Analysis of clinical benefit, harms, and cost-effectiveness of screening women for abdominal aortic aneurysm

Michael J. Sweeting*, Katya L. Masconi, Edmund Jones, Pinar Ulug, Matthew J. Glover, Jonathan A. Michaels, Matthew J. Bown, Janet T. Powell, Simon G. Thompson

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

31 Citations (Scopus)

Abstract

Background: A third of deaths in the UK from ruptured abdominal aortic aneurysm (AAA) are in women. In men, national screening programmes reduce deaths from AAA and are cost-effective. The benefits, harms, and cost-effectiveness in offering a similar programme to women have not been formally assessed, and this was the aim of this study. Methods: We developed a decision model to assess predefined outcomes of death caused by AAA, life years, quality-adjusted life years, costs, and the incremental cost-effectiveness ratio for a population of women invited to AAA screening versus a population who were not invited to screening. A discrete event simulation model was set up for AAA screening, surveillance, and intervention. Relevant women-specific parameters were obtained from sources including systematic literature reviews, national registry or administrative databases, major AAA surgery trials, and UK National Health Service reference costs. Findings: AAA screening for women, as currently offered to UK men (at age 65 years, with an AAA diagnosis at an aortic diameter of ≥3·0 cm, and elective repair considered at ≥5·5cm) gave, over 30 years, an estimated incremental cost-effectiveness ratio of £30 000 (95% CI 12 000–87 000) per quality-adjusted life year gained, with 3900 invitations to screening required to prevent one AAA-related death and an overdiagnosis rate of 33%. A modified option for women (screening at age 70 years, diagnosis at 2·5 cm and repair at 5·0 cm) was estimated to have an incremental cost-effectiveness ratio of £23 000 (9500–71 000) per quality-adjusted life year and 1800 invitations to screening required to prevent one AAA-death, but an overdiagnosis rate of 55%. There was considerable uncertainty in the cost-effectiveness ratio, largely driven by uncertainty about AAA prevalence, the distribution of aortic sizes for women at different ages, and the effect of screening on quality of life. Interpretation: By UK standards, an AAA screening programme for women, designed to be similar to that used to screen men, is unlikely to be cost-effective. Further research on the aortic diameter distribution in women and potential quality of life decrements associated with screening are needed to assess the full benefits and harms of modified options. Funding: UK National Institute for Health Research Health Technology Assessment programme.

Original languageEnglish
Pages (from-to)487-495
Number of pages9
JournalThe Lancet
Volume392
Issue number10146
DOIs
Publication statusPublished - 11 Aug 2018
Externally publishedYes

Bibliographical note

Funding Information:
We are grateful to a number of people who kindly provided input, data, or analyses to help us with this project, including: Prof Jonothan Earnshaw, Jo Jacomelli, and Lisa Summers for data on screening, surveillance, and referral to surgery for men in NAAASP; Dr Sverker Svensjö (Uppsala, Sweden) for individual data on women screened for AAA in Sweden; Dr David Epstein (Granada, Spain) for analyses of resource use and costs in the EVAR-1 trial; Dr Manuel Gomes (London, UK) for analyses of resource use and costs in the IMPROVE trial; Prof Simon Griffin (Cambridge, UK) for additional discussion on possible quality of life decrements. Additional support for this project for work done at the University of Cambridge came from the UK Medical Research Council (MR/L003120/1), the British Heart Foundation (RG/13/13/30194), and the UK National Institute for Health Research (Cambridge Biomedical Research Centre). Patient and public involvement was supported by the UK National Institute for Health Research (Leicester Biomedical Research Centre).

Publisher Copyright:
© 2018 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 licence

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