Characteristics and outcomes in men screened vs not screened for AAA in Sweden

Transcription

1 Characteristics and outcomes in men screened vs not screened for AAA in Sweden Rebecka Hultgren Stockholm Aneurysm Research Group STAR Associate professor, Senior consultant Department of Vascular Surgery, Karolinska University Hospital and Karolinska Institutet Erik G Svensson Stockholm Sweden.

2 Faculty disclosure I have no financial relationships to disclose.

3 Background Screening for AAA in elderly men started in selected counties in Sweden 2013 screening in most elderly men nationally, smallest county (57000 inhabitants) has chosen not to screen. Sweden: population of 9.7 million inhabitants Benefits of a population based screening program correlates to participation rate, and to the distribution of co-morbidity and risk factors in the screened vs non-screened cohort In the MASS trial; invited non-participants in the screening had a higher mortality rate than the control population 19% vs 12% 5 yr mortality Persons identified by screening with AAA would have a better outcome than non-screened men when treated with vascular surgery for AAA.

4 Screening- participation rates and prevalence rates in Sweden published data Mid Sweden yrs 85 % Prevalence 1.7% Stockholm months 78 % (60-89%) Prevalence 1.4% Linköping yr old 86 %, yr old 84% Prevalence % Malmö yr old 80 % (64-89%) Prevalence 1.76%

5 Screening- Summarised published data Participation: 59227/72238 (81%) non-participants Prevalence 1.4%-2.3% in screened 1.9% =>1120 cases diagnosed in screening 1.9% in non-screened; 248 cases SWEDVASC annual rates AAA 1300 Elective repair AAA 1050 RAAA 250

6 Risk factors and co morbid conditions Screened men with AAA differ in expected variables from screened without AAA The non-participants have an often unknown distribution of riskfactors Low prevalence of AAA among 65 year old Swedish men Svensjö et al Circulation 2011

7 Participation rates MASS socioeconomically deprived areas; 75 % participation vs 85% Ireland; participation ; 45% Analysis of Socially deprived groups => higher prevalence 10.1 % vs 4.2 % => lowest participation rate 29 % vs 54% Scotland HASP : participation %, varies with social deprivation Sweden Malmö and Stockholm studies of participants and non-participants Invited : 8269 and men (2012, 2013). Uptake of AAA Screening, EJVES 2013, Ross et al MASS, Lancet 2002, Scottt et al. Risk Factors for AAA and the influence of social deprivation, Angiology, 2008, Badger et al The importance of socioeconomic factors for compliance and outcome, JVS, 2013, Zarrouk et al Reasons for non-participation in population based screening, BJS, Linne et al, 2014

8 ADJUSTED ODDSRATIO INCOME 1 vs 2.76 SINGLE 1 vs 2.23 IMMIGRANT 1 vs 3.25 EDUCATED 1 vs 1.28 TRAVEL 1 vs 1.23 No. of patient s danc e rate (%) Multivariable analysis Adjusted odds ratio < 0.001* Disposable income 1st quintile (highest) 2nd quintile (0.82, 1.06) rd quintile (1.02, 1.30) th quintile (1.48, 1.88) < th (lowest) quintile (2.46, 3.10) < Marital status Married < 0.001* Single or (2.08, 2.39) < divorced Widowed (1.35, 2.04) < Travel distance (km) < (0.89, 1.10) (0.87, 1.09) (0.87, 1.08) (1.10, 1.37) < Immigration < 0.001* status Native Swedish Immigrant for > (1.31, 1.20) < years Immigrant for 5 19 years (1.22, 1.78) < Immigrant for < (1.94, 5.47) < 0.001* 5 years

9 Comorbidity in non-participants Participants (n =18 876) Nonparticipants (n =5443) P* Healthcare use over 0 10 years before invitation to screening > 2 hospital admissions 5492 (29.1) 1790 (32.9) < > 2 outpatient visits (85.1) 4153 (76.3) < Co-morbidity Ischaemic heart disease 1397 (7.4) 403 (7.4) COPD 239 (1.3) 156 (2.9) < Diabetes Stroke Renal failure Malignancy 1519 (8.0) 527 (9.7) < (2.8) 245 (4.5) < (1.1) 87 (1.6) (11.0) 471 (8.7) < 0.001

10 How improve participation rates? The Malmö model: Silver gift wrap with a map Red silk tie- an aneurysmknot

11 Intervention can change participation High prevalence rates 2.6 % vs 1.76% in deprived areas The new invitation increased participation rates in deprived areas 71% => 78% 2013 In deprived areas without intervention; unchanged participation rates Cost: for this region; cost of intervention =cost of 1 raaa vs 1 elective repair (44600 E vs 33000E) Potential benefit? Stockholm County Screening invitation Non- Participants: => >164 AAA patients undiagnosed

12 OUTCOME IN SCREENED MEN VS NON-SCREENED MEN o All persons treated with elective repair for AAA, and registered prospectively in SWEDVASC were included in a Swedish multicenter study (n= 2135, exclusion women n=164) o Screened men were matched for age (350 screened vs 350 non-screened patients) maj 2012 dec o There were no differences in baseline characteristics or comorbidities besides age (median 66 vs. 68 ) Low postoperative mortality after surgery on patients with screening-detected abdominal aortic aneurysms: A Swedvasc registry study., in press EJVES 2014 Anneli Linné 1 *, Kristian Smidfelt 2 *, Marcus Langenskiöld 2, Rebecka Hultgren 3, Joakim Nordanstig 2, Björn Kragsterman 4, David Lindström 3

13 More Screened Men Treated with OR

14 Mortality similar- apart from 90 Days-EVAR treated Open Repair (n=352) Screening- Non detected screeningdetected n (%) n (%) p EVAR (n=348) Screening Non detected screeningdetected n (%) n (%) n day 2/195 (1.0) 5/157 (3.2) /155 (0) 0/193 (0) 90-day 4/195 (2.1) 7/157 (4.5) /155 (0) 6/193 (3.1) year 7/173 (4.0) 9/155 (5.8) /140 (1.4) 9/191 (4.7) 0.12 p

15 Summary Men with AAA, diagnosed within the population based screening program, have a stronger socioeconomic situation and better risk profile than the nonparticipants. Highly probable that the prevalence rates would changed with a higher participation rate; ie participants have poorer smoking habits and comorbidity profile. Further improvement should be performed of the present invitation to screeningprograms, in order to minimize low participation rates in the particularly deprived areas. The differences in co-morbidity and socioeconomic situation between screened and non-screened AAAs that are treated with elective repair does however not influence the excellent outcome after treatment for AAA. The low event rate overall after AAA surgery in Sweden can of course contribute to this lack of shown differences in outcome.

16 Stockholm Aneurysm Research group STAR Some coworkers from STAR 9/18/2014 Rebecka Hultgren 16

17 Thank you STAR Karolinska Institutet

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