Current issues of ACP Journal Club are published in Annals of Internal Medicine


Early surgery was more expensive than surveillance for small abdominal aortic aneurysms but slightly improved health perception and bodily pain

ACP J Club. 1999 May-June;130:72. doi:10.7326/ACPJC-1999-130-3-072

Source Citation

The UK Small Aneurysm Trial Participants. Health service costs and quality of life for early elective surgery or ultrasonographic surveillance for small abdominal aortic aneurysms. Lancet. 1998 Nov 21; 352:1656-60.



In patients with symptomless, small, abdominal aortic aneurysms, are costs and quality-of-life outcomes similar for early surgery and ultrasonographic surveillance of aortic diameter?


Economic analysis that was included in a randomized controlled trial {with up to 7 years of follow-up}* (mean 4.6 y).


93 hospitals in the United Kingdom.


1090 patients {who were 60 to 76 years of age (mean age 69 y, 83% men); were fit for elective surgery}*; and had symptomless, infrarenal, abdominal aortic aneurysms 4.0 to 5.5 cm in diameter (mean diameter 4.6 cm). {Exclusion criteria included tender aneurysm.}* Follow-up was complete.


Patients were allocated to early surgery (n = 563) or ultrasonographic surveillance of aortic diameter (n = 527).

Main cost and outcome measures

Direct health service costs to the National Health Service were assessed in 1996 to 1997 U.K. pounds. The use of health service resources in inpatient and day-case episodes, duration of hospital stay, attendance at outpatient clinics, and self-reported consultations with family physicians were measured. Annual discount rates of 0%, 3%, and 6% were used. Health-related quality of life was assessed by using the Medical Outcomes Study Short Form-36 Health Survey (SF-36) (score range 0 to 100, with higher scores being better).

Main results

Analysis was by intention to treat. Health-related quality-of-life scores for physical, role, and social functioning and mental health subscales were similar at 1 year for both groups. The early surgery group had higher scores than the surveillance group on subscales for health perception (mean score difference 8.1, 95% CI 4.6 to 11.6) and bodily pain (mean score difference 5.1, CI 0.7 to 9.8) at 1 year. Early surgery was more expensive than ultrasonographic surveillance when costs were undiscounted (mean cost difference £835, CI £559 to £1111) or discounted at 3% (mean cost difference £955, CI £686 to £1225) or 6% (mean cost difference £1064, CI £799 to £1328). Early surgery continued to cost more when assumptions were varied about the time between ultrasonographic examinations and the unit cost of aneurysm repair.


In patients with symptomless, small, abdominal aortic aneurysms, early surgery cost more than ultrasonographic surveillance of aortic diameter but led to some improvement in patients' health perception and bodily pain.

Sources of funding: Medical Research Council and the British Heart Foundation.

For correspondence: Dr. J.F. Forbes, Public Health Sciences, University of Edinburgh, Medical School, Edinburgh EH8 9AG, Scotland, UK. FAX 44-131-503-224.

*The UK Small Aneurysm Trial Participants. Lancet. 1998;352:1649-55.


Early surgery did not reduce 6-year mortality in patients with small abdominal aortic aneurysms

Theoretically, the optimal time at which an asymptomatic abdominal aortic aneurysm should be repaired is when the probability of perioperative death (if the patient has surgery) is approximately equal to the probability of death from a ruptured abdominal aortic aneurysm (if the patient does not have surgery). In this well-done study by the U.K. Small Aneurysm Trial Participants, no difference in mortality existed between patients who had immediate repair (mean aortic diameter 4.6 cm) and those who were followed with ultrasonography until the aneurysm reached 5.5 cm. Interestingly, 11 patients in the surveillance group died from a ruptured abdominal aortic aneurysm, and 8 patients in the surgery group died from perioperative complications. Thus, it seems reasonable to follow patients until the aneurysm reaches 5.5 cm, becomes symptomatic, or grows by more than 1 cm/y. A U.S. trial is also addressing this issue, and it is hoped that the results will be reported shortly (1).

Patients in the surveillance group had ultrasonography every 6 months, decreasing to every 3 months, for aneurysms between 5.0 and 5.5 cm. Thus, patients must be followed carefully to ensure that the results of surveillance ultrasonography are replicated in actual practice. Over a mean follow-up of 4.6 years, 61% of patients in the surveillance group eventually had surgery, indicating that in most cases surveillance delayed—not prevented—surgery. The 30-day perioperative mortality rate in the study was 5.8%, which is similar to mortality rates of other multicenter studies, and reinforces the fact that even in the 1990s, elective abdominal aortic aneurysm surgery is associated with considerable risk. The use of endovascular stents may reduce the perioperative mortality rate in the future, but experience to date has found similar mortality rates for stents and open repair (2-4). However, stents seem to be associated with less blood loss, shorter stays in intensive care and the hospital, and possibly less morbidity, although this has not been shown in a randomized trial.

The finding that patients with small aneurysms who receive immediate surgery incur more health care costs than those followed by surveillance is not surprising. However, it is not possible to reliably transfer the results of a costing study from one health care system to another. Unfortunately, few data about the amount of resources used by patients in the study (e.g., mean number of ultrasonograms and mean days in the hospital) were provided, which makes it difficult to compare treatments across regions. Further, patient-borne costs were not included, although these are unlikely to have been a major factor in the analysis.

The finding that patients in the surgery group had less bodily pain and more improved health perceptions than patients in the surveillance group is intriguing. One can hypothesize that patients in the surveillance group were more anxious that their aneurysm might rupture and, thus, had poorer health perceptions. Now that patients can be told that ultrasonographic surveillance leads to outcomes similar to those of early surgery, one wonders whether their health perceptions would also be similar. It is not clear why bodily pain should be improved in the surgery group.

It is likely that some patients will always prefer to have their aneurysm repaired earlier rather than later, whereas others will be comfortable to have their aneurysm followed for some time. Now that this excellent study has provided data about the outcomes of immediate surgery compared with ultrasonographic surveillance, the time seems right to develop a decision aid to give patients detailed information about the choices available to them and the consequences of those choices (5, 6). This will allow patients to participate fully in the decision about the timing of surgery and to make the choice that is right for them.

Andreas Laupacis, MD, MSc
Loeb Heart Research UnitOttawa, Ontario, Canada


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