Annual Check-ups - Time Wasted or Time Misused?
Nearly a century has passed since the American Medical Association endorsed “periodic medical examinations of apparently healthy persons.”
These examinations were “designed to detect the early evidence of disorder before discomfort, inconvenience, interference with work, or anxiety [had] driven [apparently healthy people] to seek medical advice for the treatment of established disease,” Haven Emerson, MD, chair of the AMA’s Committee on Health and Public Instruction, wrote in JAMA in 1922.
Despite Cigna’s recent television commercials, in which TV physicians exhorted viewers to get an annual examination, real physicians and other interested parties have debated the value of checkups for decades.
Randomized trials comparing outcomes among participants receiving periodic health checks or no health checks have found the examinations did not reduce morbidity or mortality overall or from cardiovascular disease or cancer. Based on these studies, the Society of General Internal Medicine, as part of the “Choosing Wisely” initiative, concluded that “the evidence base is definitely insufficient to support routine use of annual general health checks for asymptomatic adults without a specific concern, chronic condition, or evidence-based prevention strategy.”
According to a more recent Cochrane Review of 17 randomized trials involving 251 891 participants aged 18 to 64 years, “high-certainty evidence” suggests general health checks are unlikely to benefit patients and might lead to unnecessary tests and treatments.
More Than Disease Screening
The Cochrane Review defines health check as “screening for more than one disease or risk factor in more than one organ system,” but advocates of well-adult visits say they are more than that, although there’s still room for improvement.
“Why do people come [to a checkup] if it were of no value?” asked Allan Goroll, MD, a professor of medicine at Harvard Medical School and a primary care general internist at Massachusetts General Hospital. “The answer is it has to do with things that [trials] are not looking at. That is my critique of the evidence. It strictly looks at the measurable. They forget that there are other things people get out of an annual visit, and they’re not looking at those things.”
The real purpose of an annual checkup, Goroll said, is “the development and sustaining of a trusting healing relationship.” To illustrate his point, he told of a recent patient with severe coronary artery disease who finally quit smoking. That man would not have been able to accomplish that goal if he had not been working with him, Goroll said. “A problem with our society is that relationships have become scarcer and undervalued,” he said.
Lasse Krogsbøll, MD, PhD, a coauthor of the recent Cochrane Review and a general surgeon at Bispebjerg Hospital in Copenhagen, acknowledged that “it’s possible that [a checkup] leads to a better physician-patient relationship.” But, he said, “it might just be expensive and a waste of time if there are no problems.”
Krogsbøll said he and his coauthors updated their 2012 review because many of the trials it had included were quite old. Of the 14 trials, 9 started between 1963 and 1971, before the era of statin drugs and angiotensin-converting enzyme inhibitors, effective treatments for conditions that could be detected by screening at a checkup.
The 2012 review also didn’t include the final results of one of the largest trials to date, the Inter99 study, which weren’t published until 2014, he noted. This study involved nearly 60 000 suburban Copenhagen residents. About 20% of them were randomized to the intervention group invited for screening, risk assessment, and lifestyle counseling up to 4 times over a 5-year period. The control group was not invited for screening. After 10 years of follow-up, the study found no difference in ischemic heart disease, stroke, or mortality between the intervention and control groups.
One reason the Inter99 and other trials included in the recently updated Cochrane Review found no difference in outcomes between people assigned to get health checks and those who weren’t was because they were done in countries where people generally have access to primary care, said Krogsbøll, who is affiliated with the Nordic Cochrane Center.
“One of the most important things to note is everybody in the control groups had access to a general practitioner,” he said. “This is not a matter of health checks vs no primary care.”
Screening and other services provided at health checks are “an integrated part of primary care in most countries, and that’s what’s been going on in the control groups,” Krogsbøll said. Primary care physicians “seem to be doing well when they see patients for other reasons,” he noted.
If trials defined health checks as simply visits for screening tests, it’s no surprise they didn’t find evidence of benefit, Goroll said. But, he said, that speaks more to the need to reframe the concept of checkups instead of abandoning them altogether.
The point of a checkup should be to develop and maintain a long-term plan for good health, Goroll said, adding, “It doesn’t have to be annual. It can be matched to the patient’s needs.” Much of what takes place at checkups these days, such as asking about seatbelt use or physical activity, could be handled online or by other staff, freeing primary care physicians to spend time talking with patients about what’s important to them, he added.
“There is no question that the stripped-down, check-the-boxes excuse for an annual visit has no value, and shame on us for offering that to patients,” Goroll said. “What we need are high-value visits that are personal, that focus on building trusting relationships, that focus on key concerns of patients.”
JAMA. Published online June 19, 2019. doi:10.1001/jama.2019.6605