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Ultrasound Screening: Misleading the Public

There is a new industry offering preventive health screening services direct to the public. A few years ago it was common to see ads for whole body CT scan screening at free-standing CT centers. That fad sort of faded away after numerous organizations pointed out that there was considerable radiation involved and the dangers outweighed any potential benefits.

Now what I most commonly see are ads for ultrasound screening. In fact, I am sick and tired of finding them in my mailbox and between the pages of my local newspaper. Ultrasound is certainly safe, with no radiation exposure. It sounds like it might be a good idea, but it isn’t.

Life Line Screening advertises itself as “America’s leading provider of quality health screenings.” They offer “4 tests in less than 1 hour – tests that can save your life.” They travel around the country, setting up their equipment in community centers, churches, and YMCAs. For $129 you get ultrasounds of your carotid arteries, your abdominal aorta, your legs, and your heel bone. They mail you your results 21 days later.

They had celebrity endorsements. Peggy Fleming urged me to make an appointment for screening. I wrote her and told her why I thought her advice was bad. I never got a response, but I don’t see her name on the website any more, so maybe she listened.

Besides “Peggy Fleming says so,” the website offers five reasons to get screened:
(1) Stroke is the leading cause of serious, long-term disability, and the third leading cause of death in the US.
(2) 700,000 Americans suffer a stroke each year, one every 45 seconds.
(3) Most people who have strokes and aneurysms do not experience symptoms. [I think they meant before the stroke; surely patients have symptoms when the stroke occurs.]
(4) 12 million Americans suffer from Peripheral Arterial Disease (PAD). They are 4-5 times more likely to die of a heart attack.
(5) Life Line Screening offers painless, inexpensive, and non-invasive preventive health exams right in your neighborhood.

No, I’m sorry but those are not reasons to get screened. That’s like saying that lots of people die from cancer and Life Line takes pretty photographs so I should let them take my photograph. If screening reduced morbidity and mortality, that might be a reason to get screened, but they are not claiming that. They can’t claim it, because there is no evidence to support doing these tests in the general population.

For a screening test to be worthwhile, it has to meet several criteria.  You want to know the predictive value of a positive test in the population being screened.  You want to know not just whether it picks up an abnormality, but whether picking up that abnormality will allow earlier treatment that will make a difference in outcome. You want to know whether false positive tests will lead to harmful invasive procedures. Bottom line: does the test do more good than harm? 

These tests are worthwhile when used by doctors to help diagnose patients with symptoms or patients at high risk, but when used to screen the general population of mostly healthy people, they are likely to be useless or even to do more harm than good. 

Ultrasound can show a narrowing of the carotid artery. I guess that’s nice to know. It’s also nice to know that if you have no symptoms, it’s probably not going to make a difference. Even if the artery is 60-99% blocked, surgery may only reduce the risk of stroke by 1% a year, and the surgical risks may outweigh any benefit. If you have symptoms from carotid artery narrowing, surgery might be life-saving. But then you probably would have consulted your doctor about the symptoms in the first place instead of going to a church to get a screening test.  If you have an asymptomatic narrowing that does not require surgery, you can work on reducing your other risk factors for stroke, but that would be a good idea anyway, even if you didn’t know what your carotid arteries looked like.  

Ultrasound screening for osteoporosis is not very accurate. About 50% of people screened will be told they are OK. The other 50% will have to be tested further with a DEXA test.  If you’re going to be tested, why not get the more accurate DEXA test in the first place?

If your screening test shows PAD, there’s not going to be anything you can do about it other than exercising and not smoking. Why not encourage everyone to exercise and stop smoking instead of bothering with a screening test?

Various medical organizations and the United States Preventive Services Task Force (USPSTF) have put great thought into recommending which screening tests are worthwhile for the general public.  Their current recommendations include:

(1) Carotid artery screening not recommended.

(2) Abdominal aortic aneurysm screening recommended only once for men between the ages of 65 and 75 who have ever smoked.

(3) Screening for PAD not recommended.

(4) Osteoporosis screening recommended only for women over the age of 65 (or 60 if they have risk factors).

The evidence indicates that screening outside these guidelines is not likely to benefit patients. It does not improve patient-oriented outcome in any significant way and may cause harm from undue worry, expense, further testing that may be invasive, unnecessary surgery, etc. The Life Line folks do not tell their customers any of this. They let them assume that the tests are life-saving,  can prevent strokes, and are highly recommended.

In the last flyer I got, they have mysteriously replaced the osteoporosis part of the screening with a new test: atrial fibrillation testing, with an EKG rhythm strip. And the price has gone up to $139.  A press release capitalizes on the fact that Dick Cheney was in the news with this diagnosis last fall. This is no more than shameless exploitation.

AF screening might be a good idea, but it is not even mentioned by the American Heart Association, the American Stroke Association, the American Academy of Family Physicians, the USPSTF or any other organization I could find.   We simply don’t have any good data that population screening for AF reduces the risk of stroke, morbidity or mortality.  One study suggested that teaching people to check their own or another’s pulse for irregularity might be an effective, low-cost way to make the diagnosis. One consideration is that the treament of AF carries risks of its own. Before AF screening can be recommended for the general public, we need to know whether giving all those extra people blood thinners and surgery will do more good or harm overall.

The Life Line company is making a profit by feeding its customers misleading information. Insurance and Medicare do not cover Life Line screening, although they usually do cover the kind of screening tests recommended by the USPSTF. I have been unable to find out whether the venues that offer them space (churches, etc.) charge them for that space or offer it as a supposed public service. If they offer it free, it is not genuinely of service to the public. Either way, they are contributing to the company’s profits by sharing their prestige. Their support implies that they endorse the screening.

I think what Life Line is doing is unethical. Let me make this clear: I have no objections to any consumer getting any screening test, whether it is recommended by the USPSTF or not. It is not unethical to offer these tests. What is unethical is withholding information that the average reasonable person would like to know before making a decision. If Life Line informed their customers that the tests are not recommended by any medical authority and explained why, then the customers could give informed consent to the screening. Instead, customers are only told the tests can help them avoid a stroke or save their lives.

I’m all for patient autonomy, but only if patients have access to the pertinent information.

If Life Line were seriously interested in improving health rather than just making profits, they would be concentrating on screening tests of proven value like blood pressure screening, and they would be addressing the most significant modifiable risk for health: smoking.

Posted in: Health Fraud, Medical Ethics, Public Health

Leave a Comment (21) ↓

21 thoughts on “Ultrasound Screening: Misleading the Public

  1. apteryx says:

    So many doctors will not acknowledge the risks of excessive screening and prophylaxis. Kudos to you for a very useful article.

  2. qetzal says:

    I was curious to know what they tell their customers after a screening. I found the following on their General Health Screening Questions page:

    Q. Do I get the results of my general health screenings or do they go directly to my doctor?
    A. The results of your health screening will be sent to you. If your results are within the normal range, you will receive a letter explaining the results along with a written report of these results for you to share with your doctor. If we recommend further evaluation, you will receive a letter explaining your results, a written report of the screening results and the pictures of the arteries scanned so that you can follow up with your personal physician. We will also include a letter, questionnaire and critique for both you and your doctor, so we can better monitor our quality and professionalism.

    Q. Will I get my pictures back?
    A. You will receive printed images of your screenings only if we are recommending that you see your own physician for further evaluation. Otherwise you will receive a detailed written report.

    I wonder what they actually say when they recommend further evaluation? I wonder how patients’ personal physicians react to such reports? My guess is they will feel significant pressure to order more tests, even if only for CYA purposes.

  3. weing says:

    Someone is making some good money. The afib screening is one I hadn’t heard before. I wonder what they would do if they had a bus load of patients with Parkinson’s show up.

  4. daedalus2u says:

    In my state (MA) medical tests require a prescription. These tests are offered in MA. Presumably there is some MD writing prescriptions for these tests. The report that you get 21 days later has to be from some MD because it is diagnosing disease. The technicians running the instruments can’t “diagnoses” anything, all they can do is run the equipment.

    It is the MDs that are behaving unethically and should be called on it.

    They do list the names of the MDs who read the scans. Perhaps they would be willing to explain how they see the ethics of it?

  5. marilynmann says:

    About 5 years ago, Lifeline (or a similar company) came to the health unit where I work (a federal agency). Not knowing any better, I had the screening tests. They told me that I had a leak in my mitral valve and that I should go to a cardiologist. I did. The cardiologist found no problem with my mitral valve (or the leak was so small as to be of no clinical significance), but because of minor repolarization abnormalities on my EKG, he felt he had to order a stress test. The stress test was normal (I was in my 40s at the time, non-smoker, etc.).

    I’m telling this story to illustrate one problem with screening tests. The test may find something, causing more tests to be ordered. Sometimes those tests find something else, leading to more tests, etc. As one test leads to another, you can get into tests that actually have potential harms, in some cases (radiation from CT scans, etc.). It can also become expensive, time-consuming, and stressful.

    Marilyn

  6. BlazingDragon says:

    I’d often wondered about the utility of these tests. LifeLine used to advertise heavily on Discovery Science channel/Discovery Channel (about the only channels I watch), especially in the evening/night. I thought they were BS. Nice to know I was right.

    I think daedalus brings up a very valid point. Medical Doctors have to be involved in this process somewhere. Would their license be subject to action (or even revocation) for being involved in a useless (and potentially harmful) scam like this?

  7. PeterHansen says:

    This is the same company that screened a patient of mine a few years ago. They notified him 3 months after the screen that his aorta was at high risk. He called in a panic. This is a man who has never had a day of elevated blood pressure. No risk whatsoever.

    I got him an ultrasound quickly, from a technician and doctor I trust. Not enlarged at all.

    Benefit of screening: zero.
    Harm: 1. Financial. 2. Worry.

    I consider it very unethical. I have tried to let patients at risk for this scam know about it. They market through employers, and churches. That is the slimiest tactic, in my opinion.

  8. urology-resident says:

    I think people often have a problem understading that diagnosing a disease early can potentially cause more harm than good. They think: “how come finding a cancer earlier cannot lead to better outcomes”?

    Screening for prostate cancer is still controversial with different opinions obtained from the American Urologic Association (who recommends screening) versus the recommendations from United States Preventive Services Task Force (USPSTF) (which say there is insufficient evidence the recommend in favor or against.

    17% of Americans are diagnosed with prostate cancer but only 3% of Americans die from prostate cancer. Autopsies done on people that died from car accidents for example, have found small focuses of prostate cancer in 1/3 to 1/4 of people in their 30-50′s. The majority of these people would have not live on to die from prostate cancer so diagnosing them and treating them could only have cause unnecessary diagnostic and therapeutic procedures with their attendant complications like: erectile dysfunction, incontinence, etc.

  9. Egaeus says:

    @daedalus2u

    These doctors probably missed that class in basic probability where they demonstrated that due to the rate of false positives (and false negatives), testing the general public for any disease is unworkable and generally a bad idea. I’m not a doctor. I took Engineering Probability and Statistics and learned that much (our class’s example was HIV).

    Then again, there’s the old adage:

    Q: What do you call the person who graduated last in their class in med school?

    A: Doctor.

    Where do they work? Places like Life Line apparently.

  10. weing says:

    I wish they would get the guidelines straight regarding prostate. Right now the ambiguity is a paradise for plaintiffs lawyers. We meed protection from failure to diagnose lawsuits. These are the most common in my part of the country.

  11. Eyzrbrn says:

    Ok, I read this title of this blog and thought no way. What a great idea as I have a clotting disorder, I am always clotting…but you get a bad result, which I can bet there are ALOT, guess what, you have to take that to your regular doctor/ER, who will REDO the tests. Of course your doctor would have to go from there. Lots of time and money wasted.

    Get your results in 21 days?! What if I used this screening for a DVT because hey it was convenient and I didn’t want to waste my doctors time for a false call? In 21 days, I could be dead from a PE because the DVT broke off and ended up in my lung.

    To whoever brought up the MDs need to be involved. Totally correct. Otherwise, they are practicing without a license. Sounds like it is time to get the attorney general involved in this scam.

    Besides, ultrasounds are only as good as the person who is doing them.

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  13. SMChisholm says:

    I was a little suspicious of this company / program when I first received an invite to a screening. At the time (mid 2006) I didn’t find any negative comments so I did eventually go to a screening in Dec 2006. The mailing was was for two artery tests. At the screening location they offered two additional tests, bone density (osteoporosis) being one of them, for only $10 more. When the results came back all was fine except the bone density test. This was rather surprising since I am a male in my early 50s. The report indicated I should contact my primary physician to discuss follow-up tests / actions. At the time I didn’t actually have a primary physician in the US as I had just returned from living in Europe for 8 years. It took about a year to finally fin a physician taking on new patients, have an full exam and to review the results. My physician was a bit skeptical of the LL results due to age and gender. Even so a Dexa scan was scheduled and performed. The results were reviewed with me on 26 Dec 2007. The Dexa indicated the problem was worse than the scan of a year early indicated and I immediately started taking calcium supplements, Vitamin D and a prescription medication to hopefully reduce the deterioration of my bones. I understand my new physician is now scanning other male clients over the age 50 and I am not the only male client that has this condition. My physician recently requested I have a complete lipid panel performed in April and it appears LL can perform this test for less money then the lab associated with the physician (an she has indicated she will accept LL’s results). While I won’t say the testing LL pushes is for everyone in my case I think it has been beneficial and therefore they may not be the demons many people think they are. I do think their advertising should be less melodramatic and they should be more open about the pro’s and con’s of their activity and also about their business model.

  14. Harriet Hall says:

    Ultrasound screening may indeed find life-threatening problems and save lives in certain individuals. That’s not the point. If we offer screening to everyone in the general public, the harm done to the many will outweigh the good done to a few. That’s the dilemma we face in deciding whether to do any screening test.

  15. Stevert says:

    Very Interesting!

    What’s best for our seniors here? I actually provide ultrasound screenings to the public yearly. I have a very strong opinion that the screenings that I perform has saved 100 or more lives over the past 5 years of screening. I wish I had alliances with the U.S. Preventive Services Task Force because I can show that an average of 80% of those screened have some sort of undiagnosed pathology! I have people often tell me that the just came from their doctors office after a complete work up & where told they were fine. I’m almost sinical with my responces but am discouraged at how our health care system & MD’s fail patient’s daily.

    30-40% of people seen have insurance but don’t see a doctor annually or their health is not a priority so insurance is not a priority. After a screening, suddenly their health is a priority. I got a call from one MD that said he has 35 new patients from my screenings.

    Screening for asymptomatic carotid artery stenosis in the general adult population. Not Recommended? The service is ineffective or that harms outweigh benefits? Please explain to me what harm a carotid ultrasound screening has? Do you actually know what ultrasound is? Cold gel? Sound waves? I guess they could get hurt climbing onto the table. It’s a lot less harmfull finacially to prevent illness then to treat it. What’s really best for our seniors is to review the endless list of Med’s MD’s prescribe!

    Why offer a blood pressure test to asymptomatic patients? Why oscoltate?

    AAA screenings resulted from a congressmans father that passed away from an AAA. He then championed a bill that passed for AAA screenings. 1 in every 300 screened may have an AAA but 1 out of 2 have Carotid plaque. What is frustating is that the 3rd leading killer of americans in the US is CVA’s and yet AAA’s or not even on the top 10 list. It dosen’t surprise me that a task force allines it’s self the politics. By the way, I have history of 50-60 year olds with AAA’s. They don’t count?

    The real problem with health care is the insurace co’s limit the MD’s ability to practice. The MD’s become complacent and quality decreases. Insurances have decreased fee’s so more appointments are needed to make a good waige.

    Steve Astorga

  16. Harriet Hall says:

    Stevert,
    It sounds as if you did not read my article carefully and did not read the other comments, but simply took the opportunity to display your own bias.

    Of course the ultrasound itself is harmless! It is the response to findings that can harm people. For any screening test, the benefits must be balanced against the harms (worry, invasive tests, etc.) from findings that are not life-threatening. Doctors are very concerned with preventing illness, but there is no evidence that screening outside the carefully considered recommendations actually prevents illness or benefits patients. The USPSTF looked at all the available evidence before making its recommendations.

    It may be your “strong opinion” that you have saved lives, but that opinion is not supported by evidence. The advertisements for ultrasound screenings are full of testimonials like “They found my carotid stenosis and saved my life” but many of those patients got unnecessary, potentially life-threatening surgery and their lives were not in danger in the first place. It takes science to sort out the testimonials from the reality.

  17. zalsobrooks says:

    my name is zac and i used to work for one of these companies your speaking of now. We had a woman come in one day and got our test done and while i was preforming her test she told me her husband had just passed a month prior due to complete blockage of his carotid arteries (something that is clearly seen with ultrasound) he was scheduled to have the exam done with her but sadly he was too late. these screening arent bogus the trained sonographers take pictures and they are read by very experienced radiologists the results come to you by mail with much detail you can take these images to your doctor for further testing if needed. if you had a gall stone your doctor could order tons of expensive tests trying to figure out what was going on or you could have your gall bladder scanned by a health screen company for around 45 bucks and the stones are clearly seen.

  18. doppler says:

    While I have mixed emotions on this very subject. Whether to be screened or not to be screened that is the question.

    I’m a Vascular Sonographer and I get patient that have come from a Screening Company’s and I’m often asked of my opinion about these company’s. The following is My opinion only.

    1. I feel that I never want to discourage a patient for being proactive in their Health Care. Lets be proactive rather then reactive.

    2. Are these company’s companies in it for profit? I can only assume the answer is yes. Lets be honest! but what company out there isn’t?

    3. Remember that these exams are only screening tools. These are not Formal Examination. Physician’s should and usually follow up the these screening with a Formal Exam, and if severly abnormal, they will test furher with some kind of contrast CT or MRI before any surgery is even considered. If an exam is mild it may be followed by your Physician.

    4. These Screening are COMPLETE VOLUNTARY no one is forcing people to have these peformed.

    5. Let’s face it. Health Care Professional’s can not be responsible for the way people act to news. How many times have you heard of Doctor giving bad news, and then it follow with a disclaimer like “but it can’t be confimed until the blood work comes back”, or “until we get the results of the MRI”, ect? If you cant handle it, maybe you should reconsider the screening. Ask your phsician if you cant decided.

    6. Educate yourself! YOU ARE YOUR OWN BEST PATIENT ADVICATE!

    7. I have to be honest with myself here, These companies, have found a nitch in the market and some may be doing very well. I only had wish I could be able to do something like this.

    8. If you have a exerinced qualified Technician doing these kinds of screenings, what could be wrong with that? I myself have woked with a well know Hospital doing these very test. I was paid for my services. Was this Hospital being irresponsible? How could this hospital manage all the follow ups? Should the Hospital be repremended for causing mass hesteria?

    If it were my mother who lives in another state, and was going to pay to have this done I would tell her to go ahead. However I would caution her to check their credentials, and most important. ALWAYS FOLLOW UP WITH YOUR DOCTOR!
    whether your result are good or bad.

  19. Harriet Hall says:

    doppler said,
    “If you have a exerinced qualified Technician doing these kinds of screenings, what could be wrong with that?”

    I thought I explained what could be wrong with that: indiscriminate screening can cause more harm than good, for the reasons I explained.

    I have no problem with patients choosing to be screened; I only think they should be told which tests are not recommended by medical organizations and why.

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