Analysis of clinical benefit, harms, and cost-effectiveness of screening women for abdominal aortic aneurysm
Michael J Sweeting, Katya L Masconi, Edmund Jones, Pinar Ulug, Matthew J Glover, Jonathan A Michaels, Matthew J Bown, Janet T Powell, Simon G Thompson, Michael J Sweeting, Katya L Masconi, Edmund Jones, Pinar Ulug, Matthew J Glover, Jonathan A Michaels, Matthew J Bown, Janet T Powell, Simon G Thompson
Abstract
Background: A third of deaths in the UK from ruptured abdominal aortic aneurysm (AAA) are in women. In men, national screening programmes reduce deaths from AAA and are cost-effective. The benefits, harms, and cost-effectiveness in offering a similar programme to women have not been formally assessed, and this was the aim of this study.
Methods: We developed a decision model to assess predefined outcomes of death caused by AAA, life years, quality-adjusted life years, costs, and the incremental cost-effectiveness ratio for a population of women invited to AAA screening versus a population who were not invited to screening. A discrete event simulation model was set up for AAA screening, surveillance, and intervention. Relevant women-specific parameters were obtained from sources including systematic literature reviews, national registry or administrative databases, major AAA surgery trials, and UK National Health Service reference costs.
Findings: AAA screening for women, as currently offered to UK men (at age 65 years, with an AAA diagnosis at an aortic diameter of ≥3·0 cm, and elective repair considered at ≥5·5cm) gave, over 30 years, an estimated incremental cost-effectiveness ratio of £30 000 (95% CI 12 000-87 000) per quality-adjusted life year gained, with 3900 invitations to screening required to prevent one AAA-related death and an overdiagnosis rate of 33%. A modified option for women (screening at age 70 years, diagnosis at 2·5 cm and repair at 5·0 cm) was estimated to have an incremental cost-effectiveness ratio of £23 000 (9500-71 000) per quality-adjusted life year and 1800 invitations to screening required to prevent one AAA-death, but an overdiagnosis rate of 55%. There was considerable uncertainty in the cost-effectiveness ratio, largely driven by uncertainty about AAA prevalence, the distribution of aortic sizes for women at different ages, and the effect of screening on quality of life.
Interpretation: By UK standards, an AAA screening programme for women, designed to be similar to that used to screen men, is unlikely to be cost-effective. Further research on the aortic diameter distribution in women and potential quality of life decrements associated with screening are needed to assess the full benefits and harms of modified options.
Funding: UK National Institute for Health Research Health Technology Assessment programme.
Copyright © 2018 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 licence. Published by Elsevier Ltd.. All rights reserved.
Figures
References
- Office for National Statistics Deaths registered in England and Wales (Series DR) 2016.
- Anjum A, Powell JT. Is the incidence of abdominal aortic aneurysm declining in the 21st century? Mortality and hospital admissions for England & Wales and Scotland. Eur J Vasc Endovasc Surg. 2012;43:161–166.
- Cosford PA, Leng GC. Screening for abdominal aortic aneurysm. Cochrane Database Syst Rev. 2007;2 CD002945.
- Lederle FA. The last (randomized) word on screening for abdominal aortic aneurysms. JAMA Intern Med. 2016;176:1767–1768.
- Wanhainen A, Hultgren R, Linne A. Outcome of the Swedish nationwide abdominal aortic aneurysm screening program. Circulation. 2016;134:1141–1148.
- 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;103:1125–1131.
- Guirguis-Blake JM, Beil TL, Sun X, Senger CA, Whitlock EP. US Agency for Healthcare Research and Quality; Rockville, MD: 2014. Primary care screening for abdominal aortic aneurysm: a systematic evidence review for the US Preventive Services Task Force.
- Giardina S, Pane B, Spinella G. An economic evaluation of an abdominal aortic aneurysm screening program in Italy. J Vasc Surg. 2011;54:938–946.
- Scott R, Bridgewater S, Ashton H. Randomized clinical trial of screening for abdominal aortic aneurysm in women. Br J Surg. 2002;89:283–285.
- Ulug P, Powell J, Sweeting M, Bown M, Thompson S. Meta-analysis of the current prevalence of screen-detected abdominal aortic aneurysm in women. Br J Surg. 2016;103:1097–1104.
- Glover M, Kim L, Sweeting M, Thompson S, Buxton M. Cost-effectiveness of the National Health Service abdominal aortic aneurysm screening programme in England. Br J Surg. 2014;101:976–982.
- Svensjö S, Mani K, Bjorck M, Lundkvist J, Wanhainen A. Screening for abdominal aortic aneurysm in 65-year-old men remains cost-effective with contemporary epidemiology and management. Eur J Vasc Endovasc Surg. 2014;47:357–365.
- Stackelberg O, Bjorck M, Larsson SC, Orsini N, Wolk A. Sex differences in the association between smoking and abdominal aortic aneurysm. Br J Surg. 2014;101:1230–1237.
- Department of Health . Department of Health and Social Care; London: 2015. NHS reference costs 2014 to 2015.
- Svensjö S, Björck M, Wanhainen A. Current prevalence of abdominal aortic aneurysm in 70-year-old women. Br J Surg. 2013;100:367–372.
- Glover MJ, Jones E, Masconi KL, Sweeting MJ, Thompson SG, SWAN Collaborators Discrete event simulation for decision making in health care: lessons from abdominal aortic aneurysm screening. Med Decis Making. 2018;38:439–451.
- Ulug P, Sweeting MJ, von Allmen RS, Thompson SG, Powell JT, SWAN Collaborators Morphological suitability for endovascular repair, non-intervention rates, and operative mortality in women and men assessed for intact abdominal aortic aneurysm repair: systematic reviews with meta-analysis. Lancet. 2017;389:2482–2491.
- Kent KC. Clinical practice. Abdominal aortic aneurysms. N Engl J Med. 2014;371:2101–2108.
- Thompson SG, Brown LC, Sweeting MJ. Systematic review and meta-analysis of the growth and rupture rates of small abdominal aortic aneurysms: implications for surveillance intervals and their cost-effectiveness. Health Technol Assess. 2013;17:1–118.
- Sidloff DA, Saratzis A, Sweeting MJ. Sex differences in mortality after abdominal aortic aneurysm repair in the UK. Br J Surg. 2017;104:1656–1664.
- NHS Digital Hospital Episode Statistics. 2016.
- Khashram M, Jones G, Roake J. Prevalence of abdominal aortic aneurysm (AAA) in a population undergoing computed tomography colonography in Canterbury, New Zealand. Eur J Vasc Endovasc Surg. 2015;50:199–205.
- Lindholt JS, Sogaard R. Population screening and intervention for vascular disease in Danish men (VIVA): a randomised controlled trial. Lancet. 2017;390:2256–2265.
- Ashton H, Buxton M, Day N. The Multicentre Aneurysm Screening Study (MASS) into the effect of abdominal aortic aneurysm screening on mortality in men: a randomised controlled trial. Lancet. 2002;360:1531–1539.
- Kind P, Dolan P, Gudex C, Williams A. Variations in population health status: results from a United Kingdom national questionnaire survey. BMJ. 1998;316:736–741.
- Office for National Statistics National Life Tables, United Kingdom: 2012–2014. 2015.
- Office for National Statistics Deaths registered in England and Wales (Series DR) 2015.
- Patel R, Sweeting MJ, Powell JT, Greenhalgh RM, for the EVAR trial investigators Endovascular versus open repair of abdominal aortic aneurysm in 15-years' follow-up of the UK endovascular aneurysm repair trial 1 (EVAR trial 1): a randomised controlled trial. Lancet. 2016;388:2366–2374.
- IMPROVE Trial Investigators Comparative clinical effectiveness and cost effectiveness of endovascular strategy v open repair for ruptured abdominal aortic aneurysm: three year results of the IMPROVE randomised trial. BMJ. 2017;359:j4859.
- Curtis L, Burns A. University of Kent; Canterbury: 2015. Unit costs of health and social care 2015.
- Mani K, Lees T, Beiles B. Treatment of abdominal aortic aneurysm in nine countries 2005–2009: a vascunet report. Eur J Vasc Endovasc Surg. 2011;42:598–607.
- Waton S, Johal A, Heikkila K, Cromwell D, Boyle J, Loftus I. The Royal College of Surgeons of England; London: 2017. National Vascular Registry: 2017 annual report.
- Rogers IS, Massaro JM, Truong QA. Distribution, determinants, and normal reference values of thoracic and abdominal aortic diameters by computed tomography (from the Framingham Heart Study) Am J Cardiol. 2013;111:1510–1516.
- Johansson M, Jorgensen KJ, Brodersen J. Harms of screening for abdominal aortic aneurysm: is there more to life than a 0·46% disease-specific mortality reduction? Lancet. 2016;387:308–310.
- Cotter AR, Vuong K, Mustelin L. Do psychological harms result from being labelled with an unexpected diagnosis of abdominal aortic aneurysm or prostate cancer through screening? A systematic review. BMJ Open. 2017;7:e017565.
- Rasmussen JF, Siersma V, Pedersen JH, Heleno B, Saghir Z, Brodersen J. Healthcare costs in the Danish randomised controlled lung cancer CT-screening trial: a registry study. Lung Cancer. 2014;83:347–355.
- Deery SE, Soden PA, Zettervall SL. Sex differences in mortality and morbidity following repair of intact abdominal aortic aneurysms. J Vasc Surg. 2017;65:1006–1013.
- Alabas OA, Gale CP, Hall M. Sex differences in treatments, relative survival, and excess mortality following acute myocardial infarction: national cohort study using the SWEDEHEART registry. J Am Heart Assoc. 2017;6:e007123.
Source: PubMed