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A call for health checks to help those in need, rather than the “worried well”

Amid growing international debate about the value of routine health checks in primary care, health policy analyst Dr Lesley Russell suggests there is a need to ensure high-risk populations benefit.

Lesley Russell writes:

Over the past five years I have written on a number of occasions about the lack of evidence to support the cost-effectiveness or benefits of health assessments. For example:

2008: Geriatric health assessments are a waste of health money.

2010: Rethinking Indigenous health checks.

2011: Healthy Kids’ Checks are not working.

2013: Health assessments for Indigenous people and follow-up services are low in relation to population numbers and the known prevalence of chronic disease.

So my eye was caught by a recent paper in the British Medical Journal titled “Where’s the evidence for NHS health checks?” As indicated by the title, this paper is skeptical about the evidence supporting this program.

Originally promised by Prime Minister Gordon Brown in 2008, the NHS program, which offers health checks to all 40-74 year olds every five years, was not fully implemented until 2012-13.  Data show that 1.3 million of the 15 million people aged between 40 and 74 were given a check over the past year. The program costs £300 million annually.

An economic model on which the policy was based suggested that the program could prevent 1,600 heart attacks and strokes, over 4,000 new cases of diabetes and at least 650 premature deaths each year.  However, this modelling is not backed with evidence and has thus led to discussions like that in the BMJ paper.

Researchers from the Nordic Cochrane Centre say the Health Check program “operates in direct conflict with the best available evidence” and is likely to lead to patients taking drugs they do not need. Public Health England has conceded that there is no direct evidence the health checks worked, but argues that the “precautionary principle” justifies efforts to check for risk factors for disease.

Some researchers have publicly warned that busy family doctors are wasting time on the “worried well” instead of treating people who are actually sick.  The Chair of the Royal College of GPs has called for an end to routine checks, saying they “devalued medicine”.

The issues are complicated but deserving of due consideration. General and preventive health checks have become a key feature of primary care in Australia, at significant cost to the health budget, and thus warrant an effort to assess their effectiveness and whether they could be better targeted.

Last year, health assessments for Australians cost Medicare $270 million. My analysis of Medicare data for MBS items 701, 703, 705, 707, 715, and 10986 shows that in 2012, 821,828 services were provided at a cost of $148.7 million, up from 672,798 services at a cost of $120.2 million in 2011.

These figures show that many eligible people are missing out; what we don’t know is if these are the people most at risk, for whom a health check could be valuable.  Most of the longer consultations are for those aged 75 and over; children aged 0-4 years are most likely to get the shortest consultation or an assessment from a Practice Nurse or an Aboriginal Health Worker; and the health checks for people aged 45-54 years, which should be looking for potential problems such as diabetes and cardiovascular risk factors, are also short.

In the absence of linked data it is not possible to know how, or even if, problems revealed in health checks are addressed.

Australian researchers have spoken about the value of these health checks.  Professor Paul Glasziou, from Bond University’s Centre for Research in Evidence-Based Practice, says periodic general health checks are not only ineffective but may prove harmful in terms of false positives and over-diagnosis.  There is also evidence that there is an inequitable uptake of routine health checks and that those with higher clinical needs or risk factors are least likely to get them.

Professor Mark Harris, a member of the RACGP’s National Standing Committee on Quality Care, says the college’s view is that health checks should be targeted to high-risk population groups and result in evidence-based interventions.

The veracity of that statement is borne out by work at the Inala Indigenous Health Service. Researchers found  that adult health checks for Indigenous people were a viable tool for detecting chronic disease risk factors, uncovering important new diagnoses and prompting preventive health interventions. These include smoking cessation advice, identification of depression and suicidal ideation, identification of diabetes, and vaccination.

The weight of evidence, from both Australia and overseas, is that unless real efforts are made to both target health checks appropriately and ensure that problems discovered in health checks are addressed effectively, they are useless.  Worse, they waste valuable resources and time and can contribute to inequalities via the inverse care law.

However, as the Inala results show, simply abandoning health checks is not the correct response.

What is needed is appropriate service redesign, including outreach to high-risk populations and incentives to ensure that there are follow-ups and evidence-based interventions as needed.

Importantly, the focus for policy makers and clinicians must turn from measures of the volume of health checks conducted to the value of improved health outcomes that result from these checks.

• Dr Lesley Russell is Senior Research Fellow, Australian Primary Health Care Research Institute, Australian National University

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