Does the inclusion of whole population medical screening undermine the benefits of wellness programmes?

Question

Workplace wellness programmes are becoming increasingly popular as employers (and governments) attempt to control escalating healthcare costs. They offer the promise of making the workforce healthier and, in principle, lowering the cost of providing their healthcare.

Many of the aspects of such programs are uncontroversial. Few people, for example, would argue against incentives to eat more healthy food or do more exercise.

But many workforce programs also include significant elements of medical screening. Screening programs use a variety of diagnostic techniques in an attempt to discover early signs of disease. The promise being that, if disease is spotted early, it can be treated more effectively. This sounds as though screening can only be good for your health. Many experts, however, disagree. Al Lewis argues, in an article on thehealthcareblog titled "Caution: Wellness Programs May Be Hazardous to Your Health" that:

...many ... HRAs [health risk assessments] and screens, from well-known vendors, provide blatantly incorrect advice that can potentially cause serious harm if followed.

Is he right that population screening can undermine the benefit of wellness programs?

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NB To avoid some of the misunderstandings that previous versions of this question have encountered here are some definitions and notes on the focus and intent of the question.

The question is not whether wellness programs as a whole are good but whether the inclusion of population screening makes them worse. Screening is not a necessary element of such programs and could be eliminated without affecting the remaining components.

Population screening is the use of a variety of diagnostic tests on a whole group with no specific risk factors for the diseases being screened for. The statistics of screening are radically different if screens are only applied to "at risk" groups. The key issue is whether screens applied to whole populations have net benefits.

While there are a lot of different techniques and screens, they all possess a set of common statistical characteristics. The root cause of concern that critics of population screening express are mostly based on those common characteristics so a good answer doesn't have to evaluate every possible screening technique but can focus mostly on those common characteristics.

Some specific techniques have been discussed in detail on sceptics.SE in other questions. For example: Is routine screening for breast cancer for asymptomatic women worthwhile? and Does screening for prostate cancer save lives?

Answer 1

What is the situation?

Fifty-five percent of large firms (200 or more workers) and 26% of smaller firms offering health benefits report offering biometric screening to employees. (The Kaiser Family Foundation - 2013 Employer Health Benefits Survey)

What are the common screens included in workplace wellness programs?

A biometric screening is a health examination that measures an employee’s risk factors, such as body weight, cholesterol, blood pressure, stress, and nutrition. (ibid.)

health risk assessments (HRAs) and biometric screenings, such as body mass index (BMI), blood pressure, cholesterol, and glucose levels. (Consensus Statement of the Health Enhancement Research Organization, American College of Occupational and Environmental Medicine, and Care Continuum Alliance - Biometric Health Screening for Employers)

height, weight, calculated BMI, waist circumference, hip circumference, body fat and/or body composition, blood pressure, pulse rate (ibid. at p. 1245)

What are the common characteristics of these screens (if any)?

As far as I can tell, the only common characteristic of these screens is ease of use within a wellness program:

Biometric screening: the measurement of physical characteristics such as height, weight, body mass index, blood pressure, blood cholesterol, blood glucose, and aerobic fitness tests that can be taken at the worksite and used as part of a workplace health assessment to benchmark and evaluate changes in employee health status over time. (Centers for Disease Control and Prevention)

What does the evidence say about the efficacy of these screens outside of wellness programs?

height, weight, BMI

"The USPSTF recommends screening all adults for obesity. Clinicians should offer or refer patients with a body mass index (BMI) of 30 kg/m2 or higher to intensive, multicomponent behavioral interventions. Grade B recommendation." (USPSTF - Obesity)

• USPSTF Evidence Report

waist circumference, hip circumference, body fat and/or body composition

These measurements are taken to mitigate potential false positives of the BMI test when applied to particular individuals, such as athletes and body builders. (Joint consensus statement, at p. 1245)

Regarding body fat percentage, "although body fat is considered a better measure for determining healthy weight and health risks, it can be difficult to accurately and consistently measure in the workplace." (ibid.)

blood pressure

"The USPSTF recommends screening for high blood pressure in adults age 18 and older. Grade A recommendation." (USPSTF - Blood pressure)

• USPSTF Evidence report

blood cholesterol

• The U.S. Preventive Services Task Force (USPSTF) strongly recommends screening men aged 35 and older for lipid disorders. Grade A recommendation.
• The USPSTF recommends screening men aged 20 to 35 for lipid disorders if they are at increased risk for coronary heart disease. Grade B recommendation.
• The USPSTF strongly recommends screening women aged 45 and older for lipid disorders if they are at increased risk for coronary heart disease. Grade A recommendation.
• The USPSTF recommends screening women aged 20 to 45 for lipid disorders if they are at increased risk for coronary heart disease. Grade B recommendation.

• The USPSTF makes no recommendation for or against routine screening for lipid disorders in men aged 20 to 35, or in women aged 20 and older who are not at increased risk for coronary heart disease. Grade C recommendation. (All from USPSTF - Lipid disorders)

• Evidence report

blood glucose (type 2 diabetes)

"The USPSTF recommends screening for type 2 diabetes in asymptomatic adults with sustained blood pressure (either treated or untreated) greater than 135/80 mm Hg. Grade B recommendation." (USPSTF - Type 2 Diabetes)

"The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for type 2 diabetes in asymptomatic adults with blood pressure of 135/80 mm Hg or lower. Grade I Statement." (ibid.)

• Supporting article
• Evidence synthesis

aerobic fitness tests

The USPSTF has no recommendation regarding aerobic fitness tests.

stress

The USPSTF has no recommendation regarding checking stress levels. However, they do recommend "screening adults for depression when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and follow-up", but not if "staff-assisted depression care supports are not in place". (USPSTF - Depression)

nutrition

"The U.S. Preventive Services Task Force (USPSTF) concludes that the evidence is insufficient to recommend for or against routine behavioral counseling to promote a healthy diet in unselected patients in primary care settings." (USPSTF - Behavioural Counseling in Primary Care to Promote a Healthy Diet)

What is the effect of including these screens in a wellness program?

Wellness programs and the effect of the inclusion of screenings can only be assessed on a case-by-case basis. (Joint consensus statement, at p. 1250)

The characteristics well-designed workplace screening programs include (ibid. at p. 1249):

• Following consistent protocols for all participants in a target population
• Adhering to industry standards and scientific/clinical guidelines regarding quality, accuracy, privacy, and safety
• Following referral protocols based on national guidelines for individuals whose results are outside the normal range
• Having an established process for communicating results to the participant's physician

The asker claims that "Screening is not a necessary element of such programs and could be eliminated without affecting the remaining components." This not true. "Companies and other organizations implement screenings to ... tailor health management programs to individual employee needs, provide data to help motivate employees to take appropriate actions to improve their health, and refer individuals to their respective health care providers". (Joint consensus statement, at p. 1245)

"The value of [biometric screenings] is more fully realized when they are integrated into an overall health management program that offers various approaches, interventions, incentives, and environmental support to help employees and employers act on the data gathered." (ibid.)

"When integrated into a well-designed health management program, screenings can play an important role within the context of primordial, primary, secondary, and tertiary prevention efforts." (ibid.)

Further reading

Consensus Statement of the Health Enhancement Research Organization, American College of Occupational and Environmental Medicine, American Cancer Society and American Cancer Society Cancer Action Network, American Diabetes Association, and American Heart Association. "Guidance for a reasonably designed, employer-sponsored wellness program using outcomesbased incentives." J Occup Environ Med 54, no. 7 (2012): 889-96.