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Screening for abdominal aortic aneurysm (AAA) in men 65 to 74 years of age was cost-effective for AAA mortality at 10 years

Question What is the long-term cost-effectiveness of screening for abdominal aortic aneurysm (AAA) in men 65 to 74 years of age? Methods Design Cost-effectiveness analysis from a UK health service perspective based on 10-year follow-up of a randomized controlled trial (Multicentre Aneurysm Screening Study [MASS]). Current Controlled Trials ISRCTN37381646. Setting 4 centers in the UK. Patients Population-based sample of 67770 men 65 to 74 years of age. Intervention 33883 men received an invitation to screening for AAA. If an aneurysm 3 cm was detected, men were rescanned every 3 months or annually depending on the size of the aneurysm; men were referred for elective surgery for aneurysms 5.5 cm or that expanded by 1 cm/y, or if symptoms were reported. 33887 men received no invitation to screening. Outcomes Deaths related to AAA and costs (invitation and reinvitation to screening, initial scan, recall scan, referral for elective surgery, elective surgery, and emergency surgery). Main results 27204 men (80%) in the invited group attended screening, and 1334 aneurysms 3 cm were detected. Mortality related to AAA was lower in the invited group at 10 years (Table). The incremental cost-effectiveness ratio was 7600 (95% CI 5100 to 13000) per life-year gained. Conclusion Screening men 65 to 74 years of age for abdominal aortic aneurysm (AAA) reduced AAA-related mortality and was cost-effective at 10-year follow-up. Invitation to screening for abdominal aortic aneurysm (AAA) vs no invitation (control) in a population-based sample of men 65 to 74 years of age* Outcomes Invitation to screening (n) Control (n) RRR (95% CI) NNS (CI) Death related to AAA 0.46% (155) 0.87% (296) 48% (37 to 57) 240 (202 to 312) Difference Survival (life-days) 2747.8 2743.0 4.8 (2.9 to 6.7) Costs 208 108 100 (82 to 118) *NNS = number needed to screen; other abbreviations defined in Glossary. RRR, NNS, and CI calculated from hazard ratios in article. Based on deaths related to AAA, adjusted for other causes. 1.00 = $1.65. Costs based on 2000 to 2001 prices adjusted to reflect 2008 to 2009 prices. Costs and survival are discounted at 3.5%/y. Commentary The results of the large UK study by Thompson and colleagues showed a persistent mortality benefit for AAA screening, with cost per life-year gained well below the traditional threshold of $50000 per quality-adjusted life-year (QALY) gained. However, the absolute benefit for an individual was quite small. AAA mortality declined from about 1% to 0.5% over 10 years with screening; the average man gained 5 days of life. Deaths prevented, unlike those from ischemic cardiomyopathy or breast cancer, are not usually preceded by many months of suffering. With such a small benefit of screening, potential harms must be thoroughly examined. About 5% of screened men will be found to have AAA; nearly half of these will eventually have surgery. Surgery entails a 2% to 5% perioperative mortality rate, which was measured in this study, but also has high rates of complications and institutionalization (1). Cost per QALY increases markedly, assuming only a small impairment in quality of life after diagnosis (2). What else could affect the conclusions? The costs of relevant services tend to be higher in other countries, including the USA. This difference would increase the cost per QALY gained (3). Since this study began, there has been a shift toward endovascular rather than open surgery for AAA. Endovascular repair has lower perioperative morbidity and mortality than open repair but higher costs and more long-term complications (4). Increased use of endovascular surgery would probably worsen the cost-effectiveness of AAA screening. Screening, under the costs and conditions in the UK a decade ago, modestly decreased AAA-associated mortality at an acceptable cost per life-year gained, but without adjustment for quality of life. The higher costs in the USA, the probable decrease in quality of life in many patients having surgery for AAA, and the increased costs and long-term complications associated with endovascular repair suggest that the cost per QALY gained under current conditions in the USA would be substantially less favorable.