Retail Medicine: Hype or Hope for the 'Worried Well'

Retail Medicine: Hype or Hope for the 'Worried Well'

By Kelly M. Pyrek

The burgeoning concept of "retail medicine," or healthcare that is available to the masses outside of a traditional institution setting, is carving out a new niche in the elective outpatient medicine marketplace. The $5 billion aesthetic retail medicine market encompasses everything from cosmetic surgery to preventive medicine. While there is no definitive estimate of the number of these kinds of retail medicine centers in the United States, established outpatient facilities want to cash in on the trend and diversify their existing menu of diagnostic and surgical services.

For example, in 2000, The Plastic Surgery Company partnered with Image Sculpting International to develop what it touts as combined "one-stop retail centers" for elective procedures of laser vision correction, cosmetic surgery and cosmetic lasers. The joint venture created an integrated program to deliver three of the fastest-growing retail medicine services in high-traffic, conveniently located retail venues with evening and weekend hours available. In 1999, according to Business Wire data, these specialties accounted for more than 5 million outpatient procedures.

"Preventive imaging centers are growing in number and the variety of procedures is increasing," observes James Ehrlich, MD, medical director of the Colorado Heart and Body Imaging in Denver and the medical co-director of Heart Scan centers in Houston and Washington, D.C. "Many new centers are promoting general body imaging, heart scanning, lung screening and virtual colonoscopy. The setting for screening and imaging varies from outpatient radiology clinics to specific locations in heart hospitals to the occasional wellness Mecca or spa. Another trend has been the realization by radiology practices that they need to expand the uses of expensive diagnostic equipment designed for symptomatic patients to the larger group of individuals who are currently without symptoms, but concerned about prevention."

Stephen Koch, MD, medical director of Imaging for Life in New York City and White Plains, N.Y., estimates there are probably about 100 privately owned or institution-affiliated screening centers in the United States. He believes as many as 400 centers may be operating within the next few years.

Koch says two business models for screening exist. "The first is run more like a standard medical/radiology office, where a patient would come to a facility, images are taken and then the patient has a one-on-one consultation with an internist/primary physician. The images are immediately read following acquisition and the results are discussed with the patient at the time of the visit. The patient leaves with a complete set of images and a report with recommendations. The second model gives the industry its bad name and that is 'mall medicine.' These facilities are either located in an actual shopping mall or some put on semi trucks and moved from parking lot to parking lot, where the images are obtained and the patient consent on his/her way. The images are usually transmitted to a radiology group, at times in a completely different region of the United States where they are read, and the patient receives a radiology report in the mail a week or so later."

Koch emphasizes that affiliation with a medical academic institution is critical because quality assurance, professional coverage as well as credibility are important components in screening. "An unfortunate part of the screening industry is that any individual/ entrepreneur with enough capital could open a screening center and hire a radiologist to do the readings," he adds.

THE "WORRIED WELL"

The retail medicine trend is also introducing new buzzwords within the healthcare community, including "medical entrepreneurs" who are marketing their services to what is being known as the "worried well" and the "worried wealthy." However, as the price of body scans drop, Ehrlich says such technology is becoming accessible to almost anyone.

"Early on, typical consumers were more wealthy, proactive by nature, independent thinkers not relying solely upon physician advice. The interest level has broadened as more middle-class individuals have friends, colleagues or family members who have succumbed to diseases that were discovered at a late stage. In addition, there are now thousands of scanned individuals talking about their experiences and advertising and media stories are pervasive."

As aging baby boomers -- the vast majority of the individuals who consume retail medicine -- search for peace of mind about their health, they succumb to the promise of a false sense of security. One of the most sought-after components of the retail medicine trend is the full-body scan, which medical entrepreneurs say will reveal abnormalities in the body that can be addressed before they have a chance to become life threatening. Computerized tomography (CT) scans promise to detect latent signs of conditions ranging from tumors to gallstones, clogged arteries to cancer.

"Imaging centers generally use spiral (helical) CT scanners (single or multiple slice) or a CT scanner designed primarily for heart imaging called "Electron Beam Computed Tomography" (EBCT)," Ehrlich says.

"The main impetus behind retail medicine has been the public's perception of the inadequacies of managed care medicine, which does not encourage screening practices or specialized preventive procedures," Ehrlich adds. "Retail medicine is often preventive in nature, which is largely ignored by hospitals and physician practice. Proactive citizens frequently will pay out of pocket for more sophisticated or attentive medical services. The owners of screening centers are giving the public what they inherently understand --- that prevention is better than a cure and early detection is the key to successful preventive strategies."

Despite body scans' popularity among healthcare consumers, medical and scientific organizations are raising concerns about procedures like body scans. Organizations raising issues about CT scans include the American Heart Association, the American College of Cardiology, the American College of Radiology and the American Institute of Physicists in Medicine (AAPM).

The AAPM asserts that CT scans are "not scientifically justified" for patients without symptoms and that there is no scientific data showing whole-body scanning to be effective in detecting disease. The AAPM says CT scans are best for obtaining information on known or physician-suspected problems rather than searching for healthy patients for unknown disease.

"I don't think that we, as medical physicists, are necessarily speaking out against our radiologist colleagues; indeed, the American College of Radiology has a similar statement in regard to whole-body CT scanning, and the ACR is a large group of radiologists (with some medical physicist members)," says John Boone, PhD, FAAPM, professor of radiology at the University of California Davis Medical Center's Research Imaging Center in Sacramento, Calif. Boone was responsible for drafting the AAPM's official statement on CT scanning. "I think medical physicists and radiologists are saying that patients should approach whole-body CT scanning with due caution and in light of the possible down sides, including false positives and subsequent follow-up costs if something suspicious is found."

THE RISKS

According to the AAPM, whole-body scans expose individuals to "significant radiation." Most medical professionals try to avoid exposing patients to unnecessary radiation unless the potential benefits outweigh the risks. That risk consists of damage to healthy cells in later years as radiation doses accumulate. According to the AAPM, whole-body scans deliver significantly higher radiation doses than other X-ray procedures because while a standard chest X-ray takes a single snapshot, a CT scanner takes multiple snapshots as it rotates around the patient's body. As a result, a CT scanner may deliver a radiation dose about 250 times greater (15 millisieverts) than a patient receives in a chest X-ray.

"There has been concern that unnecessary medical radiation could increase the risks for future cancer," Ehrlich says. "In general, the amount of radiation from medical imaging procedures is modest but one should still be concerned about lifetime cumulative exposure to X-rays. The body scan is a procedure that is not medically necessary, yet there are components to the body scan (heart imaging) that is very often useful, so the risk/benefit ratio of a heart scan is favorable. Electron Beam Tomography exposes individuals to less radiation than multislice CT scanners."

When asked if body scans are safe, Boone replies, "Is flying in an airplane safe? It's a tough question to answer. If 10,000 people have CT scans that average perhaps 1 REM (10 mSieverts) of effective dose, it is estimated that four will die from a radiation-induced malignancy. That's assuming the population having these whole-body CT scans is representative of the normal United States population. It is likely, however, that the people having these scans are older than average and this would reduce the risks. It is also likely that many of these individuals actually suspect there is something wrong with them due to mild symptoms they may be having. There is a very small risk that the radiation would, years later, induce a malignancy. The risk is very small and essentially gets smaller as the person being scanned gets older, since we are all closer to death from other natural causes. Death from other causes would obviously mask or prohibit detection of any complications from a radiation-induced cancer."

Koch says that when evaluating the risks associated with whole-body scans, the operative word is "excessive." He adds, "Why is a single screening exam that may be performed once every five years considered excessive? No one really knows at what point radiation will cause disease. The atomic radiation and subsequent disease caused by the atomic explosions at Hiroshima, Nagasaki and Chernobyl are well documented, but X-rays are not the same as nuclear particulate radiation. Would I recommend that a person get exposed to X-rays for hours on end, the answer is no. There are different types of ionizing radiation, from high-energy X-rays that primarily go right through the body with only a minimal amount of radiation absorption to low-energy neutrons, alpha and beta particles from atomic explosions that are almost 100 percent absorbed. Anecdotally, if one understood how often patients in hospitals get CT scans when they are very sick versus an occasional screening scan, maybe a relevant perspective could be obtained. Sometimes in the hospital setting a patient could get a half a dozen CT scans in a short hospital stay to document progression or resolution of disease. No one criticizes the excessive use of the technology for this purpose. But an elective scan done occasionally gets tremendous criticism. The real risk is ignorance, not knowing the presence of a curable disease process that may have a deadly outcome that could be cured with early intervention. The real task is to differentiate those individuals who may benefit from a screening exam and therefore justifying the elective radiation, from those who should not get one."

FALSE ALARMS

Patients wanting to know what lurks inside their bodies pay a heavy emotional price if they receive a false positive on their scan results. However, Boone says there isn't sufficient data on the number of false positives produced by CT scans. "There is the perception that many people are being worked up subsequent to 'abnormal' CT scans. The work-up can involve ultrasound examination, another CT examination with the injection of X-ray contrast media, or an MRI. These add thousands of dollars to the price tag and typically these follow-up examinations are paid for partially by one's insurance company. Anecdotal evidence would suggest the overwhelming number of these cases end up being 'normal.' The person in which a CT scan actually finds a malignancy in which anything can be done to improve prognosis is thought to be quite rare. The obvious downside of detecting an incurable cancer before there are symptoms is that you find out that you have it and potentially waste a few good months of your remaining life worrying about it. Without the scan you may have been blissfully ignorant and having fun."

"Very few physicians realize that there are essentially no false positives in coronary imaging, as we are looking for plaque, not obstruction," Ehrlich says. "However, the public should be informed that many lesions found in the lungs and abdomen will have little or minimal medical significance and can be considered false positives -- it is the price we pay for very sensitive screening tests looking for problems that are generally not prevalent. In general, radiologists are able to characterize abnormal findings in appropriate language so that innocent-appearing lesions are not described in alarming language. However, it is important that patients receive follow-up communications to make sure that they are not excessively worried by such findings. There are definitely some individuals who are not well prepared for any news about their medical condition and should carefully consider whether screening procedures are appropriate. It is true that abnormal findings on these scans increase worry levels and often lead to further testing."

Adds Boone, "The idea with screening is that early detection will play an important role in surviving the disease if it is found. Whole-body screening of presumably healthy persons has not been subjected to a wide-scale clinical trial so we don't have the data to know if it is medically efficacious. Indeed, it would be very difficult to ever show clinical efficacy of such an exam because it's too unfocused."

Koch maintains there is value in searching for disease in asymptomatic individuals. "It is important to understand these scans are not for everyone. Many individuals have a significant family history of certain diseases and/or are at risk for disease because of lifestyle choices. There is no question that early intervention can save lives. So, there is a fine line between how a scanning exam can help someone and an individual who may be wasting his/her money. Having a personal physician involved in the decision-making is extremely important, although, most primary physicians don't necessarily understand why a person would choose a screening exam. Unfortunately, an annual physical cannot diagnose many diseases that a screening exam may pick up in its early stages. Screening should only be used as an adjunct to an annual physical and should never be used as the end all of medical care. A false sense of security is always a risk with a screening exam but the patient must understand the limitations of these studies because they should only be used for the three leading killers in the United States namely, lung cancer, heart disease and colon cancer. Everything else that is seen on these exams is gray."