How many of the “best” hospitals provide low-value cardiovascular screening?

If you follow the Lown Institute blog, you know that more is not always better when it comes to medicine. However, when hospitals try to attract wealthy patients, they tend to offer more anyway. 

A few years ago, professors of medicine at the University of Chicago Adam Cifu and James Woodruff wrote in the Baltimore Sun about the “executive health programs” offered by medical centers competing for wealthy patients. These programs often include screenings for tests such screening cardiac stress tests, skin and prostate cancer screening, peripheral artery disease screening, and screening for carotid artery stenosis, none of which are proven to save lives, according to the U.S. Preventive Services Task Force. Although it makes sense that screening healthy people prevents disease by detecting it early, in reality many types of screening can be harmful by leading to care cascades and overdiagnosis

Now, a new study in JAMA Internal Medicine shows that even the “best” hospitals in the nation commonly offer unnecessary cardiovascular screening tests as part of their “executive programs.” St. Louis University medical student Alan Ge and Washington University School of Medicine professor and cardiologist David L. Brown called 25 of the top-hospitals ranked by US News & World Report for cardiology and heart surgery. They asked administrators at these hospitals if they had executive screening programs offered to individuals, which tests were offered, and at what cost. 

Out of the 21 hospitals that were reachable, they discovered that 18 hospitals offered executive screening programs. Some hospitals offered more than one, bringing the total number of different available programs to 28. The authors identified 12 tests plus a resting electrocardiogram offered in these programs. The most commonly offered tests were an ECG (included in 83% of programs), cholesterol lab test (offered in 71% of programs), and cardiac stress test (offered in 68% of programs).

“Of the 12 tests, none of them are recommended by the ACC/AHA, USPSTF, or ACPM to be applied indiscriminately to asymptomatic adults,” Ge and Brown wrote. The price for these programs, including a ubiquitous “appointment fee” ranged from $995 to a whopping $25,000.

The fact that most of these hospitals are teaching hospitals is also disturbing, because having the executive health programs sends two bad messages to trainees: 1) rich people get different care than other people, and 2) evidence doesn’t matter. 

This study also lends some insight into the criteria we use to rank hospitals. US News ranked these 18 hospitals among the best based on how well they perform medical procedures, but did not evaluate hospitals based on whether they should perform these procedures. In fact, the program ranked #1 in cardiovascular care by US News in 2019–the Cleveland Clinic–was the program with the most expensive executive health program. Had overuse and cost-efficiency been a part of their ranking, maybe they would not have ended up at the top…