Information Services Division Publication Report Scottish Abdominal Aortic Aneurysm (AAA) Screening Programme Statistics Year ending 31 March 2016 Publication date – 7 March 2017 An Official Statistics Publication for Scotland Information Services Division Contents Introduction ................................................................................................................................ 2 AAA screening programme ..................................................................................................... 3 Main points ................................................................................................................................. 4 Results and Commentary ........................................................................................................... 5 Key Performance Indicators (KPIs) ........................................................................................ 5 Key Performance Indicators: Scotland Results ....................................................................... 6 Invitation to screening ............................................................................................................. 7 Attendance at screening ......................................................................................................... 8 Attendance at screening by deprivation ................................................................................ 10 Surveillance screens attendance .......................................................................................... 11 Quality of screening .............................................................................................................. 13 Referral, clinical intervention and outcomes ......................................................................... 15 Results from initial screening for eligible cohort .................................................................... 18 Results from initial screening for self-referrals ...................................................................... 20 Glossary ................................................................................................................................... 21 Bibliography ............................................................................................................................. 23 List of Tables ............................................................................................................................ 24 Contact ..................................................................................................................................... 26 Further Information ................................................................................................................... 26 Rate this publication ................................................................................................................. 26 Appendices .............................................................................................................................. 27 A1 – Background Information ............................................................................................... 27 A2 – Publication Metadata (including revisions details) ........................................................ 29 A3 – Early Access details (including Pre-Release Access) .................................................. 32 A4 – ISD and Official Statistics ............................................................................................. 33 1 Information Services Division Introduction A screening programme for Abdominal Aortic Aneurysms (AAA) for men aged 65 was implemented in Scotland in line with the advice from the UK National Screening Committee (NSC). There was a phased roll-out of the programme from June 2012. NHS Highland and NHS Western Isles were the first NHS Boards to implement the screening programme and by November 2013 all NHS Boards were participating. An AAA is a swelling of the aorta, the main artery in the body, as it passes through the abdomen. As some people get older, the wall of the aorta in the abdomen can become weak and balloon out to form an aneurysm. The condition is most common in men aged 65 and over and usually there are no symptoms. Large aneurysms are uncommon but can be very serious. As the wall of the aorta stretches, it becomes weaker, and it can rupture (burst). If the aneurysm ruptures, this leads to life- threatening internal bleeding and, in 8 out of 10 cases, death [1]. The Scottish AAA screening programme aims to reduce deaths associated with the risk of aneurysm rupture in men aged 65 and over by identifying aneurysms early so that they can be monitored or treated. The screening test is a simple ultrasound scan of the abdomen which takes around 10 minutes. Men aged 65 are invited to attend AAA screening and men aged over 65 can self-refer into the screening programme. Most men have a normal result and are discharged from the screening programme. Men with detected small or medium aneurysms are invited for regular surveillance screening to check the size of the aneurysm. Men with large aneurysms are referred to vascular specialist services. Further information on the AAA screening programme in Scotland can be found on the NHS Inform website. The first publication of Scottish AAA screening statistics in March 2016 covered the implementation phase of the programme and was released as developmental statistics. This publication provides an update on the screening programme to include data for the year ending 31 March 2016, and reports on the key performance indicators for the programme for the first time. These key performance indicators cover information on invitation and attendance at screening, the quality of screening, and vascular referrals. The report also includes data on screening results and self-referrals. The new key performance indicator data on invitations and attendance at initial screening (KPI 1.1 to KPI 1.3) are not directly comparable to the developmental invite and attendance data in the previous publication. The data in the previous publication provided an overall measure of invitations and attendance at the point of reporting, and did not apply strict time restrictions on when men were invited or attended for screening. As the programme has now progressed beyond the implementation phase, the method used to calculate the invite and attendance rates has been revised. The revision means that strict time criteria on when men are invited and attend for screening are now applied to the calculation of the invite and attendance rates. These time criteria are clearly described in each KPI. Additionally, there are some minor differences between some of the figures in this year’s publication and the broadly comparable figures for the equivalent time period in last year’s publication. This is due to improvements in the methodology used to collate the statistics in line with the new key performance indicators. 2 Information Services Division AAA screening programme The screening test is an ultrasound scan of the abdomen and there are five possible results: Result Aortic diameter Pathway Normal Less than 3.0cm Discharged from screening programme (negative) Small AAA Between 3.0 and 4.4cm Annual surveillance scans (positive) Medium AAA Between 4.5 and 5.4cm Surveillance scans every 3 months (positive) Large AAA 5.5cm or over Referred to vascular specialist services (positive) Non-visualisation Aorta cannot be fully If an aorta cannot be fully visualised at visualised the first scan, an invitation for a further scan is sent Most men have a normal result and are discharged from the screening programme. Men with a small or medium-sized aneurysm are invited to attend surveillance appointments to check the size of the aneurysm regularly to monitor any growth. Men with small aneurysms are invited for annual surveillance scans. Men with medium aneurysms are invited for surveillance scans every three months. Most aneurysms grow very slowly, and many men with a small or medium aneurysm never need treatment. Men with a large aneurysm are referred to vascular specialist services for further investigation and to discuss treatment options. If an aorta cannot be fully visualised at the first scan, an invitation for a further scan is sent. Men with a second non-visualisation scan are discharged from the screening programme into the care of their GP. 3 Information Services Division Main points Key Performance Indicator results for the year ending 31 March 2016  The screening programme in Scotland met or exceeded the essential target in 10 of the 12 performance indicators.  97.0% of men in Scotland who turned 66 in the year ending March 2016 were invited for screening before their 66th birthday, meeting the essential threshold of 90%.  Uptake of the AAA screening programme was high with 84.0% of men in Scotland tested before age 66 and 3 months, meeting the essential threshold of 70%. All NHS Boards achieved high uptake, with a rate of 80% or higher.  Uptake of screening was lower in the most deprived areas. The essential threshold of 70% uptake was met in all deprivation quintiles.  72.0% of men referred to vascular specialist services were seen within two weeks, slightly below the essential threshold of 75%.  Only 28.2% of the 71 men deemed appropriate for surgery were operated on by a vascular specialist within eight weeks. This was substantially below the essential threshold of 60%.  Since the programme began, the 30-day mortality rate following elective open surgery for aneurysm repair was 2.5%, which meets the desirable threshold of below 3.5%.  The 30-day mortality rate following Endovascular Aneurysm Repair (EVAR) was 0%, which meets the desirable threshold of below 2%. Screening tests and results  Among men in the routine eligible cohort who turned 66 in the year ending 31 March 2016 there were over 25,500 men tested and 376 (1.5%) men had a positive result.  There were also nearly 900 men who self-referred into the programme and were tested in the most recent year and 29 men (3.3%) had a positive result.  In total, among the eligible cohort from implementation to 31 March 2016, over 87,500 men in Scotland have been tested and 1,308 (1.5%) men had a positive result.  There were also over 4,000 men who self-referred into the programme and were tested in the cumulative period from implementation and 118 men (2.8%) had a positive result. 4 Information Services Division Results and Commentary Key Performance Indicators (KPIs) The Key Performance Indicators for the Scottish AAA screening programme are intended to offer a focus on aspects of the patient journey from invitation, through the delivery of the scan, to referral for clinical assessment, to outcome of surgical intervention if this is required. The KPIs are not intended to cover all aspects of the AAA Screening programme nor the detail of any subsequent surgical intervention. They are designed to assess critical achievement of aspects of the screening pathway: Invitation; Attendance; Quality of screening, Referral; Clinical Intervention; and Outcomes. The purpose of reporting achievement of the KPIs is to give a high level view of the performance of the AAA screening programme, act as a driver for continuous improvement, and to direct specific review of any areas that (from the KPIs) appear to be underperforming. Each KPI has two thresholds:  Essential: the minimum level of performance which the screening programme is expected to attain.  Desirable: the screening programme should aspire towards attaining and maintaining performance at this level. Following the implementation phase of the programme, NHS Boards are expected as a minimum to meet the essential thresholds for these performance indicators, although there are three indicators which will not take full effect until data for the year ending 31 March 2017 is available. This publication includes KPI data for the year ending 31 March 2015 and the year ending 31 March 2016. The report commentary mainly focuses on data for the year ending 31 March 2016 as the first benchmark of performance against the KPIs. 5 Information Services Division Key Performance Indicators: Scotland Results Results for year Essential Desirable ending 31 March Key Performance Indicator Threshold Threshold 2016 Scotland Invitation and attendance Percentage of eligible population who are sent an initial offer to screening before ≥ 90% 100% 97.0% reaching age 66 Percentage of men offered screening who are ≥ 70% ≥ 85% 84.0% tested before reaching age 66 and 3 months Quintile 1 76.0% (most deprived) Percentage of men offered screening who are 81.7% Quintile 2 tested before reaching age 66 and 3 months ≥ 70% ≥ 85% 84.3% Quintile 3 by Scottish Index of Multiple Deprivation (SIMD) quintile 87.4% Quintile 4 Quintile 5 88.8% (least deprived) Percentage of annual surveillance appointments due where men are tested 96.3% within 6 weeks of due date ≥ 90% 100% Percentage of quarterly surveillance appointments due where men are tested 96.7% within 4 weeks of due date Quality of screening Percentage of screening encounters where < 3% < 1% 1.5% the aorta could not be visualised Percentage of men screened where the aorta < 3% < 1% 1.3% could not be visualised Percentage of screened images that failed the quality assurance audit and required < 4% < 1% 0.4% immediate recall Referral, clinical intervention and outcomes Percentage of men with AAA≥5.5cm seen by vascular specialist within two weeks of ≥ 75% ≥ 95% 72.0% screening Percentage of men with AAA≥5.5cm deemed appropriate for intervention/operated on by ≥ 60% ≥ 80% 28.2% vascular specialist within eight weeks of screening 30-day mortality rate following open elective < 5% < 3.5% 2.5% AAA surgery1 30-day mortality rate following EVAR < 4% < 2% 0% intervention1 1. Due to small numbers, data is presented for the cumulative period from the start of the national screening programme, which began a phased implementation on 29 June 2012, to 31 March 2016. 6 Information Services Division Invitation to screening Men become eligible for AAA screening when they reach 65 years of age and should be invited for screening before their 66th birthday. KPI 1.1 measures the percentage of the men eligible for screening who are sent an initial offer of screening before their 66th birthday. NHS Boards were not expected to meet the essential threshold for this KPI during the implementation phase of the programme. The introduction of the AAA screening programme in Scotland was phased from June 2012, and by November 2013 all NHS Boards were participating. On implementation NHS Boards were required to screen both the 'one-off' annual cohort of men who were 65 years of age on the NHS Board implementation date, as well as the cohort of men who turned age 65 following implementation (the routine eligible cohort). As NHS Boards required sufficient time to implement the programme and screen both these cohorts, NHS Boards were not required to meet the timescale of inviting men in the routine cohort before their 66th birthday during this phase. NHS Boards are expected to meet the essential criteria for this KPI for the cohort of men turning age 66 in the year ending 31 March 2017 i.e. for men who first became eligible from 1 April 2015 to 31 March 2016. These figures will be available in the next annual update of this publication.  Overall 97.0% of men in Scotland who turned 66 in the year ending March 2016 were invited before their 66th birthday, meeting the essential threshold of 90%.  Most NHS Boards achieved the essential threshold. Eight NHS Boards also achieved the desirable threshold, inviting 100% of eligible men before age 66 (Figure 1). Figure 1 KPI 1.1: Percentage of eligible population who are sent an initial offer to screening before age 66 by NHS Board of residence; men who turned 66 in year ending 31 March 2016 7 Information Services Division Attendance at screening KPI 1.2 measures the percentage of men offered screening who are tested (screened) before age 66 and 3 months. Although men should be invited for screening before their 66th birthday, some men may reschedule their appointment or not attend their first screening appointment. Therefore the uptake of screening is measured at age 66 and 3 months, giving men a further 3 months to attend following their 66th birthday.  Uptake of the AAA screening programme was high with 84.0% of men in Scotland tested before age 66 and 3 months for the year ending 31 March 2016.  All NHS Boards achieved an uptake rate of 80% or higher, and were therefore well above the essential threshold of 70%. Eight NHS Boards also met the desirable threshold of 85% (Figure 2). Figure 2 KPI 1.2: Percentage of men offered screening who are tested before age 66 and 3 months by NHS Board of residence; men who turned 66 in year ending 31 March 2016 Five of the six NHS Boards which did not meet the desirable threshold all lie in the central belt of Scotland (Figure 3). The next section discusses how uptake of screening is lower in the most deprived areas and this partly explains why uptake rates were slightly lower in some of these NHS Board areas. For example, NHS Greater Glasgow & Clyde has a higher proportion of its eligible population living in the most deprived areas and this partly explains the slightly lower uptake rate in this NHS Board area. However the uptake of screening in NHS Greater Glasgow & Clyde was still high at 80.1%. 8 Information Services Division Figure 3 KPI 1.2: Percentage of men offered screening who are tested before age 66 and 3 months; men who turned 66 in year ending 31 March 2016 9