Kaiser Health News Labels Routine Clinical Laboratory Testing and Other Screening of Elderly Patients an ‘Epidemic’ in US

Some experts in medical community question value of health screenings of older patients with shortened life expectancies, though many aging adults are skeptical of calls to skip tests

What does it mean when a credible health organization makes the assertion that there is an “epidemic” of clinical laboratory testing being ordered on the nation’s elderly? Clinical laboratory leaders and anatomic pathologists know that lab tests are a critical part of screening patients.

Health screenings, particularly those for chronic diseases, such as cancer, can save lives by detecting diseases in their early stages. However, as consumers become more engaged with the quality of their care, one trend is for healthcare policymakers to point out that many medical procedures and care protocols may not bring benefit—and may, instead, bring harm.

No less an authority than Kaiser Health News (KHN) also is questioning what it calls an “epidemic” of testing in geriatric patients. Since medical laboratory tests are part of many screening programs, a rethinking of what tests are necessary in older patients would likely impact clinical laboratories and pathology groups going forward.

Treatment Overkill or Necessary Clinical Laboratory Tests?

“In patients well into their 80s, with other chronic conditions, it’s highly unlikely that they will receive any benefit from screening, and [it is] more likely that the harms will outweigh the benefits,” Cary Gross, MD, Professor of Medicine and Director of the National Clinician Scholars Program at the Yale School of Medicine, told KHN as part of an investigative series called “Treatment Overkill.”

That opinion is supported by a 2014 study published in the Journal of the American Medical Association (JAMA) Internal Medicine. The researchers concluded, “A substantial proportion of the US population with limited life expectancy received prostate, breast, cervical, and colorectal cancer screening that is unlikely to provide net benefit. These results raise concerns about over screening in these individuals, which not only increases healthcare expenditure but can lead to patient harm.”

Yet, seniors and their family members often request health screenings for themselves or their elderly parents, even those with dementia, if they perceive doing so will improve their quality of life, KHN noted.

Cary Gross, MD

Cary Gross, MD, Professor of Medicine and Director of the National Clinician Scholars Program at Yale University, told Kaiser Health News patients “well into their 80s, with other health conditions” are unlikely candidates for the many routine health screening tests administered to elderly patients. Were this to become a trend, medical laboratories could see a drop in physician-ordered screening tests. (Photo copyright: Yale University.)

Meanwhile, an earlier study in JAMA Internal Medicine found older adults perceived screening tests as “morally obligatory” and were skeptical of stopping routine screenings.

In its series, KHN noted two studies that outlined the frequency of screening tests in seniors with limited life expectancies due to dementia or other diseases:

  1. According to the American Journal of Public Health, nearly one in five women with severe cognitive impairment are still getting regular mammograms;
  2. Likewise, 55% of older men with a high risk of death over the next decade still receive PSA tests for prostate cancer, the 2014 JAMA Internal Medicine study found.

“Screening tests are often done in elderly patients as a knee-jerk reaction,” Damon Raskin, MD, a board-certified internist in Pacific Palisades, Calif., who also serves as Medical Director for two skilled nursing facilities, told AgingCare.com.

Correct Age or Correct Test?

While a movement may be afoot to reduce screening tests in older patients, a one-size-fits-all answer to who should continue to be tested may not be possible.

“You can have an 80-year-old who’s really like a 60-year-old in terms of [his or her] health,” Raskin noted. “In these instances, screening tests such as mammograms and colonoscopies, can be extremely valuable. However, I’ve seen 55-year-olds who have end-stage Parkinson’s or Alzheimer’s disease. For those individuals, I probably wouldn’t recommend screenings, for quality of life reasons.”

However, for the general population, researchers have emphasized that the focus should not be on whether physicians are ordering “unnecessary” lab tests, but whether they are ordering the “correct” tests.

A 2013 study published in the online journal PLOS ONE analyzed 1.6 million results from 46 of medicine’s 50 most commonly ordered lab tests. Researchers found, on average, the number of unnecessary tests ordered (30%) was offset by an equal number of necessary tests that went unordered.

“It’s not ordering more tests or fewer tests that we should be aiming for. It’s ordering the right tests, however few or many that is,” senior author Ramy Arnaout, MD, Harvard Medical School, Assistant Professor of Pathology and Associate Director of the Clinical Microbiology Laboratories at Beth Israel Deaconess Medical Center in Boston, stated in a news release. “Remember, lab tests are inexpensive. Ordering one more test or one less test isn’t going to ‘bend the curve,’ even if we do it across the board. It’s everything that happens next—the downstream visits, the surgeries, the hospital stays—that matters to patients and to the economy and should matter to us.”

Since the elderly are the fastest growing population in America, and since diagnosing and treating chronic diseases is a multi-billion-dollar industry, it seems unlikely that such a trend to move away from medical laboratory health screenings for the very old will gain much traction. Still, with increasing focus on healthcare costs, the federal government may pressure doctors to do just that.

—Andrea Downing Peck

Related Information:

Cancer Screening Rates in Individuals with Different Life Expectancies

Doing More Harm Than Good? Epidemic of Screening Burdens Nation’s Older Patients

Large-Scale Analysis Describes Inappropriate Lab Testing Throughout Medicine

Preventive Screening for Seniors: Is that Test Really Necessary?

Impact of Cognitive Impairment on Screening Mammography Use in Older US Women

Cancer Screening Rates in Individuals with Different Life Expectancies

The Landscape of Inappropriate Laboratory Testing

Older Adults and Forgoing Cancer Screening: ‘Think it would be Strange’

Harvard and Beth Israel Deaconess Researchers Use Machine Learning Software Plus Human Intelligence to Improve Accuracy and Speed of Cancer Diagnoses

Machine learning software may help pathologists make earlier and more accurate diagnoses

In Boston, two major academic centers are teaming up to apply big data and machine learning to the problem of diagnosing cancers earlier and with more accuracy. It is research that might have major implications for the anatomic pathology profession.

A collaborative effort between teams at Beth Israel Deaconess Medical Center (BIDMC) and Harvard Medical School (HMS) has resulted in an innovation that could result in more accurate diagnoses in the pathology laboratory. The teams have been working on a machine learning software program that will eventually function as an artificial intelligence (AI) to improve the accuracy of diagnostics. They hope to someday build AI-powered computer systems that can accurately and quickly interpret pathology images. (more…)

MedStar Health Latest Victim in String of ‘Ransomware’ Attacks on Hospitals and Medical Laboratories That Reveal the Vulnerability of Healthcare IT

Hollywood Presbyterian Medical Center makes headlines by opting to pay bitcoin ransom in order to quickly regain control of its computer systems

In recent weeks, hackers temporarily shut down MedStar Health—one of the biggest healthcare systems in the Washington, D.C. region—in the latest example of why cyberattacks are a threat not only to hospitals, but to anatomic pathology labs and clinical laboratories as well.

This latest incident is another example of a “ransomware” attack in which cybercriminals lock out computer users from accessing critical records and files. They then extort money by posting a digital ransom note warning users they must pay a ransom amount within a specific number of days if they want the digital key that will release their data.


Pathologist/Researcher Offers Two Suggestions to Reduce Inappropriate Testing and Improve Patient Safety

Whether either or both of these suggestions can be put into practice is the challenge most clinical laboratories face

For Pathologist Ramy A. Arnaout, MD, DPhil, one of the biggest issues all pathologists face today is how to overcome the breakdown in cooperation between pathologists and referring physicians that can cause patient harm.

An Associate Director of the Clinical Microbiology Laboratories at Beth Israel Deaconess Medical Center (BIDMC), Arnaout was a panel member during a webinar in December sponsored by STAT News and T.H. Chan Harvard School of Public Health. During the webinar, “Medical Tests: Inaccuracies, Risks and the Public’s Health,” Arnaout explained that when errors occur in a lab, they usually happen during test selection and result interpretation, sometimes called the “pre-pre-analytical” and “post-post-analytical” phases. In these two phases of the lab-testing process, pathologists and ordering physicians need to collaborate more closely to help avoid errors and reduce the level of patient harm, he explained. (more…)

Patient Safety Guru Lucian Leape, MD, Discusses How Medical Laboratories and Pathology Groups Can Do More to Improve Patient Safety

Panel of webinar speakers included several physicians, a pathologist, and a director from the Food and Drug Administration (FDA)

Patient safety continues to be a major factor in the ongoing transformation of healthcare in the United States. As it does, more scrutiny is being given to how medical laboratories and anatomic pathology groups can contribute to improving patient safety.

One example of the heightened scrutiny of patient safety as it relates to clinical laboratory testing services was a recent webinar at the Harvard T.H. Chan School of Public Health and the online healthcare site, Stat. Titled “Medical Tests: Inaccuracies, Risks and the Public’s Health,” this webinar featured nationally-known healthcare experts and policy makers.

Issues of patient safety associated with medical laboratories was a major topic during this webinar, including discussion about concerns associated with the clinical use of laboratory-developed tests. (more…)