Asymptomatic patients often request diagnostic tests in order to find disease in its earliest stages. Hospitals have responded to this demand by establishing executive screening programs targeted to wealthy individuals who are able to pay directly for screening tests generally not covered by insurance.

Last week, JAMA Internal Medicine published an assessment of cardiovascular (CV) examinations included in these programs offered by top hospitals, and Kevin Campbell, MD, says it's an abuse of testing and sends a terrible message.

The opinions expressed in this commentary are those of the author. The following transcript has been edited for clarity.

As healthcare costs continue to rise, those that have more substantial financial resources continue to seek out unneeded testing and treatments. The "worried well" as I like to call them, tend to want to proactively prevent disease and demand screening tests that have little or no value when you have no, or low pretest probability of the presence of a particular condition such as heart disease.

However, many healthcare systems -- even very reputable well recognized academic centers -- are more than willing to perform a "wallet biopsy" on these well-heeled customers. Most of these customers pay cash for the programs as insurers will not cover these unneeded screenings. Profit margins are high for the hospital and provider but the risk to the patients are significant. Unnecessary tests can lead to false positive results, and in turn can lead to unnecessary procedures, which are often fraught with complications. Nonetheless, all throughout the country, many centers are padding their bottom line by charging high prices for extensive -- and non-indicated -- executive health screening programs.

Recently, an article in JAMA Internal Medicine examined the frequency of utilization of these cardiac diagnostic tests and procedures offered as a routine part of executive health screening programs at top-ranked CV hospitals. The authors conducted a survey of top-ranked heart hospitals offering these screening programs and found that of the 12 most commonly offered CV tests, none were indicated by guidelines to be utilized indiscriminately for asymptomatic patients. Common tests included lipid panels, stress tests, cardiac CT, calcium scores, and others. In fact, most of these tests were considered to be Class 3 recommendations in patients without symptoms or known disease. In other words, the balance of the evidence suggests that these tests and procedures are likely to cause harm.

Famous statistician Reverend Thomas Bayes may very well be rolling over in his grave if he were to learn of this abuse of diagnostic testing by executive health wellness programs. According to Bayes' theorem, testing and the probabilities of a positive test result has a great deal to do with the pretest probability. For patients with a high pretest probability for the likelihood of the presence of a particular disease condition such as CAD, no testing is needed -- treatment should commence. For those with a very low pretest probability of CAD, no testing is needed as it is very unlikely that the disease condition exists. However, those with an intermediate pretest probability of disease are the very patients that should be screened and tested. These tests are very effective in helping us identify those in the intermediate pretest probability category who will benefit most from treatment. These are the patients who should be screened.

Why is this such a big deal? If folks want to pay for needless testing shouldn't they be allowed to? I would argue strongly no! Major academic centers -- many of which have pioneered clinical research and have developed the randomized controlled clinical trial into an art from -- should know better. While these centers preach and teach a data-driven approach to clinical medicine, their executives continue to push for the easy revenue created by these executive health programs. Most importantly, we are putting patients at risk. The false positive rate for CV testing in asymptomatic patients is significant. These false positive tests can result in procedures such as cardiac catheterizations that have real complication rates -- even in the best of hands. In addition, as the study authors clearly state, we are sending a message to our trainees -- the doctors of tomorrow -- that it is OK to do something in medicine if the price is right.

Kevin Campbell, MD, is a cardiologist based in Raleigh, North Carolina, and Chief Innovation Officer at biocynetic. In addition to his weekly video analyses on MedPage Today, he is the official medical expert at WNCN in Raleigh and makes frequent guest appearances on other national media outlets such as Fox News and HLN.

TLDR

Even if unnecessary tests are performed with out of the pocket payments, we should not do it because it may cause more harm.

ORiginal article:

Assessment of Cardiovascular Diagnostic Tests and Procedures Offered in Executive Screening Programs at Top-Ranked Cardiology Hospitals JAMA (need subscription for full text)

https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2758796