Risk attitude and patients’ experience with treatment of abdominal aortic aneurysm and severe claudication

Abstract

The overall aim of this thesis was to investigate the effect of information on well-being after open surgical repair (OR) of abdominal aortic aneurysm (AAA) and to explore the experience of the care pathway of OR from the patients perspective as well as to describe risk attitude and preference for treatment of AAA and severe intermittent claudication (IC). The effect of information was assessed during the first week after returning to the surgical ward using a study-specific questionnaire in patients with AAA randomized to receive either additional written information (EG) or best practice (CG). The experience of the care pathway was investigated in patients with AAA three months after going through OR using in-depth interview. Risk attitude and preference for treatment was evaluated in a general population sample stratified in four age groups facing a hypothetical scenario of going through OR, in patients scheduled for AAA treatment as well as in patients with severe IC before and six months after treatment using time trade off (TTO), standard gamble (SG) questions and a derived TTO value. Health related quality of life as well as cost-effectiveness was also evaluated in patients with severe IC.

Preoperative written information did not have beneficial effects on postoperative recovery in patients with AAA. The EG reported a significantly worse psychological well-being during the first three days after returning from ICU. Otherwise there were no significant differences between the EG and CG in physical or psychological well being. The experience of the care pathway of OR describe patients awareness of having a deadly disease, feeling no option to decline surgery and the physical and emotional impact of OR which is difficult to cope with. During the care pathway there was a need for information and dialogue not fully met by the health care staff. Not understanding the risk and implications with surgery resulted in being unprepared for the long recovery period. A hypothetical situation of having AAA and facing OR was tested in otherwise healthy persons showing that the oldest age group was not prepared to take a deadly risk with treatment or trade off years to live their remaining life without the risk of rupture, to the same extent as reported by the three younger age groups. A decreased HRQL and functional ability in patients with severe IC influences risk attitude and preference for treatment, showing that the patients were prepared to accept a considerable treatment risk and shorten their remaining life to be free from their symptoms. Clinical parameters, HRQL and walking ability improved considerably after revascularization. Revascularization could also be considered cost-effective.

In conclusion, patients with AAA seem to need better structured information and a possibility for a dialogue with the health care staff during the care pathway. The physical and emotional impact of OR has to be assessed to meet patients need. Preference for treatment should be considered individually, with special attention to the reluctance of taking a risk with OR seen in the very elderly and to patients with severe IC willing to take considerable risks with treatment.