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New study reports lack of benefit from general health checkups

Robin Wulffson MD's picture
health checkup, physical exam, benefit, harm, mortality, morbidity

Many Americans undergo a regular health checkup on a regular basis, even in the absence of health problems. However, a new study questions the benefits of this practice. Researchers affiliated with the Nordic Cochrane Centre in Denmark published their findings online ion October 17 in the Cochrane Database of Systematic Reviews.

The researchers noted that general health checks are common elements of healthcare in some nations. The goal of these examinations is to detect disease and risk factors for disease with the purpose of reducing morbidity and mortality. The authors explain that most of the commonly used screening tests offered in general health checks have been incompletely studied. Furthermore, screening leads to increased use of diagnostic and therapeutic interventions, which can be harmful as well as beneficial. Therefore, they designed a study to assess whether general health checks do more good than harm.

The researchers attempted to quantify the benefits and harms of general health checks with an emphasis on patient-relevant outcomes such as morbidity (harmful effects) and mortality (death) rather than on surrogate outcomes such as blood pressure and serum cholesterol levels. The authors conducted a large review study; they searched The Cochrane Library, the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Effective Practice and Organisation of Care (EPOC) Trials Register, MEDLINE, EMBASE, Healthstar, CINAHL, ClinicalTrials.gov, and WHO International Clinical Trials Registry Platform (ICTRP) up to July 2012. Two authors screened titles and abstracts, assessed papers for eligibility, and reviewed reference lists. One author used citation tracking (Web of Knowledge) and asked researchers about additional studies.

The investigators included randomized trials comparing health checks with no health checks in adults unselected for disease or risk factors. They did not include geriatric trials (studies of seniors). They defined health checks as screening general populations for more than one disease or risk factor in more than one organ system. Two authors independently extracted data and assessed the risk of bias in the trials. They contacted authors for additional outcomes or trial details when necessary. For mortality outcomes, they analyzed the results with a random-effects model meta-analysis; for other outcomes we did a qualitative synthesis because a meta-analysis was not feasible.

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Included in the study were 16 trials, 14 of which had available outcome data (182,880 subjects). Nine trials provided data on total mortality (155,899 subjects; 11,940 deaths). The average follow-up time was nine years. Eight trials provided data on cardiovascular mortality (152,435 participants; 4567 deaths), and eight trials on cancer mortality (139,290 participants; 3,663 deaths).

The authors did not find an effect on clinical events or other measures of morbidity; however, one trial found an increased occurrence of hypertension and hypercholesterolemia with screening and one trial found an increased occurrence of self-reported chronic disease. One trial found a 20% increase in the total number of new diagnoses per participant over six years compared to the control group. No trials compared the total number of prescriptions; however, two out of four trials found an increased number of individuals using antihypertensive drugs. Two out of four trials found small beneficial effects on self-reported health; however, the authors noted that this could be due to reporting bias because the trials were not blinded. They did not find an effect on admission to hospital, disability, worry, additional visits to the physician, or absence from work; however, most of these outcomes were poorly studied. They did not find useful results on the number of referrals to specialists, the number of follow-up tests after positive screening results, or the amount of surgery.

The authors concluded that general health checks did not reduce morbidity or mortality, neither overall nor for cardiovascular or cancer causes; however, the number of new diagnoses was increased. Important harmful outcomes, such as the number of follow-up diagnostic procedures or short term psychological effects, were often not studied or reported and many trials had methodological problems. With the large number of participants and deaths included, the long follow-up periods used, and considering that cardiovascular and cancer mortality were not reduced, general health checks are unlikely to be beneficial.

Take home message:
Many healthcare professionals may question the findings of this study because undiagnosed conditions such as hypertension or early cervical cancer can be detected. Individuals with a family history of, or increased risk for, certain diseases, should be screened at regular intervals. Of more importance than a regular exam are healthy lifestyle choices (i.e., healthy diet, regular exercise, and avoidance of tobacco). Obviously, if symptoms occur, one should have them promptly evaluated.

Reference: Cochrane Database of Systematic Reviews