Invited commentary

Abstract

The authors have developed a Markov decision analysis model to examine the cost-effectiveness of different ultrasound scanning-based screening strategies for abdominal aortic aneurysms (AAAs) in men. The various assumptions incorporated into the model were supported by an extensive systematic review of the literature and were appropriately tested by using multiple sensitivity analyses. Although the utility of the model and the validity of the results are contingent on the accuracy of these assumptions, it seems that the authors were both thoughtful and thorough in their approach. The authors reported that the cost per life-year saved was $10,474 for a 65-year-old man screened once, with a range from $8309 to $14,084 for the various other strategies, including patients with popliteal artery aneurysms and those who had a sibling with an AAA. Notably, screening resulted in only modest 0.1- and 0.6-year increases in the mean life expectancies among all the patients screened and the subset of those with an AAA, respectively. The risk of aneurysm rupture and long-term survival had the most dramatic effect on the cost-effectiveness of the screening strategies in the sensitivity analyses. The results of the model were validated by comparison with several large clinical trials that examined both the screening and treatment of AAAs, although this validation was not completely surprising because several of these definitive trials were incorporated into the model assumptions. The cost per quality-adjusted life-year saved for the aneurysm screening was well below the frequently quoted $50,000/quality-adjusted life-year threshold and was below the values reported for cervical cancer, breast cancer, and hypertension screening, as reported by the authors. Unfortunately, the authors’ conclusions that “screening for AAA may be cost-effective in 65-year-old men, while screening 60-year-old men with a re-screening could be equally cost-effective with the advantage of more LYG (life years gained)” were not definitive. The authors state that additional studies are necessary before the preferred screening strategy can be identified. It is important to note that all the AAA repairs in the model were performed by using the open surgical technique. Although this simplifies the analyses, it potentially limits the impact of the study, given the expanding applications of the endovascular technique. It is conceivable that the lower perioperative mortality rate associated with the endovascular approach may offset the increased device- and surveillance-related costs, as suggested by the authors. The findings in this study further justify screening for AAA in elderly men and demonstrate its cost-effectiveness. During the review process of the authors’ manuscript, the United States Preventative Task Force issued a report recommending a single screening ultrasound scan for AAA in men 65 to 75 years of age who have a smoking history. The Preventative Task Force stated that the literature did not substantiate AAA screening for women, even among those with a family history of AAA, and stated that the harms of screening outweighed the risks. Despite the strength of the evidence supporting screening and the Preventative Task Force recommendations, several challenges must be overcome before screening becomes a routine clinical practice. We, as a collective group of health-care providers that deal with patients with AAA, must educate our primary care and cardiology colleagues. Furthermore, we must lobby our respective lawmakers in support of the pending screening legislation initiated by the National Aneurysm Alliance and the Society of Vascular Surgery. Finally, we must initiate the appropriate clinical trials to resolve the outstanding issues highlighted by the authors and the Preventative Task Force. Cost-effectiveness of different screening strategies for abdominal aortic aneurysmJournal of Vascular SurgeryVol. 41Issue 5PreviewThe primary objective of this study was to develop a simulation model to assess the cost-effectiveness of different screening strategies for abdominal aortic aneurysms (AAAs) in men. Full-Text PDF Open Archive