Posted on 02/01/2005 7:45:22 AM PST by neverdem
In a sharp change from current policy, an influential medical advisory group is recommending that all men ages 65 to 75 who have ever smoked have an ultrasound screening test to see if they are developing a condition that could kill them in minutes by bursting a major artery in the abdomen.
The group, the United States Preventive Services Task Force, is an independent panel of medical experts that advises the federal Agency for Healthcare Research and Quality. Its recommendations help set government policy and are generally followed by primary care doctors.
The task force last looked at the condition, abdominal aortic aneurysms, in 1996 and concluded that there was insufficient evidence that a screening test would save lives. But now, it said, four large clinical trials have provided the evidence it needs, at least for those most at risk.
Finding aneurysms early, with a scan that can cost $350 to $400, and repairing them with an operation that can cost $15,000 to $20,000 if there are no complications, can cut the death rate by a third. Although the surgery can itself cause death, the risk that a large aneurysm will suddenly rupture and kill the patient is greater, the group said.
The condition kills at least 9,000 people a year in the United States. With screening, "the science comes down to saying this is worth doing," said Dr. Ned Calonge, chairman of the task force and chief medical officer of the Colorado Department of Public Health and Environment.
"We think our recommendation will translate into physicians incorporating screening into their practice," said Dr. Calonge, who does not screen for or repair aneurysms nor determine payments for health care, and said he has no conflicts of interest in making the recommendation.
The recommendation affects about 9.8 million Americans, the 70 percent of the nation's 14 million men ages 65 to 75 who are smokers or have ever smoked. The task force defined the group to include any man who had smoked at least 100 cigarettes in his life.
The test was not recommended for women because they are at much lower risk of developing the aneurysms.
The task force estimated that for every 500 men who meet its criteria and are screened, one death would be prevented over five years. In comparison, the only test for colorectal cancer that was evaluated in a randomized controlled trial, the fecal occult blood test, requires that 1,374 people be screened to prevent one death over five years.
"This is huge," said Dr. Frank A. Lederle of the University of Minnesota and the Minneapolis Veterans Affairs Medical Center, who reviewed the clinical trial data for the task force. "A major test for a major disease - it just doesn't come along very often."
Almost no one is screened now for abdominal aortic aneurysms, vascular surgeons say. Medical researchers suspect the true death rate is higher than 9,000 a year because often the swift deaths are attributed to a heart attack or stroke.
"If it ruptures, you're dead," Dr. Lederle said. Most bleed to death so quickly that they never make it to the hospital. And half of those who do make it to the hospital do not survive.
The review of the trial data on abdominal aortic aneurysms, along with the task force's recommendations, is published today in the Annals of Internal Medicine.
An abdominal aortic aneurysm is a small weakened area of the aorta, the large artery that carries blood from the heart and winds down along the spinal cord to the abdomen. Over the years, the weak spot slowly balloons and eventually bursts. There are no symptoms as the aneurysm grows. But once it reaches five and a half centimeters, or a little over two inches, in diameter, it may burst at any moment. That is the time to repair it, medical researchers say, explaining that smaller aneurysms posed too little danger to be worth the risk of operating on them.
Of course, finding small aneurysms also leads to a screening dilemma: patients will discover that they have a time bomb in their body but will have to wait and monitor it before getting it fixed. Still, vascular surgeons say, that is far better than the current situation, in which most aneurysms are not found until they rupture and the few that are discovered earlier are found by accident.
"Frequently we end up with someone who has back pain and gets a CT scan or an M.R.I. of the back," said Dr. Samuel Money, the chief of vascular surgery at the Ochsner Clinic Foundation in New Orleans. The doctor, he said, looks at the scan and says, "Holy smoke, you have a 6.2-centimeter aneurysm."
The task force limited its recommendations to men aged 65 to 75 who have smoked because rupture is rare in people under age 65 and is at least three times as likely in people who have smoked. The condition is about four times as common in men as in women. Anyone with a family member who had an aneurysm is at increased risk. High blood pressure is a more minor contributor to risk and cholesterol does not seem to make much difference, researchers say.
After 75, the life expectancy is considered too short and the operation too risky.
The group recommended neither for nor against screening men ages 65 to 75 who never smoked. Those men should consult their doctors, it said. Women, however, should not be screened, the task force said, because it is much less likely that they will have a ruptured aneurysm and, if they do, the rupture usually occurs in their 80's.
Screening can be costly. It usually involves a complete ultrasound scan of the abdomen, at $350 to $400. There also are quick ultrasound tests that cost about $50 to $100. If they show an aneurysm, patients are referred for a more complete test to confirm the diagnosis.
Medicare does not pay for preventive medicine unless Congress requires it. But vascular surgeons say the new recommendation should give Congress an impetus to make screening for the aneurysms, like screening for colon and breast cancer, part of Medicare's benefits.
Lobbying for Medicare coverage has been intense, said Dr. Robert Zwolak, professor of surgery at Dartmouth Medical School. Dr. Zwolak lobbies Congress as chairman of the National Aneurysm Alliance, a group of doctors, professional societies and companies. But, he said, one holdup has been the Preventive Services Task Force, which, until now, had not recommended screening.
"I would say that in two-thirds of the offices I visit, they ask, 'What does the task force say?' " Dr. Zwolak said.
Now, he says, he expects Congress will pass a bill requiring Medicare to pay for screening.
"It's just wonderful what the task force has done," Dr. Zwolak said.
His main concern, shared by his colleague Dr. Jack L. Cronenwett, the chief of vascular surgery at Dartmouth-Hitchcock Medical Center, is that the recommendations do not go far enough. Women with a family history of the aneurysms and who have smoked have the same risk as a nonsmoking man, Dr. Cronenwett said.
"If Medicare bases a coverage decision on the recommendations, a woman could have three brothers with aneurysms and she could be a smoker and she still wouldn't get reimbursement," Dr. Cronenwett said.
Medicare does pay for the repair of aneurysms by either of two methods.
One involves opening the abdomen and replacing the damaged area with a synthetic tubing. In the other method, endovascular repair, a doctor threads a catheter through the groin to the aneurysm and relines the damaged section of blood vessel from the inside, inserting a segment of synthetic material.
About 4 percent of surgery patients die. The death rate from putting in an endovascular graft is about 1.5 percent. But researchers worry that those grafts may not provide lasting results and are awaiting data from large clinical trials comparing the two methods.
"Some of us think the long-term benefits of grafts are not proven," said Dr. Lederle, an internist who is directing one of the clinical trials and takes no money from the industry. But grafts, he said, are a huge market, widely promoted. "This has created tension in the field," he added.
Dr. Calonge of the task force said the question for insurers was going to be whether to pay for the screening. He knows that world well, he says, because until a few years ago he was the chief of preventive medicine for the Kaiser Permanente health care company in Colorado and had to decide whether new tests and services should be provided.
"People don't sit down and say: 'Here's $60,000. I want a year of life,' " he said. "What you end up doing is to say, what's the cost of the program and how does that affect what I charge and does it help or hurt in the marketplace?"
The task force's role was a bit different, he said. "Cost does not enter into the task force's recommendations," Dr. Calonge said. "We're looking for a balance of harm to potential risk. You will have the benefit in terms of lives saved and years given back to those men."
But for insurers the question is a bit different, Dr. Calonge said, "They will say, 'At what cost and can we afford this?' "
FReepmail me if you want on or off my health and science ping list.
Well on that we certainly agree. I'd venture that someone is always out to make a buck.
IIRC, there was an article in the NY Times recently about how the whole "scanning" industry had collapsed..an economic wastland ..sounds to me like an effort to gainmarketshare through fear-mongering..
Good point.
The problem is with "anyone who EVER smoked"..I'm 57..started smoking when I went into the service, everyone did back then.. at 21, quit when I got out, at 24..haven't touched ANY tobacco since, and am in great health..now I should worry?..seems toi me I have a greater risk of being hit by a piece of frozen excrement falling from an airplane..
I look forward to reading any information you want to share!
Yeah, I got no problem with that. My problem comes when they expect me to pay for it, which is clearly what this article is pushing. This is how incremental socialism works... it's "for the children" or for old sick people, ad infinitum, until all citizens are subject-slaves of the state.
I would have gladly paid the fee to have him screened had we even known about the problem and the test, especially considering our family history. And when you consider that the emergency surgery to save him was the same surgery that would have been performed to repair the aneurysm BEFORE it burst, the early screening would not only have likely saved his life, but cost significanly less when done on a non-emergency basis. Consider further, that since the blood lost prior to surgery was significant, there was no guarantee that if he would have survived, he would not have suffered brain or other organ damage. I suspect that given the choice paying for a screening test AND surgical repair as a preventative measure versus paying for the emergency response and care, even the insurance company would have favored paying early.
To all the statisticians on this thread certain that these deaths are insignificant: May your children have the joy of a loving grandfather to care for, nurture, play with, teach, and just plain love them. Mine do not.
Who gets rich off of these tests? Families whose loved ones will live as a result.
While I do share you skepticism about the tendancy for recommendations like this to be over used in the practice of defensive medicine, funded by the public, or restricted by the insurance industry, the dissemination of this knowledge to those like me, who may have a genetic predisposition to this problem or others who may have environmentally induced risk factors that elevate their risk of instant death is potentially life saving.
And don't be too quick to conclude the that money isn't well spent. As is often said: "You can pay me now, or you can pay me later ... either way you're gonna pay."
Yeah, that's fair. And it is also fair for us to call them out on trying to profiteer by creating health scares.
My doctor said he wouldn't think of touching it until it was 5 cm,that we should just monitor it from time to time. He seemed to think that the surgery would be very risky and not necessary until and unless it grows.
I don't mind saying that this makes me a little apprehensive.
So you're a smoker?
To get errors in the screening process, if you're talking about the actual sonogram, would require your sonographer to be blind. The diameter of the aorta is measured, it's either normal, borderline enlarged or there's an aneurysm.
P.S. I've never met a blind sonographer.
That was in reference to whole-body CT scanning, which people paid premium prices for out-of-pocket. The ultrasound industry has not collapsed; quite the contrary. There are not enough trained, credentialed untrasound techs to meet the growing demand.
ah..thanks for correcting my stupidity..course, in my defense.. I just scan the Times..
In the article itself... 9,000 people a year die from it, and because of that they want to screen 14 million? The chances of having this problem are 0.064%, or over 1 in 1555, and that's just of the narrow target range of specific individuals most likely to be affected. To recommend 14 million scans (and presumably another 2 million a year or so as new men reach that age) for such an unlikely probability, does not logically follow, unless there is a financial benefit for one party or another in having so many scans done.
It is???
Damn! I need to raise my fees. :-)
Medicare pays a global fee of $87.94.
OK, films in hand we went to a Cardiac & Vascular surgeon who mentioned that by looking at the films from both MRI'S it had gone from 2.7 to a 4.8 which is nearing a dangerous point.
Of course both of us were dumbfounded, because we were never told that an aneurysm showed up on the first test. We have since learned to ask for a copy of the results of ALL tests taken.
I won't go further about this because it is not helpful information and that is what I want to explain here.
We were told that there are two ways this can be fixed, both required surgery. The first has been done for the past 20 years and proved to be successful, but, was quite complex and had a longer and slower recovery period. The newer less evading, and faster recovery rate was two years old, but lacked much data for it's success.
After the vascular doctor consulted with a number of doctors and the manufactures of this device called a stint, it was decided that my husband who is 75 years old was a good candidate for this new surgery and it was performed last Sept.
All went well for two months, and then my husband started getting pains in his legs. We went to the Vascular Surgeons office and a ultra sound was performed where they saw nothing wrong so they sent him to a back doctor.
Again this doctor couldn't find anything. Slowly the pain got worse and he was walking with a cane. He could take no more than ten steps and he had to stop.
I won't go into how we happen to go back to the Vascular doctor two months later, but they found at that time he had very little blood circulating in his right leg, and the stint was bent.
He went for surgery a second surgery the first of this year,where they had to open the one stint add an additional one to it and run that across his abdomen into the other leg, because the stint for that one had a blood clot in it.
It is now a month after his surgery and things seem fine, but of course, it is to soon to know if this one has be successful. I pray it is. Would we do this again, I doubt it. There are no guarantee's even the second one will work. We are very sorry we didn't have the first and successful operation.
Two things I would suggest, are: ask doctors for copies of your tests, they're yours and you have a right to copies of them and more important, ask your doctor how many times he has performed the surgery he is suggesting.
WEll you just stated the results which by your analysis are NOT skewed since they posted the numbers
It is up to the individuals involved or at risk to make that decision
Disclaimer: Opinions posted on Free Republic are those of the individual posters and do not necessarily represent the opinion of Free Republic or its management. All materials posted herein are protected by copyright law and the exemption for fair use of copyrighted works.