Morbidity and mortality reviews at Broken Hill Health Service identified a number of patients presenting late with Abdominal Aortic Aneurysm (AAA), with uniformly poor outcomes. Action through the local community resulted in a self-funded program of ultrasound-based screening on eligible members of the community.

In 2007 and 2008, all males residing in the Broken Hill area between the ages of 65 and 74 years received invitations to attend screening days at the Community Centre.  Approximately 63% of those contacted accepted the invitation and were screened.  Several large aneurysms were found and the subjects were referred via their local General Practitioners for definitive treatment.

Screening was well tolerated and increased health awareness in this group of people.

To identified silent AAAs, allowing early definitive treatment, and to demonstrate the possibility of achieving this goal in larger-scale, even national, screening programs.

Morbidity and Mortality meetings held at Broken Hill Health Service consistently showed several cases a year of older men presenting with leaking or ruptured abdominal aortic aneurysm (AAA). Survival rates were poor, due to the overall poor prognosis of leaking AAA, compounded by Broken Hill’s distance from vascular surgical facilities.

AAA is a manifestation of poor vascular health that may not be detected until it presents as an emergency.  Our aim was to detect as many people in the community as possible with silent AAAs, so that they can be treated electively by less invasive and hazardous procedures than emergency surgery.

Over a period of five years, a number of men were admitted with leaking or ruptured AAA, all of whom either died before surgery could be undertaken or shortly after surgery. 

Knowing that the prevalence of clinically silent AAA is 4.8% in men aged over 65 years , we knew that there were likely to be others in the community with undiagnosed AAA.  As an area with high prevalence of vascular disease and the background risk factors (smoking, overweight and obesity, high blood pressure) that cause it, we felt compelled to take action.

This project relates directly to the NSW Health and GWAHS Strategic Direction 1 "Making Prevention everyone's business". The first objective is healthier people. One of the strategies was to conduct programs and campaigns, using evidence – based strategies, to promote health and wellness and prevent injury and illness. Every AAA found, from minor to large, has resulted in early treatment preventing future presentations with sometimes catastrophic illness complications.

A Community Round Table considered the issue and founded the Triple A Initiative, which raised funds by a wide range of community activities. When a reasonable amount had been raised, the leaders of the initiative met to consider the options. It was resolved to engage the services of the Westmead Vascular Laboratory to perform AAA screening by ultrasound examination of the abdomen, using sophisticated ultrasound equipment on loan, operated by specialist vascular ultrasonographers.

Discussions with the University Department of Rural Health emphasized the potential of the initiative as a demonstration project for other communities. A grant from the NSW Institute for Rural Clinical Research and Teaching funded data collection for this purpose. Institutional Research Ethics Committee approval allowed for the use of the Commonwealth Electoral Roll to recruit subjects for screening.

Screening sessions were preceded by intense publicity within the local community. Local groups which had been involved in the fund-raising effort, principally the Lions' Club, helped with word-of-mouth promotion. Lions' Club volunteers attended the screening sessions to reassure local men prior to and after the screening test and provided transport to and from the Centre on request.

Health-related anxiety and depression score and evaluation questionnaires were offered to all participating subjects and most filled them out.  Preliminary analysis of a subset of questionnaires has shown good tolerance of the screening procedure by the subjects and very little apparent triggering of anxiety by the process.

AAA screening of this group of men in this community has been strongly supported by local people and accepted well by the subjects.  Screening uncovered the expected number of small, medium-sized and large aneurysms and all of these were followed up through local general practices. Those subjects prescribed diet/lifestyle modifications as a result are compliant to date.

Previous randomised clinical trials of AAA screening in the UK, Denmark and Western Australia have had response rates ranging from 63% to 80%3. Our response is comparable to these RCTs.  The take-up rate by local men is probably a result of the extensive local involvement in the fund-raising and early planning stages. Word-of-mouth promotion and support by local news media also contributed.

Sufficient funds remain in the control of the Community-based organization to support repeat screening sessions every two years for a further 3 or 4 sessions. It is possible, however, that population-based AAA screening will eventually be introduced into Australia, as it has already been in the USA. The lessons of this activity should inform the discussions on this subject and guide implementation of screening programs.

The basis of the study, its implementation and the results of evaluation will be prepared for publication and dissemination through academic meetings. Ultimately, we expect to present the results to the Commonwealth Department of Health and Ageing’s Standing Committee on Health Screening for their consideration.  Given the prevalence of silent AAA in older males and the proven cost-effectiveness of screening, it remains only to demonstrate the essential components of a successful community-based screening program.

Patient Safety & Clinical Quality Manager, Clinical Governance Unit
Greater Western Area Health Service
Ph: 02 6393 3559