Department of Veterans Affairs 

Office of Inspector General 

Healthcare Inspection 

Abdominal Aortic Aneurysm 

Management in VA Medical Facilities 

Report No. 07-00348-49 December 29, 2008

VA Office of Inspector General 

Washington, DC 20420 
To Report Suspected Wrongdoing in VA Programs and Operations 

Call the OIG Hotline – (800) 488-8244 
Abdominal Aortic Aneurysm Management in VA Medical Facilities 

Executive Summary 

The VA Office of Inspector General, Office of Healthcare Inspections completed an 

evaluation to determine whether VHA medical facilities had implemented abdominal 

aortic aneurysm (AAA) screening policies and protocols and whether clinicians were 

managing diagnosed AAAs in accordance with the United States Preventative Service 

Task Force (USPSTF) recommended guidelines. We conducted this evaluation in 

conjunction with 33 Combined Assessment Program (CAP) reviews of VHA medical 

facilities completed from January 1–September 30, 2007. 

The aorta carries oxygen-rich blood from the heart to the organs and other body parts. 

When the aorta becomes weak and bulges, an aneurysm is formed. Aneurysms are a 

health risk because they can rupture and cause fatal internal bleeding. It is estimated that 

more than 200,000 people are diagnosed with AAAs annually, and 15,000 die of ruptured 

AAAs each year in the United States alone. To decrease mortality, the USPSTF 

recommended AAA screening for men aged 65–75 who had ever smoked. 

Despite concerns expressed by VHA and facility-level managers that there may be 

insufficient resources (radiology and surgery) to meet the potential demand for AAA 

screening, we found that some of the 33 facilities had implemented protocols and 

initiated actions to secure additional equipment, staff, and contractual resources needed to 

screen patients for AAAs. We noted that two facilities were conducting concurrent and 

retrospective reviews of abdominal imaging studies that were completed for other 

reasons. In those cases where studies included the aorta, radiologists could comment on 

the presence or absence of an aneurysm. This finding suggests that if providers consider 

the need for AAA screening when ordering abdominal imaging studies for other reasons, 

and expand the scope of those studies to ensure inclusion of the aorta, the need for 

additional imaging resources could be mitigated. 

We also reviewed the medical records of 250 patients diagnosed with AAA made since 

February 1, 2003, and found that patients were consistently managed appropriately. 

We recommended that the Under Secretary for Health: 

• Advise clinicians to consider patients’ risk factors for AAA when ordering abdominal 

imaging studies, and when appropriate expand the scope of studies to include the 

aorta. 

• Develop a plan, within the context of available resources, to implement AAA 

screening for male smokers 65–75 years old. 

The Under Secretary for Health concurred with our findings and submitted acceptable 

action plans. 

VA Office of Inspector General i 
Abdominal Aortic Aneurysm Management in VA Medical Facilities 

VA Office of Inspector General 1 

Introduction 

Purpose 

The VA Office of Inspector General (OIG), Office of Healthcare Inspections completed 

an evaluation to determine whether Veterans Health Administration (VHA) medical 

facilities had implemented abdominal aortic aneurysm (AAA)1

 screening policies and 

protocols and whether clinicians were managing diagnosed AAAs in accordance with the 

United States Preventative Service Task Force (USPSTF) recommended guidelines as 

adopted by VHA’s Technology Assessment Program (VA TAP) within the Office of 

Patient Care Services (PCS). 

Background 

The aorta is the largest artery in the body; it carries oxygen-rich blood from the heart to 

the organs and other body parts. When the aorta becomes weak and expands or bulges, a 

AAA is formed. Aneurysms are a health risk because they can rupture and cause fatal 

internal bleeding. It is estimated that more than 200,000 people are diagnosed with 

AAAs annually, and 15,000 die of ruptured AAAs each year in the United States alone.2

 

Because most people do not experience any symptoms, AAAs are usually discovered 

through physical examination or by ultrasound,3

 computed tomography (CT), or 

magnetic resonance imaging (MRI). In general, AAAs that are 5.5 centimeters (cm) in 

diameter or greater are considered for surgical repair. AAAs less than 5.5 cm are 

assessed for changes through periodic imaging studies. 

USPSTF. The USPSTF conducts rigorous, impartial assessments of the scientific 

evidence for the effectiveness of a broad range of clinical preventive services, including 

screening, counseling, and preventive medications.4

 The mission of the USPSTF is to 

evaluate the benefits of individual services, make recommendations about which 

preventive services should be incorporated routinely into primary medical care and for 

which populations, and identify a research agenda for clinical preventive care. 

The USPSTF reviewed four randomized controlled trials (RCTs) of screening for AAA. 

In one study conducted in the United States, 100,000 men aged 65–75 who ever smoked 

were screened with ultrasound, and men with AAAs greater than 5.5 cm were referred for 

possible surgical repair. That study showed a 42 percent reduction in AAA-related 

 

1

 An aneurysm is a localized widening (dilatation) of an artery, vein, or the heart. At the area of an aneurysm, there 

is typically a bulge and the wall is weakened and may rupture. The acronym for an abdominal aortic aneurysm is 

AAA and is commonly called “a triple A” in health care settings. 

2 A Silent Killer: Abdominal Aortic Aneurysm. October 15, 2004. Robert Wood Johnson University Hospital 

http//www.rwjuh.edu/news/silentkiller.html. 

3

 Diagnostic imaging technique used to visualize muscles and internal organs, their size, structures, and possible 

pathologies. 

4 About USPSTF. U.S. Preventive Services Task Force. November 2007. Agency for Healthcare Research and 

Quality, Rockville, MD. http://www.ahrq.gov/clinic/uspstfab.htm. 
Abdominal Aortic Aneurysm Management in VA Medical Facilities 

VA Office of Inspector General 2 

mortality. Because of the low prevalence of large AAAs in women and male nonsmokers, the number of AAA-related deaths that can be prevented by screening this 

population is small. 

USPSTF found “good evidence” that screening for AAA and surgical repair of large 

AAAs in men aged 65–75 who have ever smoked (referred to as “male smokers” in this 

report) results in decreased AAA mortality.5

 In February 2005, the USPSTF 

recommended that male smokers receive a one-time screening by ultrasound for AAA. 

VA TAP. This group is part of VHA’s Patient Care Services and is comprised of 

internationally recognized experts in health care information management and in health 

care technology assessment. VA TAP’s role is to carry out systematic reviews of the 

medical literature to identify best practices in health care, to improve health care through 

evidence-based decision making, and to provide impartial, peer-reviewed, evidencebased reports to support better resource management in VHA.6

VA TAP agrees that AAAs, with their high propensity to rupture and associated 

mortality, are a significant health problem in the United States. In September 2005, the 

VA TAP adopted the USPSTF recommendation for AAA screening in male smokers. 

VHA Information Letter IL 10-2007-011. On August 27, 2007, the Under Secretary for 

Health distributed Information Letter IL 10-2007-011, Abdominal Aortic Aneurysm 

Screening. The purpose of the letter was to inform VA facilities of VA National Center 

for Health Promotion and Disease Prevention recommendations for AAA screening, but 

did not mandate screening as a policy. Currently, VHA has no directive requiring AAA 

screening. 

Other Insurers and Organizations Adopting AAA Screening. During the course of this 

review, several insurers, including Aetna, Blue Cross and Blue Shield of North Carolina, 

and the Centers for Medicare and Medicaid Services, adopted the USPSTF 

recommendation for one-time screening by ultrasound for male smokers. In addition, 

VHA’s Office of Quality and Performance adopted the USPSTF recommendation for 

AAA screening as one of its clinical practice guidelines. 

Scope and Methodology 

We conducted this evaluation in conjunction with Combined Assessment Program (CAP) 

reviews of VHA medical facilities completed from January 1–September 30, 2007. The 

33 facilities that we visited represented a mix of facility size, affiliation, geographic 

 

5

 Recommendation Statement; Screening for Abdominal Aortic Aneurysm, February 2005, Agency for Healthcare 

Research and Quality of the U.S. Department of Health and Human Services. 

http://www.ahrq.gov/clinic/uspstf05/aaascr/aaars.htm. 6

 United States Department of Veterans Affairs, VHA Technology Assessment Program (VA TAP), Program 

Information, May 2007. http://www.va.gov/vatap/program.htm. 
Abdominal Aortic Aneurysm Management in VA Medical Facilities 

VA Office of Inspector General 3 

location, and Veterans Integrated Service Networks (VISNs). In addition to evaluating 

whether facilities had implemented AAA policies and protocols, we interviewed facility 

leaders to determine their perceptions about barriers that would hinder implementation of 

AAA screening. 

We also evaluated whether clinicians appropriately managed AAAs after diagnosis. We 

selected a sample population of men who:

• Had at least one outpatient visit in fiscal year (FY) 2006. 

• Were identified as smokers on medical record problem lists. 

• Were 65–75 years old as of February 1, 2005 (when the USPSTF 

recommendation was published). 

• Had a AAA diagnosis (ICD-9 code 441.4) after February 1, 2003.7

While we informed facility managers of our AAA findings during CAPs, we did not 

include these findings in our CAP reports. The current report includes analysis of data 

collected from all of the CAPs and provides VHA with a broader perspective on facilitylevel AAA activities. 

We conducted the inspection in accordance with Quality Standards for Inspections 

published by the President’s Council on Integrity and Efficiency. 

Inspection Results 

This review focused on the implementation of AAA policies and protocols and the 

management of AAA after diagnosis. 

Facility-Level Screening Activities

VHA officials expressed concern that should AAA screening become mandatory, some 

VA medical facilities may lack the resources (equipment and personnel) to adequately 

respond to the increased demand for imaging studies. In fact, senior managers at 19 of 33 

facilities (57 percent) told us that they had concerns regarding implementing AAA 

screening due to staffing, budgetary, equipment, and/or space constraints. 

Despite these concerns, we found that 15 of 33 facilities reviewed (45 percent) had taken 

one or more of the following actions and 4 other facilities were planning similar actions: 

(a) Implemented clinical reminders8

 for AAA screening. 

 

7

 We selected this date to allow enough time to elapse so that appropriate follow-up treatment and surveillance 

actions could occur. 

8

 Clinical reminders are electronic alerts that remind providers to perform specified healthcare maintenance 

activities, such as annual screenings or follow-up tests. 
Abdominal Aortic Aneurysm Management in VA Medical Facilities 

(b) Implemented screening policies and protocols for AAA. 

(c) Contracted for community radiology services and included AAA screening in the 

contract for services. 

(d) Purchased additional imaging equipment. 

(e) Increased staffing to meet demand. 

(f) Increased training funds to support ultrasound technicians’ certifications. 

(g) Completed concurrent and/or retrospective reviews of ultrasounds or other 

imaging studies that had been completed for another reason. If the images 

included the aorta, then clinicians could retrospectively evaluate for AAA. 

We found item (g) above to be a compelling activity that could increase VHA’s ability to 

screen for AAA while minimizing the need for additional resources. Even though 

imaging studies may not have been completed for the purpose of AAA screening, patients 

nonetheless received a study that could have been used for AAA screening. This finding 

suggests that providers should consider the need for AAA screening when ordering 

abdominal imaging studies for other reasons, and expand the scope of those studies to 

ensure adequate imaging of the aorta. 

AAA Diagnosis and Follow-Up

To determine whether patients with diagnosed AAA received appropriate follow-up care 

according to USPSTF guidelines, we reviewed the medical records of 250 patients with a 

diagnosis of AAA made since February 1, 2003. 

Patients with AAA Excluded From Follow-Up Review

Reasons for Exclusion Patients 

Excluded 

Patients 

Remaining 

250 

AAA size unknown or not documented (follow-up requirements unknown) 19 231 

Patient received care in the private sector (VA follow-up not required) 48 183 

AAA <3cm (follow-up not required) 20 163 

Patient not a surgical candidate (follow-up not required) 7 156 

Patient already had AAA repair (follow-up not required) 30 126 

Too soon for follow-up (semi-annual or annual US not due yet) 16 110 

Patient refused follow-up 1 109 

After excluding patients for whom screening was not possible or necessary (see Table), 

we found 109 patients who should have received follow-up care for AAA. Ninety-one of 

94 patients with 3–4.5 cm aneurysms (97 percent) received appropriate annual or semiVA Office of Inspector General 4 
Abdominal Aortic Aneurysm Management in VA Medical Facilities 

VA Office of Inspector General 5 

annual imaging follow-up. Each of the 15 patients diagnosed with aneurysms larger than 

4.5 cm were appropriately referred to vascular surgery specialists for evaluation. 

Conclusions 

Despite concerns expressed by VHA and facility-level managers that there may be 

insufficient resources to meet the potential demand for AAA screening, we found that 

some facilities have implemented protocols and initiated actions to secure additional 

equipment, staff, and contractual resources needed to screen patients for AAAs. We 

noted that two facilities were conducting concurrent and retrospective reviews of 

abdominal imaging studies that were completed for other reasons; in cases where studies 

included the aorta, radiologists could comment on the presence or absence of an 

aneurysm. This finding suggests that if providers consider the need for AAA screening 

when ordering abdominal imaging studies for other reasons and expand the scope of 

those studies to ensure inclusion of the aorta, the need for additional imaging resources 

could be mitigated. 

Patients diagnosed with AAA were consistently managed appropriately. 

Recommendations 

Recommendation 1. We recommended that the Under Secretary for Health advise 

clinicians to consider patients’ risk factors for AAA when ordering abdominal imaging 

studies, and when appropriate expand the scope of studies to include the aorta. 

Recommendation 2. We recommended that the Under Secretary for Health develop a 

plan, within the context of available resources, to implement AAA screening for male 

smokers 65–75 years old. 

Comments 

The Under Secretary for Health concurred with the findings and recommendations in this 

report and submitted acceptable improvement plans to implement the recommendations. 

(See Appendix A, pages 7–10, for full text of these comments. We will follow up on all 

corrective actions until the plan has been fully implemented. 

 (original signed by:)

JOHN D. DAIGH, JR., M.D. 

Assistant Inspector General for 

Healthcare Inspections 
Abdominal Aortic Aneurysm Management in VA Medical Facilities 

Appendix A 

Under Secretary for Health Comments 

VA Office of Inspector General 6 

Department of 

Veterans Affairs Memorandum

Date: December 10, 2008 

From: Under Secretary for Health (10) 

Subject: OIG Draft Report: Abdominal Aortic Aneurysm 

Screening and Management in VA Medical Centers 

(Project Number 2007-00348-HI-0207) 

To: Assistant Inspector General for Health Care (54) 

1. I have reviewed the draft report and concur with the report findings 

and recommendations. The Veterans Health Administration (VHA) 

has recognized the importance of screening our veteran population at 

risk for Abdominal Aortic Aneurysm (AAA). On August 27, 2007, I 

issued VHA Information Letter IL 10-2007-011 to reinforce the need 

to screen all eligible veterans at risk for AAA, and to offer an example 

of a clinical reminder screen for adoption by local facilities for 

improved screening and compliance. 

2. In addition, the Offices of the Deputy Under Secretary for Health 

for Operations and Management and Patient Care Services have been 

working diligently to implement the guidelines set forth by the United 

States Preventive Services Task Force for a one time screening by 

ultrasound (or other acceptable abdominal imaging study) for male 

smokers between the ages of 65-75. As early as January 2007, the 

Chief Consultant for Diagnostic Services began the education process 

by briefing Veterans Integrated Service Network Chief Medical 

Officers on those recommendations, and by outlining strategies to 

implement the guidelines and minimize the backlog. 

3. We believe that this combination of efforts has been a significant 

factor in continued improvement in VHA’s overall screening 

percentages among eligible veterans, but we recognize that more work 
VA Office of Inspector General 7 

will need to be done to ensure that every veteran who needs screening 

for AAA receives it. The attached action plan outlines 

implementation of the report recommendations towards that effort. 

 (original signed by:) 

Michael J. Kussman, MD, MS, MACP 
Abdominal Aortic Aneurysm Screening and Management in VA Medical Facilities 

 

OIG Draft Report, Healthcare Inspection - Abdominal Aortic Aneurysm 

Management in VA Medical Facilities 

Project No.: 2007-00348-HI-0207 

Date of Report: November 10, 2008 

________________________________________________________ 

Recommendations/ Status Completion 

Actions Date______

Recommendation 1. We recommended that the Under Secretary for 

Health advise clinicians to consider patients’ risk factors for AAA when 

ordering abdominal imaging studies, and when appropriate, expand the 

scope of studies to include the aorta.

Concur 

The Under Secretary for Health (USH) fully supports the screening of 

veterans for Abdominal Aortic Aneurysm (AAA) by ultrasound (US) who 

meet the established risk factors, and will continue ongoing efforts to educate 

Veterans Health Administration (VHA) clinicians through clinical calls and 

staff meetings concerning those risks, and re-educate them on VHA 

Information Letter IL 10-2007-011 on Abdominal Aortic Aneurysm (AAA) 

Screening. Additionally, the National Center for Health Promotion and 

Disease Prevention (NCP) expects to release a patient brochure and provider 

fact sheet about screening for AAA (already developed, pilot tested, and 

under final revisions), and will develop a clinical preventive guidance 

statement about screening for AAA. 

Patient Care Services (PCS) and the Chief Consultant for Primary Care (PC) 

will convene a task group by January 31, 2009, that will be asked to develop 

a national clinical reminder for AAA screening for use by every VHA 

facility. The Chief Consultant for Diagnostic Services (DS) and PC will 

continue to participate in Chief Medical Officer (CMO) and Veterans 

Integrated Service Network (VISN) calls outlining AAA screening guidelines 

and best practices for working through backlogs of veterans, and to ensure 

that when ordering diagnostic imaging of the abdomen for any reason, that 

providers consider the risk factors of those patients and request a review of 

the aorta as part of the study if one is warranted. Additionally, the National 

Director for Radiology Services will work to educate facility radiologists that 

when any such studies are ordered, that they remember to consider the risk 

factors of the patients undergoing diagnostic testing, and to include a review 

VA Office of Inspector General 8 
VA Office of Inspector General 9 

of the aorta, and to document a note into the patient’s medical record 

indicating that the review was done, regardless of the original purpose of the 

study. 

 In process March 31, 2009 

 Recommendation 2. We recommended that the Under Secretary for 

Health develop a plan, within the context of available resources, to 

implement AAA screening for male smokers 65 – 75 years old. 

Concur 

The Deputy Under Secretary for Health for Operations and Management 

(DUSHOM), in collaboration with PCS, will issue a memorandum to the 

field, directing facilities to develop their own individual plans to reduce 

clinical backlog of unscreened patients based on their assessed workload and 

available resources, as each facility faces unique challenges, such as 

equipment and or space constraints, and in their ability to hire ultrasound 

technicians or contract for community radiology services based on local 

market conditions. 

In process March 31, 2009 
Abdominal Aortic Aneurysm Management in VA Medical Facilities 

Appendix B 

OIG Contact and Staff Acknowledgments 

OIG Contact Victoria Coates, Acting Director 

St. Petersburg Regional Office of Healthcare Inspections 

(404) 929-5962 

Acknowledgments Annette Robinson, Project Manager 

Marilyn Barak 

Andrea Buck, M.D., J.D. 

Marisa Casado 

Bertha Clarke 

Limin X. Clegg, Ph.D. 

Sheila Cooley 

Charles Cook 

Dorothy Duncan 

David Griffith 

Jerome Herbers, M.D. 

Deborah Howard 

Jennifer Kubiak 

Michelle Porter 

Reba Ransom 

Jennifer Reed 

Wilma Reyes 

Sunil Sen-Gupta 

James Seitz 

Carol Torczon 

Susan Zarter 

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Abdominal Aortic Aneurysm Management in VA Medical Facilities

Appendix C 

Report Distribution 

VA Distribution

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

Office of General Counsel 

Veterans Integrated Service Network Directors (1-23) 

Non-VA Distribution

House Committee on Veterans’ Affairs 

House Appropriations Subcommittee on Military Constructions, Veterans Affairs, and 

Related Agencies 

House Committee on Oversight and Government Reform 

Senate Committee on Veterans’ Affairs 

Senate Appropriations Subcommittee on Military Constructions, Veterans Affairs, and 

Related Agencies 

Senate Committee on Homeland Security and Governmental Affairs 

National Veterans Service Organizations 

Government Accountability Office 

Office of Management and Budget 

This report is available at http://ww.va.gov/oig/publications/reports-list.asp 

VA Office of Inspector General 11