Screening women aged 65 years or over for abdominal aortic aneurysm: a modelling study and health economic evaluation
Screening women aged 65 years or over for abdominal aortic aneurysm: a modelling study and health economic evaluation
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DOI：
10.3310/hta22430
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发表时间：
2018-08-01
影响因子：
3.6
通讯作者：
Sweeting, Michael J.
中科院分区：
文献类型：
--
作者：
Thompson, Simon G.;Bown, Matthew J.;Sweeting, Michael J.
背景：英国已经为男性建立了腹主动脉瘤(AAA)筛查计划，以减少AAA破裂的死亡。目的：评估女性AAA人群筛查的成本-效果，并比较各种筛查方案。设计：建立离散事件模拟(DES)模型，为AAA的筛查、监测、选择性和紧急修复手术提供一个临床现实的模型。采用了专门针对妇女的输入参数。该模型在1000万名女性中运行，参数不确定性通过概率和确定性敏感性分析解决。地点：英国人口筛查。参与者：年龄和年龄；主要观察指标：手术次数、AAA相关死亡率、质量调整寿命年(QALY)、NHS费用和每年折扣后的成本效益。资料来源：AAA监测数据、国家血管登记、医院事件统计、择期和急诊AAA手术试验和NHS腹主动脉瘤筛查计划(NAAASP)。综述方法：对AAA患病率和择期手术的系统评价，血管内动脉瘤修复的适宜性，非干预率，手术死亡率和其他参数的文献综述。结果：AAA的患病率(>；=3.0 cm)在65岁女性中估计为0.43%，在75岁时为1.15%。邀请参加筛选后的相应出席率估计分别为73%和62%。基础病例模型采用与男性NAAASP相同的筛查年龄(65岁)、AAA定义(直径=3.0 cm)、监测间隔(直径3.0~4.4 cm者为1年，直径4.5~5.4 cm者为3个月)和AAA直径(5.5 cm)。每名受邀参加筛查的女性，QALY的估计收益为0.00110，增量成本为33.99英镑。这带来了每QALY增加31,000磅的增量成本效益比(ICER)。在每获得20,000磅的阈值下，相应的增量净货币收益为-12.03磅(95%不确定区间-27.88磅至22.12磅)。几乎没有敏感性分析将ICER降低到每QALY 20,000磅以下；一个例外是AAA患病率翻了一番，达到0.86%，这导致ICER为13,000磅。替代筛查方案(将筛查年龄提高到70岁，将考虑手术的门槛降低到5.0厘米或4.5厘米，将女性AAA的直径降低到2.5厘米，延长对最小AAA的监测间隔)不会使ICER低于20000磅/QALY，无论是单独考虑还是合并考虑。限制：针对女性的模型没有直接根据经验数据进行验证。一些参数估计得很差，可能缺乏相关性或对女性来说不可用。结论：目前还没有达到基于人群的AAA筛查计划的公认标准。未来的工作：需要对在相关年龄筛查的女性的确切主动脉大小分布进行大规模研究。DES模型可用于评估男性的筛查选项。研究登记：这项研究登记为PROSPERO CRD42015020444和CRD42016043227。
Background: Abdominal aortic aneurysm (AAA) screening programmes have been established for men in the UK to reduce deaths from AAA rupture. Whether or not screening should be extended to women is uncertain.Objective: To evaluate the cost-effectiveness of population screening for AAAs in women and compare a range of screening options.Design: A discrete event simulation (DES) model was developed to provide a clinically realistic model of screening, surveillance, and elective and emergency AAA repair operations. Input parameters specifically for women were employed. The model was run for 10 million women, with parameter uncertainty addressed by probabilistic and deterministic sensitivity analyses.Setting: Population screening in the UK.Participants: Women aged >= 65 years, followed up to the age of 95 years.Interventions: Invitation to ultrasound screening, followed by surveillance for small AAAs and elective surgical repair for large AAAs.Main outcome measures: Number of operations undertaken, AAA-related mortality, quality-adjusted life-years (QALYs), NHS costs and cost-effectiveness with annual discounting.Data sources: AAA surveillance data, National Vascular Registry, Hospital Episode Statistics, trials of elective and emergency AAA surgery, and the NHS Abdominal Aortic Aneurysm Screening Programme (NAAASP).Review methods: Systematic reviews of AAA prevalence and, for elective operations, suitability for endovascular aneurysm repair, non-intervention rates, operative mortality and literature reviews for other parameters.Results: The prevalence of AAAs (aortic diameter of >= 3.0 cm) was estimated as 0.43% in women aged 65 years and 1.15% at age 75 years. The corresponding attendance rates following invitation to screening were estimated as 73% and 62%, respectively. The base-case model adopted the same age at screening (65 years), definition of an AAA (diameter of >= 3.0 cm), surveillance intervals (1 year for AAAs with diameter of 3.0-4.4 cm, 3 months for AAAs with diameter of 4.5-5.4 cm) and AAA diameter for consideration of surgery (5.5 cm) as in NAAASP for men. Per woman invited to screening, the estimated gain in QALYs was 0.00110, and the incremental cost was 33.99 pound. This gave an incremental cost-effectiveness ratio (ICER) of 31,000 pound per QALY gained. The corresponding incremental net monetary benefit at a threshold of 20,000 pound per QALY gained was -12.03 pound (95% uncertainty interval -27.88 pound to 22.12) pound. Almost no sensitivity analyses brought the ICER below 20,000 pound per QALY gained; an exception was doubling the AAA prevalence to 0.86%, which resulted in an ICER of 13,000 pound. Alternative screening options (increasing the screening age to 70 years, lowering the threshold for considering surgery to diameters of 5.0 cm or 4.5 cm, lowering the diameter defining an AAA in women to 2.5 cm and lengthening the surveillance intervals for the smallest AAAs) did not bring the ICER below 20,000 pound per QALY gained when considered either singly or in combination.Limitations: The model for women was not directly validated against empirical data. Some parameters were poorly estimated, potentially lacking relevance or unavailable for women.Conclusion: The accepted criteria for a population-based AAA screening programme in women are not currently met.Future work: A large-scale study is needed of the exact aortic size distribution for women screened at relevant ages. The DES model can be adapted to evaluate screening options in men.Study registration: This study is registered as PROSPERO CRD42015020444 and CRD42016043227.