Hold the needle: Multistage screening as good as lab testing

Think twice before requesting a cholesterol lab test to assess a patient’s risk of cardiovascular disease. A study published online Jan. 14 in Circulation: Cardiovascular Quality and Outcomes determined that doctors could obtain comparable results faster and at less cost using a multistage screening strategy.

Most primary cardiovascular disease screening guidelines recommend assessments that include at least one laboratory-based test, such as blood low-density lipoprotein cholesterol, to identify high-risk patients who might benefit from statin treatment. Lead author Ankur Pandya, PhD, of Weill Cornell Medical College in New York City, and colleagues proposed that non-lab-based approaches incorporating factors such as age, smoking status, blood pressure and body mass index might suffice for predicting cardiovascular risk.       

Their study had two parts: to validate a risk stratification approach for adults with no history of cardiovascular disease using various multistage screening systems compared with the Framingham cardiovascular disease risk score; and to perform a cost-effectiveness analysis.

The screening strategies used data from the Third National Health and Nutrition Examination Survey (NHANES). Pandya and colleagues looked at three strategies. The first strategy mirrored many statin treatment guidelines that call for a single-stage, Framingham-based approach. The second was a single-stage, non-lab-based strategy with risk characterization based on non-lab-based total risk. The third used multistage screening that called for a subset of people deemed intermediate-risk in a non-lab-based assessment to then receive laboratory testing.

Pandya and colleagues developed a model to evaluate the cost-effectiveness of the various strategies, using NHANES data from 2005 to 2006 and 2007 to 2008 populations.

They found that the multistage screening strategies were comparable to the Framingham score for stratifying risk but with 25 percent to 75 percent less laboratory testing. The single-stage, Framingham strategy provided the least value.

“Our risk discrimination results would confirm the intuition physicians might hold for low- and high-risk individuals screened for primary CVD [cardiovascular disease] risk, which is that laboratory testing will not change the risk assessment and treatment decisions in most cases,” they wrote.

The results reflect a movement away from primary assessment based on one single risk factor to broader approaches that include all risk factors, they wrote. “The incorporation of a non–laboratory-based component can allow physicians to make treatment decisions faster and at lower costs compared with current laboratory-based recommendations.”