Why Early Screening for COPD May Not Be Cost Effective
A recently released position statement from the U.S Preventive Services Task Force (USPSTF) states that there is no current evidence that shows that screening for COPD in adults without symptoms results in improved health outcomes.
Why is this statement and finding so important?
COPD is, afterall, the third leading cause of death in the United States, and a major cause of disability and health care costs. So wouldn’t it make sense to identify the condition early, in as many people as possible, by using screening methods?
What is the U.S. Preventive Services Task Force?
The U.S. Preventive Services Task Force (USPSTF) was created in 1984. It is an independent panel of national experts in prevention and evidence-based medicine. Their recommendations are deemed necessary because with the increasing cost of health care, it’s not feasible to allow everyone to make their own decisions with regards to what is appropriate (and effective) for prevention of disease. This is especially relevant when you consider that health care is an industry where the consumer is often not directly responsible for the costs. So insurers want to know what screening tools are worth the money they cost.
There are 18 members who make up the USPSTF and not all of them are physicians. You may think it strange that this new recommendation for prevention of a serious respiratory condition, such as COPD, is being made by non- physicians and physicians who are not respiratory specialists. These individuals arrive at their conclusions by looking at the costs of prevention and the outcomes after these measures are implemented. The panel offers different levels of recommendations after their analysis, assigning a letter grade (A, B, C or D) to the recommendation, based on the levels of evidence.
Who uses the panel’s recommendations?
Their recommendations are often adopted and implemented by insurance payers. As an example, in the past doctors were told that doing regular chest X-rays on smokers would be appropriate to find tumors at an early stage, and would likely increase the possibility of catching lung cancer at an early stage. That should result in making lung cancer more likely to be completely curable by surgery. After that screening protocol was implemented, new evidence showed that screening smokers with this approach did not reduce mortality (death) from lung cancer. The practice of doing regular screening X-rays was then halted.
Doctors were also told that doing frequent spirometry testing (lung function tests done by making the patient blow into a machine that measures lung capacity) would help to identify early deterioration in the lung function and help to identify patients likely to develop COPD. The rationale was that COPD develops early on, before people actually have frank symptoms and, therefore, don’t seek medical care.
Now, this practice is discouraged. Not everyone in the health care field agrees with the benefits of the testing as an effective screening tool. Still many believe that COPD in its early stages is reversible with treatment since it only affects the airways at that point. At later stages, when the disease causes changes in the size and elasticity of the lungs (the emphysema component of COPD), the changes are permanent.
Does early diagnosis and treatment of COPD impact health care costs?
Even if we identify lung disease like COPD earlier, the medications currently available have not shown the kind of dramatic impact in preventing progression of disease, like we see with blood pressure or cholesterol-lowering medications. There is, however, some improvement in delay of symptoms when we identify early COPD. The other advantage of early diagnosis is that changes can be made in the home environment and work conditions of susceptible individuals, once they are identified.
Are campaigns that promote habit change or avoiding a habit like smoking effective for prevention?
No one can argue with efforts that highlight the health benefits of quitting smoking, and campaigns that educate individuals so that a non-smoker doesn’t start. When you make these recommendations in a general way, to the masses, they often miss the targeted level of urgency necessary to impact vulnerable individuals. And impact is a key factor in lowering risk of disease and lowering health care costs.
The real take home message is that every individual has to create his own preventive measures. In the case of lung disease, begin with avoidance of smoking and seek appropriate testing when symptoms, especially early symptoms, develop. Do not depend on the current health care system to do this for you.