Top Cardiac Centers Offer Unproven 'Executive Screening'

Batya Swift Yasgur MA, LSW

January 22, 2020

A large number of prestigious academic medical centers offer "executive screening" programs designed to allow asymptomatic people to obtain early risk assessment and detection of cardiovascular disease, presumably with the aim of earlier intervention and more favorable outcomes if an abnormality is identified.

The problem is that indiscriminate screening is not only expensive but runs counter to evidence-based recommendations of medical societies for asymptomatic individuals without specific risk factors, say authors of a research letter published January 13 in JAMA Internal Medicine.

"Most of the best and most prestigious cardiology programs in the US have these executive screening programs that charge a lot of money, are not covered by insurance, and have no evidence to back up their value," David Brown, MD, professor of medicine, John T. Milliken Department of Internal Medicine, Cardiovascular Division, Washington University School of Medicine, St. Louis, told | Medscape Cardiology.

"These programs provide an institutional stamp of approval on a two-tier system of medicine: those who can afford to buy whatever they want, and the rest of us who can't afford to do so," he added. "They also make a statement that if someone is willing to pay enough money, they can be given whatever test they want, even if there is no evidence to support it."

"Finger in the Eye"

In this new analysis, investigators assessed the cardiovascular examinations offered in these programs at 18 "top hospitals" for cardiology and heart surgery, as ranked by US News and World Report, encompassing 28 programs.

They found that the programs included 12 cardiovascular tests plus a resting electrocardiogram (ECG): abdominal aortic ultrasonography; cardiac calcium score; cardiac stress test (including exercise ECG or echocardiography); cardiovascular counseling; carotid artery ultrasonography; carotid intima-media thickness (IMT); coronary artery CT scan; exercise consultation; lipid panel; lipoprotein(a); and vascular screening.

The most commonly offered tests were a lipid panel and cardiac stress testing, offered in 20 of 28 (71%) and 19 of 28 (68%) institutions, respectively. Cardiac CT scans either to determine the calcium score or to visualize the coronary arteries were included in 12 of the 28 programs (43%).

Two programs included cardiovascular counseling and one included exercise consultation.

The lowest-cost program, at $995, was the Comprehensive Health Assessment at Houston Methodist Hospital, while the highest-cost program, which cost $25,000, was the Premier Executive Health Program at Cleveland Clinic.

Only three programs submitted charges to an insurance carrier.

"The premise of using these tests is that the results may help reduce mortality from CVD through earlier disease detection or more precise risk assessment; however, no data support that premise," the authors note, as reflected in guidelines from the American College of Cardiology/American Heart Association (ACC/AHA), the United States Preventive Services Task Force (USPSTF), and the American College of Preventive Medicine (ACPM).

Certain tests or interventions may be recommended under specific circumstances; for example, the USPSTF recommends offering or referring adults who are overweight or obese and have additional cardiovascular risk factors to intensive behavioral counseling interventions for CVD protection.

However, in the current executive screening programs, "a company's CEO who is a marathon runner might get the same testing as a CEO who weighs 300 pounds and is completely sedentary," Brown said.

"There should be no indiscriminate testing where your only qualification is that you have the money to pay for it," he emphasized.

The fact that these are offered at academic medical centers "sends negative messages not only to the public, but also to students, residents, and trainees," putting a "finger in the eye both to the equity of healthcare and to evidence-based medicine at the same time."

And these tests are not without harm, he noted. "There is a downstream cascade effect, where an incidental finding might lead to more tests, then more procedures, and more complications from procedures, and anxiety on the part of the patients."

Application of Anecdotes

Commenting on the study for | Medscape Cardiology, Ty Gluckman, MD, medical director, Center for Cardiovascular Analytics, Research, and Data Science (CARDS), Providence Heart Institute, Providence St. Joseph Health, Portland, Oregon, said that, in "selected circumstances, all of these tests might have clinical value, but from the standpoint of more widespread unselected testing/screening, most of the listed tests have little or no value in asymptomatic individuals, and instead, just drive up costs."

Moreover, unnecessary testing that yields indeterminate findings can prompt further testing that "may also be of little clinical value and potentially engender harm."

He acknowledged that there are anecdotal reports of individuals who were found to have abnormalities on tests, leading to interventions that "saved their lives."

The problem, he said, "is the application of anecdotes to the broader patient population."

He noted that the 2013 ACC/AHA guideline on cardiovascular risk recommends that one's 10-year risk for adverse cardiovascular events (fatal and nonfatal myocardial infarction and stroke) be assessed using an equation that includes demographic factors, blood pressure — which, he noted, should be assessed at every physical exam — cholesterol levels, diabetic status, and history of tobacco use.

"In short, only one lab value, a cholesterol panel, is suggested for initial cardiovascular risk assessment, and not all of these other tests," he pointed out.

In individuals at intermediate risk, the 2018 AHA/ACC cholesterol guidelines now endorse consideration of using coronary calcium scoring to help further refine the estimated risk if there is uncertainty whether patients should be placed on cholesterol-lowering therapy.

The "flip side of these recommendations is that the current preponderance of evidence doesn't support unselected coronary calcium scoring, unselected stress testing, or unselected carotid ultrasounds to further assess the risk profile of a given individual," said Gluckman, who is also chair of the ACC's Solution Set Oversight Committee (SSOC) and was not involved with the study.

Pandora's Box?

Also commenting for | Medscape Cardiology, Rita Redberg, MD, MSc, professor of medicine, University of California, San Francisco, said that "imaging tests with no known benefits, such as offered by the executive screening programs, open a Pandora's box," and "it is hard to put the genie of incidental findings back in the bottle."

It is an "axiom that one (unnecessary) test begets another," said Redberg, who is the editor of JAMA Internal Medicine and the coauthor of an accompanying editorial.

Redberg, who was not involved with the study, said that she "sees many patients in clinic who are losing much sleep and more over meaningless but worrisome incidental findings found on inappropriate imaging tests."

If these programs are to be offered, "patients should be informed accurately and completely of the data on risks and benefits and allowed to decide accordingly," she said.

Brown went further, adding: "There is no need for these programs, which, I think, are done to generate revenue, donations from these wealthy patients.

"You have to show that a screening program prevents people from dying and there is no evidence of that," he said.

No source of funding reported. The study and editorial authors and Gluckman report no relevant financial relationships.

JAMA Intern Med. Published online January 13, 2020. Research letter, Editorial

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