Wednesday, October 17, 2012

Fwd: qotd: The Cochrane study of general health checkups

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Subject: qotd: The Cochrane study of general health checkups
Date: Wed, 17 Oct 2012 12:52:06 -0700
From: Don McCanne <>
To: Quote-of-the-Day <>

The Cochrane Library
October 17, 2012
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.

Video of Dr. Welch's response to the Cochrane study:

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.

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