An ounce of prevention might be worth a pound of cure, but applying that proverb too broadly is just bad medicine.
Look before you leap is a much wiser approach to mobile medical screenings, as shown earlier this month in a story by Kaiser Health News and the Washington Post.
Health-care facilities (mainly hospitals) seeking to boost their brand and, by extension, patient population, are partnering with medical-screening outfits to address consumer’s medical concerns. That’s one way of looking at it; another is that some community outreach efforts are stoking irrational fear about potentially deadly problems like heart disease and stroke.
Fear mongering has always been profitable in health care.
You’ve probably seen mobile vans at the shopping mall or sports center offering screening tests for a range of health issues including ultrasounds and EKGs. These are a far cry from a simple blood pressure test you might self-administer at the local drugstore while you wait for your prescription to be filled.
As we wrote last year, often these commercial come-ons do more harm than good, and the KHN/Post story elaborates: “What their promotions don’t say is that an influential government panel recommends against using many of the tests on people without symptoms or risk factors. The panel says such screenings find too few problems to outweigh their drawbacks, which include false positive results, follow-up procedures and potentially unnecessary surgery. Other medical experts warn that the tests could needlessly raise health-care spending.”
For example, Inova Health System, a large hospital network in the Virginia suburbs of Washington D.C., has hooked up with HealthFair, a medical screening company in a direct-mail promotion of a $139 package of what it calls “five life-saving tests for heart disease and stroke.” Usually not covered by insurance, the tests are administered from specially equipped buses bearing the Inova logo.
Although Inova and other hospitals claim such screenings help raise awareness of heart disease and stroke, and encourage conversation between patients and their doctors, Dr. Steven Weinberger, executive vice president and chief executive of the American College of Physicians, told KHN/Post that “A lot that ends up being found is clinically of no importance at all.” He’s co-author of a study in the Annals of Internal Medicine that said it’s unethical for hospitals not to inform patients of the downside of these screenings.
False positives, further-and often more invasive, painful and expensive-screening and the fear that comes with them all must be disclosed as potential harms.
Dr. David Spinosa, medical director of the Invova Heart and Vascular Institute, admitted to KHN/Post that the likelihood of finding a critical problem during a mobile screening is “very low,” but that’s not why they perform them. “If people learn they have early signs of a disease-if their physicians know that-then they have an opportunity to aggressively modify their risk factors.”
And why wouldn’t their physicians know that under normal circumstances of patient care? People interested in protecting and improving their health do so by having a productive, ongoing relationship with their care providers, who are much better able to assess their individual risks and order tests appropriate for them, not the population at large.
Here’s all you need to know about this made-up sense of medical urgency: Spinosa said that about half-45 in 100-of 8,000 people screened since the program’s inception showed some abnormal finding; but critical problems were found in fewer than 1 in 100 cases. That means scores of people suffered unnecessary worry, and unnecessary further testing.
Inova makes no money from the off-site testing; in fact, it pays HealthFair to slap its logo on the buses. But before you’re screened, you agree to allow the hospital group to contact you to discuss abnormal findings, and, presumably, arrange for further testing that you or your insurer pays for.
Although one Inova communications official declined to tell KHN/Post say how much the five-hospital chain pays HealthFair, or how many referrals it gets as a result of the testing, another from Life Line Screening, an Ohio firm that partners with 180 hospitals to offer screenings, realized the ethical concerns: “Hospitals want to do outreach. They feel they need to,” she said “[But] there’s also a philosophical debate here: Do people have a right to know what’s going on inside their bodies and have screenings they feel are right for them?”
The five-test basic package promoted by HealthFair is much more elaborate than the safe and effective screenings hospitals routinely sponsor at health fairs and other community events. According to KHN/Post, it includes:
- ultrasound tests for blockages of the carotid artery and weak spots in the abdominal aorta;
- a resting electrocardiogram, or EKG;
- a test of elasticity of the arteries;
- a test for blockages in arteries serving the legs (peripheral arterial disease).
The U.S. Preventive Services Task Force (see our blog, “Who Are These Guys?”) recommends against routine use of four of the five tests in adults who don’t have symptoms or risk factors. And it recommends testing for the fifth only for male smokers ages 65 to 75.
Two of the tests-EKGs and ultrasounds for blocked carotid arteries-are among 130 procedures that a numerous physician organizations say are overused and should be questioned by both patients and their doctors.
As described by KHN/Post, “False-positives, or results that erroneously indicate disease, are more likely when screening widely for a condition that affects only a small percentage of people – for instance, narrowing of the carotid artery, a risk factor for stroke estimated to affect about 1% of people over age 65.
“Because the condition is so rare, the task force estimates that 4,348 people would need to be screened with both ultrasound and a follow-up magnetic resonance imaging test to prevent a single stroke.”
The president of the American College of Cardiology told KHN/Post that his group and the heart association do not endorse HealthFair or any other screening company. “Neither organization recommends broad screening or specific drugs, devices or companies in those guidelines,” he said.
In addition to its shaky medical foundation, the community outreach come-on is just wrong: All of the patients KHN/Post interviewed at one HealthFair bus stop said that direct mail or newspaper advertisements had prompted them to sign up for the tests. Some of the mail included a cover letter that said “80% of strokes can be prevented.”
“I’m not aware of any study that proves that number,” Dr. Geoffrey Toonder, a retired cardiothoracic surgeon, told KHN/Post. Yet his signature appears on the mailing.