One attendee asked whether intervention should begin at a smaller aneurysm size in women, who present with rupture more often than do males and have greater in-hospital mortality. Dr. Greco said that a separate system for women would not be necessary, as they are included in the new model and the stringency of the test on smaller aneurysms is affected by lowering the score threshold.
Ultimately, society would need to decide whether additional funds should be allocated to expand screening to women and younger persons. A cost analysis was not performed at the time of the analysis, but is being planned, Dr. Greco said in an interview.
Several audience members questioned how best to distribute the new scoring system to the public and encourage them to get screened. One attendee suggested that the AAA risk form could be sent to the estimated 40 million members of the AARP.
It would take 156 screenings with the current guidelines to get a single AAA, versus 85 with the scoring system.
Source DR. GRECO
My Take
Waiting for Randomized Trials
Dr. Greco and his colleagues correctly point out that this scoring system needs to be prospectively validated before it can be used. This is particularly important when the data set is not all comers that arrive in our day to day practice, but those who specifically have sought out screening. This creates a selection bias.
If the authors are able to validate the scoring system, the next question becomes “Does the screening make a difference in outcomes?” The reason the current U.S. Preventive Services Task Force guidelines do not recommend screening in women is because screening studies have not demonstrated an improved outcome in women screened for AAA compared to those not screened.
Before this scoring tool is used in practice, it needs to be prospectively tested in a randomized controlled trial demonstrating that it helps improve patient outcomes, and it should be compared in some fashion to the current guideline. I have plenty to do already trying to manage the 30%-plus of the population who is obese, let alone trying to ferret out conditions that affect 0.14% of the population, when I don't know that finding them with a new screening tool will change outcomes.
PAUL OGDEN, M.D., M.S.P.H., is a family physician in private practice in Denver. He practices age management medicine and consults in preventive medicine. He served on the development team for Kaiser Permanente's current AAA screening clinical practice guideline.
