DETECTION AND PREVENTION OF CHRONIC DISEASE UTILIZING MULTIPHASIC HEALTH SCREENING TECHNIQUES THURSDAY, SEPTEMBER 22, 1966 U.S. SENATE, SUBCOMMITTEE ON HEALTH OF THE ELDERLY Washington, D.C. The Subcommittee on Health of the Elderly met at 10 a.m., pursuant to recess, in room G-308, New Senate Office Building, Senator Maurine B. Neuberger (chairman), presiding. Present: Senator Neuberger. Committee staff members present: Thomas S. Biggs, Jr., counsel to the special committee; William E. Oriol, professional staff member; Patricia G. Slinkard, chief clerk; and Diane LaBakas, minority research assistant. Senator NEUBERGER. The hearings will come to order. This is the third and last day of our hearings on the subject of detection and prevention of chronic disease utilizing multiphasic health screening techniques. During these interesting 2 days previous to now we have heard expert testimony on our subjects from a number of eminent witnesses, and have enjoyed the demonstration of some of the screening instrumentation programs. Today we will have witnesses who will deal primarily with existing screening programs. Before I introduce our first witness, I would like to submit for the record a telegram from Dr. Dacso, president of the American Academy of Physical Medicine and Rehabilitation. (Telegram follows:) Hon. MAURINE B. NEUBERGER, NEW YORK, N.Y., September 20, 1966. Chairman, Subcommittee on Health of the Elderly, U.S. Senate Special Committee on Aging, Washington, D.C.: The last national heart survey revealed the existence of millions of people whose disabilities severely impaired their physical and mental performance. In spite of the anticipated complications in connection with a multiphasic screening program mentioned in your recent letter, our organization is in favor of exploring the possibilities of such a program. The academy as an organization and its individual members will always be available to offer their experience in planning such activities. AMERICAN ACADEMY OF PHYSICAL MEDICINE AND REHABILITATION, Senator NEUBERGER. Our first witness is a pioneer in modern multiphasic health screening techniques. He is Dr. Collen, director of the Permanente Foundation Multiphasic Health Screening Clinic in Oakland, Calif. 213 Dr. Collen, I don't know whether you are a pioneer in setting up the kind of a screening program we have been reading about and hearing about in connection with your hospital, but as one of the existing modern ones, yours is the only one we can find to refer to. Is that true? STATEMENT OF MORRIS COLLEN, M.D., DIRECTOR, PERMANENTE FOUNDATION MULTIPHASIC HEALTH SCREENING CLINIC, OAKLAND, CALIF. Dr. COLLEN. Thank you, Senator Neuberger. There are many programs existing at the present time that utilize the various phases of multiphasic screening. I think what we have done is to put together the largest-coordinated program that functions on line with a computer. Perhaps that is our contribution to develop a larger package, so to speak. Senator NEUBERGER. Several of the witnesses have referred to you as being quite a leader in this area; so we have looked forward to your appearance today. Dr. COLLEN. Thank you. The Kaiser Foundation Health Plan is a prepaid comprehensive medical care and health program which provides hospital and medical services to 12 million people on the west coast and Hawaii. The Kaiser Foundation Health Plan contracts with Kaiser Foundation hospitals to provide hospital facilities and services to its members. Kaiser Foundation Health Plan and hospitals are both nonprofit, tax-exempt corporations, with a board of directors consisting of Mr. Henry Kaiser, Mr. Edgar Kaiser, Dr. Sidney Garfield, the founder of our program, and several of their associates. The Kaiser Foundation Health Plan also contracts with partnerships of physicians to provide the professional medical services to its members. I am a physician in the Permanente Medical Group, which provides the medical services to the 685,000 health plan members in the San Francisco Bay area. When our health plan was established in Oakland in 1942, one of the earliest principles formulated by Dr. Garfield was that of preventive medicine. Accordingly, periodic health examinations have always been one of the prepaid services provided by our health plan. Traditionally in the annual health evaluation, the physician conducts a routine historical review and physical examination. He then arranges for the patient to receive a series of routine laboratory, electrocardiographic and X-ray examinations, and then subsequently the patient returns for report, diagnosis, treatment, and followup procedures. In our program, the patient receiving this periodic health examination, first obtains a battery of tests and procedures, conducted by paramedical personnel in an automated, multitest laboratory. Subsequently an internist reviews the multitest laboratory report, conducts a physical examination, and then proceeds in a traditional manner to diagnose, treat, and arrange followup procedures. This method of applying multiple screening techniques to periodic health examinations has been used by this program since 1950. Automated multitest laboratories are presently operating in the Kaiser-Permanente Medical Centers in Oakland and San Francisco, Calif, where each is processing 2,000 cases monthly within a 40-hourweek schedule. The patient proceeds through a series of 20 stations in a period of 2 to 3 hours and receives a battery of tests and procedures. At the first station, a patient registers at the reception desk approximately every 3 minutes from 1 p.m. to 8 p.m. daily. Here he receives a clipboard which contains a medical questionnaire form and a deck of cards which are prepunched with his medical record number for computer input. This is an actual deck of cards as they are prepared by the computer for the patient before his appointment. The patient at station 2, removes the outer body garments in a dressing booth and puts on a dísposable paper gown. The patient then proceeds to station 3, where the six-lead electrocardiogram is recorded. These are subsequently read by the cardiologist, who records his interpretation on a card, using pencil marks which can be sensed directly by a card-reading machine for input into the computer. Automatic analysis of the electrocardiograms by the computer is being tested. The patient drinks a solution of 75 grams of glucose in carbonated water, and the time of glucose ingestion is recorded by a time stamp on the back of the card, and the patient at that time is assigned a sequencing number from 1 to 24 for control purposes. The patient then proceeds to receive a chest X-ray, which is subsequently read by the radiologist, who records his interpretation on the mark-sense card. X-rays of the breast are performed on all women over age 45, and these are also read by the radiologists. Weight and skin thickness are measured and then by means of an automated anthropometer, a dozen height and transverse body measurements are recorded directly onto the patient's punchcard in 3 minutes. At the next station, the pulse rate and blood pressure are measured and recorded. The patient then returns to his dressing booth and redresses. Visual acuity is then tested by reading a wall chart, and ocular tension is measured by a nurse with a tonometer, and the reading is recorded on a card. A drop is then placed in one eye to dilate the pupil for later retinal photography. The vital capacity is measured with a spirometer. The hearing is tested with an automated audiometer, and the readings are recorded on a marked sense card. At station 14, a self-administered medical questionnaire form, which the patient received at the first station, and which was completed while waiting between stations-this questionnaire is now audited by the nurse. The patient is then assigned to one of 24 questionnaire booths in accordance with the sequencing number which was assigned to the patient at station 4. Here the patient receives a box which contains a deck of 207 punched cards, each having a separate question printed on a card. The questions have been selected which are adjudged medically to be of value in discriminating patients with specific diseases from nondiseased perThe patient responds to each question by taking the card from the top section of the divided letterbox and dropping the card into the middle section if his answer is "Yes," or into the bottom section if the sons. answer is "No." This procedure automatically sorts yes responses for direct input into the computer by means of a card-reading machine. As a part of the preventive medical program, the patient receives a booster dose of tetanus toxoid, and when an hour has elapsed since the ingestion dose, the patient is called from the questionnaire booth and sent to the laboratory, where blood samples are drawn for hemoglobin, blood count, test for syphilis, and rheumatoid factor; these test factors are recorded on the marked-sense cards. Also, eight blood chemistry determinations, glucose, albumin, total protein, cholesterol, creatinine, uric acid, calcium, and transaminase are simultaneously done within 12 minutes by the multichannel automated chemical analyzer, with the test results directly punched in the cards. A urine speciman is collected, and tests are done for bacteria, for the urine pH, glucose, blood, and protein, and the results are marked into the patient's test cards.. The patient then returns to his questionnaire booth, and when he has completed all of his questions, he then goes to the next station, where a photograph is taken of the right retina, with a camera. These retinal photographs are subsequently read by an ophthalmologist, who records his interpretation on a mark-sense card. The patient now returns to station 20, the last station, where he turns in his clipboard containing the marked and punched cards, and the questionnaire form, and there exchanges the box which contains assorted medical questionnaire cards for a second box of cards by which a psychological test is evaluated. By the time the patient turns in this last questionnaire, the on-line computer processing has been completed and supplemental tests and appointments are advised by the programed rules of the computer, and these are arranged for the patient. Routinely advised are a sigmoidoscopy for all patients aged 40 or more and for all women a gynecological examination with cervical smear for cancer detection. A majority of the data is recorded on prepunched or mark-sense cards, so as to permit its immediate introduction into the data-processing system. Thus as an on-line procedure, while the patient waits at station 20, the computer processes the information from the punched cards, from the prepunched sorted cards, and from the reproduced mark-sense cards; in the central facility these punched cards are entered directly into the computer. In the San Francisco facility the punched cards are read into a data communicating system and transmitted via telephone line to the central computer in Oakland, 15 miles away. The processor now goes through a program routine containing various test limits and decision rules and prints out a report constituting "advice" as to any additional procedures which should be done prior to the patient's next visit. These advice rules have been previously established by the internists, and the receptionist is instructed to arrange certain additional tests and appointments for the patient before his physical examination visit with the physician. For example, if the 1-hour serum glucose is greater than a predetermined normal limit for the patient's age and sex and hours since last food intake, the computer prints out instructions to the receptionist to return the patient to station 16 for a 2-hour serum glucose. If a serious abnormality is detected, an earlier appointment with the physician is advised. As an off-line procedure, the computer collates and stores on the random access disk pack the physician interpretations that arrive 2 days later. These are the mark-sense reports from the X-rays, electrocardiograms, and the remaining laboratory tests. When all the information has been received and stored, the computer then produces a printed summary of all the test reports and the questions answered "Yes" by the patient. When he sees the patient, the internist reviews the summary report at the time of the patient's first office visit. The physician directs his attention toward elaborating on the questions to which the patient has answered "Yes" and to the test abnormalities reported from the automated multitest laboratory. He completes his physical examination and then proceeds to arrange whatever medical care is necessary for his patient in a customary manner. Now, in order to evaluate this program, we study its effectiveness for disease detection and its effectiveness in preventing or postponing disease and disability. To give you some concept as to its effectiveness in disease detection, we have abstracted a few statistics from an analysis we performed last year, when we processed 39,524 patients. Forty percent of the patients were aged 50 years and over. Fifty-five percent of the patients were women and forty-five percent were men. Hypertension and hypertensive heart disease was diagnosed in 9 percent of all patients. The electrocardiogram had some abnormality reported in 20 percent of all patients. Over the age of 50, 25 percent of women and 31 percent of men had some abnormality reported. In men ages 50 to 59, 25 percent; men ages 60 to 69, 35 percent; and men aged 70 years or more, in 52 percent of their electrocardiograms, some abnormality was reported. Similarly, the chest X-ray had some abnormality reported in 24 percent of all patients over age 50, in 33 percent of women and 43 percent of men. In men ages 50 to 59, in 30 percent; 60 to 69, 48 percent; and in men 70 years or more, 68 percent had some abnormality reported in the chest X-ray. Pulmonary emphysema was diagnosed in 0.5 percent of our women and 2.5 percent of our men. Mammography X-ray examination of the breasts, for cancer detection showed that cancer of the breast in women aged 50 years or more, proven by surgery, was found in 1 out of every 500 women. Visual acuity of 20/20 or 20/30 is considered as within normal limits. Visual acuity of 20/40 or less indicates need for refraction; 7.5 percent of all people had a visual acuity of 20/40 or less. For aged 60 to 69, it was 12 percent, and for age 70 or more, 26 percent of all people had a visual acuity of 20/40 or less. Glaucoma was diagnosed in 1 percent of our patients, and deafness in 2.5 percent. The retinal photograph of the fundus of the eye had some abnormality reported in 9 percent of all patients. The urine contained sugar in significant amounts in 11.5 percent of all patients; urine protein in 1.2 percent; urine bacteria in significant amounts in 1 percent of men and 3 percent in all women. Diabetes was diagnosed in 3 percent of all patients; anemia was diagnosed in 1 percent of men, and 7.5 percent of all women. Gout was diagnosed in 1 percent of men, osteoarthritis in 3 percent of men and 7.5 percent of women. Our most common diagnosis is obesity, which was diagnosed in 12 percent of men and 20 percent of women. 69-803 0-66—15 |