Guideline scope Abdominal aortic aneurysm

15 Pages·2015·0.21 MB·English

by  Clifford Middleton

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NATIONAL INSTITUTE FOR HEALTH AND CARE
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EXCELLENCE
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Guideline scope
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Abdominal aortic aneurysm: diagnosis and
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management
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6 Topic
7 The Department of Health in England has asked NICE to develop a clinical
8 guideline on abdominal aortic aneurysm.
9 This guideline will also be used to develop the NICE quality standard for
10 abdominal aortic aneurysm.
11 Who the guideline is for
12  People using services, families and carers and the public.
13  Healthcare professionals in primary care.
14  Healthcare professionals in secondary care, including:
15  vascular specialists, including clinicians, surgeons, nurses and
16 technologists
17  anaesthetists
18  radiologists
19  care of the elderly clinicians
20  generalist clinicians and surgeons
21  emergency care physicians.
22  Commissioners and providers of services, including:
23  specialist vascular services
24  surgical services
25  anaesthesia services
26  radiology services
27  emergency departments
28  ambulance services.
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29 NICE guidelines cover health and care in England. Decisions on how they
30 apply in other UK countries are made by ministers in the Welsh Government,
31 Scottish Government, and Northern Ireland Executive.
32 Equality considerations
33 NICE has carried out an equality impact assessment [add hyperlink in final
34 version] during scoping. The assessment:
35  lists equality issues identified, and how they have been addressed
36  explains why any groups are excluded from the scope, if this was done.
1 What the guideline is about
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38 1.1 Who is the focus?
39 Groups that will be covered
40  People with an increased risk of an abdominal aortic aneurysm (abdominal
41 aortic aneurysm will be defined as infrarenal aortic aneurysms, juxtarenal
42 aortic aneurysms, suprarenal aortic aneurysms and type IV
43 thoracoabdominal aneurysms, as well as aortoiliac aneurysms).
44  People with a suspected or confirmed abdominal aortic aneurysm
45 (including ruptured and symptomatic unruptured).
46  Specific subgroups for whom the diagnosis and management of abdominal
47 aortic aneurysm may vary and for whom subgroup or separate analyses
48 will be considered. These may include, but are not limited to:
49  women
50  people with comorbidities when the comorbidity (or management of that
51 comorbidity) may affect the diagnosis or management of an abdominal
52 aortic aneurysm, including people with other cardiovascular conditions,
53 people with obesity, people who smoke and people nearing the end of
54 life.
55 Groups that will not be covered
56  People with type I, II, III or V thoracoabdominal aneurysms, thoracic aortic
57 aneurysms, or isolated iliac aneurysms.
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58 1.2 Settings
59 Settings that will be covered
60  All settings in which NHS-funded care is received.
61 1.3 Activities, services or aspects of care
62 Key areas that will be covered
63 1 Identifying people with abdominal aortic aneurysms:
64  signs, symptoms and risk factors that might initiate imaging for
65 abdominal aortic aneurysms
66  imaging of abdominal aortic aneurysms
67 2 Management of asymptomatic unruptured abdominal aortic aneurysms:
68  checking for aneurysm growth and risk of rupture, including how often
69 this happens and the type of imaging used
70  non-surgical interventions to reduce the rate of aneurysm growth and
71 reduce the risk of rupture, including drug therapy and risk factor
72 management
73  planning of surgery, taking into account aneurysm size, preoperative
74 risk assessment to determine whether surgery is suitable for a person,
75 preoperative imaging, interventions to reduce potential complications
76 and the type of surgery used
77 3 Management of symptomatic unruptured abdominal aortic aneurysms
78 and ruptured abdominal aortic aneurysms:
79  signs, symptoms and risk factors that could indicate a ruptured
80 abdominal aortic aneurysm
81  prehospital care, including permissive hypotension
82  care and investigations in the emergency department, including
83 imaging
84  referral and transfer to a specialist vascular unit
85  specialist care, including emergency surgical intervention and
86 perioperative management
87 4 Postoperative care:
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88  monitoring aneurysm growth or rupture in people who have had
89 surgery for an abdominal aortic aneurysm, including how often this
90 happens and the type of imaging used
91  checking for complications in people who have had surgery for an
92 abdominal aortic aneurysm, including how often this happens and the
93 type of imaging used
94  interventions to reduce the risk of postoperative complications in
95 people who have had surgery for an abdominal aortic aneurysm,
96 including antithrombotics
97  management of postoperative complications
98 5 Service organisation:
99  volume-outcome relationships in the provision of surgery
100 Note that guideline recommendations will normally fall within licensed
101 indications; exceptionally, and only if clearly supported by evidence, use
102 outside a licensed indication may be recommended. The guideline will
103 assume that prescribers will use a medicine’s summary of product
104 characteristics to inform decisions made with individual patients.
105 Areas that will not be covered
106 1 Prevention of abdominal aortic aneurysm:
107  management of risk factors for abdominal aortic aneurysm in those
108 without a suspected or confirmed abdominal aortic aneurysm
109 2 Identifying people with abdominal aortic aneurysm:
110  population screening for abdominal aortic aneurysm
111 1.4 Economic aspects
112 We will take economic aspects into account when making recommendations.
113 We will develop an economic plan that states for each review question (or key
114 area in the scope) whether economic considerations are relevant, and if so
115 whether this is an area that should be prioritised for economic modelling and
116 analysis. We will review the economic evidence and carry out economic
117 analyses. The reference case used will be that for interventions with health
118 outcomes in NHS settings; therefore the preferred unit of effectiveness will be
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119 the quality-adjusted life year (QALY), and costs will be considered from an
120 NHS and personal social services (PSS) perspective.
121 1.5 Key issues and questions
122 While writing this scope, we have identified the following key issues, and key
123 questions related to them:
124 1 Identifying people with abdominal aortic aneurysms:
125  Which signs, symptoms and risk factors (or combinations of these)
126 are most accurate in predicting the presence of an abdominal aortic
127 aneurysm?
128  What is the effectiveness of available risk assessment tools?
129  In addition to ultrasound, or in cases in which the aortic diameter
130 cannot be seen using ultrasound, which imaging techniques are the
131 most useful in confirming the presence of an abdominal aortic
132 aneurysm?
133 2 Management of unruptured abdominal aortic aneurysms:
134  What are the key comorbidities experienced by people with an
135 abdominal aortic aneurysm, and how will this affect the management
136 of their abdominal aortic aneurysm?
137  How often should people with an unruptured abdominal aortic
138 aneurysm be monitored?
139  Which imaging techniques are most useful when monitoring people
140 with an unruptured abdominal aortic aneurysm? In particular, which
141 are most useful in the assessment of the risk of rupture and the
142 suitability of the aneurysm for surgery?
143  What risk factors are associated with abdominal aortic aneurysm
144 growth and rupture?
145  Which non-surgical interventions (including drug therapy and risk
146 factor management) are effective in preventing growth and rupture in
147 people with unruptured abdominal aortic aneurysms?
148  What is the effectiveness of early surgical intervention compared with
149 a ‘watchful waiting’ approach in people with unruptured abdominal
150 aortic aneurysms?
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151  Which factors predict poor and good surgical outcomes in people with
152 unruptured abdominal aortic aneurysms?
153  What is the effectiveness of available risk assessment tools?
154  Which type of surgery is most effective in repairing unruptured
155 abdominal aortic aneurysms?
156  What additional interventions (including statin therapy or the use of
157 antithrombotic drugs) are effective in improving outcomes during
158 surgery for unruptured abdominal aortic aneurysms?
159 3 Management of ruptured abdominal aortic aneurysms:
160  Which signs, symptoms and risk factors (or combinations of these)
161 are most accurate in indicating the presence of a ruptured abdominal
162 aortic aneurysm?
163  What is the effectiveness of available risk assessment tools?
164  What interventions, such as permissive hypotension, can be used
165 before a person with a suspected ruptured abdominal aortic aneurysm
166 reaches the hospital to increase their chance of survival or improve
167 the stability of their condition?
168  What interventions can be used once a person with a suspected
169 ruptured abdominal aortic aneurysm reaches the emergency
170 department to increase their chance of survival or improve the stability
171 of their condition?
172  What investigations, including imaging, should the emergency
173 department use in a person with a suspected ruptured abdominal
174 aortic aneurysm?
175  Which factors predict poor and good outcomes in the transfer of
176 people with ruptured abdominal aortic aneurysms, and therefore
177 indicate which people are stable enough for transfer to a specialist
178 vascular unit?
179  What interventions, facilities or staffing improve outcomes in the
180 transfer of people with ruptured abdominal aortic aneurysms to a
181 specialist vascular unit?
182  Which type of surgery is most effective in repairing ruptured
183 abdominal aortic aneurysms?
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184  What perioperative care (including type of anaesthesia, or statin
185 therapy or the use of antithrombotic drugs) is effective in improving
186 outcomes during surgical repair of ruptured abdominal aortic
187 aneurysms?
188 4 Postoperative care:
189  How frequently should people be monitored for postoperative
190 complications, further aneurysm growth and aneurysm rupture after
191 surgical repair of an abdominal aortic aneurysm?
192  When checking people after they have had surgical repair of an
193 abdominal aortic aneurysm, which imaging techniques are most
194 useful for detecting postoperative complications, further aneurysm
195 growth and aneurysm rupture?
196  What interventions (including statins or antithrombotic drugs) are
197 effective in reducing the risk of complications after surgical repair of
198 an abdominal aortic aneurysm?
199  How should complications, including endoleak and stent kinking or
200 migration, be managed if they do arise?
201 5 Service organisation:
202  Do hospitals with a higher volume of surgeries per year have better
203 surgical outcomes?
204 1.6 Main outcomes
205 The main outcomes that will be considered when searching for and assessing
206 the evidence are:
207 1 Diagnostic accuracy (sensitivity, specificity, positive and negative
208 predictive values)
209 2 Mortality
210 3 Rate of aneurysm growth
211 4 Incidence of rupture
212 5 Incidence of adverse events or complications
213 6 Acceptability of approach to patients
214 7 Health-related quality of life
215 8 Resource use and cost
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2 Links with other NICE guidance and NICE
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Pathways
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218 2.1 NICE guidance
219 NICE guidance that will be updated by this guideline
220  Endovascular stent–grafts for the treatment of abdominal aortic aneurysms
221 (2009) NICE technology appraisal guidance 167
222 It is proposed that this guideline will update all recommendations from
223 TA167.
224 NICE guidance about the experience of people using NHS services
225 NICE has produced the following guidance on the experience of people using
226 the NHS. This guideline will not include additional recommendations on these
227 topics unless there are specific issues related to abdominal aortic aneurysm:
228  Patient experience in adult NHS services (2012) NICE guideline CG138
229  Medicines adherence (2009) NICE guideline CG76
230  Surgical site infection: prevention and treatment of surgical site infection
231 (2008) NICE guideline CG74
232 NICE guidance in development that is closely related to this guideline
233 NICE is currently developing the following guidance that is closely related to
234 this guideline:
235  Endovascular aneurysm sealing (EVAS) for abdominal aortic aneurysm.
236 NICE interventional procedure guidance. Publication date to be confirmed.
237 2.2 NICE Pathways
238 NICE Pathways bring together all related NICE guidance and associated
239 products on a topic in an interactive topic-based flow chart.
240 When this guideline is published, the recommendations will be added to a new
241 NICE pathway. Other relevant guidance will also be added to the pathway,
242 including:
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243  Endovascular stent–grafts for the treatment of abdominal aortic aneurysms
244 (2009) NICE technology appraisal guidance 167
245  Laparoscopic repair of abdominal aortic aneurysm (2007) NICE
246 interventional procedure guidance 229
247  Stent-graft placement in abdominal aortic aneurysm (2006) NICE
248 interventional procedure guidance 163
249 The new pathway will update and replace the existing section on abdominal
250 aortic aneurysms in the pathway on aortic aneurysms.
251 A draft pathway outline, based on the draft scope, is included below. It will be
252 adapted and more detail added as the recommendations are written during
253 guideline development.
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3 Context
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256 3.1 Key facts and figures
257 Aortic aneurysms develop when the wall of the aorta weakens, causing it to
258 bulge and form a balloon-like projection. When this weakening and expansion
259 of the aorta occurs in the abdomen and reaches a diameter at least 1.5 times
260 the normal diameter of the aorta, or greater than 3 cm diameter in total, the
261 condition is known as an abdominal aortic aneurysm.
262 Further stretching of the wall of the aorta and an increase in tension may
263 eventually lead the wall of the aneurysm to rupture. If people with a ruptured
264 aneurysm do not quickly get emergency surgical repair, the subsequent
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