Abstract
This survey study of hospital administrators assesses the cardiovascular examinations included in the executive health screening programs offered by the top hospitals for cardiology and heart surgery as ranked by US News & World Report.
Very few screening tests have been reported to reduce mortality in asymptomatic individuals.1 Nevertheless, there is an enduring belief in the benefit of using diagnostic tests to find disease in its earliest stages. Hospitals have responded to the demand for early diagnosis by establishing executive screening programs targeted to wealthy individuals who are able to pay directly for screening tests that are generally not covered by insurance.2 Since cardiovascular disease represents the leading cause of mortality in the United States,3 we assessed the cardiovascular examinations included in the executive health screening programs offered by the top hospitals for cardiology and heart surgery as ranked by US News & World Report.4
Methods
This survey study was approved by the institutional review board at the St Louis University School of Medicine with a waiver of informed consent. Data were obtained via telephone call. Between May 1, 2019, and June 28, 2019, we called the administrators from hospitals regularly listed from 2016 to 2019 in the US News & World Report ranking of Best Hospitals for cardiology and heart surgery4 and requested information regarding the availability of executive screening programs offered to individuals, specific tests offered, and costs. The telephone call was initiated with an introductory request for more information about the executive screening program followed by the first question, (1) “Do you have different packages? Such as a standard package and a premium package?” The 3 follow-up questions were (2) “Can this service be billed to insurance?” (3) “What is the cost? Is there an appointment fee?” and (4) “Do you have a brochure that includes all of the tests that you can send to my email?”
We compared the tests offered with the recommendations for asymptomatic individuals by the American College of Cardiology/American Heart Association (ACC/AHA),3 the United States Preventive Services Task Force (USPSTF),5 and the American College of Preventive Medicine (ACPM).6 Analyses were performed without statistical software using basic math. This study adhered to the minimum disclosure requirements of the American Association for Public Opinion Research (AAPOR) Code of Professional Ethics and Practice.
Results
We attempted to contact 25 of the top-hospitals ranked by US News & World Report for cardiology and heart surgery. Of the 21 hospitals that responded to our inquiries, 18 offered 28 different executive health screening programs for individuals (Table 1). Total costs with appointment fee ranged from $995 for Comprehensive Health Assessment at Houston Methodist Hospital (ranked 13) to $25 000 for a Premier Executive Health Program at Cleveland Clinic (ranked 1). Three programs would submit charges to an insurance carrier. Twelve different cardiovascular screening tests plus a resting electrocardiogram were offered by the executive physical programs (Table 2). The most commonly offered tests were a lipid panel (71% [20 of 28]) and a cardiac stress test (68% [19 of 28]). Cardiac computed tomographic scanning, either to determine a calcium score or to visualize the coronary arteries, was included in 43% (12 of 28) of programs. Cardiovascular counseling was included in 2 programs and an exercise consultation was included in 1 program. Of the 12 tests, none of them are recommended by the ACC/AHA, USPSTF, or ACPM to be applied indiscriminately to asymptomatic adults.
Table 1. Tests and Costs in 18 USNWR–Ranked Hospitals.
| Hospital and Executive Screening Program | 2019 USNWR Rank | Cardiovascular Test | Total Cost With Appointment Fee, $ |
|---|---|---|---|
| Cleveland Clinic | 1 | ||
| Executive Health Program (1-d examination) | Cardiac calcium score; cardiac stress test; ECG (resting); vascular screening | 5000-15 000 | |
| Premier Executive Health Program | Cardiac calcium score; cardiac stress test; ECG (resting); vascular screening | 5000-25 000 | |
| Mayo Clinic | 2 | ||
| Executive Health Program | Cardiac calcium score; cardiac stress test; ECG (resting); vascular screening | 5000-11 000 | |
| Cedars-Sinai Medical Center | 3 | ||
| Comprehensive Evaluation | Abdominal aortic ultrasonography; carotid artery ultrasonography; coronary artery CT scan; ECG (resting); C-reactive protein/homocysteine; lipid panel | 3800 (men), 4200 (women) | |
| Essential Evaluation | Abdominal aortic ultrasonography; coronary artery CT scan; ECG (resting); C-reactive protein/homocysteine; lipid panel | 2400 (men), 2700 (women) | |
| New York-Presbyterian Hospital – Columbia | 4 | ||
| Executive Health | Abdominal aortic ultrasonography; carotid artery ultrasonography; ECG (exercise); ECG (resting); lipid panel | 5000 | |
| Massachusetts General Hospital | 5 | ||
| Executive Physical Program | Cardiac stress test; C-reactive protein/homocysteine; lipid panel | 3000 | |
| Hospitals of the University of Pennsylvania-Penn Presbyterian | 18 | ||
| Executive Health Assessment | Coronary artery CT scan; ECG (resting); lipid panel | 3000 | |
| Northwestern Memorial Hospital | 7 | ||
| Executive Health | Cardiovascular counseling; ECG (resting) | Appointment fee of 3195 (additional cost dependent on insurance coverage) | |
| Brigham and Women's Hospital | 9 | ||
| Executive Health and Physical Program | ECG (resting); lipid panel | 2500 | |
| Mount Sinai Hospital-New York | 6 | ||
| Half-Day Program | Carotid artery ultrasonography; ECG (exercise); ECG (resting); C-reactive protein/homocysteine; lipid panel; lipoprotein(a) | 4425 (men), 4300 (women) | |
| Full-Day Program | Carotid artery ultrasonography; ECG (exercise); ECG (resting); C-reactive protein/homocysteine; lipid panel; lipoprotein(a) | 7325 (men), 7200 (women) | |
| Johns Hopkins Hospital | 12 | ||
| Executive and Preventive Health Program | ECG (exercise); ECG (resting); lipid panel | 2750-3150 | |
| Houston Methodist Hospital | 16 | ||
| Premier Health Assessment | ECG (exercise); ECG (resting); vascular screening | 2150 | |
| Comprehensive Health Assessment | ECG (exercise); ECG (resting); vascular screening | 995 | |
| Duke University Hospital | 23 | ||
| Executive Health (self-pay) | Cardiac stress test; ECG (resting); C-reactive protein/homocysteine; lipid panel | 3790 (men), 3661 (women) | |
| Executive Health (insurance) | Cardiac stress test; ECG (resting); C-reactive protein/homocysteine; lipid panel | 6100-6300 | |
| UCLA Medical Center | 8 | ||
| Executive Physical | ECG (resting); lipid panel | 3000 | |
| Executive Health (insurance) | Cardiac stress test; ECG (resting); C-reactive protein/homocysteine; lipid panel | 5700 | |
| Vanderbilt University Medical Center | 35 | ||
| Executive Health Physical | Cardiac stress test | 3500 | |
| Minneapolis Heart Institute at Abbott Northwestern Hospital | 14 | ||
| Executive Physical Examination | ECG (resting); C-reactive protein/homocysteine; lipid panel | 2200-2300 | |
| Atlantic Health Morristown Medical Center | 26 | ||
| Executive Health Program (half-day physical examination) | ECG (resting) | 5000 | |
| Executive Health Program (full-day physical examination) | Abdominal aortic ultrasonography; cardiac calcium score; cardiac stress test; cardiovascular counseling; carotid artery ultrasonography; CT scan (cardiac); ECG (resting); C-reactive protein/homocysteine; lipid panel; lipoprotein(a) | 11 000 | |
| Baylor Scott and White – Dallas | 27 | ||
| Personal EDGE, Bronze Assessment | Cardiac stress test; lipid panel | 2200 | |
| Personal EDGE, Silver Assessment | Cardiac stress test; C-reactive protein/homocysteine; lipid panel | 2700 | |
| Personal EDGE, Gold Assessment | Cardiac stress test; coronary artery CT scan; C-reactive protein/homocysteine; lipid panel | 3200 | |
| Scripps La Jolla Hospitals | 29 | ||
| Whole person examination (half day) | Cardiac stress test; carotid IMT; coronary artery CT scan; EECG (resting); femoral artery scan; C-reactive protein/homocysteine; lipid panel | 2963 (men), 2915 (women) | |
| Whole person examination (full day) | Cardiac stress test; carotid IMT; coronary artery CT scan; ECG (resting); exercise consultation; femoral artery scan; C-reactive protein/homocysteine; lipid panel | 3583 (men), 3535 (women) |
Abbreviations: CT, computed tomography; ECG, electrocardiogram; EECG, exercise electrocardiogram; IMT, intima-media thickness; UCLA, University of California, Los Angeles; USNWR, US News & World Report.
Table 2. Guideline Recommendations.
| Cardiovascular Test | Programs Offering (N = 28), No. (%) | ACC/AHA3 | USPSTF5 | ACPM6 |
|---|---|---|---|---|
| Abdominal aortic ultrasonography | 4 (14) | Recommends screening in men aged 65-75 y who have ever smoked and in men aged ≥60 y who are the sibling or offspring of someone with an abdominal aortic aneurysm | Recommends one-time screening for abdominal aortic aneurysm with ultrasonography in men ages 65-75 y who have ever smoked | Recommends screening in men aged 65-75 y who have ever smoked. Routine screening in women not recommended |
| Cardiac calcium score | 4 (14) | Reasonable for cardiovascular risk assessment in asymptomatic adults at intermediate risk | The current evidence is insufficient to assess the balance of benefits and harms | Does not recommend routine screening of the general adult CT scanning |
| Cardiac stress test (including exercise electrocardiography or echocardiography) | 19 (68) | May be considered for cardiovascular risk assessment in intermediate-risk asymptomatic adults | Recommends against screening with resting or exercise electrocardiography | Does not recommend routine screening of the general adult population |
| Cardiovascular counseling | 2 (7) | NA | Recommends offering or referring adults who are overweight or obese and have additional cardiovascular disease risk factors to intensive behavioral counseling interventions to promote a healthful diet and physical activity for CVD prevention | NA |
| Carotid artery ultrasonography | 5 (18) | Recommends against ultrasonography screening for carotid artery stenosis | Recommends against screening for asymptomatic carotid artery stenosis | Routine screening not recommended |
| Carotid IMT | 3 (11) | Reasonable for cardiovascular risk assessment in asymptomatic adults at intermediate risk | Current evidence is insufficient to assess the balance of benefits and harms | Does not recommend routine screening of the general adult population |
| Coronary artery CT scan | 8 (29) | Recommends against screening the general population | Recommends against routine screening | Does not recommend routine screening of the general adult population |
| C-reactive protein | 13 (46) | Recommends against the use of inflammatory markers in screening the general population for cardiovascular risk | Current evidence is insufficient to assess the balance of benefits and harms in asymptomatic adults | Recommends considering testing in individuals at intermediate (10-y risk of 10%-20%) risk of CHD |
| Exercise consultation | 1 (4) | NA | Recommends offering or referring adults who are overweight or obese and have additional cardiovascular disease risk factors to intensive behavioral counseling interventions | NA |
| Lipid panel | 20 (71) | Recommends as part of CHD risk assessment using tools to estimate the 10-y risk of CHD events in people with 2 or more risk factors | Strongly recommends screening men aged 35 and older for lipid disorders | Recommends a part of CHD risk assessment tool to assess CHD risk |
| Lipoprotein(a) | 3 (11) | Not recommended for cardiovascular risk assessment in asymptomatic adults | Current evidence is insufficient to assess the balance of benefits and harms | Does not recommend routine screening of the general adult population |
| Vascular screening | 7 (25) | Recommends the use of ABI for screening in appropriately targeted populations | Recommends against routine screening for peripheral arterial disease | Routine screening not recommended |
Abbreviations: ABI, ankle brachial index; ACC/AHA, American College of Cardiology/American Heart Association; ACPM, American College of Preventive Medicine; CHD, coronary heart disease; CVD, cardiovascular disease; IMT, intima-media thickness; NA, not applicable; USPSTF, the United States Preventive Services Task Force.
Discussion
The top-rated US News & World Report cardiology programs commonly provide cardiovascular tests as part of executive screening programs that are not recommended by current guidelines for indiscriminate use among asymptomatic individuals. The premise of using these tests is that the results may help reduce mortality from cardiovascular disease through earlier disease detection or more precise risk assessment. However, no data support that premise as reflected in the guidelines of the ACC/AHA, USPSTF, and ACPM.
This study has limitations. First, we did not obtain information directly from physicians involved in the executive screening programs. It is possible that the testing procedures may be more tailored to the individual than was represented by administrators who provided the information. Second, although 3 programs would submit charges to insurance carriers, we have no information regarding whether any insurance carriers would actually reimburse for the services provided.
In addition to clinical care, the top cardiology hospitals also provide medical education. Offering executive physicals with tests that are not recommended for healthy persons to anyone who can pay out of pocket potentially sends the message to trainees that a 2-tier health care system is acceptable, and that evidence is not important. Furthermore, indiscriminate screening can create a cascade effect and thus violate the principle of primum non nocere (first do no harm) wherein unnecessary tests may create a chain of events resulting in additional ill-advised tests or treatments that may cause avoidable physical or psychological harm. In summary, executive screening programs are not consistent with the goals of health care to provide evidence-based cost-effective equitable care.
References
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