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

<< Ethical analysisSocial aspects >>

Organisational aspects

Authors: Janek Saluse, Kristi Liiv, Raul-Allan Kiivet

Summary

A national systematic population-based abdominal aortic aneurysm (AAA) screening programme has been implemented in the European Union (EU)  in the UK and Sweden. Most of the information used in the current domain originates from the UK.

Based on clinical effectiveness studies is AAA screening offered for men aged 65 years. In the UK men older than 65can participate in the screening programme by self-referral. For better availability screening is organised through local screening centres that are located in local healthcare facilities (clinics, hospitals, primary care facilities). Screening is carried out by a sonographer using an ultrasound machine. Results are highly accurate and are communicated to men immediately after the procedure. For men with normal results no re-screening is offered. For men who have a small aneurysm an invitation for follow-up screening is given. Men with a large aneurysm (diameter over 5.5 cm) are referred to a vascular surgeon to discuss treatment. Possible treatment options include elective surgery and endovascular aneurysm repair (EVAR). Because of the relatively high risk of death (5%) during surgery a minimum of 20 elective operations per unit is defined as the quality standard.

As a result of screening fewer emergency operations and more elective operations are needed.

The quality of screening should be guaranteed by applying quality criteria – appropriate training of staff, standardised calibration of equipment, and monitoring of screening outcome and of performance (AAA related morbidity and mortality). All monitoring processes are carried out using information technology (identification and collation of screening cohort; management of administration, screening and referral process; recording of AAA surgery and outcomes).

Human resources for AAA screening include: clinical staff (director/clinical lead, ultrasound clinician, consultants in vascular units), screening staff (ultrasound screening technicians, clinical skills trainer, nurse practitioner), management/administrative/technical staff (coordinator, clerical officer, medical physicist, information technology (IT) lead, governance (strategic health authorities, primary care trusts, primary care providers, local screening programme, diagnostic and treatment services).

Costs of AAA screening include: administration costs (salaries of administrative workers), screening and treatment costs (resources for maintenance of equipment; costs of ultrasound exam, elective operation and emergency surgery), and capital costs (ultrasound machines and computers, premises for administrative and diagnostic purposes or mobile screening unit). Screening programmes are usually financed directly by national or local government. But it is also possible to apply cost-sharing.

AAA screening is relatively well accepted by both patients and vascular surgeons.

Introduction

The organisational domain assesses what types of resources (material, human skills, knowledge, money, etc) must be mobilised and organised when implementing a new technology, and what changes or consequences the use can cause in an organisation. In this core health technology assessment (HTA) the new technology is systematic population-based abdominal aortic aneurysm (AAA) screening and the objective is to assess the organisational effects of AAA screening introduction compared with the situation without AAA screening (which includes opportunistic screening and incidental detection of AAA without age or sex limitation while performing abdominal ultrasound examinations for indications other than AAA or unclear clinical indications.

Based on the material found while working on the current domain, systematic population-based AAA screening for healthy individuals has been implemented only in two European countries – the UK and Sweden. No written and freely available materials about the AAA screening organisation in Sweden were found. Therefore this domain is mainly based on UK guidelines and other UK National Health Service (NHS) materials about AAA screening.

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
G0001ProcessWhat kind of work flow, participant flow and other processes are needed?yesWhat kind of work flow, participant flow and other processes are needed when implementing AAA Screening?
What kind of changes are required in existing work processes when implementing AAA Screening?
What kind of changes are required in patients path when implementing AAA Screening?
G0012ProcessWhat kind of quality assurance is needed and how should it be organised?yesWhat kind of quality assurance is needed and how should it be organised?
G0002ProcessWhat kind of involvement has to be mobilized for participants and important others?yesWhat kind of patients (and relative) involvement in screening has to be mobilized when implementing AAA Screening?
G0003ProcessWhat kind of staff, training and other human resources are required?yesWhat kind of staff, training and other human resources are required when using AAA Screening?
G0004ProcessWhat kind of co-operation and communication of activities have to be mobilised?yesWhat kind of co-operation and communication of activities does AAA Screening require?
G0005StructureHow does de-centralisation or centralization requirements influence the implementation of the technology?yesHow does de-centralisation or centralization requirements influence the implementation of AAA Screening?
What consequences will AAA Screening have for de-centralisation or centralisation?
G0006StructureWhat kinds of investments are needed (material or premises) and who are responsible for those?yesWhat kinds of investments are needed (material or premises) when introducing AAA Screening?
Who are responsible for those investments?
G0007StructureWhat is the likely budget impact of the implementation of the technology for the payers (e.g. government)?yesWhat is the likely budget impact of the implementation of AAA Screening for the payers (e.g. government)?
G0008ManagementWhat management problems and opportunities are attached to the technology?yesWhat management problems and opportunities are attached to AAA Screening?
G0013ManagementWhat kind of monitoring requirements and opportunities are there for the technology?yesWhat kind of monitoring requirements and opportunities are there for AAA Screening?
G0009ManagementWho decides which people are eligible for the technology and on what basis?yesWho decides which people are eligible for AAA Screening and on what basis?
G0010CultureHow is the technology accepted?yesHow is AAA screening accepted by clinicians?
How do the patients accept AAA Screening?
How do the financial management of the health care organizations accept AAA Screening?
G0011CultureHow are the other interest groups taken into account in the planning / implementation of the technology?no

Methodology description

Information sources

Specific organisational aspects other than just naming the resources needed and their costs are rarely analysed within clinical studies, economic analysis and HTA reports, so the current analysis required several activities. Systematic review of the literature was not enough to answer the research questions of this domain. So grey literature and national guidelines were added. The search strategy is described below. Since organisational aspects are strictly linked to country contexts, it is useful to integrate results with the experience of local experts in this area. For this purpose the results of the survey of AAA screening in European countries (EUnetHTA, 2012) were used.

Literature search

Published literature was obtained by searching MEDLINE, CDSR (Cochrane Database of Systematic Reviews), CCRCT (Cochrane Central Register of Controlled Trials), and DARE (Database of Abstract of Reviews of Effects), all by using EBSCO-HOST as search engine; and HTA Database CRD (Centre of Reviews and Dissemination). Multiple search strategies were used {ORG-1}. From scientific and HTA report databases no relevant information about organisational aspects of AAA screening was found. Additional searches on Internet Google search engine were done for national guidelines of AAA screening. The author of the current domain is sufficiently competent only in Estonian and English languages, so the search was run in English (it was known by the author that in Estonia systematic population-based screening has not been implemented). Going through reference lists of publications found on the Internet and the websites where they were uploaded gave a few additional sources.

Methods

For the whole domain a specific search on the Internet was performed (Google) – “abdominal aorta aneurysm screening” and “abdominal aorta aneurysm screening guidelines” were used as search phrases. The search was done in 13 March 2012 by Kristi Liiv (UTA). The website of the UK AAA screening programme (http://aaa.screening.nhs.uk/) was widely used for additional information. For research questions that could not be answered using the above described search results, more specific searches were carried out (in these cases the search strategy is described in the result card).

Quality assessment tools or criteria

Quality assessment using criteria for clinical effectiveness is not pertinent in the investigation of organisational aspects. We are currently not aware of suitable formal instrument of classifications using explicit quality criteria for articles looking at healthcare organisation.

Result cards

Process

Result card for ORG1: "What kind of work flow, participant flow and other processes are needed when implementing AAA Screening?", ORG16: "What kind of changes are required in existing work processes when implementing AAA Screening?" and ORG17: "What kind of changes are required in patients path when implementing AAA Screening?"

View full card
ORG1: What kind of work flow, participant flow and other processes are needed when implementing AAA Screening?
Result

Importance: Critical

Transferability: Partially

ORG16: What kind of changes are required in existing work processes when implementing AAA Screening?
Result

Importance: Important

Transferability: Partially

ORG17: What kind of changes are required in patients path when implementing AAA Screening?
Result

Importance: Optional

Transferability: Completely

Result card for ORG15: "What kind of quality assurance is needed and how should it be organised?"

View full card
ORG15: What kind of quality assurance is needed and how should it be organised?
Result

Importance: Important

Transferability: Partially

Result card for ORG2: "What kind of patients (and relative) involvement in screening has to be mobilized when implementing AAA Screening?"

View full card
ORG2: What kind of patients (and relative) involvement in screening has to be mobilized when implementing AAA Screening?
Result

Importance: Optional

Transferability: Partially

Result card for ORG3: "What kind of staff, training and other human resources are required when using AAA Screening?"

View full card
ORG3: What kind of staff, training and other human resources are required when using AAA Screening?
Result

Importance: Important

Transferability: Partially

Result card for ORG4: "What kind of co-operation and communication of activities does AAA Screening require?"

View full card
ORG4: What kind of co-operation and communication of activities does AAA Screening require?
Result

Importance: Optional

Transferability: Partially

Structure

Result card for ORG5: "How does de-centralisation or centralization requirements influence the implementation of AAA Screening?" and ORG6: "What consequences will AAA Screening have for de-centralisation or centralisation?"

View full card
ORG5: How does de-centralisation or centralization requirements influence the implementation of AAA Screening?
Result

Importance: Optional

Transferability: Partially

ORG6: What consequences will AAA Screening have for de-centralisation or centralisation?
Result

Importance: Unspecified

Transferability: Unspecified

Result card for ORG7: "What kinds of investments are needed (material or premises) when introducing AAA Screening?" and ORG8: "Who are responsible for those investments?"

View full card
ORG7: What kinds of investments are needed (material or premises) when introducing AAA Screening?
Result

Importance: Critical

Transferability: Not

ORG8: Who are responsible for those investments?
Result

Importance: Important

Transferability: Partially

Result card for ORG9: "What is the likely budget impact of the implementation of AAA Screening for the payers (e.g. government)?"

View full card
ORG9: What is the likely budget impact of the implementation of AAA Screening for the payers (e.g. government)?
Method
Result

Importance: Important

Transferability: Not

Management

Result card for ORG10: "What management problems and opportunities are attached to AAA Screening?"

View full card
ORG10: What management problems and opportunities are attached to AAA Screening?
Result

Importance: Optional

Transferability: Partially

Result card for ORG18: "What kind of monitoring requirements and opportunities are there for AAA Screening?"

View full card
ORG18: What kind of monitoring requirements and opportunities are there for AAA Screening?
Result

Importance: Important

Transferability: Partially

Result card for ORG11: "Who decides which people are eligible for AAA Screening and on what basis?"

View full card
ORG11: Who decides which people are eligible for AAA Screening and on what basis?
Result

Importance: Important

Transferability: Completely

Culture

Result card for ORG12: "How is AAA screening accepted by clinicians?", ORG13: "How do the patients accept AAA Screening?" and ORG14: "How do the financial management of the health care organizations accept AAA Screening?"

View full card
ORG12: How is AAA screening accepted by clinicians?
Result

Importance: Optional

Transferability: Partially

ORG13: How do the patients accept AAA Screening?
Result

Importance: Optional

Transferability: Partially

ORG14: How do the financial management of the health care organizations accept AAA Screening?
Result

Importance: Unspecified

Transferability: Unspecified

Discussion

Based on the guidelines from the UK a fairly complete overview of organisational aspects of AAA screening is given. However, this overview is specific to UK clinical practice and it is unclear how transferable these guidelines are to other EU countries. All organisational aspects (concerning healthcare systems staff and funding; demographic and geographic distribution of potential screening subjects) are more or less country specific. So the current overview can be used as starting point, but it is crucial to take into consideration country-specific aspects (carrying out research or analysing information already available) when implementing AAA screening.

References

  1. NHS. AAA Screening pathway. (2010).
  2. NHS Abdominal Aortic Aneurysm Screening Programme. Essential elements in developing an Abdominal Aortic Aneurysm (AAA) Screening and Surveillance Programme. Version 3.0; 2011.
  3. CMO and Public Health Directorate: Health Improvement Strategy Division. Scottish Abdominal Aortic Aneurysm Screening Programme; 2010.
  4. Lindholt JS, Norman P. Screening for Abdominal Aortic Aneurysm Reduces Overall Mortality in Men. A Meta-analysis of the Mid- and Long-term Effects of Screening for Abdominal Aortic Aneurysms. Eur J Vasc Endovasc Surg 2008;36:167–171.
  5. Mani K, Lees T, Beiles B, et al. Treatment of abdominal aortic aneurysm in nine countries 2005-2009: a vascunet report. Eur J Vasc Endovasc Surg 2011;42:598–607.
  6. The Vascular Society of Great Britain and Ireland. Framework for improving the results of elective AAA repair; 2011.
  7. Berman L, Curry L, Gusberg R, et al. Informed consent for abdominal aortic aneurysm repair: The patient’s perspective. J Vasc Surg 2008;48:296–302.
  8. Timmermans D, Molewijk B, Stiggelbout A, Kievit J. Different formats for communication surgical risks to patients and the effect on choice of treatment. Patient Educ Couns 2004;54:255–263.
  9. Lindholt JS, Juul S, Henneberg EW, Fasting H. Is screening for abdominal aneurysm acceptable to the population? Selection and recruitment to hospital-based mass screening for abdominal aortic aneurysm. J Public Health Med 1998;20:211–217.
  10. Multicentre aneurysm screening study (MASS). Cost effectiveness analysis of screening for abdominal aortic aneurysms based on four year results from randomised controlled trial. BMJ 2002;325:1135.
  11. Eunethta (WP4 Strand B). AAA Screening Survey Results; 2012.
  12. Mohler ER. Patient information: Abdominal aortic aneurysm 2011  [cited 2011-12-16]; Available from: http://www.uptodate.com/contents/patient-information-abdominal-aortic-aneurysm
  13. UK National Screening Committee. Structured review for the UK National Screening Committee appraising the viability, effectiveness and appropriateness of an abdominal aortic aneurysm screening programme (Appendix 1); 2004.

Appendices

Appendix {ORG-1}. Abdominal aortic aneurysm basic search

Databases: Cochrane Library: Cochrane Database of Systematic Reviews (CDSR), Database of Abstract of Reviews of Effects (Other Reviews), Health Technology Assessments D. (HTA), Central Register of Controlled Trials (CENTRAL). Centre for Reviews and Dissemination, EMBASE (Ovid), Ovid MEDLINE

Search date: 25.10.2011

Study design: Systematic Reviews, (Randomised) Controlled Trials

References: total: 167 total (243 including duplic.)

41 SR/HTA

126 RCT

Searched by: Ingrid Harboe, research librarian

Database: Cochrane Library

Results: Cochrane Reviews [2], Other Reviews [2], Clinical Trials [63], Methods Studies [1], Technology Assessments [11]

Search strategy:

1

MeSH descriptor Aortic Aneurysm, Abdominal, this term only

503

2

(Abdominal Aort* Aneurysm*):ti,ab,kw

681

3

(#1 OR #2)

681

4

MeSH descriptor Mass Screening, this term only

3415

5

screen*:ti,ab,kw

14943

6

(#4 OR #5)

14943

7

(#3 AND #6)

102

Database: for Reviews and Dissemination

Results: 12 SR/HTA

Search strategy:

1

MeSH DESCRIPTOR Aortic Aneurysm, Abdominal EXPLODE ALL TREES

154

2

("Abdominal Aortic Aneurysm") IN DARE, HTA

68

3

#1 OR #2

174

4

MeSH DESCRIPTOR Mass Screening EXPLODE ALL TREES

1704

5

("Mass Screening") IN DARE, HTA

720

6

#4 OR #5

1785

7

#3 AND #6

32

8

(#7) IN DARE, HTA

12

Database: Embase 1980 to 2011 Week 42 &

Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations and Ovid MEDLINE(R) 1948 to Present

  • Search filter:
  • Systematic Reviews: reviews (maximises specificity) & systematic* review*.ti,ab.

Randomised controlled trials: therapy (best balance of sensitivity and specificity)

Search strategy:

1

abdominal aorta aneurysm/use emez

15240

2

Aortic Aneurysm, Abdominal/use prmz

11591

3

abdominal aort* aneurysm*.tw.

23463

4

or/1-3

32698

5

mass screening/

114617

6

screen*.tw.

819044

7

or/5-6

858256

8

4 and 7

1925

9

remove duplicates from 8

1148

10

9 use emez [Embase]

1017

11

9 use prmz [Medline]

131

12

limit 11 to "reviews (maximises specificity)"

3

13

limit 10 to "reviews (maximises specificity)"

25

14

9 and systematic* review*.ti,ab.

22

15

or/12-14

29

16

limit 10 to "therapy (best balance of sensitivity and specificity)"

121

17

limit 11 to "therapy (best balance of sensitivity and specificity)"

15

18

or/16- 17

136

19

15 use emez

26

20

15 use prmz

3


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