Primary Care not Annual Check-Ups
The Cochrane Library
October 17, 2012 (http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009009.pub2/abstract)
General health checks in adults for reducing morbidity and mortality from disease
By Lasse T Krogsbøll, Karsten Juhl Jørgensen, Christian Grønhøj Larsen, Peter C Gøtzsche
Plain language summary
General health checks involve multiple tests in a person who does not feel ill with the purpose of finding disease early, preventing disease from developing, or providing reassurance. Health checks are a common element of health care in some countries. To many people health checks intuitively make sense, but experience from screening programmes for individual diseases have shown that the benefits may be smaller than expected and the harms greater. One possible harm from health checks is the diagnosis and treatment of conditions that were not destined to cause symptoms or death. Their diagnosis will, therefore, be superfluous and carry the risk of unnecessary treatment.
We identified 16 randomised trials which had compared a group of adults offered general health checks to a group not offered health checks. Results were available from 14 trials, including 182,880 participants. Nine trials studied the risk of death and included 155,899 participants and 11,940 deaths. There was no effect on the risk of death, or on the risk of death due to cardiovascular diseases or cancer. We did not find an effect on the risk of illness but one trial found an increased number of people identified with high blood pressure and high cholesterol, and one trial found an increased number with chronic diseases. One trial reported the total number of new diagnoses per participant and found a 20% increase over six years compared to the control group. No trials compared the total number of new prescriptions but two out of four trials found an increased number of people using drugs for high blood pressure. Two out of four trials found that health checks made people feel somewhat healthier, but this result is not reliable. We did not find that health checks had an effect on the number of admissions to hospital, disability, worry, the number of referrals to specialists, additional visits to the physician, or absence from work, but most of these outcomes were poorly studied. None of the trials reported on the number of follow-up tests after positive screening results, or the amount of surgery used.
One reason for the apparent lack of effect may be that primary care physicians already identify and intervene when they suspect a patient to be at high risk of developing disease when they see them for other reasons. Also, those at high risk of developing disease may not attend general health checks when invited. Most of the trials were old, which makes the results less applicable to today's settings because the treatments used for conditions and risk factors have changed.
With the large number of participants and deaths included, the long follow-up periods used in the trials, and considering that death from cardiovascular diseases and cancer were not reduced, general health checks are unlikely to be beneficial.
Comment on this study by H. Gilbert Welch, MD, The Dartmouth Institute, Community and Family Medicine
I think that there has been a growing realization that we've oversold the value of screening for early cancers or early disease, that we sort of suggested that there is considerable benefit when, in fact, the evidence about benefit is at least open to question. It's not a huge benefit. And we've downplayed or ignored entirely the downsides of the problem. I'm not saying there's one right answer, but I am saying that there are two sides to the story. And I think that there is a growing realization that there are benefits - that everyone knew - but there are also harms, and people have to balance those.
Dr. McCanne's comment:
General health checkups or routine physicals have been a mainstay of keeping people healthy, or so we thought. Finding disease early and providing appropriate interventions seems like a recipe for success in maintaining health. However, because some doubts have arisen over this concept, The Cochrane Collaboration studied randomized trials of health checks and found that "general health checks are unlikely to be beneficial."
Though this study does indicate that the formal health check is unlikely to be beneficial, does that apply to isolated procedures such as blood pressure checks, serum lipid screening, cervical cancer screening, or skin screening for melanomas? Numerous studies have suggested that early intervention is effective in these disorders. If not, then it wouldn't be logical to treat hypertension, hypercholesterolemia, or most early cancers, yet we do it all the time.
H. Gilbert Welch, MD, co-author of the enlightening book, "Overdiagnosed - Making People Sick in the Pursuit of Health," provides perspective in his comments on the Cochrane study. He says that we need to balance the benefits "that everyone knew" with the harms that interventions can cause.
It seems that rather than promoting general health checkups as an isolated process, we should use this information to promote primary care. Establishing a long-term relationship with a primary care professional or team can provide continuity in health screening procedures, both in their timeliness and appropriateness.
What does this have to do with single payer reform? Simply that the single payer model includes reinforcement of our primary care infrastructure as an important and effective means of providing higher quality and less costly care for everyone.
We need a health care financing system that emphasizes and supports primary care, which manifestly the private health insurance business model does not.
Dr. Joe Jarvis