Commentary on ‘A Decision Aid Regarding Treatment Options for Patients with an Asymptomatic Abdominal Aortic Aneurysm: A Randomised Clinical Trial’

Abstract

vascular surgery: how can we better inform patients with abdominal aortic aneurysm (AAA), and involve them actively in the surgical decision-making? The study was performed in six vascular centres in Amsterdam. Patients who were recently diagnosed with an AAA with a diameter of 4 cm or more were randomised between standard care and adding an interactive CD-ROM informing them of the pros and cons of elective surgery and watchful waiting. The results are quite interesting. The patients who received the extra standardised information had better knowledge, but anxiety, satisfaction, and decisional conflict scores did not differ between the groups. How should we interpret these findings? Having an AAA is a worrying situation, and being better informed does not necessarily reduce anxiety. To decide between two alternatives that both include a risk of death is a difficult existential conflict. A patient attitude that was quite common in the 1970s when I started to practise surgery, was that the patient placed his fate in the hands of the surgeon. “Doctor, you know best!”, was a frequent comment. Strangely enough, these patients gave the impression of having great confidence in the young surgeon who was to operate on them, and did not seek more information. We still meet these patients, although this is increasingly uncommon. The colleagues in Amsterdam are to be congratulated for having performed another important clinical study, and a randomised controlled trial, giving us the highest level of evidence. Yet there are, as always in research, some limitations.Anoutstandingissue,thatmaylimitthegeneralisability of the investigation, is the quality of “standard care.” We know from other studies on interventions that standard care has the tendency to improve during the time that an investigation is carried out. It is possible that the surgeons participating in the study may have improved their practice, informing their patients better than at baseline, before the studywasinitiated.Unfortunately,therearenobaselinedata. Wehaveinvestigatedqualityoflife(QoL)withShort-Form36 beforeandafterscreeningforAAA,thuswithtruebaselinedata before the ultrasound investigation of the aorta was performed, 2 and12monthslater.Wefoundthatamongthosewho had an age-adjusted normal QoL prior to screening and who were found to have the disease, no negative effects were observed on QoL. Those who suffered a low QOL prior to screening, however, had their QoL further impaired by the diagnosis of an AAA. Thus, there seems to exist a small vulnerablesubgroupofpatients,which,amongpsychiatrists,is sometimes labelled “the orchids”, as opposed to the “the