Therapeutics

Review: Primary care–based general health checks improve surrogate but not clinical outcomes

Si S, Moss JR, Sullivan TR, Newton SS, Stocks NP. Effectiveness of general practice–based health checks: a systematic review and meta-analysis. Br J Gen Pract. 2014;64:e47-53.

Clinical impact rating: F ★★★★★✩✩ Question

Source of funding: No external funding.

Do primary care–based general health checks improve surrogate and clinical patient outcomes compared with usual care?

For correspondence: Dr. N.P. Stocks, University of Adelaide, Adelaide, South Australia, Australia. E-mail [email protected]. ■

Review scope

Commentary

Included studies compared primary care–based general health checks, with or without interventions, with usual care or no health screening in populations with a mean age of 35 to 65 years. Exclusion criteria included studies aiming to evaluate interventions. Outcomes were all-cause and cardiovascular (CV) mortality, blood pressure, body mass index (BMI), total cholesterol level, and smoking status.

Review methods MEDLINE, EMBASE/Excerpta Medica, and Cochrane Central Register of Controlled Trials, all to Oct 2012; SCOPUS citation search; and Google Scholar were searched for English-language, randomized, controlled trials (RCTs) or pseudo-RCTs. 6 RCTs (n = 1507 to 7229, follow-up 1 to 10 y) met the selection criteria: 4 were done in general populations, and 2 in high-risk patients and their partners. 6 RCTs had low risk for bias in allocation concealment and blinding of outcome assessors, 1 in completeness of outcome data, and none in blinding of patients and study personnel.

Main results Primary care–based general health checks reduced the number of patients with high levels of total cholesterol, diastolic blood pressure, and BMI and increased CV mortality compared with usual care (Table). Groups did not differ for smoking status, all-cause mortality, or number of patients with high systolic blood pressure (Table).

Conclusion Primary care–based general health checks improve surrogate but not clinical outcomes compared with usual care. Primary care–based general health checks vs usual care* Outcomes

Number of trials (n)† Odds ratio (95% CI)

Smoking

5 (17 144)

0.91 (0.82 to 1.02)‡

All-cause mortality

4 (25 914)

1.03 (0.90 to 1.18)

Total cholesterol ≥ 6 or ≥ 8 mmol/L

4 (13 676)

0.63 (0.50 to 0.79)

BMI ≥ 27.5 or ≥ 30 kg/m2

4 (13 794)

0.89 (0.81 to 0.98)

DBP ≥ 90 or ≥ 100 mm Hg

4 (13 794)

0.63 (0.53 to 0.74)

Cardiovascular mortality

3 (22 450)

1.30 (1.02 to 1.66)

SBP ≥ 140 mm Hg

2 (3113)

0.59 (0.28 to 1.23)‡

The systematic review by Si and colleagues suggests that health checks are not effective for improving hard health outcomes (indeed, the increase in CV deaths is a particular concern), even though they improved surrogate outcomes of risk factor status. There are several possible explanations for these results: Average trial length was less than a decade—too short to expect much difference in mortality; technical trial design difficulties would inevitably result in contamination (i.e., control group receiving the intervention) and a consequent, anomalous reduction in any intervention benefit; and the increase in CV deaths could be attributed to possible coding error bias. Nevertheless, these findings broadly confirm the results of a Cochrane review addressing a similar question (1). Many of the studies included in the review by Si and colleagues were initiated in the 1990s or earlier, which means that therapeutic options were more limited. However, this might have been offset by greater risks (especially for CV disease), implying a greater capacity for improvement. This is not to suggest that we should become nihilistic about preventive activities in primary care. Good evidence suggests that specific preventive activities for specific diseases are effective, including most childhood vaccinations, cervical and breast cancer screening, detection of increased blood pressure, smoking cessation, and so on (2, 3). Many of these activities do not require a special visit for a health check because they can be offered opportunistically during normal visits for primary care problems. Chris Del Mar, MD Bond University Gold Coast, Queensland, Australia References 1. Krogsbøll LT, Jørgensen KJ, Grønhøj Larsen C, Gøtzsche PC. General health checks in adults for reducing morbidity and mortality from disease. Cochrane Database Syst Rev. 2012;10:CD009009. 2. US Preventive Services Task Force. Recommendations. www.uspreventiveservicestaskforce.org/recommendations.htm (accessed 9 Apr 2014). 3. Canadian Task Force on Preventive Health Care. Guidelines. www.canadiantaskforce.ca/guidelines/ (accessed 9 Apr 2014).

*BMI = body mass index; DBP = diastolic blood pressure; SBP = systolic blood pressure; CI defined in Glossary. Data were pooled in the article using a random-effects model. Odds ratio < 1 indicates benefit with health checks. †Number of patients in each analysis provided by the author. ‡Heterogeneity I2 > 50%, P < 0.05

17 June 2014 | ACP Journal Club | Volume 160 • Number 12

© 2014 American College of Physicians

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ACP Journal Club. Review: primary care-based general health checks improve surrogate but not clinical outcomes.

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