Disclaimer
This information collection is a core HTA, i.e. an extensive analysis of one or more health technologies using all nine domains of the HTA Core Model. The core HTA is intended to be used as an information base for local (e.g. national or regional) HTAs.

Abdominal Aorta Aneurysm Screening

AAA Screening compared to not doing anything in the screening of Abdominal Aorta Aneurysm (AAA) in elderly at moderate risk of developing AAA

(See detailed scope below)

HTA Core Model Application for Screening Technologies 1.0
Core HTA
Published
Tom Jefferson (age.na.s, Italy), Nicola Vicari (age.na.s, Italy), Katrine Bjørnebek Frønsdal (NOKC, Norway)
Claudia Wild, LBI-HTA (Health problem and current use); Daniela Pertl and Sophie Brunner-Ziegler, GÖG (Description and technical characteristics); Iñaki Imaz, ISCIII-AETS (Safety); Katrine Frønsdal and Ingvil Sæterdal, NOKC (Clinical effectiveness), Suvi Mäklin and Taru Haula, THL-FINOHTA (Costs and economic evaluation); Gottfried Endel, HVB (Ethical analysis); Kristi Liiv and Raul Kiivet, UTA (Organisational aspects); Anne Lee, Lotte Groth Jensen and Claus Loevschall, SDU/CAST (Social aspects); Ingrid Wilbacher, HVB (Legal aspects)
Agenzia nationale per i servizi sanitari regionali (age.na.s), Italy
Central Denmark (Denmark), GÖG (Austria), HVB (Austria), ISCIII – AETS (Spain), LBI-HTA (Austria), NOKC (Norway), SDU/CAST (Denmark), THL - FINOHTA (Finland), UTA (Estonia)
4.5.2011 15.16.00
31.1.2013 18.04.00
Jefferson T, Vicari N, Frønsdal K [eds.]. Abdominal Aorta Aneurysm Screening [Core HTA], Agenzia nationale per i servizi sanitari regionali (age.na.s), Italy; 2013. [cited 30 June 2022]. Available from: http://corehta.info/ViewCover.aspx?id=106

Abdominal Aorta Aneurysm Screening

<< Health Problem and Current Use of the TechnologySafety >>

Description and technical characteristics of technology

Authors: Daniela Pertl, Sophie Brunner-Ziegler

Summary

The main purpose of the present domain was to describe current screening strategies for abdominal aortic aneurysm (AAA) with special emphasis on the gold standard technical device, the ultrasound sonography device.

Generally, “screening” aims to identify pathological conditions in their preclinical and potentially curable stage. Basic criteria, published by the WHO in 1968, should ideally be fulfilled for a condition to qualify for screening. While population-based systematic screening concentrates systematically on the entire population or on subgroups of the entire population by using quality assured programmes, opportunistic screening practices are performed occasionally during individual routine healthcare examinations. Screening results of both types are used as a basis for potential further diagnostic assessments and therapies. Major limitations of screening involve the psycho-social burden of concerned people, and unnecessary investigations and treatment as a result of false positive results.

In the case of AAA current screening practices and funding policies differ between healthcare systems. With the exception of Sweden and the United Kingdom, no specific nationwide screening programmes have been implemented within European Countries. Instead, individualised care is strongly recommended for each patient. When the best-established and most used screening guidelines were compared, the highest rigor/quality score (AGREE score) was for the guidelines of the US Preventive Services Task Force from 2005 (score: nearly 80%), in contrast to the Society for Vascular Surgery practice guidelines, which scored only 25%. 

According to the US Preventive Services Task Force, all men, aged 65 to 75 years, who have ever smoked in their lifetime, should be screened by abdominal ultrasonography.

Introduction

The aim of the following domain is to give a short overview of screening in general and to characterise the technical details of the ultrasound sonography device, which has been internationally accepted as the gold standard methodology for abdominal aortic aneurysm (AAA) screening procedures. AAA is usually detected either during population based screening or during various opportunistic screening strategies.

First we consider the history, diverse definitions, strengths and limitations of screening in general, with special emphasis on the distinction between different screening strategies, such as population based and various opportunistic screening strategies. A survey of the different AAA screening approaches in the individual countries, in the context of their healthcare systems, was performed. The survey indicated that approaches vary not only in terms of the context in which screening takes place, but also in the target population, towards whom they are directed.

Second, technical details of ultrasound sonography are introduced: special features relevant to this technique, such as cut-off points and necessary material investments are discussed. Some information is described in detail in other domains, for example, qualifications needed, training and quality assurance processes and necessary investments.

Methodology

Frame

The collection scope is used in this domain.

TechnologyAAA Screening
Description

Population-based systematic abdominal aortic aneurysm (AAA)screening. This includes one single invitation for the whole target population to do one ultrasound scan examination. Purpose of use: Detect abdominal aortic aneurysm in unruptured phase in order to treat those aneurysms with high risk of rupture.

Intended use of the technologyScreening

Screening programme for abdominal aortic aneurysm

Target condition
Abdominal Aorta Aneurysm (AAA)
Target condition description

All men and women aged 64 or more

Target population

Target population sex: Any. Target population age: elderly. Target population group: Possible future health condition.

Target population description

All men and women aged 64 or more

For: All men and women aged 64 or more.

There is some international variance in the prevalence of AAA. In the western countries the prevalence varies between 5 to 10 % for the 65 – 74 years old men.

In Japan the prevalence is 1 % for the same group of men. The prevalence increases with age.

In England the prevalence is 2 % for men aged 50 – 64 year and 12 % for men aged 80 years or older.

In Denmark the prevalence is 4 % for men aged 65 – 69 and 6 % for men aged 70 – 74 years old. The prevalence for women is significant lower than the prevalence for men.

Comparisonnot doing anything
Description

No population-based AAA screening.

This includes incidental detection of AAA without age or sex limitation while performing abdominal ultrasound examinations due to other/unclear clinical indications and various opportunistic AAA-screening practices

Assessment elements

TopicIssue RelevantResearch questions or rationale for irrelevance
B0001Features of the technologyWhat is this technology?yesWhat is Screening?
Are there different strategies for Abdominal Aorta Aneurysm Screening?
Has any technical device for the detection of AAA established as internationally accepted golden standard?
B0002Features of the technologyWhy is this technology used?yesWhy is Abdominal Aorta Aneurysm Screening used?
B0004Features of the technologyWho will apply this technology?yesWhich professionals use the technology and is there a difference between the screening strategies?
B0016Features of the technologyTo what population(s) will this technology be used on?yesTo what population(s) will Abdominal Aorta Aneurysm Screening be used on?
B0003Features of the technologyWhat is the phase of the technology?yesWhat is the background of the golden standard technical device?
B0006Features of the technologyAre there any special features relevant to this technology?yesAre there any special features relevant to the golden standard technical device for Abdominal Aorta Aneurysm Screening?
B0005Features of the technologyIn what place and context is the technology intended to be used?yesIn what place and context are Abdominal Aorta Aneurysm Screening strategies intended to be used?
B0018Features of the technologyAre the reference values or cut-off points clearly established?yesAre the reference values or cut-off points for the diagnosis of AAA by the golden standard technical device clearly established?
B0017Features of the technologyIs this technology field changing rapidly?noTechnology field is not changing rapidly. Even if technical details are minimally changing (by being updated), basic requirement of application does not change and there are no requirements fo re-training for the end-users.
B0007Investments and tools required to use the technologyWhat material investments are needed to use the technology?yesWhat material investments are needed to use the golden standard technical device for Abdominal Aorta Aneurysm Screening?
B0009Investments and tools required to use the technologyWhat equipment and supplies are needed to use the technology?yesWhat equipment and supplies are needed to use the golden standard technical device for Abdominal Aorta Aneurysm Screening ?
B0010Investments and tools required to use the technologyWhat kind of data and records are needed to monitor the use the technology?yesWhat kind of information is needed to monitor the use of the technical device for Abdominal Aorta Aneurysm Screening ?
B0008Investments and tools required to use the technologyWhat kind of special premises are needed to use the technology?noThere is no need for special premises for the usage of the technology, as there is no radiation exposure associated with ultrasonography. There is no need for usage of contrast media and the technology is even authorized for application in pregnant women. However, the technical device requires a person (medical doctor, medical technician assistent), who is well trained and highly experienced with the assessment procedure.
B0011Investments and tools required to use the technologyWhat kind of registers are needed to monitor the use the technology?noThere is no need for the establishment of registers, as there are internationally consistent guidelines for diagnosis of AAA by ultrasonography.
B0012Training and information needed to use the technologyWhat kind of qualification, training and quality assurance processes are needed for the use or maintenance of the technology?yesWhat kind of qualification, training and quality assurance processes are needed for the use or maintenance of the technical device for Abdominal Aorta Aneurysm Screening ?
B0013Training and information needed to use the technologyWhat kind of training is needed for the personnel treating or investigating patients using this technology?yesWhat kind of training is needed for the personnel treating or investigating patients using the technical device for Abdominal Aorta Aneurysm Screening ?
B0014Training and information needed to use the technologyWhat kind of training and information should be provided for the patient who uses the technology, or for his family/carer?noFor ultrasonographic assessment of the abdomen persons should be in a fasten condition. Special medication to make the intestine free from gas might be applicated the day before the assessment.
B0015Training and information needed to use the technologyWhat information of the technology should be provided for patients outside the target group and the general public?noPatients outside the target group are not invited for population based screening.

Methodology description

Domain frame

The project scope is applied in this domain:

Technology description

Population-based systematic abdominal aortic aneurysm (AAA) screening. This includes one single invitation for the whole target population to do one ultrasound scan examination. Purpose of use: Detect abdominal aortic aneurysm in unruptured phase in order to treat those aneurysms with high risk of rupture. Target condition: Abdominal aortic aneurysm (AAA) MeSH: ”Mass screening”.

Intended use of technology

For: All men and women aged 64 or more. There is some international variance in the prevalence of AAA. In the western countries the prevalence varies between 5 to 10 % for the 65 – 74 years old men. In Japan the prevalence is 1 % for the same group of men. The prevalence increases with age. In England the prevalence is 2 % for men aged 50 – 64 year and 12 % for men aged 80 years or older. In Denmark the prevalence is 4 % for men aged 65 – 69 and 6 % for men aged 70 – 74 years old. The prevalence for women is significant lower than the prevalence for men.

Comparison

No population-based AAA screening. This includes incidental detection of AAA without age or sex limitation while performing abdominal ultrasound examinations due to other/unclear clinical indications and various opportunistic AAA-screening practices.

Outcome

All

Design

Systematic Reviews

HTA

RCT

national guidelines

grey literature

technical literature

Information sources

  • Basic systematic search

Basic search strategy

A basic search strategy to identify systematic reviews and randomised controlled trials to suit the overall project definition was developed by investigators from the different domains. This search strategy combined MeSH terms on the intervention exclusively. The search was performed by a research librarian from the Norwegian Knowledge Centre for the Health Services (NOKC) in the Cochrane Library, HTA, CENTRAL, CRD, DARE, EMBASE, MEDLINE and ISI databases. The search resulted in 167 titles (41 Systematic Reviews/HTAs, 126 RCTs).

Selection of literature from the basic search

Abstracts were scanned by each of the two assessors (Sophie Brunner-Ziegler and Daniela Pertl). Articles were included if considered relevant by one of the assessors (based on title and eventual abstract). The literature scan resulted in a net list of six publications, which were distributed among the assessors for further assessment and eventual inclusion in the result cards.

  • Hand search

(citations from peer reviewed literature, tertiary literature and technical literature)

The description and technical characteristics of the technology are rarely analysed within clinical studies, economic analysis, systematic reviews and HTA reports, so the analysis required additional search for national guidelines, grey literature and technical literature to answer the research questions of this domain.

Therefore, the Guidelines International Network (GIN), manufacturer’s websites and technical literature was scanned and 28 articles were included. Reports in the English and German languages were included. The search was done by Sophie Brunner-Ziegler and Daniela Pertl. 

  • Survey

Furthermore, a questionnaire to EUnetHTA partners internationally was used to get information about technical aspects of the technology because this information was not fully available in the basic literature search. Survey questions concerning the TEC domain contained six relevant questions (screening strategies, gold technical device, national guidelines, responsibilities).

Quality assessment tools or criteria

Quality assessment using criteria for clinical effectiveness is not pertinent in the investigation of this domain and other quality assessment criteria are not available. We therefore chose to use peer reviewed literature as the source.

Analysis and synthesis

We performed a descriptive analysis of the articles selected. The research questions were answered by cooperation between the two participants.

Result cards are covered by evidence issued from basic search, hand searched literature and survey results.  Appendix TEC-1 provides the list of result cards of this domain, related result cards of other domains and following agreements on assessments.

Result cards

Features of the technology

Result card for TEC1: "What is Screening?", TEC2: "Are there different strategies for Abdominal Aorta Aneurysm Screening? " and TEC3: "Has any technical device for the detection of AAA established as internationally accepted golden standard?"

View full card
TEC1: What is Screening?
Result

Importance: Critical

Transferability: Partially

TEC2: Are there different strategies for Abdominal Aorta Aneurysm Screening?
Result
Comment

Importance: Important

Transferability: Partially

TEC3: Has any technical device for the detection of AAA established as internationally accepted golden standard?
Result
Comment

Importance: Important

Transferability: Partially

Result card for TEC4: "Why is Abdominal Aorta Aneurysm Screening used?"

View full card
TEC4: Why is Abdominal Aorta Aneurysm Screening used?
Method
Result
Comment

Importance: Important

Transferability: Completely

Result card for TEC6: "Which professionals use the technology and is there a difference between the screening strategies?"

View full card
TEC6: Which professionals use the technology and is there a difference between the screening strategies?
Result
Comment

Importance: Important

Transferability: Partially

Result card for TEC14: "To what population(s) will Abdominal Aorta Aneurysm Screening be used on?"

View full card
TEC14: To what population(s) will Abdominal Aorta Aneurysm Screening be used on?
Result
Comment

Importance: Critical

Transferability: Partially

Result card for TEC5: "What is the background of the golden standard technical device?"

View full card
TEC5: What is the background of the golden standard technical device?
Result
Comment

Importance: Optional

Transferability: Completely

Result card for TEC8: "Are there any special features relevant to the golden standard technical device for Abdominal Aorta Aneurysm Screening?"

View full card
TEC8: Are there any special features relevant to the golden standard technical device for Abdominal Aorta Aneurysm Screening?
Result
Comment

Importance: Important

Transferability: Completely

Result card for TEC7: "In what place and context are Abdominal Aorta Aneurysm Screening strategies intended to be used?"

View full card
TEC7: In what place and context are Abdominal Aorta Aneurysm Screening strategies intended to be used?
Result
Comment

Importance: Optional

Transferability: Partially

Result card for TEC15: "Are the reference values or cut-off points for the diagnosis of AAA by the golden standard technical device clearly established?"

View full card
TEC15: Are the reference values or cut-off points for the diagnosis of AAA by the golden standard technical device clearly established?
Result

Importance: Critical

Transferability: Completely

Investments and tools required to use the technology

Result card for TEC9: "What material investments are needed to use the golden standard technical device for Abdominal Aorta Aneurysm Screening?"

View full card
TEC9: What material investments are needed to use the golden standard technical device for Abdominal Aorta Aneurysm Screening?
Result
Comment

Importance: Optional

Transferability: Completely

Result card for TEC10: "What equipment and supplies are needed to use the golden standard technical device for Abdominal Aorta Aneurysm Screening ?"

View full card
TEC10: What equipment and supplies are needed to use the golden standard technical device for Abdominal Aorta Aneurysm Screening ?
Result
Comment

Importance: Optional

Transferability: Completely

Result card for TEC11: "What kind of information is needed to monitor the use of the technical device for Abdominal Aorta Aneurysm Screening ?"

View full card
TEC11: What kind of information is needed to monitor the use of the technical device for Abdominal Aorta Aneurysm Screening ?
Result

Importance: Unspecified

Transferability: Unspecified

Training and information needed to use the technology

Result card for TEC12: "What kind of qualification, training and quality assurance processes are needed for the use or maintenance of the technical device for Abdominal Aorta Aneurysm Screening ?"

View full card
TEC12: What kind of qualification, training and quality assurance processes are needed for the use or maintenance of the technical device for Abdominal Aorta Aneurysm Screening ?
Result

Importance: Unspecified

Transferability: Unspecified

Result card for TEC13: "What kind of training is needed for the personnel treating or investigating patients using the technical device for Abdominal Aorta Aneurysm Screening ?"

View full card
TEC13: What kind of training is needed for the personnel treating or investigating patients using the technical device for Abdominal Aorta Aneurysm Screening ?
Result

Importance: Unspecified

Transferability: Unspecified

Discussion

Ultrasonography, based on the principle of the Doppler effect, has been established world wide as a gold standard technical device not only for screening but also for monitoring potential size progression of AAAs. This non-invasive method is highly sensitive and specific, but the display of the images is not yet internationally standardised. Further strengths of this method include safety, portability and low costs. The investigation can be carried out not only by physicians, but also by medical technical assistants, however, intensive training and experience of the investigator is highly important to keep intraobserver reproducibility as low as possible.

For the present domain, literature on screening in general and on different screening practices was readily available, however as detailed technical information on ultrasonography was scarce in databases, such as Medline, educational books and manufactories websites had to be added to the literature research. Answers to the distributed questionnaire results on the present domain were helpful and demonstrated that actual screening practices differ in the participating countries. Population-based systematic screening programmes for AAA currently exist in only a few European countries (i.e. the NHS AAA Screening Programme in the United Kingdom). In most countries, AAA screening is performed by various opportunistic screening practices in the outpatient primary care setting.

References

  1. Raffle A, Grey MJA. Screening: Durchführung und Nutzen von Vorsorgeuntersuchungen. Bern: Hans Huber; 2009.
  2. UK Screening Portal UK National Screening Committee. What is screening?  2012  [cited Februar 2012 ]; Available from: http://www.screening.nhs.uk/screening
  3. Morabia A. ZF. History of medical screening; from concepts to action. Postgrad Med J. 2004;80:469.
  4. Wilson JMG, G. J. Principles and practice of screening for disease. 1968.
  5. NHS Abdominal Aortic Aneurysm Screening Programme. Essential Elements in Developing an Abdominal Aortic Aneurysm (AAA) Screening and Surveillance Programme. Version 30, 23 July 2011  2011  [cited January 2012]; Available from: http://aaa.screening.nhs.uk
  6. Engelgau MM. AR, Thompson TJ., Herman WH. Screening for NIDDM in nonpregnant adults. A review of principles, screening tests, and recommendations. Diabetes Care. 1995;Dec;(18(12)):1606-18.
  7. US Preventive Services Task Force. Screening for Abdominal Aortic Aneurysm. Recommendation Statement. Ann Intern Med. 2005;142:202.
  8. EUnetHTA Joint Action 1 Work Package 4 Core HTA. Abdominal Aortic Aneurysm Screening. Survey Report for retrieving information on the use of technology in European countries. 2012.
  9. Lederle FA. Screening for AAA in the USA. Scandinavian Journal of Surgery. 2008;2008(97):141.
  10. The Official US Government Site for Medicare. Abdominal Aortic Aneurysm (AAA) Screenings.  2012  [cited December 2011]; Available from: http://www.medicare.gov/(X(1)S(o4tc1j55vjeusa55ajsqfki2))/navigation/manage-your-health/preventive-services/abdominal-aortic-aneurysm.aspx?AspxAutoDetectCookieSupport=1
  11. Ferket BS, Grootenboer N, Colkesen EB, Visser JJ, van Sambeek MR, Spronk S, et al. Systematic review of guidelines on abdominal aortic aneurysm screening. Journal of vascular surgery : official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter. 2012 May;55(5):1296-304 e4.
  12. Appraisal of Guidelines for Research & Evaluation (AGREE). Introduction to AGREE II.  2012  [cited December 2011]; Available from: http://www.agreetrust.org/
  13. Debus ES, Kölbel T, Böckler D, Eckstein HH. Abdominelle Aortenaneurysmen. Gefässchirurgie. 2010;15(3):154-68.
  14. Eckstein HH, Bockler D, Flessenkamper I, Schmitz-Rixen T, Debus S, Lang W. Ultrasonographic screening for the detection of abdominal aortic aneurysms. Deutsches Arzteblatt international. 2009 Oct;106(41):657-63.
  15. Thanos J RM, Shragge BW, Urbach D,. Vascular Ultrasound Screening for Asymptomatic Abdominal Aortic Aneurysm. Vaskuläres Ultraschall-Screening bei Asymptomatischem Abdominalem Aortenaneurysma. Health Policy. 2008;2008 Nov(4(2)):83.
  16. Lindholt JS, Vammen S, Juul S, Henneberg EW, Fasting H. The validity of ultrasonographic scanning as screeninig method for abdominal aortic aneurysm. Eur J Vasc Endovasc Surg 1999;17:275
  17. Mastracci TM, Cina CS, Canadian Society for Vascular S. Screening for abdominal aortic aneurysm in Canada: review and position statement of the Canadian Society for Vascular Surgery. Journal of vascular surgery : official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter. 2007 Jun;45(6):1268-76.
  18. Giardina S PB, Spinella G, Cafueri G, Corbo M, Brasseur P,   . An economic evaluation of an abdominal aortic aneurysm screening program in Italy. Journal of vascular surgery : official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter. 2011;54(4):946.
  19. Sayyahmelli Sima RA. Screening for Abdominal Aortic Aneurysm. In: Reinhart T Grundmann, editor. Diagnosis and Treatment of Abdominal and Thoracic Aortic Aneurysms Including the Ascending Aorta and the Aortic Arch. Iran: InTech; 2011.
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  23. Riegert-Johnson DL, Bruce CJ, Montori VM, Cook RJ, Spittell PC. Residents can be trained to detect abdominal aortic aneurysms using personal ultrasound imagers: A pilot study. Journal of the American Society of Echocardiography 2005;18(5).
  24. Beales L, Wolstenhulme S, Evans JA, West R, Scott DJ. Reproducibility of ultrasound measurement of the abdominal aorta. The British journal of surgery. 2011 Nov;98(11):1517-25.
  25. BMJ. John Wild. British Medical Journal. 2009;339:b4428
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Appendices

Appendix TEC-1 Result cards and related domains

Result card

Result card question

Related result cards

Features of the technology

B0001 (core)

What is Screening?

 

B0001 (core)

Are there different strategies for abdominal aortic aneurysm screening?

Partly related to A0012, D0029

B0001 (core)

Has any technical device for the detection of AAA established as internationally accepted golden standard?

Partly related to D0029, D0030

B0002 (core)

Why is abdominal aortic aneurysm screening used?

(Partly) related to A0001, A0009, B0001, C0008, D1019, D1007

B0003 (core)

What is the background of the golden standard technical device?

Partly related to A0019, A0020, F0001

B0004 (core)

Which professionals use the technology and is there a difference between the screening strategies?

Partly related to A0013, A0014

B0005 (core)

In what place and context are abdominal aortic aneurysm screening strategies intended to be used?

(Partly) related to G0001, G0005

B0006 (core)

Are there any special features relevant to the golden standard technical device for abdominal aortic aneurysm screening?

(Partly) related to C0007, C0060, D0022

B0016 (core)

To what population(s) will abdominal aortic aneurysm screening be used on?

(Partly) related to A0007, C0005, G0009

B0018 (core)

Are the reference values or cut-off points for the diagnosis of AAA by the golden standard technical device clearly established?

 

Investments and tools required to use the technology

B0007 (core)

What material investments are needed to use the golden standard technical device for abdominal aortic aneurysm screening?

(Partly) related to B0010, E0001, E0002, G0006

B0009 (core)

What equipment and supplies are needed to use the golden standard technical device for abdominal aortic aneurysm screening?

(Partly) related to B0009, E0001, E0002, G0004

B0010 (core)

What kind of information is needed to monitor the use of the technical device for abdominal aortic aneurysm screening?

Related to G0008

Training and information needed to use the technology

B0012 (core)

What kind of qualification, training and quality assurance processes are needed for the use or maintenance of the technical device for abdominal aortic aneurysm screening?

Related to G0003, G0004, C0062, C0063

B0013 (core)

What kind of training is needed for the personnel treating or investigating patients using the technical device for abdominal aortic aneurysm screening?

Related to G0003, G0004, C0062, C0063


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