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Editor's Choice – Treatment Decisions for Descending Thoracic Aneurysm: Preferences for Thoracic Endovascular Aneurysm Repair or Surveillance in a Discrete Choice Experiment
- Source :
- European Journal of Vascular and Endovascular Surgery. (1):13-22
- Publisher :
- European Society for Vascular Surgery. Published by Elsevier Ltd.
-
Abstract
- Objective To investigate and rank factors that influence endovascular treatment decisions by specialists for patients with descending thoracic aortic aneurysm (dTAA). Methods Specialists completed a diagrammatic survey describing uncertainty about the benefit of thoracic endovascular aneurysm repair (TEVAR) for dTAA with respect to age, sex, and aneurysm diameter. Subsequently, a detailed discrete choice experiment was designed. Specialists were recruited and asked to indicate treatment their preference (TEVAR or surveillance) in 25 hypothetical cases of dTAA, with variable patient attributes: age, sex, American Society of Anesthesiologists (ASA) grade, aneurysm diameter, adequate landing zone distal to left subclavian artery (LSA), and length of aortic coverage. Data were analysed using multiple logistic regression. Results The diagrammatic survey, based on 50 respondents, showed that uncertainty about the benefits of TEVAR was greatest for patients aged 80–85 years (up to 47% of respondents were “unsure”) and that uncertainty increased with increasing aneurysm diameter (for an 80-year-old man, 7% were unsure at 5.5 cm and 33% were unsure at 7.0 cm). Seventy-one specialists (mainly from Europe and North America, 86% vascular surgeons and 98% working in units offering TEVAR) completed the discrete choice experiment. Preference for TEVAR increased greatly with enlarging diameter: adjusted odds ratios (OR) >5.5–6.0 cm = 15.8 (95% confidence interval [CI] 9.83–25.40); >6.0–6.5 cm = 393.0 (95% CI 202.00–766.00); >6.5–7.0 cm = 1829.0 (95% CI 400.00–4,181.00). TEVAR was less likely to be preferred in patients older than 75 years (>75–80 years OR 0.32, 95% CI 0.21–0.49; >80–85 years = 0.18, 95% CI 0.11–0.28); in women (OR 0.52, 95% CI 0.37–0.74); in patients classified as ASA grade 4 (OR 0.44, 95% CI 0.36–0.57); and in patients with aorta coverage >25 cm (OR 0.48, 95% CI 0.32–0.74). The proximal landing zone did not influence preference. Conclusion Specialists' preferences for endovascular repair of degenerative dTAA vary widely, and demonstrate clinical uncertainty, especially in octogenarians, and a reluctance to offer TEVAR to women. Aneurysm diameter dominates treatment preferences, but patient fitness and length of aortic coverage (>25 cm) also were influential, although the landing zone distal to LSA was not.
- Subjects :
- Male
medicine.medical_specialty
Time Factors
Multivariate analysis
medicine.medical_treatment
Logistic regression
Risk Assessment
Endovascular aneurysm repair
Thoracic aortic aneurysm
Blood Vessel Prosthesis Implantation
Sex Factors
Aneurysm
Risk Factors
Surveys and Questionnaires
Odds Ratio
medicine
Humans
Healthcare Disparities
Practice Patterns, Physicians'
Watchful Waiting
Aged
Aged, 80 and over
Medicine(all)
Aortic Aneurysm, Thoracic
business.industry
Patient Selection
Age Factors
Uncertainty
Odds ratio
Middle Aged
Professional preferences
medicine.disease
Confidence interval
Surgery
Logistic Models
Treatment Outcome
Discrete choice experiment
Endovascular procedures
Treatment variation
Health Care Surveys
Multivariate Analysis
Female
Cardiology and Cardiovascular Medicine
business
Watchful waiting
Subjects
Details
- Language :
- English
- ISSN :
- 10785884
- Issue :
- 1
- Database :
- OpenAIRE
- Journal :
- European Journal of Vascular and Endovascular Surgery
- Accession number :
- edsair.doi.dedup.....11354f3dd548072361b00c5aa92eb295
- Full Text :
- https://doi.org/10.1016/j.ejvs.2014.03.015