Matthew Mell, MD, has spent a lot of time looking into issues around screening for abdominal aortic aneurysms (AAAs). The problem, says the chief of vascular surgery at University of California Davis in Sacramento, California, is a difficult one to shake: “In the U.S., we under-screen.”
Mell looks at some of the studies that have come out of the Kaiser Permanente healthcare system in Southern California—a fully integrated health maintenance organization (HMO), or closed system—as instructive. There, physicians were able to use an electronic health record (EMR) to help increase AAA screening rates to “a very high” 50–80%.
But in non-HMO, or open, systems like his own institution, no one had attempted to find out if such an approach might help boost screening rates, he tells Vascular Specialist.
Mell and colleagues recently sought to fill that void in the literature against a backdrop of more than 70% of Medicare beneficiaries not being enrolled in a fully integrated HMO and AAA screening poorly utilized by Medicare at-risk populations.
Mell et al established that primary care providers (PCPs) are “key to optimizing AAA screening rates” and that “out-of-network patients are particularly vulnerable due to a lack of a PCP.” To improve screening rates, at-risk patients need a PCP, and PCPs need both knowledge of U.S. Preventive Services Taskforce (USPSTF) recommendations and active partnership with vascular surgeons to increase patient buy-in, the research team suggested.
“We looked at both in-network and out-of-network patients—in other words, patients who had their primary care provider within our system and without, or who got their care within our system or their care outside, and what we found was that patients who got the care in our system were much more likely to have a PCP,” Mell explains. “We found that patients who had a PCP were far more likely to accept screening when we offered it to them. I will say, though, that the screening rate was still low. Our patients who have PCPs, I think, had around a 35 or 36% acceptance rate, which was low compared with closed healthcare systems.”
The UC Davis findings—presented earlier this year during the 2022 Vascular and Endovascular Surgery Society (VESS) winter annual meeting in Snowmass, Colorado, by medical student Angela Aguirre, BS—showed that of 1,073 eligible patients, review of medical records and calls confirmed previous imaging in 46%. Among the remaining 578, in-network patients (n=117, or 20%) were more likely to have a PCP (95% vs. 53%, p<.001). Successful contact was more likely for patients with a PCP (odds ratio, 2.36; 95% confidence interval 1.62– 3.45; p<.001). Of those offered screening, 31.9% accepted. The most common reason for declining was deference to a PCP (58%). On multivariate analysis, having a PCP remained the strongest predictor of screening.
“We concluded with this study that engaging the PCP, both at the individual level and, perhaps, at a system level, is going to be really, critically important to improving screening rates for patients who are at risk and eligible,” Mell says.
Locally, Mell and colleagues have set up educational meetings between their group and primary care to elucidate who is eligible for screening, how to receive it and clear up misconceptions among patients over who pays for screening. “In Europe and in other systems, healthcare systems that are nationalized, patients are used to getting a piece of mail from the healthcare system saying, ‘You’re eligible for this screening test,’ and they go and do it. We have don’t have that, and I think it is clear that a much more personalized approach is really the only way to be effective.”