Medical Technology and the Health Care System A Study of the Diffusion of Equipment-Embodied Technology (1979) / Chapter Skim
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APPENDIX C: A CASE STUDY OF MULTIPHASIC HEALTH TESTING
APPENDIX C: A CASE STUDY OF MULTIPHASIC HEALTH TESTING
Pages 124-172
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DEFINITIONS AND PURPOSES Definitions Personal preventive services in primary care are based to some extent upon periodic reevaluation of the health status of people. Such health examinations (health evaluations, health appraisals, or health checkups)
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MHT involves more equipment-embodied technology than the traditional health checkup, and, as used herein, multiphasic health testing includes both MHT and AMHT programs. Functions and Purposes of MHT Since MHT should always function as an integral part of some medical community, program, or system (e.g., a medical foundation, a health care delivery system, a public health program, an industry, a military program, etc.)
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7. Improve accessibility of health care by making health checkups more readily available.
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a group of primary care physicians who will support MHT by referring to it patients for examination and accepting patients referred from MHT for followup care. Test Selection for Health Problems It is important to identify a set of health conditions, test, and preventive procedures for each MHT program, customized to fit the needs of its target population.
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evolved as a systemized approach to provide health examinations more efficiently to large groups. The concept of health checkups is not new, as for decades the practice of periodic health examinations has been recommended generally.
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offering, on a voluntary basis, health examinations under the auspices of the district medical societies in cooperation with the community hospitals and other interested groups. In l95l, the first multiphasic screening project within a comprehensive prepaid health plan was initiated in KaiserPermanente's Oakland medical center and a year later in its San Francisco medical center.35 These were supervised and conducted by the same physicians who furnished the physical examinations, treatment, and followup care as an integral part of the group practice, prepaid medical care plan.
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Public Health Service, the multiphasic screening programs then operating in the Kaiser-Permanente Oakland and San Francisco medical centers were replaced by the first automated multiphasic health testing (AMHT) programs.
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Recently multiphasic health testing centers have been reported to be opening at a rate of two a week in some urban areas of the United States, some operated by nonphysicians; and at least in the State of Florida, legislation has been introduced to regulate MHT centers as to their supervision, quality, costs, and advertising.108 MHT programs are now widespread throughout the developed countries of the world. As of l976 there were about 300 in the United States, about 40 in Japan, about 30 in Europe, and a few in Australia, Asia, Canada, and Latin America.
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Consumer cooperative groups and unions are increasingly negotiating for periodic health examinations as a health welfare benefit. It can be expected that the general public increasingly will want health checkups as it becomes more aware of the fact that company executives, political leaders, union groups, and health plan members are receiving such health services.
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The number of full-time equivalents of personnel and the use of space, equipment, and supplies are also important to identify and measure by a cost analysis. For the health care delivery system within which MHT is located, the costs of resources used should include the costs of followup care from MHT referrals.
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WHO advocates that evaluations of effectiveness of screening programs should consider the effect of MHT on patient outcome.111 However, patient outcome is probably more dependent upon effectiveness of therapy than upon effectiveness of disease detection. The ability to favorably alter the course of the condition should be a criterion for MHT test selection and is an important factor in MHT cost-benefit analysis, but it is essential that evaluation distinguish between the medical care process of (l)
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. Thus MHT can be used to evaluate health status and to separate out those who need "health" care from those who need "medical" or "sick" care.
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7 5 3l. 5 3 Chest X ray 2.
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whether they thought the positive test was clinically important (i.e., warranted therapy)
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a TABLE 4 Categories of Screening Test Results Total Screening Test Patients Health Status Test Results Sick Well Results Positive (+) True +'s False +'s Total + Negative (-)
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) Costs of False-Negatives A false-negative is a more serious error if the condition missed is potentially a disabling one, e.g., failing to detect early pulmonary tuberculosis by the screening chest X ray has always been a great concern to the radiologist, whether the screening program was only for a single disease, tuberculosis, or whether in a multiphasic program it was for several conditions including tuberculosis.
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On pp. l43-l45 is presented a cost comparison of patients evaluated by MHT as compared to the traditional physician's health examination, and Table 5 shows the significantly lower costs for the MHT group for the initial workup and l2 months followup care.
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The unit cost per positive chest X ray for a clinically important abnormality in the 60 years or older age-group was $8. The low prevalence and high unit cost per positive test for chest X rays for young adults has caused many MHT programs to omit chest X rays for this group.
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The following study compared, for patients "new" to the doctor, the costs of health examinations provided by MHT (with and without nurse practitioner physical examinations) to the traditional health examinations provided by physicians.
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The MHT-MD mode reduced the physician time used in the initial examination by onehalf and decreased somewhat the physician time used for followup evaluation, so that the average total was only 25.5 minutes, or 42 percent less MD time than was associated with the traditional health examination. The MHT-RN approach further decreased the use of the initial physician time to only that for supervising the nurse practitioners who performed the routine physical examinations.
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As an alternative, by first providing a multiphasic health testing battery of tests, followed by either a physician (MHT-MD) or nurse practitioner (MHT-RN)
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Since this is a very time-consuming and expensive process, it is usually not done for every phase. "A Case Study of Mammography, as an example of a specific test-evaluation process, comprises Appendix B.1>9 Cost-Benefits of MHT Although it would be desirable to conduct cost-benefit studies of health checkups and of the MHT mode of providing such checkups, no such cost-benefit studies have yet been completed due to the inability to measure and include all benefits.
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The study did not demonstrate, however, that multiphasic health checkups provided similar cost-benefits for other groups, such as 35-44-year-old males or 35-54-year-old females. Effect on Mortality of Urging Multiphasic Checkups The most important objective of periodic health checkups is to decrease morbidity and mortality.
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By July l975, the average number of checkups per person was 5.2 in the study group and 2.0 in the control group. About 68 percent of both groups are still Health Plan subscribers.
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•P X ostate ( , hypert hyper ten cular di Ul •o id id Ul tn -H 0 id > •H H rH 0)
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l973 Category Deaths Per son- Years) Ratio 0 38,384.33 3l0 8.08 l.38 l l9,039.42 ll2 5.88 l.02 2 ll,l88.58 5l 4.56 0.74 3 7,873.67 36 4.57 0.7l 4-6 l3,282.50 59 4.44 0.62 7+ 3,959.00 l3 3.28 0.40 likely to use preventive services when they are poor, have little education, are isolated from community groups and social networks, have limited health knowledge, have unfavorable attitudes towards preventive care, and have little confidence in the health care system.
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Accordingly, time lost from work or usual activity is usually less from a multiphasic health checkup. Acceptance of MHT by Physicians Health checkups are generally accepted by primary care practitioners as a routine part of their work.
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This question applies primarily to mass screening programs and not to personal health checkups, whether the latter use the traditional or multiphasic modes. The American Medical Association in its guidelines has attempted to formulate ethical principles for MHT.160 Bates7 surveyed 4l7 physicians to ascertain their acceptance and followup of multiphasic screening tests and demonstrated the lack of responsiveness of practitioners in confirming an abnormal test or initiating management of detected abnormalities.
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Kaiser-Permanente's studies indicate that periodic multiphasic health checkups do favorably decrease mortality after age 35, so it would appear advisable to recommend health examinations every l-2 years after age 35, and less often for younger persons. Summary of MHT Evaluation Since MHT is still an evolving component of health care delivery, its objectives are still developing and its applications are becoming more diversified.
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X VDRL X X X X Tuberculin X X X Pap smear (females) X XXX X X Stool guaiac X XXX X Physical examination, general X XXX X X Breast examination (females)
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b. Provides the most efficient method of providing health examinations to a large population.
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POLICY IMPLICATIONS In the United States, the increasing interest in preventive medicine, the inclusion of health checkups by some Blue Shield plans, the passage of the Health Maintenance Act of l973, and the concept that "health care is a right"81 will all tend to increase the public demand for periodic health examinations. Already this demand is encouraging the opening of MHT programs as stand-alone, commercial for-profit laboratories, and these will require governmental regulating just as do clinical laboratories.
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The occasional checkup is of lesser value than periodic health examinations. Providing the physician with test results of prior examinations for comparison permits trend analysis for borderline abnormalities and aids in better diagnoses.
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B., et al. Automated Multiphasic Health Testing.
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"AMHT in Perspective -- Accomplishments and Problems." In Automated Multiphasic Health Testing. Engineering Foundation Research Conferences.
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F "Periodic Health Examinations Using An Automated Multi-Test Laboratory." Journal of the American Medical Association l95(l966)
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D "The Usefulness of Periodic Health Examinations." Archives of Environmental Health 2(l96l)
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M "The American Medical Association and Periodic Health Examinations." American Journal of Public Health l5(l925)
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Hall, W "AMHTLC." In Automated Multiphasic Health Testing.
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D "Automated Multiphasic Health Testing as an Adjunct
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"Factors Affecting the Acceptance of Automated Multiphasic Health Testing and Services Among Consumers and Providers. Provisional Guidelines for Automated Health Testing and Services.
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l32. Provisional Guidelines for Automated Multiphasic Health Testing and Services.
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J "The Values and Limitations of Periodic Health Examinations." Journal of Chronic Diseases 9(l959)
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P "Unanswered Questions about the Periodic Health Examination." Annals of" Internal Medicine 83(l975)
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S "Some General Principles and Some General Guidelines." Section II in Provisional Guidelines for Automated Multiphasic Health Testing Services.
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Part IV: "Provisional Guidelines for Automated Multiphasic Health Testing Services." Vol.
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