Cost-effectiveness of targeted screening for abdominal aortic aneurysm in siblings.

Background: Population screening for abdominal aortic aneurysm (AAA) in 65­year­old men has been shown to be cost­effective. A risk group with higher prevalence is siblings of patients with an AAA. This health economic model­based study evaluated the potential cost­effectiveness of targeted AAA screening of siblings. Methods: A Markov model validated against other screening programmes was used. Two methods of identifying siblings were analysed: direct questioning of patients with an AAA (method A), and employing a national multigeneration register (method B). The prevalence was based on observed ultrasound data on AAAs in siblings. Additional parameters were extracted from RCTs, vascular registers, literature and ongoing screening. The outcome was cost­effectiveness, probability of cost­effectiveness at different willingness­to­pay (WTP) thresholds, reduction in AAA death, quality­adjusted life­years (QALYs) gained and total costs on a national scale. Results: Methods A and B were estimated to reduce mortality from AAA, at incremental cost­effectiveness ratios of €7800 (95 per cent c.i. 4627 to 12 982) and €7666 (5000 to 13 373) per QALY respectively. The probability of cost­effectiveness was 99 per cent at a WTP of €23 000. The absolute risk reduction in AAA deaths was five per 1000 invited. QALYs gained were 27 per 1000 invited. In a population of ten million, methods A and B were estimated to prevent 12 and 17 AAA deaths, among 2418 and 3572 siblings identified annually, at total costs of €499 500 and €728 700 respectively. Conclusion: The analysis indicates that aneurysm­related mortality could be decreased cost­effectively by applying a targeted screening method for siblings of patients with an AAA.

Low post-operative mortality after surgery on patients with screening-detected abdominal aortic aneurysms: a Swedvasc registry study.

OBJECTIVES: Screening for abdominal aortic aneurysms (AAAs) substantially reduces aneurysm-related mortality in men and is increasing worldwide. This cohort study compares post-operative mortality and complications in men with screening-detected vs. non-screening-detected AAAs. METHODS: Data were extracted from the Swedish National Registry for Vascular Surgery (Swedvasc) for all screening-detected men treated for AAA (n = 350) and age-matched controls treated for non-screening-detected AAA (n = 350). RESULTS: There were no differences in baseline characteristics besides age, which was lower in the screening-detected group than in the non-screening-detected group (median 66 vs. 68, p < .001). Open repair was used more frequently than endovascular aortic repair (EVAR) in patients with screening-detected AAAs than in non-screening-detected controls (56% vs. 45% p = .005). No differences in major post-operative complications at 30 days were observed between the groups. In patients treated with open repair there were no differences in 30-day, 90-day or 1-year mortality in screening-detected patients compared to non-screening-detected controls (1.0% vs. 3.2% p = .25, 2.1% vs. 4.5% p = .23, 4.1% vs. 5.8% p = .61). None of the patients treated with EVAR in either group died within 30 days. The 90-day mortality after EVAR was lower in patients with screening-detected AAA than in those with non-screening-detected AAAs (0.0% vs. 3.1%, p = .04). No difference in the 1-year mortality was detected in the EVAR-patients between the two groups (1.4% vs. 4.7%, p = .12). CONCLUSIONS: The contemporary post-operative mortality after AAA surgery was low in this national audit of patients with screening-detected AAAs and age-matched controls. Patients with screening-detected AAAs have the same frequency of complications at 30 days as patients with non-screening-detected AAA. This study gives further support to national screening programs for the detection of AAA in men.

Reasons for non-participation in population-based abdominal aortic aneurysm screening.

BACKGROUND: A population-based screening programme for abdominal aortic aneurysm (AAA) started in 2010 in Stockholm County, Sweden. This present study used individual data from Sweden's extensive healthcare registries to identify the reasons for non-participation in the AAA screening programme. METHODS: All 65-year-old men in Stockholm are invited to screening for AAA; this study included all men invited from July 2010 to July 2012. Participants and non-participants were compared for socioeconomic factors, travel distance to the examination centre and healthcare use. The influence of these factors on participation was analysed using univariable and multivariable logistic regression models. RESULTS: The participation rate for AAA screening was 77·6 per cent (18 876 of 24 319 men invited). The prevalence of AAA (aortic diameter more than 2·9 cm) among participants was 1·4 per cent. The most important reasons for non-participation in the multivariable regression analyses were: recent immigration (within 5 years) (odds ratio (OR) 3·25, 95 per cent confidence interval 1·94 to 5·47), low income (OR 2·76, 2·46 to 3·10), marital status single or divorced (OR 2·23, 2·08 to 2·39), low level of education (OR 1·28, 1·16 to 1·40) and long travel distance (OR 1·23, 1·10 to 1·37). Non-participants had a higher incidence of stroke (4·5 versus 2·8 per cent; P < 0·001) and chronic pulmonary disease (2·9 versus 1·3 per cent; P < 0·001). Daily smoking was more common in residential areas where the participation rate for AAA screening was low. CONCLUSION: Efforts to improve participation in AAA screening should target the groups with low income, a low level of education and immigrants. The higher morbidity in the non-participant group, together with a higher rate of smoking, make it probable that this group also has a high risk of AAA.

[Drug information must be critically scrutinized. Industry's only wish: prescription from the physician to the patient]. / Läkemedelsinformationen måste granskas kritiskt. Industrins enda önskade sluteffekt: receptet från doktorn till patienten.

The purpose of drug information from the pharmaceutical industry is to increase sales. The message is often simplified, short, with emphasis on Unique Selling Points (USP). Information is often given in a pleasant environment, food is served, gifts handed out. The same information is repeated in advertising campaigns. However, the information is often incomplete and the level of evidence not discussed. The purpose of producer independent information is to give scientific facts according to the principles practiced by evidence-based medicine. This information focuses on the level of evidence of published papers but is often more lengthy, may be difficult to understand and may even be regarded as boring. There are, however, useful principles to apply when analysing the information given by the pharmaceutical industry on specific drugs. There are also several sources of independent drug information to turn to.

Association of outpatient utilisation of non-steroidal anti-inflammatory drugs and hospitalised heart failure in the entire Swedish population.

OBJECTIVE: Individual-based studies on restricted geographical settings have suggested that non-steroidal anti-inflammatory drugs (NSAIDs) may precipitate congestive heart failure. As NSAID use is very extensive, it might increase the occurrence of symptomatic heart failure in the general population. Therefore, in order to study the impact of NSAID utilisation (prescribed and over the counter) on hospitalised heart failure in an entire country (Sweden), we performed an ecological analysis, a design appropriate for studying large geographical areas. METHODS: We employed weighted (population size) ecological linear regression to study the association between outpatient utilisation of NSAIDs during 1989-1993 and hospitalised heart failure in 1993 in 283 of Sweden's 288 municipalities. Data were adjusted for age and gender proportions, socio-economic factors, latitude and utilisation of cardiovascular drugs, aspirin, low-dose aspirin and paracetamol. RESULTS: The unadjusted relative risk of hospitalised heart failure for each increase of one standard deviation of NSAID utilisation (5.8 defined daily doses/1000 inhabitants/day) was 1.23 [95% confidence interval (CI) 1.18, 1.27]. After adjustments, the relative risk was 1.08 (95% CI 1.04, 1.12); the corresponding values if aspirin (non-low-dose) was included as an NSAID were 1.26 (95% CI 1.23, 1.28) and 1.07 (95% CI 1.04, 1.10). There was no such adjusted association with the utilisation of paracetamol-0.95 (95% CI 0.92, 0.98). CONCLUSION: The NSAID--heart failure association already established by individual-based studies on restricted geographical settings was corroborated in the present ecological study based on the whole population of an entire country (Sweden). Efforts should be made to promote a rational use of NSAIDs in the general population.

Survival after initial hospitalisation for heart failure: a multilevel analysis of patients in Swedish acute care hospitals.

STUDY OBJECTIVE: Although national variation in short-term prognosis (that is, 30 day mortality) after a patient's first hospitalisation for heart failure may depend on individual differences between patients, dissimilarities in hospital practices may also influence prognosis. This study, therefore, sought to disentangle patient determinants from institutional factors that might explain such variation. DESIGN: A multilevel logistic regression modelling was performed with patients (1st level) nested in hospitals (2nd level). Institutional effects (that is, 2nd level variance and intra-hospital correlation) were calculated unadjusted and adjusted for specific patient (that is, age and previous diseases) and institutional (that is, size of hospital) characteristics. Patients were followed up until death or 30 days from hospital admission. SETTING: Hospitals in Sweden. PATIENTS: The study identified all the 20420 men and 17923 women (ages 65 to 85) admitted to the 90 acute care hospitals in Sweden during the period 1992-1995 for their first hospitalisation attributable to heart failure. MAIN RESULTS: Patient age and previous diseases (particularly senile dementia) were major determinants of impaired prognosis. Institutional factors explained only 1.6% and 2.3% of the total variation in 30 day mortality in men and women, respectively. These modest institutional effects remained after adjusting for patient age and previous diseases, but were in part explained by hospital size. CONCLUSIONS: National variation in short-term prognosis after an initial hospitalisation for heart failure was mainly explained by differences between patients, with hospital factors playing a minor part. Of the latter, hospital size seemed to emerge as one determinant (that is, the greater the number of patients, the better the individual prognosis).

The effects on knowledge of the systematic education of patients with joint diseases treated with NSAIDs and diuretics.

In a randomised, controlled trial, patients with joint diseases and concomitant treatment with NSAIDs and diuretics received systematic education. The intervention group was given information by a self-conducted, interactive Kodak Photo-CD program in addition to personal drug information and non-commercial drug leaflets. Awareness of drug interactions and encouragement of self-adjustment of treatment was focused on. Control patients received conventional information. Three months after randomisation, knowledge was tested by means of a questionnaire. At 3 months there was a significant difference in attained score between the intervention group and the control group. Greater knowledge was achieved, especially on drug interaction, in the intervention group. In conclusion, less than 1 h of systematic education significantly improved patients' knowledge on essential issues of concomitant treatment with NSAIDs and diuretics. Knowledge of effects, side-effects and interactions of drugs is essential for self-adjustment of treatment. The method employed, which is standardised and produces a reproducible quantity of education, might be applicable to several other medical conditions.

Health care costs of heart failure: results from a randomised study of patient education.

BACKGROUND: Heart failure is a serious syndrome with a bad prognosis. Hospitalisation is common and readmittance rate is high; factors which influence the cost of care and treatment. Only scarce data on detailed patient materials regarding health care costs are known. AIMS: To describe in detail the health care costs for heart failure patients. METHODS: Costs for patients (n=108) who completed a randomised education trial were studied for 6 months after hospital discharge. Costs for hospital stay, out-patient visits, diagnostic tests and procedures, laboratory analyses and drug treatment were calculated. Official unit prices list used to reimburse providers of cross-boundary health services and prices for drugs in the Swedish Drug Compendium were employed. RESULTS: The total cost for a heart failure patient was approximately 20000 SEK (2564 US$, 7.80 SEK=1 US$) for 6 months. There was a 27-fold variation between patients. There was no relation between age or sex and cost. In decreasing order cost for hospitalisation was followed by costs for out-patient visits, diagnostic tests and procedures, laboratory analyses and drugs. CONCLUSION: Hospitalisation was the largest part of the total cost and there was a large inter-individual variation. Efforts to reduce the economic burden should be focused on hospitalisation. Due to skewed distribution, individual data must be considered in the analysis of the efforts.

Effects of systematic education on heart failure patients' knowledge after 6 months. A randomised, controlled trial.

BACKGROUND: Many procedures for patient education are introduced in clinical practice without proper evaluation in randomised trials. AIMS: To compare systematic nurse and pharmacist led education including an interactive Kodak Photo-CD Portfolio technique with conventional information regarding heart failure patients' knowledge. METHODS: One hundred and thirty heart failure patients discharged from hospital were randomised to receive either conventional information or additional structured education with a follow-up of 6 months. Difference in knowledge was tested by questionnaire after 6 months. RESULTS: At the end of the study there was a significant difference in the intervention group (n = 50) compared to the control group (n = 58) regarding knowledge as tested by a questionnaire. Of maximal 28 points the intervention group attained 17.2 points (mean) and the control group 14.3 points (mean), 95% confidence interval for difference 1.0-4.7 points (P = 0.0051). CONCLUSIONS: Two to 3 hours of systematic education improved heart failure patients' knowledge on essential issues. High age does not preclude the introduction of a new technique for patient education.

Non-compliance and knowledge of prescribed medication in elderly patients with heart failure.

AIMS: To determine the extent of non-compliance to prescribed medication in elderly patients with heart failure and to determine to what extent patients recall information given regarding their medication. METHODS AND RESULTS: Non-compliance and knowledge of prescribed medication was studied in 22 elderly heart failure patients [mean age 79 +/- 6 (range 70-97); 14 (64%) male], using in-depth interviews performed 30 days after having been prescribed medication. All patients received standardised verbal and written information regarding their medication. Only 12 (55%) patients could correctly name what medication had been prescribed, 11 (50%) were unable to state the prescribed doses and 14 (64%) could not account for when the medication was to be taken, i.e. at what time of day and when in relation to meals the medication was to be taken. In the overall assessment six (27%) patients were found non-compliant and 16 (73%) patients were considered as possibly being compliant with their prescribed medication. CONCLUSIONS: Non-compliance was common in elderly heart failure patients, as were shortcomings in patients knowledge regarding prescribed medication, despite efforts to give adequate information. There exists a need for alternative strategies to improve compliance in these patients.

The development of an interactive education program for heart failure patients: the Kodak Photo CD Portfolio concept.

Written information, as well as movie and video film, and computer programs have been used for information and education of patients. CD-ROM is now about to be used for the same purpose. The CD has several advantages over computer programs, such as high capacity and low production, duplication and distribution costs. It is unerasable and insensitive to electromagnetic forces. Heart failure (HF) is a common disease with poor prognosis. Due to diagnostic and treatment improvements new guidelines on evaluation and care of patients with HF have been published. Some advocate educational programs as a routine part of the care. Patients with HF (mostly elderly persons) use many drugs and need considerable education for effective self-care. To improve HF patients' knowledge of the disease and the drug treatment of the disease we have made an interactive, computer generated education program which is presented on a Kodak Photo CD Portfolio disc. The major steps and efforts in the development of the program, which uses a new principle, are explained, including some hardware and software issues. The program can be viewed on an ordinary TV set and run by the patients themselves. Unlike many educational products for health care professionals and patients, this product has now been included in a randomised patient education trial.