27th June 2021, Dr Chee L Khoo
We all do it. Either we arrange for patients to come in once a year to have a “general check-up” or patients come in requesting one. There are no set rules what we check for and what blood tests to order. Somehow, patients feel better that they have been given a clean bill of health and at times, we feel that we have check them out properly and all is good. Is it? Are we kidding ourselves or are we kidding patients? How much do these general check-ups achieve? Do they reduce mortality or morbidity? Should we check everyone over a certain age? Should we do annual check-ups at all?
General health checks are also known as general medical examinations, periodic health evaluations, checkups, routine visits, or wellness visits. Although there is no common definition of general health checks, they can generally be described as health care encounters that include multiple screenings, and identification of risk factors, with a goal of initiating early interventions to prevent future illness. Patients like general health checks. It’s a feel good activity. What does the evidence tell us?
In the most recent review of trials that evaluated health checks, randomised trials and observational studies with control groups were examined. Liss D et al reviewed randomised control trials and observation studies between January 2000 and March 2021 as well as all randomised trials reviewed in previous systematic reviews (1).
Seventeen studies were conducted in Europe (9 in Scandinavia and 8 in the UK), 11 in the US, 3 in Asia, and 1 in Canada. Six studies were restricted to patients aged 40-64 years; 8 were restricted to patients ≥ 65 years and 18 included patients in multiple, other, or unspecified age groups. Fourteen
included studies began prior to 1990 (i.e. before medications such as statins were widely available), 7 began during the 1990s, and 11 began during the 21st century.
What did they check?
General health check intervention formats and components varied widely. Half of the examinations were conducted by doctors while the others were conducted by non-doctor health professionals.
The format of the check ups could include:
- Screening questions to identify risk factors
- Physical examination
- Laboratory blood and urine tests
- Other diagnostic testing of lung, heart, or eye function
- Lifestyle interventions and health behaviour coaching
How often were they checked?
Among the 19 randomised control trials, some (5) evaluated single general checks, some (7) evaluated annual checks, some (1) evaluated biannual checks and some (6) evaluated checks at different frequencies. The follow up period ranged from 6 months to 30 years.
Did the checks save lives?
Mortality
In 13 randomised trials that evaluated mortality, 11 reported no significant all-cause mortality benefit. For example, in the South-East London Screening Study (n = 7229), adults aged 40 – 64years who were invited to 2 screening sessions over 2 years, compared with adults not invited to screening, had no benefit in 8-year mortality or 9-year mortality (2). In the DanMONICA trial, conducted among 17 845 individuals in Denmark, invitation to screenings and interventions at baseline, 5 years, and 10 years, compared with no invitation, resulted in no difference in 30-year all-cause mortality (3).
Cardiovascular events
In all the randomised trials, general health checks failed to reduce cardiovascular events or cardiovascular disease incidence.
Chronic disease
There was an increase in detection of some chronic disease. For example, in the Check-In Study conducted among Danish patients aged 45 – 64 years with low levels of education, 5%of patients randomised to receive a single preventive health check and 2%of those randomised to receive usual care received a new antidepressant prescription over 1 year (4).
However, there were no differences in detection of hypertension, hypercholesterolemia, or diabetes. In the UK Health Check study, general check ups were associated with higher odds of newly diagnosed diabetes, hypertension, and stage 3 to stage 5 chronic kidney disease (5). Additionally, 11.5% of NHS Health Check attendees received a new statin prescription vs 8.2% of patients who did not attend an NHS Health Check.
Others
In 7 of the clinical trials and 4 observational studies, there were improvements in measures including blood pressure, cholesterol, and cardiovascular risk scores. For example, in the UK Family Heart Study (n = 12 924),women and men randomised to receive a general health check at baseline with follow-up every 2 – 6 months, compared with those who did not have a general health check, had reduced systolic blood pressure and diastolic blood pressure after 1 year (6).
In the Minnesota Heart Health Project (n = 906), rural adults aged 25 to 74 years randomised to receive a single general health check visit that included multimodal screening and education, compared with adults randomised to receive no health checks, had small but statistically significant reductions in mean diastolic blood pressure (1.3 mm Hg) and total cholesterol (0.12 mmol/L) after 1 year (7).
General health checks may be associated with limited decreases in weight in some of the studies. In 4 randomised trials and 5 observational studies, all of which were conducted in North America, general health checks were consistently associated with higher uptake of clinical preventive services like colorectal, breast cancer, depression and fall risk screening. There was higher uptake of tobacco cessation intervention and pneumococcal vaccination but not influenza vaccination. However, there were variation in persistence of those preventative activities once the check up ended.
Across 9 randomised trials and 2 observational studies some studies demonstrated an association between general health checks and modest improvements in health behaviours such as exercise and diet.
Patient outcomes
Amongst the 6 randomised trials and 1 observational study that evaluated patient-reported outcome measures, 5 trials reported positive patient reported outcomes like reduction in health worry, quality of well-being, quality of life, and self-rated health. In 2 European trials, there were reports of reduced anxiety among men.
Were there any harm with these check ups?
Surely, there is no harm in conducting these check ups whether there were benefits or not, right? Well, Four randomised trials demonstrated potential adverse effects of general health checks. In the A Healthy Future trial, which examined a preventive services benefit package for Medicare beneficiaries, participants in the intervention group 75 years or older, compared with those 75 years or older who received usual care, had increased mortality over 2 years and 4 years. A follow-up analysis attributed this finding to increased completion of advance directives and decreased receipt of unwanted life-sustaining treatment in the intervention group.
In the Inter99 study—a population-based ischemic heart disease prevention trial in Denmark (n = 59 616), women in the intervention group who lived in an area with high health check participation had 32% higher all-cause mortality risk than control participants which was driven by higher risks of lifestyle-related mortality and cancer-related mortality. Study investigators hypothesized in a post hoc analysis the potential for high use of nutritional supplements that could have increased smoking-related cancers.
In the DanMONICA trial, patients in the intervention group who were invited to as many as 3 health checks between 1982 and 1994, compared with those who were not invited to screening, had 14% higher stroke incidence over 30-year follow-up. The authors hypothesized that the increase in stroke could be due to overdiagnosis, overtreatment, injury from testing, distress from test results, or false reassurance.
What does all these mean in primary care?
Are annual general check ups beneficial? This review suggests that general check ups were not associated with improvements in mortality or cardiovascular disease. They were associated with increases in chronic disease detection, moderate improvements in risk factor control, increased uptake of clinical preventive services, limited changes in some health behaviours, and improvements in patient-reported outcomes.
I guess it depends on what GPs do in Australia. We are already doing opportunistic health checks as patients present with their acute illness or their repeat prescription. There is not that much of a need for an annual check up. The results do highlight the important role of GPs in reinforcing preventative health measures including various health screening programs, vaccinations, healthy lifestyles and risk reductions.
References:
- Liss DT, Uchida T, Wilkes CL, Radakrishnan A, Linder JA. General Health Checks in Adult Primary Care: A Review. JAMA. 2021 Jun 8;325(22):2294-2306. doi: 10.1001/jama.2021.6524.
- The South-East London Screening Study Group. A controlled trial of multiphasic screening in middle-age: results of the South-East London Screening Study. Int J Epidemiol. 977;6(4):357-363. doi:10.1093/ije/6.4.357
- Skaaby T, Jorgensen T, Linneberg A. Effects of invitation to participate in health surveys on the incidence of cardiovascular disease: a randomized general population study. Int J Epidemiol. 2017;46 (2):603-611.
- Kamstrup-Larsen N, Dalton SO, Gronbak M, et al. The effectiveness of general practice-based health checks on health behaviour and incidence on non-communicable diseases in individuals with low socioeconomic position: a randomised controlled trial in Denmark. BMJ Open. 2019;9(9):e029180. doi:10.1136/bmjopen-2019-029180
- Robson J, Dostal I, Madurasinghe V, et al. NHS Health Check comorbidity and management: an observational matched study in primary care. Br J Gen Pract. 2017;67(655):e86-e93. doi:10.3399/bjgp16X68883
- Family Heart Study Group. Randomised controlled trial evaluating cardiovascular screening and intervention in general practice: principal results of British family heart study. BMJ. 1994;308 (6924):313-320. doi:10.1136/bmj.308.6924.313
- Murray DM, Luepker RV, Pirie PL, et al. Systematic risk factor screening and education: a community-wide approach to prevention of coronary heart disease. Prev Med. 1986;15(6):661-672. doi:10.1016/0091-7435(86)90071-X