Tobacco Documents Online

Mu.ltiphasie Screening: Time for A Turnaround? . Unless you are completely fascinated by the subject, few literary exercises are more difficult-and less re- warding-than that of reading what educators and researchers have always referred to as a State-of-the- Art Paper. While such studies are the stuff that scientific progress often begins with, and eventually is made of, they are also a kind of king-size catalog of footnotes, unfamiliar nomenclature, overwhelming statistics, repititious quotations, appendices, tables, and "additional references" to sources not always available in the country of your choice. In short, a State-of-the-Art Paper is not really for the layman; it'is of consuming interest to only a limited number of professionals; and it is avoided with trepidation by newsletter editors whose facility with short, timely, provocative news items can be mangled beyond re- pair by long, erudite, circumlocutory analysis. For Whom It Tolls: Having placed our caveats on the table, however, let it also be noted here that a well- done State-of-the-Art Paper may contain information you can't get anywhere else. It may-by linking all known factors together-become a landmark in the evolution of a process or system or technique to ad- vance universal medical practices. It may-even with- out your reading it-help to save your life one day. Abstracts from AHP' Papers: On these next few pages, consequently, we are abstracting certain comments and findings from two papers completed by The American Health Foundation this past year. One is aptly titled, "Multiphasic Health Testing/Screening Systems-State of the Art." It was sponsored by the U.S. Public Health Service, Department of Health, Education, and Welfare, and AHF was the contrac- tor. The other is titled, "Automated Multiphasic Health Testing," and it represents a preliminary iin- vestigation for the Health Surveillance Center which AHF plans to open in New York City as a prototype for other communities. Anna C. Gelman, assistant professor of epidemiology at Columbia University, served as the AHF project director responsible for preparing both papers. A Group Concept: For those who by now are fairly certain that they don't know what multiphasic screen- ing is all about-automated or not-the stylized flow- chart above will help to visualize its operations. Generally speaking, multiphasic screening is distin- guished from the comprehensive annual health check- ups many people now undergo, for the latter cus- tomarily include diagnostic procedures. Screening per se is defined as "the presumptive identification of unrecognized disease or defect" by a series of tests, examinations, or other procedures. Multiphasic screening, on the other hand, is the application of two or more tests in combination to large groups of people. It is a means of rapidly identifying the ap- 3

parently well persons who probably have a disease and those who probably do not. State-of-the-Art Today: Desirable as its objectives might seem, the proclaimed merits of AMHT (auto- mated multiphasic health testing)-and whether di- agnostic or follow-up treatment should be included- have provoked considerable debate within medical circles. Those who champion AMHT say it is eco- nomical, time-saving, reliable, and with more studies and experience will become even better. Those op- posed question how it can be integrated into our present health-care system. They also charge it dumps large numbers of disease suspects upon pri- vate practitioners-while failing to provide financing or facilities for diagnosis and treatment. Variations on these themes have reverberated through medical conferences for well over half a century. But today, with medical costs skyrocketing and new alternatives needed, there is increasing agreement among physi- cians that "multiphasic screening is here, and we had better learn how to adjust to it." The Case for Periodic Preventive Examinations In the first AHF paper on AMHT's status, readers are reminded, "The belief that it is good practice. to visit one's physician periodically for a preventive examination is not new." Lecturing in London in 1861, the paper notes, Horace Dobell recommended that such an examination for all members of the family-to include family history, personal and medi- cal histories, advice and follow-up-would confer "immense benefit upon the public." Since that time-and before, in fact-there have been many other advocates of a periodic preventive ex- amination. Indeed, such examinations are being conducted today by many physicians and medical groups. One survey, conducted in 1957-59, found that there had been approximately 74 million visits to doctors annually for a general checkup-about 8% of all physician visits. Acceptance of the concept has been increasing. The Ideal Way: No one can deny that in an ideal situation every person would consult his or her per- sanal physician-who is ready and waiting, with a modern, fully-equipped office and qualified technical staff for a thorough physical examination, as well as facilities for follow-up treatment. However, there are just not enough general practitioners, internists, and pediatricians available for such annual face-to-face services. At best, if all 260,000 licensed physicians in the U.S.-regardless of specialty-were to assume responsibility for an annual physical examination, it wouldn't work very well. For based on the estimated figure of 60-65 "family service" physicians per 100,600 population, each doctor would have to per- form roughly seven physical examinations a day-if all 200,000,000 of us were examined annually. Who, then, would have time to treat the sick? Seen under these conditions, the "ideal" way becomes more visionary than viable, and AMHT seems more in- evitable. 4 Here's how U.S. spent $63-billion f or medical care in 1969. Annual cost is expected to reach $200-billion by the early 1980's. Advantages of Automation: Since there is a shortage of doctors, and since medical schools can't graduate them fast enough, the medical profession is virtually being compelled to take greater advantage of tech- nological alternatives. Automatic recording devices, biochemical and hematological autoanalyzers, sensi- marked questionnaires, and data processing systems are mushrooming everywhere. It has been estimated, moreover, that "a 3% increase in the productivity of the physician would be equivalent in service to all members of graduating classes in all medical schools in a given year." Can we afford, then, not to have a wide network of AMHT centers, public and private, within the framework of the existing organization of medical care in this country? If definitive answers are lacking-and they are-there is no lack of opin- ions or interest or planning. Where Industry Stands: Investment capital believes that the answer to AMHT is affirmative, and is rapidly movirig to "get in on the ground floor." The entrepreneur is concerned with whether or not this new system can be marketed. Among the many in- dustries involved already are the data processing companies, and their satellites, all looking for fresh outlets for their services. Instrument manufacturers, too, see in AMHT the competition for more ac- ceptable instrumentation. Systems designers and architectural firms anticipate. a growth market for stationary health care centers and mobile units alike. Pharmaceutical companies, always interested in ex- panding their biochemical and other testing services, are also waiting in the wings. And not to be over- looked, of course, is the insurance industry. With few exceptions, insurance policies do not currently provide for preventive examinations, but future.

31 C AMHT centers may very well affect disability and hospital claims as well as longevity. A Concert of Constraints: It would not be quite cricket to say that either a loyal or a disloyal opposition to the go and no-go aspects of AMHT has developed. What has happened to mitigate its momentum is that, from many responsible sources, special interest problems are being evaluated and the end results of change are still in need of a consensus. Govern- mental agencies are concerned with both the validity and legality of various AMHT components in order to protect the individual consumer at whom all of this automation is directed. Consumers themselves, as represented by unions and other consumer groups, are asking for evidence that AMHT is something desirable which will be of benefit to them. Employers, in turn, are more interested in knowing whether the use of such a system will lessen - absenteeism and increase production. Even among scientists- particularly epidemiologists, geneticists, biostatisti- cians, social scientists, sociologists, health planners- the ability of AMHT to provide valid and significant numbers relating to the variables of health and dis- ease is a matter of great concern. Challenging the Status Quo: Perhaps the most search- ing and sensitive questions have been raised by the professional groups. Educators, psychologists, hos- pital administrators, and biochemists, among others, have laid it on the line. Does AMHT create new op- portunities, they are asking, or does it threaten the status quo-which is the product of many centuries? Organized medicine, as represented by the A.M.A., is currently of the opinion that "automated multi- phasic screening at this point in time is a promising technique which requires further experimentation and controlled evaluation to fully identify its benefits, limitations, and ultimate potential." The fact that AMHT must be supported by follow-up treatment for the identified "high risk" patient, seemingly does not influence A.M.A.'s position. A not dissimilar stand was taken by The American Public Health Association in the 1968 policy state- ment of its Governing Council: "Comprehensive multiphasic screening programs of the type recom- mended require careful detailed planning and coordi- nation. Time and effort must be spent to survey exist- ing programs, past histories of different programs, existing community needs, services and resources, the cost, value and feasibility of various tests, and to sample the attitudes and desires of the target popula- tions and the medical community concerning a screening program. Only after this basic work has been completed can an effective program be tailored to the specific community concerned." Slowly but Surely: Unlike the Gordian Knot-which had to be severed by sword-the conflicting convic- tions of private enterprise on the one hand and those of medical and public health professionals on the other are apt to come unraveled one at a time, though not overnight. If the periodic health examination has been an acceptable procedure since the early part of this century, if science and automation are man's to control, then surely the future of AMHT is secure. Variables in Cost of AMIIT vs. Cost of Illness High among the obstacles to overcome before any new program such as AMHT can be integrated into the overall medical care system are predictable ques- tions about its cost and its benefits. "Will it be worth the expenditure?" That's the inevitable query from government, industry, medicine, and insur- ance. Undeniably, automated multiphasic health testing installations do require vast expenditures of time, effort, personnel, and money, even before a center can open for service. In addition, the cost of conducting such a center requires a steady stream of examinees to keep it solvent. i Since AMHT has only been in operation for a rela- tively short time, data on cost, cost benefit, and cost effectiveness are sorely lacking. Much time is being spent, however, on the development of appropriate cost formulas. These will eventually be of value in detecting unnecessary examinations, the need for new or less expensive instrumentation, relating cost of test to frequency of the abnormality detected in the population group under study, and many other variable factors. Meanwhile, it must be recognized that the cost of tests in one program may differ widely from another because of the volume of tests performed. Also, if an AMHT center is associated with a hospital which already has much of the es- sential equipment, facilities, and professional staff, its cost per examination may be less than one which stands alone. In other situations, the geographic loca- tion of the facility-in terms of heating needs, rental costs, labor, and various overhead charges-will in- fluence the cost. Basis for Comparisons: One of the largest and best known of AMHT programs is that conducted by the Permanente Medical Group in Oakland, California. According to a cost analysis study reported (5/8/69) in the New England Journal of Medicine, the cost to Permanente per multiphasic screening was $21.32. This figure included data processing, direct and in- direct charges, and related to a patient load of 2,000 per month. If only 1,000 patients were screened, the cost was estimated at $40-50 per examination. If the patient load could be raised to 3,000 per month, it was estimated the cost would drop to $15-17. This same article pointed out: "On the basis of two multiphasic laboratories, each operating for 40 hours weekly and each examining about 500 patients a week, the cost per screening was $21.32, including central staff and data pro- cessing and all direct and indirect charges. This figure includes physician interpretations of electro- cardiograms, x-ray films and retinal photographs, but excludes physicians' physical and supplemental follow-up examinations. Personnel salaries at $8.60 per patient examination comprised the largest cost category. Clinical laboratory and mammography were the most expensive phases." ~ 5 ~

~ I Claims and Counter-Claims: While the Permanente cost study is indicative and revealing, it is not con- clusive. For most of the other currently operating AMHT centers have not been in operation long enough to evaluate the impact of their efforts. They are not yet in a position to evaluate.their procedures in terms of yield, effectiveness, interpretation, ac- ceptance by both patient and physician, cost and cost benefits, etc. And there are no available regula- tory guidelines for the conduct of non-governmental sponsored centers, for quality control and repro- ducibility of results, for interpretation of findings and long-term effect upon medical demands, hos- pital bed utilization, and patient benefits. Some supporters of AMHT do claim to have suf- ficient evidence to justify their programs. But their opponents offer a variety of criticisms directed against the preventive examination concept in gen- eral, the danger of overwhelming busy physicians with trivial abnormalities, the imperfections of auto- mated procedures, etc. It is to be hoped, nonetheless, that the availability of automated data processing and automated instrumentation will make it possible to rapidly analyze the data derived from AMHT centers, so that the questions posed by A.M.A., A.P.H.A., and other groups can be answered with authority. The Ultimate Decisions: If the AHF papers seem to dwell heavily on the restraints invoked by AMHT- and they do-they also make a very compelling case for the future of this complex preventive concept. They do not put a price tag on building an AMHT center for the reasons already cited. But they do point to multiphasic screening programs which have tso ~ HosDital daily cn,,,es All medf ~ue so anyslc h /~ E I I I ' I ost of l ~ In f{ationary prices are the biggest single contributor to medical costs in the U.S. today. 6 cal ns ivinq brought the cost of comprehensive physical examina- tions to a point that most people can comfortably afford. They do not advocate the replacement of traditional medical practices and doctrines. But they do conclude that what we have is not enough, and that something more is needed to strengthen our current health care system. Seen within these parameters, it may well be that the ultimate decisions concerning AMHT will be made for us-not by medical authorities, but by the imperatives of our national needs and resources. Look at the soaring 1970 census figures, and one can only conclude that a population of 205-million -with its medical services already over-burdened- must take full advantage of preventive medicine tech- niques and automated facilities. Look at the $63- billion spent (see chart on P. 4) for U.S. medical care in 1969, or compare the rising costs (see chart on P.6) of medical care with the cost of living, and again one concludes that medicine today needs all the help it can get. Used in Many Ways: Apart from their contribution to periodic preventive examinations, AMHT centers can and should be used for physical fitness ap- praisals: by athletes in competitive sports; by chil- dren entering school, summer camp, or college; by the armed services for pre-induction physicals; by many employers for hazardous occupations; and by inmates of public institutions. There are, in fact, a vast number of other special uses for AMHT, including pre-trial assessment of health status after an accident, periodic nutrition surveys to detect abnormalities before and after therapy, and determining the medical needs of persons obtaining government assistance. Physicians would supervise all such programs, and perform those examinations which only a physician is qualified to do. Many of the tests and the data processing, however, could be performed by para- medical personnel and technicians-so that physi- cians can concentrate on diagnostic problems and patient care. Some Wait, Some Won't: Clearly, then, AMHT is a system with the potential for widespread applica- tion. The cost problems can be solved-with tech- nology, with good management. The primary con- sideration should be whether AMHT is an effective method of administering that part of the "physical check-up" which it encompasses, and whether it conserves medical manpower without lowering ex- amination standards. Today, laboratory examina- tions, EKG's, x-rays, and many other testing devices are an accepted part of the requirements for sound medical practice. They are also a part of the pa- tient's expectation. Thus, in its present state-of-the- art, AMHT appears to be the next logical extension of what has now been accepted by many physicians and much of the general public. While some wait for its promise to be proven and perfected, others see AMHT as a portal to chronic disease control through early detection and follow-up treatment.