LifeLine Screening - Stretching fluff into false advertising?

To: Karen R. Law
Director of Clinical Operations
LifeLine Screening
6150 Oak Tree Blvd.
Independence OH 44131

Dear Ms. Law,

Thank you for your letter of invitation for LifeLine Screening in Pleasanton on July 17th. Two of your statements are quite interesting.

"Unfortunately, 4 out of 5 people that suffer a stroke have no apparent symptoms or warning signs."

and

"Ultrasound screenings have proven to be accurate in detecting vascular disease prior to active warning signs and before a major medical incident such as stoke or sudden death from aneurysm rupture."

Your first statement is, "unfortunately," unsubstantiated, and as shown below, appears to be an outright lie, while your second statement takes out of context the position of the Society for Vascular Surgery.

Your letter lacks a reference for the first statement, and I have not found a reference to authenticate it. None of the information I found from by American Heart Association (1), the National Stroke Association (2) or the Society for Vascular Surgery (3) support your statement. The AHA, NSA and SVS information, in fact, regarding silent cerebral infarction strongly suggests your statement is untrue.

There are some related facts that I found. "Four out of five American families will be touched by stroke at some time." (4) "About four out of five people who die of coronary heart disease are 65 or older."(5) "Up to 80% of strokes are preventable."(6) These related facts, even taken together and with inferences, however, do not support that your statement is true.

Every reference I found containing your "4 out of 5" statement was an advertisement for your services. These include the Larry King Cardiac Foundation, the American Senior Benefits Association, and other organizations, such as a letter like yours that I received in April from the American Society for Mechanical Engineers. Based on the lack of authentication, I conclude that your statement is fabricated.

The closest independent supporting statement I found was from a doctor who stated that Peggy Fleming said in 2004, "50% of all strokes occur in people who show no symptoms." (7) I am unaware of where or how Ms. Fleming gained her expertise to make that statement. If true, I suspect the rise from 50% to 80% (4 of 5) of asymptomatic stroke in five years would undoubtedly raise alarm and be in the publications of the American Heart Association and the National Stroke Association. While proving a negative is generally not possible, the absence of support for a statement is accepted as disproving the statement, particularly when, as here, other facts fail to support the statement. At best, is the statement of SVS that "[v]ascular disease is … generally asymptomatic until a catastrophic event occurs." As an educated person, you are aware that "generally" is meaningless. Based on the lack of authentication, I conclude that your statement is fabricated.

Your second statement, attributed to the Society for Vascular Surgery, omitted the sentence before ihttp://www.blogger.com/img/blank.gift. If you are not aware of the sentence, here it is:

Individuals 55 years of age or older with cardiovascular risk factors such as a history of hypertension, diabetes mellitus, smoking, hypercholesterolemia, or known cardiovascular disease may benefit from preventive screening for vascular disease.(8)

Taken in proper context, the paragraph clearly limits the benefits of "preventive screening for vascular disease" to "individuals 55 years of age or older WITH cardiovascular risk factors." Your letter omits this important fact. Thus, your statement plainly takes the Society for Vascular Surgery position out of context. For that reason, I am copying them this letter and your letter.

Furthermore, the accompanying tiny leaflet magnifies the distortion under the question of "Who needs to be screened?" As with many 3-point marketing misrepresentations, (9) the answer of "anyone over 50 who wants to be proactive about his or her health" misconstrues the NSA fact following it. Neither these statements nor those in the letter substantiate the conclusion that people with risk factors "may wish to be screened, even if you are in your 40s." This conclusion, in fact, clearly misrepresents the SVS position above suggesting screening of people with risk factors over the age of 55. While 55 may be the new 40, being 40 with risk factors for stroke does not equate to being 55 with such risk factors. For this misrepresentation, I am copying this letter and your letter to SVS.

I also found other inconsistencies. Your letter says, "LifeLine Screening is … important to keep you and your loved ones healthy and independent." As a Registered Diagnostic Medical Sonographer, Registered Diagnostic Cardiac Sonographer, and Registered Vascular Technologist, you know that screening does not "keep [a person] healthy and independent." Those come with a beneficial diet, exercising, negating risk factors, and treatment. Your use of your credentials to appear to authenticate these lies is a discredit to the medical profession (I was formerly a medical technician). For that reason, I am copying to ARDMS this letter and your letter.

In addition, your letter states the cost as $149. Just two months ago the cost was $135. (10) In 2005, the cost was $109. (11) Collectively, it appears that LifeLine is more interested in inflating its price and fluffing its advertising, and not in keeping its price and facts current with reality.

Wishing you the best of health,

/s/ Gerald R. Prettyman

cc: Society for Vascular Surgery, 633 N. St. Clair, 24th Floor; Chicago, IL 60611;
ARDMS, 51 Monroe Street, Plaza East One, Rockville, Maryland 20850-2400.



cc: Society for Vascular Surgery, 633 N. St. Clair, 24th Floor; Chicago, IL 60611

---Endnotes---
((1) Stroke Warning Signs, American Heart Association, 2009. Available at http://www.americanheart.org/presenter.jhtml?identifier=4742.
(2) Stroke 101, National Stroke Association, 2009. Available at http://www.stroke.org/site/DocServer/STROKE_101_Fact_Sheet.pdf?docID=4541
(3) Society for Vascular Surgery, SVS Position Statement On Vascular Screenings, 2009. Available at: http://www.vascularweb.org/patients/screenings/SVS_Position_Statement_on_Vascular_Screenings.html
(4) USC Neurosurgery - Stroke / Brain Attack - Cause Symptoms Treatment Risk, USC Neurosurgeons, Inc., Last Modified 5-9-2009. Available at: http://www.uscneurosurgery.com/stroke.html.
(5) Heart Attack / Stroke, Kent Fire/Fire District 37, Brochure fdfp6714, 10/05. Available at: http://www.ci.kent.wa.us/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=7142.
(6) What is Stroke? National Stroke Association, 2009. Available at: http://www.stroke.org/site/PageServer?pagename=STROKE.
(7) Dentist Saves Lives!!! (Oral Cancer), Ralph Parkin D.M.D., citing a 2004 letter. Available at: http://www.myhealthymouth.com/Content/DisplayArticle.aspx?ArticleID=1.
(8) Society for Vascular Surgery, SVS Position Statement On Vascular Screenings, 2009. Available at: http://www.vascularweb.org/patients/screenings/SVS_Position_Statement_on_Vascular_Screenings.html.
(9) Gerald R. Prettyman, Life Line Screening - Turning Facts and Half-truths into a Marketing Marvel, April 23, 2009. Available at: http://grpblawg.blogspot.com/.
(10) American Society Of Mechanical Engineers, LifeLine Screening in Dublin, CA, April 6, 2009, Letter on file.
(11) January W. Payne, Screening With Holes in It? July 19, 2005, HE01, http://www.washingtonpost.com/wp-dyn/content/article/2005/07/18/AR2005071801175.html.

Life Line Screening - Turning Facts and Half-truths into a Marketing Marvel

Life Line Screening of America is a Cleveland-based mobile ultrasound company. (1) Life Line performs four tests to "screen for: plaque buildup in the carotid artery of the neck, which can lead to a stroke; an enlarged abdominal aorta, a higher risk for a potentially deadly rupture; peripheral arterial disease, a hardening of the arteries of the leg; and low bone density in the heel, which can indicate the bone-thinning disease osteoporosis." (2) Life Line has screened over 6 million people, which translates to about $600,000,000 in revenue from its humble beginnings in 1993. (3)

These tests raise a lot of debate, in part because medical insurance does not cover the cost, and for other reasons as discussed below. The Life Line website cites several examples of people crediting Life Line for saving them or a loved one from a stroke. (4) Conversely, at least one doctor calls Life Line a scam. (5) As with all marketing stories, there is more to the story than the flyer states.

First up, when you make your reservation, be ready for a not-so-inexpensive credit card hit. The current cost is $140 ($139.99 but that's $140 in my checkbook), although group tie-in marketing drops the price to $135.00. (6) A trip to the doctor generally costs half as much. (7) Life Line also seems to follow the fast rising cost of medicine. In 2005, the cost was $109. (8) The cost was $119 in 2007. (9) The 2009 cost is 28% higher than the 2005 cost. Wow, talk about inflation. (N.B. to everyone, the "specially priced" package that every group gets is $135.00 - what a savings from the public price (not)).

The other debates focus on the usefulness of the tests, and the marketing ploys.

Arterial plaque disease occurs in several areas of the body, not just the carotid (neck) or coronary (heart) arteries. Many tests may detect arterial plaque disease. These include lipid blood tests, blood pressure monitoring, carotid pulse palpitation, ultrasound (external and intravenous), catheterization, cardiac stress test and heart monitoring. (10) There is no single test for diagnosing the likelihood of a stroke. Each test suffers from detecting only one or more aspects of arterial plaque disease or the test is specific to the measured locale only. In addition, some methods, such as ultrasound, are subject to technical error. (11) Thus, a good testing regime uses multiple tests or views as the case may be. More important, however, is a good preliminary oral screening to select the proper test.

Oral screening starts with questions such as, do you or anyone on either side of your family have a history of heart disease, stroke, or signs of peripheral artery disease? Some information indicates that coldness in the legs or arms, or recurrent cramping or pain in one location may indicate blockage or "a problem with blood flow in the arteries." (12) If so, skip Life Line, talk to your doctor, and do not be bashful about demanding more than just a measurement of your blood pressure or the doctor feeling your pulse in your neck. Neither of these detect all vascular problems that may cause a stroke or heart attack from dislodged plaque.

A problem with Line Line, and with every screener for that matter, is that even a battery of tests can miss a diagnostic opportunity if the preliminary oral screening missed a question, or the answer did not alert the screener to call for the proper spot-on diagnostic test. A good friend of mine with a history of smoking had a series of dizzy spells (TIA for you medical types) at about age 60. His bean-counting health care plan (corporation) failed to perform, or misread the result of the diagnostic procedure that would have detected the arterial blockage that led to his stroke that disabled him completely on one side of his body. One year later, as he was recuperating, his wife took him to Life Line because his health plan would not do the scan. Shortly into the procedure, Life Line sent him to the hospital because of the severity of the blockage Life Line found. 'K' re-checked him, and cleaned out the artery. He was a semi-walking killer-stroke waiting to happen. (He is doing much better, but many effects of the first stroke persist). While this seems like a Life Line success story, the gist of it was that he already had one severe stroke preceded by multiple TIA's so a reasonable doctor would look for compounding problems. This was more a failure with the health care corporation than a Life Line success story.

A good example of a less decisive 'get-scanned' example is my family. Both sides of my family have a history of debilitating stroke or heart disease, although each afflicted person was in the 70's, 80's or 90's years of age at the time of the first event. Rather expectedly, the age of onset followed the risk factors. (13) The latter-afflicted persons were non-smokers, not too over-weight, non-or light drinkers, with low cholesterol, had some form of regular activity and they did not live in air-polluted areas, which is also linked to heart disease. (14) The earlier-afflicted persons were overweight by 25% or more, with less activity, drank alcohol, had related health problems, and in some cases, smoked.

With this family history, those of us that are younger are wondering like crazy whether we should go to Life Line for screening. This is where the rest of the debate comes in. The Line Line advertising, whether by flyer or other posting, uses three to four common marketing tactics, or as lawyers call them, arguments. The debate focuses on the truthfulness of the arguments. Generally, the first arguments are wholly or mostly true (fluff), with the truth getting more lost as more arguments are used. What the debate ignores, however, is who makes the statement, and that is the crux of misrepresentation.

In its opening arguments, Life Line uses two bold bullets that combine statistics with fear:
· Stroke is the number one reason that people move into nursing homes and the third leading cause of death in the United States. Yet, many strokes can be prevented.
· Amazingly, 4 out of 5 strokes occur in people who show no prior symptoms.

As noted above, the first bullet point is true, or at least "many strokes can be prevented" is true (diet, exercise, medicine, etc.), as is the statistic that stroke is "the third leading cause of death in the United States." (15) Life Line and Peggy Fleming, however, seem to be the only authorities of the statistic that "[s]troke is the number one reason that people move into nursing homes." (16) This former medical technician turned lawyer has been to many nursing homes over many years. Having seen many residents, infirmity is, in my experience, the number one reason that people move into nursing homes. There is an article from the Wall Street Journal that "[s]troke is the leading cause of disability in the U.S." (17) Once released from the hospital, however, many stroke victims live at home, in assisted living, or in skilled nursing facilities (which are not nursing homes), so the Life Line statement is at best a fuzzy exaggeration.

Under the principle of tiered arguments (marketing), the second argument is somewhat fuzzy compared to the first, but follows the same reasoning. Life Line has it here with the second bullet point, again a statistic with fear, but with a fuzzy 4 of 5 (not 80%, see the difference). Life Line also follows the tier rule that the second argument does not have to be as true, i.e., there can be more exaggeration. In this case, the statistic seems unsubstantiated, or is perhaps a fluffy exaggeration, as Peggy Fleming said it was only 50%, but two of four does not sound as dire as 4 out of 5. (18)

The next stage is to tie the first two arguments with a third argument, and then close with a super coupe implication. To do so, Life Line starts with an apparent authority. Citing the Wall Street Journal of September 24, 2004, the Life Line flyer states: "Many vascular specialists say two diagnostic tests - carotid ultrasound an the ankle-brachial test - can provide a clear window into artery disease that can lead to strokes …" At this point, however, Life Line crosses the line from fuzzy marketing to a half-truth. While the cited line is directly quoted from the Wall Street Journal article, the title and topic of the article is "Screening for Artery Disease Is Good Idea for People Over 60." (19) At best, the Wall Street Journal supports Life Line's half-truth only for the portion of those under 60, "with a variety of risk factors for stroke." (20) The rest of the population can and should ignore Life Line. What is important for Life Line, however, is that it did not lie.

Despite the half-truths, Life Line is not finished, as the flyer or posting adds a second apparent authority that is not really so much an authority as a pitchperson duped into delivering the closing (and untrue) coupe. For Life Line, the apparent authority is the person who signs the flyer (an executive of the tie-in organization) and who "encourage[s] you to read … about these … life-saving tests." Obviously, the pitch is that Life Line screening is life saving. The wise reader will recognize, however, that the screening is not life saving. The life saving comes in changing your diet, exercising, taking medicine, other treatment, etc.

There is another interesting aspect to the life-saving test statement. For clarification, "bait and switch" is illegal because the seller does not intend to sell the advertised product or service. (21) Advertising a need for a product or service is not illegal unless the ad is directed to a specific person to sell "a part, replacement, or repair service [a]s needed when it is not." (22) Even if someone proved the life-saving test statement was directed to a specific person, Life Line is not on the hook because the flyer expresses the statement as the opinion of the executive of the tie-in organization, and Life Line is not responsible for what the organization says.

Consequently, Life Line has done its homework of turning facts and half-truths into a marketing marvel. So now that I have reviewed all this, I suppose the best thing for me is to watch what I eat and weigh, exercise, routinely check my blood pressure, take my medications, and have a check-up each year. Guess I'll get the Life Line scan at age 60.

Gerald R. Prettyman is an Attorney at Law licensed in California and Minnesota and with the U.S. Patent Office as a Registered Patent Attorney. His contact information is at http://grpjrlaw.com.

(1) See http://www.lifelinescreening.com/aboutus/Pages/default.aspx.
(2) January W. Payne, Screening With Holes in It?, July 19, 2005, HE01, http://www.washingtonpost.com/wp-dyn/content/article/2005/07/18/AR2005071801175.html.
(3) Screening value from Life Line. See http://www.lifelinescreening.com/aboutus/Pages/default.aspx. Gross revenue estimated as 6 million times $100 per screening. Simply Hired reports revenue as less than $5 million year. See http://www.simplyhired.com/job-id/woa7rs64ou/crossover-med-jobs/.
(4) See http://www.lifelinescreening.com/aboutus/personalstories/Pages/default.aspx.
(5) Ed Zimney, MD, October 21, 2008, Life Line Screening: A scambuster report. http://www.everydayhealth.com/blog/zimney-health-and-medical-news-you-can-use/life-line-screening-a-scambuster-report/.
(6) American Society for Mechanical Engineers, April 6, 2009, Priority Code BEJA-045.
(7) The current price of Life Line screening is $140 while "the national average doctor's office visit is approximately $60." See Life Line website and Doctor's Office Versus E.R. Visits. Blue Cross Blue Shield of Texas, (citing American Medical Association, "Physician Socioeconomic Statistics," 2001), http://www.bcbstx.com/employer/hccc/topic6.htm.
(8) January W. Payne, Screening With Holes in It?, July 19, 2005, HE01, http://www.washingtonpost.com/wp-dyn/content/article/2005/07/18/AR2005071801175.html.
(9) Monroe Clinic and Life Line Screening Partner to Promote Healthier Communities, August 23, 2007, http://www.monroeclinic.org/News/Releases/2007/Monroe+Clinic+and+Life+Line+Screening+Partner+to+Promote+Healthier+Communities.htm.
(10) While I'm not an M.D., I was formally schooled in medical technology, I'm familiar with all of these tests, and I have been a patient for many of them.
(11) "Carotid tests … [in] a hospital … is the best [as the] tests can be hard to read for an untrained eye." Thomas M. Burton, The Wall Street Journal, Screening for Artery Disease Is Good Idea for People Over 60, September 24, 2004; Page B3, http://engs.net/health/WSJstrokescreen.html.
(12) National Institutes of Health, Department of Health & Human Services, Peripheral artery disease, Page last updated: 24 March 2009, http://www.nlm.nih.gov/medlineplus/ency/article/003184.htm
(13) American Heart Association, Inc., Stroke Risk Factors, April 22, 2009, http://www.americanheart.org/presenter.jhtml?identifier=4716.
(14) American Physiological Society, March 23, 2009, Inhaling A Heart Attack: How Air Pollution Can Cause Heart Disease, http://www.the-aps.org/press/releases/09/8.htm.
(15) American Heart Association, Inc., Stroke Statistics, April 22, 2009, http://www.americanheart.org/presenter.jhtml?identifier=4725
(16) The online references this author found stating this information were hawking Life Line or other screening companies. One dental surgeon (D.M.D.) cited Peggy Fleming (the ice skater) as his authority! See http://www.myhealthymouth.com/Content/DisplayArticle.aspx?ArticleID=1. The most credible authority was from an advertisement in 2007 (the time of the screening), who was the Chief Nurse Executive of a clinic, but she was hawking the Life Line tie-in to the clinic and repeating what Life Line states in its promotions, so that negates her credibility. See: http://www.monroeclinic.org/News/Releases/2007/Monroe+Clinic+and+Life+Line+Screening+Partner+to+Promote+Healthier+Communities.htm http://www.monroeclinic.org/News/Releases/2006/Elmer+and+Weldon+Promoted+at+Monroe+Clinic.htm
(17) Thomas M. Burton, The Wall Street Journal, Screening for Artery Disease Is Good Idea for People Over 60, September 24, 2004; Page B3, http://engs.net/health/WSJstrokescreen.html.
(18) This author could not independently substantiate this so-called fact, although Peggy Fleming (cited above) supposedly wrote in 2004, "50% of all strokes occur in people who show no symptoms."
(19) Thomas M. Burton, The Wall Street Journal, Screening for Artery Disease Is Good Idea for People Over 60, September 24, 2004; Page B3, http://engs.net/health/WSJstrokescreen.html.
(20) Thomas M. Burton, The Wall Street Journal, Screening for Artery Disease Is Good Idea for People Over 60, September 24, 2004; Page B3, http://engs.net/health/WSJstrokescreen.html.
(21) Cal. Civil Code § 1770(9). The law of your jurisdiction may vary.
(22) Cal. Civil Code § 1770(15). The law of your jurisdiction may vary.