Tuesday Dec 03, 2019
Patients Need to Know the True Cost of 'Free' Screenings
I was in college the first time I observed World AIDS Day.(www.worldaidsday.org) I spent the night with others from our Gay-Straight Student Alliance, tying red ribbons and placards to the palm trees that lined the main campus lawn. Our focus was raising awareness of the impact of HIV/AIDS in different communities and fighting the stigma associated with the disease.
Since then, the focus (for the alliance and other advocates) of subsequent World AIDS Days, which is observed each year on Dec. 1, has shifted from simple awareness of HIV/AIDS to supporting free proactive HIV screening tests and education about pre-exposure prophylaxis.
The results of these collective efforts (along with making HIV medications accessible to people living with HIV) are as you would expect. Progress is slow, but the rate of new HIV infections is at the lowest level ever.(www.hiv.gov) However, we are still missing critical populations. Black men who have sex with men, for example, account for a high proportion of new HIV diagnoses.
There's an obvious lesson here: When it comes to health awareness and screening, it's all about getting the right methods into the right communities. This is consistent with what we already know about screening asymptomatic patients for disease, a practice that is based on longstanding, clear principles(apps.who.int) (availability of an accurate test, identification of an appropriate population and ability to act on results obtained).
But we are shifting into a world of direct-to-consumer screening tests, and the result is that patients think that acquiring information -- in any form -- is better for their health. There is a drive to constantly track and improve our health.
That's why it's even more interesting to reflect on why HIV screening tests are (somewhat) a success story in the world of patient-driven screenings compared with other offerings.
Take, for example, the carotid artery ultrasound. Most people don't need this test to screen for carotid artery stenosis. So imagine my surprise when, early in my career, a healthy patient in her 40s told me she needed a referral to a cardiologist after she had somehow gotten this test at a mobile health fair offering "heart screening."
I've since learned that hospitals and third-party vendors offer things such as stroke screening packages. For my patient, it was the carotid artery ultrasound. For others, the free or low-cost screenings may involve EKGs or ultrasounds of the abdominal aorta.
The subsequent harms from these tests can be tremendous. They may yield false-positive results or incidental findings that lead to riskier procedures and increased costs to our health care system -- all while failing to make people healthier.
In the medical community, the idea that screening tests might cause more harm than good is far from novel. Robust studies have shown no to low reduction in mortality from certain screening tests.(www.ncbi.nlm.nih.gov) Every physician understands the sensitivity and specificity of screening tests. We know the pitfalls of false negatives. We know the fallacy of the idea that early detection prolongs life and we know the definition of lead time bias.
Yet despite the evidence and our education, we've collectively failed to deliver cohesive messaging to patients about screening tests, especially information regarding which patients to screen.
For the HIV screening test, most patients are able to appropriately self-select while avoiding overscreening. In fact, many patients who should get tested still don't. Contrast that with EKGs or carotid artery ultrasounds, which many patients think they would benefit from although most patients don't need them.
Mass media is partly responsible for this critical missing piece of the narrative. Patients who are the exception to the rule generally get airtime, telling stories that are often steeped in fearmongering: the missed pancreatic cancer diagnosis, the rare young patient with a stroke or the atypical presentation of a heart attack.
"Disease of the month" awareness campaigns often are well-intentioned but may also lead to unnecessary overscreening. Breast cancer screening is probably the most misunderstood example of screening complexities. Only 10 of 10,000 women in their 50s will have their lives extended by annual screening mammography, but 940 patients will undergo an unnecessary biopsy. And 62 of those 10,000 women will still die from breast cancer.(jamanetwork.com)
But patients still believe the blanket "early detection is key" mantra and insist that mammograms will save their life.
Given all these nuances, patients shouldn't be expected to navigate the confusing health care landscape on their own. Literally, the reason the U.S. Preventive Services Task Force exists is to guide clinicians, and earlier this year, the USPSTF published its first recommendation on preexposure prophylaxis. The task force recommends that clinicians offer PrEP to patients who are at high risk of acquiring HIV infection. That recommendation, supported by the AAFP, carries an "A" rating, which means the treatment should (eventually) be covered by payers.(www.healthaffairs.org)
Family physicians are the first line of defense when it comes to patient education. It's our role to show patients that screenings are not primary preventive care. No screening test can actually prevent cancer; rather, they exist to detect cancer.
When it comes to reducing risk of disease, primary prevention is best. Eating your vegetables, quitting smoking, taking PrEP. Giving PrEP to just 10 young black men who have sex with men will prevent one new HIV infection.(www.ncbi.nlm.nih.gov) No screening test can beat those numbers.
On World AIDS Day this past weekend, I reflected on the work being done to fight AIDS -- the research, the increased access to medications, the times I've appropriately screened a patient for HIV infection, the times I've diagnosed it and initiated treatment. I'm proud of all that work. But I'm even prouder of the times I've taught my patients about PrEP and reduced their risk of being infected in the first place.
Natasha Bhuyan, M.D., is a board-certified family physician in Phoenix. You can follow her on Twitter @NatashaBhuyan.(twitter.com)
Read other Fresh Perspectives posts by this blogger.
Posted at 10:25AM Dec 03, 2019 by Natasha Bhuyan, M.D.