Not worth it

Ruptured abdominal aortic aneurysms (AAA) rarely end well. But ultrasound scans can detect them before they pop, and elective repair has 95% survival, so they may justify screening. On the other hand surgery is expensive, especially on the sort of overweight smokers who are at most risk of AAA, they don’t all burst, and keeping a watch on the borderlines stresses people out, so screening might do more harm than good. Fortunately we have evidence.

Three large randomised controlled trials have conclusively shown, at least for men aged over 65, that screening saves lives (click here). About 200 men need to be scanned for each life saved, at a net cost according to the NHS experts of about £100 per man screened or £7,600 per additional year of life in full health – Quality Adjusted Life Year or QALY in the jargon. This is better value for money than many other NHS treatments (details here). In about six years I’ll get an invitation. What’s not to like?

The trouble is the cost benefit analysis is flaky.  A recent paper (click here) found seven economic models of AAA screening all based on the same trial evidence.  The cost per QALY varied from €4,000, in an analysis from the UK (click here) to €57,000 per QALY in one from Denmark (click here). The review authors reckoned the differences were due to different assumptions within each model, which outside observers cannot easily judge as correct or not.  I can’t contribute to that sort of technical discussion, but I can see one big flaw in those models I can understand.

None of the models include the cost of success.  Ruptured aortic aneurysm is usually a quick way to go. About half simply drop dead, and at least half the rest die after a few days in hospital. If this quick death is prevented by screening, the patient still has to die of something. Since most deaths are slow, it’s likely to be more expensive, much more if it’s Alzheimers. Even the successfully treated man who lives into his 90’s is spending his pension, rather than generating wealth. Once we stop working we cost less dead. If I’m right all the models underestimate the costs substantially.

There’s another reason to doubt the lower cost estimates – why isn’t there a free market AAA screening programme aimed at moderately wealthy old geezers?  £100 per man screened is not much for a person on even a modest pension. Plenty of countries with rich people in them don’t have state-funded screening programmes.  If the net cost was really £100 per punter there should be money to be made offering scan/operation packages.  Nowhere in the world are private practitioners offering AAA screening to the uninsured for £100 a pop – excuse the pun – or anything like it.

Lack of a private service should give the NHS cause for thought. If no middle class men anywhere, fork out for AAA screening, why should we believe some economist who is essentially saying they they don’t know what’s good for them.

But perhaps I’m wrong.  Maybe it really is as cheap as the health economists say. I still object to paying for it.

Whatever happened to the idea of deserving and undeserving patients. It may be politically unacceptable to say that some people deserve health care more than others, but it doesn’t make it less true.  I’d rather spend money on a cancer treatment for teenagers that cost £20,000 per QALY,  than on AAA screening at £7,600 per QALY.  A year of life at 20 is worth more than one at 70, and if you’re struck down through no fault of your own, you’re more deserving than an old geezer who’s been smoking, boozing and overeating half his life.

Jim Thornton