title: A Sustained Mortality Benefit from Screening for Abdominal Aortic Aneurysm The Multicentre Aneurysm Screening Study (MASS) into the effect of abdominal aortic aneurysm screening on mortality in men: a randomised controlled trial A comparative study of the prevalence of abdominal aortic aneurysms in the United Kingdom, Denmark, and Australia Requiring physicians to respond to computerized reminders improves their compliance with preventive care protocols Multicentre aneurysm screening study (MASS): cost effectiveness analysis of screening for abdominal aortic aneurysms based on four year results from randomised controlled trial. The aneurysm detection and management study screening program: validation cohort and final results. Aneurysm Detection and Management Veterans Affairs Cooperative Study Investigators. Opportunistic electronic reminders. Improving performance of preventive care in general practice. Screening for abdominal aortic aneurysm with electronic clinical reminders.
abstract: Context Is it cost-effective to screen older adults for abdominal aortic aneurysm ( AAA ) ? Contribution This 7-year follow-up report of a large r and omized trial in the United Kingdom found that men age 65 to 74 years who were invited to have ultrasonography and surveillance for AAA  had lower mortality rates than did those who were not invited ( hazard ratio , 0.53 [ CI , 0.42 to 0.68 ] ) . Cost-effectiveness for AAA-related deaths , based on costs applied to the events experienced by the men , was estimated at $ 19500 ( CI , $ 12400 to $ 39800 ) per life-year gained . Caution s Only men were studied .  Actual costs of screening and surveillance  may vary substantially in different setting s. The Editors A fast-growing body of literature is providing evidence in favor of screening men for abdominal aortic aneurysm ( AAA ) . Several large , r and omized trials published in the past few years ( 14 ) have consistently shown that screening reduces AAA-related mortality . A few observational studies of programs under way in localized areas have established the feasibility of systematic screening and have explored its practical implementation ( 57 ) . In addition to the mortality benefit , evidence indicating that screening is highly cost-effective is increasing ( 811 ) . In light of this evidence , national screening programs are now being considered in many countries ( 1214 ) . However , there is little evidence regarding long-term outcomes after AAA screening ; almost all of the evidence from r and omized trials is limited to the first 4 years after screening ( 14 ) . Moreover , long-term cost-effectiveness has been estimated only through health economic modeling ( 10 ) . We describe cost-effectiveness based on 7-year follow-up from the largest of the 4 trials of AAA screeningthe Multicentre Aneurysm Screening Study ( MASS ) ( 2 ) . The trial r and omly assigned approximately 67800 men age 65 to 74 years to receive an invitation to screening or to not receive an invitation .  At 4-year follow-up , the trial reported a substantial relative reduction of 42 % ( 95 % CI , 22 % to 58 % ) in AAA-related mortality and an incremental cost-effectiveness ratio of $ 44900 ( CI , $ 24000 to $ 231000 ) per life-year gained ( 9 ) , which is at the borderline of the commonly accepted threshold for interventions . All values are reported in U.S. dollars ( U.K. 1 = U.S. $ 1.58 ) ( 15 ) . The costs of AAA screening are primarily incurred at the start of the program , but benefits continue to accrue in terms of life-years gained in patients in whom AAA rupture is avoided through elective surgery . It is therefore expected that cost-effectiveness of screening will improve over time . The mid-term results of MASS provide reliable , trial-based information regarding clinical outcomes and cost-effectiveness over a longer period . Methods The details of the MASS protocol were described previously ( 2 ) , but a brief summary is provided ( Figure 1 ) . Between 1997 and 1999 , a population -based sample of 70495 men age 65 to 74 years from 4 centers in the United Kingdom was identified by obtaining records for every man in this age range who was registered with a family physician ( registered persons account for approximately 98 % of the population ) . Persons who were ineligible for the trial ( incorrect details , known AAA , previous AAA surgery , or terminal illness ) were excluded before r and omization . The remaining 67770 men were r and omly assigned to receive an invitation to ultrasonography for AAA or to not receive an invitation to ultrasonography . At screening , men with an aortic diameter of 3.0 cm or greater were defined as having an AAA and were subsequently invited for recall scans to monitor growth of the aneurysm . Men with an aortic diameter of 3.0 to 4.4 cm were rescreened every year , and those with an aortic diameter of 4.5 to 5.4 cm were rescreened every 3 months . Participants were considered for elective surgery when the aortic diameter reached 5.5 cm , aortic expansion was 1.0 cm or more in 1 year , or they experienced symptoms attributable to the aneurysm . Men with an aortic diameter less than 3.0 cm on the initial scan were not rescreened . Blood pressure was also measured ; although family physicians were informed of these measurements , no further intervention was provided through the screening program . We obtained approval from local ethics committees at each center , and all patients who had screening provided signed informed consent . Figure 1 . Study flow diagram . Additional data on follow-up scans and AAA surgeries were collected from hospital records . Deaths up to 31 March 2005 were confirmed by the U.K. Office of National Statistics after matching of the unique National Health Service number for each person . Follow-up ranged from 5.9 to 8.2 years ( mean , 7.1 years ) . The primary outcome of interest , AAA-related mortality , is defined as all deaths within 30 days of any AAA surgery ( elective or emergency ) plus all deaths with International Classification of Diseases , Ninth Revision , codes 441.3 ( ruptured abdominal aortic aneurysm ) , 441.4 ( abdominal aortic aneurysm without mention of rupture ) , 441.5 ( ruptured aortic aneurysm at unspecified site ) , or 441.6 ( aortic aneurysm at unspecified site without mention of rupture ) . The use of codes 441.5 and 441.6 may result in inclusion of some thoracic aortic aneurysm deaths . Investigation of the accuracy of cause-of-death coding on the death certificates was done by an independent mortality working party that was blinded to group allocation . The results of this analysis showed that inaccuracies in coding did not have an important impact on study outcomes ( 2 ) . Statistical Analysis All analyses were done by using Stata , version 9 ( Stata Corp. , College Station , Texas ) . Deaths related to AAA ( primary analysis ) and all-cause mortality ( secondary analysis ) were compared between the 2 r and omized groups by using unadjusted Cox regression by intention-to-treat analysis . Adjustment for age at baseline did not influence the results . The proportional hazards assumption was tested by using Schoenfeld residuals . An unbiased r and omization-based estimate of the benefit of  screening  was also obtained ( 16 ) . This estimate is calculated by subtracting from the control group a subgroup that is equivalent in terms of survival to the nonadherent subgroup in the invited group . Thus , the remaining controls are comparable to the group of invited patients who attended screening . Life-years gained are estimated as the area between the KaplanMeier curves for both groups ( 17 ) . The cost-effectiveness of screening  is estimated from a health service perspective for follow-up truncated at 7 years , with adjustment for censoring ( 18 ) . Details of the costing exercise in the trial at 20002001 prices were reported previously ( 9 ) . The unit costs obtained ( U.K. 1 = U.S. $ 1.58 for the year 2000 [ 15 ] ) are inflated to the 20042005 financial-year level by using annual hospital and community health services pay and price inflation indices ( 19 ) . Costs are applied to the following events on the basis of individual re source use : invitation to screening ( $ 2.46 ) , reinvitation after nonresponse ( $ 2.42 ) , initial scan ( $ 35.95 ) , recall scan ( $ 86.74 ; done in the hospital rather than in the community and including costs for periodic routine meetings with a consultant ) , consultation for elective surgery ( $ 583.79 ) , elective AAA surgery ( $ 13015.74 ) , and emergency AAA surgery ( $ 21054.32 ) . Costs relating to scans of incidentally detected AAAs in the control group are not included ( data not available ) , but costs relating from result ant AAA repair surgery are included . Sensitivity analyses were done by using 1 ) costs retained at the 20002001 financial-year level for comparison with previous publications , 2 ) quality -adjusted life-years based on age-related reductions , 3 ) U.S.-based unit cost estimates for scans and surgeries , 4 ) an increase of 50 % in the cost of a consultation  ( a U.S.-based estimate was not available , but this analysis reflects possible additional assessment s ) , 5 ) 3 and 4 combined . Quality -of-life adjustments are made only on the basis of age , with an adjustment of 0.78 for life-years gained between the ages 65 and 74 years and an adjustment of 0.75 for life-years gained at ages older than 75 years ( 20 ) . The U.S.-specific estimates for scans ( initial and recall ) are based on Medicare reimbursement for AAA screening at $ 90.95 ( Current Procedural Terminology code G0389 ) ( 21 ) , and U.S.-specific costs for surgeries are based on previously published estimates ( 22 , 23 ) that were inflated to 2004 prices ( 24 ) : $ 18160 for elective procedures and $ 31106 for emergency procedures . Discounting is applied at the current recommended values of 3 % per annum for costs and effects ( 25 ) . Estimates of AAA-related costs and effects take into account the rate of nonAAA-related deaths across both groups over time . The Fieller method is used to calculate bounds for the CI for cost-effectiveness ( 26 , 27 ) . Role of the Funding Source This study was funded by the Medical Research Council . The funding source had no role in the design , implementation , or analysis of the study . Results Figure 1 shows the flow of participants through the trial . Numbers differ slightly from earlier publications because of identification of a few duplicate records in the data base . Of 67770 r and omly assigned men , 33883 were invited to be screened : 27204 ( 80 % ) attended and 1334 ( 4.9 % ) AAAs were identified . The mean age at r and omization was 69.2 years in both groups . Loss to follow-up because of death was 2.1 % overall ( 2.2 % in the control group and 2.1 % in the invited group ) . Loss to clinical follow-up ( nonattendance at recall scans ) was 19 % at 4 years and 24 % at 7 years . The Appendix Table shows surgeries and deaths within 30 days in each of the r and omly assigned groups . A few endovascular operations are included in these figures6 in the control group and 14 in the invited group . As expected , the total number of elective procedures is greater in the invited group than in the control group BACKGROUND Opposing views have been published on the importance of ultrasound screening for abdominal aortic aneurysms . The Multicentre Aneurysm Screening Study was design ed to assess whether or not such screening is beneficial . METHODS A population -based sample of men ( n=67800 ) aged 65 - 74 years was enrolled , and each individual r and omly allocated to either receive an invitation for an abdominal ultrasound scan ( invited group , n=33839 ) or not ( control group , n=33961 ) . Men in whom abdominal aortic aneurysms ( > or =3 cm in diameter ) were detected were followed-up with repeat ultrasound scans for a mean of 4.1 years . Surgery was considered on specific criteria ( diameter > or = 5.5 cm , expansion > or = 1 cm per year , symptoms ) . Mortality data were obtained from the Office of National Statistics , and an intention-to-treat analysis was based on cause of death . Quality of life was assessed with four st and ardised scales . The primary outcome measure was mortality related to abdominal aortic aneurysm . FINDINGS 27147 of 33839 ( 80 % ) men in the invited group accepted the invitation to screening , and 1333 aneurysms were detected . There were 65 aneurysm-related deaths ( absolute risk 0.19 % ) in the invited group , and 113 ( 0.33 % ) in the control group ( risk reduction 42 % , 95 % CI 22 - 58 ; p=0.0002 ) , with a 53 % reduction ( 95 % CI 30 - 64 ) in those who attended screening . 30-day mortality was 6 % ( 24 of 414 ) after elective surgery for an aneurysm , and 37 % ( 30 of 81 ) after emergency surgery . INTERPRETATION Our results provide reliable evidence of benefit from screening for abdominal aortic aneurysms Objectives To compare attendance and prevalence of abdominal aortic aneurysm ( AAA ) in population based r and omised trials of sonographic screening in the United Kingdom , Western Australia , and Denmark . Methods 65 290 men were r and omised to screening in the four trials , and data were collected and analysed from 46 397 aortic scans for men aged between 64 and 83 years who attended one of four community screening programmes .  Comparisons were made for age st and ardised population s ( 65–74 years ) . Results Age st and ardised attendance varied between 74 % and 81 % , and was highest in the United Kingdom and lowest in Western Australia . Age st and ardised prevalence of AAAs of 3.0 cm or more varied significantly between 4.5 % and 7.7 % , and was highest in the United Kingdom and lowest in Denmark . Conclusions Participation in the four programmes compares favourably with other reported screening studies . The possibility that variations may reflect the different recruitment methods used is discussed . The prevalence of AAA in central Denmark would appear to be significantly different from that in southern Engl and and Western Australia Objective : To improve compliance with computer-generated reminders to perform fecal occult blood testing ( FOBT ) , mammography , and cervical Papanicolaou ( Pap ) testing . Design : Six-month prospect i ve , r and omized , controlled trial . Setting : Academic primary care general internal medicine practice .Subjects : Thirty-one general internal medicine faculty , 145 residents , and 5,407 patients with scheduled visits who were eligible for any of the three cancer screening protocol s . Intervention : Primary care teams of internal medicine residents and faculty received either routine computer reminders ( control ) or the same reminders to which they were required to circle one of four responses : 1 ) “ done/order today , ” 2 ) “ not applicable to this patient , ” 3 ) “ patient refused , ” or 4 ) “ next visit . ” Results : Intervention physicians complied more frequently than control physicians with all reminders combined ( 46 % vs 38 % , respectively , p=0.002 ) and separately with reminders for FOBT ( 61 % vs 49 % , p=0.0007 ) and mammography ( 54 % vs 47 % , p=0.036 ) but not cervical Pap testing ( 21 % vs 18 % , p=0.2 ) . Intervention residents responded significantly more often than control residents to all reminders together and separately to reminders for FOBT and mammography but not Pap testing . There was no significant difference between intervention and control faculty , but the compliance rate for control faculty was significantly higher than the rate for control residents for all reminders together and separately for FOBT but not mammography or Pap testing . The intervention ’s effect was greatest for patients ≥70 years old , with significant results for all tests , together and singly , for residents but not faculty . Intervention physicians felt that the reminders were not applicable 21 % of the time ( due to inadequate data in patients ’ electronic medical records ) and stated that their patients refused 10 % of the time . Conclusions : Requiring physicians to respond to computer-generated reminders improved their compliance with preventive care protocol s , especially for elderly patients for whom control physicians ’ compliance was the lowest . However , 100 % compliance with cancer screening reminders will be unattainable due to incomplete data and patient refusal OBJECTIVE To assess the cost effectiveness of ultrasound screening for abdominal aortic aneurysms . DESIGN Primary analysis : four year cost effectiveness analysis based directly on results from a r and omised controlled trial in which patients were individually allocated to invitation to ultrasound screening ( intervention ) or to a control group not offered screening . Secondary analysis : projection of the data , based on conservative assumptions , to indicate likely cost effectiveness at 10 years . SETTING Four centres in the United Kingdom .  Screening delivered in primary care setting s with follow up and surgery offered in the main hospitals Participants : Population based sample of 67 800 men aged 65 - 74 years . MAIN OUTCOME MEASURES Mortality from and costs ( screening , follow up , elective and emergency surgery ) related to abdominal aortic aneurysm ; cost per life year gained . RESULTS Over four years there were 47 fewer deaths related to abdominal aortic aneurysms in the screening group than in the control group , but the additional costs incurred were pound 2.2 m . After adjustment for censoring and discounted at 6 % the mean additional cost of the screening programme was pound 63.39 ( $ 97.77 , euro;100.48 ) ( 95 % confidence interval pound 53.31 to pound 73.48 ) per patient . The hazard ratio for abdominal aortic aneurysm was 0.58 ( 0.42 to 0.78 ) . Over four years the mean incremental cost effectiveness ratio for screening was pound 28 400 ( pound 15 000 to pound 146 000 ) per life year gained , equivalent to about pound 36 000 per quality adjusted life year . After 10 years this figure is estimated to fall to around pound 8000 per life year gained . CONCLUSIONS Even at four years the cost effectiveness of screening for abdominal aortic aneurysms is at the margin of acceptability according to current NHS thresholds . Over a longer period the cost effectiveness will improve substantially , the predicted ratio at 10 years falling to around a quarter of the four year figure BACKGROUND We previously reported the prevalence and associations of abdominal aortic aneurysm ( AAA ) in 73451 veterans aged 50 to 79 years who underwent ultrasound screening .  OBJECTIVE To underst and the prevalence of and principal positive and negative risk factors for AAA , and to assess reproducibility of our previous findings . METHODS In the new cohort of veterans undergoing screening , 52 745 subjects aged 50 to 79 without history of AAA underwent successful ultrasound screening for AAA  , after completing a question naire on demographics and potential risk factors . RESULTS We detected AAA of 4.0 cm or larger in 613 participants ( 1.2 % ; compared with 1.4 % in the earlier cohort ) . The direction and magnitude of the important associations reported in the first cohort were confirmed . Respective odds ratios for the major associations with AAA for the second and for the combined cohorts were as follows : 1.81 and 1.71 for age ( per 7 years ) , 0.12 and 0 . 18 for female sex , 0.59 and 0.53 for black race , 1.94 and 1.94 for family history of AAA , 4.45 and 5.07 for smoking , 0.50 and 0.52 for diabetes , and 1.60 and 1.66 for atherosclerotic diseases . The excess prevalence associated with smoking accounted for 75 % of all AAAs of 4.0 cm or larger in the total population of 126 196 . Associations for AAA of 3.0 to 3.9 cm were similar but tended to be somewhat weaker . CONCLUSIONS Our findings confirm our previous cohort findings . Age , smoking , family history of AAA , and atherosclerotic diseases remained the principal positive associations with AAA , and female sex , diabetes , and black race remained the principal negative associations BACKGROUND Preventive care is an important role for general practitioners , yet opportunities for prevention are often missed . METHOD We provided an automatic electronic record preventive care reminder system for  12 preventive care activities for one 10 doctor practice . All patients who attended were r and omised by the terminal digit of their record number . RESULTS The control uptake of opportunistic prevention was low ; ranging from 1.5 % ( tetanus immunisation ) to 27 % ( influenza immunisation ) . The reminders increased this by significant but small amounts for four out of 12 activities ( immunisation for tetanus and pneumococcus and recording of allergies and weight ) , insignificant increases for four ( mumps , measles and rubella immunisation , recording of smoking , and taking of cervical smears and of blood pressure ) , and insignificantly decreased influenza immunisation , and screening for diabetes and hyperlipidaemia . DISCUSSION Opportunistic electronic reminders have the potential to increase preventive care in general practice BACKGROUND Based on r and omized , population -based screening protocol s , a single ultrasound examination reduces mortality from an abdominal aortic aneurysm ( AAA ) by facilitating elective surgical intervention before rupture . Ultrasound screening is accurate , noninvasive , inexpensive , and cost effective . By using a comprehensive electronic medical record , we inquired whether an age-prompted clinical reminder would facilitate the detection of AAA . METHODS The  AAA risk screen  was installed in May 2007 via a computerized patient record system prompt for male veterans ages 65 to 75 who ever smoked . This abbreviated ultrasound examination uses a 3.5- to 4-MHz scan head , measures anteroposterior and transverse planes , and reports the largest infrarenal aortic diameter . RESULTS Of 1437 examinations there were 73 AAAs of 3.0-cm diameter or larger ( 5.1 % ) ; 33 AAAs of 4.0-cm diameter or larger ( 2.3 % ) ; 15 AAAs of 5.0-cm diameter or larger ( 1.0 % ) ; and 11 AAAs of 5.5-cm diameter or larger ( .77 % ) . Fifty ( 68 % ) received counseling for abnormal findings . CONCLUSIONS Recognition of newly diagnosed AAA compared favorably with that of previous screening studies . Electronic clinical reminders identify undiagnosed , life-threatening AAAs before rupture . Immediate counseling is available in the vascular setting
target: Electronic reminders are a simple EMR addition that can provide evidence -based education while improving adherence rates with preventive health screening measures
background: Abstract : The 2014 United States Preventive Services Task Force systematic review found abdominal aortic aneurysm ( AAA ) screening decreased related mortality by close to half .
  Despite the simplicity of screening , research suggests poor adherence to the recommended AAA screening guidelines .