“Excessive” Screening Questionnaires: Unhelpful, Inefficient, Potentially Harmful

Some patients received more than 100 excess screening questionnaires when they saw their doctor, the researchers report.

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A new study in JAMA Internal Medicine has found that more than a third (34.9%) of all screening questionnaires performed are “excessive.” They defined “excessive” as screening that happens more often than guidelines recommend (usually annually).

“Federal funders and managed care insurers often provide financial incentives for health care clinicians to perform standardized screening questionnaires,” the researchers write, which “may lead to overuse of these screening tools, creating an unnecessary burden for patients and primary care clinicians and decreasing the efficiency of the clinical practice.”

The research was led by Jodi Simon at Alliance Chicago and included researchers from Heartland Health Centers, Northwestern University, and the American Medical Association.

Guidelines from Canada and the UK do not promote screening at all for psychosocial experiences, such as depression and substance use, as they acknowledge that there is no evidence that screening leads to better outcomes in these cases. However, US guidelines do promote screening for such experiences, despite the lack of evidence.

Screening has also been criticized for creating problems by mistakenly identifying healthy people as having a problem, leading to unnecessary treatment, and for wasting resources because screening mostly identifies people who have very mild forms of distress that are likely to improve on their own without further treatment.

Additionally, screening positive can lead to a “nocebo” effect, in which a person begins to believe that they have a problem despite considering themselves healthy previously.

The new study doesn’t consider these issues, though—just whether the screening questionnaire is given more often than recommended. But the medical system fails even that low bar more than a third of the time.

In particular, the researchers looked into the following screenings: the Patient Health Questionnaire-2 for depression, the Generalized Anxiety Disorder 2-item for anxiety, and screening for tobacco use, passive smoke exposure, preferred learning style, and health literacy. Most of these are recommended by US guidelines to be conducted annually, although preferred learning style and health literacy are recommended to be conducted only once in a lifetime.

The researchers used data from 24 federally qualified health centers (FQHCs), including 323,531 patients. A total of almost 6 million screenings were given, and the researchers considered more than 2 million (34.9%) of them to be “excessive.”

On average, each patient received 6.4 excess screenings and, according to the authors, “more than 40 patients had 100 or more excess screenings.”

Mitchell Katz, the deputy editor for JAMA Internal Medicine, wrote an editorial to accompany the article. He writes:

“While some may think that little harm is done by having patients complete excess questionnaires, patients can hardly be expected to know when their answers matter, and when they will go in a pile of unread papers.”

 

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Simon, J., Panzer, J., Adetoro, E., Wright, K. M., Masinter, L., Mohanty, N., & Sinsky, C. A. (2021). Frequency of administration of standardized screening questions in federally qualified health centers. JAMA Intern Med. Published online June 14, 2021. doi:10.1001/jamainternmed.2021.2503 (Link)

Katz, M. H. (2021). A response to excessive screening questions. JAMA Intern Med. Published online June 14, 2021. doi:10.1001/jamainternmed.2021.2925 (Link)

5 COMMENTS

  1. These have been very interesting articles, Peter. Quite thought-provoking. It occurs to me that I’ve never had a discussion with my doctors about ANY of the screening questions I’ve answered, either when I first started seeing a doctor or at subsequent appointments. You’d think some of my family history of metabolic disease, diabetes and heart disease would elicit some discussion of diet and lifestyle choices at the least. I have to wonder if doctors don’t initiate further discussion about this because of concern about being reviewed negatively as a “fat shamer”.

    I think the only useful discussion that has ever resulted from screening for me has been that of smoking history.

    I also tend to wonder whether doctors have frank conversations with their patients about much of anything anymore with as time constrained as the majority of visits seem to be.

    • I have to say, kindredspirit, I found screening for smoking, which in my case, resulted in the prescription of an antidepressant, disingenuously called a “safe smoking cessation med.” A drug which did not help me quit smoking, so was inappropriately, abruptly discontinued by my PCP. Resulting in the common symptoms of antidepressant discontinuation syndrome being misdiagnosed as a whole bunch of things, but ultimately misdiagnosed as “bipolar.” Which, of course, leads to a whole bunch of extremely harmful anticholinergic toxidrome poisonings. So I found screening for smoking to be quite harmful.

    • Oh, they’ll still fat shame. If you don’t hear it out loud while you’re talking with your doc, it’ll be throughout your medical chart: office visit notes, “Problems” lists, in referral notes sent to other providers…

      I don’t really mind a single “Yeah, she be fat!” diagnosis on my “Problems” list. It’s true, after all, and does have quantifiable stats to determine it. But I don’t know that physicians need to be making further soft diagnoses around being fat. And they will, usually psychological ones.

      The biggest problem facing patients with stigmatizing health issues (obesity, smoking, substance use, mental health diagnoses) is that those diagnoses are more likely to ensure that you DON’T receive care outside of those diagnoses.

      I have pulled a number of my recent referrals and they all have several references to years-old diagnoses for depression, anxiety, or alcoholism. The referrals were for: cancer screening (specifically endocrine), an ascending aortic aneurysm of 4.8 cm, and persistently high serum B12 (while my “active” B12 is low normal), also usually a disease marker. For all 3 of those I have reams of lab results, in one case over the course of two years.

      But I just need Prozac.

      It’s ugly out there, people. Refuse these screenings. They will just be used against you in your care.

      Get your records. Demand amendments to your records, if they’re biased. You have the legal right. Learn key phrases. “Document your refusal to treat and why in my record and refer me elsewhere.” Doctors do not want to put “I’m not going to treat a crazy person.” in writing. Looks bad. If they don’t have another legit reason to refuse testing, they’ll cave.

      Your State has a Licensing board. Report the really egregious offenders, if you don’t mind a crapton of paperwork. I can almost guarantee your local disability rights organization, local NAMI, local ACLU, & State legislators are not going to give a crap that you’re being systematically discriminated against. They certainly don’t in Maine.

      The Licensing Board can be a real inconvenience for a physician, though. Time, minor cash, but the biggest threat is loss of reputation and, potentially, their career. It may make them think twice about their actions in the future. Remember, there are also specialty organizations they belong to. Save all your Lincensing paperwork and forward the complaint on down the chain.

      You are not powerless.

      And there ARE excellent doctors out there. My sleep apnea guy, my ENT (thus far, he’s new), my gyn, my cardiovascular specialist… All excellent and professional. “Just the facts, ma’am.” It takes many tries and I’ve just given up on the PCP front. I am thinking naturopath at this point, if they can do referrals to specialists.

      When switching docs (or getting referrals), if you’re not in a terrible hurry, review those records first! You have that right, noted on the standard Release of Information form. Send clean records to the next doc. Labs, imaging & symptoms only. “I want your opinion. I already have theirs.”

      And don’t make your records worse with those screenings!

  2. I had heard that these screenings were an opportunity for PCPs to identify and treat depression pharmaceutically even when depression wasn’t the primary concern patients were seeking treatment for. I was already on an antidepressant when I sought treatment for an upper respiratory infection caused by the flu which had left me bedridden. Yes, I was depressed by being so run down and unable to get back to life after a month of not being able to sleep prone due to coughing fits, with no energy to do anything. The doctor I saw declared I was generally depressed, not just depressed from being sick, and sent me to a psychiatrist who prescribed Effexor. I was impressionable, and followed his directive, and so took Effexor for 12 years which came with more labile moods, followed by the insanity of trying to come off. Had I never seen that particular doctor, who I think had been encouraged to identify depression and encourage treatment in his patients, I might never have entered this next phase of treatment with a drug that proved to be more damaging to me than helpful. I think there was a health screening questionnaire involved which included questions about depression (this was around 2004).

    • I am so sorry! That is awful.

      I think it happens frequently. I just saw a hematologist for the weirdly elevated serum B12 and he suggested Prozac for my fatigue.

      There really ought to be some checks in the medical system every time a psych med is prescribed for a completely non-pysch medical situation. Wouldn’t common sense dictate we get people measurably more medically “normal” (infection cleared, TSH level improved, pain treated, etc.) before we diagnose them with depression? Does situational depression need meds? If we’re sick and in pain, we’re going to be down, low energy, etc. Fix the sick and in pain part first.

      That check rarely happens, though. People with hypothyroid get Prozac. People with vitamin D deficiency get Prozac. And you get meds… And you get meds… We ALL get meds!!! (Oprah reference.)

      I’m really sorry you are part of the shitty “Inappropriately Medicated” club. None of us enjoy it much and it’s really hard to quit.

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