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Thursday, May 17, 2007

Screening for abdominal aortic aneurysm-looks like a good idea

The May 15,2007 issue of the Annals of Internal Medicine features several articles and an editorial strongly supporting screening for AAAs -at least in men 64 to 74 years of age ,if they ever smoked ( I guess when you get to 75 you are too old to worry about).The USPSTF recommends one time screening for men aged 64 to 75 who have ever smoked but not for the never-smokers. The Annals editorial makes a reasonable argument that non-smokers should be included as well.

One of the articles, done in Great Britain, indicated than the screening is even cost effective.

There is a systematic review (Lederle et al)of treatment of unruptured abdominal aortic aneurysms which found for those aneurysms less than 5.5. cm in diameter no benefit was demonstrated either in all cause or in AAA related mortality.

However,for larger aneurysms and rapidly enlarging aneurysms repair is indicated. I say "repair" because now there is an alternative to the major AAA surgery in the form of a endovascular repair, about which the jury is out regarding the long term results. Certaintly the post procedure recovery time is much more pleasant with the endo aproach.

According to the MKSAP 14,( pg. 72 of the Cardiovascular Medicine booklet) surgery is indicated for AAA greater then 5.5cm in men and for those greater than 4.5. to 5.0 in women. A ruptured AAA is said to have an approximately 80% mortality. One of my former partners collapsed in the hospital while rounding and was very quickly attended by an excellent vascular surgeon who quickly diagnosed the problem and in spite of a rush to the O.R. and a very expeditious effort at surgery, he died on the table.

Ever alert as I am to gratuitous comments promoting P4P particularly from the American College of Physicians, I could not help but chaff a bit at one comment slipped into the editorial.

"AAA screening should be considered ...in pay-for-performance and other large- scale quality initiatives"

I can remember a time-not that long ago really-when a recommendation was made because it was the right thing to do for the patient not because of P4P (aka being bribed to do the right thing) and not because some insurance entity was going to check to see if we had done it according to their version of what should be done.

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