Screening medical tests- desirable or distracting

To make an intelligent decision about your own screening, you need a physician who reviews your past and current medical history, your family history, and your health goals.

Both doctors and patients have mixed emotions about diagnostic tests done to screen for disease. We physicians want to help patients stay healthy, prevent disease, and treat problems early and effectively.But the time spent counselling, ordering, performing, and reviewing these tests means less time available to manage patients’existing medical problems.

I agree with Dr. William Zinn, family physician in Boston, who wrote

“Keeping track of the ever-increasing health maintenance requirements and cancer screening sometimes make it hard to remember why the patient came to the office in the first place.”

JAMA, January 7, 2020

For patients the issues are similar. While they want to stay healthy, prevent disease, and get treated promptly, they don’t like the inconvenience, time away from work, cost, and sometimes discomfort the tests require.

What are screening tests?

A screening medical test is done to uncover a disease or disorder in a person who may or may not be a risk for it and who otherwise feels well and has a normal exam. Suppose we are considering screening a group of people for disease X. Let’s start by dividing them into 3 groups.

  • Those with no symptoms, feel fine, at average risk of health condition X.
  • Those with no symptoms, feel fine, at increased or high risk of condition X.
  • Those who have symptoms suggestive of condition X, or have had other testing that suggests they might have it

Screening for X in groups 1 and 2 might be appropriate, based on medical guidelines, physician judgement, and patient preference. For group 3, with symptoms of condition X, testing would be considered diagnostic; a doctor would test for X, and possibly other conditions that the symptoms suggest.

Diagnostic vs Screening

That might seem like a picky difference, but there are several implications for both doctors and patients.

Documentation- The medical record needs to reflect accurately why a test is being ordered and done. This is necessary for billing because inaccurate coding can make doctors and clinics liable for fraud. Also, the government and other payers are starting to judge doctors’ quality of care based on medical record audits of care given or not given, and why.

Interpretation and Follow up-A test is rarely interpreted in isolation. The history and exam together with the test lead to a diagnosis.

Reimbursement– Most if not all insurances, including Medicare, reimburse differently based on whether a test is diagnostic or screening. And this usually determines how much the patient pays for each. Screening tests are usually covered 100% while diagnostic testing may require a deductible or copay .

A Country Doctor Writes blog explains this dilemma in detail –

But because in the inscrutable wisdom of the Obama Affordable Care Act, it was decided that screening colonoscopies done on people with no symptoms whatsoever are a freebie, whereas colonoscopies done when patients have symptoms of colon cancer are subject to severe financial penalties.

read more at this link

This link at FamilyDoctor.org helps explain how medical insurance coverage works.

Does disease screening make a difference?

Screening tests don’t prevent disease although they may be helpful for health maintenance or improvement. They may prevent progression or complications of a disease, but don’t prevent it’s onset. They may not even prevent death from the disease, although we like to believe they do. Screening may diagnose the disease before symptoms develop, so the patient lives longer with the disease, but not affect the eventual outcome.

So when should we offer screening tests?

If there is a clear benefit to patients from an effective treatment available to make a difference in the disease course or

If knowledge of the condition helps the patient and family make choices about managing the condition’s likely course or the need for family members to be screened

If the test is reliable enough to identify most people with the disease without falsely identifying people who don’t have it. The scientific terms for this are sensitivity and specificity.

When the benefits clearly outweigh the risks and costs.

How to decide for yourself

These are just some of the factors involved in deciding when to undergo screening tests. To make an intelligent decision about your own screening, you need a physician who reviews your past and current medical history, your family history, and your health goals. Then the doctor can make recommendations based on your needs and desires with the help of expert guidelines published by medical organizations who carefully review the medical literature.

Review the graphics in this post for recent guidelines from professional organizations and discuss with your physician. Help your doctor help you by scheduling a health maintenance visit rather than bringing it up when you are there sick or for chronic care. These discussions deserve your physician’s full attention.

further information from the National Institutes of Health.

To Screen or Not to Screen

¿Hacer o no hacer pruebas de detección?

exploring the HEART of health maintenance

I appreciate all of you who follow this blog; there are numerous other blogs to choose from so I am honored you chose to spend some time here. A special welcome to all my new followers from this past month.

Thanks for following this blog. If you’re visiting, I would love for you to start following Watercress Words : use the form to get an email notification of new posts. Don’t worry, you won’t get anything else from me. I also want you to find and follow me on Facebook, Pinterest , Instagram, and LinkedIn .

                              Dr. Aletha 

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2019 Women’s health update- hormones, the heart, and HPV

results of the Nurses Health Study over 18 years shows no increase in incidence of these complications in women who used vaginal estrogen, suggesting this is a safe option for women who elect to use estrogen. (from the journal Menopause)

Multiple health issues impact women exclusively or differently than men, so new and updated information is important to share. The issues we women face vary with our age, stage of life and health status.

Let’s look at some medical news about women’s health issues, information I picked up recently from several medical journals I follow.

This is current, general medical information that helps a doctor and patient make decisions about what is right for her. Medical recommendations and practice changes as we learn new things.
If you deal with any of these issues , please discuss with your doctor before  taking any action.

I’m illustrating this post with photos of art featuring women. I’ll tell you more about the source at the end.

statue of a woman holding an infant

Human papillomavirus and cancer 

Infection with the human papillomavirus, HPV, can cause  genital warts and cervical cancer.

The percentage of young women with confirmed HPV (human papillomavirus) infection  in the United States fell significantly from 2006 to 2012. Women who had received the HPV vaccine showed the greatest decline in infection rates, compared to those who had not. Even one dose was effective, even though 2 or 3 are recommended.

A new study reported by the New England Journal of Medicine shows that women who become infected with the HPV strains 16 and 18 have a much higher risk of changes in their cervix called CIN-cervical intraepithelial neoplasia-which can be a precursor to cancer. These changes may not be picked up by a Papanicolaou (Pap) test.

Thus, protection against infection with HPV should also provide protection against cancers caused by HPV.

Human papillomavirus vaccine

Gardasil, a vaccine which targets the HPV has been available to females and males from 9 years old to 26 years old. Now the age has been extended through age 45 years for both genders.

Here is a link to detailed information about HPV vaccination from the National Cancer Institute.


Human Papillomavirus (HPV) Vaccines

statue of a pioneer woman with rifle and infant

Long-acting reversible contraception-LARC  

Two forms of long-acting reversible contraception are available to women in the United States.

Nexplanon, a contraceptive implant, slowly releases the hormone progestin and does not have estrogen. It can be used in women who cannot take estrogen, such as those with uterine fibroids or endometrial cancer.

Intrauterine devices, IUDs, containing copper only are appropriate for women with past or present breast cancer, ischemic heart disease, and women at risk for blood clots.

Use of LARCs accounts for 12% of all contraceptive use. Additional benefits include controlling excessive menstrual bleeding, potentially saving women from surgery.

Here is a link to Quick Fact about intrauterine devices and other forms of contraception from the Department of Health and Human Services

Intrauterine Device

statue of woman, holding infant, standing next to a child

Hormone therapy and prevention of heart disease

A 2015 Cochrane review of 40,410 postmenopausal women examined the use of oral hormone therapy (estrogen with or without progesterone) taken for at least six months, compared with placebo (no real drug), to determine the effect on death from any cause, and deaths caused by heart disease, stroke, and blood clot in a leg or lung.

The review found no benefits for preventing heart attack (fatal or nonfatal), or death due to any cause.

In women who took hormones they found

 
1 in 165 women had a stroke
1 in 118 women had a blood clot in the leg or lung
1 in 242 women had a blood clot in the lung

The women in this study were all older than 60 years old, so it is possible there might be benefit in younger women.

statue of woman with arm raised and holding an infant

Vaginal estrogen and heart health

While estrogen replacement after menopause is effective at controlling the undesirable effects of night sweats, hot flashes, and vaginal dryness, it potentially increases the risk of developing cardiovascular disease-heart attacks and stroke, and some cancers-breast and uterine.

However, results of the Nurses Health Study over 18 years shows no increase in incidence of these complications in women who used vaginal estrogen, suggesting this is a safe option for women who elect to use estrogen. (from the journal Menopause)

The photos- a tribute to women

I took these photos during a recent visit to Woolaroc ,a museum and wildlife preserve located in the Osage Hills of Northeastern Oklahoma. Woolaroc was established in 1925 as the ranch retreat of oilman Frank Phillips. 

These statues displayed there were all models considered for a larger project now known as the Pioneer Woman Statue in Ponca City, Oklahoma.

What do you think? Would you have chosen one of the other statues for the final version?

More women’s health info

exploring the HEART of women’s health

I appreciate all of you who follow this blog; there are numerous other blogs to choose from so I am honored you chose to spend some time here. A special welcome to all my new followers from this past month.

Thanks for following this blog. If you’re visiting, I would love for you to start following Watercress Words : use the form to get an email notification of new posts. Don’t worry, you won’t get anything else from me. I also want you to find and follow me on Facebook, Pinterest , Instagram, and LinkedIn .

                              Dr. Aletha 

a statue of a woman holding a child, "CROSSING THE PRAIRIE"
“CROSSING THE PRAIRIE” by Glenna Goodacre, Broken Arrow, Oklahoma
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