Willingness of patients to attend abdominal aortic aneurysm surveillance: The implications of COVID-19 on restarting the National Abdominal Aortic Aneurysm Screening Programme

Editor

Clinical activity within the United Kingdom National Health Service (NHS) and other healthcare systems underwent a significant transformation to deal with the COVID-19 pandemic. Non-essential activity was postponed to reduce patient exposure to the hospital setting and to allow resources to be focused towards treating COVID-19 patients¹.

In the United Kingdom, men aged 65 are invited to take part in the National Abdominal Aortic Aneurysm Screening Programme. After scanning, those with aneurysms below the established threshold for immediate treatment enter an ultrasound community-based surveillance programme².

In March 2020 both screening and surveillance scans were suspended.

South London has 667 men under surveillance with small to medium sized aneurysms (3-5·4 cm). Some 271 men had surveillance scans postponed due to service suspension. The remaining 354 were seen prior to shut down or were scheduled for scanning later in the year.

In May 2020, to gauge patient willingness to attend surveillance scanning with a view to restarting both surveillance and screening scans we surveyed 200 men who had scans postponed (Table 1). A stratified COVID risk score was calculated from known co-morbidities using a local toolkit.

Table 1.

Telephone survey responses by COVID-19 stratified risk score

		COVID-19 Risk Score*
		Low Risk n = 30	High Risk n = 148	Very High Risk n = 22	Overall n = 200
If you were invited for your AAA screening in July 2020, how likely are you to attend?	Will not attend	0	5	1	6
	Unlikely to attend	3	16	1	20
	Don't know	4	22	4	30
	Likely to attend	3	19	4	26
	Will attend	20	86	12	118
What concerns you most regarding your health at the moment?	Your Aneurysm	10	35	6	51
	Catching COVID-19	8	66	11	85
	Other Health Condition	3	20	3	26
	No Concerns	9	27	2	38
Have you received a letter from your GP advising you to ‘shield’ due to you being high risk to COVID-19?	Yes	4	28	9	41
	No	25	120	13	158
What concerns you about your AAA screening appointment?	Having to leave my home	1	14	4	19
	Public transport to venue	9	49	5	63
	Waiting in an open waiting area	8	33	4	45
	Being seen straight after another patient	1	2	0	3
	Other	1	4	2	7
	No Concern	10	46	7	63
If all the screening venues are not open, how far would you be willing to travel to be screened?	1-3 Miles	17	84	11	112
	4-7 Miles	5	10	6	21
	7-10 Miles	2	14	0	16
	No Limit	6	30	2	38
	Not prepared to leave home	0	10	3	13

^* COVID-19 Stratified Risk Score; low risk = 0–3·9, high risk = 4–6·9, very high risk = > 7

Only 59% of the men stated they would definitely attend their surveillance scan appointment. Pre-COVID-19 pandemic (April 2018 to March 2019) there was a greater than 90% attendance rate for both annual and quarterly surveillance scans³. The potential drop in attendance demonstrated represents a problem for the resumption of services. Reduced surveillance attendance may be mirrored by lowered uptake for initial screening appointments. The possible fall in surveillance attendance is even more worrying given that these men know they have an aneurysm, indeed 42·5% (n = 85) of those surveyed were more concerned about catching COVID-19 than their aneurysm. Lower screening attendance could mean the incidence of aneurysm-related deaths increases and presentation of ruptured aortic aneurysms rises.

The men contacted were not aware of their stratified COVID-19 risk score unless they had received shielding advice from their doctor and may have responded differently to the questions if they were aware they were in a high or very high risk group. This information may further reduce the uptake leading to a high number of patients not attending planned appointments.

There was concern associated with contracting COVID-19 as a result of attending the appointment. This tallied with the fall in presentations to emergency departments across the country⁴. Despite assurance that the NHS remained open for business, patients had not been attending due to the perceived risk of COVID-19. Creating a clinical environment where patients feel safe to visit poses its own challenges. It had been suggested that NHS staff be tested regularly for COVID-19, up to twice a week, in order to reassure patients that they are not unknowingly carriers⁵. Distancing measures are in place across clinical waiting areas and regulations on the compulsory wearing of facemasks have been implemented.

Many do not own a private vehicle leading to a further potential reduction in uptake when 31·7% of men were concerned about having to utilize public transport to attend their appointment. Conversely men, who can, may wish to utilize their own private transport which could impact upon facilities with inadequate parking availability. Should all scanning centres not able to open as before, men may find that they need to travel further afield for surveillance and given that 56% of men felt they would only be prepared to travel 1 to 3 miles for an appointment this may further increase the level of non-attendance.

Overall, the responses generated from this survey do raise questions with respect to restarting aneurysm surveillance and screening services and may have wider implications for the delivery of other national screening programmes.