For years, the most common phrase in healthcare has been “evidence-based medicine.” The phrase always had a funny sound to it, because it implied that most medicine was based on no evidence at all. Truth is, medicine has been and always will be “an art and a science.” The problem was never the lack of evidence, but the lack of rigorous evidence that could truly prove one treatment was better than another. Even today, most studies that “compare” one treatment to another are poorly done and infected by bias.
Given that background, a new article in the New England Journal of Medicine, “Thresholds for Abdominal Aortic Aneurysm Repair in England and the United States,” was a sight for sore eyes. Researchers at St. George’s University in London and Harvard Medical School noticed that physicians in England waited longer to repair aortic aneurysms than physicians in the United States, so the researchers compared the outcomes in the two countries. It sounds so simple and obvious, but these kinds of reviews are woefully rare.
Various associations for vascular surgery have published guidelines on aortic aneurysm repair. In general, an abdominal aortic aneurysm should be repaired once their diameter exceeds 55 mm (in men) or 50 mm (in women). Despite the guidelines, there are huge differences in practice. As the researchers found, in the United States aortic aneurysms were repaired at an average diameter of 58.6 mm, and in England aortic aneurysms were repaired at an average diameter of 64.1 mm.
The consequences of this difference are exactly what you would expect: in England, hospitalizations due to aneurysm rupture are more than twice as common than they are in the United States, and deaths are more than three times as common.
Certainly, England has a much more severe problem on its hands, but we shouldn’t let that distract us from the fact that America’s doctors also aren’t following the guidelines. The researchers found both countries were waiting too long to operate on abdominal aortic aneurysms. Disturbingly, it seems doctors were even less diligent about female patients:
In the United States:
- Men had an operation at an average aneurysm diameter of 58.6 mm, or 3.5 mm beyond the guidelines
- Women had an operation at an average aneurysm diameter of 56.3 mm, or 6.3 mm beyond the guidelines
- Men had an operation at an average aneurysm diameter of 64.1 mm, or 9.1 mm beyond the guidelines
- Women had an operation at an average aneurysm diameter of 61.7 mm, or 11.7 mm beyond the guidelines
Hopefully this research will serve as a wake-up call to cardiologists and vascular surgeons on both sides of the Atlantic.