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Abdominal Aortic Aneurysm: Epidemiological and Health Economic Aspects
Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kirurgiska vetenskaper, Kärlkirurgi.
2010 (Engelska)Doktorsavhandling, sammanläggning (Övrigt vetenskapligt)
Abstract [en]

Abdominal aortic aneurysm (AAA) is a common disease that is life threatening when rupture occurs. The aims of this thesis were to study (I) the long-term survival after AAA repair, (II) the cost of repair with open (OR) and endovascular (EVAR) technique, (III) the effect of different statistical methods on interpretation of cost data, (IV) the prevalence of the disease among patients with suspected arterial disease referred to the vascular laboratory, and (V) the cost-effectiveness of selective high-risk screening. Analyses of data from the Swedish vascular registry (Swedvasc), local patient registries, patient records and hospital cost registries form the basis of this thesis.

Short- and long-term survival after intact AAA repair improved over the past two decades, despite increasing patient age and rate of comorbidities over time. Compared to a general population adjusted for age, sex and calendar year, the relative 5-year survival was 90% among those surviving repair. While short-term survival improved over time after ruptured repair, relative long-term survival was stable. Despite differences in patient selection and cost structure, the total cost of AAA repair with EVAR and OR was similar in a population based setting (€28,193). There was lack of consistency in the methods used in cost-analysis in the current literature, and p-values were highly dependent on test method.

The practice of selective (non-population-based) screening for AAA among patients referred to the vascular laboratory was studied. The prevalence of AAA was 4.2% among male and 1.5% among female patients. AAA was associated with high age and prevalence of arterial stenosis. Of AAAs detected through selective screening, 21.5% had undergone elective repair at 7.5 years follow-up. In a health-economic evaluation, the incremental cost-effectiveness ratio of selective screening was €11,084 per life year gained.

In conclusion, survival after intact AAA repair has improved over time, despite changes in case-mix. Results of health economic reports on cost of AAA repair can be highly dependent on patient selection as well as presentation of data and the statistical methods used. Selective screening for AAA among patients referred to the vascular laboratory is cost-effective.

Ort, förlag, år, upplaga, sidor
Uppsala: Acta Universitatis Upsaliensis , 2010. , s. 86
Serie
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 503
Nyckelord [en]
Abdominal aortic aneurysm, cost, cost-effectiveness, endovascular aneurysm repair, screening, surgery, survival
Nationell ämneskategori
Kirurgi
Forskningsämne
Kirurgi
Identifikatorer
URN: urn:nbn:se:uu:diva-110810ISBN: 978-91-554-7670-0 (tryckt)OAI: oai:DiVA.org:uu-110810DiVA, id: diva2:278416
Disputation
2010-02-19, Auditorium Minus, Museum Gustavianum, Uppsala, 13:15 (Engelska)
Opponent
Handledare
Tillgänglig från: 2009-12-18 Skapad: 2009-11-25 Senast uppdaterad: 2010-02-05Bibliografiskt granskad
Delarbeten
1. Improved long-term survival after abdominal aortic aneurysm repair
Öppna denna publikation i ny flik eller fönster >>Improved long-term survival after abdominal aortic aneurysm repair
2009 (Engelska)Ingår i: Circulation, ISSN 0009-7322, E-ISSN 1524-4539, Vol. 120, nr 3, s. 201-11Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

BACKGROUND: Treatment of abdominal aortic aneurysm (AAA) has changed significantly over the past 2 decades. In this perspective, time trends in long-term survival were studied. METHODS AND RESULTS: We identified 8663 primary intact and 4171 ruptured AAA repairs in the Swedish Vascular Registry from 1987 to 2005. Mortality was obtained from the national population registry. Crude survival was analyzed, including all mortality. To analyze the long-term outcome among those surviving the AAA repair, relative survival, which denotes the survival rate of patients compared with that of the general population adjusted for age, sex, and calendar year, was calculated, excluding 90-day mortality. In a comparison of AAA repairs from 1987 to 1999 and 2000 to 2005, age (71.4 versus 72.5 years; P<0.001), patients with comorbidities (65.0% versus 68.5%; P<0.001), and endovascular repair (1.6% versus 17.0%; P<0.001) increased. After intact AAA repair, crude 5-year survival was 69.0% (99% confidence interval [CI], 67.7 to 70.4), and relative 5-year survival excluding 90-day mortality was 90.3% (99% CI, 88.6 to 92.0). Relative 5-year survival was better for those operated on from 2000 to 2005 compared with 1987 to 1999 (difference, 4.7%; 99% CI, 1.3 to 8.1), for men versus women (4.6%; 99% CI, 0.4 to 8.8), and for octogenarians versus patients <80 years of age (10.2%; 99% CI, 1.5 to 18.8); no difference was observed between open and endovascular repair (6.0%; 99% CI, -1.5 to 13.4). After ruptured AAA repair, crude 5-year survival was 41.7% (99% CI, 39.6 to 43.7) and relative 5-year survival was 87.1% (99% CI, 83.9 to 90.3). No significant differences in relative 5-year survival were observed between time periods, sex, or age groups. CONCLUSIONS: Long-term survival improved over time after intact AAA repair despite a change in case mix toward older patients with more comorbidities. Long-term survival was stable after ruptured AAA repair.

Nationell ämneskategori
Medicin och hälsovetenskap
Identifikatorer
urn:nbn:se:uu:diva-108642 (URN)10.1161/CIRCULATIONAHA.108.832774 (DOI)000268110900005 ()19581497 (PubMedID)
Tillgänglig från: 2009-09-25 Skapad: 2009-09-25 Senast uppdaterad: 2017-12-13Bibliografiskt granskad
2. Similar cost for elective open and endovascular AAA repair in a population-based setting
Öppna denna publikation i ny flik eller fönster >>Similar cost for elective open and endovascular AAA repair in a population-based setting
2008 (Engelska)Ingår i: Journal of Endovascular Therapy, ISSN 1526-6028, E-ISSN 1545-1550, Vol. 15, nr 1, s. 1-11Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

PURPOSE: To compare cost differences between elective open repair (OR) and endovascular repair (EVAR) of abdominal aortic aneurysm in a population-based setting. METHODS: Clinical data and hospital-related costs (pre-, peri-, and postoperative) were analyzed for 109 consecutive AAA procedures (98 men; mean age 73 years, range 48-95; mean aneurysm diameter 61 mm, range 42-120) performed from 2001 to 2005 (58 OR, 51 EVAR) in our primary catchment area. Data were obtained through case records and hospital accounting systems. Nonparametric bootstrap was used for cost comparison. RESULTS: EVAR patients were older (76 versus 70 years, p<0.001) and had more comorbidities (ASA class 2.6 versus 2.3, p = 0.025). OR patients more often had anatomically complex aneurysms (52% versus 14%, p<0.001). Comparison of data with diagnosis-based reimbursement levels nationally and internationally indicated adequate cost level in the study. No difference was observed in total cost between OR and EVAR (euro29,786 versus euro26,382; p = 0.336). Preoperative cost was lower for OR compared to EVAR (euro661 versus euro1494, p = 0.002). OR patients had higher cost of intensive care [36% (euro8921) of perioperative cost versus 7% (euro1460), p = 0.001], while EVAR had higher implant cost [36% (euro7468) versus 2% (euro448), p<0.001]. Mean follow-up was 2.5 years (range 0.5-5.4). Mean postoperative cost was similar (OR euro4613 versus EVAR euro4403, p = 0.209; 16% and 17% of total cost, respectively). Postoperative cost after OR was high early on, with lower cost thereafter. Postoperative cost after EVAR was more homogeneously distributed, leveling off at euro500 to euro1000 annually over 5 years. CONCLUSION: In a population-based setting, total cost was similar for OR and EVAR. There were, however, important differences in patient characteristics and cost structure.

Nyckelord
abdominal aortic aneurysm, surgery, endovascular aneurysm repair, hospital costs, cost-benefit analysis
Nationell ämneskategori
Medicin och hälsovetenskap
Identifikatorer
urn:nbn:se:uu:diva-108646 (URN)10.1583/07-2258.1 (DOI)000253060300001 ()18254676 (PubMedID)
Tillgänglig från: 2009-09-25 Skapad: 2009-09-25 Senast uppdaterad: 2018-06-26Bibliografiskt granskad
3. Challenges in analysis and interpretation of cost data in vascular surgery
Öppna denna publikation i ny flik eller fönster >>Challenges in analysis and interpretation of cost data in vascular surgery
2010 (Engelska)Ingår i: Journal of vascular surgery, ISSN 0741-5214, Vol. 51, nr 1, s. 148-154Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

OBJECTIVE: Health economic arguments have become increasingly important in clinical decision making, especially when new treatment modalities are introduced. This study reviews the methods used in health economic reports of abdominal aortic aneurysm (AAA) repair and uses original cost data to study how different methods affect interpretation of results in terms of cost differences and economic efficiency. DESIGN: Publications referenced in PubMed from 2003 to 2008 studying cost of AAA repair were reviewed. Original population-based cost data of AAA repair were analyzed, comparing open (OR) and endovascular repair (EVAR). Means, medians, and cost distributions were calculated, and differences were analyzed with four different statistical methods. RESULTS: The review showed a mixture of statistical methods used in AAA treatment cost-comparison studies. Presentation of cost data and inclusion criteria varied between studies. The analysis of original data showed skewed distribution of cost data, with large differences between mean and median cost. Although mean values indicated a lower total, perioperative, and postoperative cost for EVAR, the median values indicated OR was the least costly method. Exclusion of extreme values lowered mean perioperative cost of OR by 10%, while cost of EVAR was unaffected. Inferential testing of cost differences by means of four statistical methods showed that P values were highly dependent on test methodology. CONCLUSIONS: Conclusions of health economic reports can be highly dependent on how the data are presented and the statistical methods that are used. We recommend that cost data be presented as mean values with distributions. Exclusion of outliers and focus on P values should be avoided.

Nationell ämneskategori
Kirurgi
Identifikatorer
urn:nbn:se:uu:diva-110809 (URN)10.1016/j.jvs.2009.08.042 (DOI)000273708500027 ()19889511 (PubMedID)
Tillgänglig från: 2009-11-25 Skapad: 2009-11-25 Senast uppdaterad: 2011-12-19Bibliografiskt granskad
4. Selective screening for abdominal aortic aneurysm among patients referred to the vascular laboratory
Öppna denna publikation i ny flik eller fönster >>Selective screening for abdominal aortic aneurysm among patients referred to the vascular laboratory
2008 (Engelska)Ingår i: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 35, nr 6, s. 669-74Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

BACKGROUND: Patients examined for peripheral arterial disease at the vascular laboratory, Uppsala University Hospital, are since 1993 screened for abdominal aortic aneurysm (AAA). The objective of this study was to study the prevalence of AAA found at this selective high-risk screening. METHODS: All files in the vascular laboratory were retrospectively reviewed. Of 9296 persons examined with arterial duplex between 1993 and October 2005, 5924 were screened for AAA. The primary target vessel was the carotid arteries in 3772 subjects, the renal arteries in 1529 subjects and the lower extremity arteries in 1457 subjects. An AAA was defined as an infrarenal aortic diameter >/=30mm. RESULTS: 179 subjects were found to have an AAA. In a logistic regression model male gender, age and duplex-verified arterial stenosis were independently associated with AAA (odds ratio 3.2, 2.0/20 years and 2.0, respectively, p<0.001). In men <60 years the AAA prevalence was 0.9% (95% confidence interval 0.2-1.6%) when arterial stenosis was absent and 1.5% (0.0-3.2%) when present. In men >/=60 years the AAA prevalence was 4.0% (3.0-5.1%) when no arterial stenosis was found and 7.3% (5.7-8.9%) when found. The corresponding prevalences in women were 0%, 0%, 1.2% (0.5-1.8%), and 3.1% (1.9-4.3%), respectively. CONCLUSIONS: Men >/=60 years referred for arterial examination have a significant risk of having an AAA while only women >/=65 years with a duplex verified arterial stenosis have a sufficient risk of having an AAA. Studies to evaluate the benefit of selective high-risk screening are warranted.

Nationell ämneskategori
Medicin och hälsovetenskap
Identifikatorer
urn:nbn:se:uu:diva-108645 (URN)10.1016/j.ejvs.2007.12.014 (DOI)000257044700006 ()18258461 (PubMedID)
Tillgänglig från: 2009-09-25 Skapad: 2009-09-25 Senast uppdaterad: 2017-12-13Bibliografiskt granskad
5. Screening for Abdominal Aortic Aneurysm among Patients Referred to the Vascular Laboratory is Cost-effective
Öppna denna publikation i ny flik eller fönster >>Screening for Abdominal Aortic Aneurysm among Patients Referred to the Vascular Laboratory is Cost-effective
Visa övriga...
2010 (Engelska)Ingår i: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 39, nr 2, s. 208-216Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

Screening for abdominal aortic aneurysm (AAA) in high-risk groups has been recommended based on a high prevalence of disease, while being questioned due to a high frequency of co-morbidities and inferior life-expectancy. We evaluated the long-term outcome and the cost-effectiveness of selective AAA screening among patients referred to the vascular laboratory for arterial examination. METHODS: A total of 5924 patients, referred to the vascular laboratory of a university hospital, were screened for AAA with ultrasound (definition: slashed circle>/=30mm), 1993-2005. Outcome data were gathered through hospital records and the national population registry. A Markov model was used for health-economic evaluation. RESULTS: An AAA was detected in 181 patients (mean age 72.8 years), of whom 21.5% underwent elective repair (perioperative mortality 5.1%) after 7.5 years of follow-up. Four of six patients diagnosed with AAA rupture were operated upon. Relative 5-year survival compared with the general Swedish population, controlled for age and sex, was 80.4% (95% confidence interval (CI): 70.8-88.8). The cost-effectiveness was robust in base-case (11 084 Euro/life year gained) and in sensitivity analyses of prevalence, cost and survival. CONCLUSIONS: Patients in whom AAA was detected at selective screening had inferior long-term survival and were operated on less frequently, compared with AAA patients described in previous studies. Yet, selective screening at the vascular laboratory was cost-effective.

Nyckelord
Abdominal aortic aneurysms, Screening, Cost-benefit analysis
Nationell ämneskategori
Medicin och hälsovetenskap
Identifikatorer
urn:nbn:se:uu:diva-108639 (URN)10.1016/j.ejvs.2009.11.004 (DOI)000275985900014 ()19942460 (PubMedID)
Tillgänglig från: 2009-09-25 Skapad: 2009-09-25 Senast uppdaterad: 2017-12-13Bibliografiskt granskad

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