General health checks don’t workBMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g3680 (Published 09 June 2014) Cite this as: BMJ 2014;348:g3680
All rapid responses
Peter Gøtzsche et al argue that it is time to let general health checks go, they don’t work (1). This statement is based on their Cochrane review (2) and the recent Inter99 publication (3), which found no effect of systematic screening for risk factors for ischemic heart disease and life style counseling. We would, however, like to challenge their conclusion. The Cochrane review was primarily based on old trials (seven of nine studies were from before 1975) and consequently tested outdated screening tests and treatments (4). A more recent meta-analysis of general practice-based health checks demonstrated statistically significant, but clinically small, improvements in surrogate outcomes, especially among high-risk patients (5). Most studies in general practice, including those in the Cochrane review were not originally designed to assess mortality (5). The Inter99 study (3) (which prompted the editorial by Gøtzsche et al (2)) was a population based intervention study. It was based on lifestyle counselling only and did not include pharmacological intervention. The participation rate in the intervention group (N=11.629) was 52.4%. A total of 3552 at high risk were offered group based counselling of which only 38.6% participated.
In contrast to the above mentioned studies, modelling studies indicate that screening for diabetes (6;7) and cardiovascular risk is cost-effective (8). The Anglo-Danish-Dutch study of intensive treatment of people with screen detected diabetes in primary care found a 17% non-significant reduction in first cardiovascular event comparing intensive treatment with routine care (9). The lack of a significant difference may be due to a high treatment quality in the routine care group, i.e. a significant fall in systolic and diastolic blood pressure, total cholesterol, body weight, and absolute reduction in percent of smokers from base line to 5 years (-11,7/-4,8mmHg, -1,2mmol/l, -1,9 kg, -9,4%)) (9;10). A post hoc analysis among people with screen detected diabetes in Denmark (11) demonstrated, that those considered with highest cardiovascular risk at screening, due to HbA1c≥48 mmol/mol at screening, had a seven year all-cause mortality rate that was not significantly different from people with normal glucose tolerance at screening. People with screen detected diabetes considered with low risk of cardiovascular disease at screening, due to HbA1c less than 42mmol/mol at screening, had all-cause mortality twice as high. Those considered with high cardiovascular risk were more intensively treated with lipid-, blood pressure- and glucose-lowering drugs than people considered at lower risk. The most likely explanation for this paradox is that general practitioners may have been falsely reassured by low HbA1c values and thus did not offer full preventive interventions targeting risk factors for cardiovascular disease (11).
In contrast to the editorial by Gøtzsche et al (3) we find that screening in general practice for diabetes and cardiovascular risk followed by lifestyle intervention and preventive drug treatment may still work. Future studies will clarify this, but may well guide us how to improve screening strategies and treatment intensity and on how to maximize attendance rates and compliance in those with highest risk. Meanwhile general practitioners should still offer opportunistic screening for people at high risk diabetes and cardiovascular risk (3;10).
Torsten Lauritzen1, Annelli Sandbaek1, Knut Borch-Johnsen2
1 Department of Public Health, Section of General Practice, University of Aarhus, Aarhus, Denmark, 2 Holbæk Hospital, Holbæk, Denmark
(1) Gotzsche PC, Jorgensen KJ, Krogsboll LT. General health checks don't work. BMJ 2014;348:g3680.
(2) Krogsboll LT, Jorgensen KJ, Gronhoj LC, Gotzsche PC. General health checks in adults for reducing morbidity and mortality from disease: Cochrane systematic review and meta-analysis. BMJ 2012;345:e7191.
(3) Jorgensen T, Jacobsen RK, Toft U, Aadahl M, Glumer C, Pisinger C. Effect of screening and lifestyle counselling on incidence of ischaemic heart disease in general population: Inter99 randomised trial. BMJ 2014;348:g3617.
(4) Sox HC. The health checkup: Was it ever effective? could it be effective? JAMA 2013 Jun 19;309(23):2496-7.
(5) Si S, Moss JR, Sullivan TR, Newton SS, Stocks NP. Effectiveness of general practice-based health checks: a systematic review and meta-analysis. British Journal of General Practice 2014 Jan 1;64(618):e47-e53.
(6) Kahn R, Alperin P, Eddy D, Borch-Johnsen K, Buse J, Feigelman J, et al. Age at initiation and frequency of screening to detect type 2 diabetes: a cost-effectiveness analysis. The Lancet 2010 Apr 17;375(9723):1365-74.
(7) Clare LG, Paul CL, Keith RA, Alex JS, Nicola JC, Ron TH, et al. Different strategies for screening and prevention of type 2 diabetes in adults: cost effectiveness analysis. BMJ 2008 May 22;336.
(8) Schuetz CA, Alperin P, Guda S, van HA, Cariou B, Eddy D, et al. A standardized vascular disease health check in europe: a cost-effectiveness analysis. PLoS One 2013;8(7):e66454.
(9) Griffin SJ, Borch-Johnsen K, Davies MJ, Khunti K, Rutten GE, Sandbaek A, et al. Effect of early intensive multifactorial therapy on 5-year cardiovascular outcomes in individuals with type 2 diabetes detected by screening (ADDITION-Europe): a cluster-randomised trial. Lancet 2011 Jul 9;378(9786):156-67.
(10) Lauritzen T, Borch JK, Davies MJ, Khunti K, Rutten GEHM, Sandbaek A, et al. What do the results of the ADDITION trial mean for clinical practice? Diabetes Management 2013;3(5):367-78.
(11) Lauritzen T, Sandbaek A, Carlsen AH, Borch-Johnsen K. All-cause mortality and pharmacological treatment intensity following a high risk screening program for diabetes. A 6.6 year follow-up of the ADDITION study, Denmark. Prim Care Diabetes 2012 Oct;6(3):193-200.
Competing interests: Shares in Novo Nordisk.
Gotzsche's interpretation of the Inter99 results mixes two statements: "Doctors should not offer general health checks to their patients, and governments should abstain from introducing health check programmes…"
The second statement may be true, if participation rates in check-up-programmes stay as low as they were in Inter99. But the first statement has no evidence base.
In the health check-ups, which my Prevention First Clinics offer for employees of large companies (average age of 46 years), we see that >30% of the male patients and >20% of female patients fulfill the IDF 2010-criteria for the Metabolic Syndrome, 35% are unfit (VO2 max below 25th percentile for age), and more than 40% of male and 20% of female patients have undiagnosed hypertension. (1)
In the “Fit in life – fit on the job” programme that we are organizing together with the department of occupational medicine of Boehringer Ingelheim, the participation rate in the first round was remarkably high with >93%, which is nearly the double of Inter99. We have shown in both our programmes with Boehringer Ingelheim (2) and Deutsche Bank employees (unpublished data), that by a tailored lifestyle intervention (individual exercise prescription and low-carb-mediterranean diet) >80% of the expected cases of Type 2 Diabetes can be prevented, that fitness improves significantly in those who came unfit to the first check-up, and that we get a good hypertension control rate of around 50% after a mean follow-up of 3,5 years (German average 36% according to EURIKA study (3)). These results are valuable for our patients, and if sustained will lead to a 20-25% reduction in CVD morbidity and mortality (calculated on the basis of the Reynolds´ Risk Formulae for men and women published by Paul Ridker 2007/2008).
Of course, at Prevention First we do not have a control group (how could we?), and yes - we do have a selection bias of motivated and well educated patients. But why shouldn´t doctors give the best available information about CVD and diabetes prevention to motivated patients? What is the argument against this concept, if it has been shown to produce good results? Most of those younger employees at high risk for CVD or diabetes never would have consulted their GP and many problems thus would have remained undetected. Prevention therefore should be addressed in the workplace setting.
Inter 99, too, reported significant improvements in the risk factor profile of those, who participated in the lifestyle counseling. I wonder why there was no mortality follow-up or any other outcome reported for this subgroup.
We recently have learnt from the PREDIMED study, that dietary changes can reduce CVD mortality and diabetes incidence. (4,5) In my opinion the question is not, if lifestyle counseling does work (if the content of the counseling is evidence-based, practicable and understandable for the patient), but how we can reach and motivate those at high risk. If people do not participate, then obviously public health programmes cannot work.
Prevention of CVD is necessary and it can be very effective. On the individual level it is successful in those, who are motivated. The question remains, how to motivate those, who are not aware that they should take care for their own health.
On the population level we must therefore implement changes in many different areas to give "nudges" (like banning trans-fatty acids, taxing SSBs and high-carb foods, making fruits and vegetables cheaper, and building more cycling roads and thus facilitate physical activity). Changing the environment into a preventive direction may be more valuable in prevention CVD than screening initiatives.
I could agree, that on a population level health check-ups may not be the solution for the CVD epidemic, but I am absolutely convinced that good health check-ups make sense for those, who want to learn about their risk profile and lifestyle options to stay healthy. It is our obligation as doctors to give them the best available information!
Dr. med. Johannes Scholl
President of the German Academy for Preventive Medicine (www.akaprev.de)
(1) Schneider M, Scholl J. Analysis of the current health status of middle-aged persons. Arbeitsmed.Sozialmed.Umweltmed. 42, 596-604. 2007.
2) Scholl J., Schneider M., Lifestyle modification and risk factor management for cardiovascular prevention in a workplace setting: The FIT IN LIFE – FIT ON THE JOB Study; European Heart Journal (2012) 33 (Abstract Supplement) 953
3) Banegas JR et al. Achievement of treatment goals for primary prevention of cardiovascular disease in clinical practice across Europe: the EURIKA study. Eur Heart J 2011; 32(17):2143-2152.
4) Salas-Salvado J, Bullo M, Estruch R et al. Prevention of diabetes with Mediterranean diets: a subgroup analysis of a randomized trial. Ann Intern Med 2014; 160(1):1-10.
5) Estruch R et al.,(1) Primary Prevention of Cardiovascular Disease with a Mediterranean Diet. New England Journal of Medicine 2013. doi: 10.1056/NEJMoa1200303
Competing interests: I am working as a specialist in Preventive Medicine, so this might be my conflict of interest.
This is a very interesting discussion. It should be noted, however, that there is recent, rigorous evidence supporting population-based screening and awareness around CVD. The CHAP cluster community RCT published in BMJ in 2013(1) showed that after adjustment for hospital admission rates in the year before the intervention, CHAP was associated with a 9% relative reduction in the composite end point (rate ratio 0.91, 95% confidence interval 0.86 to 0.97; P=0.002) or 3.02 fewer annual hospital admissions for cardiovascular disease per 1000 people aged 65 and over.
Janusz Kaczorowki PhD
1. Kaczorowski J, Chambers LW, Dolovich L, Paterson JM, Karwalajtys T, Gierman T, Farrell B, McDonough B, Thabane L, Tu K, Zagorski B, Goeree R, Levitt CA, Hogg W, Laryea S, Carter MA, Cross D, Sebaldt RJ. Improving cardiovascular health at the population level: A 39 community cluster-randomized trial of the Cardiovascular Health Awareness Program (CHAP). BMJ 2011;342:d442 doi:10.1136/bmj.d442
Competing interests: No competing interests
How valuable is health screening in primary prevention of cardiovascular disease (CVD)? Many question whether or not widespread health checks are of value. This perspective aims to demonstrate the opportunities afforded by mass population screening.
If we look at the magnitude of the global problem of CVD and its cost at personal, national and international levels, we can better assess the benefits which CVD reduction could potentially achieve.
Annually globally 17 million people die from CVD. 1
Every year 20 million people survive heart attacks and strokes and many require costly clinical care. 2
In 2005 the EU lost the equivalent of £ 75 billion based on lost years of healthy life (DALYs), due to CVD 3
Most of these deaths are potentially avoidable, by targeting risk factors such as smoking, alcohol, unhealthy diet & obesity, physical inactivity, hypertension, diabetes, raised lipids and stress.
Two complementary strategies are usually advocated for primary prevention .
The Population based approach aims to reduce the burden of disease in the whole community while conferring small benefits to each individual. Community- wide interventions, requiring legislation, such as smoke free areas and restrictions on advertising & sale of alcohol & tobacco, seek to modify behaviours and reduce risk factors in the population. Even modest changes in risk factors will contribute to a substantial reduction in the cumulative population risk of CVD because of the large number of people affected. There are small benefits to each individual.
Population based approach is cost effective and has been shown to reduce risk of developing CVD.
The high risk approach, however, depends mainly on health professionals in their direct work with individual patients. It seeks to identify the individuals who are at high risk because of marked elevation of single or multiple risk factors. Targeted behavioral or pharmacological interventions will be needed in these cases. Health screening including Cardiovascular risk assessment highlights those individuals who should be targeted. This provides the greatest risk reduction in individuals.
In practice both approaches should be introduced to achieve maximal results.
Population strategy contributes a 30-40% reduction in CVD mortality. High risk strategy contributes 20-30%.
Cardiovascular risk assessment aims To reduce the incidence of CVD in the community. To identify those individuals at risk. To improve the quality of life. To improve life expectancy. To reduce the economic impact of CVD.
Mass population Health screening has potential benefits, limitations in particular false negatives & false positives and possible dangers, such as over-diagnosis, over-treatment & psychological distress.
Performing health screening may reveal actual or potential problems but in the absence of subsequent measures to treat or reduce the risk of developing ailments no beneficial effect on morbidity or mortality will be shown.4
The value, or lack of value, of health screening can only be assessed if studies include details of measures taken to treat or prevent problems highlighted by the screening.
Wilson & Junger's criteria must be applied. 5 Knowledge of the disease, namely does it have a recognisable latent period. Knowledge of the test, it terms of specificity, sensitivity and acceptability to the population. Treatment for the disease must be available. Cost effectiveness.
Discussion continues regarding the cost-effectiveness of preventive measures. 6
Some measures may only benefit a very small proportion of the population and can be more expensive than treating the developed condition. However, there is general agreement that targeting those at high risk increases the cost-effectiveness. Certain measures, in particular tobacco and alcohol screening & counselling, reduction of hypertension by dietary salt restriction, weight loss and exercise , daily low dose aspirin in secondary CVD prevention, cholesterol screening & statin use are generally recognised to be cost-effective.
Any intervention that achieved even a modest population-wide reduction in any major cardiovascular risk factor would produce a net cost saving to the NHS, as well as improving health.
A programme which reduced cardiovascular events by just 1% would result in savings to the health service worth at least £30m a year.
Reducing cholesterol concentrations or blood pressure levels in the population by 5% would result in annual savings worth at least £80m to £100m. Measures to reduce dietary salt intake by 3 g/day would prevent approximately 30,000 cardiovascular events, and save at least £40m a year. Reducing intake of industrial trans fatty acid by approximately 0.5% of total energy content might gain around 570,000 life years and generate NHS savings of £230million a year.
The American Heart Association states that policy, community and pharmacological interventions are likely to be cost-effective and cost-saving. They propose future preventive research should include clarifying the additive benefits of lifestyle modification and clarifying potential benefits, harms & costs of early interventions such as prophylactic statin usage. 7
The long time frames involved in evaluating preventive interventions make cost-effectiveness analysis difficult. High direct medical care and indirect cost of CVD make this a critical medical & societal issue.
Evidence from developed and developing countries has shown that individuals with increased risk of CVD can reduce their risk of cardiovascular morbidity and mortality by modifying their lifestyle.
In the United States the Framingham project has convincingly demonstrated the importance of life-style risk factors, in the development of CVD. 9
Studies in North Karelia in Finland have demonstrated the dramatic beneficial effects of modifying diet and smoking habits and controlling blood pressure. 10
Cochrane studies in 2013 11 have shown the benefits from prophylactic statin usage in at risk individuals.
Early detection of risk factors can lead to lower disease rates, reduced employer health costs, reduced absenteeism, enhanced job satisfaction and increased productivity.
However studies, such as detailed in the Cochrane review 2012 12 concluded that health checks reduce neither morbidity nor mortality from preventable diseases.
Every five years potentially 15 million individuals will be offered NHS health checks . At present only about half of those offered screening take it up.
Screening on this scale presents a long-awaited opportunity to assess the benefits of lifestyle modification.
2. J Am Coll Cardiol 2008; 52 (23) 1817-1825
3. Leal Economic Burden of CVD in the enlarged European Union European Heart 2006
4. European Guideline on CVD Prevention in Clinical Practice (version 2012) European Heart Journal 2012 33, 1635-1701
5. Wilson J Principles & Practice of screening for disease WHO 1968
6. Barton Effectiveness & cost effectiveness of CVD prevention in whole population: modelling study BMJ 2011;343:d4044
7. AHA Forecasting the Future of CVD in the United States Circulation 2011; 123: 933-944
8. Graham I, Atar D, Borch-Johnsen K, et al. European guidelines on cardiovascular disease prevention in clinical practice: executive summary. Fourth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (Constituted by representatives of nine societies and by invited experts). Eur Heart J 2007;28:2375–414
9. Framingham Heart Study National Heart Lung & Blood Institute 2013
10. Pekka Puska The North Karelia Project: 30 years successfully preventing chronic diseases 2008
11. Statins for the Primary Prevention of CVD Cochrane review 2013
12. General health checks in adults for reducing morbidity and mortality from disease Cochrane review 2012
Competing interests: No competing interests
I read with interest the recent editorial entitled " General Health Checks don't work - It's time to let them go" (1).
In this editorial it was also mentioned that in clinical practice, we should use only interventions that work and current programmes, like the free NHS Health Check in the United Kingdom, should be abandoned (1).
At present, cardiovascular disease is the leading cause of death in the US and accounts for 17% of overall healthcare expenditures. In the past, the medical costs of cardiovascular disease increased at an average annual rate of 6%, and this growth in costs has been associated with an increase in life expectancy. That said, there are "many opportunities to further improve cardiovascular health while controlling costs," according to the AHA.
By 2030, the prevalence of cardiovascular disease is expected to increase 9.9%, with the prevalence of heart failure and stroke increasing approximately 25%. Total direct costs will increase to $818 billion by 2030, according to the AHA estimates, and the total indirect cost to the US in terms of lost productivity is close to $275 billion.
Hypertension has the greatest projected medical cost, in part because of the aging population, although the increase in prevalence and cost is not explained fully by age. Rising obesity rates are also contributing to the increasing rates of hypertension. The AHA notes that the downstream medical costs of high blood pressure--including its impact on cardiovascular disease and stroke--approximately double the cost of hypertension, making it a "particularly valuable target to modify the future total costs of cardiovascular disease."'
Data from the Coronary Artery Risk Development in Young Adults (CARDIA) study suggest that cardiovascular disease prevention should begin earlier in life. In CARDIA, risk-factor levels in individuals younger than 30 years old were predictive of subclinical atherosclerosis 15 years later. The data, they write, also show that modest improvements in risk factors earlier in life have a larger impact than more substantial reductions later in life.
Of 58 million deaths globally, 60% were attributed to chronic diseases in 2004. Deaths from chronic diseases are projected to increase dramatically between now and 2030.
Considering all risk factors trends together, the forecast for cardiovascular disease burden in low-income and middle income countries over the next few decades comprises a population emergency that will cost tens of millions of preventable deaths, unless rapid actions are taken by governments and health care systems worldwide. In the long term, the most effective strategic approach is through a population level risk factors control.
However, a recent analysis of 23 low income and middle income countries indicated that the capacity of these countries to effectively deal with existing and projected burden of non communicable disease is limited. The decision by the United General Assembly to convene a “high level meeting on the prevention and control of non-communicable disease worldwide” in September 2011 provided a unique opportunity to elevate chronic diseases to the global political agenda.
More evidence-based effective policy should be applied in the prevention, early detection, and management of cardiovascular disease risk factors. Through a combination of improved prevention of risk factors and treatment of established risk factors, the dire projection of the health and economic impact of cardiovascular disease can be diminished.
The UK National Screening Committee recommends that NHS professionals should offer screening only if there is evidence that, overall, the benefits of screening outweigh the potential harms. Thus, screening should not be offered in the absence of known evidence. On the other hand, doing nothing is going to cost the world $ 47 trillion in the next 25 years, including $ 500 billion a year in low- and middle income countries, where 80% of deaths from CVD now occur (2).
In conclusion, the UK National Screening Committee agrees that there are a number of accepted principles of screening that the NHS professionals should adhere to: only offer screening if there is a proven evidence that, overall, the benefits of screening outweigh the potential arms. This means that screening and preventative programmes should not be offered in the absence of known evidence provided by international scientific guidelines published by international scientific medical societies.
1. Heidenreich PA, Trogdon JG, Khavjou MA et al on behalf of the American Heart Association. Forecasting the future of cardiovascular disease in the United States- A policy statement from the American Heart Association. Circulation 2011; 123(8):933-44
2. De Lorenzo F. Evidence-based screening to prevent and control cardiovascular disease worldwide. Int J Pract 2014; 68 (5): 533-535
Competing interests: No competing interests
The Inter99 trial1 is an important study and deserves careful analysis. It would be a shame if the debate about its implications was limited to the points raised in your editorial.2 We also agree with Jorn Olsen that the stark message of the editorial’s title is not supported by its arguments. The NHS Health Check Expert Scientific and Clinical Advisory Panel (ESCAP) has carefully reviewed the Inter99 trial and its implications3 for the NHS Health Check programme. We highlight below some of our conclusions.
The study sets out to measure a population level impact from screening for cardiovascular risk and uses an intention to treat analysis. While this is methodologically strong it is also very demanding both as a research objective and a public health one. The relatively few participants receiving the intervention frequently achieved positive lifestyle changes and, therefore, many of them are likely to have benefited or will benefit in future years. However, the level of that benefit may be insufficient after ten years to be detectable at population level. Given the known efficacy of the interventions at individual level it is probably only decades later when substantial benefits would be expected.4
The intervention and the population in Inter99 are inevitably not directly comparable with those of the NHS Health Check programme. There is an important difference in the age profile (30- 60 years) of the Danish study population compared with the English programme (40-74 years). The underlying cardiovascular disease risk distribution in the Danish study may also be substantially less than that reported in England. Primary care management of detected diabetes, renal disease or hypertension is an important component of the NHS Health Check programme. These components were not directly included in Inter99 as part of the study intervention although some patients in the intervention group may have been referred for treatment. In general, the NHS Health Check is intended to be part of a wider range of interventions to promote earlier risk assessment and management Some occur at an individual level, some at community level whereas Inter99 focussed on individual lifestyle interventions.
Despite these differences there are clearly some important lessons from Inter99 for any population based programme intended to reduce cardiovascular risk. Most important is the need to reassess whether in addition to awareness raising, risk assessment and management, a population level objective is a feasible one. Relevant modelling suggests that redirecting such programmes more firmly towards higher risk individuals would increase cost-effectiveness.5 While the current NHS Health Check programme is offered to all individuals, it would be possible and permissible to direct and target in this way. It also reinforces the message that public health authorities should design integrated strategies to reduce risk in populations that are tailored to the nature of those populations, their risk profile and the local context. Finally, the article makes the point that even well-intentioned interventions can be harmful and these harms must be considered and minimised where possible. Individual interventions such as drug treatments for diabetes and hypertension need to have demonstrably positive risk-benefit profiles.
We disagree with the authors that opportunistic screening in primary care is a reason that systematic approaches such as health checks show no benefit and are not required. If all general practitioners were to undertake systematic “anticipatory care” as described by Julian Tudor Hart in his classic study,6 then this might be true, but they do not. Without such a systematic process, the extent to which primary care is likely to detect existing disease may even be inversely proportional to the level of ill health in the population, making health inequalities greater (personal communication Prof C. Bentley). The authors also state that responders to invitations to a health check are likely to be the worried well and from higher socio-economic groups. Evidence emerging from the NHS Health Check programme suggests that this is not inevitable7 and that high levels of undiagnosed treatable illness are being detected by the programme.7,8 We recently held a research and evaluation symposium on the NHS Health Check programme. This highlighted the opportunity for further studies and we will be publishing a research and evidence strategy for the programme in the coming months.
In summary, the Inter99 trial is indeed reason to reflect on the value and design of population-based health check programmes. It illustrates many of the problems that are associated with attempting to achieve large-scale change in health outcomes by extrapolating from an incomplete evidence base. This is a common problem in public health and one that requires careful thought and mature debate.
1 Jørgensen,K.J, Jacobsen,R.K., Toft,U., Aadahl,M., Glümer,C., Pisinger,C. Effect of screening and lifestyle counselling on incidence of ischaemic heart disease in general population: Inter99 randomised trial. British Medical Journal. 2014; 348:g3617
2Gøtzsche,P.C, Jørgensen,K.J. and Krogsbøll,L.T (2014) General health checks don’t work. British Medical Journal. 2014; 348:g3680
3 ESCAP (2014) Inter99 trial: a statement from the NHS Health Check Expert Scientific and Clinical Advisory Panel. www.healthcheck.nhs.uk/commissioners_and_healthcare_professionals/progra...
4 Gunning-Schepers,L.J., Barendregt,J.J. and Van der Maas,P.J Population interventions reassessed. The Lancet. 1989; 1(8636) 479-81
5 Schuetz,C.A, Alperin,P., Guda,S., van Herick,A., Cariou,B., Eddy,D., Gumprecht,J., Nicolucci,A., Schwarz, P., Wareham, N.J., Witte, D.R, Smith,U. A standardized vascular disease health check in Europe: A cost-effectiveness analysis. PLoS ONE 2013; 8(7): e66454. doi:10.1371/journal.pone.0066454
6 Hart J,T. Milroy Lecture: the marriage of primary care and epidemiology: continuous anticipatory care of whole populations in a state medical service. Journal of the Royal College of Physicians of London. 1974; 8:299-314.
7 Robson,J. NHS Health Checks in East London: the first three years. 2013; www.healthcheck.nhs.uk/commissioners_and_healthcare_professionals/nation...
8 Khunti K, Morris, D.H, Weston, C.L, Gray, L.J., Webb, D.R, Davies, M.J. Joint Prevalence of Diabetes, Impaired Glucose Regulation, Cardiovascular Disease Risk and Chronic Kidney Disease in South Asians and White Europeans. PLoS ONE 2013; 8(1): e55580. doi:10.1371/journal.pone.0055580
Competing interests: The authors work for Public Health England the agency responsible for supporting the implementation of the NHS Health Check programme. Authors are members of the NHS Health Check Expert Scientific and Clinical Advisory Panel.
Many like catchy titles of their paper, even editors of scientific journals. Sometimes they should resist the temptation.
The Nordic Cochran Centre, known for their strong standpoints on many controversial issues, published an editorial for the BMJ with the title ‘General health checks don´t work’ period. The documentation they provide does not justify this conclusion and it is in general a bad idea to use a conclusion as the title of a paper in a scientific journal. They could perhaps have added ‘on average’ because the truth is that general health checks do work. Sometimes they do well. Sometimes they perform badly but they do work. A health check is not only a ‘neutral’ activity.
Further, using the generic term ‘general health checks’ indicates there is only one such thing but health checks come in many different variants. The research that lies ahead of us to identify those who benefit from well-defined health checks from those who are placebo-like or have no benefits.
Jørn Olsen, M.D., PhD
Professor in Epidemiology at Aarhus University and UCLA
Goetzsche PC, Joergensen KJ, Krogsboell LT. General health checks don´t work. BMJ.2014; 348:g3680.
Competing interests: No competing interests
This paper and editorial highlight ethical issues of crucial importance in medicine.
It is not just the lack of benefit that is the issue.
It is not just the harm suffered by patients who previously thought themselves healthy frightened by their ‘high risk’, who will never think of themselves as healthy again.
It is the waste of resources as governments around the world encourage, and sometimes pay, doctors and nurses to screen healthy patients for cardiovascular risk, producing tonnes of paper with guidelines and recommendations and rainbow coloured risk charts.
It is the harm to health systems in the opportunity costs of time spent in such assessments. Most health systems are struggling with the rise in health care costs. With the pressure on primary care services and strain on providers in the UK and in other developed countries the opportunity costs of spending time on checks with no evidence of benefits and potential for harm creates an issue of distributive justice. Though largely overlooked in the literature summaries than underpinned recommendations around risk assessment, primary care studies of cardiovascular risk screening from years ago have shown the enormous resource requirements as well as the lack of any benefit that might be meaningful to patients. 1-3 These finite resources are then unavailable or available in a less timely way for patients who would benefit from medical care.
Expecting to address the health outcomes of lifestyle issues often tethered to socioeconomic disparity and environmental constraints through individual clinical care has always seemed a futile exercise. Adverse drug events have risen almost by stealth into the list of leading causes of death in most developed countries. Attending to political and social drivers of poor health, creating healthy environments and taking a stand to create a regulatory and clinical environment that provides truthful and transparent information from trials and supports a doctor and a patient in truly assessing the risk benefit balance of medications would likely give a much greater population health gain. The therapeutic imperative in medicine means we're very good at rushing to do things that might 'save lives' but not very good at not doing or undoing. Its time to drink from the Wizard of Oz’s Cup of Courage.
1. Effectiveness of health checks conducted by nurses in primary care: results of the OXCHECK study after one year. Imperial Cancer Research Fund OXCHECK Study Group. British Medical Journal. 29 Jan 1994;308(6924):308-312.
2. [No authors listed]. Randomised controlled trial evaluating cardiovascular screening and intervention in general practice: principal results of British family heart study. Family Heart Study Group. British Medical Journal. 29 Jan 1994;308(6924):313-320.
3. Hippisley-Cox J, Pringle M. General practice workload implications of the national service framework for coronary heart disease: cross sectional survey. British Medical Journal. Aug 4 2001;323(7307):269-270.
Competing interests: No competing interests
Generalized blanket statements based on randomized trials may give an impression about the futility of health check ups. However, it is essential to remember that screening for health in certain special situations or in groups is useful provided there is a back up for intervention or treatment. One such example is routine health check ups for pregnant women where detection of preventable diseases such as iron deficiency anaemia, gestational diabetes, hypertensive disorders of the pregnancy etc. are detected and appropriate treatment can be given. Similarly, routine health check ups among workers in certain occupational groups such as coal miners, sugarcane, cotton factories etc. are important to detect pneumoconiosis, tuberculosis, chronic obstructive airways diseases, bagassosis, byssinosis and other debilitating diseases related to the occupation early and to institute treatment so that they can have a healthy life.
These are a few examples of the usefulness of routine health check ups. Certainly one may argue that detection of diseases in a health check up does not necessary lead to treatment. Ideally, screening programmes should have adequate support mechanisms and referral systems for treatment of the detected condition. If this is not followed, then health check ups are not useful. Screening should also be done in the population where the disease is widely prevalent, have a clear natural history of disease, and appropriate treatment measures. We should follow these principles for screening for meaningful health check ups, lest it is of no use. Unless specified for other purposes such as research, screening should always be followed by treatment.
Competing interests: No competing interests
"People who accept invitations to general health checks tend to have ... lower mortality"
Really? I naively thought that mortality was always 100%.
Competing interests: No competing interests