Most doctors will not be surprised to learn that general health checks are of no benefit for a typical patient. Yet they participate in burdensome accreditation schemes that claim clinical services benefit from a similar approach.
CPA and ISO 15189 may require a lab to be headed by a Fellow of the Royal College of Pathologists. These standards correctly ensure a highly trained leadership but are as false a security against privatisation as they are against mismeasurement. A private company can employ a Fellow. UKAS accredits private labs with minimum wage staff. It plans to “assure” all medical measurements to ISO management standards. Does no-one see where this parallel is leading?
Why don’t all the victims of accreditationism step back and ask whether ISO inspection might be a close analogy to health checks for the individual – normally useless.
Read Medscape’s report below and ponder why similar tests of efficacy – and of cost-effectiveness – have not been applied to the parasitic quality cartel.
News Author: Elizabeth DeVita-Raeburn
CME Author: Hien T. Nghiem, MD
General health checks are commonly emphasized as part of standard healthcare in some countries. The aim of these examinations is to detect disease and risk factors for disease, with the purpose of reducing morbidity and mortality risks. However, most of the commonly used screening tests offered in general health checks have been incompletely studied and are not supported with high-quality randomized studies. Also, screening may lead to increased use of diagnostic and therapeutic interventions, which can be harmful as well as beneficial. Overall, it is uncertain whether general health checks do more good than harm.
The aim of this study by Krogsbøll and colleagues was to quantify the benefits and harms of general health checks, with an emphasis on patient-relevant outcomes such as morbidity and mortality.
Study Synopsis and Perspective
Performing general health checks and screening asymptomatic adults for diseases or their risk factors did not reduce either overall morbidity or mortality, according to a review published online October 17 in the Cochrane Database of Systematic Reviews.
The large number of participants and deaths in the studies, the long follow-up, and the absence of a reduction in cardiovascular and cancer mortality suggest that general health checks are unlikely to be beneficial, conclude Lasse T. Krogsbøll, MD, and colleagues, all from the Nordic Cochrane Centre in Denmark.
The review included data from 16 randomized studies from primary care or community settings comparing health checks or no health checks in adults “unselected” for disease or risk factors.
Fourteen studies (182,880 participants) had outcome data available for analysis. Nine trials provided data on total mortality (155,899 participants, 11,940 deaths). In those trials, the median follow-up time was 9 years, the authors note, which yielded a risk ratio of 0.99 (95% confidence interval [CI], 0.95 – 1.03) for the health check group compared with the non–health check group.
Eight trials provided data on cardiovascular mortality (152,435 participants, 4567 deaths; risk ratio, 1.03; 95% CI, 0.91 – 1.17), and 8 trials on cancer mortality (139,290 participants, 3663 deaths; risk ratio, 1.01; 95% CI, 0.92 – 1.12).
One trial revealed an increase in the diagnosis of hypertension and hypercholesterolemia with health checks. Another found an increase in self-reported chronic disease. Two of 4 trials found more people taking antihypertensive medication with health checks, and another found a 20% increase in the total number of new diagnoses per participant over the course of 6 years compared with the non–health check group.
Benefits Smaller, Harms Greater
In addition to the lack of clear benefit, general health checks potentially cause harm, the authors write. “[E]xperience from screening programmes for individual diseases have shown that the benefits may be smaller than expected and the harms greater,” they note.
Among the harms they cite are the diagnosis of conditions that were never destined to cause symptoms or death and the risk for unnecessary treatment. “While we cannot be certain that screening leads to benefit, all medical interventions can lead to harm,” the authors note. The study, however, did not document harm.
The researchers “make an excellent point that a well person can go in for a general check-up and have screening done that can lead to a cascade of events that can lead to more harm than good,” said Glen Stream, MD, MBI, chair of the board of directors at the American Academy of Family Physicians.
However, “some of the methodology in the studies they reviewed were not all that strong,” Dr. Stream told Medscape Medical News. He also noted, among other issues, the lack of specific data on harm caused by general health checks. “It makes you wonder if there’s [just not] good information out there,” he said.
The authors defined general health checks as screens of the general population for more than 1 disease or risk factor in more than 1 organ system. Screening methods varied considerably from study to study, including questionnaires, physical examinations, blood assays, imaging, stool testing, and the assessment of cardiovascular risk factors.
Studies that enrolled people older than 65 years were excluded. Subgroup and sensitivity analyses did not change the findings, the authors said. The results, they add, are consistent with earlier reviews.
Health Checks a Recent Phenomenon
Health checks of healthy people are a recent phenomenon, the authors noted. The evolution of medicine and new diagnostic methods in the latter half of the twentieth century, they write, has “increased expectations that many diseases can be prevented or discovered before there is irreversible damage.” However, studies such as this one suggest that these expectations may not be met, they add.
The authors of the study acknowledged other problems in most of the trials, citing lack of blinding and missing outcome data as the 2 most common issues. “[D]etection bias, biased reporting of subjective outcomes, and biased drop-out were major concerns in many of the trials,” they add.
Despite this, the authors of the study were emphatic about the overall significance of their findings. “Public healthcare initiatives to systematically offer general health checks should be resisted, and private suppliers of the intervention do so without the support from the best available evidence,” they conclude.
Dr. Stream does not agree. “They made a stronger conclusion than the evidence presented in their discussion section would support, because they didn’t demonstrate harm,” he said.
From his point of view, he said, the study raises as many questions as answers. Are doctors merely measuring the wrong things? Is there a hidden benefit in establishing a doctor-patient rapport that benefits care when problems do arise? “It’s a call-out to the research community,” he said.
Part of the salary for Dr. Krogsbøll was supplied by Trygfonden. The other authors and commentator have disclosed no relevant financial relationships.
Cochrane Database Syst Rev. Published online October 17, 2012. Abstract
- The researchers performed a literature search in the Cochrane Library, the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Effective Practice and Organization of Care (EPOC) Trials Register, MEDLINE, EMBASE, Healthstar, CINAHL, ClinicalTrials.gov, and WHO International Clinical Trials Registry Platform (ICTRP) to July 2012.
- Randomized trials comparing health checks vs no health checks in adults unselected for disease or risk factors were included.
- Geriatric trials with people 65 years or older were excluded. Also, studies in a population or people with specific known risk factors or diseases were excluded.
- Health checks were defined as screening general populations for more than 1 disease or risk factor in more than 1 organ system.
- The primary outcomes were all-cause and disease-specific mortality.
- 2 authors independently extracted data and assessed the risk for bias in the trials.
- Authors of trials were contacted for additional outcomes or trial details when necessary.
- For mortality outcomes, the results were analyzed with random-effects model meta-analysis. For other outcomes, a qualitative synthesis was performed.
- Overall, 16 trials were included — 14 of which had available outcome data for 182,880 participants.
- 9 trials provided data on total mortality (155,899 participants, 11,940 deaths), with a median follow-up time of 9 years, giving a risk ratio of 0.99 (95% CI, 0.95 – 1.03).
- 8 trials provided data on cardiovascular mortality (152,435 participants, 4567 deaths), with a risk ratio of 1.03 (95% CI, 0.91 – 1.17).
- 8 trials on provided data on cancer mortality (139,290 participants, 3663 deaths), with a risk ratio of 1.01 (95% CI, 0.92 – 1.12).
- Overall, results from this study did not find an effect of general health checks on total or cause-specific mortality.
- Additionally, results did not find an effect on clinical events or other measures of morbidity. However, 1 trial found an increased occurrence of hypertension and hypercholesterolemia with screening, and another trial found an increased occurrence of self-reported chronic disease.
- 1 trial found a 20% increase in the total number of new diagnoses per participant during 6 years vs the control group.
- No trials compared the total number of drug prescriptions, but 2 of 4 trials found an increased number of people using antihypertensive drugs.
- 2 of 4 trials found small beneficial effects on self-reported health, but this finding could be the result of reporting bias because the trials were not blinded.
- There were no effects on admission to the hospital, disability, worry, additional visits to the clinician, or absence from work, but most of these outcomes were poorly studied.
- No useful results on the number of referrals to specialists, the number of follow-up tests after positive screening results, or the amount of surgery were found.
- The aim of the general health examination is to detect disease and risk factors for disease, with the purpose of reducing morbidity and mortality risks.
- Overall, general health checks were not found to reduce total or cause-specific morbidity or mortality risks.