Annals of Internal Medicine tip sheet for Aug. 28, 2012

August 27, 2012

1. Insufficient Evidence to Recommend Routine Screening for Chronic Kidney Disease

Chronic kidney disease (CKD) affects 11 percent of the U.S. population. CKD is associated with advanced age, diabetes, hypertension, and cardiovascular disease and most people with CKD have no symptoms. Screening and monitoring patients before they have symptoms could lead to earlier interventions that improve health outcomes. Researchers at the United States Preventive Services Task Force (USPSTF) reviewed published randomized, controlled trials to assess the benefits and harms of screening, monitoring, and treatment of early-stage CKD in asymptomatic adults. The Task Force found no studies on the accuracy of screening for CKD and no studies that directly evaluated the effectiveness of screening. Treatment of early stages of CKD is targeted to associated conditions, primarily using medications to control hypertension, diabetes, and cardiovascular disease. There is insufficient evidence that identification and early treatment of CKD in asymptomatic adults without these conditions results in improved outcomes. The researchers found few studies on early treatment of CKD in people without chronic diseases. While there were no studies on the direct harms of screening for CKD, potential harms include adverse effects from venopuncutre, psychological effects of labeling, and a false-positive result leading to unnecessary treatment and diagnostic interventions. The Task Force concludes that there is insufficient evidence to recommend routine CKD screening for people without hypertension, diabetes, or cardiovascular disease.

2. Commercial Screening Tests Inflate Health Care Costs, Undermine Physician Efforts to Provide High-value, Cost Conscious Care

Appropriate use of screening tests can improve the health of the population and reduce health care costs through the avoidance of expensive care for advanced disease. Recent publications have emphasized the importance of shared decision-making between physicians and patients who are fully informed about the benefits and harms of screening for common and chronic conditions. However, according to Steven E. Weinberger, MD, Executive Vice President of the American College of Physicians (ACP), and his co-authors, physician efforts to provide high-quality, cost-conscious care are being "undermined by the increasing availability of direct-to-consumer screening tests." Currently, there is a trend of companies selling screening packages directly to consumers. These companies encourage consumers to discuss "abnormal" results with their physicians, potentially leading to more testing, treatment, and/or follow up that may not have been necessary. The authors recommend that purveyors of such tests should be required to openly state for whom the screening tests are indicated (based on current evidence-based guidelines) and inform customers of potential risks. While some believe that patients may modify risky behaviors if they have a disease identified through screening, evidence proves the opposite. The authors use carotid ultrasound as an example. Although the prevalence of carotid stenosis is high in patients who smoke and who are interested in quitting, those with an abnormal carotid ultrasound (a screening test commonly offered by commercial screening companies) are no more likely to quit smoking than those who had a negative ultrasound or those who did not receive an ultrasound. The authors conclude that medical entities and physicians should refrain from sponsoring or supporting health screenings that do not practice ethical standards.

Another opinion piece by radiologist authors being published in the same issue raises analogous issues. The authors call for health care providers to limit imaging tests that are inappropriate, wasteful, or redundant. The authors note that a large proportion of the tests noted by the Choosing Wisely campaign are imaging studies. Choosing Wisely is an initiative by the American Board of Internal Medicine Foundation (ABIMF) that identifies commonly overused tests and treatments. In January, the ACP published a list of 37 medical tests - of which 18 were imaging tests - that were overused in medical practice. An accompanying editorial pointed out that five percent of the country's GNP is spent on tests and procedures that don't improve patient outcomes. According to the authors, campaigns that draw attention to overuse of imaging, coupled with greater physician knowledge would benefit both patients and the health care system.

American College of Physicians

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