Surveillance Intervals for Small Abdominal Aortic Aneurysms

Bown, Matthew J.; Sweeting, Michael; Brown, Louise; Powell, J.T.; Thompson, Simon G.

doi:10.1001/jama.2013.950

Cited by 200 publications

(62 citation statements)

References 44 publications

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“…11 AAA growth rates increase as the AAA gets larger. [12][13][14] Growth rates have also been shown to be higher in smokers [15][16][17][18] and lower in patients taking beta blockers, 19 angiotensin-converting enzyme inhibitors or statins 20,21 and lower in patients with diabetes. 16,18,22,23 Most AAAs continue to grow until the aneurysm ruptures or is repaired or the patient dies of other causes.…”

Section: 10mentioning

confidence: 99%

“…18,47 The aim of the RESCAN project was to inform the evidence base for choice of appropriate surveillance intervals for small AAAs. Information on AAA growth and risk of rupture was obtained from an analysis of IPD from existing surveillance programmes.…”

Section: Aneurysm Growth and Risk Of Rupturementioning

confidence: 99%

“…For AAA diameters outside that included in the RESCAN project, information on AAA growth and risk of rupture was taken from other previously published studies. [47][48][49][50] DATA SOURCES NIHR Journals Library www.journalslibrary.nihr.ac.uk…”

Section: Aneurysm Growth and Risk Of Rupturementioning

confidence: 99%

“…This schedule could be optimised, 47 and indeed the ARDA can incorporate different surveillance schedules. While the aneurysm is growing the patient remains under surveillance until a threshold diameter is reached.…”

Section: Data Sources and Variable Estimationmentioning

confidence: 99%

“…Annual growth rates are assumed to be independent. The RESCAN analysis 47 includes only growth rates up to an AAA diameter of 5.0 cm. Beyond this, growth rates in this DES model are extrapolated up to 6.0 cm and assumed constant beyond that.…”

Section: Data Sources and Variable Estimationmentioning

confidence: 99%

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Calculating when elective abdominal aortic aneurysm repair improves survival for individual patients: development of the Aneurysm Repair Decision Aid and economic evaluation

Grant

Sperrin

Carlson

et al. 2015

Health Technology Assessment

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BackgroundAbdominal aortic aneurysm (AAA) repair aims to prevent premature death from AAA rupture. Elective repair is currently recommended when AAA diameter reaches 5.5 cm (men) and 5.0 cm (women). Applying population-based indications may not be appropriate for individual patient decisions, as the optimal indication is likely to differ between patients based on age and comorbidities.ObjectiveTo develop an Aneurysm Repair Decision Aid (ARDA) to indicate when elective AAA repair optimises survival for individual patients and to assess the cost-effectiveness and associated uncertainty of elective repair at the aneurysm diameter recommended by the ARDA compared with current practice.Data sourcesThe UK Vascular Governance North West and National Vascular Database provided individual patient data to develop predictive models for perioperative mortality and survival. Data from published literature were used to model AAA growth and risk of rupture. The cost-effectiveness analysis used data from published literature and from local and national databases.MethodsA combination of systematic review methods and clinical registries were used to provide data to populate models and inform the structure of the ARDA. Discrete event simulation (DES) was used to model the patient journey from diagnosis to death and synthesised data were used to estimate patient outcomes and costs for elective repair at alternative aneurysm diameters. Eight patient clinical scenarios (vignettes) were used as exemplars. The DES structure was validated by clinical and statistical experts. The economic evaluation estimated costs, quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratios (ICERs) from the NHS, social care provider and patient perspective over a lifetime horizon. Cost-effectiveness acceptability analyses and probabilistic sensitivity analyses explored uncertainty in the data and the value for money of ARDA-based decisions. The ARDA outcome measures include perioperative mortality risk, annual risk of rupture, 1-, 5- and 10-year survival, postoperative long-term survival, median life expectancy and predicted time to current threshold for aneurysm repair. The primary economic measure was the ICER using the QALY as the measure of health benefit.ResultsThe analysis demonstrated it is feasible to build and run a complex clinical decision aid using DES. The model results support current guidelines for most vignettes but suggest that earlier repair may be effective in younger, fitter patients and ongoing surveillance may be effective in elderly patients with comorbidities. The model adds information to support decisions for patients with aneurysms outside current indications. The economic evaluation suggests that using the ARDA compared with current guidelines could be cost-effective but there is a high level of uncertainty.LimitationsLack of high-quality long-term data to populate all sections of the model meant that there is high uncertainty about the long-term clinical and economic consequences of repair. Modelling assumptions were necessary and the developed survival models require external validation.ConclusionsThe ARDA provides detailed information on the potential consequences of AAA repair or a decision not to repair that may be helpful to vascular surgeons and their patients in reaching informed decisions. Further research is required to reduce uncertainty about key data, including reintervention following AAA repair, and assess the acceptability and feasibility of the ARDA for use in routine clinical practice.FundingThe National Institute for Health Research Health Technology Assessment programme.

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Section: 10mentioning

confidence: 99%

Section: Aneurysm Growth and Risk Of Rupturementioning

confidence: 99%

Section: Aneurysm Growth and Risk Of Rupturementioning

confidence: 99%

Section: Data Sources and Variable Estimationmentioning

confidence: 99%

Section: Data Sources and Variable Estimationmentioning

confidence: 99%

See 3 more Smart Citations

Calculating when elective abdominal aortic aneurysm repair improves survival for individual patients: development of the Aneurysm Repair Decision Aid and economic evaluation

Grant

Sperrin

Carlson

et al. 2015

Health Technology Assessment

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Impairment Related to Diseases of the Aorta

Demeter¹

2013

AMA Guides® Newsletter

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Aneurysms may result in ratable permanent impairment, and this article provides a basic understanding of aneurysms and how to rate them using the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition. An aneurysm is a bulge in a blood vessel, commonly in the arterial circulation and in the cerebral and renal vasculature or in the aorta. Because ruptured aneurysms frequently are lethal, generally they are treated prophylactically once they have reached a certain size. Endovascular repair is associated with an increased risk of all-cause mortality and abdominal aortic aneurysm mortality. The AMA Guides, Fifth Edition, rated aneurysms solely on the risk of rupture (ie, a future impairment, one of the few exceptions to their general proscription in the AMA Guides), and the impairment percentages can be quite large. These impairments are rated using the rating systems for the affected organ system when the individual is at maximum medical improvement (MMI). In addition, the risk of future impairment should be assessed when the individual is at MMI, and that rating should be combined with the rating for organ system vascular compromise. The justification for rating the risk of future events should be clarified in the report, which should cite the method reported in the present article because the AMA Guides, Sixth Edition, does not provide a methodology for rating this disease process.

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