of time and resource (Against) Prof Pete Holt St Georges Vascular - PowerPoint PPT Presentation

Debate: surveillance is a waste of time and resource (Against) Prof Pete Holt St George’s Vascular Institute, London

Cost Effectiveness Clinical Outcomes QUALITY Patient Safety Patient Experience

Key issues in post-EVAR surveillance  Cost - Direct & resource use  Effectiveness - Clinical & cost  Delivery - Compliance, Access, Acceptability, Patient Education  Modality - Time, Cost, Risk to patient, Diagnostic accuracy  Interval presentations  Opponent

“Surveillance remains mandatory post -EVAR CEUS would have greater cost implications than DUS… CEUS therefore cannot be recommended… DUS performs equivalently to CT with 30% cost reduction, no nephrotoxicity and no radiation”

“…a 100% probability that EVAR is a cost - effective treatment” “The increased procedural costs of open repair are NOT outweighed by greater surveillance & reintervention costs after EVAR”

Cost Effectiveness Clinical Outcomes QUALITY Patient Safety Patient Experience

POORLY INFORMED DECISIONS, CARE RATIONING AND SUPPORTING OVERT BIAS

NON-CREDIBLE A relatively easy Theory  Born 1879, Ulm, Germany  1948 – admitted with abdominal pain  “Grapefruit - sized” aortic aneurysm  Wrapped anteriorly in cellophane  12 April 1955 – readmitted with pain  Died 0115, April 18, 1955 (aged 76)

Mortality and rate of EVAR in the UK 2005-2018 100 14 90 12 80 10 70 60 8 50 6 40 30 4 20 2 10 0 0 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Axis Title %EVAR mortality Expon. (mortality)

10 “The overall in -hospital mortality rates for open and EVAR procedures for the period between 9 2015 and 2017 were 3.0% and 0.6%, 8 respectively.” 7 EVAR 1: 4.7 v 1.7 Death Rate % 6 5 4 3 2 1 0 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Year

ACM OR 1.43, p<0.0001 Failure of surveillance results in higher overall mortality and emphasises the importance of routine surveillance.

ACM OR 1.43, p<0.0001 ACM (OR 1.81) ARM (OR 1.47) EVAR 1 Trial <1:10 surviving patients in surveillance at 8 years

EVAR SCREEN v. . EVAR 1: : It Its not ju just about the op

Attitude and Views to Risk • 96% Surveillance is necessary • 81% High risk, more scans • Pre-operative risk 77% Post-EVAR • 73% Low risk, less scans • Personalised schedule 67% Patient based on risk Preference Study Modality Preference • Ultrasound vs CT 69%

Surveillance can be improved but saves lives  Improve surveillance programmes Clinical Cost  Define optimal intervals Outcomes Effectiveness  Risk-based, dynamic & personalised surveillance  Delivery close to home QUALITY  Reliable, safe, non-toxic, non-carcinogenic Patient  Investigate and rectify problems early Patient Safety Experience  Sac size increase is pathological  I/III Endoleaks are clinical urgencies