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Scans and Scams: Necessary and Unnecessary Screening Tests

Scans and Scams: Necessary and Unnecessary Screening Tests. Martin Donohoe. Outline. Evidence-based screening Appropriate and unnecessary testing Risks of unnecessary testing Unnecessary testing and luxury care Recognizing health scams Current pseudoscience / anti-science

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Scans and Scams: Necessary and Unnecessary Screening Tests

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  1. Scans and Scams:Necessary and Unnecessary Screening Tests Martin Donohoe

  2. Outline • Evidence-based screening • Appropriate and unnecessary testing • Risks of unnecessary testing • Unnecessary testing and luxury care • Recognizing health scams • Current pseudoscience / anti-science • Conclusions and Suggestions

  3. Criteria for Evidence-Based Screening • Disease reasonably common, significantly affects duration and/or quality of life • Existence of acceptable, effective treatment(s) • Asymptomatic period during which detection and treatment can improve outcome • Treatment during asymptomatic period superior to treatment once symptoms appear • Test safe, affordable, adequate sensitivity and specificity

  4. Evidence-Based Screening: Examples • Blood pressure monitoring (age>21) • Cholesterol tests (ages 35-65) • Oral glucose tolerance testing during pregnancy • HPV testing/Pap smears • But much overuse, 75% of annual cervical cancer screenings unnecessary in one study

  5. Evidence-Based Screening: Examples • Mammography (biennial age 50-74) • May decreases death rate from breast cancer by up to 20% (but no change on all-cause mortality) • Nevertheless, Congress ignored USPSTF recommendations and amended ACA to require DHHS to cover screening every 1-2 yrs between ages 40 and 50) • Inadequate evidence to recommend adjunctive US or MRI despite profusion of breast density laws (requiring notification of benefits and/or coverage of costs of adjunctive ultrasound in women with dense breasts)

  6. Cost-Saving Interventions • One time colonoscopy • Condom distribution • Safety belt laws • Hip protectors for elderly women at risk for falls • Streetlights

  7. Low Cost/QALY Interventions • HIV testing of donated blood • Most immunizations • Pap/HPV screening • Screening for DM2 and DM retinopathy • Smoking cessation education

  8. Low Cost/QALY Interventions • Air bags in autos • Restrictions on cell phone use in cars • Publicly-accessible automated external defibrillators • Suicide prevention programs

  9. Underuse of Appropriate Screening Tests • Most Americans do not get recommended preventive tests (which are covered under PPACA) • Cancer screening rates inadequate: • Breast cancer: 62% - 72% • Cervical cancer: 45% - 59% • Colorectal cancer: 24% - 59%

  10. Excessive Phlebotomy of Hospitalized Patients • Phlebotomy can cause patient discomfort and hospital-acquired anemia (Hg decrease from normal to < 11, seen in nearly 20% of hospitalized patients), which is associated with additional testing, prolonged hospitalizations, unnecessary transfusions, and increased mortality for patients with cardiopulmonary diseases

  11. Preoperative/Routine Screening Tests Overutilized/Rarely Helpful (UptoDate) • Routine preoperative laboratory tests have not been shown to improve patient outcomes among healthy patients undergoing surgery • 85% unnecessary in one study • Routine testing in healthy patients has poor predictive value, leading to false-positive test results and/or increased medicolegal risk for not following up on abnormal test results

  12. Recommendations for Preoperative ScreeningTests (UptoDate) • Baseline Hg for patients 65 or older who are undergoing major surgery and for younger patients undergoing surgery that is expected to result in significant blood loss (not necessary for younger patients undergoing minor surgery unless the history suggests anemia)

  13. Recommendations for Preoperative ScreeningTests (UptoDate) • Do not check electrolytes, blood glucose, liver function, hemostasis, or urinalysis in the healthy preoperative patient • Check pregnancy test in all reproductive age women prior to surgery, rather than using history alone to determine pregnancy status

  14. Recommendations for Preoperative ScreeningTests (UptoDate) • Do not check Cr, except: • For patients over 50 undergoing intermediate or high risk surgery • For younger patients suspected of having renal disease • When hypotension is likely during surgery • When nephrotoxic medications will be used

  15. Recommendations for Preoperative ScreeningTests (UptoDate) • Do not ordering an EKG for asymptomatic patients undergoing low-risk surgical procedures (consider for average risk operations) • Check ECG in patients with known CAD, significant arrhythmia, PAD, cerebrovascular disease, or other significant structural heart disease, except for those undergoing low-risk surgery

  16. Recommendations for Preoperative ScreeningTests (UptoDate) • Do not order routine preoperative CXRs or PFTs in healthy patients • Obtain preoperative CXR in patients with cardiopulmonary disease and those older than 50 years of age who are undergoing abdominal aortic aneurysm surgery or upper abdominal/thoracic surgery

  17. Preoperative Tests Before Elective Surgery

  18. Unnecessary Testing • Early radiography for non-specific LBP • Annual EKGs on low risk patients without symptoms • Pre-op CXRs on patients with unremarkable H and Ps • Brain imaging with simple syncope or migraine and normal neurological exam • Unnecessary brain imaging for primary headache disorders costs over $1 billion/yr • Too frequent colonoscopies, Pap tests, ovarian cancer screenings • See “Choosing Wisely” (ABIM Foundation)

  19. Unnecessary Testing • Routine fetal ultrasonography • Tom Cruise/Katie Holmes personal US machine (cost $15,000 - $200,000) for daily use • Vertebrate data suggest prolonged and frequent use of fetal US can cause fetal anomalies • FDA: “unapproved use of a medical device” • May also violate state laws and regulations

  20. Diagnostic Yield: Utility and Reimbursement • Diagnostic yield • History = 75% • Physical exam = 10-15% • Testing = 10% • US reimbursement system financially incentivizes in reverse order

  21. Overuse of Diagnostic Testing • Lake Wobegon Effect • Most “average” patients are at below average risk (i.e., median risk is below average risk) • Thus, for many interventions, expected benefit is lower for “average” patients

  22. Overuse of Diagnostic Testing • Patients report higher satisfaction with care when x-rayed and/or scanned • But symptoms may not decrease • Patients overestimate benefits of testing, underestimate risks of harm • Physicians eager to please • But continuity of care associated with decreased overuse

  23. Wasteful Healthcare Spending • Estimated cost of excessive medications, labs, and radiographic procedures = $200 - $250 billion (imaging $100 billion+) • 50-70% of physicians acknowledge ordering unnecessary tests or procedures at least once per week • Defensive medicine accounts for estimated 1/5 CT scans; inaccessibility of prior studies another 1/5 • Physicians paid per procedure order more procedures than physicians paid on capitation basis

  24. Wasteful Healthcare Spending • Oncologists reimbursed for administering chemotherapy administer more (and more expensive) agents • Estimated $800 billion (1/3 of all healthcare spending) wasted in unnecessary diagnostic tests, procedures and extra days in the hospital • EHRs lead to increased testing

  25. Unnecessary Procedures

  26. Full Body CT Scans • Popularity increased after Oprah Winfrey underwent testing in 2001 • Self-referral body imaging centers proliferating • Highly profitable

  27. Full Body CT Scans • Typical costs for full body CT scans $1000-$2000 • 2004 survey of 500 Americans • 85% would choose a full-body CT scan over $1000 cash • 2005 study: • 86% of patients had at least one abnormality • Mean = 3 abnormal findings per patient

  28. Full Body CT Scans are Opposed by • FDA • AMA • ACR • ACC • ACS • AHA • Many other professional organizations

  29. Marketing Scans • Companies market in areas of higher SES • Prey on fear of heart disease and cancer, and on the natural desire to detect health problems early in hopes of achieving a cure, or at least avoiding potentially disfiguring or toxic therapies • Some companies offering SPECT brain scans to diagnose and manage neuropsychiatric problems (including to children)

  30. Radiologic Imaging • Over 1 billion radiology exams/yr in North America • Overall cost > $100 billion in US • 10% of health care costs • Fastest growing component of medical costs (#2 = pharmaceuticals)

  31. Radiologic Imaging • Utilization driven by introduction of new technologies, new uses for existing technologies, self-referral, patient demand, and defensive medicine • FDA estimates 30%-50% of imaging tests unnecessary • Some data show defensive medicine might be effective against malpractice suits

  32. Changes in Radiologic Imaging1996-2010 • Radiography: 1.2% annual increase • Angiography/flouroscopy: 1.3% annual increase • Nuclear medicine: 3% annual decrease • Ultrasonography: 3.9% annual increase • Use doubled • CT scans: 7.8 annual increase • Use quadrupled • Decrease in all noninvasive diagnostic imaging and in CT scans noted 2010-2015

  33. Radiologic Imaging in the U.S.2013 • 215 CT scans / 1,000 people • 107 MRIs / 1,000 people (Canada less than half this)

  34. Radiologic Imaging is Expensive • Institute of Medicine estimates $30 billion wasted annually on unnecessary imaging (2012) • Adding a CT scan to an ER visit (for any cause) can double Medicare reimbursement

  35. Radiologic Imaging is Expensive • 80 million CT scans ordered in 2016 • Compared to 2.7 million in 1995 • Estimated that 40% unnecessary • Number of preventable duplicates very low per one study

  36. Radiologic Imaging is Expensive • Overall Medicare imaging costs more than doubled from 2000-2006 (to $14 billion) • 2009 costs down to $12 billion • Use of CT scans for ER patients with respiratory symptoms quadrupled between 2001 and 2010 with no measurable clinical benefit

  37. Benefits of Diagnostic CT scans • Decreased cancer mortality • Decreases in exploratory surgeries • Decreased time to triage of patients, especially trauma patients

  38. ?Value of Radiologic Imaging? • Lumbar spine imaging for uncomplicated lower back pain (i.e., no significant trauma, fever, steroids IVDU, etc.) very common but without benefit

  39. ?Value of Radiologic Imaging? • CT/MRI ordered in 6% of ER visits in 1998; 15% in 2007 • Most common reasons = flank pain, AP, HA • CT scans solely for HA rarely influence management or outcome (CA risk from scan approximately 1/20,000 • However, no change in percent of patients admitted to hospital or to ICU over same period • 33% show incidental findings (most of which are not reported to patients)

  40. ?Value of Radiologic Imaging? • Use of head CT and MRI for headache almost doubled between 1990 and 2000, use remains high • Use of CT for dizziness in ER up from 10% of visits (1995) to 25% of visits (2004) without increase in CNS diagnoses • One study found ¼ of CT and MRI studies at one academic institution unnecessary

  41. ?Value of Radiologic Imaging? • 1/3 of the 4.25 million CT scans performed each year on children felt to be unnecessary • Will result in est. 4,870 cancers • ¼ pediatric patients with isolated headache gets at least one head CT (minimal yield, dangerous)

  42. “Epidemic” of Thyroid Cancer in Korea, US • 100-fold increase over less than one decade • May be due to widespread screening • Exposure to flame retardants (ubiquitous in household furnishings) another contributor • Entire increase due to detection of papillary thyroid CA (up to 1/3 of adults may harbor small papillary thyroid CAs) • However, these are associated with exposure to flame retardants (ubiquitous)

  43. “Epidemic” of Thyroid Cancer in Korea, US • Mortality rate unchanged • Of those undergoing surgery, 11% developed hypoparathyroidism, 2% vocal cord paralysis • USPSTF recommends against screening asymptomative adults

  44. Thyroid Nodules • Found in up to 75% of thyroid ultrasounds, 25% of contrast-enhanced chest CT scans, 5%-18% of neck CT and MRI scans • For nodules found by CT or MRI, evaluate further with US if suspicious features (e.g., local invasion or cervical lymphadenopathy)

  45. Thyroid Nodules • For nodules found by CT or MRI, if no suspicious features: • Nodules ≥ 1.0 cm in patients < 35 yo, and nodules ≥ 1.5 cm in patients > 35 yo should be evaluated with US • Purely cystic nodules have < 1% risk of malignancy, require no bx or further w/u

  46. Radiologic Imaging is Expensive • U.S. physicians order 7 times more CT scans than UK doctors (3X French doctors, 2X German doctors) • US has almost twice the number of MRI machines per capita than any other country • Many CT/MRI/other scans ordered because of defensive medicine • Radiology benefits managers

  47. Radiologic Imaging is Profitable • 1/6 physician practices owns advanced imaging equipment (CT and/or MRI) • “medical arms race” • Cardiologists/vascular surgeons earn 36%/19% of their Medicare revenue from in-office imaging • Installation of CT scanners in US cardiology practices tripled between 2006 and 2008

  48. Radiologic Imaging is Profitable • Screening CT coronary angiography now a Medicare covered benefit in all 50 states • Device manufacturers strong lobby • Medicare to cut fees for CT coronary scans significantly between 2010 and 2014

  49. Radiologic Imaging is Profitable • Ownership of scanners by physicians growing dramatically • FDA now requires physicians to declare ownership of imaging devices/facilities to patients • Physicians who self-refer for scans conduct twice as many imaging procedures

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