Five-Year Outcomes of a Randomized Trial of Treatments for Varicose Veins.

Adult Cost-Benefit Analysis Endovascular Procedures / economics Female Follow-Up Studies Humans Intention to Treat Analysis Laser Therapy / economics Male Middle Aged Quality of Life Quality-Adjusted Life Years Sclerotherapy / economics Surveys and Questionnaires Treatment Outcome Ultrasonography, Interventional Varicose Veins / surgery

Journal

The New England journal of medicine
ISSN: 1533-4406
Titre abrégé: N Engl J Med
Pays: United States
ID NLM: 0255562

Informations de publication

Date de publication:
05 09 2019
Historique:
entrez: 5 9 2019
pubmed: 5 9 2019
medline: 2 10 2019
Statut: ppublish

Résumé

Endovenous laser ablation and ultrasound-guided foam sclerotherapy are recommended alternatives to surgery for the treatment of primary varicose veins, but their long-term comparative effectiveness remains uncertain. In a randomized, controlled trial involving 798 participants with primary varicose veins at 11 centers in the United Kingdom, we compared the outcomes of laser ablation, foam sclerotherapy, and surgery. Primary outcomes at 5 years were disease-specific quality of life and generic quality of life, as well as cost-effectiveness based on models of expected costs and quality-adjusted life-years (QALYs) gained that used data on participants' treatment costs and scores on the EuroQol EQ-5D questionnaire. Quality-of-life questionnaires were completed by 595 (75%) of the 798 trial participants. After adjustment for baseline scores and other covariates, scores on the Aberdeen Varicose Vein Questionnaire (on which scores range from 0 to 100, with lower scores indicating a better quality of life) were lower among patients who underwent laser ablation or surgery than among those who underwent foam sclerotherapy (effect size [adjusted differences between groups] for laser ablation vs. foam sclerotherapy, -2.86; 95% confidence interval [CI], -4.49 to -1.22; P<0.001; and for surgery vs. foam sclerotherapy, -2.60; 95% CI, -3.99 to -1.22; P<0.001). Generic quality-of-life measures did not differ among treatment groups. At a threshold willingness-to-pay ratio of £20,000 ($28,433 in U.S. dollars) per QALY, 77.2% of the cost-effectiveness model iterations favored laser ablation. In a two-way comparison between foam sclerotherapy and surgery, 54.5% of the model iterations favored surgery. In a randomized trial of treatments for varicose veins, disease-specific quality of life 5 years after treatment was better after laser ablation or surgery than after foam sclerotherapy. The majority of the probabilistic cost-effectiveness model iterations favored laser ablation at a willingness-to-pay ratio of £20,000 ($28,433) per QALY. (Funded by the National Institute for Health Research; CLASS Current Controlled Trials number, ISRCTN51995477.).

Sections du résumé

BACKGROUND
Endovenous laser ablation and ultrasound-guided foam sclerotherapy are recommended alternatives to surgery for the treatment of primary varicose veins, but their long-term comparative effectiveness remains uncertain.
METHODS
In a randomized, controlled trial involving 798 participants with primary varicose veins at 11 centers in the United Kingdom, we compared the outcomes of laser ablation, foam sclerotherapy, and surgery. Primary outcomes at 5 years were disease-specific quality of life and generic quality of life, as well as cost-effectiveness based on models of expected costs and quality-adjusted life-years (QALYs) gained that used data on participants' treatment costs and scores on the EuroQol EQ-5D questionnaire.
RESULTS
Quality-of-life questionnaires were completed by 595 (75%) of the 798 trial participants. After adjustment for baseline scores and other covariates, scores on the Aberdeen Varicose Vein Questionnaire (on which scores range from 0 to 100, with lower scores indicating a better quality of life) were lower among patients who underwent laser ablation or surgery than among those who underwent foam sclerotherapy (effect size [adjusted differences between groups] for laser ablation vs. foam sclerotherapy, -2.86; 95% confidence interval [CI], -4.49 to -1.22; P<0.001; and for surgery vs. foam sclerotherapy, -2.60; 95% CI, -3.99 to -1.22; P<0.001). Generic quality-of-life measures did not differ among treatment groups. At a threshold willingness-to-pay ratio of £20,000 ($28,433 in U.S. dollars) per QALY, 77.2% of the cost-effectiveness model iterations favored laser ablation. In a two-way comparison between foam sclerotherapy and surgery, 54.5% of the model iterations favored surgery.
CONCLUSIONS
In a randomized trial of treatments for varicose veins, disease-specific quality of life 5 years after treatment was better after laser ablation or surgery than after foam sclerotherapy. The majority of the probabilistic cost-effectiveness model iterations favored laser ablation at a willingness-to-pay ratio of £20,000 ($28,433) per QALY. (Funded by the National Institute for Health Research; CLASS Current Controlled Trials number, ISRCTN51995477.).

Identifiants

DOI: 10.1056/NEJMoa1805186 PMID: 31483962
pubmed: 31483962
doi: 10.1056/NEJMoa1805186
doi:

Banques de données

ISRCTN
['ISRCTN51995477']

Types de publication

Comparative Study Journal Article Multicenter Study Randomized Controlled Trial Research Support, Non-U.S. Gov't

Langues

eng

Sous-ensembles de citation

IM

Pagination

912-922

Subventions

Organisme : Chief Scientist Office
ID : HERU1
Pays : United Kingdom
Organisme : Department of Health
ID : 06/45/501
Pays : United Kingdom
Organisme : Chief Scientist Office
ID : HSRU1
Pays : United Kingdom
Organisme : Health Technology Assessment Programme
ID : 06/45/02
Pays : International
Organisme : Department of Health
ID : 06/45/02
Pays : United Kingdom

Commentaires et corrections

Type : CommentIn
Type : CommentIn

Informations de copyright

Copyright © 2019 Massachusetts Medical Society.

Auteurs

Julie Brittenden (J)

From the Institute of Cardiovascular Research, University of Glasgow (J.B.), and the Institute of Applied Health Research, Nursing, Midwifery, and Allied Health Professions Research Unit, Glasgow Caledonian University (A.E.), Glasgow, the Health Services Research Unit (D.C., S.C.C., G.M., C.R.R., M.K.C.) and the Health Economics Research Unit (M.D., G.S., E.T.), University of Aberdeen, and the Department of Vascular Surgery, NHS Grampian, Aberdeen Royal Infirmary (P.B.), Aberdeen, the Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh (J.N.), the School of Medicine, Medical and Biological Sciences, University of St. Andrews, St. Andrews (J.M.B.), the Department of Vascular Surgery, Royal Devon and Exeter Hospital, Exeter (B.C.), the Department of Vascular Surgery, Hull Royal Infirmary, Hull (I.C.), the School of Surgery, University of Leeds (M.G.), and Vascular Surgery, St. James University Hospital (J.S.), Leeds, Vascular Surgery, Gloucestershire Royal Hospital, Gloucester (J.E.), Vascular Surgery, Freeman Hospital, Newcastle upon Tyne (T.L.), the Vascular Surgical Unit, Royal Bournemouth Hospital, Bournemouth (S.A.B.), and the School of Health Sciences, City University of London, London (J.F.) - all in the United Kingdom.

David Cooper (D)

From the Institute of Cardiovascular Research, University of Glasgow (J.B.), and the Institute of Applied Health Research, Nursing, Midwifery, and Allied Health Professions Research Unit, Glasgow Caledonian University (A.E.), Glasgow, the Health Services Research Unit (D.C., S.C.C., G.M., C.R.R., M.K.C.) and the Health Economics Research Unit (M.D., G.S., E.T.), University of Aberdeen, and the Department of Vascular Surgery, NHS Grampian, Aberdeen Royal Infirmary (P.B.), Aberdeen, the Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh (J.N.), the School of Medicine, Medical and Biological Sciences, University of St. Andrews, St. Andrews (J.M.B.), the Department of Vascular Surgery, Royal Devon and Exeter Hospital, Exeter (B.C.), the Department of Vascular Surgery, Hull Royal Infirmary, Hull (I.C.), the School of Surgery, University of Leeds (M.G.), and Vascular Surgery, St. James University Hospital (J.S.), Leeds, Vascular Surgery, Gloucestershire Royal Hospital, Gloucester (J.E.), Vascular Surgery, Freeman Hospital, Newcastle upon Tyne (T.L.), the Vascular Surgical Unit, Royal Bournemouth Hospital, Bournemouth (S.A.B.), and the School of Health Sciences, City University of London, London (J.F.) - all in the United Kingdom.

Maria Dimitrova (M)

From the Institute of Cardiovascular Research, University of Glasgow (J.B.), and the Institute of Applied Health Research, Nursing, Midwifery, and Allied Health Professions Research Unit, Glasgow Caledonian University (A.E.), Glasgow, the Health Services Research Unit (D.C., S.C.C., G.M., C.R.R., M.K.C.) and the Health Economics Research Unit (M.D., G.S., E.T.), University of Aberdeen, and the Department of Vascular Surgery, NHS Grampian, Aberdeen Royal Infirmary (P.B.), Aberdeen, the Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh (J.N.), the School of Medicine, Medical and Biological Sciences, University of St. Andrews, St. Andrews (J.M.B.), the Department of Vascular Surgery, Royal Devon and Exeter Hospital, Exeter (B.C.), the Department of Vascular Surgery, Hull Royal Infirmary, Hull (I.C.), the School of Surgery, University of Leeds (M.G.), and Vascular Surgery, St. James University Hospital (J.S.), Leeds, Vascular Surgery, Gloucestershire Royal Hospital, Gloucester (J.E.), Vascular Surgery, Freeman Hospital, Newcastle upon Tyne (T.L.), the Vascular Surgical Unit, Royal Bournemouth Hospital, Bournemouth (S.A.B.), and the School of Health Sciences, City University of London, London (J.F.) - all in the United Kingdom.

Graham Scotland (G)

From the Institute of Cardiovascular Research, University of Glasgow (J.B.), and the Institute of Applied Health Research, Nursing, Midwifery, and Allied Health Professions Research Unit, Glasgow Caledonian University (A.E.), Glasgow, the Health Services Research Unit (D.C., S.C.C., G.M., C.R.R., M.K.C.) and the Health Economics Research Unit (M.D., G.S., E.T.), University of Aberdeen, and the Department of Vascular Surgery, NHS Grampian, Aberdeen Royal Infirmary (P.B.), Aberdeen, the Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh (J.N.), the School of Medicine, Medical and Biological Sciences, University of St. Andrews, St. Andrews (J.M.B.), the Department of Vascular Surgery, Royal Devon and Exeter Hospital, Exeter (B.C.), the Department of Vascular Surgery, Hull Royal Infirmary, Hull (I.C.), the School of Surgery, University of Leeds (M.G.), and Vascular Surgery, St. James University Hospital (J.S.), Leeds, Vascular Surgery, Gloucestershire Royal Hospital, Gloucester (J.E.), Vascular Surgery, Freeman Hospital, Newcastle upon Tyne (T.L.), the Vascular Surgical Unit, Royal Bournemouth Hospital, Bournemouth (S.A.B.), and the School of Health Sciences, City University of London, London (J.F.) - all in the United Kingdom.

Seonaidh C Cotton (SC)

From the Institute of Cardiovascular Research, University of Glasgow (J.B.), and the Institute of Applied Health Research, Nursing, Midwifery, and Allied Health Professions Research Unit, Glasgow Caledonian University (A.E.), Glasgow, the Health Services Research Unit (D.C., S.C.C., G.M., C.R.R., M.K.C.) and the Health Economics Research Unit (M.D., G.S., E.T.), University of Aberdeen, and the Department of Vascular Surgery, NHS Grampian, Aberdeen Royal Infirmary (P.B.), Aberdeen, the Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh (J.N.), the School of Medicine, Medical and Biological Sciences, University of St. Andrews, St. Andrews (J.M.B.), the Department of Vascular Surgery, Royal Devon and Exeter Hospital, Exeter (B.C.), the Department of Vascular Surgery, Hull Royal Infirmary, Hull (I.C.), the School of Surgery, University of Leeds (M.G.), and Vascular Surgery, St. James University Hospital (J.S.), Leeds, Vascular Surgery, Gloucestershire Royal Hospital, Gloucester (J.E.), Vascular Surgery, Freeman Hospital, Newcastle upon Tyne (T.L.), the Vascular Surgical Unit, Royal Bournemouth Hospital, Bournemouth (S.A.B.), and the School of Health Sciences, City University of London, London (J.F.) - all in the United Kingdom.

Andrew Elders (A)

From the Institute of Cardiovascular Research, University of Glasgow (J.B.), and the Institute of Applied Health Research, Nursing, Midwifery, and Allied Health Professions Research Unit, Glasgow Caledonian University (A.E.), Glasgow, the Health Services Research Unit (D.C., S.C.C., G.M., C.R.R., M.K.C.) and the Health Economics Research Unit (M.D., G.S., E.T.), University of Aberdeen, and the Department of Vascular Surgery, NHS Grampian, Aberdeen Royal Infirmary (P.B.), Aberdeen, the Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh (J.N.), the School of Medicine, Medical and Biological Sciences, University of St. Andrews, St. Andrews (J.M.B.), the Department of Vascular Surgery, Royal Devon and Exeter Hospital, Exeter (B.C.), the Department of Vascular Surgery, Hull Royal Infirmary, Hull (I.C.), the School of Surgery, University of Leeds (M.G.), and Vascular Surgery, St. James University Hospital (J.S.), Leeds, Vascular Surgery, Gloucestershire Royal Hospital, Gloucester (J.E.), Vascular Surgery, Freeman Hospital, Newcastle upon Tyne (T.L.), the Vascular Surgical Unit, Royal Bournemouth Hospital, Bournemouth (S.A.B.), and the School of Health Sciences, City University of London, London (J.F.) - all in the United Kingdom.

Graeme MacLennan (G)

From the Institute of Cardiovascular Research, University of Glasgow (J.B.), and the Institute of Applied Health Research, Nursing, Midwifery, and Allied Health Professions Research Unit, Glasgow Caledonian University (A.E.), Glasgow, the Health Services Research Unit (D.C., S.C.C., G.M., C.R.R., M.K.C.) and the Health Economics Research Unit (M.D., G.S., E.T.), University of Aberdeen, and the Department of Vascular Surgery, NHS Grampian, Aberdeen Royal Infirmary (P.B.), Aberdeen, the Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh (J.N.), the School of Medicine, Medical and Biological Sciences, University of St. Andrews, St. Andrews (J.M.B.), the Department of Vascular Surgery, Royal Devon and Exeter Hospital, Exeter (B.C.), the Department of Vascular Surgery, Hull Royal Infirmary, Hull (I.C.), the School of Surgery, University of Leeds (M.G.), and Vascular Surgery, St. James University Hospital (J.S.), Leeds, Vascular Surgery, Gloucestershire Royal Hospital, Gloucester (J.E.), Vascular Surgery, Freeman Hospital, Newcastle upon Tyne (T.L.), the Vascular Surgical Unit, Royal Bournemouth Hospital, Bournemouth (S.A.B.), and the School of Health Sciences, City University of London, London (J.F.) - all in the United Kingdom.

Craig R Ramsay (CR)

From the Institute of Cardiovascular Research, University of Glasgow (J.B.), and the Institute of Applied Health Research, Nursing, Midwifery, and Allied Health Professions Research Unit, Glasgow Caledonian University (A.E.), Glasgow, the Health Services Research Unit (D.C., S.C.C., G.M., C.R.R., M.K.C.) and the Health Economics Research Unit (M.D., G.S., E.T.), University of Aberdeen, and the Department of Vascular Surgery, NHS Grampian, Aberdeen Royal Infirmary (P.B.), Aberdeen, the Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh (J.N.), the School of Medicine, Medical and Biological Sciences, University of St. Andrews, St. Andrews (J.M.B.), the Department of Vascular Surgery, Royal Devon and Exeter Hospital, Exeter (B.C.), the Department of Vascular Surgery, Hull Royal Infirmary, Hull (I.C.), the School of Surgery, University of Leeds (M.G.), and Vascular Surgery, St. James University Hospital (J.S.), Leeds, Vascular Surgery, Gloucestershire Royal Hospital, Gloucester (J.E.), Vascular Surgery, Freeman Hospital, Newcastle upon Tyne (T.L.), the Vascular Surgical Unit, Royal Bournemouth Hospital, Bournemouth (S.A.B.), and the School of Health Sciences, City University of London, London (J.F.) - all in the United Kingdom.

John Norrie (J)

From the Institute of Cardiovascular Research, University of Glasgow (J.B.), and the Institute of Applied Health Research, Nursing, Midwifery, and Allied Health Professions Research Unit, Glasgow Caledonian University (A.E.), Glasgow, the Health Services Research Unit (D.C., S.C.C., G.M., C.R.R., M.K.C.) and the Health Economics Research Unit (M.D., G.S., E.T.), University of Aberdeen, and the Department of Vascular Surgery, NHS Grampian, Aberdeen Royal Infirmary (P.B.), Aberdeen, the Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh (J.N.), the School of Medicine, Medical and Biological Sciences, University of St. Andrews, St. Andrews (J.M.B.), the Department of Vascular Surgery, Royal Devon and Exeter Hospital, Exeter (B.C.), the Department of Vascular Surgery, Hull Royal Infirmary, Hull (I.C.), the School of Surgery, University of Leeds (M.G.), and Vascular Surgery, St. James University Hospital (J.S.), Leeds, Vascular Surgery, Gloucestershire Royal Hospital, Gloucester (J.E.), Vascular Surgery, Freeman Hospital, Newcastle upon Tyne (T.L.), the Vascular Surgical Unit, Royal Bournemouth Hospital, Bournemouth (S.A.B.), and the School of Health Sciences, City University of London, London (J.F.) - all in the United Kingdom.

Jennifer M Burr (JM)

From the Institute of Cardiovascular Research, University of Glasgow (J.B.), and the Institute of Applied Health Research, Nursing, Midwifery, and Allied Health Professions Research Unit, Glasgow Caledonian University (A.E.), Glasgow, the Health Services Research Unit (D.C., S.C.C., G.M., C.R.R., M.K.C.) and the Health Economics Research Unit (M.D., G.S., E.T.), University of Aberdeen, and the Department of Vascular Surgery, NHS Grampian, Aberdeen Royal Infirmary (P.B.), Aberdeen, the Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh (J.N.), the School of Medicine, Medical and Biological Sciences, University of St. Andrews, St. Andrews (J.M.B.), the Department of Vascular Surgery, Royal Devon and Exeter Hospital, Exeter (B.C.), the Department of Vascular Surgery, Hull Royal Infirmary, Hull (I.C.), the School of Surgery, University of Leeds (M.G.), and Vascular Surgery, St. James University Hospital (J.S.), Leeds, Vascular Surgery, Gloucestershire Royal Hospital, Gloucester (J.E.), Vascular Surgery, Freeman Hospital, Newcastle upon Tyne (T.L.), the Vascular Surgical Unit, Royal Bournemouth Hospital, Bournemouth (S.A.B.), and the School of Health Sciences, City University of London, London (J.F.) - all in the United Kingdom.

Bruce Campbell (B)

From the Institute of Cardiovascular Research, University of Glasgow (J.B.), and the Institute of Applied Health Research, Nursing, Midwifery, and Allied Health Professions Research Unit, Glasgow Caledonian University (A.E.), Glasgow, the Health Services Research Unit (D.C., S.C.C., G.M., C.R.R., M.K.C.) and the Health Economics Research Unit (M.D., G.S., E.T.), University of Aberdeen, and the Department of Vascular Surgery, NHS Grampian, Aberdeen Royal Infirmary (P.B.), Aberdeen, the Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh (J.N.), the School of Medicine, Medical and Biological Sciences, University of St. Andrews, St. Andrews (J.M.B.), the Department of Vascular Surgery, Royal Devon and Exeter Hospital, Exeter (B.C.), the Department of Vascular Surgery, Hull Royal Infirmary, Hull (I.C.), the School of Surgery, University of Leeds (M.G.), and Vascular Surgery, St. James University Hospital (J.S.), Leeds, Vascular Surgery, Gloucestershire Royal Hospital, Gloucester (J.E.), Vascular Surgery, Freeman Hospital, Newcastle upon Tyne (T.L.), the Vascular Surgical Unit, Royal Bournemouth Hospital, Bournemouth (S.A.B.), and the School of Health Sciences, City University of London, London (J.F.) - all in the United Kingdom.

Paul Bachoo (P)

From the Institute of Cardiovascular Research, University of Glasgow (J.B.), and the Institute of Applied Health Research, Nursing, Midwifery, and Allied Health Professions Research Unit, Glasgow Caledonian University (A.E.), Glasgow, the Health Services Research Unit (D.C., S.C.C., G.M., C.R.R., M.K.C.) and the Health Economics Research Unit (M.D., G.S., E.T.), University of Aberdeen, and the Department of Vascular Surgery, NHS Grampian, Aberdeen Royal Infirmary (P.B.), Aberdeen, the Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh (J.N.), the School of Medicine, Medical and Biological Sciences, University of St. Andrews, St. Andrews (J.M.B.), the Department of Vascular Surgery, Royal Devon and Exeter Hospital, Exeter (B.C.), the Department of Vascular Surgery, Hull Royal Infirmary, Hull (I.C.), the School of Surgery, University of Leeds (M.G.), and Vascular Surgery, St. James University Hospital (J.S.), Leeds, Vascular Surgery, Gloucestershire Royal Hospital, Gloucester (J.E.), Vascular Surgery, Freeman Hospital, Newcastle upon Tyne (T.L.), the Vascular Surgical Unit, Royal Bournemouth Hospital, Bournemouth (S.A.B.), and the School of Health Sciences, City University of London, London (J.F.) - all in the United Kingdom.

Ian Chetter (I)

From the Institute of Cardiovascular Research, University of Glasgow (J.B.), and the Institute of Applied Health Research, Nursing, Midwifery, and Allied Health Professions Research Unit, Glasgow Caledonian University (A.E.), Glasgow, the Health Services Research Unit (D.C., S.C.C., G.M., C.R.R., M.K.C.) and the Health Economics Research Unit (M.D., G.S., E.T.), University of Aberdeen, and the Department of Vascular Surgery, NHS Grampian, Aberdeen Royal Infirmary (P.B.), Aberdeen, the Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh (J.N.), the School of Medicine, Medical and Biological Sciences, University of St. Andrews, St. Andrews (J.M.B.), the Department of Vascular Surgery, Royal Devon and Exeter Hospital, Exeter (B.C.), the Department of Vascular Surgery, Hull Royal Infirmary, Hull (I.C.), the School of Surgery, University of Leeds (M.G.), and Vascular Surgery, St. James University Hospital (J.S.), Leeds, Vascular Surgery, Gloucestershire Royal Hospital, Gloucester (J.E.), Vascular Surgery, Freeman Hospital, Newcastle upon Tyne (T.L.), the Vascular Surgical Unit, Royal Bournemouth Hospital, Bournemouth (S.A.B.), and the School of Health Sciences, City University of London, London (J.F.) - all in the United Kingdom.

Michael Gough (M)

From the Institute of Cardiovascular Research, University of Glasgow (J.B.), and the Institute of Applied Health Research, Nursing, Midwifery, and Allied Health Professions Research Unit, Glasgow Caledonian University (A.E.), Glasgow, the Health Services Research Unit (D.C., S.C.C., G.M., C.R.R., M.K.C.) and the Health Economics Research Unit (M.D., G.S., E.T.), University of Aberdeen, and the Department of Vascular Surgery, NHS Grampian, Aberdeen Royal Infirmary (P.B.), Aberdeen, the Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh (J.N.), the School of Medicine, Medical and Biological Sciences, University of St. Andrews, St. Andrews (J.M.B.), the Department of Vascular Surgery, Royal Devon and Exeter Hospital, Exeter (B.C.), the Department of Vascular Surgery, Hull Royal Infirmary, Hull (I.C.), the School of Surgery, University of Leeds (M.G.), and Vascular Surgery, St. James University Hospital (J.S.), Leeds, Vascular Surgery, Gloucestershire Royal Hospital, Gloucester (J.E.), Vascular Surgery, Freeman Hospital, Newcastle upon Tyne (T.L.), the Vascular Surgical Unit, Royal Bournemouth Hospital, Bournemouth (S.A.B.), and the School of Health Sciences, City University of London, London (J.F.) - all in the United Kingdom.

Jonothan Earnshaw (J)

From the Institute of Cardiovascular Research, University of Glasgow (J.B.), and the Institute of Applied Health Research, Nursing, Midwifery, and Allied Health Professions Research Unit, Glasgow Caledonian University (A.E.), Glasgow, the Health Services Research Unit (D.C., S.C.C., G.M., C.R.R., M.K.C.) and the Health Economics Research Unit (M.D., G.S., E.T.), University of Aberdeen, and the Department of Vascular Surgery, NHS Grampian, Aberdeen Royal Infirmary (P.B.), Aberdeen, the Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh (J.N.), the School of Medicine, Medical and Biological Sciences, University of St. Andrews, St. Andrews (J.M.B.), the Department of Vascular Surgery, Royal Devon and Exeter Hospital, Exeter (B.C.), the Department of Vascular Surgery, Hull Royal Infirmary, Hull (I.C.), the School of Surgery, University of Leeds (M.G.), and Vascular Surgery, St. James University Hospital (J.S.), Leeds, Vascular Surgery, Gloucestershire Royal Hospital, Gloucester (J.E.), Vascular Surgery, Freeman Hospital, Newcastle upon Tyne (T.L.), the Vascular Surgical Unit, Royal Bournemouth Hospital, Bournemouth (S.A.B.), and the School of Health Sciences, City University of London, London (J.F.) - all in the United Kingdom.

Tim Lees (T)

From the Institute of Cardiovascular Research, University of Glasgow (J.B.), and the Institute of Applied Health Research, Nursing, Midwifery, and Allied Health Professions Research Unit, Glasgow Caledonian University (A.E.), Glasgow, the Health Services Research Unit (D.C., S.C.C., G.M., C.R.R., M.K.C.) and the Health Economics Research Unit (M.D., G.S., E.T.), University of Aberdeen, and the Department of Vascular Surgery, NHS Grampian, Aberdeen Royal Infirmary (P.B.), Aberdeen, the Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh (J.N.), the School of Medicine, Medical and Biological Sciences, University of St. Andrews, St. Andrews (J.M.B.), the Department of Vascular Surgery, Royal Devon and Exeter Hospital, Exeter (B.C.), the Department of Vascular Surgery, Hull Royal Infirmary, Hull (I.C.), the School of Surgery, University of Leeds (M.G.), and Vascular Surgery, St. James University Hospital (J.S.), Leeds, Vascular Surgery, Gloucestershire Royal Hospital, Gloucester (J.E.), Vascular Surgery, Freeman Hospital, Newcastle upon Tyne (T.L.), the Vascular Surgical Unit, Royal Bournemouth Hospital, Bournemouth (S.A.B.), and the School of Health Sciences, City University of London, London (J.F.) - all in the United Kingdom.

Julian Scott (J)

From the Institute of Cardiovascular Research, University of Glasgow (J.B.), and the Institute of Applied Health Research, Nursing, Midwifery, and Allied Health Professions Research Unit, Glasgow Caledonian University (A.E.), Glasgow, the Health Services Research Unit (D.C., S.C.C., G.M., C.R.R., M.K.C.) and the Health Economics Research Unit (M.D., G.S., E.T.), University of Aberdeen, and the Department of Vascular Surgery, NHS Grampian, Aberdeen Royal Infirmary (P.B.), Aberdeen, the Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh (J.N.), the School of Medicine, Medical and Biological Sciences, University of St. Andrews, St. Andrews (J.M.B.), the Department of Vascular Surgery, Royal Devon and Exeter Hospital, Exeter (B.C.), the Department of Vascular Surgery, Hull Royal Infirmary, Hull (I.C.), the School of Surgery, University of Leeds (M.G.), and Vascular Surgery, St. James University Hospital (J.S.), Leeds, Vascular Surgery, Gloucestershire Royal Hospital, Gloucester (J.E.), Vascular Surgery, Freeman Hospital, Newcastle upon Tyne (T.L.), the Vascular Surgical Unit, Royal Bournemouth Hospital, Bournemouth (S.A.B.), and the School of Health Sciences, City University of London, London (J.F.) - all in the United Kingdom.

Sara A Baker (SA)

From the Institute of Cardiovascular Research, University of Glasgow (J.B.), and the Institute of Applied Health Research, Nursing, Midwifery, and Allied Health Professions Research Unit, Glasgow Caledonian University (A.E.), Glasgow, the Health Services Research Unit (D.C., S.C.C., G.M., C.R.R., M.K.C.) and the Health Economics Research Unit (M.D., G.S., E.T.), University of Aberdeen, and the Department of Vascular Surgery, NHS Grampian, Aberdeen Royal Infirmary (P.B.), Aberdeen, the Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh (J.N.), the School of Medicine, Medical and Biological Sciences, University of St. Andrews, St. Andrews (J.M.B.), the Department of Vascular Surgery, Royal Devon and Exeter Hospital, Exeter (B.C.), the Department of Vascular Surgery, Hull Royal Infirmary, Hull (I.C.), the School of Surgery, University of Leeds (M.G.), and Vascular Surgery, St. James University Hospital (J.S.), Leeds, Vascular Surgery, Gloucestershire Royal Hospital, Gloucester (J.E.), Vascular Surgery, Freeman Hospital, Newcastle upon Tyne (T.L.), the Vascular Surgical Unit, Royal Bournemouth Hospital, Bournemouth (S.A.B.), and the School of Health Sciences, City University of London, London (J.F.) - all in the United Kingdom.

Emma Tassie (E)

From the Institute of Cardiovascular Research, University of Glasgow (J.B.), and the Institute of Applied Health Research, Nursing, Midwifery, and Allied Health Professions Research Unit, Glasgow Caledonian University (A.E.), Glasgow, the Health Services Research Unit (D.C., S.C.C., G.M., C.R.R., M.K.C.) and the Health Economics Research Unit (M.D., G.S., E.T.), University of Aberdeen, and the Department of Vascular Surgery, NHS Grampian, Aberdeen Royal Infirmary (P.B.), Aberdeen, the Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh (J.N.), the School of Medicine, Medical and Biological Sciences, University of St. Andrews, St. Andrews (J.M.B.), the Department of Vascular Surgery, Royal Devon and Exeter Hospital, Exeter (B.C.), the Department of Vascular Surgery, Hull Royal Infirmary, Hull (I.C.), the School of Surgery, University of Leeds (M.G.), and Vascular Surgery, St. James University Hospital (J.S.), Leeds, Vascular Surgery, Gloucestershire Royal Hospital, Gloucester (J.E.), Vascular Surgery, Freeman Hospital, Newcastle upon Tyne (T.L.), the Vascular Surgical Unit, Royal Bournemouth Hospital, Bournemouth (S.A.B.), and the School of Health Sciences, City University of London, London (J.F.) - all in the United Kingdom.

Jill Francis (J)

From the Institute of Cardiovascular Research, University of Glasgow (J.B.), and the Institute of Applied Health Research, Nursing, Midwifery, and Allied Health Professions Research Unit, Glasgow Caledonian University (A.E.), Glasgow, the Health Services Research Unit (D.C., S.C.C., G.M., C.R.R., M.K.C.) and the Health Economics Research Unit (M.D., G.S., E.T.), University of Aberdeen, and the Department of Vascular Surgery, NHS Grampian, Aberdeen Royal Infirmary (P.B.), Aberdeen, the Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh (J.N.), the School of Medicine, Medical and Biological Sciences, University of St. Andrews, St. Andrews (J.M.B.), the Department of Vascular Surgery, Royal Devon and Exeter Hospital, Exeter (B.C.), the Department of Vascular Surgery, Hull Royal Infirmary, Hull (I.C.), the School of Surgery, University of Leeds (M.G.), and Vascular Surgery, St. James University Hospital (J.S.), Leeds, Vascular Surgery, Gloucestershire Royal Hospital, Gloucester (J.E.), Vascular Surgery, Freeman Hospital, Newcastle upon Tyne (T.L.), the Vascular Surgical Unit, Royal Bournemouth Hospital, Bournemouth (S.A.B.), and the School of Health Sciences, City University of London, London (J.F.) - all in the United Kingdom.

Marion K Campbell (MK)

From the Institute of Cardiovascular Research, University of Glasgow (J.B.), and the Institute of Applied Health Research, Nursing, Midwifery, and Allied Health Professions Research Unit, Glasgow Caledonian University (A.E.), Glasgow, the Health Services Research Unit (D.C., S.C.C., G.M., C.R.R., M.K.C.) and the Health Economics Research Unit (M.D., G.S., E.T.), University of Aberdeen, and the Department of Vascular Surgery, NHS Grampian, Aberdeen Royal Infirmary (P.B.), Aberdeen, the Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh (J.N.), the School of Medicine, Medical and Biological Sciences, University of St. Andrews, St. Andrews (J.M.B.), the Department of Vascular Surgery, Royal Devon and Exeter Hospital, Exeter (B.C.), the Department of Vascular Surgery, Hull Royal Infirmary, Hull (I.C.), the School of Surgery, University of Leeds (M.G.), and Vascular Surgery, St. James University Hospital (J.S.), Leeds, Vascular Surgery, Gloucestershire Royal Hospital, Gloucester (J.E.), Vascular Surgery, Freeman Hospital, Newcastle upon Tyne (T.L.), the Vascular Surgical Unit, Royal Bournemouth Hospital, Bournemouth (S.A.B.), and the School of Health Sciences, City University of London, London (J.F.) - all in the United Kingdom.

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