Showing papers by "Jonathan Beard published in 2003"

Screening for abdominal aortic aneurysm

Abstract: Abdominal aortic aneurysm (AAA) affects 5 per cent of men over the age of 65 years and aneurysm rupture causes 2 per cent of all deaths in this age group. Unfortunately, most AAAs remain asymptomatic until rupture occurs and 50 per cent of patients die without reaching hospital. The mortality rate for emergency repair is 40 per cent compared with 6 per cent for elective repair and once repaired, life expectancy returns to near normal1. Ultrasonography can detect an asymptomatic AAA in 99 per cent of patients2. It seems clear that all the criteria for screening are met: a common, serious condition; a window of opportunity for detection while asymptomatic; an inexpensive, noninvasive, reliable test; and an effective treatment with good long-term results. The Multicentre Aneurysm Screening Study (MASS) Group has recently published the results of a large, randomized trial assessing mortality, quality of life and cost effectiveness3,4. This study reinforces the favourable results of two smaller randomized trials from the UK5 and Denmark6, and two UK-based non-randomized population screening programmes7,8. A single ultrasonographic scan at the age of 65 years, with subsequent repair of an AAA exceeding 5·5 cm in diameter, reduced the risk of death from a ruptured AAA by 42 per cent in the 33 839 men invited for screening, resulting in 47 fewer deaths than in an unscanned population. The study was not powered to detect a reduction in overall mortality rate, but combining the data with those of concurrent trials from Denmark and Western Australia should achieve this9. Such a reduction in mortality rate is associated with a small deterioration in the health status of those who screen positive, but this adverse effect disappears 12 months after screening or operation. Additional costs total £2·2 million – a mean cost of £63 per patient. After 4 years the cost effectiveness is £36 000 per quality-adjusted life-year gained and this should fall to £8000 at 10 years (710 men screened to prevent one death). One should also remember the traumatic effect of a ruptured AAA on the quality of life of a patient’s relatives and hospital staff. Affected patients leave a devastating trail of tearful loved ones and exhausted staff, whether or not they survive. An AAA screening programme increases the number of elective repairs, especially in the short term, but experience in those centres involved in the trials is that the increase in workload is manageable. The added elective work is balanced by a reduction in the number of aneurysm ruptures, which become infrequent after 10 years of screening. Such a reduction may have significant implications for vascular surgical training and service provision in the future. Haldipur et al.10 have already shown a worrying reduction in trainees’ experience of repairing ruptured AAAs as a result of the European Working Hours Directive. A screening programme will make it almost impossible for them to obtain sufficient experience to perform this operation independently as newly appointed consultants. Aneurysm ruptures may in future require a team approach, with assistance from more senior vascular surgeons. Fortunately, screening should produce such a dramatic reduction in the frequency of ruptured AAA that a consultant vascular surgeon would be able to cover a larger population when on duty for emergencies. This should both facilitate the provision of emergency vascular surgical services and reduce the cost. Like all good trials the MASS raises several new questions, but at least it is now clear that AAA screening is beneficial and cost effective, especially when compared with existing screening programmes, such as those for breast, prostate and cervical cancer. The main question is how, not whether, to establish national screening programmes. National providers of healthcare cannot ignore these results and must act quickly; failure to act promptly will invite the piecemeal introduction of screening, producing inequality of healthcare provision at a time when many are striving to reduce such inequality. While men over the age of 65 years may be regarded by governments as a drain on, rather than a benefit to, the economy, and while there may be few votes to be won from AAA screening, doing nothing in the face of the evidence smacks of ageism. The benefit and effectiveness of AAA screening may be further enhanced by risk factor modification, as the presence of an AAA indicates an increased risk of cardiovascular death. Should one prescribe aspirin, a statin and an angiotensin-converting enzyme inhibitor for all patients with an AAA? Smoking cessation reduces the expansion rate of an aneurysm and drugs, such as metalloproteinase inhibitors and antihypertensive agents, may do the same11. The response rate of 80 per cent to the invitation for screening should improve with the

Trials and tribulations of vascular surgical benchmarking

Abstract: Background Benchmarking is a new tool to assess the efficiency of different hospitals. Classification of operations using healthcare resource groups (HRGs) is related to parameters including number of cases, length of stay (LOS) and age profile. Methods A National Comparative Database was used to compare three hospitals. Analysis was confined to the major HRGs involved with vascular/venous surgery. Results For high-volume low-complexity varicose vein surgery, all three hospitals had similar numbers of patients and LOS. In contrast, the LOS for routine vascular operations in hospital A was double that in hospital B (16.3 versus 7.4 days). Hospital A had three times as many patients classified as 'other - peripheral vascular disease' as hospital C and six times as many as hospital B (329, 49 and 111 for hospitals A, B and C respectively). LOS following major amputation in hospitals A and C was nearly double that in hospital B (32.4, 18.3 and 33.6 days for hospitals A, B and C respectively). Conclusion There were a number of significant variations between the three hospitals during the 9-month interval. Explanations included the methods of coding, local facilities including availability of rehabilitation beds and difference in the patients' age profiles. Benchmarking in its present format reveals a number of variations which may not necessarily reflect real differences in clinical performance.