When Jennifer Welsh, a 40-year-old from New Britain, Connecticut, visited her doctor about pain in her joints and neck, her doctor sent her to the emergency department (ED) to rule out meningitis. The ED did rule that out, as well as strep, so Welsh went to her follow-up appointment a few days later, hoping for answers or at least more tests to get those answers.
Instead, the doctor — a different one from the same practice as her primary care physician (PCP) — wouldn't even talk to Welsh about her symptoms because she couldn't see the ED's results and refused to view the results that Welsh could pull up online.
"She just completely shut me down," Welsh recalled. "It was a really awful appointment, and I left in tears. I was in physical pain, I had just been to the ER, nothing is really resolved, I'm stressed out about it, and this woman is completely dismissing me."
She had been able to schedule an appointment with her regular PCP later that week, but after the harrowing experience with this doctor, she wondered if her PCP would order the rheumatoid arthritis (RA) test that Welsh suspected she needed. So, she took matters into her own hands.
"I was searching for what test to ask for from my doctor," she said, and she found that she could order it on her own from a major lab company she was already familiar with. For around $100, "I could get it done and see what it says on my own," she said.
But that's not how it worked out. Her regular PCP apologized for the other doctor's behavior and ordered the RA test as well as additional tests — and got results while Welsh still waited for the one she ordered to arrive over a week later.
At first, Welsh was grateful she could order the RA test without her doctor's referral. "I felt it gave me a sense of control over the situation that I felt really not in control of, until the system failed me, and I didn't get the results," she said. But then, "not having someone I could call and get an answer about why my tests were delayed, why I wasn't able to access them, why it was taking so long — it was definitely anxiety-inducing."
A Growing Market
Welsh is one of a growing number of patients who are ordering direct-to-consumer (DTC) lab tests without the recommendation or guidance of a doctor. They're offered online by labs ranging from well-established giants like Quest and Labcorp to smaller, potentially less vetted companies, although some smaller companies contract with larger companies like Quest. Combined, the DTC market is projected to be worth $2 billion by 2025.
Yet the burgeoning industry has also drawn critiques from both bioethicists and privacy experts. A research letter in JAMA last year, for example, found that less than half of the 21 companies identified in an online search declared Health Insurance Portability and Accountability Act compliance, while more than half "indicated the potential use of consumer data for research purposes either internally or through third-party sharing." That study found the most commonly offered tests were related to diabetes, the thyroid, and vitamin levels, and hormone tests for men and women, such as testosterone or estradiol.
But a number of companies also offer tests related to rheumatologic conditions. A handful of tests offered by Labcorp, for example, could be used in rheumatology, such as tests for celiac antibodies or high-sensitivity C-reactive protein. Quest similarly offers a handful of autoimmune-related tests. But other companies offer a long slate of autoimmune or antibody tests.
The antinuclear antibody (ANA) test and RA panel offered by Quest are the same tests, run and analyzed in the same labs, as those ordered by physicians and hospitals, according to James Faix, MD, the medical director of immunology at Quest Diagnostics. Their RA panel includes rheumatoid factor and anti-cyclic citrullinated peptide as well as antibody to mutated citrullinated vimentin, "which may detect approximately 10%-15%" of patients who test negative to the first two.
Quest's ANA test with reflex costs $112, and its RA panel costs $110, price points that are similar across other companies' offerings. Labcorp declined to respond to questions about its DTC tests, and several smaller companies did not respond to queries about their offerings. It can therefore be hard to assess what's included or what the quality is of many DTC tests, particularly from smaller, less established companies.
Oversight and Quality Control
Anthony Killeen, MD, PhD, president of the Association for Diagnostics & Laboratory Medicine (ADLM) and director of Clinical Laboratories at the University of Minnesota Medical Center in Minneapolis, said via email that the ADLM supports "expanding consumer access to direct-to-consumer laboratory testing services that have demonstrated analytical and clinical validity and clinical utility," given the importance of individuals learning about their health status and becoming more involved in health decisions. But the ADLM also recommends "that only CLIA-certified laboratories perform direct-to-consumer testing," he said.
"There are direct-to-consumer tests on the market that are not medical-grade laboratory tests and that may be performed in nonaccredited laboratories," Killeen said. "We advise consumers to steer clear of such tests." The ADLM also encourages consumers to "work with qualified healthcare providers when making decisions based off the results they receive from any direct-to-consumer tests" and recommends that DTC test companies "provide consumers with sufficient information and/or access to expert help to assist them in ordering tests and interpreting the results."
Yet it's unclear how much support, if any, consumers can receive in terms of understanding what their tests mean. Most of the companies in the 2023 study offered optional follow-up with a healthcare professional, but these professionals ranged from physicians to "health coaches," and all the companies had disclaimers that "test results did not constitute medical advice."
At Quest, the only company to respond to Medscape Medical News's request for comment, consumer-initiated tests ordered online are first reviewed by a physician at PWNHealth, an independent, third-party physician network, to determine that it's appropriate before the lab order is actually placed.
"Once results are available, individuals have the option to discuss their results with an independent physician at no extra cost," Faix said. ANA or RA results outside the normal ranges may trigger a "call from a PWNHealth healthcare coordinator, who can help provide information, suggestions on next steps, and set up time for the individual to speak with an independent physician to discuss questions or concerns regarding the results," he said.
"Our goal is not to replace the role of a healthcare provider," Faix said. "We are providing an alternate way for people to engage with the healthcare system that offers convenience, gives people more control over their own healthcare journeys, and meets them where they are, supporting both consumers and their care teams." The company has expanded its offerings from an initial 30 tests made available in 2018 to over 130 today, deciding which to offer "based on consumer research and expertise of clinical experts." The company has also "seen steady interest in our two consumer rheumatology offerings," Faix said.
DTC Landscape in Rheumatology
Within rheumatology, among the most popular tests is for ANA, based on the experience of Alfred Kim, MD, PhD, an associate professor of medicine at Washington University School of Medicine in St Louis, St Louis, Missouri.
"For a lot of people, losing control over their health is maybe the most frightening experience they can have, so I think a lot of patients use this as a way to kind of have ownership over their health," Kim said. "Let's say they've been to four doctors. No one can explain what's going on. They're getting frustrated, and so they just turn to solutions where they feel like they have ownership over the situation."
Though the market is undoubtedly growing, the growth appears even across geography and institution types. Kim has seen a "fair number of referrals," with patients coming in with results from a DTC test. Michael Putman, MD, MSci, an assistant professor of medicine at the Medical College of Wisconsin in Milwaukee, Wisconsin, hasn't seen it much. "I know that patients can get testing done themselves independently, but I don't have people routinely coming in with tests they've ordered in advance of our appointment," Putman said, but, like Kim, he recognizes why patients might seek them out.
"I'm a big fan of patient empowerment, and I do think that medicine serves a gatekeeper role that sometimes can be a little too far," Putman said. "I think there is value to patients being able to get more information and try to understand what is happening in their bodies. I have a lot of compassion for someone who would try to find testing outside of the normal channels."
Indeed, bringing these test results to a visit could be informative in some scenarios. A negative ANA test, for example, pretty much excludes lupus 100%, Kim said. But a positive ANA doesn't tell him much, and if his clinical suspicion for a condition is high, he likely would order that test anyway, even if the patient came in with their own results. Putman also pointed out that the vast majority of tests used in rheumatology have a high rate of false positives.
"I think that will be the major area where this causes quite a lot of grief to patients and some frustration to some providers," he said. A rheumatoid factor test like the one Welsh ordered, for example, might test positive in 10 out of 100 people randomly gathered in a room, but the majority of those individuals would not have RA, he said.
That test is another popular rheumatology one, according to Timothy Niewold, MD, vice chair for research in the Hospital for Special Surgery Department of Medicine in New York City. Among the possible reasons people might order these tests are the delay in diagnosis that can often occur with a lot of rheumatologic conditions and that "it can take a while to see a rheumatologist, depending on what part of the country you're in and what the availability is," he said. He's not surprised to see tests for Sjögren disease among the offerings, for example, because it's a condition that's difficult to diagnose but reasonably common within autoimmune diseases.
Risks vs Benefits
DTC testing is not an answer to the national shortage of rheumatologists, however, especially given the risks that Niewold, Putman, and Kim worry outweigh potential benefits. On the one hand, getting online test results may help expedite a referral to a specialist, Niewold said. But a long wait for that appointment could then easily become a bigger source of anxiety than comfort, Putman said.
"It's a trade-off where you are accepting a lot more people getting false-positive diagnoses and spending months thinking they have some disease where they might not, in exchange for a couple people who would have had a delayed diagnosis," Putman said. "There's an enormous amount of existential suffering," that's familiar to rheumatologists because some patients may dread the diagnosis of a rheumatic disease the way they might fear a cancer diagnosis, especially if they have lost a family member to a condition that they suspect they share, he said. "To put yourself into an existential catastrophe — that's not a small harm."
Niewold agreed, pointing out that patients with a positive ANA test may "get unnecessarily worried and stay up all night reading about lupus, getting scared for weeks on end before seeing a specialist." And there are financial harms as well for patients who may order the same test multiple times, or a whole slate of tests, that they don't need for hundreds or thousands of dollars. There's also the lost time and effort of researching a condition or even seeking out support groups that patients may pursue, Niewold said.
The likely biggest risk to individuals, however, is the potential for overdiagnosis or misdiagnosis.
"If someone comes in and they've read the textbook on lupus and they have a positive ANA, it's really hard as a rheumatologist to walk that back," Putman said. "The human mind is a powerful thing," he added, and people who get a positive test will likely start to notice things like joint pain or a rash on their cheeks and begin attributing it to a diagnosis they risk convincing themselves they have. "When people come into your clinic not knowing what a disease would look like and they just tell you how they're feeling, it's a much cleaner and more honest way to approach diagnosis."
Most patients likely don't realize, for example, that none of the tests rheumatologists usually order are diagnostic in and of themselves, Niewold said. "They're all kind of like stars in the constellation of a diagnosis," he said. "They're helpful, but none of them is sufficient by itself."
Killeen agreed, noting that "consumers might not understand the nuances of these tests well enough to know whether it is appropriate to order them or how to interpret the results correctly." Given the long-term implications of a diagnosis for a rheumatologic disease, "I would have concerns about consumers ordering and interpreting rheumatologic tests without working closely with their physicians," Killeen said. "The main concern that lab experts have about direct-to-consumer tests is the potential for people to get misleading results and/or to misinterpret their results, which in turn could lead to people not getting the treatment they need or getting treatment when they don't need any at all."
It's one thing for patients to come in asking for a particular treatment they may not need but which a doctor may be able to dissuade them from seeking. But Kim also pointed out the risk that patients may decide to treat themselves with therapies that haven't undergone rigorous testing or haven't been recommended by a physician.
"We tend to have people who come in with a pretty clear idea of what they want done, but the problem is, we don't know if their reasoning is correct from a clinical perspective," Kim said. Companies offer these tests with the belief that they're "providing patients a choice, an option to take ownership," he said, "but the potential harm can be realized very quickly because there are going to be people who are misdiagnosing themselves and, worse yet, may then pursue their own treatment plan that’s going in the opposite direction of where we think it needs to go."
Or, on the flip side, if a patient erroneously believes they have the answer to what ails them, it may delay diagnosis of a more serious condition that's rarer or harder to detect. Kim pointed to, for example, intravascular lymphoma, which is notoriously as difficult to identify as it is rare and aggressive. If a patient's confirmation bias has led them to believe they have an autoimmune condition, they may not receive the more serious diagnosis until it's advanced too far to treat.
Patient-Provider Relationship Friction
Another concern is how these tests may lead to confusion and frustration that can erode the patient-provider relationship, particularly because most patients don't know how to interpret the results or understand the bigger context in which the results have to be interpreted. Many patients may think a test can come back with a binary answer, a positive or negative, and that means they do or don't have a condition. That's generally true for pregnancy tests, COVID tests, and sexually transmitted infection tests — the kinds of tests that have long been available to consumers and which have fairly straightforward answers.
But physicians know that's not the case for many conditions, particularly those in rheumatology.
"In rheumatic diseases, because the tests have such marginal value in terms of diagnosis, almost always we develop a suspicion before we even think about ordering the tests, and then that dictates whether or not we cross that threshold," Kim said. "A negative test doesn't exclude the fact that you may have disease X, but a positive test also doesn't mean you have disease X. All they provide is an idea of the risk."
But some patients who come in with DTC test results have "already made the decision in their mind that they have a certain condition," Kim said. "This is obviously dangerous because the majority of these patients do not have the condition they think they have, and it leaves a very uncomfortable feeling after the visit because they feel like they've been either betrayed by me or by the test, and they leave more confused."
Patients may also come in with tests that a doctor isn't familiar with or isn't sure how to interpret on its own, at least for that particular patient.
"For ANA testing, we have a pretty good idea of its positive and negative value for predictive value because it's ordered so much, but for many of these tests being offered, there are specific autoantibodies, and we tend to only get them in people where there's a clinical suspicion," Kim said. "Within that very specific context, we kind of understand what that value means, but if you give it to the general public, then those numbers aren't as applicable and most likely overestimate the risk of disease."
Even if providers consider the results of a DTC test in their differential, they may want to be sure it's from a trustworthy source. "If a provider is uncertain about whether a direct-to-consumer testing company is reputable or about whether a direct-to-consumer test result is reliable, I would encourage them to consult with their laboratory medicine colleagues," Killeen said.
Responding to Patients
Like any other patient coming to a clinical visit, the most common reason patients are likely ordering these tests is that they're seeking answers. Kim doesn't typically see patients doing their own monitoring for diagnosed conditions between visits — the expense would add up too quickly — or testing for genetic markers, which likely wouldn't be very helpful either.
"Even though most of our diseases probably have a genetic underpinning, how much it contributes is always unclear," Kim said. Even conditions with clear genetic variants, such as familial Mediterranean fever, spondyloarthritis, and Behçet disease, can only support a diagnosis, not diagnose it on its own, Killeen said. And these are not among the tests currently available on most DTC company sites.
While there are also tests that can offer information about genetic risks for certain medications, such as a thiopurine methyltransferase test to find out if a patient lacks the enzyme needed to break down the immunosuppressant drug azathioprine, Kim hasn't seen patients seeking these out either.
"The more global and more compassionate way to think about this is that we have a lot of people who are struggling to understand what's going on with their bodies, and most physicians really don't know what the next steps are for these people," Kim said. "They're desperate, and their quality of life is so poor that they're going to take extreme steps to try to manage their own frustration with this condition."
That means clinicians' most powerful tools when patients come in with DTC test results are their listening skills.
"Empathy is the most important thing, just being able to share the patient's frustration to the point where they had to take matters into their own hands," Kim said. "I think a lot of rheumatologists are actually pretty comfortable being in this position."
Additionally, doctors should know that some patients may be engaging in attempts to self-diagnose, self-treat, or otherwise self-manage their symptoms or perceived condition. "They just need to be aware and try to make sure there's no harm being done," Kim said.
Welsh didn't seek treatment or diagnosis on her own, but getting her test also did not give her the control she was seeking. "Looking back, it was kind of a waste of money, but it felt good in the moment," Welsh said. "I was so upset, and I wanted that control, and in the end, it didn't get me results any sooner, and it didn't give me peace of mind."
It was Welsh's primary care doctor listening to her concerns, ordering the same test she had ordered with several others, and working with her to seek answers that reassured her that her provider cared about her well-being.
"A lot of what I do in my business is reassure people that you know what they have is treatable or not going to end their life as they know it," Putnam said. "And you certainly can't reassure them if they're not in your clinic yet."
Putman has participated in clinical trials with AbbVie, consulting with Novartis and GSK, and clinical trials and consulting with Amgen and AstraZeneca. Niewold reported receiving research grants from EMD Serono and Zenas BioPharma and consulting for Thermo Fisher Scientific, Progentec Diagnostics, Roivant Sciences, AstraZeneca, S3 Connected Health, Flagship Pioneering, and Guidepoint. Kim reported sponsored research agreements with AstraZeneca, Bristol Myers Squibb, Novartis, and CRISPR Therapeutics; royalties from Kypha; and consulting/speaking for Amgen, ANI Pharmaceuticals, Atara Biotherapeutics, Aurinia Pharmaceuticals, CARGO Therapeutics, Exagen Diagnostics, GSK, Hinge Bio, Kypha, Progentec Diagnostics, Synthekine, and UpToDate. Killeen had no relevant financial relationships to disclose.
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