June 23rd, 2014

Unethical Health Screening: When Unnecessary Tests Do More Harm Than Good

The policy group Public Citizen is urging 20 hospitals in eight states to sever their relationships with HealthFair Health Screening because they believe the company’s heavily promoted, community-wide cardiovascular health screening programs are unethical and are more likely to do harm than good. ACC president Patrick O’Gara released a statement saying that, “The questions raised about screening have some merit.” CardioExchange asked Ethan Weiss, an Associate Professor at the UCSF School of Medicine, to share his thoughts on this issue. Further details are included in CardioExchange’s news coverage.

Conceptually, people (including many doctors) believe that we should do everything we can to discover occult disease like heart disease. The assumption is that if we look hard enough, we can find disease and intervene to change the outcome in a positive way. People may ask, “What’s the harm?” However, for cardiology at least, there is no evidence to support this assumption outside of screening for hypertension, lipid abnormalities, and diabetes. This situation is worsened when options such as executive physicals are offered, which harden the perception that there must be some health benefit, but you just need money to access it. Again, sadly, this is not supported by evidence.

There can be serious consequences to false-positive results. Usually the harm is limited to unnecessary anxiety caused by false-positive tests, but there are also costs (many of these tests are not reimbursed) and the rare cases where false positives result in more tests that lead to complications and very serious medical consequences.

I once had a symptomatic patient with well-managed risk factors who insisted on having a nuclear stress test annually. It had been something started by a colleague of mine who had seen him before me — a very senior and respected doctor — and it was hard for me as a young doctor to overcome the perception that I did not know what I was talking about.

I kept doing the stress tests for a few years, but all the while I tried to convince him it was a mistake. I finally resorted to telling him that I was concerned about all the radiation he was getting. He continued to insist on the tests because he believed (firmly) that this was helping him and could not harm him.

One summer, I got an urgent call from him from the U.S./Canada border where he was being detained — he had set off the Geiger counter crossing the border a few days after his stress test. He was shaken. I reassured him and convinced the border patrol that he was not a terrorist. The next time he came to see me, he agreed to stop having stress tests and has not had one since.

I do believe that we can and will eventually improve our prediction tools. Right now blood pressure, lipids, and diabetes are the only validated — and thus, recommended — things to screen. This does not mean that we shouldn’t talk about other factors such as weight, body composition, nutrition, and exercise with our patients. The truth is that the evidence base for these factors is pretty flimsy too, but we make the assumption that it can’t hurt, and I try to inform patients where we have strong evidence and where we do not.

The bottom line for me is to be honest with patients about what prediction and prevention tools we have and what the evidence base is for each of them. Going forward, we need to work on more robust and careful studies from which we can learn how to better identify at-risk individuals and also validate whether the new tools do what they should. Finally, we should work to show that the information we learn from these tools can help improve clinical outcomes.

7 Responses to “Unethical Health Screening: When Unnecessary Tests Do More Harm Than Good”

  1. Enrique Guadiana, Cardiology says:

    I agree with Dr. Weiss, the only way this could happen is in the presence of dishonesty from institutions and physicians. But we must be very careful to not become some kind of inquisition. The people have the right to choose, even if they make mistakes, this is the base of a free society. Our obligation is to be honest, do not harm, and help our patients. Our mission is not by any means to judge our patients. Even if we believe they are wrong we must respect their decisions. We are doctors not gods. Diversity is the rule.

  2. in india we get a deduction on taxable income in lieu of health check ups & premiums paid for health insurance. just as u rightly talked about healthfair health proggramme, here we have numerous ones, without any regulatory body or pressure groups looking for authenticity. Hundreds of corporations mostly private get these tests done for their millions of employees each year & futher reap benefits out of those expenditures – without any outcome.

    my percetion / science, gets further strengthened by this discussion.

  3. Thierry Legendre, MD says:

    It is difficult to discover a serious disease in healthy asymptomatic subjects. The healthier they are, the more complex the tests must be . According to the Bayesian theorem ( low pretest probability ), the risk of a false positive test is high inducing new tests again and again for a prohibitive cost and often risk for the patient.

    Moreover, let’s bear in mind that treating sooner does not necessarily lead to improved prognosis .

  4. Juerg Kuoni, M.D. says:

    The USPSTF is clear about cardiovascular screening in healthy asymptomatic People: it does more harm than good. I agree with Thierry Legendre: it rarely does improve prognosis. Treating sooner generally means treating longer.

  5. Jean-Pierre Usdin, MD says:

    The American College of Physicians towards the same way.
    See this summary found in JWatch Women’s health alerts, this morning:

    Against performing routine pelvic exam in well-women visits!

    Whither the Routine Pelvic Exam?

    Andrew Kaunitz, MD Reviewing Sawaya GF and Jacoby V., Ann Intern Med 2014 Jul 1; 161:78

    The American College of Physicians recommends against performing routine pelvic examinations as part of well-women visits.

  6. “Right now blood pressure, lipids, and diabetes are the only validated — and thus, recommended — things to screen.”___Really?

    Coronary calcium quantification has been shown to be dramatically more powerful a screen for vascular risk than all conventional risk factors combined. A calcium score of 0 is associated with 300 in MESA was associated with >9 fold increase in risk for events compared to the the event rate predicted by conventional risk factors.

    A study of young (men younger than 55, women younger than 65) non-diabetics with heart attacks, demonstrated that only 1 in 4 would have been identified as being at sufficient risk to justify a statin prior to their MI (JACC 2003:41 1475-9).

    Khot, et al. JAMA. 2003 found that 64% of men with heart attacks had 0-1 risk factor and would rarely qualify for (or take) statin therapy.

    An study in Circulation from years ago demonstrated that the majority of heart attacks occur in subjects with less than 70% obstruction in the vessel responsible for the MI and therefore almost always missed on stress imaging (Falk E, Shah PK, Fuster V Circulation 1995;92:657-671).

    As vascular disease remains the leading cause of death and disability in this country, it seems foolish to continue to insist on the inadequate predictive ability of conventional risk factors.

    Selection of screening tests however is important. To do annual nuclear stress tests is not only of no demonstrated value, it is of no theoretical value and provides a level of radiation that can cause harm.

    As stress testing it looking for obstruction, and the vast majority of heart attacks occur as a result of rupture of non-obstructive plaque, the stress test will miss most at risk. Of those found to have obstruction, the stress test often leads to angiography and stents. We now have 7 prospective, randomized studies that show no improvement in MI or Coronary survival from stenting. The most recent Fame II showed this in those documented to have severe narrowing in the vessels.

    Coronary calcium screening however is extraordinarily powerful in identifying those at risk for MI, motivates behavioral changes in those with positive scores, is inexpensive and when performed properly on the correct equipment emits very little radiation.


  7. Ravindra Tongia, MD MRCPI FRCP FACC says:

    “Executive” Health Checkups ahve become deeply ingrained in the minds of patients, doctors, hospital adminstrators, and big corporates – further facilitated by the successful lobbying and getting tax exemptions in India, despite no proof of any benefit – except to the diagnostic centre or hospital. The facility where I work offers thirteen different ‘packages’ as specialized preventive health checks! While benefit to an individual(who is not really a patient till he gets his results!)are not proven, the harm induced are many: like chasing the so-called abnormal biochemistry values which fall outside the “normal” range means more unnecessary and expensive/potentially harmful tests. A silent gall-bladder stone discovered by sonography done as part of package often ends up in cholecystectomy; a ‘positive’ stress-test in an otherwise healthy asymptomatic person gets a coronary angio and sometimes stent placement! List can go on and on.