25 studies were included, 21 including QoL and using different scales (included in the table below) and four studies using a qualitative methodology (not included in the table).

Being offered the chance to participate in a screening programme may trigger both negative and positive reactions among those invited. Experiences from other screening programmes indicate that different psychological effects may occur when implementing a screening programme. These include fear, anxiety and other psychometric reactions. In an ideal research design of a screening programme, you would have to consider the effects of being invited to participate in the screening programme and the effects of accepting the invitation. The next step would be to examine whether  participants react different accordingly to the result of the screening test. The most informative design would be to compare participants from the screening programme with a matched population, not participating in the screening programme, instead of comparing subgroups within the screening programme.

Except from the qualitative studies, all the studies included in this review measure psychological changes by means of QoL measurement.

In an overall perspective, a screening programme for AAA contains different points in time, where it seems relevant to measure QoL. Figure 2 illustrates these points in time.

Figure 2: An outline of relevant points in time for measuring quality of life among people invited to participate in a screening programme for AAA

Table 1 displays all the quantitative studies included in the review in terms of e.g. design, study quality and effects. This provides an overview of the effects on QoL, following screening for AAA. The participants are classified in three groups. Overall there are no significant differences between the groups, but a description and interpretation of the results follows below the table.  

Table 1: Comparison of Quality of Life in different patients groups, following screening for AAA

i) Studies using more than one study design or different follow-up, ii) Octogenarians were compared with a younger group of patients in a crossover design, iii) Patients operated for small aneurysms, iv) Operative vs. elective, v) Operative vs. non-operative, vi) Operative vs. population

Patients with small AAA/or on waiting list (AAA) for operation compared with patients whose screening results were negative or non-screened controls

Some of the studies indicate that patients diagnosed with at small AAA are more affected, in terms of QoL, than other groups identified in relation to screening for AAA. In Lindholt 2000, patients diagnosed with a small AAA, had the lowest QoL compared with a group of age and gender matched people, who did not attend the screening programme. Patients diagnosed with a small AAA were enrolled in a control set up with scanning of the aorta at fixed intervals. While participating in this control set up, the patients got worse in terms of QoL. However the differences between Lindholt 2000 and the other studies are considered minor {9}.

A qualitative study by Petterson et al. showed that some of the patients diagnosed with a small AAA felt that the frequent follow-up gave rise to questions about what would happen if it ruptured and to thoughts about death. Waiting for surgery was for some people experienced as similar to waiting for a death sentence. On the other hand almost all patients expressed gratitude that the AAA had been discovered. Gratitude for being alive appears to have outweighed the suffering and the sacrifice of well-being following treatment {24}. Letterstål et al. also reported, in a qualitative study, that understanding the seriousness of the situation created distress while waiting for surgery. Sleep disturbances caused by nightmares and thoughts were also experienced by some of the patients {2}. It is possible that the qualitative studies capture some of the psychological effects of screening for AAA, which are not captured in the generic measurements of QoL.

Ruptured abdominal aortic aneurysm compared with an elective group or matched population

In nine studies QoL was assessed in patients operated on for a ruptured AAA. Eight studies used a cross-sectional design {10-17} and one study is a review {18}. The studies are mainly of a moderate quality regarding internal validity. QoL is measured using six different validated QoL scales. Overall no difference in QoL could be shown between the groups. As described in the table, QoL in patients operated for a ruptured AAA was compared with QoL in an elective group of patients operated for AAA or QoL in a matched population. Five cross-sectional studies compared patients with a ruptured AAA to a normal population, and three cross-sectional studies to elective patients. Typically the studies identified patients from historical patient records and then measured QoL (self-rated) in a cross-sectional design. Laukontaus et al. showed a significantly lower EQ-5D score among survivors, than in the background population {14}. This result is inconsistent with Korhonen et al. (who used the same basis for recruitment) {10}. The difference in results may be explained by different questionnaires and a small sample size.

There is a risk of selection bias in the studies since a considerable number of the patients operated for a ruptured AAA died, before the researchers could collect relevant data. Furthermore it is also possible that healthier patients are more likely to answer questionnaires than less healthy patients.

In spite of the weak designs of the studies and the risk of bias, the results taken as a whole do not imply any differences in QoL in patients operated for a ruptured AAA compared with a group of elective patients or an age- and sex-adjusted normal population. Consequently most studies suggest that survivors of ruptured AAA can expect a good QoL, which is comparable to that of patients undergoing elective repair or a normal population.

Patients operated for small AAA or AAA compared with surveillance and/or controls

In seven studies QoL was assessed in patients operated on for a small AAA or AAA compared with patients undergoing surveillance or healthy controls. Three studies used a cross-sectional design {7,19,21} and four studies were randomised controlled trials (RCTs) {6,20,22,23}. The studies vary in quality regarding internal validity from low to high with two RCTs being of high quality. Eight different fully (or partially) validated and one non-validated (ScreenQL) QoL scales were used to measure QoL, with follow-up times from 3 months to 8 years in the RCTs.

In general no difference in QoL can be shown between the groups. There is a tendency towards better, short lasting effect on QoL in patients undergoing surgery. However, the effect levels out in time.

Four studies investigate patients with a small AAA, and two studies examine patients with AAA > 5.5 cm. Sandström et al. examined patients with AAA between 4.7 and 7.5 cm {21}. De Rango et al. showed changes in mean SF-36 scores at 6 months from baseline that were significantly higher for early EVAR patients than for surveillance patients, although the effect size is considered small {20}. The effect levelled out in the final follow-up. In spite of the varying study designs and varying quality of the studies, the results above all point in the direction of no difference in QoL in patients operated for an AAA compared with patients under surveillance or controls. Some short-term effects can be identified, but it does not change the overall picture, which suggests that there is no difference between the groups.

Two qualitative studies, one by Langenberg et. al. {25} and one by Brannstorm et al.{26}, show that the participants use different coping strategies when confronted with diagnoses of AAA and that patients generally derive reassurance from the professionals and the professional set-up around the screening programme.

All things considered, this review does not reveal any significant changes or differences in quality of life following screening for AAA. If screening for AAA is implemented, it might be advisable to pay close attention to the group of patients diagnosed with a small AAA and participating in a control set up. Some of the studies indicate that these patients might constitute a particularly vulnerable group.

A weakness in this review is the fact that a lot of the studies included lack a control group outside the study. The studies are designed to compare groups within the screening programme and not with an outside control group.