Impact Of Changing Abdominal Aortic Aneurysm Screening Guidelines For Smoking Women
Vy T. Ho, MD, Kenneth Tran, MD, Elizabeth L. George, MD MS, Manuel Garcia-Toca, MD MS, Jonathan H. Chen, MD PhD, Jason T. Lee, MD.
Stanford University, Palo Alto, CA, USA.
OBJECTIVES: In July 2014, the United States Preventative Services Task Force (USPSTF) shifted from recommending against AAA screening in women to stating insufficient evidence screening 65 to 75-year-old female smokers. We analyzed the impact of this change on screening and diagnosis rates for non-ruptured AAA in female smokers.
METHODS: The Truven Health Marketscan Commercial Claims and Encounters Database with Medicare Supplement was queried for 65 to 75 year-old women with at least 1 year of continuous enrollment from January 2006 to December 2016. Patients with prior AAA diagnosis were excluded. The primary endpoint was incident AAA diagnosis per 1,000 beneficiaries per month, and the secondary endpoint was AAA screening ultrasound per 1,000 beneficiaries per month. Poisson regression models were developed and adjusted for age, Charlson comorbidity score, month, year, and geographical region. Endpoints were modeled as count data with the number of eligible beneficiaries incorporated as an offset. Difference-in-difference was assessed via an interaction term between policy initiation and smoking status.
RESULTS: 47,229 women were diagnosed with a non-ruptured AAA during the study period (4.2% post-policy). On univariate analysis, female smokers were significantly older at the time of diagnosis in the post-policy period compared to the pre-policy period (70.6 years vs. 69.9 years, p <0.01). In a difference-in-difference model, change in guidelines was not associated with change in AAA diagnosis rates (IRR 1.04, p-value = 0.29, Figure 1). 18,301 women underwent screening ultrasound for AAA. On univariate analysis, non-smoking patients screened after the guidelines change had a high Charlson comorbidity score compared to non-smokers screened afterwards (9.9 vs 9.6, p <0.01). In a difference-in-difference model, change in guidelines was not associated with an increase in AAA screening via ultrasound in smokers versus non-smokers (IRR 0.93, p-value = 0.25, Figure 1).
CONCLUSIONS: Shifting USPSTF guidelines from recommending against towards insufficient evidence for AAA screening in female smokers 65 to 75-years of age did not change ultrasound utilization or AAA diagnosis rates compared to female nonsmokers. Priority should be given to generating the high-quality evidence base needed to justify more aggressive guideline changes to improve aortic disease detection in women.
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