Innovative screening programs outside the formal healthcare setting for chronic conditions- like diabetes, hypertension, and high cholesterol- are increasingly popular but the effects and added value have been hard to quantify.
A recent study shows these programs may cause changes in participants’ care seeking behavior. Researchers Rebecca Myerson, Lisandro Colantonio, Monika Safford, and Elbert Huang found that Medicare beneficiaries whose biomarker assessments indicated undiagnosed high cholesterol, high blood pressure, or diabetes increased semi-annual doctor visits for these conditions by 22 percentage points two years after assessment. The results were published in Health Services Research.
“Screening outside the formal healthcare setting is exciting as an outreach tool for the same reason its impact is so uncertain,” said Rebecca Myerson, the lead author on the study. “It can reach patients with unmet health care needs who don’t regularly see a doctor. Our question was whether these patients would circle back to the formal health care system and seek care from a doctor if their biomarker assessment showed abnormal results.”
Myerson, who is an assistant professor at the USC School of Pharmacy and the USC Schaeffer Center for Health Policy & Economics, worked with colleagues to address this question by seeking data from a unique epidemiologic study merged with Medicare data. This unique dataset permitted analysis of how health care seeking behavior changes as a result of the new information the participants were given about their biomarkers.
In comparison to the change in behavior for previously undiagnosed conditions, doctor visits for previously diagnosed conditions did not change. This provides evidence that patients changed their health care seeking behaviors only when the assessment taught them about abnormal biomarkers of which they were previously unaware.
Measuring the Effect of Opportunistic Screenings
When individuals are screened outside of a formal health care setting, the information from the tests may not make it into their medical records. This has made it difficult to evaluate whether screening outside a health care setting, termed opportunistic screening, actually works.
A potential benefit of opportunistic screening is its ability to reach individuals that are less connected to the healthcare system and thereby close gaps in care among underserved populations. However, because previous studies approaching this topic with survey data have shown high loss to follow-up among underserved populations, the impacts among these populations were difficult to assess.
The analysis of Myerson and her colleagues side-steps these barriers by using data from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study linked to Medicare claims data. The REGARDS study is an epidemiological study that recruited participants from across the continental United States from 2003-2007 using random telephone calls. People who agreed to participate in the study had biomarkers related to diabetes, hypertension, and high cholesterol assessed by a technician outside of a healthcare setting (typically, the participant’s home) and were informed of their results using standard text.
The authors assessed the impact of this biomarker assessment on health care seeking behavior by comparing rates of doctor visits for evaluation and management of diabetes, hypertension, and high cholesterol before and after the assessment for patients whose conditions were previously diagnosed vs. previously undiagnosed. The researchers also exploited the rolling recruitment of the study over a number of years to tease out the impact of screening from the impact of societal changes.
New Information Changes Care Seeking Behavior
Myerson and her colleagues found that assessment of biomarkers in the REGARDS study increased semi-annual doctor visits for previously undiagnosed conditions by 15 percentage points one year after assessment and by 22 percentage points two years after assessment.
Broken down by previously undiagnosed condition, semi-annual doctor visits increased by 45 percentage points for diabetes, 19 percentage points for high cholesterol, and 20 percentage points for hypertension.
Furthermore, follow-up was similar in populations known for having health disparities such as African Americans, participants living in counties designated as a Health Professional Shortage Area, and participants with low-income or less than a high school education. “One might be concerned that if health disparities populations are less likely to receive doctor visits for their newly diagnosed conditions, additional biomarker assessments could actually exacerbate disparities in chronic condition care. Our findings indicate that, at least among Medicare beneficiaries, this might not be the case,” Myerson said. “That said, it’s possible that the impact on health disparities could be different in populations without insurance. It’s a question for future research.”
Integrating Screenings into New Frameworks for Care
In the past decade, there has been a push to integrate screening for diabetes, hypertension, and high cholesterol into settings that will be easier for individuals to access than traditional healthcare. For example, major pharmacy chains like CVS and Walgreens provide screening to customers. Given that these chronic conditions are highly prevalent in the US and often asymptomatic, these sorts of strategies to reach individuals seem promising.
Coupled with these efforts, new models of care like Accountable Care Organizations and Accountable Health Communities give health providers incentives to improve access to screening.
Though knowledge about the burden of chronic diseases has increased, many individuals remain undiagnosed. The researchers note that about 20 percent of participants in the study sample were undiagnosed for at least one of the conditions analyzed, despite having Medicare insurance. Delays in diagnosis and treatment put patients at risk for heart attack, stroke, and other complications.
This research provides the best evidence to date that assessing a patient’s biomarkers outside a health care setting and informing patients about their health status can actually increase the number of doctor visits for previously undiagnosed conditions and thus improve a patient’s access to treatment and disease management.