Screening for Abdominal Aortic Aneurysm

Abdominal Aortic Aneurysm (AAA) is a common disease with a prevalence of 1.5-2.0% in 65-year old men in Sweden. The risk of having AAA is increased with smoking, high age, family history of AAA and cardiovascular disease. Women have a lower prevalence (0.5%) and develop AAA later in life. An AAA seldom gives any symptom prior to rupture. Untreated rupture is associated with 100% mortality, while surgically treated rupture is associated with 25-70% mortality. Prophylactic surgery is associated with a relatively low risk (30-day mortality of 1-3%). Commonly, prophylactic surgery is offered at size 5.5 cm in men and 5.0 cm in women. As a result of randomized trials showing a benefit in terms of AAA-related mortality and all cause mortality, screening of 65-year old men have been implemented in Sweden. If a high proportion of invited persons chose not to participate in as creening programs, this will affect the positive effects of a screening program. Efforts to better understand and thereby to improve the participation rate should be made. This thesis is focused on different aspects of screening for AAA. In the first and second studies we investigated siblings to AAA-patients in two different regions in Sweden. We examined 150 siblings in mid-Sweden (Stockholm) and 379 siblings in north Sweden (Norrbotten). In both regions a prevalence of 17% in brothers and 6% in sisters was found, strikingly high numbers as compared to the general population. We did not detect regional differences in prevalence. Further analysis of the 53 siblings found with AAA revealed that 32% had a large AAA and 16% had a large AAA before the age 65. Organized screening of both male and female siblings is motivated since the population-based screening is not sufficient for all of them. The third study investigated reasons for non-participation in the population based AAA-screening program in Stockholm County. The individual socioeconomic- and health-status of 24319 men invited to screening was investigated and compared between participants and non-participants in screening. The risk of non-participation is increased with low income, low education, marital status single, immigrants and persons with long travel distance to examination-centre. The non-participants had a higher proportion of co-existing diseases. We concluded that immigrants and people with long travel-distance should be targeted in further attempts to improve screening-participation. The fourth study concerns men with screening-detected AAA and their outcome when treated with prophylactic surgery. We compared all available treated screeningdetected men in Sweden (n=350) to age matched, non screening-detected controls. There was no differences in comorbid conditions between the groups but open repair was used more frequently than EVAR in patients with screening-detected AAA´s than in nonscreening-detected controls (56% vs 45%). In terms of outcome, a lower 90-day mortality in screening-detected men was found, but no difference in 30-day or 1-year mortality. The overall 30-day mortality in all 700 men was very low at 1%. This gives further support to national screening programs for the detection of AAA´s in men. Efforts should be made to find AAA’s with improved screening of siblings and groups with low participation-rates in the screening programs

Follow-up after surgical treatment for intermittent claudication (FASTIC) : A study protocol for a multicentre randomised controlled clinical trial

Background: Intermittent claudication (IC) is a classic symptom of peripheral arterial disease, and strongly associated with coronary heart disease and cerebrovascular disease. Treatment of IC and secondary prevention of vascular events include best medical treatment (BMT), changes in lifestyle, most importantly smoking cessation and increased physical exercise, and in appropriate cases surgery. A person-centred and health promotion approach might facilitate breaking barriers to lifestyle changes and increasing adherence to secondary prevention therapy. The FASTIC study aims to evaluate a nurse-led, person-centred, health-promoting follow-up programme compared with standard follow-up by a vascular surgeon after surgical treatment for IC. Methods: The FASTIC-study is a multicentre randomised controlled clinical trial. Patients will be recruited from two hospitals in Stockholm, Sweden after surgical treatment of IC through open and/or endovascular revascularisation and will be randomly assigned into two groups. The intervention group is offered a nurse-led, person-centred, health-promoting programme, which includes two telephone calls and three visits to a vascular nurse the first year after surgical treatment. The control group is offered standard care, which consists of a visit to a vascular surgeon 4-8 weeks after surgery and a visit to the outpatient clinic 1 year after surgical treatment. The primary outcome is adherence to BMT 1 year after surgical treatment and will be measured using The Swedish Prescribed Drug Registry. Clinical assessments, biomarkers, and questionnaires will be used to evaluate several secondary outcomes, such as predicted 10-year risk of cardiovascular and cerebrovascular events, health-related quality of life, and patients' perceptions of care quality. Discussion: The FASTIC study will provide important information about interventions aimed at improving adherence to medication, which is an unexplored field among patients with IC. The study will also contribute to knowledge on how to implement person-centred care in a clinical context. Trial registration: ClinicalTrials.govNCT03283358, registration date 06/13/2016

Increasing patients’ awareness of their own health : Experiences of participating in follow-up programs after surgical treatment for intermittent claudication

Introduction: Claudication is the most usual symptom of peripheral artery disease, it is described as painful contractions in the leg when walking and alleviated upon resting. People with claudication have an added risk of cardiocerebrovascular events, amputation, and death. Adherence to medical treatment and changes in lifestyles can lower this risk, but this secondary prevention therapy requires engagement, participation, and adherence from the patient. Objective: To explore patients’ experiences of participating in a 1-year multicentre clinical trial with two follow-up programs evaluating a nurse-led, patient-centered health-promoting programme after surgical treatment for claudication, the FASTIC study. Methods: A descriptive design with qualitative semi-structured interviews was used among participants in the FASTIC study. The study was conducted at two centres for vascular surgery in the city of Stockholm, Sweden. In all, 17 patients (nine men and eight women) who had completed the FASTIC study participated. Data was analysed using qualitative content analysis with an inductive approach. Results: Two main categories were identified, ‘Patient-Professional collaboration’ and ‘Experience of one´s health’, which were associated with four subcategories: facing opportunities and obstacles, cooperating based on the illness experience, increasing awareness of one's own health, and maintaining a healthy lifestyle. Conclusions: Patients' participation in follow-up programs after surgical treatment for claudication is highly valuable for an increased awareness of one's own health. A person-centered care with patient-professional collaboration is experienced as important for maintaining a health-promoting lifestyle

Patient related outcomes after receiving a person centred nurse led follow up programme among patients undergoing revascularisation for intermittent claudication : A secondary analysis of a randomised clinical trial

OBJECTIVE: The aim was to evaluate the effect of a person centred nurse led follow up programme on health related quality of life (HRQoL), health literacy, and general self efficacy compared with standard care for patients undergoing revascularisation for intermittent claudication (IC), and to describe factors associated with HRQoL one year after revascularisation. METHODS: This was a secondary analysis of a randomised controlled trial. Patients with IC scheduled for revascularisation at two vascular surgery centres in Sweden between 2016 and 2018 were randomised to intervention or control. During the first year after surgery, the intervention group received a person centred follow up programme with three visits and two telephone calls with a vascular nurse, while the control group received standard follow up with two visits to a vascular surgeon or vascular nurse. Outcomes were HRQoL measured by VascuQol-6, health literacy, and general self efficacy measured by validated questionnaires. RESULTS: Overall, 214 patients were included in the trial; this secondary analysis comprised 183 patients who completed the questionnaires. One year after revascularisation, HRQoL had improved with a mean increase in VascuQol-6 of 7.0 scale steps (95% CI 5.9 - 8.0) for the intervention and 6.0 scale steps (95% CI 4.9 - 7.0) for the control group; the difference between the groups was not significant (p = .18). In an adjusted regression analysis, the intervention was associated with higher VascuQoL-6 (2.0 scale steps, 95% CI 0.08 - 3.93). There was no significant difference between the groups regarding health literacy or general self efficacy. The prevalence of insufficient health literacy among all participants was 38.7% (46/119) at baseline and 43.2% (51/118) at one year. CONCLUSION: In this study, a person centred, nurse led follow up programme had no significant impact on HRQoL, health literacy, or general self efficacy among patients undergoing revascularisation for IC. The prevalence of insufficient health literacy was high and should be addressed by healthcare givers and researchers

Effects of a person-centred, nurse-led follow-up programme on adherence to prescribed medication among patients surgically treated for intermittent claudication : Randomized clinical trial

BACKGROUND: Management of intermittent claudication should include secondary prevention to reduce the risk of cardiocerebrovascular disease. Patient adherence to secondary prevention is a challenge. The aim of this study was to investigate whether a person-centred, nurse-led follow-up programme could improve adherence to medication compared with standard care. METHODS: A non-blinded RCT was conducted at two vascular surgery centres in Sweden. Patients with intermittent claudication and scheduled for revascularization were randomized to the intervention or control (standard care) follow-up programme. The primary outcome, adherence to prescribed secondary preventive medication, was based on registry data on dispensed medication and self-reported intake of medication. Secondary outcomes were risk factors for cardiocerebrovascular disease according to the Framingham risk score. RESULTS: Some 214 patients were randomized and analysed on an intention-to-treat basis. The mean proportion of days covered (PDC) at 1 year for lipid-modifying agents was 79 per cent in the intervention and 82 per cent in the control group, whereas it was 92 versus 91 per cent for antiplatelet and/or anticoagulant agents. The groups did not differ in mean PDC (lipid-modifying P = 0.464; antiplatelets and/or anticoagulants P = 0.700) or in change in adherence over time. Self-reported adherence to prescribed medication was higher than registry-based adherence regardless of allocation or medication group (minimum P < 0.001, maximum P = 0.034). There was no difference in median Framingham risk score at 1 year between the groups. CONCLUSION: Compared with the standard follow-up programme, a person-centred, nurse-led follow-up programme did not improve adherence to secondary preventive medication. Adherence was overestimated when self-reported compared with registry-reported