Introduction
Ruptured abdominal aortic aneurysms (rAAA) - the final section of the aorta that transports oxygenated blood to the abdominal organs, pelvis and legs - are the 15th leading cause of death in the United States (Guirguis-Blake, 2019). Like many diseases of the cardiovascular system, the fatality of the rupture is most frequently a- a result of having no prior diagnosis of the AAA (Mansoor, 2024). Fortunately, if diagnosed early enough, a AAA can often be managed through observation by a medical professional, though there is no current medical therapy for the disease (Golledge, 2020). If required due to increasing size, the AAA can be surgically repaired with a survival rate of 78% at the population level (Bastos Gonçalves, 2016). This rate varies depending on the patient's risk level, determined by medical tests, imaging, and other patient-specific factors (Isselbacher, 2022).
When a rupture does occur, the disease becomes life-threatening. 50% of patients die before reaching a treatment center (Wise, 2015) - the reported 1-year survival rate following repair of the ruptured AAA is ~ 53% (Roosendaal, 2021). However, if a rupture occurs and the patient is fortunate enough to make it to a nearby hospital - which is not a given as 50% of patients die before reaching a treatment center (Wise, 2015) - the reported 1-year survival rate following repair of the ruptured AAA is ~ 53% (Roosendaal, 2021). It is worth noting that the survival rates at the individual level are highly dependent on the number and severity of risk factors associated with AAAs that the patient has, in addition to evidence suggesting that busier hospitals (ones with a high volume of procedures) have better survival rates on average
(Dimmick, 2003). Notwithstanding this information, survival rates associated with any rupture of a AAA are significantly lower than those surgically repaired before rupture, and even lower than those that qualify for medical management (Bastos Gonçalves, 2016).
Issue
Preventative vascular health is a public health matter with the number of deaths caused not only by AAAs but many other types of vascular disease that can be significantly decreased with an increase in federally mandated screening for AAA and other diseases of the cardiovascular system. For the scope of this post, the focus will be on screening AAA.
Literature
From the division of Vascular Surgery at Stanford, work regarding the prevalence of screening for AAA, where screening rates for those eligible for screening, as defined by the United States Preventive Task Force (USPSTF), was analyzed. Of the 35,154 people eligible for screening in the study, only 13,612 (38.7%) had undergone screening at the time of the study, where the overall worst state for screening was Minnesota (24.4%), and the best was Montana (51.6%). Overall, the screening rates were almost half of the recommended screening rate as defined by the USPSTF, and even lower for those living outside of metropolitan areas. Comparatively, those receiving care in capitated healthcare systems like Kaiser Permanente and Veterans Affairs (VA) are screened at rates between 74%-79% (Ho, 2023). Screening rates for capitation systems can be explained, in part, due to financial incentives present in these healthcare systems, whereby spending more on healthcare - in this case, the increased cost of repairing a AAA that wasn’t previously screened for - ultimately comes out of the pocket
of the government. In the case of Kaiser, the state government of California and for the VA, the federal government.
The paper concludes that further reimbursement incentives for screening need to be set up, in addition to putting more effort into screening folks in non-metropolitan areas. These recommendations are a start to addressing preventative healthcare in the United States - in this instance, vascular care. However, suggests that further diligence may be required in promoting screening as the piece did not include stratification for potentially confounding variables such as race or ethnicity. While not guaranteed, the screening rates mentioned may vary by race, along with other variables such as socioeconomic standing, gender, and additional possible confounders (Vogel, 2022).
Work from the division of Vascular and Endovascular Surgery, along with the division of Cardiothoracic Surgery at Baylor and the DeBakey VA group in Waco, Texas, demonstrated that Black Americans are significantly more likely to have a ruptured AAA (rAAA) than an intact AAA (iAAA) operated on, suggesting that Black Americans are likely receiving screening at a significant rate below caucasians. It is also worth noting that current literature, albeit from Norway and Australia, suggests that the rate of rAAA for aneurysms previously screened is a mere 0.2%-0.3% (Barshes, 2022). For the Texas work, it is worth noting the possible scope limitations to the state of Texas and not the broader United States.
Concluding Thoughts & Discussion
AAA is one just form of vascular disease within surgery, medicine, and public health, a field broad enough to include more pathologies than are currently knowable by any individual. However, the questions surrounding vascular disease - how it’s treated, detected, and, hopefully, one day, mostly prevented - are similar to many of the
diseases that public health officials and the U.S. healthcare system will need to grapple with. The question of how to prevent vascular disease relates to the type of healthcare available to folks is beyond the scope of any one individual, but the question of who is screened for these diseases - be it by race, ethnicity, socioeconomic standing, gender, sex - are more within the hands of healthcare workers and public health officials.
Health equity is a complex topic wrought with nuance. However, preventative measures for vascular screening in the United States. To promote a future increase in health equity in American healthcare, the next question of, “Who is this disease most impacting?” must always be asked and considered in the most inclusive terms, because who should live and who should not, is not based on hierarchy or any merit other than shared humanity.
References
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