UNECESSARY CHECKUPS
In the Philippines, screening for diseases is bogged down with inappropriate and costly tests. A task force on effective screening among apparently healthy Filipinos comes out with recommendations.
By Michelle B. Ciriacruz
Medical Writer
Is an ounce of prevention really worth a pound of cure? Not if things that ought to work don't, which is a situation that is as common and as hazardous in disease prevention as it is in curative medicine.
More is best, many seem convinced of this also, especially those who have transgressed health warning and are feeling apprehensive and those who simply wish to remain healthy, and so will go for as many screening tests---X-rays, CT scans, urinalysis, etc.--as they could afford, with the idea of preventing diseases, or at least catching them early.
Since this is also the mindset in the majority of medical institutions here, this practice is a thriving business in the country. Most institutions, whether government or private, routinely have their people go through executive checkups, which most likely would include a chest X-ray, urinalysis, stool exam, blood-pressure check, blood test, etc.
But does it profit us? Contrary to popular belief, screening indiscriminately invites not only profligate use of resources but also harms those who go through it, according to the co-chair of the task force on effective screening for diseases among apparently healthy Filipinos Dr. Antonio Dans, adult-medicine specialist and professor at the University of the Philippines-College of Medicine.
A need for a consensus
In 1996, together with cardiologist Dante Morales, now medical director at the Manila Doctor's Hospital, Dans did a survey of medical admissions in nine randomly selected hospitals in Metro Manila.
He found out, to his dismay, that almost eight percent of total medical admissions were for executive checkups. "Ang dami n'un," he exclaims.
This means that one out of every 12 beds was occupied by healthy people who don't need to be in the hospital, who spent from around PhP4,000 to 25,000 each yearly to have their executive checkups.
Given that Filipinos spend billions yearly on these executive checkups, that it is in fact a booming business for many entrepreneurs, Dans and Morales realized the need for a consensus on how proper checkups should be done.
Also, we hear about cases of serious illness or emergency situations that were turned away by medical institutions because, supposedly, there weren't enough vacant beds to accommodate them.
According to the World Health Organization, screening is the use of presumptive methods to detect unrecognized health risks or asymptomatic disease in apparently healthy individuals in order to permit prevention and timely intervention.
The United States took the cudgels for this and the word spread that to take all medical tests possible would translate to a clean bill of health. We took our cue from this and a similar mindset was born here.
In the mid 1980s, however, Dans relates, before things got out of hand in the US, health and medical organizations came out with recommendations to stop doing it that way. Because, "it is not a rational way to promote health."
But we never caught on. Compared with the cost in pesos of the recommended set of screening interventions (height, weight, blood pressure, Papanicolau smear, total blood cholesterol, fecal occult blood test, mammogram or clinical breast exam, and auditory testing with no hospital admission) by the Preventive Services Task Force of the US Department of Health and Human Services in 1996, which adds up to only a little over PhP1,000 per year, what we are spending here seems grossly exaggerated.
An appeal for a rational system
Dans and Morales raised these questions, if money were not an issue: What tests are necessary among the roughly 250 tests that could possibly be done on a healthy person? Can too much testing be dangerous? How often should these tests be done? Is a confinement necessary?
Up to now, "those who can't afford have nothing. Those who can afford have everything, even the tests that they don't need," Dans points out.
The two physicians concluded that we needed to develop guidelines on periodic health examination for effective screening for diseases among apparently healthy Filipinos, and following funding from the Department of Health (DOH), National Institutes of Health, Metrobank Foundation, and several medical societies and private organizations in 2000, they were able to form a task force to come out with recommendations, recently published and available at the Information, Publication, and Public Affairs Office on the eighth floor of the Philippine General Hospital.
The task force assessed 213 medical screening tests commonly done here and abroad using an evidence-based approach--more than a thousand references were reviewed.
The effort is "an appeal for rational medical decision-making, and an important step towards the equitable distribution of health and health resources," state the two proponents in the book.
They also outline two compelling rationale for the setting up of criteria on when health screening should be done: "Although treating early disease may be cheaper and easier, the savings are often offset by the costs of having to do the screening tests on large numbers of apparently healthy individuals;" and "health screening carries the potential for harm."
Hazards of being inappropriate
There are hazards in doing inappropriate tests in healthy patients, stresses Dans. "Tests have side effects," he explains. They're not just a waste of money, "they can have terrible consequences."
He cites the most common side effects: Radiation exposure from X-rays could cause cancer; dye allergy from contrast media could be fatal; the bowels could be perforated during an endoscopic procedure; and a heart attack could occur during a stress test.
However, what we should be most cautious about, it seems, is that medical tests are prone to natural errors--errors that are independent of how they're done. The statistical behavior of tests is often overlooked, explains Dans.
"Positive tests are often wrong if you do them on healthy people," he points out. The definition for normal and abnormal for many tests, like uric acid, creatinine, and other blood chemistries, is often the percentile, with abnormal defined as belonging in the upper and lower 2.5 percentile, he explains.
This means that five percent of people who have a test are going to be labeled as abnormal, "not because they're sick but because they're in the upper and lower percentile," he says. Actually, this just makes their results "unusual."
Dans illustrates: "If I do one test, five percent lang. If I do two tests, palaki na ang percentage. If I do a hundred tests, you're going to be sick for sure. I'm going to find five tests out of those hundred that will prove to me you're sick of something. So, hindi na depende sa health mo ang abnormalcy, depende na sa number of tests [done on you]."
The probability, therefore, of abnormal results is proportional to the number of tests done.
And according to Dans, these "labeled"patients suffer--psychological and even physical anguish.
He relates that in a study done in the US, children were told they had heart disease even if they didn't have. These children lost weight, became less active in school, and socialized less with other kids--it was if these children adapted to the illness that labeled them, Dans surmises.
Criteria for effective screening
There are four criteria for recommending a test in healthy patients, Dans discusses.
Treatment must be effective.
Simply explained, why look for something that is incurable or does not require treatment, asks Dans? "If we spend millions of pesos to detect a disease for which there is no effective treatment, then the act of screening would have been rendered futile," Dans and Morales explain in the book.
Prevalence must be high enough.
For example, if the disease is one in 60 million, only after screening 60 million would we find one with the disease. "You would already have spent billions," comments Dans. Screening for a disease must be a worthwhile exercise, therefore.
The test must be accurate.
The sensitivity and specificity of a test for detecting a particular disease must be high enough. The errors that should be minimized before a test can be acceptable are its false-positive errors and false-negative errors.
The task force's chairs point out that in false-negative tests, patients miss the chance for an early cure or treatment; while in false-positive tests, the physical and psychological effects may be more severe than the disease itself--depression, unemployment, suicide, etc.--and often lead to a battery of expensive and unnecessary follow-up procedures.
Dans cites a DOH-initiated program to detect chronic kidney disease (CKD) on school children through urine testing. But, exclaims Dans, a urinalysis "is so inaccurate for doing that." Aside from that, CHD is very rare in this population; there is no treatment if found early to prevent it from worsening, and the test is very expensive.
"[The urinalysis] failed all the criteria for an acceptable screening test, he points out.
Which is probably why it's a dead program now. Reports then were that around 200,000 children were found to have CHD. But we should not even believe the results, Dans says.
"Remember, we're talking about healthy people who were not feeling anything. [So] doing a urinalysis on a healthy child who's not feeling anything is a waste of his time and does him more harm--[it] makes him worry," he explains. "But, if you have symptoms, that's an entirely different story," he qualifies.
Both the treatment and test must be cost-effective.
"It must be affordable. Kasi, you're going to do it in everyone," Dans points out. He illustrates again: If a urinalysis is only at PhP100 per person, a urinalysis for all 80 million Filipinos would then amount to a staggering PhP8 billion--for a test that's not even accurate.
A clinical breast exam (CBE) is a test, however, that studies have shown can reduce deaths from breast cancer, the most common cause of cancer in women, and save on costs. A local study, Dans reports, has shown a cost-savings of PhP3 million for every 100,000 women screened.
Furthermore, a CBE has been shown accurate in detecting breast cancer, with a sensitivity of around 80 percent and specificity of around 90 percent.
"You don't lose money, you earn money from doing this (breast examination)," he observes, by preventing the expenses these women would have incurred had they developed cancer, been hospitalized, or died. These women, in fact, would stay productive.
So for a 40-year-old woman who comes for a periodic exam, CBE should be done, since it passes all four criteria of an acceptable screening test.
Besides an assessment of tests, the Philippine Guidelines on Periodic Health Examination include instructions on how to do them and how to interpret test results. The recommendations aim to to guide practitioners in the screening of apparently healthy individuals for disease and risk factors.
Ultimately, the beneficiaries of the recommendations are all Filipinos, who deserve quality and accessible health care, Morales and Dans say in the book.
Although, testing indiscriminately can waste resources--money, time, and hospital beds, the more compelling argument for Dans to have come out with this set of recommendations is the harm.
"Pinagastos mo na, sinaktan mo pa," he explains.
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