Annals of Vascular Surgery
Volume 22, Issue 1 , Pages 16-24, January 2008

Ultrasound Screening for Abdominal Aortic Aneurysm in Medicare Beneficiaries

  • Marc Schermerhorn

      Affiliations

    • Department of Surgery, Darthmouth Hitchcock Medical Center, Hanover
    • Corresponding Author InformationCorrespondence to: Marc Schermerhorn, MD, Department of Surgery, Harvard Medical School, 110 Francis Street, Boston, MA 02115, USA
    • ,
  • Robert Zwolak

      Affiliations

    • Department of Surgery, Darthmouth Hitchcock Medical Center, Hanover
    • ,
  • Omaida Velazquez

      Affiliations

    • Hospital of the University Pennsylvania, Philadelphia, PA
    • ,
  • Michel Makaroun

      Affiliations

    • University of Pittsburgh Medical Center, Pittsburgh, PA
    • ,
  • Ronald Fairman

      Affiliations

    • Hospital of the University Pennsylvania, Philadelphia, PA
    • ,
  • Jack Cronenwett

      Affiliations

    • Department of Surgery, Darthmouth Hitchcock Medical Center, Hanover

published online 04 December 2007.

Article Outline

Ultrasound screening for abdominal aortic aneurysm (AAA) has been shown to be beneficial and cost-effective for men aged 65-74. However, most screening studies have been conducted in Europe and Australia, where attendance for screening was higher than the single large U.S. study involving only veterans. The prevalence of AAA in the U.S. general population is not well defined, nor is the best method of recruitment for screening. Letters of invitation for a free screening ultrasound for AAA were sent to 30,000 randomly selected Medicare beneficiaries from the hospital referral region of three university-affiliated hospitals without restriction by age, gender, or comorbidity. Attendance for screening was calculated by age, gender, and travel distance to the screening center. Telephone calls to a random sample of nonresponders were made to determine the reason for failure to attend. Prevalence of AAA by ultrasound and known risk factors for AAA (e.g., age, gender, smoking status) were determined. The attendance rate was 7% (2,005). Attendance was greater with male gender (p < 0.01), younger age (p < 0.05), and decreased travel distance to the screening center (p < 0.05). The primary reasons for failure to attend included incorrect address or vital status, poor health, and lack of interest. Prevalence of previously undetected AAA was 2.8% in men and 0.2% in women. AAA was predicted by smoking status and male gender (p < 0.01 for each). Unselected invitation of Medicare beneficiaries for ultrasound screening for AAA results in a low attendance and low yield of AAA. The prevalence estimates from this study may not reflect the entire Medicare population given the low attendance and may reflect the healthy habits of those most interested in screening. Patients should be selected for screening based on their suitability for repair if an AAA is found as well as their risk factors for AAA. The best method of recruitment for screening of those most at risk for AAA in the United States remains to be determined.

 

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Introduction 

The U.S. Preventive Services Task Force (USPSTF) has recently recommended ultrasound (U/S) screening for abdominal aortic aneurysm (AAA) for men aged 65-75 who have ever smoked.1 This recommendation was based on a review of the literature including four recent randomized trials.2, 3, 4, 5 The largest of these trials, the Multicentre Aneurysm Screening Study (MASS), demonstrated a significant benefit of screening men in this age group, while the others showed a nonsignificant benefit. Meta-analysis of all trials again showed significant benefit.6 The MASS trial also demonstrated screening to be cost-effective for men aged 65-74.7

However, these trials were conducted in Europe where, all citizens are registered with primary-care physicians, and Australia, where national access to driver's licenses allowed invitation of all citizens within the designated age range. Attendance rates for screening in these trials ranged 68-80%. Only one randomized trial included women and found no benefit of screening.8 The only large screening study in the United States was conducted at Veterans Affairs hospitals.9 Attendance for screening in this study (23%) was substantially lower than that in the European and Australian studies. In addition to age, gender, and smoking, screening studies have shown AAA to be associated with family history of AAA, hypertension, and other manifestations of cardiovascular disease.9, 10, 11, 12, 13, 14, 15, 16, 17, 18 The Society for Vascular Surgery has recommended screening all men aged 60-85, women aged 60-85 with cardiovascular risk factors, and men and women over 50 with a family history of AAA—in those considered fit for intervention if AAA is discovered.19

We sought to determine the prevalence of AAA in both male and female Medicare beneficiaries with no age limit and the impact of potential risk factors for AAA to determine which patients may benefit from screening in the United States. We also sought to determine the attendance rate in Medicare beneficiaries in response to letters of invitation and the impact of age, gender, and distance from the examination site on the attendance rate.

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Methods 

Selection/Invitation 

Medicare beneficiaries from the hospital referral region (HRR) of Dartmouth-Hitchcock Medical Center (Lebanon, NH), the Hospital of the University of Pennsylvania (Philadelphia, PA), and the University of Pittsburgh Medical Center (Pittsburgh, PA) were identified from denominator files from the Centers for Medicare and Medicaid Services (CMS). Thirty thousand beneficiaries over age 65 were randomly selected for invitation for AAA screening. Beneficiaries were sent a letter of invitation for a free screening U/S with an accompanying letter with information about AAA. A second letter of invitation was subsequently mailed to nonresponders. Those with prior aortic surgery, a known AAA, or recent abdominal imaging were excluded. There was no exclusion for old age or comorbidity. Responders meeting eligibility criteria were scheduled for screening U/S.

Screening Exam 

A limited abdominal U/S was performed after fasting. The maximum aortic diameters in the anteroposterior, lateral, and oblique planes were recorded. AAA was defined as an aortic diameter ≥3.0 cm in any of these planes. The examination time and the proportion in which the aorta could not adequately be visualized were recorded. A history of smoking, hypertension (HTN), cerebrovascular accident or transient ischemic attack (CVA/TIA), or family history of AAA was obtained by the technician. Patient age and gender were recorded.

Telephone Interview with Nonresponders 

After a low response rate was noted, we randomly selected 120 nonresponders from the Dartmouth-Hitchcock Medical Center HRR for telephone contact. Twenty beneficiaries each were selected from the age groups 65-74, 75-84, and ≥85 of both men and women. These beneficiaries were questioned to determine why they did not respond to the invitation. Those who stated that they had not received the invitations were sent additional copies and invited to participate.

Statistical Analysis 

Attendance rates after the first and second invitations were calculated. Attendance rates by age category, gender, and zip code distance to the screening center were calculated. The overall prevalence of AAA was determined as well as in subgroups with potential risk factors (age, gender, smoking, HTN, family history, CVA/TIA). Comparisons were made using the χ2 test, Fisher's exact test, and analysis of variance, as appropriate. Travel distance to the exam site was calculated using beneficiary zip code data and Spheresoft® software (http://www.Spheresoft.com). Univariate analysis of variance was used to compare the distance traveled between the three exam centers as well as between the examined and not examined groups within the centers.

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Results 

Letters of invitation were sent to 30,000 Medicare beneficiaries from the three HRRs. Fifty-nine percent of those invited were women.

Attendance 

The overall attendance rate was 6.7% (2,005 beneficiaries). This varied between the three sites from 2% to 13%. Men were more likely to attend than women (7.1% vs. 4.5%, p < 0.01). The attendance rate decreased with age (p < 0.01, Table I). One hundred eighty beneficiaries were invited with ages 100-131. None of these attended.

Table I. Attendance for screening U/S for AAA by age in Medicare beneficiaries
Age (years)Number invitedAttendance
65-694,93110.3%
70-747,3109.1%
75-796,9567.1%
80-845,4324.4%
85-893,3622.6%
≥902,0090.7%
100-131a1800%

aIncluded in those ≥90.

Distance to the exam site was closer in those who attended screening than those who did not attend (p ≤ 0.05, Fig. 1). This was noted in all three sites, although the average travel distance differed widely between the three sites.

Telephone calls to randomly selected nonresponders were made to determine the reason for failure to attend. More than half of the beneficiaries did not have phone numbers listed for the given name and the corresponding address (Table II). Seventy-three percent of women were not listed under either their full name or last name at the given address versus 33% of men (p < 0.05). Nearly 20% did not answer the phone despite at least two separate attempts. Seven percent were confirmed dead by relatives or guardians. Only 21% were actually contacted. Of the 25 beneficiaries who were contacted, reasons given for nonattendance can be categorized as either no recollection of receiving the letter (28%), poor health (24%), lack of interest (24%), known AAA (8%), or recent abdominal imaging (4%); 8% who were initially not interested said they would reconsider after speaking with their primary-care physician. One beneficiary who did not recall receiving the invitation also felt her health was too poor to undergo screening. All others who did not recall receiving the invitation were sent additional copies and allowed to participate.

Table II. Results of attempts to contact 120 nonresponders by telephone (20 from each age group among men and women)
No listingNo answerDeadContacted
M 65-749218
M 75-8444210
M 85+71210
F 65-7414303
F 75-8414114
F 85+16130
Totals64 (53%)23 (19%)8 (7%)25 (21%)

Ultrasound Exam 

The U/S exam was felt to be technically adequate in 1,975 patients (98.5%) with visualization of the aorta sufficient to record diameter measurements. The aorta was not adequately visualized in 30 patients (1.5%).

Prevalence of AAA 

The overall prevalence of AAA (≥3.0 cm) was 1.6%. In men the prevalence was 2.8% (29 of 1,042) compared to 0.2% (2 of 963) in women. AAA prevalence increased with age, peaked at ages 75-79, and decreased thereafter (Table III). The prevalence of AAA in those with selected risk factors associated with AAA is shown in Table IV. Male gender (p < 0.01) and smoking status (p < 0.01) were associated with AAA in univariate analysis.

Table III. Prevalence of AAA (≥3.0 cm) in men and women by age (only two aneurysms were found in 963 women)
Age (years)Number screened (men and women)AAANumber screened (men only)AAA
65-695061.0%2542.1%
70-746681.4%3602.5%
75-794912.4%2444.9%
80-842391.3%1291.6%
85-89871.1%492.0%
≥90140%60
Table IV. Prevalence of AAA in groups with selected risk factors for AAA
Risk factornPrevalence
Male1,0422.8%
Female9630.2%
Current smoker1486.8%
Former smoker8381.1%
Never smoker1,0200.5%
Family history positive1982.0%
No family history1,8081.5%
HTN1,1031.9%
No HTN9031.1%
CVA/TIA1883.2%
No CVA/TIA1,8181.4%

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Discussion 

Our study found that unselected invitation of Medicare beneficiaries results in a low attendance rate and low yield of AAA. The risk factors male gender and smoking status were confirmed in the U.S. Medicare population.

Attendance for screening has been high in large European and Australian studies (59-83%).2, 4, 5, 11, 12, 20, 21, 22, 23 The single large study conducted in the United States (with AAA defined as aortic diameter ≥3.0 cm) was in the Veterans Administration system and had an attendance rate of 23%.9 Attendance in the current study was considerably lower. There are several likely reasons for this. (1) We placed no upper age limit on those to be invited. Our goal was to determine the prevalence of AAA in all age groups. As age increased, beneficiaries were less likely to attend. Kim et al.24 demonstrated this effect in the MASS trial. (2) In Europe, patients are registered with a primary-care physician and letters of invitation came from the physician's office. In our study, letters came from an academic institution within the HRR from physicians the subjects were unlikely to know personally. (3) The Medicare database does not have updated addresses on all beneficiaries. The vital status of the beneficiaries on this list is also questionable given that invitations were sent to 180 people aged 100-131. It is obviously difficult to keep this database current in the most elderly segment. (4) Distance to the examination site was associated with attendance rate. It is possible that if beneficiaries had options for screening U/S at locations closer to home, the attendance rate would be improved. Lindholt et al.25 noted a moderate effect of travel distance on attendance in a hospital-based U/S screening program for AAA in Denmark.

The prevalence of AAA in this study was low. In other large screening studies, prevalence of AAA in men ranged 4.1-8.8% and in women 0.6-6.2%.2, 4, 5, 9, 11, 12, 15, 21, 23, 26 With a low attendance rate, the prevalence estimate from the current study may not accurately reflect the Medicare population. This group may represent only those most interested in screening, e.g., those willing to travel potentially long distances based on information that came from an unknown physician. It is possible that this group had healthier habits (a “healthy volunteer” effect). Current smokers made up only 7% of our study group, while 49% were ever-smokers. In other large population-based screening studies, current smokers made up 16-25% and ever-smokers made up 61-98% of the population screened.9, 10, 11, 12, 13 In the U.S. population, 10% of those over age 65 are current smokers and 50% are ever-smokers.27 Our results may also reflect a lower prevalence of smoking in the nonveteran population compared to the European and Australian populations. Approximately 25% of U.S. adult males were current smokers in 1999-2001 compared to 38% of European adult males in the same period.27, 28 For women the rates are more similar (23% in Europe vs. 21% in the United States). The proportion of the elderly who smoke decreases with increasing age (approximately 54% of U.S. citizens aged 65-74 compared to 44% of those ≥75 were ever-smokers).27 We included beneficiaries over age 75 in our study. This is another reason the proportion of smokers (and perhaps therefore the prevalence of AAA) may have been lower in our study than others. Unlike other studies that have demonstrated a continued increase in AAA prevalence over age 80,12, 23 we found a peak prevalence of AAA in those aged 75-79.

The low attendance rate and low yield of AAA suggest that our method of recruitment for screening was not adequate. As we were trying to determine the prevalence in all Medicare beneficiaries, we did not select patients for screening. In practice, however, it would be appropriate to select for screening only those who would be considered candidates for repair if an AAA were discovered. A specific upper age limit may not be appropriate since comorbidity determines operative risk and life expectancy more so than absolute age.29, 30, 31, 32 In the United States, the average life expectancy of an 80-year-old is 8.8 years.33 Decisions about the appropriateness of AAA repair should be based on a careful consideration of an individual patient's rupture risk, operative risk, and life expectancy.34, 35 The best physician to assess whether a given patient would be appropriate for screening would logically be the primary-care physician. It is notable that although approximately 90% of Medicare beneficiaries visit a primary-care physician annually, many preventive services recommended by the USPSTF and covered by CMS are not actually received by patients.36 McGlynn et al.37 found that only 52% of recommended screening tests were actually received. Additionally, it is likely that those who visit their primary-care physician regularly are less likely to smoke or have uncontrolled HTN. As the prevalence of AAA increases in the population screened, the cost-effectiveness of screening is improved.38 Therefore, screening in the Medicare population should include those most at risk. To this end, the U.S. Congress recently passed legislation offering AAA screening to male ever-smokers and to men and women with a family history of AAA.

This study confirms that male gender and smoking status are associated with increased risk of AAA in the Medicare population. Primary-care physicians should be educated regarding the benefits of U/S screening for AAA. This group of physicians is the most likely to see Medicare beneficiaries on a regular basis and to make a determination as to whether patients would be fit for AAA repair and, therefore, appropriate for screening. Screening examinations should be offered locally to increase compliance. The patients at highest risk for AAA may be the most difficult to recruit. Therefore, special efforts should be made to enroll these groups. However, the best method to reach those at highest risk remains to be determined in the United States.

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Appendix 

Dear Medicare Beneficiary:

This letter is to inform you about an opportunity for a free screening test to detect an abdominal aortic aneurysm. The examination is an ultrasound study of the abdomen, which is painless and risk-free. The examination will take about 15 minutes. This study is being conducted at Dartmouth-Hitchcock Medical Center in conjunction with the Hospital of the University of Pennsylvania and the University of Pittsburgh Hospital and is designed to determine if Medicare beneficiaries should undergo such testing routinely.

What is an abdominal aortic aneurysm? 

An abdominal aortic aneurysm is a dilation (ballooning) of the aorta (the large artery that brings blood from the heart to the rest of the body). The portion of the aorta in the abdomen will occasionally develop an aneurysm. This occurs in about 5% of people over age 60. Abdominal aortic aneurysms are usually asymptomatic, meaning that you cannot tell if it is present. Abdominal aortic aneurysms tend to grow slowly over time. When they become large, they can break, leading to internal bleeding which is usually fatal. Fortunately, they can be detected with ultrasound before they rupture, even when they are small. Small abdominal aortic aneurysms need only to be monitored over time, while larger abdominal aortic aneurysms can be treated with a variety of options.

For more information, please see the enclosed article from the Wall Street Journal on January 13, 2003, in which they discuss this study.

Who is eligible for this screening examination? 

Everyone age 65 and over is potentially eligible.

Who is not eligible? 

People who are under age 65;

People who have had an ultrasound or CT scan (CAT scan) of the abdomen within the past 5 years;

People who have had surgery on the abdominal aorta

Why should I have this done? 

Studies similar in Europe have shown that death due to ruptured AAA can be reduced by 50% by identifying aneurysms with ultrasound.

How do I arrange this? 

Please call toll-free at (866) 302-3462 or locally in the Lebanon area at (603) 653-1990 to confirm your eligibility and to schedule your examination at a convenient time. The examinations are performed at Dartmouth-Hitchcock Community Health Center located on Buck Road in Hanover, Monday through Friday from 8:00 AM to 4:30 PM.

Sincerely,

Marc Schermerhorn, MD

Jack Cronenwett, MD

Dear Medicare Beneficiary,

We previously sent you an invitation for a free ultrasound screening for abdominal aortic aneurysm. A copy of that invitation is included. Please take a few moments to review this information. We recommend that you speak with your primary care physician if you still have questions about whether this is appropriate for you.

We hope that you will help us to potentially help you and other Medicare beneficiaries by participating in this study. Please call toll-free at (866) 302-3462 or locally in the Lebanon area at (603) 653-1990 to schedule an appointment for your free ultrasound examination.

Sincerely,

Marc Schermerhorn, MD

Jack Cronenwett, MD

Aneurysm Tests Could Save a Lot of Lives, if Performed 

Flaw Is Fixable if Found and Often a Killer if Not

By THOMAS M. BURTON

Staff Reporter of THE WALL STREET JOURNAL

Jo-Anne Coe took every medical test recommended by doctors and was determined to stay healthy. At 69 years old, she was working as an aide to former Sen. Bob Dole while remodeling a Virginia farmhouse.

But on Sept. 27, while shopping for kitchen cabinets, Ms. Coe felt an intense pain in her back and went to an emergency room. Unlike chest pain, back pain often isn't regarded as urgent, so she waited 90 minutes to see a doctor. After finding that blood was pouring into her body from a leaking aneurysm—a ballooned section of a blood vessel—alarmed doctors rushed her into surgery. During the operation, on her torn aorta, she died.

The popular impression is that aneurysms are like lightning: striking rarely, suddenly and unpredictably. In fact, the most lethal aneurysms, those on the aorta, develop slowly, are often easy to diagnose with an inexpensive ultrasound test, and can usually be treated.

But most are never diagnosed, with the result that bursting aneurysms in the abdomen and chest kill an estimated 18,000 Americans a year—more than AIDS or brain cancer, and four times as many as cervical cancer. Based partly on estimates from doctors, deaths from all types of aneurysms, including cerebral, equal prostate cancer's toll and approach that of breast cancer.

Neglected Disease 

For all this, there is no national effort to find aneurysms before they rupture. Doctors almost never inquire about a family history of aneurysms, even though they have a strong familial link. They draw minuscule research funding. And while vast medical industries have grown up to detect ills such as prostate cancer and diabetes—with doctors routinely ordering tests and insurers routinely paying—doctors hardly ever suggest that a well patient take a simple test that could detect countless repairable aortic aneurysms. It costs as little as $40 at some centers.

“These deaths are basically preventable if people just got themselves screened,” says M. David Tilson, who has treated and researched aneurysms for more than a quarter-century and now holds an endowed chair in surgery at Columbia University. “Aneurysm disease is one of the most neglected diseases in American history.”

Why this anomaly? An important reason is that aneurysms produce no large group of patients motivated to raise awareness and funding. Most people with an aneurysm never have symptoms and don't know about it. If it bursts, they're usually dead or disabled. In a third scenario, where the aneurysm is found and surgically repaired, patients aren't likely to become activists. Most are essentially cured, unlike the many people who live for years fighting cancer, AIDS or heart disease.

A rare exception is Bill Maples, who launched a support group and Web site out of his home after having an aneurysm found and fixed. “We have no funding whatsoever,” says Dr. Maples, a retired college biology professor in Carrollton, Ga.

A different obstacle prevents screening tests from becoming common and covered by insurance. Many insurers take their cue from Medicare, which doesn't cover aneurysm screening. Now, however, a debate is stirring in medicine over whether some groups of people with no symptoms should be screened for aneurysms.

K. Craig Kent, chief of vascular surgery at New York Presbyterian Hospital–Cornell, did an economic analysis concluding that ultrasound screening for abdominal aneurysms would be more economical, in terms of life-years saved, than mammography. In an article last August in the journal Surgery, Dr. Kent recommended that all men over 60 be offered a quick ultrasound exam of the stomach. He also urges the test for all women over 60 who have a family history of aneurysms.

“Social Dilemma” 

What such a policy might add to the country's surging medical bill is unknown. The cost would include not only the screening but also monitoring of aneurysms found, and surgery for some of them. To Rodney White, a surgery professor at UCLA, “It's a social dilemma because you can't afford to screen everybody. But the argument for screening is stronger now [and] a lot of professional groups are advocates for screening.”

Aneurysms arise when a thinning, weakening section of an artery wall balloons out. Such spots are considered aneurysms when they reach twice the artery's normal diameter. The deadliest occur in the aorta, the big vessel stretching from the heart to the abdomen.

They usually produce no symptoms. The majority never burst. But when they do, the patient dies about 90% of the time, often never reaching a hospital. By contrast, when a large aortic aneurysm is found and operated on, the survival rate is typically 95% or better, depending on the hospital and where on the aorta the aneurysm is.

Most deaths from aortic aneurysms involve the abdomen, where they can be detected by the inexpensive, and very accurate, ultrasound test. The rest of aortic-aneurysm deaths—an estimated 2,500 a year in the U.S.—occur where the vessel runs through the chest. Spotting these usually requires a CT scan, which can cost as much as $800.

Cerebral aneurysms present a more complicated case, because detecting them costs more and it's not so clear which ones need surgery. But these, too, can be deadly. They kill roughly 14,000 Americans a year, estimates Gary Steinberg, chief of neurosurgery at Stanford University Medical Center.

The aneurysm toll actually may be much higher. In the absence of autopsies, coroners tend to attribute sudden deaths to cardiac failure. Each year in the U.S., about 450,000 sudden deaths, most of them unautopsied, are ascribed to cardiac events. Dr. Kent says it's likely a substantial portion actually are due to burst aortic aneurysms.

High blood pressure raises the risk, both that an aneurysm will develop and that it will someday burst. Yet while doctors routinely check blood pressure, and warn about heart risk, they rarely mention aneurysms.

Meanwhile, doctors and fitness experts are increasingly preaching the benefits of weightlifting, including for the elderly. But “heavy weightlifting and heavy straining could worsen aneurysms,” says Christopher K. Zarins, chief of vascular surgery at Stanford University Medical Center. He suggests that people with aneurysms use only light weights.

The National Institutes of Health will spend $2.77 billion for research on AIDS this year, along with $732 million on breast cancer and $408.3 million on prostate cancer. The amount for abdominal aneurysms is just over $6 million.

Some doctors say cerebral aneurysms, in particular, warrant more study. It is difficult to know which ones are likely to burst, and it takes a $1,500 magnetic-resonance or CT scan to find them. Despite the uncertainty, experts recommend the exams in a number of cases, such as persistent severe headaches and vision problems.

Devastated 

Lois Porteous might have benefited. Suffering from severe headaches and a loss of peripheral vision on one side, she was given headache medicine but no scan. Last Jan. 30, the 58-year-old in Zebulon, N.C., collapsed in her kitchen after an aneurysm behind her eye burst. She survived but needs 24-hour care. “It just devastated her,” says a son, Michael.

Screening for aneurysms on the aorta would be simpler, because these appear in more distinct patterns. For instance, 80% occur in men, and the odds rise with hypertension, smoking and arteriosclerosis.

In addition, when this type of aneurysm is spotted, it's easier to know if surgery is needed, because the risk of rupture increases with size. Normal aortas range between 1.6 and 2.8 centimeters wide. Doctors say any sections wider than four centimeters generally need to be watched closely. Many are stable, but when they start growing, alarms go off. If a spot gets as wide as 5.5 centimeters, the risk of rupture may be high enough to call for surgery. The death rate in surgery isn't negligible but is much lower than that from burst aneurysms.

U.S. surgeons repair about 50,000 abdominal aneurysms each year, typically replacing the puffed-out area with a plastic or fabric tube. Some now use a less-invasive procedure that threads a tubular device called a stent-graft into the bubble.

Over two decades, the number of intact aortic aneurysms diagnosed in the U.S. has tripled to about 200,000 a year. The surge appears partly to reflect the greatly increased use of CTs, MRIs and the like, to check for tumors or other conditions. Relatively few scans are done simply to hunt for aneurysms.

Would insurers pay if tests to detect aneurysms were done to screen symptomless patients, rather than to diagnose symptoms in individual cases? So far, insurers haven't faced the issue. When asked, some point to the added costs that would result from monitoring and surgery, and say they haven't been convinced that screening would be broadly effective.

Some doctors also are reluctant to endorse widespread testing. Robert Zwolak, a vascular surgeon at Dartmouth Medical School, says, “We think we can identify a risk group for whom aortic aneurysm screening is appropriate, but we need more substantiation.”

A huge British study provided some last fall. After following 61,000 men aged 65 to 74 for an average of four years, it found a 42% drop in risk of death from abdominal aortic aneurysm among those who had been screened. Their aneurysm death risk was 1.9 per 1,000, vs. 3.3 in the others. “Screening can significantly reduce mortality rates associated with abdominal aortic aneurysms,” concluded the study, published Nov. 17 in The Lancet, the British medical journal.

A large new study is being organized in the U.S. by the medical schools of Dartmouth, the University of Pennsylvania and the University of Pittsburgh. Initially it will measure the prevalence of aneurysms; a later phase will check for a mortality benefit from screening.

“There is reasonable emerging evidence suggesting that it's reasonable to screen men over 60” for abdominal aortic aneurysm, “particularly if they have a history of smoking, and anyone with a first-degree relative with an aneurysm,” says Jack L. Cronenwett, a study organizer and chief of vascular surgery at Dartmouth. That would have included Ms. Coe in Virginia: Her mother, too, had an aortic aneurysm.

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References 

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 Supported in part by a grant from the Centers for Medicare and Medicaid services.

PII: S0890-5096(07)00311-1

doi:10.1016/j.avsg.2007.07.026

Annals of Vascular Surgery
Volume 22, Issue 1 , Pages 16-24, January 2008

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