450 - Vision/Hearing Screening, CRC Screening Cost, PeerARTxMed – Yes
Take 3 – Practical Practice Pointers©
A Two-fer From the USPSTF
1) Screening for Visual and Hearing Loss in Asymptomatic Adults
Age-related sensorineural hearing loss is the third most common chronic condition in the United States with nearly 16% of US adults 18 years or older report difficulty hearing. The prevalence of perceived hearing loss increases with age with 34 million adults aged 50 years or older having hearing loss in both ears and 60 million having loss in at least 1 ear. For adults 70 years or older, 2 of 3 experience some form of hearing loss. This can adversely affect an individual’s quality of life and ability to function independently and has been associated through observational studies with increased risk of falls, hospitalizations, need for nursing care, social isolation, depressive symptoms, and cognitive decline or dementia.
Similarly, though to a lesser extent, impairment of visual acuity is a serious public health problem in older adults. The number of persons 60 years or older with impaired visual acuity (defined as best corrected visual acuity worse than 20/40 but better than 20/200) was estimated at 2.91 million in 2015, and the number who are blind (defined as best corrected visual acuity of 20/200 or worse) was estimated at 760 000. Impaired visual acuity is consistently associated with decreased quality of life in older persons, including reduced ability to perform activities of daily living, work, and drive safely, as well as increased risk of falls and other unintentional injuries.
In 2021 the USPSTF updated its 2012 recommendation on screening for hearing loss in asymptomatic adults 50 years or older. The Task Force concluded that the current evidence continues to be insufficient to assess the balance of benefits and harms of screening for hearing loss in older adults. (I statement) In the systematic review, the authors noted that although the use of hearing aids can increase auditory acuity, the evidence showing benefit from hearing aids on hearing related function among adults with screen-detected or newly detected hearing loss is limited to studies enrolling veterans.
In May of 2022, the USPSTF updated its 2016 recommendation evaluating the benefits and harms of screening for impaired visual acuity in asymptomatic adults aged 65 and older. The Task Force concluded that the current evidence continues to be insufficient to assess the balance of benefits and harms of screening for impaired visual acuity in asymptomatic older adults. (I statement) In the systematic review, the authors found that effective treatments are available for refractive errors, cataracts, and wet (advanced neovascular) or dry (atrophic) age-related macular degeneration (AMD), but there were no differences between visual screening vs no screening on visual acuity or other outcomes.
As a reminder, the purpose of screening programs is twofold: First, they must effectively detect health conditions earlier than would have been detected with routine care. Secondly, that early identification makes treatment easier or more effective in reducing morbidity and/or mortality. Both these interventions have the potential to accomplish the first. Where the evidence is lacking is with the second. For hearing loss screening, there have been legislative, insurance, and business processes that have not kept up with technological advances. By doing so, they have prevented the comprehensive study of and have often limited access to interventions that are known to improve hearing.
A reminder that an “I” recommendation does not mean don’t do it nor that it is not effective, only that there is insufficient data to have confidence in the screening test to impact health-related outcomes. It certainly seems prudent to be asking our elders about their hearing and visual acuity, and perhaps checking with those who spend time with them as well. Having cared for many persons with hearing challenges in particular, the social and relational impact of non-intervention can be quite real and unfortunate.
· US Preventive Services Task Force. Screening for Impaired Visual Acuity in Older Adults: US Preventive Services Task Force recommendation statement. JAMA. Published online May 24, 2022. Article
· US Preventive Services Task Force. Screening for Hearing Loss in Older Adults. US Preventive Services Task Force Recommendation Statement. JAMA. 2021;325 (12):1196-1201. Article
From the Literature and the US Government
2) Out of Pocket Costs for Colorectal Cancer (CRC) Screening
The US Preventive Services Task Force has recommended colorectal cancer screening since 1996, using a variety of both stool-based tests (fecal immunochemical testing, etc.) and direct visualization tests (colonoscopy, etc.). A recent focus on increasing the proportion of screened adults by emphasizing stool-based screening has been hampered by insurance company insistence that any follow up colonoscopy is a diagnostic, not a screening procedure, and is therefore billable with the customary amount of cost-sharing from the patient.
Researchers at several universities, along with a researcher from Exact Sciences Corp. (the makers of Cologuard), have analyzed a Medicare and commercial claims dataset to understand the costs associated with colorectal cancer screening. Claims data was obtained for approximately 87 thousand patients who were deemed to be of average risk for colorectal cancer and who had had a positive stool blood test. Additional out of pocket costs to the patients for the required follow up colonoscopies were found in 48.2% of commercial claims and 77.9% of Medicare claims. These costs varied from $99 to $231, depended on the choice of stool test, and were higher when polypectomy was performed.
I am not surprised to see Exact Sciences’ involvement with this study, but I still believe the documentation of this problem is helpful. We know this has been an issue with asking our patients to undergo stool-based colorectal cancer screening.
However, some promising news is on the horizon. As of May 31st, 2022, new regulations state that insurers will be required to fully cover (i.e., without cost-sharing) colonoscopies after a positive stool-based colorectal cancer screening test. But, this policy applies only to new, non-grandfathered insurance plans and does not apply to Medicare and Medicaid. I hope they will follow suit, and soon.
· Fendrick AM, Princic N, Miller-Wilson LA, Wilson K, Limburg P. Out-of-Pocket Costs for Colonoscopy After Noninvasive Colorectal Cancer Screening Among US Adults With Commercial and Medicare Insurance. JAMA Network Open. 2021;4(12):e2136798. Link
· US Departments of Labor, Health & Human Services and Treasury. FAQs about Affordable Care Act Implementation Part 51, Families First Coronavirus Response Act and Coronavirus Aid, Relief, and Economic Security Act Implementation.; 2022:10-12. Accessed May 25, 2022. Link
From PeerRxMed ( www.PeerRxMed.org )
3) Introducing PeerARTxMed: Saying “Yes” to Life … Now
The healing arts are creative practices that can help promote healing, recovery, coping, wellness, connection, and personal change. Traditional healing arts include music, art (painting, drawing), dance/movement, poetry/writing/literature, and drama. When the PeerRxMed process was first piloted in July of 2019, there was an additional component to it, called PeerARTxMed, which was intended to integrate the healing arts into the peer support process.
Initial feedback from those colleagues who participated in the pilot indicated that while they appreciated the incorporation of the arts, the frequency of every other week felt a bit overwhelming. So, I decided to put this aspect on hold … until now.
One incredible power of the arts is to provide a mechanism for the expression of thoughts and feelings which seem to defy such expression. This is certainly the case for much of what we are challenged with on a day-to-day basis in healthcare. Add on all that has gone on in the world over the past 2+ years or just the past few months … or even the past week, and it would be easy to find oneself, as I’ve recently found myself, dulled and numb – almost devoid of an ability to even identify what to think or how to feel.
And amid that, I’m reminded of the poem “Yes” by William Stafford, a poem I have returned to again and again over the years when the state of the world or just the state of me is out of kilter. I encourage you to read the poem all the way through. Then re-read it as if it is speaking directly to you – to your own soul. Notice details of the imagery and any feelings or thoughts as they arise.
It could happen any time, tornado,
earthquake, Armageddon. It could happen.
Or sunshine, love, salvation.
It could, you know. That’s why we wake
and look out — no guarantees
in this life.
But some bonuses, like morning,
like right now, like noon,
Sometime this week, please consider doing the following with your PeerRxMed partner, a colleague, or a friend:
Reflect (remember, there is no right or wrong – only what is true for you): What emotions and memories do you experience as you are reminded that the direction of a life can change in an instant, as is the case for us on a daily basis in our work? What are the “bonuses” in your life?
Respond: Share with this person your overall response to the poem, and in particular any word or phrase that specifically spoke to you. Why do you think you were drawn to this word/phrase?
Receive: Listen deeply and reflect back what this person shares, ensuring you understand the experience they convey.
Renew: Conclude any additional conversation with “what can I do to help you, support you, and/or encourage you?”
Remember: As you go about your week, allow this exercise to be a reminder of the meaning of your work and the importance of connection, which for me is not only one of the essentials of this life, but also one of the incredible bonuses. Allow it as well to be a reminder of the importance of saying “Yes” to the present moment, as it is the only one that is truly “guaranteed.”
Stay tuned for me “installments” of PeerARTxMed in the coming months – likely every other month. And remember to wake and look out ….
Mark and John
Carilion Clinic Department of Family and Community Medicine
Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.