Presentations from AAA screening networking day 2017

2. Welcome and national update
Lisa Summers, Programme Manager, NHSAAAScreening
Programme, Public Health England

3. NAAASP National Update
AAA Networking Day
Lisa Summers
NHSAAAScreening Programme Manager
June 2017
Public Health England leads the NHS Screening Programmes

4. Headline figures
4
Headline figures
2009/10 to
date
provisional
2016/17
Number men eligible for
screening
1,612,394 282,705
Number of men offered
screening
1,587,662 281,575
Number of men screened 1,248,997 223,371
Number of men with aorta
≥3.0 cm
15,760 2,387
Coverage (percentage) 77.5 79.0
Uptake (percentage) 78.7 79.3
Aneurysms detected
(percentage)
1.26 1.07
​Referred for surgery 3,653​ 790​

5. KPIs 2016 to 2017
5
• First year publishing AA2, AA3 and AA4
• Latest data – Q3 (October to December 2016)
Q3 data provisional – to be published after purdah
• AA2 (coverage of initial screen)
• Performance 63.0% (just under achievable threshold of 64%)
• 14.6% of providers (6/41) did not meet acceptable threshold of 56%
• AA3 (coverage of annual surveillance screen)
• Performance 91.2% (above acceptable threshold 85%)
• Lower than achievable threshold 95%
• AA4 (coverage of quarterly surveillance screen)
• Performance 93.2% (above Q2 and above acceptable threshold 85%)
• Lower than achievable threshold 95%
https://www.gov.uk/government/collections/nhs-screening-programmes-national-data-
reporting under the ‘Reports’ section

6. Waiting times 2016 to 2017
• 787 men referred for surgery
• 123 men inappropriate referrals or died
• 352 men operated on within 8 weeks (53%) compared to 58.6% previous
year
• 19 programmes had more than 60% of appropriate referrals operated on
within 8 weeks (varied from 4% to 86.7%)
6

7. Standards, reporting & guidance
• Review of pathway standards 2018 to 2019
• Service Specification 2018 to 2019
• Reporting requirements
• SOPs
• Policies and guidance
7

8. IT & equipment
• SMaRT:-
• Training for Co-ordinators/Admin
• User Group
• Version 9.4
• Version 9.5
• Northgate contract
• Equipment
8

9. Inequalities toolkit
Four nations approach
9

10. IEPP update
• Blogs – sign up if not already done so!
IEPP@phe.gov.uk
Helpdesk
PHE.screeninghelpdesk@nhs.net
10
Denise Dixon
Publications and
information officer

11. AAA- Overview
• Slow decrease in volumes – especially since transfer cancer
• Majority solved without escalation
• Most common categories
• Local programme contact details – 27%
• AAA Screening Qualification – 16%
• National Guidance – 13%
11
Q1 (2016) – Q4 (2017)

12. Current Position – Q4 (2017)
12

13. Easy to read information
Easy to read information
Information for trans people
Audio version leaflets -
Blind and partially sighted
13
Mike Harris
Publications
and information
manager

14. Education and training update
14

15. CAVA Qualification
(Certificate for assessing vocational achievement)
• National requirement for assessing individuals - Involves a three step
process and is relatively simple:
• Skills scan
• Discussion with assessor
• Final assessment with expert
• Takes into consideration vast amount of assessing experience of CST’s
within the programme and also as a sonographer
• As many staff as you want - ask!!!
• Register on CPD website – soon to transfer to GOV.UK
15

16. Expert witness
• Observe learner’s performance at work
• Provide evidence to support the assessment process (Verbal and non-
verbal)
• Potential to be an expert witness for learners if you:
• work within a screening programme
• are occupationally competent
• are looking for additional development
• No additional training is required but expert witnesses must:
• be occupationally competent in area/s covered by the unit/s
• have gained occupational competence working within an appropriate
role in the programme
• maintain occupational competence by actively engaging in CPD
• familiar with qualification unit providing expert witness testimony for
16

17. Non-visualisation guidance
Guidance updated and made clearer, clarifying roles:-
• Ensure imaging centres are kept informed
• Failsafes in place to track patients referred for non-visualisation
• Non-visualisations NOT to be used to identify unusual anatomy/pathology
• Remain under the screening programme
• Local providers to fund imaging
• Name of the ultrasound professional must be on the report sent back
17

18. IQA framework
• Significantly updated late 2016
• Previous requirements were not being undertake by programmes
• Incorporated new screener qualification
• Key points
• Minimum of 200 scans/annum
• 8 random scans assessed every month
• Abnormals QA’d within 30 days (7 best practice)
• Clinical observation every 4 months
• Re-accreditation every 2 years
• Update QA module and requirements in the next 18 months
• SMaRT development to reflect changes
18

19. Technician re-accreditation
• New process introduced in April 2016
• Enables a more robust, meaningful and in-depth assessment
• 2 sections:-
• Knowledge assessment
• 2 e-learning units
• Helps with knowledge of physics, image optimisation and AAA’s
• Scanning assessment
• 2 men assessed to NAAASP protocols in Scope of Practice
• Failure of one or more scans, recovery portfolio available
• Clinical assessments are more difficult
• Re-accreditation process currently being reviewed for 2018
19

20. CST training
• Updated in April 2016 and includes:-
• 7 e-learning units
• 0.5 days shadowing with another CST
• SMaRT/data session with co-ordinator
• Complete CAVA training, if appropriate
• Sign off from clinical director of the programme
• Handbook available online
• Looking at producing a range of resources over the next 12-18 months to
support the CST’s
20

21. Programme optimisation
Rapid review by Canadian team concluded…
‘insufficient evidence to recommend surveillance in men with
subaneurysmal aortas’
21

22. Other programme matters
4 nations’ results

23. Re-commissioning
• North East & Cumbria:-
• North East & North Cumbria
• Lancashire & South Cumbria
• Effective from 5 April 2017
• London:-
• North & South
23

24. Coming up….
• National Networking & Information Sharing Day – 27 June 2017
Holiday Inn, Central Birmingham
24
HOME OFFICE - VULCAN HOUSE
SHEFFIELD

25. Thank You!
25

26. Programme optimisation and
research update
Jonothan Earnshaw, Clinical Lead, NHSAAAScreening
Programme, Public Health England

27. Part of Public Health England
Abdominal Aortic Aneurysm
NHSAAAScreening Programme
Update on programme optimisation
and research
June 2017
Jonothan JEarnshaw
Clinical Lead

28. NAAASP results June 2017
Headline figures 2009/10 to date provisional 2016/17
Number men eligible for screening 1,612,394 282,705
Number of men offered screening 1,587,662 281,575
Number of men screened 1,248,997 223,371
Number of men with aorta ≥3.0 cm 15,760 2,387
Coverage (percentage) 77.5 79.0
Uptake (percentage) 78.7 79.3
Aneurysms detected (percentage) 1.26 1.1
Referred for surgery 3653 790

29. NAAASP optimisation programme
Endorsed by NSC 23.6.17
1. Reduce surveillance intervals
2. Introduce inequalities initiative: aim to improve uptake
by 10%
3. Further study of men with subaneurysmal aorta

30. 1. Surveillance intervals
• Change 3 to 4.4cm from annual to biennial (saves
12,000 scans/annum)
• Leave 4.5 to 5.4cm at 3 months, until more data on
safety
• Discuss with IT suppliers, and Advisory Board
• Final decision after NICE guidelines approved (2018)

31. 2. Inequalities initiative
• Annual local programme reports
• Toolkit for local programmes
• Local learning to update toolkit
• Aim to improve uptake by 10%

32. 3. Subaneurysmal aorta
• Approve research within programme into harms of being
in surveillance – quality of life studies using AAA SMaRT
• Modelling and retrospective review of outcomes of men
with subaneurysmal aorta at 65 years who develop a
5.5cm AAA during surveillance
• Cost benefit analysis

33. Research committee
Travel times for screening
Turn down rates
Referral threshold (NICE interested)
Prehabilitation
DNA rates (for discussion)
(now includes evaluation of service improvement/audit)

34. Issues from the programmes
1. GP endorsement of invitation letters
2. Research into men who decline or do not attend
screening

35. Update onAdvisory Board
• New Chair – Meryl Davis
• Updated membership
• Meeting Sept/Oct 2017

36. National IT update
Carol Harrison, Head of Health Services Delivery, Northgate
Public Services

37. AAA Networking Day
27th June 2017
Presented by:
Carol Harrison
NPS - Head of Health Services Delivery

38. Your NPS Support
38
AAA Programme is supported by a number of individuals and teams:
Helpdesk Team
2nd Line Team
3rd Line Infrastructure Team
Service Delivery Manager - Steve Newton
Development Team
Senior Consultant - Peter Chapman
Project Support
Programme Management:
Carol Harrison – Head of Health Services Delivery
James Thomas – Head of Health Development, Consultancy & Project Support
Alan Campbell – Head of Screening Programmes

39. Your NPS Support
39
Are you aware of the
existing AAA
customer portal for
call logging? Only
two users are using it
today……..
We would like to
encourage you to use
the portal, contact
the helpdesk to get
access if you don’t
have it already.

40. Your NPS Support
40
Advantages of portal
usage:
• Log a call – 24*7
capability,
immediate call
reference.
• View latest status of
a call – to find out
latest update of your
calls
• Update a call – you
can add an update
to the call
• Close a call – if
resolved to your
satisfaction you can
close it
Contact the helpdesk to request portal access.

41. Statistical Information
41
• How many calls do you think were logged with our
Helpdesk in 2016?

42. Statistical Information
42
• How many calls do you think were logged with our
Helpdesk in 2016? 2730

43. Statistical Information
43
• How many calls do you think were logged with our
Helpdesk in 2016? 2730
• How many calls logged so far (up to June 19th) this
year?

44. Statistical Information
44
• How many calls do you think were logged with our
Helpdesk in 2016? 2730
• How many calls logged so far (up to June 19th) this
year? 1012

45. Statistical Information
45
• How many calls do you think were logged with our
Helpdesk in 2016? 2730
• How many calls logged so far (up to June 19th) this
year? 1012
• What do you think the top 3 call types logged in
the last 6 months have been?

46. Statistical Information
46
• What do you think the top 3 call types logged in
the last 6 months have been?
General Admin - 288
Account Admin - 158
Password Resets - 147
Making up almost 60% of all calls logged

47. Statistical Information
47
• Highest call volumes logged in last 6 months:
• Programme A =56
• Programme B =52
• Programme C =48

48. Statistical Information
48
• Looking at a comparison of the types of calls
logged so far in 2017 against data in the last 6
months of 2016

49. Statistical Information
49
Comparing 6 months of 2016 data with calls in 2017
1st July - 31st December 2016: Closed 1,152 1st January - 19th June 2017: Closed 1,046
43 DNA revert 3.7% 44 DNA revert 4.2%
39 Nurse Assessment 3.4% 54 Nurse Assessment 5.2%
77 Missing 6.7% 67 Missing 6.4%
23 Measurements 2% 13 Measurements 1.2%
18 QA worklist 1.6% 18 QA worklist 1.7%
12 Surveillance Discharge 1% 14 Surveillance Discharge 1.3%
83 Imaging 7.2% 78 Imaging 7.4%
158 Password reset 13.7% 147 Password reset 14%
Total percentage of calls: 39.3% Total percentage of calls: 41.4%

50. www.northgatepublicservices.co.uk
Thank you!

51. Issues from the programmes
AnneStevenson,NationalProgrammesLead,YoungPersonandAdultScreening
Programmes,PublicHealthEngland
JonothanEarnshaw,ClinicalLead,NHSAAAScreeningProgramme,PublicHealth
England
LisaSummers,ProgrammeManager,NHSAAAScreeningProgramme,PublicHealth
England

52. Part of Public Health England
Abdominal Aortic Aneurysm
NHSAAAScreening Programme
Issues from the programmes
June 2017
Jonothan JEarnshaw, Lisa Summers
andAnne Stevenson

53. 1. GP endorsement of invitation letters
Increasing Uptake 3.53. It is recommended that:
Commissioners and providers work with local authorities and third sector organisations to
understand and develop plans to address uptake and inequalities. QA visits include an assessment of
the process to develop such plans and their implementation at a local level.
Commissioners work with providers to ensure that letters and invitations have been endorsed by
GPs (where the GP agrees), timed first and second appointments are offered and appointment
reminders are used.
Providers, commissioners and local authorities are encouraged to pilot, evaluate and publish
(preferably in peer reviewed journals) local solutions to address inequalities of access. Before piloting,
these local proposals must be agreed with the PHE screening team to ensure consistency of message
with nationally agreed letters.
PHE screening team will share new and emerging knowledge via the screening inequalities network
and blogs.

54. GP endorsement: RCT in colorectal cancer
screening
GP endorsement increased uptake:
adjusted odds ratio [OR] 1·07, 95% CI
1·04–1·10, p<0·0001).
No effect from: simplified invitation
leaflet; narrative invitation leaflet; or
enhanced reminder letter
Lancet 2016

56. GP endorsement: options
• GPs to send invitation letter
• GP endorsement as in ASCEND. Need to contact all GP
surgerys and obtain consent
• Other?

57. 2. Research into men who decline, or do
not attend screening
Until now, contacting men who have declined or failed to
attend screening, after reinvitation has not been allowed
within NAAASP.
Pressure from researchers, ethics committees and
commissioners to increase uptake
Danger:
coercion……

58. Emerging QA themes
MoragArmer, Consultant in Public Health, Head of Quality
Assurance, Screening, South, Public Health England

59. Emerging QAThemes
NAAASP Networking and information day
27th June 2017
Morag Armer
Consultant in Public Health
Head of QA South
Screening QA Service

60. Objectives:
• QA visits:
•What we’ve done
•What we’ve found – top 10 themes
• Screening safety incidents
•Numbers
•Themes & learning
60 NAAASP Networking and information day June 2017

61. What we’ve done - North

62. What we’ve done –Midlands and East

63. What we’ve done - South

64. What we’ve done –London

65. What we’ve found - governance
65 NAAASP Networking and information day June 2017

66. What we’ve found: infrastructure
66 NAAASP Networking and information day June 2017

67. What we’ve found: cohort & uptake
67 NAAASP Networking and information day June 2017

68. What we’ve found: accuracy of test
68 NAAASP Networking and information day June 2017

69. What we’ve found: referral & intervention
69 NAAASP Networking and information day June 2017

70. Learning fromAAAincidents
70 NAAASP Networking and information day June 2017
Region Q1
15/16
Q2
15/16
Q3
15/16
Q4
15/16
Q1
16/17
Q2
16/17
Total
North 2 0 3 5 3 4 17
M&E 8 1 1(1) 7 12 10 39 (1)
South 3 1 0 1 3 (2) 2 10 (2)
London 0 0 2 1 4 (1) 4 11 (1)
Nationa
l
0 0 0 0 0 1 1
Total 13 2 6 (1) 14 22 (3) 21 78 (4)

71. ThemesAAAincidents
Avoidable delay to treatment.
Man with AAA >5cm not operated on
within 8 weeks – hospital factors
Images:
incomplete transfer
not transferred
lost
AAA not identified at test.
Subsequent rupture
Patients’ records incorrectly
categorised in the software causing
deactivated instead of ‘moved
area/temporary ceased/deducted
IG issues
Cohort on SMaRT
not invited or have
inconclusive result
71 NAAASP Networking and information day June 2017

72. Learning fromAAAincidents
Referral centres to amend
diagnostic / treatments pathway
Monitor breaches
Over 12 weeks reported at PB
Internal failsafe processes to be
followed
Scan equipment serviced
regularly
Complete death notification
within SMaRT
Software supplier reviewed data
transfer process
Services check weekly
notification
Letter templates to be checked
Cohort on SMaRT
not invited or have
inconclusive result
72 NAAASP Networking and information day June 2017

73. Thank You
73 NAAASP Networking and information day June 2017

74. Launch of inequalities initiative for
2018
LisaSummers,ProgrammeManager,NHSAAAScreeningProgramme,PublicHealthEngland
JoJacomelli,DataandInformationManager,YoungPersonandAdultScreeningProgrammes,
PublicHealthEngland
LindaSyson-Nibbs,ConsultantinPublicHealth,HeadofQA,MidlandsandEast,
PublicHealthEngland

75. NHS AAA Networking and
Information Day
Addressing Inequalities
Public Health England leads the NHS Screening Programmes

76. Inequalities : shared roles & responsibilities
NHS England
Public Health
England
Local
Government
Social Care
Act 2012
Screening
service
providers
Equality Act
2010
Accessible
Information
Standard 2016
76 LDT@phe.gov.uk

77. DES Networking day

78. Who experiences screening inequalities ?
Published evidence shows that the groups at
greatest risk include ..
• Those experiencing economic deprivation
• Members of minority ethnic groups
• People with learning or physical disabilities
• People with serious and enduring mental
Illnesses
• Other protected groups identified by Equality
Act 2010
DES Networking day

79. What is the difference between
Inequality and Inequity?
• Health inequality describes the differences in health
outcomes between different population groups
according to socio-economic status, geographical area,
age, disability, gender or ethnic group.
• Health inequity describes differences in opportunity for
different population groups which result in unequal
access for example to health services
DES Networking day

80. Screening division inequalities strategy
Lead Jo Taylor Uptake and Inequalities Manager
Build on :
• Past and current programme specific work ( including spotlight )
• inequalities network
• Stakeholder engagement
Present at PHE Annual conference in September
Implement through programme specific and generic action plans
DES Networking day

81. What can we do next ?
• Little opportunity to impact on wider
determinants of health
• Adopt the concept of proportional universalism
• Improve uptake (but may worsen inequalities )
• Focus on action to reduce inequity (opportunity)
• Utilise audit …..
DES Networking day

82. Equality, fairness and inclusion
AAAToolkit
Lisa Summers
NHSAAAScreening Programme Manager
June 2017
Public Health England leads the NHS Screening Programmes

83. Inequalities toolkit
Four nations approach
83

84. Aims of Toolkit
84
• To provide local providers with clear data, enabling them to identify
areas of inequality relating to their local area(s)
• Produce guidance to enable local providers to use data to reduce
inequalities and increase coverage within their local area(s)
• To obtain and share examples of good practice to support local
providers to reduce inequalities

85. Approach
• Project board
• Good practice
• Data reports
• Ethnicity recording
• Literature review
• Toolkit
85

86. Content
• GOV.UK (with links to other nations)
• Introduction to AAA Screening Programme / Programme Objectives
• Rationale
• Information Governance
• Resources:-
Case studies A – Z
Literature review
• Reports and audit forms
• Submitting evidence
86

87. Process for submitting into toolkit
• Complete heath inequality needs assessment form
• Undertake best practice work identified (after appropriate agreement)
• Submit as per ‘Case for Shared Learning’
• Blog
87

88. Inequalities workshop
AAAnetworking day, 26 June 2017

89. Inequalities report
• Available through SMaRT quarterly
• Tables of
• Eligible, offered, screened and declined by
• GP
• LSOA
• LA
• Ethnicity of men tested by
• Programme
• LA
• Ethnicity of men with aorta ≥3.0cm
• Line list of men referred for surgery by LSOA and ethnicity
• Tool to support analysis of ethnicity and deprivation
• Guidance document available
89 Inequalities data workshop

90. Workshop
Aim: to practice reviewing and analysing the data from the report
• Data pack on table with example graphs from the analysis tool using real
programme data
• Review the charts on deprivation (IMD2015 deciles) and ethnicity
• Discuss what you think the data shows
• Discuss what you would do next
• 20 minutes then feedback
90 Inequalities data workshop

91. Questions
Does deprivation affect
• uptake?
• first appointment DNAs?
• declines?
• aneurysms?
Is the service testing a similar proportion of men compared to the
background population for each LA and the ethnic group specified?
Do you need any further information?
What would you do next?
91 Inequalities data workshop

92. Update on genetic links to AAA
disease
Matt Bown, Professor of Vascular Surgery and Director of
ClinicalAcademic Training, University of Leicester

93. NAAASP 27th June 2017
Genetic links to AAA
Matthew Bown
Department of Cardiovascular Sciences
University of Leicester

94. 0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
30 to 44 45 to 54 55+
NAAASP AAA sizes
AAA – non-surgical intervention?

95. AAA – opportunity intervention?

96. Medical treatment for AAA?

97. Medical treatment for AAA?

98. Genetics of AAA

99. Genetics of AAA

100. Genetics of AAA

101. Single nucleotide polymorphisms
AAGGCTAA
||||||||
TTCCGATT
AAGACTAA
||||||||
TTCTGATT
SNP
Individual A
Individual B
Common GeneticVariation

102. Genetic Association
No AAA AAA

103. Genetic Association
No AAA AAA

104. Gel based
Labour intensive
Interpretation difficult
Genotyping c. 2000

105. IL-10
CCR5
ACE
Telomere length
9p21
DNA resource
Genetics of AAA

106. Human genome
• Published 2000
• Currently ‘build’ 38
• 3,554,996,726 base pairs
• 24,983,387 SNPs

107. Array Genotyping

108. WTCCC GWAS - 2007

109. Leeds
Leicester
Sanger Institute
UCL/Chichester
Imperial
St Georges’
WellcomeTrust AAA GWAS - 2009

110. Leeds
Leicester
Sanger Institute
UCL/Chichester
Imperial
St Georges’
KCL
Belfast
Otago
Perth
Stockholm
Copenhagen
Viborg
Reykjavik
WellcomeTrust AAA GWAS - 2009

111. AAA GWAS - 2011
LRP1

112. USA
n=724
Iceland
n=557
UK
n=1846
Netherlands
n=840
New Zealand
n=1005
AAA GWAS Datasets

113. AAA GWAS Meta-analysis
UK:
Iceland:
USA:
NZ:
Dutch:
Total: 1846
1846
n AAA

114. AAA GWAS Meta-analysis
UK:
Iceland:
USA:
NZ:
Dutch:
Total: 2403
1846
557
n AAA

115. AAA GWAS Meta-analysis
UK:
Iceland:
USA:
NZ:
Dutch:
Total: 3127
1846
557
724
n AAA

116. AAA GWAS Meta-analysis
UK:
Iceland:
USA:
NZ:
Dutch:
Total: 4132
1846
557
724
1005
n AAA

117. AAA GWAS Meta-analysis
UK:
Iceland:
USA:
NZ:
Dutch:
Total: 4972
1846
557
724
1005
840
n AAA

118. AAA GWAS Meta-analysis

119. AAA Genes
Chr Gene
1 SORT1
1 IL6R
1 SMYD2
9 CDKN2B-AS1
9 DAB2IP
12 LRP1
13 LINC00540
19 LDLR
20 MMP9
21 ERG
Lipids
Inflammation
Vasculogenesis
Matrix remodelling
Endothelial adhesion
Cell cycle/immune function
Genomic control

120. Is this all worthwhile?
PCSK9

121. Acknowledgements

122. Screening women for AAA
Mike Sweeting, Senior ResearchAssociate, University of
Cambridge

123. Should we screen women for AAA?
SWAN Collaborative Group
Cambridge: Simon Thompson, Michael Sweeting,
Edmund Jones, Katya Masconi
Imperial: Janet Powell, Pinar Ulug
Leicester: Matthew Bown
Sheffield: Jonathan Michaels
Brunel: Matthew Glover
AAA Networking and Information
Day
June 2017

124. Background to SWAN
 NHS AAA Screening Programme (NAAASP) for men aged 65 initiated
in 2009, now rolled out across all of UK
 No systematic screening for women, since AAA prevalence is
substantially lower than in men
BUT
 Modelling of NAAASP showed that the programme would be cost-
effective down to an AAA prevalence of 0.35%
 One-third of deaths from AAA in the UK are now in women
SO
 The cost-effectiveness of AAA screening in women needs to be
formally assessed

125. Women vs. men
Against screening women:
 Lower AAA prevalence
 Elective surgery outcomes are worse
In favour of screening women:
 AAA rupture rates are higher
 Ruptured AAA outcomes are worse
 Life-expectancy is greater
Overall balance is unclear
Optimal screening scenario for women is unclear

126. UK National Vascular Registry: Sex differences for
in-hospital mortality for elective AAA operations
Sidloff et al,
Br J Surg, in
press
Also see:
Ulug et al,
Lancet 2017

127. Assessing AAA screening in women
 Modelling exercise
o Review evidence on parameters for women (e.g. AAA prevalence,
attendance rate)
o Analyse relevant datasets (e.g. NVR for surgical mortality)
o Construct a clinically realistic model (i.e. screening, surveillance,
AAA growth and rupture, surgical intervention, mortality)
 Individual simulation model rather than a Markov
multistate model
o Allows flexibility (e.g. alternative intervention thresholds)
o Constructed first for men (and shown to validate well against the
MASS trial data)
o Adapted for women
 Focus on population screening (not subgroups)

128. Sources of data for women
Parameter Sources
AAA prevalence Systematic review
Attendance rate Chichester studies, literature review
AAA growth and rupture rates RESCAN Collaboration
Incidental detection rate New Zealand study
Non-intervention rates Systematic review
Surgical mortality
NVR, Hospital Episode Statistics (HES),
systematic reviews
Screening costs NAAASP
Surgical costs
EVAR-1 trial, IMPROVE trial, HES, NHS
reference costs
Non-AAA mortality UK Office for National Statistics
Quality of life UK population norms

129. AAA prevalence in women
Ulug P et al. BJS 2016

130. Diameter distribution at screening
(NAAASP re-weighted)
0
5
10
15
20
Percent
0 1 2 3 4 5 6 7 8 9 10 11
Measured AAA diameter (cm)
0
10
20
30
Percent
3 3.5 4 4.5 5 5.5 6 6.5 7 7.5 8 8.5 9 9.5 10 10.5 11 11.5
Measured AAA diameter (cm)

131. Non-intervention rate
Women
Whittaker
Scott
Gorst
Karthikesalingam
Overall Women (I-squared = 0.00%)
Men
Whittaker
Scott
Gorst
Karthikesalingam
Overall Men (I-squared = 86.64%)
Author
Jan 2013 - Dec 2015
Jan 2006 - Apr 2012
Jul 2007 - May 2011
Jan 2008 - Dec 2009
Jan 2013 - Dec 2015
Jan 2006 - Apr 2012
Jul 2007 - May 2011
Jan 2008 - Dec 2009
Period
36.92 (26.13, 49.21)
25.42 (15.95, 37.99)
37.18 (27.22, 48.37)
35.56 (23.06, 50.39)
34.23 (28.54, 40.41)
21.34 (17.55, 25.69)
23.84 (20.36, 27.71)
22.83 (18.08, 28.40)
7.77 (4.81, 12.30)
18.63 (13.44, 25.24)
Estimate (95% CI)
27.60
20.39
33.21
26.86
27.74
25.63
19.77
% Weight
18.80
0 10 20 30 40 50
Non-intervention rate (%)
100.00
100.00
Ulug P et al. Lancet 2017

132. o AAA prevalence 0.43%
o Attendance rate 73%
o Drop out rate 5% per annum
o Incidental detection rate 3% per annum
o Non-intervention rate 34%
o Elective operation 30-day mortality 2.4% (EVAR) 8.1% (Open)
o Emergency operation 30-day mortality 36% (EVAR) 44% (Open)
Summary of data for women

133. Base-case analysis for women
Scenario (as in screening programmes for men):
 AAA is aortic diameter ≥ 3.0cm
 Age at screening is 65 years
 Intervention threshold is 5.5cm
 Surveillance intervals as for men
Modelling from age 65 to 95

134. Base-case results for women
Invitation to screening:
Elective operations:  21%
Emergency operations:  6%
AAA deaths:  4%
Per 100,000 women invited to screening:
207 years-of-life gained
£3.54m additional costs
Cost-effectiveness:
£45,000 per quality-adjusted life-year (QALY) gained
(UK guideline < £20,000 per QALY for acceptance in NHS)

135. Events over time in 10 million women
invited (or not) to screening
Elective operations AAA deaths

136. Sensitivity analyses undertaken
 Halved or doubled the:
 AAA prevalence
 incidental detection rate
 drop-out rate from surveillance
 Different data sources used for:
 aortic diameter distribution
 elective surgery parameters
 emergency surgery parameters
 re-intervention rates after surgery
 Costs increased or decreased by 20%
These analyses did not change the overall qualitative
conclusions

137. Scenario analyses
Years-of-life gained
per 100,000 women
invited
Cost effectiveness:
£ per QALY gained
Base-case
(AAA prevalence 0.43%)
207 £45,000
Screening age 70 years
(AAA prevalence 0.70%)
261 £34,000
Diagnosis at ≥2.5cm
(AAA prevalence 1.44%)
290 £35,000
Intervention at 5.0cm 214 £48,000
Intervention at 4.5cm 168 £85,000
Best combined option:
Screening age 70 years
& diagnosis at ≥2.5cm
& intervention at 5.5cm
298 £33,000

138. Discussion
 In the absence of randomised trial data, detailed modelling is
the best approach
 Some parameters are very uncertain in women; assumptions
assessed by a range of sensitivity analyses
 Conclusions
o Inviting women as in NAAASP would yield only a small
clinical benefit
o Such a screening programme would not be cost-effective in
the UK context
o We did not find any combination of screening options for
women that would make population-based AAA screening
cost-effective

139. Hunterian lecture - Aortic aneurysm
screening: from evidence, through
implementation to optimisation
Jonothan Earnshaw, Clinical Lead, NHSAAAScreening
Programme, Public Health England

140. Part of Public Health England
Abdominal Aortic Aneurysm
Hunterian Lecture
AAAscreening: from evidence
through implementation to
optimisation
Jonothan JEarnshaw
Clinical Lead, NHSAAAScreening Programme

141. John Hunter 1728-1793

143. Abdominal aortic aneurysm

144. Abdominal aortic aneurysm
Still a major killer in elderly people
4000 deaths in England in 2007
Ultrasound screening 65 year old men reduces AAA-fatality rate by almost 50%
after 10 years (MASS Trial)

145. Meta-analysis of RCTs out to 10 years
Takagi et al.Angiology 2017
• Invitation to screening reduced AAA-related mortality: hazard ratio 0.66,
0.47 to 0.93
• Invitation to screening reduced all cause mortality: 0.98, 0.097 to 0.99
• Attendance at screening reduced AAA-related mortality: 0.4, 0.31 to 0.51
• Attendance at screening reduced all cause mortality: 0.6, 0.47 to 0.75
• Non attendance did not increase AAA-related mortality: 1.19, 0.82 to 1.72
• Non attendance increased all cause mortality: 1.41, 1.23 to 1.63

146. Gloucestershire Aneurysm
Screening Programme
0%
20%
40%
60%
80%
100%
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006

147. NHS AAA Screening Programme
Working party formed to advise NSC 2003
NSC recommended Programme to Department of Health
2007
Funding agreed 2008

148. Every man aged 65 in
England on, or after 1st
April 2013 has been
invited for AAA screening
Implementation
2009 - 2013
41 Local Programmes
Population ~1 million men

149. NHS AAA Screening Programme
Mobile screening team, portable ultrasound scanners
Trained screeners, quality assurance
Outcomes:
<3cm reassured and discharged
3-4.4 offered annual surveillance
4.5-5.4cm offered 3-monthly surveillance
>5.4cm referred for intervention
Bespoke IT (AAA SMaRT)

150. Headline results June 2017
• 1,587,662 men invited
• 1,248,997 men screened (uptake 78.6%)
• Over 15,760 AAA (>3cm) detected
• Prevalence 1.26%
•Almost 13,000 men in surveillance
• Some 3653 men referred for surgery
•Some 2213 treated (0.8% mortality) (Nov 16)
results available https://www.gov.uk/topic/population-
screening-programmes/abdominal-aortic-aneurysm

151. A 4 nations approach

152. Reducing AAA-related mortality
Anjum et al. BJS 2012

153. Cost effectiveness of AAA screening
BJS, 2015
AAA screening of 65
year old men remains
cost effective to a
prevalence of 0.35%

154. Reducing prevalence
Screening year Tested Aneurysm % aneurysm
2009/10 17,133 249 1.45
2010/11 30,549 490 1.60
2011/12 98,529 1,378 1.40
2012/13 183,034 2,463 1.35
2013/14 235,409 2,941 1.25
2014/15 224,517 2,674 1.19
2015/16 227,543 2,549 1.12
2016/17 223,371 2,387 1.07

155. Death from AAA rupture in surveillance
Risk of death from AAA rupture in 11,133 men in surveillance in NAAASP

156. Other benefits: remodelling of vascular
services in England
Networking – several
smaller hospitals
collaborating with a
single intervention centre
Preimplementation
quality assurance

157. Effect of vascular remodelling
Vascunet report 2008
Elective AAA mortality 7.4%
NVR 2016
Elective AAA mortality
Open (n=1316) 3%
EVAR (n=2882) 0.4%

158. Other benefits: secondary prevention in
men in surveillance
BJS 2016; 103: 1626
Improved 5-year survival in patients with
AAA with regular prescription for aspirin,
statins and antihypertensive drugs

159. Accelerated treatment: 8-week waits
2015/16

160. Other benefits: research
• AAA growth rates
• Optimal management of men in surveillance
• Referral thresholds
• Epidemiology of AAA

161. Disbenefits of AAA screening
• Every 10,000th man invited will die after elective AAA repair, who
would not have suffered a ruptured AAA.
• Men with small and medium AAA are inconvenienced and
medicalised
• Non fatal consequences of AAA treatment
• Men who do not attend are high risk
• Screening does not abolish rupture

162. Part of Public Health England
Abdominal Aortic Aneurysm
After implementation completed –
whole programme review 2015

163. Programme optimisation
• Reduce surveillance intervals
• Improve uptake
• ?introduce surveillance for men with
subaneurysmal aorta

164. Surveillance intervals
(RESCAN Collaborators), JAMA, 2013
Maintaining risk of rupture less than 1%,
the following surveillance intervals
are acceptable:
3-4cm – several years
4-4.9cm – annual
5-5.4cm – six months

165. Surveillance intervals: proposal
• Change 3 to 4.4cm from annual to biennial (saves
10,000 scans/annum)
• Leave 4.5 to 5.4cm at 3 months, until more data on
safety
• Discuss with IT suppliers, and Advisory Board
• Final decision after NICE guidelines approved (2018)

166. Uptake of screening and aneurysms
detected by decile of deprivation

167. Equality, fairness and inclusion
programme: proposal
• Annual local programme reports
• Toolkit for local programmes
• Local learning to update toolkit
• Aim to improve uptake by 10%

168. Subaneurysmal
aorta
Wild et al, EJVES 2013

169. Subaneurysmal aorta 2.6-2.9cm

170. Subaneurysmal aorta in Glos:
risk of developing a 5.5cmAAA
0.000.250.500.751.00
1562 512 132 19 0 0Diameter = 3.0-5.4cm
1233 760 380 89 11 0Diameter = 2.6-2.9cm
Number at risk
0 5 10 15 20 25
Time (years)
Diameter=2.6-2.9cm Diameter=3.0-5.4cm
0.000.250.500.751.00
CumulativeIncidence
473 435 199 43 4 0Diameter = 3cm or more
256 220 129 37 6 0Diameter = 2.6-2.9cm
Number at risk
0 5 10 15 20 25
Time (years)
2.6-2.9cm, 5 years after 1st scan
3cm or more, 5 years after 1st scan

171. Subaneurysmal aorta (2.6-2.9cm) at age
65 years
66% reach 3cm by age 70
10% reach 5.5cm after 10 years
25% reach 5.5cm after 15 years
Number who rupture?
Number who reach 5.5cm that have treatment?
Number that survive treatment?

172. Men aged >74 years withAAA>5.4cm
Since 2009:
94 men referred for treatment
- 66 subaneurysmal at 65
- 28 aortic diameter >3cm at 65
(another 122 men under 75 years referred)

173. Turn down rate
(no intervention within 3 months of referral)
Subaneurysmal at 65 years
- 44/66 (75%) treated; 1 death (1.5%)
>2.9cm at 65 years
- 22/28 (78%) treated; no deaths
Overall NAAASP data (2015/16)
- turn down rate 21%; mortality 1.4%

174. Subaneurysmal aorta (2.6-2.9cm) at age
65 years
66% reach 3cm by age 70
10% reach 5.5cm after 10 years
25% reach 5.5cm after 15 years
Number who rupture?
Number who reach 5.5cm that have treatment?
Number that survive treatment?
Canadian rapid review 2016:
not enough evidence to recommend
surveillance for men age 65 with a
subaneurysmal aorta

175. Subaneurysmal aorta: proposal
endorsed by NSC 23.6.17
• Approve research within programme into harms of being
in surveillance – quality of life studies using AAA SMaRT
• Modelling and retrospective review of outcomes of men
with subaneurysmal aorta at 65 years who develop a
5.5cm AAA during surveillance
• Cost benefit analysis

176. Where next?
Spread the message

177. Horizon scanning
• RCT of metformin for AAA growth
• Targetted screening for women?
• Debate about referral thresholds
• When to stop surveillance

178. Horizon scanning NAAASP
• Recommissioning
• Cost reduction
• Programme enhancement ? ABPIs/cholesterol/ECG

179. Conclusion
NHS AAA Screening Programme is feasible and cost
effective.
Referral threshold safe
Still room for optimisation
On target to reduce deaths by up to 50%