The following deceptive advertisement appeared in my church's bulletin yesterday: Life Line Screening, the nation's leading provider of preventive health screenings, will offer their affordable, non-invasive, painless health screenings [in the church cafeteria] on April 9th. Five screenings will be offered that scan for potential health problems related to: blocked arteries, which is a leading cause of stroke; abdominal aortic aneurysms, which can lead to a ruptured aorta; hardening of the arteries in the legs, which is a strong predictor of heart disease; atrial fibrillation or irregular heart beat, which is closely tied to stroke risk; and a bone density screening, for men and women, used to assess the risk of osteoporosis. Register for a Wellness Package with Heart Rhythm for $149. Add Disease Risk Assessment with blood testing & biometrics for $79 more.
Although all of these tests sound good, every one is either 1) scientifically unproven; 2) proven to be beneficial only in certain groups of patients (rather than all adults); or 3) likely harmful in the long run, by increasing rates of false positive tests, subsequent unnecessary diagnostic procedures, and the adverse effects of those procedures. As you know, until last November I worked for a federally-supported program that reviews the scientific evidence to support screening tests, and based on that experience, I would not offer most of these tests to my own patients, much less market them directly to a church congregation. Specifically:
1. "Blocked arteries" / stroke screening is most likely a carotid ultrasound scan, which doesn't help because most patients with asymptomatic carotid artery blockages will not suffer strokes. Although the screening test is "non-invasive and painless," the confirmatory test, angiography, is not (it actually causes a stroke in a small number of patients) and unnecessary carotid endarterectomy can lead to death.
2. Abdominal aortic aneurysm screening is only recommended in men ages 65 to 75 who have ever smoked, because aneurysms are much less common in younger, female, and non-smoking populations. Even in men who are eligible for the test, it's important to weigh the potential benefits against the potential harms of corrective surgery, which has a not insignificant mortality rate itself.
3. "Hardening of the arteries in the legs," or screening for peripheral vascular disease with an arterial-brachial index, hasn't been proven to prevent heart attacks but will certainly lead to many false positive results.
4. I've never even heard of atrial fibrillation (irregular heart beat) screening, which I presume is doing a screening EKG, which is also totally unproven. Absolutely no organizations recommend this.
5. Screening for osteoporosis with bone density testing is the only test on the list that's actually worthwhile for a large number of adults, especially women over 65. But it's not appropriate to do this test without a prior consultation with a clinician who can discuss the risks and benefits of undergoing this type of screening. And there are still questions about whether men benefit to the same degree as women, or at all.
In a nutshell, that's why companies like Life Line have no business portraying these services as "preventive health screenings," in my church or any other community setting. (I've sent an e-mail to my pastor recommending that they be dis-invited for the reasons I've outlined above.) It's one thing to draw blood for a cholesterol test and take someone's blood pressure (which will cost a whole lot less than $149), and quite another to offer these other procedures which are, at the very least, a waste of money and quite possibly harmful.
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Completely agree! As I noted in my post, take the money and buy a good pair of walking shoes to improve overall health would be far more advantageous!
ReplyDeletehttp://davisliumd.blogspot.com/2010/05/life-line-screening-worth-money.html
Keep up the good work!
--
Davis Liu, MD
Author of Stay Healthy, Live Longer, Spend Wisely: Making Intelligent Choices in America's Healthcare System
(available in hardcover, Kindle, and iPad / iBooks)
Website: www.davisliumd.com
Blog: www.davisliumd.blogspot.com
Twitter: davisliumd
Very important post. Three or four times per year my patients bring in the brochure for this "screening". I discuss your main points with them and see what happens- usually they cancel or don't sign up. Thanks for adding even more power to the argument.
ReplyDeleteI absolutely agree with the above comments (although, for obvious reasons of what has become popular culture, will not say "ditto!").
ReplyDeleteI am going to recommend it to my blog readers.
Stroke is the 4th leading cause of death in the United States. It affects some 800,000 people a year, and the risk doubles every decade after age 55. Yet, 80% of strokes are preventable.
ReplyDeleteI have been a vascular and cardiothoracic surgeon for more than 30 years and also serve as the Chief Medical Officer of Life Line Screening. I became interested in the work that LLS does because I found it sad and tragic to be called to the ER to see a patient dying from a ruptured abdominal aortic aneurysm which, had it been discovered even a day earlier, could have been repaired. I found it similarly sad to be called to see patients who suffered completed embolic strokes and for whom nothing could be offered except the often vain hope of months or years of rehabilitation.
There are three known causes of greater than 99% of all strokes: carotid artery disease, atrial fibrillation, and hypertension. At LLSA, we screen for all three. Isn’t it better to know before the catastrophic stroke occurs, when medical therapy or a simple lifestyle change could reduce the likelihood of such a calamity?
New carotid artery guidelines by the American College of Cardiology and the American Heart Association/American Stroke Association recommend screening for people with two or more risk factors. These include age, family history, smoking, high cholesterol, high blood pressure, lack of exercise and being overweight. Life Line Screening is completely in accord with these guidelines. .
If screening for the three major causes of stroke (carotid stenosis, atrial fibrillation, hypertension) is unnecessary and not worth the cost, why then are there more than 600,000 first-ever strokes and more than 185,000 recurrent strokes in the US alone?
Many groups, such as the Society for Vascular Surgery and the American Diabetes Association, recommend Peripheral Arterial Disease screening for every diabetic age 50 and over. PAD screening is also recommended for better cardiovascular risk prediction, as documented in a paper published in the Journal of the American Medical Association (JAMA) by Jaff and colleagues from the University of Massachusetts as well as by Consumer Reports.
AAA screening is already recommended for male smokers. Now, newer research reveals that women are at higher risk than previously thought and that 50% of these women are ineligible for screening under current federal guidelines. This new AAA research was conducted by independent researchers using data from Life Line Screening.
Vascular surgeons, Drs. Kent and Zwolak, highlight the importance of vascular screening and the necessity to do more of it, when they cited Life Line Screening as an example of a successful company in the field of AAA and vascular screening in a paper in Endovascular Today, writing “The most successful of these organizations is Life Line Screening, which has screened more than 6 million individuals for vascular disease since 1993. Despite the progress made by Life Line and other companies, this is still only a fraction of the individuals at risk.”
Community-based screenings are an innovative approach that is appreciated by hospitals and doctors, who often send their patients to us. In addition, we hear regularly from people who feel the screenings save lives. We encourage everyone to talk to their doctors, visit our website, and consult their family and friends and decide for themselves whether the benefits of preventive screenings are right for them.
While smoking cessation, weight control and other modalities are very useful for the prevention of stroke and other atherosclerotic illnesses, I have found that confronting an obese, smoking patient with the hard data of significant plaque in their carotid arteries, aorta or peripheral arteries is a far more powerful motivator for behavioral change than simple physician advice.
Andrew Manganaro, MD, FACC, FACS
Chief Medical Officer
Life Line Screening
Dr. Manganaro- shame on you for exploiting fear for profit. Your arguments are unconvincing and as a practicing FP I commonly see very anxious patients with incidental findings that now need further expensive and often potentially risky further evaluation. I believe one's support of this screening is directly proportional to the profits one reaps from the procedure.
ReplyDeleteIncidentally, I don't mean to single out Life Life Screening - there are many other companies out there doing the same thing and hawking unproven screening tests to uninformed patients. (They just happened to be the one that wants to come to my church!) But let me respond to a couple of Dr. Manganaro's arguments.
ReplyDeleteIsn't it better to know if you're at elevated risk for a stroke before it occurs? Of course, IF SUCH KNOWLEDGE IS PROVEN TO LEAD TO BETTER HEALTH OUTCOMES. That's the key ingredient missing here - there is no proof except anecdotes (patients who believe that their lives were "saved" by screening) that performing a carotid endarterectomy or putting in a stent in someone with an asymptomatic, non-critical carotid stenosis detected via a community screening will do them more good than harm. Not everyone at risk will suffer the bad outcome. And even those who will won't necessarily have that bad outcome prevented through earlier intervention. And even those who do benefit may not outweigh the far greater number who suffer inconvenience and adverse effects.
The evidence that presenting patients with scan results (rather than risk calculations based on clinical factors) will motivate them more to adopt healthy lifestyle habits is also unproven. Changing behaviors is a complex and poorly understood science. On the other hand, in physicians with the technical capability to perform an intervention, a stenosis on ultrasound or CT scan will trigger the "oculostenotic reflex" - that is, if you can see a lesion, put a stent in it, even if medical management is just as good.
This lifeline screening is a complete waste of time. They are just using the church as a means to promote their ineffective method of preventive health screening. It would be better to consult with a licensed medical practitioner instead.
ReplyDeleteI thank the doctors for their candor!! My husband and I were scheduled through our local hospital for this screening but I am canceling. We are non smokers age 57 and 59. My husband had a scare he thought was his heart and it was negative with the EKG and blood test, he ended up having walking pneumonia. We don't have insurance and own our own business so we thought this would help for the future. We are starting an exercise program and we are very careful with our diets. Gloria glo_heart@yahoo.com
ReplyDeleteI agree with Dr. Lin's advice. The USPSTF is very clear with their methodologies and their reasoning for making recommendations in asymptomatic adults. It would be preferable to do a full risk assessment of patients rather than screening to provide patients with an idea of their chances of developing the disease in question (ie why not use the Framingham risk assessment tools) and then engage them in shared-decision-making, as I comment on my blog: http://clinicalpreventivemedicine.blogspot.com
ReplyDeleteIn addition, although screening may yield positive results, fear alone has been shown not to be effective in motivating people to change behavior and sustain that behavior change. Physician advice, if given in the appropriate context, such as through motivational interviewing and considering the patient's environment (moving beyond the health belief model into the social cognitive model for instance) is more effective in achieving sustainable behavior change.
Thank you for your valuable post.
ReplyDeleteWe have decided to share it with our global physician audience at PhysicianNexus.com: http://physiciannexus.com/forum/topics/preventive-health-screenings
Ruby
Team Member
www.PhysicianNexus.com
Physicians connecting worldwide
I worked for lifeline screening, until recently, I told them where to shove that job. Its definately a complete ripoff company. I was told not to spend much time talking to participants and we were to rush them in and out. Not a good practice so I quit
ReplyDeleteNot only are they a complete waste of time and a rip off they do not yield accurate results. This company makes money by preying on the elderly and un(medically)educated. They gave my mom some bogus print out explaining that she had CKD3 and for a normal person to have gotten these results it might have gone unnoticed, but because I worked in Nephrology for almost 3 years I caught it! My mother's creatnine and GFR at the lifeline screening basically would have doubled from her last CMP drawn by her physician 6 days prior meaning she lost 50% kidney function in 6 days really?! When I questioned how they did these scientific tests her response was "well it was kind of like those mobile blood banks and they pricked my finger and the lady came back with this paper" Yeah pretty sure this is VERY unorthodox, unethical and maybe even illegal.
ReplyDeleteQuote: "I've never even heard of atrial fibrillation (irregular heart beat) screening, which I presume is doing a screening EKG, which is also totally unproven. Absolutely no organizations recommend this."
ReplyDeleteI'm not sure why the author believes a screening EKG is an "unproven method" of detecting afib. I was diagnosed with afib four years ago - which was quite unexpected since I was 50 at the time and in excellent health. I have always been very sensitive to my heart rhythm so I knew immediately something abnormal was occurring and went to the ER. (I was also very symptomatic at the time - dizziness, etc.)
Since my original diagnosis I have joined an online support group for people with afib and frequently visit sites such as stopafib.org. I was surprised to learn how many people were totally unaware they were in sustained afib until it was discovered during a routine EKG. This happens much more frequently than the author seems to believe. Undetected afib can result in catastrophic stroke so it seems hard to argue against a simple and non-evasive EKG which may detect it. BTW - many of the people who were unaware of their sustained afib were like me - under 65 and otherwise in good health with no other cardiac abnormalities (aka "lone afibbers").
This study looks at screening versus routine practice in detection of atrial fibrillation in patients aged 65 or over: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1952508/
Also: http://www.preventaf-strokecrisis.org/report/call-to-action
It's definitely not true that no organizations recommend routine screening for afib.
Perhaps there is an organization that recommends routine screening for atrial fibrillation, but I'm hard pressed to name one, and certainly no major cardiology or primary care group does. The study Afibber cited actually found that the most effective "screening" strategy was taking the patient's pulse and doing EKGs on the abnormals, rather than just doing EKGs on everyone. I would argue that the former isn't screening at all, but part of standard vital signs. You don't need an EKG to suspect rapid A-fib, just a few seconds of attentive pulse taking by the doctor, nurse, or medical assistant. Screening EKGs have been promoted for other reasons, such as screening for asymptomatic left ventricular hypertrophy (a risk factor for sudden cardiac death), but a recent systematic review found no evidence this works in practice: http://www.uspreventiveservicestaskforce.org/uspstf11/coronarydis/chdupd.htm
ReplyDeleteThank you for this post and all the comments. This is what I needed to decide whether to get my mom to take these tests! And for a company to take advantage of elderly population in churches....that's simply unscrupulous and unethical!
ReplyDeleteDear all, hi my name is Luis Lee, MD, currently a PGY-4 in surgery; PGY-1/2 were clinical and PGY-3/4 in research in trauma surgery. There are a few points I'd like to make here in response to your posts:
ReplyDelete-"unnecessary carotid endarterectomy can lead to death". The ACAS and NASCET trials have given us very clear guidelines when to perform these surgeries, hence there's no such thing as "unnecessary" CEA. ie: medical management vs CEA depending on the degree of blockage.
-"oculostenotic reflex"- that doesn't exist with carotid atherosclerosis. Depending on your degree of blockage, you are either on medical management or you get a CEA. Stent options are for those with too many risk factors to undergo surgery.
-While the USPSTF is "is very clear with their methodologies and their reasoning for making recommendations" - really? I'm sure OB/GYNs and Breast surgeons would argue against you when you (FPs who strictly follow USPSTF) do screening mammography starting at the age of 50. While it's a respected task force, it's not the only one that provides guidelines. Hence, Dr. Manganaro's paragraph: "New carotid artery guidelines by the American College of Cardiology and the American Heart Association/American Stroke Association recommend screening for people with two or more risk factors. These include age, family history, smoking, high cholesterol, high blood pressure, lack of exercise and being overweight." (I am not affiliated in any way to LLC). Whether you agree with Dr. Manganaro or not, he does make a compelling case to support his business...which leads me to my next point...
-One thing I've learned about medicine is that - aside from its altruistic intentions - it IS a BUSINESS. "exploiting fear for profit..." Whether there's fear or not, exploitation or not, there WILL be profit, guaranteed. This is a capitalistic society. Perhaps you'd prefer socialized medicine. Occupy Doctor's Office? I hope not...i got too much loans to pay off...
-I think the truth is somewhere in between. I'm sure you FPs get swamped with patients telling you "doc, I saw this screening program..." "doc, I saw this ad on TV about..." that usually does nothing but to increase the patient's anxiety, and then it becomes your job to debunk their myths/beliefs. On the other hand, I don't think it's wrong to do these "screenings", as the USPSTF puts it, every screening should be individualized. Whether patients get enticed by the advertisements...that's a different story.
-"draw blood for a cholesterol test and take someone's blood pressure (which will cost a whole lot less than $149)...a waste of money and quite possibly harmful. ". False statement. The copay can vary, but what the insurance company pays the physician/practice is more than $149 - again, medicine is a business. Waste of money? probably. But at least it won't come out of the health insurance, which would keep everyone else's premiums low. "possibly harmful" - relative risk of this screening doesn't seem to be significantly different than someone getting hit by a car.
-Again, in CEA there is NO such thing as "unnecessary".
-Thank you all for reading this. I look forward to finishing my surgery residency and work with other MDs of any specialty. And if FPs think that we do "unnecessary surgeries", I hope I will change your mind about that. I love to operate, but I'd prefer Not to operate if I don't have to..
"In CEA there is no such thing as 'unnecessary'" - the medical literature says otherwise. A systematic review of the overuse of health care services in the U.S. recently published in the Archives of Internal Medicine (http://archinte.ama-assn.org/cgi/content/short/172/2/171) found 13 studies from 1996-2008 demonstrating that carotid endarterectomy was performed up to 33 percent more often than indications from the ACC/AHA guidelines recommend. (If you don't have a subscription to this journal, this Medscape article has a good summary: http://www.medscape.com/viewarticle/757527)
ReplyDeleteNow, is this overuse all driven by unscrupulous surgeons only interested in increasing their incomes? Of course not. The vast majority of surgeons, I'm sure, have only their patients' best interests in mind when they consent patients for surgery. But whether it's due to lack of awareness of current literature/guidelines, "soft" indications, or pressure from patients who are scared to death by their Life Line screenings, it's a fact that too many patients in the U.S. are undergoing CEA who are unlikely to benefit from it.
One more thing. Dr. Manganaro writes: "While smoking cessation, weight control and other modalities are very useful for the prevention of stroke and other atherosclerotic illnesses, I have found that confronting an obese, smoking patient with the hard data of significant plaque in their carotid arteries, aorta or peripheral arteries is a far more powerful motivator for behavioral change than simple physician advice."
ReplyDeleteIf it were actually true that showing someone an image of their carotid stenosis would motivate them to make lifestyle changes such as quitting smoking, I would agree that perhaps there would be a good reason to do more imaging. Unfortunately, this hypothesis was recently tested in a randomized controlled trial, and even though 58 percent of smokers in the intervention group were found to have carotid plaques, there was no statistical difference in cessation rates between the groups after one year, and patients with plaques were not more likely to quit smoking than those with normal ultrasound results: http://archinte.ama-assn.org/cgi/content/short/172/4/344
I believe kennylin might be taking his opinion a little too far. My first thought is: according to Doc, no organization recommends these screenings. Well, do you really want to live your life according to what some govt group/agency reccommends? The FDA? What a joke. I'd rather be proactive and spend the $150 to see if I am risk for a aneurysm etc that groups like lifeline does. Also, if they are of no value; why do hospitals offer these screenings? Whey do they partner up with groups like lifeline? Because its all about the money; not helping people. So shame on you doctors out there bashing screenings when the hospital that pays your salary probably has their hands in the "screening cookie jar" anyways.
ReplyDeleteThank you all for your informed opinions about the value of these screening tests. I am a naturally born skeptic and my 58 years of existence has taught me that more lies have been told in the pursuit of making money than possibly any other endeavor on the planet. The internet has provided a wonderful tool for us all to become totally confused about the truth of any subject you can imagine. I was going to schedule an appointment for these tests, but I have considered the advice given here and I think I will decline. So to those of you who say that is a mistake I can only reply that you might be right. I guess time will tell because there seems to be dissention among the jurors on this subject. jms317@gmail.com
ReplyDeleteSo, we should not have at least a Plac test done somewhere? Is just knowing I'm living and breathing today just as yesterday going to suffice?
ReplyDeleteInstead of bashing Life Line which I was considering, how about you make affordable alternative recommendation(s) for those of us that do have deceased siblings, and parents due to heart disease. Besides the 3 X weekly exercise, low fat and Blood Pressure monitoring I already do.
I am a guy from the uk aged 75...pretty fit apart from hereditary heart conditions...with a NHS not remotely interested in my welfare owing to uk govt ageist policies...despite me having paid into the system since the age of 18. I almost have to beg for simple what should be routine check ups considering my lt atrial enlargement, severe angina, rt bundle branch block...and having had severe elevated BP for years...such is the lack of concern shown...I now self medicate with NEBIVOLOL-ENTERIC COATED ASPIRIN-L-ARGININE and GOAT WEED-which has p5 factor thus enhancing Nitric oxide. I researched all myself owing to ageist attitude shown by NHS. My BP has changed from regular 169 over 90'ish..with 89 pulse to 129 over 74 with 55 pulse. I had a screening with LLS 2 years ago...yes we were given the tests on time...with efficiency and respect...so much better than last GP appt...40 minutes late...with not even my pulse taken. I am returning to LLS on 6th June jusu to see all is still ok...and answering one point in your posts ECG is certainly of value...one showed 3 undetected MRIs! My specialist diagnosed AF 6 years ago...with recommended annual checkup which my GP-earning 149,000 pounds a year took no note of...so THANK GOD for LLS-who for a meagre 139 pounds give me peace of mind! Iain Hines...UK
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