Assessment of Cardiovascular Diagnostic Tests and Procedures Offered in Executive Screening Programs at Top-Ranked Cardiology Hospitals | Cardiology | JAMA Internal Medicine | JAMA Network
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1.
Saquib  N, Saquib  J, Ioannidis  JP.  Does screening for disease save lives in asymptomatic adults? Systematic review of meta-analyses and randomized trials.  Int J Epidemiol. 2015;44(1):264-277. doi:10.1093/ije/dyu140PubMedGoogle ScholarCrossref
2.
Korenstein  D, Mamoor  M, Bach  PB.  Preventive services offered in executive physicals at top-ranked hospitals.  JAMA. 2019;322(11):1101-1103. doi:10.1001/jama.2019.10563PubMedGoogle ScholarCrossref
3.
Greenland  P, Alpert  JS, Beller  GA,  et al.  2010 ACCF/AHA guideline for assessment of cardiovascular risk in asymptomatic adults: executive summary.  J Am Coll Cardiol. 2010;56(25):2182-2199. doi:10.1016/j.jacc.2010.09.002PubMedGoogle ScholarCrossref
4.
Best hospitals for cardiology and heart surgery. https://health.usnews.com/best-hospitals/rankings/cardiology-and-heart-surgery. Accessed September 19, 2019.
6.
Lim  LS, Haq  N, Mahmood  S, Hoeksema  L; ACPM Prevention Practice Committee; American College of Preventive Medicine.  Atherosclerotic cardiovascular disease screening in adults: American College of Preventive Medicine position statement on preventive practice.  Am J Prev Med. 2011;40(3):381.e1-381.e10. doi:10.1016/j.amepre.2010.11.021PubMedGoogle Scholar
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    Research Letter
    Less Is More
    January 13, 2020

    Assessment of Cardiovascular Diagnostic Tests and Procedures Offered in Executive Screening Programs at Top-Ranked Cardiology Hospitals

    Author Affiliations
    • 1St Louis University School of Medicine in St Louis, St Louis, Missouri
    • 2Department of Medicine, Cardiovascular Division, Washington University School of Medicine in St Louis, St Louis, Missouri
    JAMA Intern Med. 2020;180(4):586-589. doi:10.1001/jamainternmed.2019.6607

    Very few screening tests have been reported to reduce mortality in asymptomatic individuals.1 Nevertheless, there is an enduring belief in the benefit of using diagnostic tests to find disease in its earliest stages. Hospitals have responded to the demand for early diagnosis by establishing executive screening programs targeted to wealthy individuals who are able to pay directly for screening tests that are generally not covered by insurance.2 Since cardiovascular disease represents the leading cause of mortality in the United States,3 we assessed the cardiovascular examinations included in the executive health screening programs offered by the top hospitals for cardiology and heart surgery as ranked by US News & World Report.4

    Methods

    This survey study was approved by the institutional review board at the St Louis University School of Medicine with a waiver of informed consent. Data were obtained via telephone call. Between May 1, 2019, and June 28, 2019, we called the administrators from hospitals regularly listed from 2016 to 2019 in the US News & World Report ranking of Best Hospitals for cardiology and heart surgery4 and requested information regarding the availability of executive screening programs offered to individuals, specific tests offered, and costs. The telephone call was initiated with an introductory request for more information about the executive screening program followed by the first question, (1) “Do you have different packages? Such as a standard package and a premium package?” The 3 follow-up questions were (2) “Can this service be billed to insurance?” (3) “What is the cost? Is there an appointment fee?” and (4) “Do you have a brochure that includes all of the tests that you can send to my email?”

    We compared the tests offered with the recommendations for asymptomatic individuals by the American College of Cardiology/American Heart Association (ACC/AHA),3 the United States Preventive Services Task Force (USPSTF),5 and the American College of Preventive Medicine (ACPM).6 Analyses were performed without statistical software using basic math. This study adhered to the minimum disclosure requirements of the American Association for Public Opinion Research (AAPOR) Code of Professional Ethics and Practice.

    Results

    We attempted to contact 25 of the top-hospitals ranked by US News & World Report for cardiology and heart surgery. Of the 21 hospitals that responded to our inquiries, 18 offered 28 different executive health screening programs for individuals (Table 1). Total costs with appointment fee ranged from $995 for Comprehensive Health Assessment at Houston Methodist Hospital (ranked 13) to $25 000 for a Premier Executive Health Program at Cleveland Clinic (ranked 1). Three programs would submit charges to an insurance carrier. Twelve different cardiovascular screening tests plus a resting electrocardiogram were offered by the executive physical programs (Table 2). The most commonly offered tests were a lipid panel (71% [20 of 28]) and a cardiac stress test (68% [19 of 28]). Cardiac computed tomographic scanning, either to determine a calcium score or to visualize the coronary arteries, was included in 43% (12 of 28) of programs. Cardiovascular counseling was included in 2 programs and an exercise consultation was included in 1 program. Of the 12 tests, none of them are recommended by the ACC/AHA, USPSTF, or ACPM to be applied indiscriminately to asymptomatic adults.

    Discussion

    The top-rated US News & World Report cardiology programs commonly provide cardiovascular tests as part of executive screening programs that are not recommended by current guidelines for indiscriminate use among asymptomatic individuals. The premise of using these tests is that the results may help reduce mortality from cardiovascular disease through earlier disease detection or more precise risk assessment. However, no data support that premise as reflected in the guidelines of the ACC/AHA, USPSTF, and ACPM.

    This study has limitations. First, we did not obtain information directly from physicians involved in the executive screening programs. It is possible that the testing procedures may be more tailored to the individual than was represented by administrators who provided the information. Second, although 3 programs would submit charges to insurance carriers, we have no information regarding whether any insurance carriers would actually reimburse for the services provided.

    In addition to clinical care, the top cardiology hospitals also provide medical education. Offering executive physicals with tests that are not recommended for healthy persons to anyone who can pay out of pocket potentially sends the message to trainees that a 2-tier health care system is acceptable, and that evidence is not important. Furthermore, indiscriminate screening can create a cascade effect and thus violate the principle of primum non nocere (first do no harm) wherein unnecessary tests may create a chain of events resulting in additional ill-advised tests or treatments that may cause avoidable physical or psychological harm. In summary, executive screening programs are not consistent with the goals of health care to provide evidence-based cost-effective equitable care.

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    Article Information

    Accepted for Publication: November 13, 2019.

    Corresponding Author: David L. Brown, MD, Cardiovascular Division, Washington University School of Medicine in St Louis, 660 S Euclid Ave, Campus Box 8086, St Louis, MO 63110 (d.brown@wustl.edu).

    Published Online: January 13, 2020. doi:10.1001/jamainternmed.2019.6607

    Author Contributions: Dr Brown had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Ge, Brown.

    Acquisition, analysis, or interpretation of data: Ge, Brown.

    Drafting of the manuscript: Ge, Brown.

    Critical revision of the manuscript for important intellectual content: Ge, Brown.

    Administrative, technical, or material support: Brown.

    Supervision: Brown.

    Conflict of Interest Disclosures: None reported.

    References
    1.
    Saquib  N, Saquib  J, Ioannidis  JP.  Does screening for disease save lives in asymptomatic adults? Systematic review of meta-analyses and randomized trials.  Int J Epidemiol. 2015;44(1):264-277. doi:10.1093/ije/dyu140PubMedGoogle ScholarCrossref
    2.
    Korenstein  D, Mamoor  M, Bach  PB.  Preventive services offered in executive physicals at top-ranked hospitals.  JAMA. 2019;322(11):1101-1103. doi:10.1001/jama.2019.10563PubMedGoogle ScholarCrossref
    3.
    Greenland  P, Alpert  JS, Beller  GA,  et al.  2010 ACCF/AHA guideline for assessment of cardiovascular risk in asymptomatic adults: executive summary.  J Am Coll Cardiol. 2010;56(25):2182-2199. doi:10.1016/j.jacc.2010.09.002PubMedGoogle ScholarCrossref
    4.
    Best hospitals for cardiology and heart surgery. https://health.usnews.com/best-hospitals/rankings/cardiology-and-heart-surgery. Accessed September 19, 2019.
    6.
    Lim  LS, Haq  N, Mahmood  S, Hoeksema  L; ACPM Prevention Practice Committee; American College of Preventive Medicine.  Atherosclerotic cardiovascular disease screening in adults: American College of Preventive Medicine position statement on preventive practice.  Am J Prev Med. 2011;40(3):381.e1-381.e10. doi:10.1016/j.amepre.2010.11.021PubMedGoogle Scholar
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