Abstract
To improve compliance with abdominal aortic aneurysm (AAA) screening in low compliance areas, individually tailored invitations were developed in collaboration with a professional advertising agency. Compliance increased in two intervention municipalities from 71.4% in 2010–2012 to 78.1% in 2013 (p = 0.025), and was then higher [odds ratio 1.7; 95% confidence interval 1.1–2.6; p = 0.013] than in two control municipalities in which compliance was unchanged (417/552 [75.5%] in 2010–12 and 122/180 [67.8%] in 2013). Compliance with AAA-screening can be increased by collaboration with a professional advertising agency, albeit at a comparably high cost.
Introduction
Ultrasound screening for abdominal aortic aneurysm (AAA, aortic diameter ≥30 mm) among 65-year old men reduces AAA-related mortality cost-effectively.1–6 All 65-year old men in the County of Skåne in Sweden are invited to AAA-screening, however, varying compliance rates decrease screening benefits. 7 We previously identified municipalities with low compliance and high prevalence of AAA as being characterized by low socioeconomic status (SES). 8 We here evaluate the utility of individually tailored screening invitations, developed in collaboration with a professional advertising agency, to improve compliance in such areas.
Methods
The four municipalities with the lowest screening compliance in 2010–11 were Landskrona (71.0%), Svalöv (71.8%), Hörby (77.3%), and Burlöv (78.2%). 8 We chose Landskrona and Hörby as intervention municipalities, and Svalöv and Burlöv as control areas.
In collaboration with an advertising agency (The Fan Club®, Malmö and Stockholm, Sweden), we developed a tailor made screening invitation that included information about AAA and the screening procedure, the date and time for the appointment, and an individual detailed map of the route from each subject’s home to our screening facilities. The invitation also included a red tie with a knot tied like an aneurysm with a tag saying “Congratulations, this year is your 65th birthday, and this is a gift from Skåne University Hospital”. The cost of the intervention was 15850 €. All invitations were in Swedish but contained a referral in English to a webpage for information in English, Spanish, Dari, Turkish, Persian, Somali, Arabic, Polish, Finnish, and Serbo-Croatian.
During 2013, all men born in 1948 from Landskrona (n = 190) and Hörby (n = 102) received the above invitation to AAA screening. Men born in 1948 from the control municipalities Burlöv (n = 101) and Svalöv (n = 79) received standard invitations from the public health system.
Chi Square test was used to evaluate differences between groups. Correlations between variables were tested with Spearman's rank correlation coefficient. SPSS® (SPSS inc, IBM, New York, USA) version 20 was used for statistical calculations. P-values <0.05 were considered significant.
The study was approved by the ethics committee of Lund University.
Results
Compliance with AAA screening before (2010–2012) and after intervention (2013) in control and intervention municipalities (n attending / n invited [%]).
Discussion
Because low compliance decreases the cost-effectiveness of screening programmes, different methods have been evaluated to address the problem, for example in breast and colorectal cancer screening9,10, and tailored invitations (though not designed or developed by professional advertising agents), telephone counselling, reminder letters, and combinations of these methods have been shown to significantly increase compliance.9,10 Ours is the first study documenting that tailored invitations developed in collaboration with a professional advertising agency were more efficient than standard invitations in increasing previously low AAA-screening compliance rates in areas with low SES.
The text of the tailored invitation was more explicit and comprehensive compared with the standard invitation, and the individualized travel-map for each subject might also have helped them to locate screening facilities up to 60 kilometers from their homes. The gift tie might have illustrated the mechanics of an AAA, and may also have persuaded men in the intervention group that the health care system had a genuine interest in their health.
The advertising agency cost was 15850 € (83 €/subject). If compliance in the intervention municipalities (71.4 % in 2010–2012) had been unchanged in 2013, 208 men would have been expected to attend screening – 20 fewer men than actually attended in 2013 (228/292). The intervention cost per additional subject attending screening in the intervention municipalities was thus 793 €. Assuming an AAA prevalence of 1.76 % (as previously demonstrated 8 ), the cost per additionally detected AAA was 45057 € (793 € / 0.0176). In our previous analysis, 8 prevalence in the municipalities we subsequently chose for intervention was higher than in the whole area: 2.6% corresponding to a hypothetical cost of 30500 € (793 € / 0.026) per AAA detected.
The mean total cost for AAA surgery in our institution is 33277 € (range 1243-329714 €) in elective cases, and 44593 € (range 1473-323661 €) in emergency ruptured cases. Elective repair of a screen-detected AAA instead of acute surgery of a ruptured one thus saves 11316 €. Converting 1.4 (15850 € / 11316 €) emergency surgeries to elective surgeries would therefore cover the total cost for our intervention.
Conclusions
Compliance with AAA-screening can be increased by invitations developed in collaboration with a professional advertising agency, albeit at a comparably high cost. Screening programmes should evaluate reasons for non-attendance and consider tailored measures to increase compliance and cost-benefits.
Footnotes
Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflict of interest
The authors have no conflicts of interest to declare.