Visit length and abdominal aortic aneurysm screening J. Eaton et al. Introduction An abdominal aortic aneurysm (AAA) is a dilation of the aorta below the renal arteries greater than 3.0 cm. AAAs occur in up to 10% of men and 1% of women aged 65 to 79 years [1,2]. In addition to male gender, other risk factors for AAA are older age, current or past tobacco use and a family history of AAA [3]. Mortality after aneurysm rupture is 80% for patients who reach the hospital and 50% for those who undergo emergency surgical repair [4]. About 2% of aneurysms less than 4 cm rupture within 5 years, while 25% of aneurysms greater than 5 cm rupture in this period [3]. Prior to the adoption of screening practices, 9000 AAA deaths occurred in the USA annually, most of them in men older than 65 years [4]. In a meta-analysis of four population-based studies, screening in men 65 years or older was shown to signiﬁcantly reduce AAA mortality [4]. This mortality beneﬁt extends beyond the initial period of the screening. Seven years after screening, the reduction in AAA mortality and all-cause mortality was sustained. In addi- tion, the cost-effectiveness based on the 7-year follow up was estimated at $19 500 per life-year gained [5]. If an AAA is absent on screening ultrasound, only 1% of 65-year-old men experience one in the next 5 years [6]. Responding to this evidence, the US Preventive Services Task Force (USPSTF) issued recommendations in 2005 for one-time AAA screening using abdominal ultrasonography in men aged 65 to 75 years who had a history of smoking [7]. Despite these recommendations, many patients do not receive appropriate screening for this condition [8]. Our goal was to examine AAA screening ordering practices in an academic primary care internal medicine clinic that uses physician reminders based on real-time clinical decision support for preventive screening and to identify why screening ordering rates vary among providers. We also explored providers’ knowledge of AAA screening guidelines and their perceptions of current screening practices in their clinic. Finally, we looked for opportunities to improve AAA screening compliance. Methods Study design and participants We retrospectively reviewed the records of all men aged 65 to 75 years with outpatient visits in the primary care practice of Mayo Clinic Rochester from 1 January to 30 April 2008, who met the USPSTF guidelines for AAA screening [7] and were current or former smokers. Men with a prior diagnosis of AAA and those who had already had an abdominal ultrasound or computed tomography scan for a reason other than AAA screening within the past 5 years were excluded. We abstracted these variables for the ﬁrst visit during the study interval: appointment date, appointment type (general medical examination vs. other visit type), provider role (staff physician vs. other provider), provider gender and whether AAA screening ultrasound was ordered during the visit. General medical examinations were at least 40-minute visits in which health maintenance was typically discussed. Other exami- nation types included acute-care visits and follow-up examina- tions, which were typically shorter. Other providers included residents and midlevel providers. For patients for whom AAA 594 screening was ordered, we recorded whether it was completed. In addition, during the 4-month study period, we counted how many outpatient visits occurred before the test was ordered. For example, a 65-year-old male smoker who ﬁt the USPSTF criteria for screening would be assigned a 0 if AAA screening had been ordered the ﬁrst time he had visited the clinic since turning 65; a 75-year-old man who met AAA screening criteria would be assigned a 4 if he had been seen four times since the guidelines were in place before AAA screening was ordered. For patients for whom screening was not ordered, we examined whether the ratio- nale for not ordering screening was documented; if so, we recorded the speciﬁc rationale. Survey of providers We developed a seven-item, anonymous electronic survey to assess providers’ knowledge of AAA screening guidelines, their perceptions of current screening practices in their clinic, their opinions regarding barriers to screening and interventions to improve rates of screening. Depending on the question, the survey asked respondents to select either the single best answer or mul- tiple answers. We emailed the survey to all 237 health care pro- viders in the primary care internal medicine clinic of Mayo Clinic Rochester. Data analysis We analysed the data using JMP software 7.0.1 (SAS Institute, Cary, NC, USA). Categorical variables were summarized as fre- quencies and percentages. A P-value of <0.05 was considered statistically signiﬁcant. Univariate and multivariate logistic regres- sion models used AAA screening ultrasound test ordered (yes vs. no) as the outcome variable. Independent variables examined were appointment type (general medical examination vs. other), pro- vider role (staff physician vs. other) and provider gender. This study was approved by Mayo Clinic Rochester’s Institutional Review Board. Results AAA screening ordering performance We identiﬁed 442 eligible patients during the study period. Of the 442, 57 (12.9%) patients had an ultrasound ordered to screen for AAA. All 57 completed the test (95% conﬁdence interval [CI]: 0.9–1.0). Of the 442 patients, 164 (37.1%) were seen for a general medical examination, and 278 (62.9%) were seen for another type of appointment (e.g. acute-care visit, follow-up examination). Most patients (340, 76.9%) were seen by staff physicians, while the remaining 102 (23.1%) were seen by another provider (64 by residents, 16 by midlevel providers and 22 by registered nurses). Most patients (340, 76.9%) were seen by male providers. Although AAA screening was not ordered for 385 (87.1%) eligible patients, the rationale for not ordering AAA screening was docu- mented for just six patients (1.3%). For three of these six patients, the rationale was patient refusal. For the remaining three, the provider documented that the patient was not a current smoker and therefore did not meet AAA screening eligibility criteria. For all three of these patients, our records indicated that the patient was a © 2011 Blackwell Publishing Ltd