aminations, and I would like to request that that document, which is called "Multiphasic Screening Examinations in California," be entered in the record as our views on the subject. (Letter and document referred to follow :) Hon. MAURINE B. NEUBERGER, STATE OF CALIFORNIA, DEPARTMENT OF PUBLIC HEALTH, Berkeley, Calif., September 19, 1966. Chairman, Subcommittee on Health of the Elderly, Washington, D.C. DEAR SENATOR NEUBERGER: I am pleased to respond to your recent letter concerning health screening programs. Unfortunately, other commitments here in California preclude my personal appearance before your Subcommittee on Health of the Elderly. However, I am glad to present my views for the record. Dr. Nemat Borhani, chief of the Bureau of Chronic Diseases of the California State Department of Public Health, will present a detailed report on our activities in the health screening field, and he will represent the Association of State and Territorial Chronic Disease Program Directors on the same subject. The various chronic diseases now account for three-quarters of the annual deaths in California. One-third of these occur among persons less than 65 years of age. Thousands of Californians who might otherwise continue normal and productive lives die needlessly or become disabled from chronic diseases each year. While the trend has been toward a higher proportion of deaths and disability from the chronic diseases, we now have many indications that this trend can be checked. For example, the cancer death rate, particularly among women, is already declining. This is especially true of the common form of the cancer of the uterus in which there has been a spectacular drop in the death rate during recent years. In California, at least, the death rate from the common forms of heart disease, that is heart disease associated with high blood pressure and coronary artery disease, has started to decline. Such facts have been insufficiently emphasized. Together with the well-known accomplishments in the field of diabetes control, tuberculosis control and the control of other important diseases, these recent indications of success with respect to cancer and heart disease suggest what we may anticipate in the future. The most important element in the situation is that these favorable trends could be greatly accelerated through organized programs of health screening. What has been achieved in the case of tuberculosis, diabetes, cancer of the uterus and other forms of cancer, hypertensive heart disease and many other chronic diseases is due to a relatively simple form of attack on the problems. That attack consists of early detection of the disease process and prompt treatment with modern methods. The technical basis for a successful attack on many important chronic diseases is well established. All that is needed is organization in the full-scale application of available tools. This should take the form of health screening programs such as those now being considered by the Congress. In your letter, you refer to my advocacy of the establishment of 5 to 10 more health screening projects such as that undertaken by Dr. Morris Collen at the Kaiser Foundation Hospitals. I believe that at least 5 to 10 more projects of similar magnitude should be undertaken promptly. Such endeavors would advance our understanding of the potential accomplishment through health screening, would aid in the refinement of present tests and lead to the discovery of new tests, would popularize the concept of health screening among physicians, other health personnel and the general public, and would permit exploration of how health screening should be conducted in different parts of the country and in different kinds of institutions. Since Dr. Collen will be presenting testimony to your Committee, I believe that it would be better for him to give estimates of the costs of such centers. In this connection, however, I would like to emphasize that a considerable proportion of the cost of the Kaiser project is attributable to research and development. The actual provision of service on a large scale utilizing presently established means of detection would be in the order of magnitude of $15-20. This would include the cost of mutiphasic screening embracing tests for more than a dozen important chronic conditions. This does not include the cost that would be necessary for the follow-up medical care of individuals found to have the chronic conditions. A brief history of health screening programs in California, which you requested, will be presented by Dr. Borhani. The development of automated and semi-automated techniques for health screening have vastly increased the potential and reduced the cost of such programs. Proper organization is needed if we are to make the best use of such technological improvements. I believe that we are on the verge of even greater developments. We should be organized to apply promptly the new developments as well as what is already known concerning the early detection of chronic diseases. You inquire also about differing screening tests for differing age groups. It is true that various chronic diseases affect the various segments of the population in differing degree. Screening programs should be designed to take this fact into account. I believe that the final responsibility for such matters should be left in the hands of the physician responsible for the individual projects. Only in this way will we favor the development of new understanding through actual experience based on different points of view. For example, we now realize that the Papanicolaou smear, the cytologic test for cancer of the uterus, should be applied to women in their 20's or even younger, rather than waiting until women reach the so-called "cancer age". Some years ago many physicians believed that the Papanicolaou smear should be limited to women over the age of 35 years. Further experience, based upon the ideas of a relatively few physicians, has shown the fallacy of the older prevailing viewpoint. In closing, I should like to emphasize one aspect of the current situation in respect to the development of health screening programs. You have asked about the desirability of establishing several more projects along the lines of that at the Kaiser Foundation Hospitals, and I have indicated above my opinion on that question. However, much more can and should be undertaken through Congressional action. A great deal could be accomplished with Federal support of health screening programs, organized on a somewhat less extensive basis than that at the Kaiser facilities. We need programs like that of Dr. Collen to test the limits of what can be accomplished and demonstrate what should be available to all persons five years from now. In the meantime, a large network of health screening programs should be organized throughout the country, utilizing health departments, clinics, hospitals and other health agencies. I hope that you and your Committee will give favorable consideration to proposals for Federal support to health screening programs utilizing what is now known, as well as to programs for research and development in this field. Sincerely yours, LESTER BRESLOW, M.D., MULTIPHASIC SCREENING EXAMINATIONS IN CALIFORNIA BACKGROUND Over 40 years ago the American Medical Association first endorsed periodic health examinations as a means of preventive medicine.' With advances in laboratory techniques, various tests were developed to aid physicians in diagnosing patients' diseases. These tests were designed to be administered mainly by technicians, with results interpreted by physicians. Persons concerned with the advancement of preventive medicine then saw the possibility of, screening large groups of people to identify persons needing physicians' attention for diagnosis and medical management." As a first step, mass screening programs for the detection of selected diseases were undertaken during World War II, mostly for the detection of tuberculosis and venereal diseases. As tests for the detection of other diseases were developed and proved satisfactory, the idea of combining a number of these tests into multiphasic screening evolved. Over the years multiphasic screening examinations have 1 American Medical Association, Periodic Health Examination: A Manual for Physicians (3d rev.), Chicago, Ill., AMA 1947, p. 7. 2 Breslow, Lester, "Prevention and Control of Chronic Diseases: V. Periodic Health Examinations and Multiple Screening," A.J.P.H., vol. 49, No. 9, September 1959, pp. 1148-1156. developed to the point at which many tests are now automated and in some instances results of screening tests are processed electronically. The goals of multiphasic screening examinations are the same as those for periodic health examinations, namely: 1. "to detect early abnormalities so that early diagnosis and treatment may prevent disability and premature death, 2. to improve patient understanding of health and disease, 3. to establish patient-physician rapport as a basis for continuing health supervision, and 4. to provide an opportunity for such specific preventive action as immunizations, and for advice concerning habits affecting health. . . ." The ideal way to detect most chronic diseases is for every person to have thorough, periodic health examinations. With the present shortage of medical manpower, this is obviously impossible. A practical alternative therefore is multiphasic screening examinations which can be easily administered by technicians. Screening examinations provide a means by which apparently well persons with undiagnosed disease are separated for more definitive diagnosis. It must be emphasized, however, that multiphasic screening examinations are not complete health examinations and do not provide medical diagnoses. They are the application of two or more simple laboratory tests, examinations or procedures on a mass basis to determine presumptive evidence of undetected or incipient disease. Persons with positive screening results must be referred for thorough clinical and laboratory examinations to arrive at definitive diagnoses. To be effective, multiphasic screening tests must follow certain criteria. In 1955, the American Medical Association outlined some basic principles involved in the selection of tests to be included in multiphasic screening examinations," namely, that the tests should: 1) be easily administered, 2) be easily interpreted, 3) be relatively inexpensive, 4) require little time to perform, and 5) meet the five criteria established by the National Conference on Chronic Illness. These are: reliability, validity, yield, cost and acceptance by the community. "Reliability The test must be reliable in that information must be available concerning reproducibility of results as limited by the technical procedure. Validity-The validity of a test is measured by the frequency with which the result of the test is confirmed by an acceptable diagnostic procedure. Yield-The yield of a screening program can be measured by the number of previously unknown verified cases of disease among the total population surveyed, the number of persons with previously unknown verified diseases benefited by referral to medical care, and the number of previously known cases not under medical care benefited by return to it. . . . . . ., and the number of cases of communicable diseases who are prevented from spreading their disease to the family or to the community. Cost-The size of the yield of the screening program must be balanced against the cost.. measured in monetary terms and in the relative amounts of time of professional nonprofessional personnel. Acceptance-Reliability, validity, yield, and cost are essential criteria for evaluation of screening tests and programs. The measurement of acceptance of the program by the physicians, individual laymen, and the community is a useful additional criterion of the effectiveness of a screening program." A basic aspect of medicine is the concept of prevention and early detection. At present, a number of chronic diseases can be controlled if detected early enough. The thousands of deaths each year from the common cancer of the uterus are truly unnecessary. The highly accurate "Pap" test can detect this form of cancer before it becomes destructive and at a time when treatment can and does save lives. Changes in vision or in the pressure of the eye, if detected early, can lead to action that will prevent blindness. A few drops of blood, analyzed in detail with modern automated techniques, can give clues to diabetes, heart disease, diseases of the liver and kidney, as well as disorders of the blood, itself. These automated laboratory techniques are highly accurate and economical. We now have means for the early detection of many common chronic diseases as well as for some of the less common. Also, automated techniques keep the time and cost per test, and per person tested, at a minimum. "Recognizing the limitations imposed by time, cost and personnel shortages on current Council on Medical Service, American Medical Association, a Study of Multiple Screening, revised 1955, p. 7. Preventive Aspects of Chronic Disease, Conference Proceedings, National Conference on Chronic Diseases, Mar. 12-14, 1951, Chicago, p. 63. opportunities for health examinations, the Commission on Chronic Illness accordingly endorsed screening as a practical supplement and alternative to comprehensive periodic health examinations. . MULTIPHASIC SCREENING PROGRAMS IN CALIFORNIA In California, multiphasic screening examinations for the early detection of chronic disease have received considerable attention, beginning with the first project in 1948. Between 1948 and 1954, with assistance from the State Department of Public Health, sixteen multiphasic screening projects were undertaken, Table 1. 7 In 1948, the first multiphasic screening program was conducted as a demonstration project in San Jose, California. In the interest of economy and of better service to persons examined, the project combined screening tests usually done separately and applied them in a single procedure to 945 employees in four industrial establishments. Included were: miniature X-ray films of the chest, blood specimens and urine samples from which the suspected presence of pulmonary disease, heart disease, syphilis, kidney disease or diabetes could be detected. Personal and medical histories of each screenee were also obtained. The results in case-finding were considerably greater than those of the then-customary single disease screening." In 1951, a multiphasic screening examination was conducted among the members of the International Longshoremen's and Warehousemen's Union in the San Francisco Bay Area (I.L.W.U.). Several organizations cooperated in this survey, including the Union-Management Welfare Fund, the Kaiser Foundation Health Plan and the California State Department of Public Health. By 1951 large-scale projects had demonstrated the feasibility of multiphasic screening examinations as a public health measure. Not previously investigated, however, was the potential of such procedures in medical care programs providing comprehensive services (i.e., Permanente Medical Group and Kaiser Foundation Hospitals). 8 The 1951 project afforded a unique opportunity to study : 1. The results of medical follow-up of multiphasic screening when there was no additional charge to the individual participant for diagnostic and treatment services, and when all records were available through one medical care organization, and 2. The cost of screening tests and of follow-up services. Three features characterized the San Francisco longshoremen program: 1. A well-organized consumer group, the Union, which took the initiative in instituting the project, 2. The existence of a prepaid medical care program for the group. Thus, no financial barrier existed for completion of follow-up, and 3. A wide array of public and voluntary health agencies in San Francisco actively participated in the program. In 1956 a five-year mortality follow-up of the I.L.W.U. was made. A ten-year follow-up was undertaken in 1960.10 11 This study had four phases: 1. Mortality follow-up of examined population, 1951-1960, 2. Morbidity follow-up of examined population, 1951-1960, 3. A repeat multiphasic screening examination in 1961, and 4. A study of "health value patterns" among persons screened and persons not screened in 1951. In both the 1951 and 1961 screening examinations approximately two-thirds of the "eligible" I.L.W.U. members participated. It should be emphasized that participation in either program was entirely voluntary and offered to all eligible members of the Union. American Public Health Association, Chronic Disease and Rehabilitation: A Program for State and Local Health Agencies, 1960, p. 51. Canelo, C. K. Bissell, D. M.; Abrams, H. Breslow, L., "A Multiphasic Screening Survey in San Jose," California Medicine, vol. 71, No. 6, December 1949. Breslow. Lester. "Multiphasic Screening in California," J. Chron. Dis., vol. 2, No. 4, October 1955, pp. 375-383. 8 Weinerman, E. R.; Breslow, L.; Belloc, N. B.; Waybur, A.; and Milmore, B. K., "Multiphasic Screening of Longshoremen With Organized Medical Follow-up," A.J.P.H., vol. 42, No. 12, December 1952, pp. 1552-67. Buechley, R. W.; Drake, R. M. and Breslow, L., "Height, Weight, and Mortality in a Population of Longshoremen," J. Chron. Dis., vol. 7, No. 5, May 1958, pp. 363-378. 10 San Francisco Longshoremen: 1951-60 Mortality and Morbidity and 1961 Multiphasic Screening Examination. Dec. 31, 1961-Final report. 11 Borhani, N. O. Hechter, H. H.; Breslow, L., "Report of a Ten-Year Follow-up Study of the San Francisco Longshoremen," J. Chron. Dis., vol. 16, 1963, pp. 1251–1266. From the ten-year mortality study a number of facts emerged." For example, "Throughout the age range 45-64, the mortality among hypertensive smokers' was approximately 9-10 times as high as that of 'nonhypertensive nonsmokers.' . . . The men who had abnormal electrocardiograms in 1951 had a death rate approximately three times as high as those who did not have abnormal electrocardiograms." Early in 1955, the late Doctor Russell S. Ferguson, Health Officer of Santa Cruz County, became concerned over the availability of medical care to aged persons living in Santa Cruz County. He sought the assistance of the Director of the County Department of Welfare in evaluating this problem. Together they concluded that an amount of money equal to that being spent for medicine and drugs for a small number of old age security recipients (O.A.S.) could provide financial support for a screening program and thus a preventive medical program for all O.A.S. recipients in the county. The Bureau of Chronic Diseases in the California State Department of Public Health was then requested to make a broader study and to prepare recommendations.12 In September 1955, the Santa Cruz County Health Department initiated a geriatric screening program to implement the recommendations. This program was a means to promote the early detection of disease and to assure prompt treatment for O.A.S. recipients. Persons in need of medical care were referred to their physicians and/or clinics for further diagnosis and treatment. In June 1956, the County Board of Supervisors appropriated funds to provide: professional services, drugs, a public health nurse and an X-ray technician. A few months later, the County Welfare Department began to reimburse the County Health Department for the cost of screening examinations. Funds were from the Welfare Department's administrative budget, half of which were available as Federal matching funds. During the first three years, $27,250 were made available to the geriatric program for medical, dental and ancillary services for which no other funds were available at that time. The State Public Assistance Medical Care Program became effective October 1, 1957. One provision of this program was that O.A.S. recipients could receive physician, X-ray and laboratory services privately; it also paid for certain drugs. Thus it became possible to shift some of the costs of the Santa Cruz Geriatric Screening Program to the State Medical Care Program." In 1959, a special study of the Santa Cruz Geriatric Screening Program was initiated to collect information on medical, social and economic characteristics of O.A.S. recipients. The purpose was to measure the degree of utilization, costs and sources of payment for medical and health services and to identify measurable items which could be used in evaluating the impact of this program on medical and related services.14 Over the years, the Department has encouraged multiphasic screening programs in the State. It has funded a number of such programs as well as projects concerned with the development and/or refinement of screening tests. Tables 2-4 summarize some current activities. Another form of activity has been consultation services to local groups involved in screening programs. An example of this activity was the Department's close cooperation with Dr. Morris Collen and the group at the Kaiser Foundation Hospital during the development of its current multiphasic screening program. In 1960, the Glaucoma Screening Project sponsored by the Sight Conservation Research Center of San Jose started operation on a twice weekly basis in the city health department clinic. The San Jose City Health Department in 1962 augmented this program by providing its Chronic Illness and Aging allotment funds to include tests for diabetes. Over 8,000 persons have been screened for diabetes since April, 1962. Of the total cases screened, 4.3 percent were diagnosed as diabetics and 2.8 percent were borderline cases." In spite of the reliability of many long-used screening tests, problems still arise. In analyzing the results of the San Jose diabetes screening tests, it is apparent that the referral of patients from evening clinics was 54 percent higher than for morning clinics. Further, when private physicians' reports on State of California, Department of Public Health, The Health Status of Old-Age Security Recipients in Santa Cruz County, Berkeley, 1956. 13 Harris. O. S., "A County Health Department Geriatric Program," Patterns for Progress in Aging, case study No. 8, U.S. Department of Health, Education, and Welfare, Washington, D.C.. June 1961. State of California, Department of Public Health, Health Care of Old-Age Security Recipients in Santa Cruz County, January 1958-June 1961, Berkeley, 1965. 15 Williams, M. T., "Diabetes Screening by a City Health Department," J. Occ. Med., vol. 18, No. 8, August 1966, pp. 422-424. |