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Behind a screen

Vascular testing at community clinics sounds helpful, but some specialists argue there are risks

By Chelsea Conaboy
Globe Staff / September 12, 2011

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A flyer comes in the mail from Tufts Medical Center advertising life-saving stroke prevention: three tests in 30 minutes, at the discount rate of $119. The tests are not covered by insurance, but bring a friend to a screening site at the local church, and you both get $10 off.

Sounds like a deal, right?

Tufts and at least two other New England hospitals have teamed up in the past year with private technology company Navix Diagnostix, Inc. to offer tests to detect vascular problems at community venues. They include an ultrasound of the carotid and aortic arteries and a blood pressure test at the ankle.

But the US Preventive Services Task Force does not recommend the screening tests for the general public - people without symptoms - citing a lack of evidence that they improve long-term health, and the risk of harm from follow-up tests and treatment.

While Tufts and Navix officials said community screenings raise awareness about stroke and heart disease, some experts say the program could lead patients to get treatment they don’t need.

“It’s just irresponsible of an academic medical center to be promoting screening tests which our government agencies or professional organizations are recommending against,’’ said Dr. Lisa Schwartz, a professor of medicine who studies medical communications at the Dartmouth Institute for Health Policy and Clinical Practice. “What’s their responsibility? Is it to the health of the community they serve, or is it to the financial bottom line?’’

Tufts supports screenings and efforts to educate people about vascular disease, said spokeswoman Brooke Tyson Hynes. Hospital administrators work with physicians when deciding if a partnership like the one with Navix is appropriate, she said.

The screenings are a new endeavor for Navix, a 20-year-old private company based in Taunton that provides cardiovascular equipment and technicians to hospitals and physician groups.

Vice President Steve Flieder said the company started the screenings about a year ago, and has partnered with Cape Cod Hospital and Eastern Connecticut Health Network, in addition to Tufts. Unlike some national screening companies, Flieder said, Navix tries to attract people who are at higher risk for disease.

The company’s mailings are targeted to households with people between the ages of 50 and 75. And after a list of statistics about the danger of strokes, the flyer includes risk factors that people should consider when deciding whether to get screened: a history of smoking, high blood pressure, diabetes, heart disease, and a family history of stroke or heart disease.

“Yes, we want to make money. We’re a commercial entity,’’ he said. “But we want to do it on real medical value.’’

Flieder said people who sign up for the tests are not provided information about what the US Preventive Services Task Force or other professional medical groups recommend. And if a woman with no risk factors calls the company’s hot line saying she is worried about stroke because her neighbor just had one, she would not be turned away.

“If nothing else, these are people who have had friends, family with vascular issues,’’ he said. “It’s a huge peace of mind - not that we’re selling peace of mind.’’

While she thinks the doctors involved likely believe the screenings benefit patients, Schwartz said, what they are actually selling are “false promises’’; people see a bunch of worrying statistics about stroke, and Navix offers the solution to ease their mind. “It’s a really insidious kind of marketing technique,’’ she said.

Navix screenings have detected some degree of previously undiagnosed disease in more than half of the people tested, according to Flieder. But Schwartz said detection should not be the measure of success.

“The goal isn’t finding disease,’’ Schwartz said. “The goal is making people feel better and live longer.’’

For many people, some narrowing of the arteries may never develop into a health problem. But a finding of disease could make them worry needlessly. And while Navix’s flyers give the impression that people can avoid stroke altogether if they get tested and treated for disease, Schwartz said that is unlikely.

A procedure to clear a severely blocked carotid artery in people who are asymptomatic and high-risk, for example, reduces the likelihood of having a stroke within five years by only about 5 percent, according to the US Preventive Services Task Force. That number is likely to be smaller for the general population. And the procedure itself carries a small chance of causing a stroke.

Dr. Daniel Gorin, a vascular surgeon at Cape Cod Hospital, said the tests are useful at identifying a small number of people who have blockages that require immediate attention. He said the tests could motivate others to have a conversation with their doctors about protecting their health through better exercise, a daily aspirin, or cholesterol drugs.

Dr. Mark Iafrati, chief of vascular surgery at Tufts Medical Center, said too few doctors are paying attention to vascular disease. He pointed to the slow uptake of a program allowing male smokers, age 65 to 75, who are at risk for an aneurysm, to receive an aortic ultrasound when they enroll in Medicare.

Tufts has done at least six screenings with Navix and is paid about $10 per patient for Iafrati to read the results. He said he reaches out directly to patients and primary care doctors if he finds something concerning.

Iafrati said the hospital was looking to expand community awareness of its vascular program when it partnered with Navix. He had a prior relationship with the company, training physicians on technology it sold.

Iafrati said he does not think it good practice to screen patients who have no risk factors, but he said the tests are not harmful and neither is the diagnostic ultrasound often required in follow-up.

“The risk of the next step, in fact the cost of the next step, is really relatively modest,’’ he said.

Critics say further follow-up care may not be, if it involves surgery or unnecessary medications.

Iafrati said there is no assumption that people screened will turn to Tufts for follow-up care, but that is a clear part of the Navix model.

The company held an online seminar this summer for hospitals interested in partnering with them. Among the slides was one titled, “Screening drives more revenue for vascular lab and downstream services.’’

Dr. Mark Creager, director of the Vascular Center at Brigham and Women’s Hospital, said when used cautiously screenings can be effective.

Creager was not familiar with the Navix program, but he said he opposes broad community screening. He worries that patients will wind up paying for tests they don’t need and possibly overreacting to the results. Some could receive false reassurances that their risk of stroke is nil, while, for others, the tests cause unnecessary anxiety, he said.

Creager believes the tests should be conducted with oversight from a doctor.

He acknowledged that most hospitals are looking for a greater volume of patients for their vascular programs. But he said, “What has to drive us all is, what’s right for the patient? That’s got to be the first thing.’’

Chelsea Conaboy can be reached at cconaboy@boston.com.

Who should get a stroke risk screening?

The US Preventive Services Task Force does not recommend the Navix tests - the ankle brachial index, the carotid scan, and the aortic scan - for the general population. The risk of harm in follow-up care may outweigh the benefits, or there is too little evidence that testing people with no symptoms will improve their long-term health, the group said.

Dr. Mark Creager, director of the Vascular Center at Brigham and Women’s Hospital and a member of the American College of Cardiology and American Heart Association task force on clinical practice guidelines, outlined these screening recommendations:

Ankle brachial index: A doctor should use this simple test - comparing blood pressure at the ankle to that of the arm to detect narrowing arteries - for two reasons: to diagnose a patient who already has symptoms such as pain or discomfort in the legs, or to screen for atherosclerosis, or a thickening of an artery wall, in people who show no symptoms but are at high risk for the disease. Risk factors include being over age 70, or being 50 to 69 with a history of smoking or diabetes.

Carotid scan: A swishing sound called a “bruit,’’ heard through a stethoscope as the blood moves through the neck’s carotid artery, could prompt a doctor to order this ultrasound test to look for narrowing. It might also be reasonable to order a scan for a patient who has multiple risk factors, including a history of smoking, a close family member who had a stroke, or high blood pressure.

A comprehensive carotid scan should take about 45 minutes to complete.

Aortic scan: The US Preventive Services Task Force recommends that men ages 65 to 75 who have smoked should be screened once by an aortic scan, an ultrasound of the largest artery in the body, which extends from the heart down through the abdomen.

Men or women who are nonsmokers generally should not be scanned unless they had a close relative who had an abdominal aortic aneurysm or something else of concern in the abdomen.

CHELSEA CONABOY

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