MinneapolisMinneapolis
Medical CenterMedical Center
Screening forScreening for
Abdominal Aortic AneurysmAbdominal Aortic A...
MinneapolisMinneapolis
Medical CenterMedical Center
Early History of AAA ScreeningEarly History of AAA Screening
• Schilli...
MinneapolisMinneapolis
Medical CenterMedical Center
Typical example of crude early studiesTypical example of crude early s...
MinneapolisMinneapolis
Medical CenterMedical Center
Criteria for ScreeningCriteria for Screening
(adapted from(adapted fro...
MinneapolisMinneapolis
Medical CenterMedical Center
Screening: why not just do it?Screening: why not just do it?
We believ...
MinneapolisMinneapolis
Medical CenterMedical Center
Randomized Trials ofRandomized Trials of
AAA ScreeningAAA Screening
• ...
MinneapolisMinneapolis
Medical CenterMedical Center
MinneapolisMinneapolis
Medical CenterMedical Center
Meta-analysis of odds ratios of all cause long term mortality in men
MinneapolisMinneapolis
Medical CenterMedical Center
MinneapolisMinneapolis
Medical CenterMedical Center
??
MinneapolisMinneapolis
Medical CenterMedical Center
Re-Screening?Re-Screening?
• ADAM: 2622 pts (50-79 yo) < 3.0 cm re-scr...
MinneapolisMinneapolis
Medical CenterMedical Center
MASS 10 yr
BMJ 6/27/09
MinneapolisMinneapolis
Medical CenterMedical Center
After the Screening TestAfter the Screening Test
• Inform patient of n...
MinneapolisMinneapolis
Medical CenterMedical Center
Cost-Effectiveness of AAA ScreeningCost-Effectiveness of AAA Screening...
MinneapolisMinneapolis
Medical CenterMedical Center
• Recommended one-time ultrasound screening forRecommended one-time ul...
MinneapolisMinneapolis
Medical CenterMedical Center
MinneapolisMinneapolis
Medical CenterMedical Center
SAAAVE Act brings (some) Medicare coverageSAAAVE Act brings (some) Med...
MinneapolisMinneapolis
Medical CenterMedical Center
Will the benefits seen in the AAA screeningWill the benefits seen in t...
MinneapolisMinneapolis
Medical CenterMedical Center
SVS/AAVS/SVMBSVS/AAVS/SVMB
Consensus StatementConsensus Statement
• Pr...
MinneapolisMinneapolis
Medical CenterMedical Center
ProgramProgram NumberNumber
ScreenedScreened
ProportionProportion
of w...
MinneapolisMinneapolis
Medical CenterMedical Center
Repair of small AAA in U.S. - PracticeRepair of small AAA in U.S. - Pr...
MinneapolisMinneapolis
Medical CenterMedical Center
• Used large Life Line dataset to identify pts w AAAUsed large Life Li...
MinneapolisMinneapolis
Medical CenterMedical Center
ConclusionConclusion
• Many in U.S. who should be screened aren’tMany ...
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Screening for Abdominal Aortic Aneurysm

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Screening for Abdominal Aortic Aneurysm

  1. 1. MinneapolisMinneapolis Medical CenterMedical Center Screening forScreening for Abdominal Aortic AneurysmAbdominal Aortic Aneurysm Frank A. Lederle, MDFrank A. Lederle, MD
  2. 2. MinneapolisMinneapolis Medical CenterMedical Center Early History of AAA ScreeningEarly History of AAA Screening • Schilling (began in 1964!): 26 of 873 (3.1%) whiteSchilling (began in 1964!): 26 of 873 (3.1%) white men aged 55-64 had AAA (men aged 55-64 had AAA (≥≥ 3.6 cm) by abd3.6 cm) by abd palpation & lateral x-rayspalpation & lateral x-rays ((Circulation 1966 ,Circulation 1966 , J Chron Dis 1974)J Chron Dis 1974) • Cabellon: 7 of 73 (9.5%) vascular pts aged 43-79Cabellon: 7 of 73 (9.5%) vascular pts aged 43-79 had ‘AAA’ by abd palpation & UShad ‘AAA’ by abd palpation & US (Am J Surg, Nov ‘83)(Am J Surg, Nov ‘83) • AlsoAlso Nov ‘83Nov ‘83, Twomey at VSSBGI meeting:, Twomey at VSSBGI meeting: US screening → 9 AAA in 84 English men > ageUS screening → 9 AAA in 84 English men > age 5050 • Followed by more 1-site & (later) pop-based seriesFollowed by more 1-site & (later) pop-based series (most in UK)(most in UK)
  3. 3. MinneapolisMinneapolis Medical CenterMedical Center Typical example of crude early studiesTypical example of crude early studies
  4. 4. MinneapolisMinneapolis Medical CenterMedical Center Criteria for ScreeningCriteria for Screening (adapted from(adapted from Frame & Carlson, 1975) 1)1) Detection & treatment of the disease beforeDetection & treatment of the disease before symptoms appear must result in lowersymptoms appear must result in lower morbidity/mortality than treatment aftermorbidity/mortality than treatment after symptoms appear (effective treatment - RCTs)symptoms appear (effective treatment - RCTs) 2)2) Screening must be acceptable to patients andScreening must be acceptable to patients and cost-effective (simple test, common disease)cost-effective (simple test, common disease)
  5. 5. MinneapolisMinneapolis Medical CenterMedical Center Screening: why not just do it?Screening: why not just do it? We believe there is an ethical difference betweenWe believe there is an ethical difference between everyday medical practice and screening. If a patienteveryday medical practice and screening. If a patient asks a medical practitioner for help, the doctor doesasks a medical practitioner for help, the doctor does the best he can. He is not responsible for defects inthe best he can. He is not responsible for defects in medical knowledge. If, however, the practitionermedical knowledge. If, however, the practitioner initiates screening procedures he is in a very differentinitiates screening procedures he is in a very different situation. He should, in our view, have conclusivesituation. He should, in our view, have conclusive evidence that screening can alter the natural history ofevidence that screening can alter the natural history of disease in a significant proportion of those screened.disease in a significant proportion of those screened. Cochrane & Holland, Br Med BullCochrane & Holland, Br Med Bull 1971;27(1):3-81971;27(1):3-8
  6. 6. MinneapolisMinneapolis Medical CenterMedical Center Randomized Trials ofRandomized Trials of AAA ScreeningAAA Screening • Four trials in men - aged 65 to 73-83Four trials in men - aged 65 to 73-83 • Randomized a population list,Randomized a population list, invited half to screeninginvited half to screening • Screening was by ultrasoundScreening was by ultrasound • 60-80% attended60-80% attended • 4-8% of these had4-8% of these had AAA (AAA (≥≥ 3.0 cm)3.0 cm) • 1° outcome: AAA-related death by intent to treat1° outcome: AAA-related death by intent to treat • Non-emergency AAA repairNon-emergency AAA repair ↑↑ 2-3 fold in invited group2-3 fold in invited group
  7. 7. MinneapolisMinneapolis Medical CenterMedical Center
  8. 8. MinneapolisMinneapolis Medical CenterMedical Center Meta-analysis of odds ratios of all cause long term mortality in men
  9. 9. MinneapolisMinneapolis Medical CenterMedical Center
  10. 10. MinneapolisMinneapolis Medical CenterMedical Center ??
  11. 11. MinneapolisMinneapolis Medical CenterMedical Center Re-Screening?Re-Screening? • ADAM: 2622 pts (50-79 yo) < 3.0 cm re-screened after 4 yrsADAM: 2622 pts (50-79 yo) < 3.0 cm re-screened after 4 yrs (Lederle, Arch Intern Med 2000;160:1117)(Lederle, Arch Intern Med 2000;160:1117) • Gloucestershire: 223 men (65 yo) < 2.6 cm, after 5 & 12 yrsGloucestershire: 223 men (65 yo) < 2.6 cm, after 5 & 12 yrs (Crow, Br J Surg 2001;88:941)(Crow, Br J Surg 2001;88:941) • Chichester: 649 men (65 yo) < 3.0 cm, q 2 yr up to 10 yrsChichester: 649 men (65 yo) < 3.0 cm, q 2 yr up to 10 yrs (Scott, EJVES 2001;21:535)(Scott, EJVES 2001;21:535) • All found low yield, small AAA, concluded not worthwhileAll found low yield, small AAA, concluded not worthwhile • Chichester: 95% of ruptures in district were in men > 65 yoChichester: 95% of ruptures in district were in men > 65 yo • Conclusion: One-time screen at age 65Conclusion: One-time screen at age 65 ..
  12. 12. MinneapolisMinneapolis Medical CenterMedical Center MASS 10 yr BMJ 6/27/09
  13. 13. MinneapolisMinneapolis Medical CenterMedical Center After the Screening TestAfter the Screening Test • Inform patient of negative test resultInform patient of negative test result • more reassuring than “no news is good news”more reassuring than “no news is good news” • Large AAA - consider elective repairLarge AAA - consider elective repair • AAA <5.5cm: ultrasound surveillance (ADAM, UKSAT)AAA <5.5cm: ultrasound surveillance (ADAM, UKSAT) • AAAAAA ≥≥ 4.0 cm: every 6 months (ADAM)4.0 cm: every 6 months (ADAM) • AAA < 4.0 cm: every 2-3 yearsAAA < 4.0 cm: every 2-3 years ((Grimshaw,Grimshaw, EJ VS 1994;8:741;EJ VS 1994;8:741; Santilli,Santilli, JVS 2002;35:666JVS 2002;35:666)) • Quit smoking (AAA enlargementQuit smoking (AAA enlargement ↓↓ in quitters)in quitters) (MacSweeney, Lancet 1994;344:651)(MacSweeney, Lancet 1994;344:651)
  14. 14. MinneapolisMinneapolis Medical CenterMedical Center Cost-Effectiveness of AAA ScreeningCost-Effectiveness of AAA Screening • MASS study: 1MASS study: 1stst reportreport ≈≈ $45$45,000 per YOLS,000 per YOLS • At 10 yr report,At 10 yr report, ≈≈ $15$15,000 per YOLS,000 per YOLS • Viborg ‘10:Viborg ‘10: ≈≈ €157 per YOLS (US = €28)€157 per YOLS (US = €28) • 5 of 6 earlier CEA’s (not based on trials)5 of 6 earlier CEA’s (not based on trials) concluded screening was cost-effectiveconcluded screening was cost-effective • Elective repair < $20,000 in European trials,Elective repair < $20,000 in European trials, but > $47,000 in USAbut > $47,000 in USA (Lee, JVS 2004;39:491)(Lee, JVS 2004;39:491) • No recent cost-effectiveness analysis for USANo recent cost-effectiveness analysis for USA • USPSTF EPC estimates < $20,000 per QALYUSPSTF EPC estimates < $20,000 per QALY
  15. 15. MinneapolisMinneapolis Medical CenterMedical Center • Recommended one-time ultrasound screening forRecommended one-time ultrasound screening for AAA in men aged 65-75 who ever smoked (B)AAA in men aged 65-75 who ever smoked (B) • No recommendation for men who never smoked (C)No recommendation for men who never smoked (C) • RecommendRecommend againstagainst routine AAA screening inroutine AAA screening in women (D)women (D)
  16. 16. MinneapolisMinneapolis Medical CenterMedical Center
  17. 17. MinneapolisMinneapolis Medical CenterMedical Center SAAAVE Act brings (some) Medicare coverageSAAAVE Act brings (some) Medicare coverage • Medicare (covers Americans over age 65) does notMedicare (covers Americans over age 65) does not include preventive services, so each requires an ‘act ofinclude preventive services, so each requires an ‘act of Congress’Congress’ • After USPSTF report, Congress added a MedicareAfter USPSTF report, Congress added a Medicare benefit for ultrasound AAA screening at the ‘Welcomebenefit for ultrasound AAA screening at the ‘Welcome to Medicare’ visitto Medicare’ visit • Covers male ever-smokers & anyone with familyCovers male ever-smokers & anyone with family history of AAAhistory of AAA • Problem: the ‘Welcome to Medicare’ visit is only forProblem: the ‘Welcome to Medicare’ visit is only for those aged 65-66!those aged 65-66!
  18. 18. MinneapolisMinneapolis Medical CenterMedical Center Will the benefits seen in the AAA screeningWill the benefits seen in the AAA screening trials be achieved in U.S. practice?trials be achieved in U.S. practice? • The AAA screening trials had strict eligibility criteriaThe AAA screening trials had strict eligibility criteria • In MASS, the key trial, AAA repaired only whenIn MASS, the key trial, AAA repaired only when ≥≥ 5.5 cm (per UKSAT & ADAM)5.5 cm (per UKSAT & ADAM) • If AAA screening and/or repair is employed muchIf AAA screening and/or repair is employed much more widely than in the trials, ratio of benefit to harmmore widely than in the trials, ratio of benefit to harm & cost will likely& cost will likely decreasedecrease • This is what seems to be happening in the U.S.A.This is what seems to be happening in the U.S.A.
  19. 19. MinneapolisMinneapolis Medical CenterMedical Center SVS/AAVS/SVMBSVS/AAVS/SVMB Consensus StatementConsensus Statement • Proposed criteria for AAA screening eligibilityProposed criteria for AAA screening eligibility much broader than USPSTF or RCTs, including:much broader than USPSTF or RCTs, including: • Men aged 60-85Men aged 60-85 • Women aged 60-85 with CV risk factorsWomen aged 60-85 with CV risk factors • Anyone > age 50 with a family history of AAAAnyone > age 50 with a family history of AAA
  20. 20. MinneapolisMinneapolis Medical CenterMedical Center ProgramProgram NumberNumber ScreenedScreened ProportionProportion of womenof women Prevalence ofPrevalence of AAA ≥AAA ≥ 3.0 cm3.0 cm MenMen WomenWomen AVAAVA 7,8417,841 60%60% 4.5%4.5% 0.85%0.85% DARE to CAREDARE to CARE 12,05512,055 59%59% 3.2%3.2% 0.5%0.5% Life Line ’07Life Line ’07 17,54017,540 57%57% 3.9%3.9% 0.7%0.7% PROMISPROMIS 979979 31%31% 4.0%4.0% 0.0%0.0% In recently published U.S. ultrasound screening programsIn recently published U.S. ultrasound screening programs • Most screenees were womenMost screenees were women • The yield of AAA was (therefore) lowThe yield of AAA was (therefore) low Many U.S. screening programs may beMany U.S. screening programs may be much less cost-effective than the RCTsmuch less cost-effective than the RCTs
  21. 21. MinneapolisMinneapolis Medical CenterMedical Center Repair of small AAA in U.S. - PracticeRepair of small AAA in U.S. - Practice • >59% of EVR at Cleveland Clinic (1996-2002) was on>59% of EVR at Cleveland Clinic (1996-2002) was on AAA < 5.5 cm (Ouriel, J Vasc Surg 2003;37:1206)AAA < 5.5 cm (Ouriel, J Vasc Surg 2003;37:1206) • 1/41/4 of AAA deaths in U.S. result from elective repairof AAA deaths in U.S. result from elective repair • ≈≈ 5000 deaths/yr from AAA rupture (CDC Wonder)5000 deaths/yr from AAA rupture (CDC Wonder) • 45,000 intact AAA repairs/year with 3% mortality45,000 intact AAA repairs/year with 3% mortality →→ ≈≈ 1400 deaths (McPhee, JVS ‘07)1400 deaths (McPhee, JVS ‘07) • >1/3 of AAA deaths are ‘w/o mention of rupture’ (CDC)>1/3 of AAA deaths are ‘w/o mention of rupture’ (CDC) • Screening in USA could lead to repair of many small AAA, resulting in more deaths
  22. 22. MinneapolisMinneapolis Medical CenterMedical Center • Used large Life Line dataset to identify pts w AAAUsed large Life Line dataset to identify pts w AAA >3 cm by generating score that “expands the>3 cm by generating score that “expands the target population for screening” beyond USPSTFtarget population for screening” beyond USPSTF • Additional AAA mostly in women and men < 65Additional AAA mostly in women and men < 65 • Rupture rare before 65 (though 3 cm AAA is not)Rupture rare before 65 (though 3 cm AAA is not) • The only RCT in women showed no benefitThe only RCT in women showed no benefit • Dx of small AAA would ↑(& cost, repairs, deaths?),Dx of small AAA would ↑(& cost, repairs, deaths?), but no evidence for ↑ benefitbut no evidence for ↑ benefit • SVS now lobbying Congress to pressure USPSTFSVS now lobbying Congress to pressure USPSTF
  23. 23. MinneapolisMinneapolis Medical CenterMedical Center ConclusionConclusion • Many in U.S. who should be screened aren’tMany in U.S. who should be screened aren’t • Many in U.S. who shouldn’t be screened areMany in U.S. who shouldn’t be screened are • If screening in U.S. leads to a large increaseIf screening in U.S. leads to a large increase in elective repair in patients whose AAA wouldin elective repair in patients whose AAA would never have ruptured, the benefit seen in thenever have ruptured, the benefit seen in the RCT’s may be lostRCT’s may be lost
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