysm Screening Programme, European Journal of Vascular and Endovascular Surgery (2016), http://dx.doi.org/10.1016/j.ejvs.2016.04.002
-,
1e5
Self-referral to the NHS Abdominal Aortic Aneurysm Screening Programme L. Meecham a b
a,*
, J. Jacomelli b, A.D. Pherwani a, J. Earnshaw
b
University Hospitals North Midlands NHS Trust, Stoke on Trent, UK NHS Abdominal Aortic Aneurysm Screening Programme (NAAASP), Public Health England, Zone B, Floor 2, Skipton House, 80 London Road, London SE1 6LH, UK
WHAT THIS STUDY ADDS This study outlines self-referral trends in the NHS abdominal aortic aneurysm screening programme. It also highlights the high detection rate of AAA (4.1%) in men who would not have otherwise undergone screening compared to their screened counterparts.
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 SPSSÒ20. Results: A total of 58,999 men have self-referred to the NAAASP since its inception. The mean age at self-referral was 73 (47e100). The mean aortic diameter was 1.9 cm (0.8e12.1). Increased self-referral rates were observed following organised publicity. The incidence of AAA was 4.1% (n ¼ 2438) compared with 1.4% in the invited cohort (age 65 years), of these 7.6% (n ¼ 186) were >5.5 cm. Of the 186, 152 (81.7%) underwent surgery, of which 55.3% (n ¼ 84) underwent EVAR. The 30-day mortality in the men treated electively was 0%. The mean time from referral to surgery was 69 (2e361) days, with 57.9% (n ¼ 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 “atrisk” men over 65 who would otherwise miss the benefits of AAA screening. Some key areas still need to be addressed. Ó 2016 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved. Article history: Received 27 October 2015, Accepted 3 April 2016, Available online XXX Keywords: Screening, Abdominal aortic aneurysm
INTRODUCTION The NHS Abdominal Aortic Screening Programme (NAAASP) was introduced in England in 2009. This followed review of randomized controlled trials of screening which suggested a single ultrasound scan of the aorta in men aged 65e74 years reduced the risk of subsequent aneurysm rupture by around 50%.1 The largest trial was the Multicentre Aneurysm Screening Study (MASS), which included 70,000 people and showed a significant reduction in death from abdominal aortic aneurysm (AAA) rupture over the next decade.2 A similar trial, the Danish Viborg trial, confirmed * Corresponding author. University Hospital of North Staffordshire, Stoke-on-Trent, UK. E-mail address: [email protected] (L. Meecham). 1078-5884/Ó 2016 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ejvs.2016.04.002
these findings and supported the cost-efficiency conclusions of MASS.3 The protocol for NAAASP is that all men in England are sent an invitation for ultrasound screening in the year they are 65. This includes almost 300,000 men every year. It is acknowledged that men over the age of 65 will never be invited for screening, and therefore the programme allows men over 65 to self-refer for an ultrasound scan. Local screening providers usually publicise this facility. Women are not invited for screening, nor can they currently selfrefer, since the cost-effectiveness of AAA screening in women is not established. Most studies have analysed potential benefits and costeffectiveness to individuals invited for screening, but have not included men who have self-referred. The aim of the present study was to provide a descriptive analysis of the group of men over the age of 65 years who have selfreferred into NAAASP since its inception in 2009, using data collected prospectively on AAA SMaRT (Screening
Please cite this article in press as: Meecham L, et al., Self-referral to the NHS Abdominal Aortic Aneurysm Screening Programme, European Journal of Vascular and Endovascular Surgery (2016), http://dx.doi.org/10.1016/j.ejvs.2016.04.002
2
Management and Referral Tracking), a bespoke database. Like all elements of this screening programme, it is important to ensure the self-referral mechanism is a useful component. METHOD The method of invitation to AAA screening and inclusion into surveillance has been published in detail elsewhere.4,5 Men aged 65 invited for AAA screening, and men over 65 who self-refer undergo abdominal ultrasound measurement of aortic diameter using a standard inner wall to inner wall measurement method.4 All men found to have a maximum aortic diameter of less than 3.0 cm are reassured and discharged. Men with an aortic diameter between 3.0 cm and 5.4 cm are enrolled into a surveillance programme and offered regular ultrasound follow-up. They are also offered an appointment for nurse assessment. Men with a large AAA over 5.4 cm are referred to their local accredited vascular surgical service for investigation and management. Although NAAASP commenced in 2009, for the first 4 years it was implemented through an expanding number of local programmes based on population sizes around 800,000. Implementation completed in 2013, and 41 local programmes now conduct ultrasound screening as close as possible to men’s homes. The present study examines the first 5 years of NAAASP data, including the first full year cohort of 65-year-old men in England (April 2013 to April 2014). For the purposes of the present study, information concerning men who referred themselves for AAA screening was collected. Information concerning basic demographic details and ultrasound results were recorded on AAA SMaRT. During nurse assessment of men with small and medium-sized AAA (3.0e5.4 cm), data collection included smoking status, blood pressure, height, weight, and aspirin and statin therapy. The results from this were compared with outcomes for 65-year-old men invited for screening. Statistical analysis Statistical analysis was performed using SPSSÒ version 20 software. Means were compared with t tests and analysis of variances performed on the variables studied. A p value <.05 was considered to be statistically significant.
L. Meecham et al.
The mean ages of those diagnosed with and those without AAA were similar at 72.6 and 72.1 respectively (p, not significant). There were no significant regional or geographic variations in the age of men who self-referred; the mean age was similar among all local screening programmes, ranging from 71.1 to 73.4 years. Annual self-referral data The number of men who refer themselves for AAA screening has increased each year (Fig. 1). This is mainly due to the enrolment of more local programmes, but also an increasing public awareness. There were several noticeable peaks in self-referrals, some of which can be related directly to national publicity. In 2010, attendance rates in February, March, and November were double those in the other months of the year. In November 2011, increased attendance followed publication of an article on AAA screening in the Daily Mail.6 A spike of self-referrals in May 2012 corresponded to successful completion of the largest phase of NAAASP’s national implementation. A threefold increase in self-referrals occurred in July 2013 after the inclusion of the Welsh and South Yorkshire programmes, which were covered on the ITV news. Self-referral in 2014 remained steady at more than 1,500 patients per month; there was a deliberate national policy not to conduct major publicity events while new local programmes were becoming established. Screen positive scans Of 2,438 (4.1%) men found to have an aortic diameter of more than 2.9 cm, 1,927 had a small AAA (3.0e4.4 cm) and 325 had a medium-sized AAA (4.5e5.4 cm). The mean aneurysm diameter was 3.8 cm (3.0e12.1 cm). Of potential interest to NAAASP for the future, it was found that 1,074 (1.6%) men with a mean age of 74 years (range, 64e96 years) had an aortic diameter of 2.6e2.9 cm (sub-aneurysmal aorta). The nurse assessment provided some data on men with an aortic diameter of 3 cm or more. Their mean height was 175.3 cm (109.0e201.0 cm). A significant majority, 1,687 (69.3%) were ex-smokers and 307 (12.6%) men were current smokers. The mean systolic and diastolic blood pressures recorded were 140.2 mmHg (range, 80.0e
RESULTS Since its inception in April 2009 to 14 August 2014, a total of 58,999 men referred themselves to NAAASP for screening (compared to 700,816 invited men who had been screened in the same time period, an uptake rate of 78.1%) and a total of 61,089 ultrasound scans were performed on these men. The mean age at self-referral was 73 years (range 47e 100 years). The mean aortic diameter noted was 1.9 cm (0.8e12.1 cm). An AAA (aortic diameter > 2.9 cm) was present in 2,438 (4.1%) men, in contrast to 1.4% in the invited cohort (aged 65 years). Most were small or mediumsized AAA, but 7.6% of these (n ¼ 186) were 5.5 cm or greater, the threshold for treatment referral.
Figure 1. Total number of annual self-referrals.
Please cite this article in press as: Meecham L, et al., Self-referral to the NHS Abdominal Aortic Aneurysm Screening Programme, European Journal of Vascular and Endovascular Surgery (2016), http://dx.doi.org/10.1016/j.ejvs.2016.04.002
NHS AAA Screening
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220.0 mmHg) and 79.5 mmHg (range, 30.0e128.0 mmHg) respectively. There was no significant difference in Aspirin and Statin therapy between small and large AAA (Table 1). Subgroup analysis was performed on the various descriptive factors. There was no significant difference between the mean aortic sizes in the different ethnicities of men found with AAA on self-referral (p ¼ .571) (Table 2), but only seven aneurysms were detected in non-white patients. Increasing height was not associated with increasing mean aortic diameter (p ¼ .057) (Table 3). There was no significant difference between the mean aortic diameter in current smokers, ex-smokers, and non-smokers (p ¼ .171). Neither systolic hypertension (>140 mmHg) nor diastolic hypertension (>80 mmHg) predisposed to a higher mean aortic diameter (p ¼ .723). Referrals for surgery Of the 186 self-referred men with a large AAA on initial scanning, 152 (81.7%) underwent surgery. Ten (5.4%) men declined surgery, nine (4.8%) were deemed unfit, 13 (6.9%) were put back into a surveillance programme at their local hospital, and two (1.0%) died while in the referral pathway. The mean age of the cohort undergoing surgery was 75.2 years (67.0e89.0 years) with a mean aortic diameter of 6.2 cm (5.5e12.1 cm). The mean systolic and diastolic blood pressures were 140 mmHg (105e187 mmHg) and 79 mmHg (53e117 mmHg), respectively. In all, 15.1% of patients were current smokers and 64.5% were ex-smokers. Of the 152 men who underwent surgery, 84 (55.3%) had endovascular repair, 59 (38.8%) had open repair, and the method of repair was unknown in nine (5.9%) men with a 30-day mortality at 0%. A small number of emergency procedures (n ¼ 8, 5.3%) were performed for symptomatic or ruptured AAA (sizes 3.5e7.7 cm), and mortality in these eight patients was 0%. The mean time from referral to the vascular service and outpatient assessment was 12.5 days (0e365 days), and from referral to surgery was 69 days (2e361 days). In all, 88 (57.9%) men were treated within 8 weeks of detection. The mean postoperative inpatient stay was 7.3 days (0e132 days) with no significant difference between mode of admission (p ¼ .990) and type of repair (p ¼ .605). There was no significant difference in aortic diameter (p ¼ .728) or mean age (p ¼ .54) in patients undergoing elective or emergency repair. There was a significant difference in diameter between AAA treated by EVAR (6.0 cm) compared with open repair (6.4 cm) (p ¼ .027). To date in this entire cohort of men over 65 self-referring into the programme, there have been 122 deaths (0.2%), but only four (0.007%) have been attributed to a ruptured AAA. Two of these patients had subtreatment threshold Table 1. Patients receiving aspirin and statin therapy when diagnosed with AAA after self-referral. Aspirin Statin
Small AAA (3e5.4 cm) 41.7% 64.9%
Large AAA (5.5 cm) 43.0% 61.3%
p .416 .681
Table 2. Mean aortic diameters by ethnicity among self-referral men who aortas measured 3 cm. Ethnicity
Total self-referrals
White Asian Black Chinese Unknown
50,037 513 157 33 8,034
Number with AAA 2,101 6 1 0 238
Mean aortic diameter (cm) 3.71 4.21 3.3 N/A 3.87
aneurysms (4.8 cm and 5.1 cm) and were being surveyed appropriately at 3-monthly intervals. One patient, a 67year-old man, found to have a 7.1-cm AAA at screening and referred to a surgeon’s clinic, died 2 days after detection from a ruptured AAA. The final patient was 79 with a 6.4-cm AAA. He was referred to a surgeon’s clinic and was undergoing preoperative tests before a decision for surgery. Unfortunately, he had a ruptured AAA and died before a decision on elective surgery was made. DISCUSSION It was recognised that implementing NAAASP to 65-year-old men only meant that men aged over 65 would never be screened. Therefore, funding was agreed so that approximately 2% of scans in the programme would be available for men to self-refer. The present analysis suggests that the prevalence of AAA among men who self refer is higher at 4.1% than those invited at age 65 (1.4%), and that a number of men with large AAA have been identified and treated, thus justifying the cost. The mean age of men who referred themselves was 73 years, and consistent across the various regions, and similar to the age range in MASS.2 There were, however, some exceptions, notably a man aged 100 who asked to be screened. This introduces the question of whether there should be any limits, such as an upper age for self-referral. Presently there are no limits on age or general fitness for self-referral. This issue is not unique to AAA screening. The US preventive services task force (USPSTF) issued guidance on screening for colorectal cancer (CRC). It recommended targeted screening for CRC in high-risk fit individuals between ages 76 and 85 and against CRC screening in those aged over 85 years.7e9 The majority of men self-referring for screening were white. It has been reported that the incidence of AAA in Table 3. Patient height and mean aortic diameter among selfreferral men who aortas measured 3 cm. Height (cm)
Number
<160 160e169 170e179 180e189 190e199 >199 Unknown
21 360 1,273 557 30 5 191
Mean aortic diameter (cm) 4.03 3.77 3.79 3.82 3.84 4.98 4.04
Please cite this article in press as: Meecham L, et al., Self-referral to the NHS Abdominal Aortic Aneurysm Screening Programme, European Journal of Vascular and Endovascular Surgery (2016), http://dx.doi.org/10.1016/j.ejvs.2016.04.002
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other ethnic groups is significantly less.10 In the invited cohort, men of non-white ethnic origin make up a far larger proportion of the screened individuals (4.3%) compared with the self-referral group (1.4%), and this may contribute to the difference in incidence of AAA noted between the two cohorts in the varying ethnic groups. Some individuals were screened despite being below the agreed inclusion age (65), the youngest being 47 years. This was during a publicity event for a regional programme launch and was certainly an exception. The number of self-referrals has increased annually, an expected trend as NAAASP was rolled out. Spikes in activity correlate with publicity in national and local press.6,11 Getting the balance right between the amount of national and local publicity, and corresponding self-referral rates, is a challenge for the programme. Some new local programmes were fragile, and there was the possibility of overwhelming them with self-referrals. Now that NAAASP is fully implemented, a cautious and planned increase in communications is possible. The value of self-referral has been questioned, yet the prevalence of AAA was 4.1%, more than twice the detection rate in 65 year olds (1.4%), and similar to MASS.12 This higher incidence along with the smaller number of men screened implies that the self-referral element to the NAAASP is more than cost-effective.13 Although this is partly explained by the fact that men who referred themselves were older, there is also the possibility that these men have a higher risk profile (smokers, family history of AAA) that encourages them to attend. It is known that men with a small aortic aneurysm often continue to progress with dilatation as time goes by.14e16 The present rate was obtained without any specific advice to men who may wish to refer themselves. It raises the possibility that a future communications policy could encourage men in higher risk groups to refer themselves, thus increasing AAA detection still further. This approach has been adopted by the US Veterans AAA Screening Programme, which uses criteria including aged between 65 and 75 years, a history of hypertension, and smoking a minimum of 100 cigarettes to encourage referral for screening. This approach yielded an incidence of 7.2%.17,18 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 “high-risk” men over 65 who would otherwise miss the benefits of AAA screening. Some key areas still need to be addressed such as whether there should be a maximum age of self-referral. ACKNOWLEDGEMENTS We would like to thank NAAASP and Public Health England for their committed help and support by providing data on self-referrals and help with its analysis. We would also like to thank the Staffordshire and South Cheshire AAA
L. Meecham et al.
screening programme for its specific contribution and all of the enrolled local programmes for their comprehensive data collection and compliance with data entry into AAA SMaRT. CONFLICT OF INTEREST J. Earnshaw is the Clinical Lead of the NHS Abdominal Aortic Aneurysm Screening Programme. A. Pherwani is the Clinical Lead for the Staffordshire and South Cheshire AAA Screening Programme & Vascular Network. FUNDING None. REFERENCES 1 Takagi H, Goto SN, Matsui M, Manabe H, Umemoto T. A further meta-analysis of population based screening for abdominal aortic aneurysm. J Vasc Surg 2010;52:1103e8. 2 The Multicentre Aneurysm Screening Study (MASS) into the effect of abdominal aortic aneurysm screening on mortality in men: a randomised controlled trial. Lancet 2002;360(9345): 1531e9. 3 Lindholt JS, Sørensen J, Søgaard R, Henneberg EW. Long-term benefit and cost-effectiveness analysis of screening for abdominal aortic aneurysms from a randomized controlled trial. Br J Surg 2010;97:826e34. 4 Davis M, Harris M, Earnshaw JJ. Implementation of the National Health Service Abdominal Aortic Aneurysm Screening Programme in England. J Vasc Surg 2013;57(5):1440e5. 5 NHS AAA Screening Programme. Essential elements in developing an abdominal aortic aneurysm screening and surveillance programme. Retrieved November 26, 2012 from: http:// aaa.screening.nhs.uk. 6 Jones B. Radio presenter saved my life: the 15-minute test that can save men from a hidden assassin. Daily Mail 15 November 2011. 7 Screening for colorectal cancer: U.S. Preventive Service Task Force recommendation statement. Ann Intern Med 2008;149(9):627e37. 8 Kahi CJ, van Ryn M, Juliar B, Stuart JS, Imeriale T. Provider recommendations for colorectal cancer screening in elderly veterans. J Gen Intern Med 2009;24(12):1263e8. 9 Hoffman RM, Walter LC. Colorectal cancer screening in the elderly: the need for informed decision making. J Gen Intern Med 2009;24(12):1336e7. 10 Benson RA, Poole R, Murray S, Moxey P, Loftus IM. Screening results from a large United Kingdom abdominal aortic aneurysm screening centre in the context of optimizing United Kingdom National Abdominal Aortic Aneurysm Screening Programme protocols. J Vasc Surg 2016;63(2):301e4. 11 http://webarchive.nationalarchives.gov.uk/20150408175925 12 Thompson SG, Ashton HA, Gao L, Scott RAP. Screening men for abdominal aortic aneurysm: 10 year mortality and cost effectiveness results from the randomised Multicentre Aneurysm Screening Study. BMJ 2009;38:b2307. 13 Glover MJ, Kim LG, Sweeting MJ, Thompson SG, Buxton MJ. Cost-effectiveness of the National Health Service Abdominal Aortic Aneurysm Screening Programme in England. Br J Surg 2014;101(8):976e82.
Please cite this article in press as: Meecham L, et al., Self-referral to the NHS Abdominal Aortic Aneurysm Screening Programme, European Journal of Vascular and Endovascular Surgery (2016), http://dx.doi.org/10.1016/j.ejvs.2016.04.002
NHS AAA Screening 14 Wild JB, Stather PW, Biancari F, Choke EC, Earnshaw JJ, Bown MJ. A multicentre observational study of the outcomes of screening detected sub-aneurysmal aortic dilatation. Eur J Vasc Endovasc Surg 2013;45(2):128e34. 15 Hafez H, Druce PS, Ashton HA. Abdominal aortic aneurysm development in men following a ‘normal’ aortic ultrasound scan. Eur J Vasc Endovasc Surg 2008;36:553e8. 16 Meecham L, Evans R, Buxton P, Allingham K, Hughes M, Pherwani AD. Abdominal aortic aneurysm diameters: a study
5 on the discrepancy between inner to inner and outer to outer measurements. Eur J Vasc Endovasc Surg 2015;49(1):28e32. 17 Chun KC, Teng KY, van Spyk EV, Carson JG, Lee ES. Outcomes of an abdominal aortic aneurysm screening program. J Vasc Surg 2013;57(2):376e81. 18 Bird AM, Davis AM. Screening for abdominal aortic aneurysm. JAMA 2015;313(11):1156e7.
Please cite this article in press as: Meecham L, et al., Self-referral to the NHS Abdominal Aortic Aneurysm Screening Programme, European Journal of Vascular and Endovascular Surgery (2016), http://dx.doi.org/10.1016/j.ejvs.2016.04.002