Does CV Screening Add Value?
Inpatient cardiovascular discharges continue to decline at a rate that causes executives’ hearts to skip a beat: Sg2’s Impact of Change® forecast suggests an 8% decrease over the next five years. Many organizations are considering cardiovascular screening programs as one way to maintain CV volumes, even though there is a paucity of data to support this. A common belief is that a broad screening program for cardiovascular conditions in an asymptomatic population has the potential to:
- Increase the organization’s visibility in the community
- Provide a community service
- Differentiate from local competitors
- Identify patients who may subsequently need downstream services (eg, a procedure)
While some of the above may be true, in order for organizations to truly create value in a CV screening program, the goals and target population must be well-defined.
CV Screening Programs Lack Documented ROI
What can realistically be generated from a screening program? There are few data published on the return on investment (ROI) for screening programs, presumably because of the lack of a positive ROI associated with many of them. Anecdotally, programs with CV disease screening for the general population have not been cost-effective, with referral yields of less than 0.5%. These initial disappointing experiences present organizations with a decision to make: refine the program to a more targeted patient population; abandon the screening program; or expand the program further.
Risk Factor Screening vs Disease Screening
Which path to follow? Well, it depends. To create a program that brings value to both organizations and patients, let’s break down screening programs into two main types: 1) risk factor screening programs; and 2) disease screening programs.
- Risk Factor Screening Programs provide a low-risk screening option that can be applied to the general patient population. Results can lead to lifestyle modification and/or prescription of medications to reduce the likelihood of cardiovascular disease in the future. Factors included are those associated with the development of atherosclerosis (eg, blood cholesterol, blood sugar, weight, blood pressure), and there are data to support that improving risk factors will improve longevity and quality of life. These screens can be performed in the physician’s office, requiring only bloodwork and simple measurements. A health care provider (PCP or advanced practitioner depending on resource availability) can screen patients at low cost (perhaps with a modest contribution margin), and increase visibility in the community as an institution that is concerned with population health.
- Disease Screening Programs have generated much more controversy and have recently been in the crosshairs of many organizations. General screens for identification of CV disease in asymptomatic populations using an imaging modality (eg, ultrasound, CT screening for vascular calcification, other CT modalities) have been discouraged by clinical societies.
In July the US Preventive Services Task Force published a recommendation against screening for asymptomatic carotid artery disease. In addition, Public Citizen, a consumer advocacy group, recently raised concerns about disease-based screening marketed to the general public as a misleading service that is costly and can result in false positives, potentially leading to unnecessary, risky procedures that could expose the institution to reputational risk and liability. The American College of Cardiology and American Heart Association agree with this position; they offer guidelines and tools to help physicians make decisions on an individual patient basis about the risk of heart disease and stroke.
Additionally, in many communities there is a desire to screen young athletes for preexisting heart conditions before they participate in athletics. An institution may want to provide this screen as a community service; it also may generate some revenue. However, there is also controversy over how much needs to be done in such screens, as mentioned in a 2014 New England Journal of Medicine article by Colbert.
There are some areas where disease screening may be warranted, such as in patients with another preexisting clinical condition or previously identified risk factors. These include screening for abdominal aortic aneurysm in elderly men who have smoked, and looking for atrial fibrillation in patients who have had a stroke or other cerebral event (transient ischemic attack). A recent study in the New England Journal of Medicine by Gladstone et al suggested that these types of targeted screens should be used more commonly in clinical practice today.
Strategies for Success
The success of any type of cardiovascular screening program relies on:
- Clearly defining the target patient population by using established clinical guidelines
- Identifying and communicating program goals to all stakeholders
- Working with physicians directly to increase adoption of appropriate screens
- Leveraging existing clinic equipment, diagnostic lab resources and staffing to maximize program value
- Regularly collecting, analyzing and sharing data across all appropriate parties
- Adjusting screening protocols based on local program data and updates to national clinical guidelines
Screening programs are an important way to progressively manage different patient populations and slow disease progression through lifestyle modification and medications, but will likely offer little in terms of downstream procedure volumes. The organizational impact will vary based on program type, requiring clear communication and expectations throughout the organization. Choosing what direction to take CV screening in your organization is a nuanced decision that must be made based on your specific market, organizational goals and capabilities. Whether you are looking to support your population health initiatives or strengthen referrals, screening programs that adhere to society guidelines can add value to your organization and community.
Note: Sg2 Consultant Chad Giese contributed to this post.
Sources: Zeltner B. Consumer group urges Summa, other hospitals to stop “unethical” mobile heart screenings [press release]. Cleveland.com. July 1, 2014; Appleby J. Hospitals, testing companies face questions about value of community screenings. Kaiser Health News. May 14, 2013; Screening for abdominal aortic aneurysm web page. US Preventive Services Task Force. June 24, 2014; Colbert JA. N Engl J Med. 2014;370:e16; Gladstone DJ et al. N Engl J Med. 2014; 370:2467–2477; Wilkins JT et al. JAMA. 2012;308:1795–1801; Public Citizen. Healthfair cardiovascular screening packages are unethical, mislead consumers, do more harm than good [press release]. June 19, 2014.