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Screenings Raise Risk as Well as Awareness

 |  By jfellows@healthleadersmedia.com  
   August 07, 2014

A constant barrage of ads from hospitals, health systems, and payers urges patients to get screened for some of the deadliest diseases. But casting a wide net is totally at odds with controlling healthcare costs through evidence-based data.

Heart disease is the leading cause of death for both men and women and reducing those numbers is a prime target for hospitals and health systems, public interest health groups, and medical specialty societies.

Years of research and data have given clinical leaders tools to help patients reduce their risk for heart disease: stop smoking, lose weight, exercise, and lower blood pressure. The treadmill stress test and other, non-invasive imaging screening tests aren't on that list because they don't improve patients' outcomes.

But those clinical best practices either aren't well-known enough or haven't trickled down to hospital marketing departments. Or both.

The logo-wrapped mobile screening buses and newspaper ads offering patients peace of mind through a screening test for any number of diseases make Patrick Alguire, senior vice president for medical education at the American College of Physicians, cringe most of the time.


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Expensive, Invasive, Dangerous
"It's a sore point with me," says Alguire. "We have to be really careful about the harms that screening can do. For example, you may have a screening test with false positives that can lead to more tests, and generally, the additional tests can be more expensive, invasive, and dangerous. If nothing more, it may create worry and anxiety."

The American College of Cardiology estimates that low-risk, asymptomatic patients make up 45% of unnecessary screenings. The ACC and ACP are two of 58 healthcare provider organizations that have created a list of five common tests or procedures that physicians and patients should talk about rather than automatically ordering as part of the American Board of Internal Medicine's Choosing Wisely campaign.

Aimed at reducing wasteful healthcare spending while ratcheting up the reliance on evidenced-based outcomes, Choosing Wisely has made healthcare organizations sit up and take notice of their own clinical attitudes toward testing and diagnoses practices.

At Reliant Medical Group, a Worcester, Massachusetts–based independent multi-specialty physician group with more than 250 doctors at 20 sites, leaders asked specialists to pick at least two of 58 Choosing Wisely Top 5 lists to assess its own reliance on tests or procedures that may be unnecessary.

"It's about shared decision making," says Betsy Hampton, vice president of population health for Reliant.

The ACP is also launching its own initiative to help physicians and other healthcare providers know when more testing or additional procedures are warranted. It's partnering with the Cleveland Clinical Journal of Medicine in a new periodic series called Smart Testing. The series' articles are presented as clinical vignettes that present common test-ordering scenarios.

For example, the first installment of Smart Testing series presents a healthy 48-year old man who wants to know if he should get a cardiac stress test. The conclusion, based on clinical, evidence-based guidelines that are consistent among the ACP, the American Heart Association, and the American College of Cardiology, is no.

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Alguire writes in the conclusion, that "several studies that included symptomatic and asymptomatic patients who had undergone angiography reported between 39% and 85% of patients had no coronary artery disease." The risk is low, if the patient undergoes stress testing, but Alguire says it's more cost without more benefit.

"Not all diseases are necessarily amenable to screening," he says.

The American Heart Association agrees. AHA President Elliott Antman, MD, a practicing senior cardiologist at Brigham and Women's Hospital in Boston, says doctors have to talk to their patients about when further testing is warranted and not have patients rely on the mass screenings.

"We prefer them coming through their primary care provider or cardiologist so we can make reasoned judgment about who needs additional testing."

Unfortunately for physicians trying to shift the perception from more tests are better to less is more, the ACP's vignette is a common reality across the country.

At Loyola University Health System, based in Maywood, Illinois, a large bus sweeps through Chicago's western suburban streets offering the community six "comprehensive heart screening" tests for $179. One of the six tests is an electrocardiogram, the same test that physicians are told to avoid in asymptomatic or low-risk patients.

No doubt the mobile screening unit raises awareness for the health system and catches and stops heart disease from progressing further in some patients. But casting a wide net is totally at odds with controlling healthcare costs through evidence-based data.

"The health screening is kind of like the cheering section for the old guard," says Howard Brody, MD, PhD, director of the Institute for the Medical Humanities at the University of Texas Medical Branch at Galveston, who is credited with spurring the Choosing Wisely campaign to come up with a "Top Five" list. He proposed the idea in his 2010 New England Journal of Medicine editorial that called out physicians' overuse of tests and procedures without any real benefit to the patient.

Contrary to Evidence-based Guidelines
As for the juxtaposition of patients being told one thing while physicians are told another, Brody says it's too early to expect the long-held view of more testing to be uprooted.

"It's early days for Choosing Wisely," says Brody. "Right now, the dialogue hasn't gone on long enough for any consensus point of view to emerge."

Meanwhile, Loyola and the contractor that provides the mobile screening unit, Health Fair, have come under fire for promoting screenings that are contrary to evidence-based guidelines. Loyola officials did not return phone calls or emails asking to clarify its screening practices or use of Choosing Wisely guidelines.

The AHA, a group that is received (and believed) by consumer and medical professionals is more diplomatic than Brody and Alguire about the delicate balance of promoting awareness and excessive screening.

But Antman ultimately comes down on the side of caution.

"The key is for healthcare practitioners to exercise their responsibility appropriately by taking the time to talk to their patients and use the available tools and guidelines to screen for heart disease and stroke rather than resorting to a policy of broad and unchecked use of imaging."

Jacqueline Fellows is a contributing writer at HealthLeaders Media.

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