General health checks may work
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Cochrane review was primarily based on old trials (seven of nine studies were from before 1975) and consequently tested outdated screening tests and treatments (4).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.