p u b l i c h e a l t h 1 2 8 ( 2 0 1 4 ) 4 7 5 e4 7 7
Available online at www.sciencedirect.com
Public Health journal homepage: www.elsevier.com/puhe
Short Communication
Case detection of disease by NHS Health Checks in Warwickshire, England and comparison with predicted performance J. Hooper, P. Chohan, M. Caley* Public Health Warwickshire, Warwickshire County Council, Warwick, UK
article info Article history: Received 19 September 2013 Received in revised form 28 January 2014 Accepted 28 January 2014 Available online 22 May 2014
In April 2009 the Department of Health (DH) in England introduced ‘NHS Health Checks.’ This is a systematic case finding and vascular risk assessment programme offered to those between the ages of 40e74 years without a prior diagnosis of cardiovascular disease or other risk factors. The aim of NHS Health Checks is to identify and treat patients at high risk of developing cardiovascular disease and identify undiagnosed cardiovascular disease, diabetes, hypertension and chronic kidney disease. This is anticipated to result in early detection and intervention to reduce the risk of future disease and is modelled to reduce future healthcare costs.1 Many of the interventions provided within NHS Health Checks and the early detection and intervention of certain conditions are well supported by evidence to improve outcomes for individual patients. However, NHS Health Checks as a programme was implemented by DH with little direct evaluation of the benefit of the programme as a vehicle to offer these interventions to the general public. There has been a good deal of debate about the relative worth of Health Checks and, although DH has commissioned some research to evaluate the impact of the programme,2 at present little published evidence exists on the actual outcomes of the programme. To
date, no research has been published that estimates the rate of case detection of different conditions by the NHS Health Check programme, nor have there been comparisons made comparing this rate of case detection with usual medical care. This study used the data collected by the NHS Health Checks programme in Warwickshire, a mixed urban and rural county in England, to estimate the rate of case detection of five health conditions by the programme. 40 GP practices offered Health Checks over a three-year period between April 2010 and March 2013. Data collected included the number of Health Checks offered (coverage), the number of Health Checks completed (uptake) and the number of cases of five separate conditions diagnosed as a direct result of the Health Check: hypertension, diabetes, chronic kidney disease (CKD), coronary heart disease (CHD) and atrial fibrillation (AF). Warwickshire is relatively unique in its ability to present case detection figures since it is one of the few areas in England that is collecting this information from its providers of NHS Health Checks. The population eligible for Health Checks was calculated as 87,551 using the standard method recommended by the NHS Health Checks programme.2 The level of coverage and uptake of Health Checks was significantly lower than predicted by modelling carried out in 2011 by the National Institute for Health and Care Excellence (NICE) on the potential effectiveness of the programme.3 37,236 Health Checks were offered, equivalent to 42.53% (95%CI: 42.20%e42.86%) of the eligible population (vs a modelled estimated coverage of 60% over three years). 16,669 Health Checks were completed which is equivalent to 19.04% of the eligible population and 44.77% (95%CI: 44.26%e45.27%) of those offered a Health Check (versus a modelled estimated uptake of 75%).
* Corresponding author. E-mail address: [email protected] (M. Caley). 0033-3506/$ e see front matter ª 2014 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.puhe.2014.01.013
476
p u b l i c h e a l t h 1 2 8 ( 2 0 1 4 ) 4 7 5 e4 7 7
Overall NHS Health Checks detected 1142 case of previously undiagnosed disease. The number of cases of conditions detected and the case detection rate for the five conditions are shown in Table 1. The actual case detection rate is similar to the lowest overall modelled case detection rates for hypertension and CKD and significantly lower for diabetes. The rate of case detection for AF and CHD were not included in the modelled estimates. Linear regression analysis showed no strong or significant association between uptake and practice deprivation score (R2 ¼ 0.08, P ¼ 0.65), practice list size (R2 ¼ 0.08, P ¼ 0.22). The case detection rate for all five conditions showed there was no strong or significant correlation between any of the variables. The findings of this study show that NHS Health Checks has been effective in the detection of previously undiagnosed disease at a local level and are the first published results showing the rate of case detection by the programme. However, figures for coverage, uptake and case detection are all lower than predicted from modelled estimates of performance. This casts some doubt on the quoted modelled benefits of NHS Health Checks both in terms of clinical and cost effectiveness. It has been suggested that the model requires reconsideration with more realistic figures in order to more accurately quantify the potential benefits and costs of the NHS Health Checks programme. The population of the study were more affluent and had a longer life expectancy than the England average. Therefore the authors might expect that the findings of this study overestimate the true national average of uptake but underestimate the true average case detection rates since more affluent populations are generally more likely to accept offers of screening and have a lower prevalence of chronic disease than more deprived populations. There is relatively little published research on NHS Health Checks. The findings on uptake are consistent with earlier evaluations of UK based CVD risk assessment programmes which showed a range of 29e66% uptake4,5 and specifically for NHS Health Checks ranging from 20% to 44.8%.6e8 Three papers have tried to analyse the backgrounds of those that took up Health Checks. In the period 2008-09, Dalton et al. were able to analyse the difference in uptake depending on practice list size which showed smaller
practices having a higher uptake 61.6% for 6000 patients.8 This finding was also supported by the work of Cochrane et al.6 However, in this study the authors found no correlation between the size of the practice and uptake. Cochrane also found that those from less affluent areas were less likely to attend for NHS Health Checks6, again in contrast to this study where there was no correlation with deprivation. A systemic review and meta-analysis that included 14 trials found no effect on total or cause specific mortality from general population health checks on an eligible population.9 However, a more recent meta-analysis showed a significant improvement in some surrogate outcomes including diastolic blood pressure, total cholesterol and BMI and a non-significant improvement in systolic blood pressure and smoking status but also showed a significant increase in CVD mortality.10 Neither of these metaanalyses included research or outcomes from the NHS Health Checks programme specifically. Whilst many of the interventions provided within NHS Health Checks including the early detection and treatment of disease have been proven to be beneficial to individual patients, the evidence of effectiveness and cost effectiveness of NHS Health Checks as a vehicle to deliver these interventions remains in some doubt. It has been shown that NHS Health Checks does detect latent disease in the general population albeit at a lower than predicted. However, a direct comparison of the performance of NHS Health Checks to usual care is lacking and must be the major focus for further research.
Author statements Acknowledgements The authors would like to thank Dr Kathryn Millard and Nicola Wright in the Warwickshire Public Health department for their support with this paper. It would not have been possible without the help of Chris Buyer from Arden Commissioning Support Services who provided the data.
Ethical approval None sought.
Table 1 e Number of cases diagnosed and case detection rate for five conditions.
Funding
Condition
None declared.
Number of cases detected
Diabetes
210
Hypertension
635
CKD
198
CHD
43
AF
56
Total
1142
Actual case detection rate (95% CI) 1.26% (1.01%e1.43%) 3.81% (3.52%e4.10%) 1.19% (1.02%e1.35%) 0.26% (0.18%e0.34%) 0.34% (0.25%e0.42%) 6.85%
Modelled estimated case detection rate 1.45% 4.05%e34.33%
Competing interests None declared.
references
1.32%e12.77% e e e
1. About NHS Health Checks. The NHS Health Check website. Available at: http://www.nhs.uk/Planners/NHSHealthCheck (accessed 13 March 2013). 2. NHS Health Checks Research. The NHS Health Checks website. Available at: http://www.nhshealthcheck.nhs.uk/default.
p u b l i c h e a l t h 1 2 8 ( 2 0 1 4 ) 4 7 5 e4 7 7
3.
4.
5.
6.
aspx?iID¼22&aID¼115&st¼research (accessed 13 March 2013). The NHS Health Check Reckoner. The NHS Health Check website. Available at: http://www.healthcheck.nhs.uk/national_ resources/ready_reckoner_tools/ (accessed 13 March 2013). Waller D, Agass M, Mant D, Coulter A, Fuller A, Jones L. Health checks in general practice: another example of inverse care? British Medical Journal 1990;300:1115. Richardson F, van Woerden H, Morgan L, Edwards R, Harries M, Hancock E, Sroczynsk S, Bowley M. Healthy hearts a community-based primary prevention programme to reduce coronary heart disease. BMC Cardiovascular Disorders 2008;8:118. Cochrane T, Gidlow C, Kumar J, Mawby Y, Iqbal Z, Chambers R. Cross-sectional review of the response and treatment uptake from the NHS Health Checks programme in Stoke on Trent. Journal of Public Health 26 October 2012;35(1):92e8.
477
7. Artac M, Dalton A, Majeed A, Car J, Huckvale K, Millett C. Uptake of the NHS Health Check programme in an urban setting. Family Practice 1 Feb 2013;30(4):426e35. http:// dx.doi.org/10.1093/fampra/cmt002. 8. Dalton A, Bottle A, Okoro C, Majeed A, Millett C. Uptake of the NHS Health Checks programme in a deprived culturally diverse setting: cross-sectional study. Journal of Public Health 5 May 2011;33(3):422e9. 9. Krogsbøll L, Jørgensen K, Larsen C, Gøtzsche P. General Health Checks in adults for reducing morbidity and mortality from disease: Cochrane systematic review and meta-analysis. British Medical Journal 2012;345:e7191. http://dx.doi.org/ 10.1136/bmj.e7191. 10. Si S, Moss JR, Sullivan TR, Newton SS, Stocks N. Effectiveness of general practice-based health checks: a systematic review and meta-analysis. British Journal of General Practice 2014;64. 618 e47ee53.
Available online at www.sciencedirect.com
Public Health journal homepage: www.elsevier.com/puhe
Short Communication
Case detection of disease by NHS Health Checks in Warwickshire, England and comparison with predicted performance J. Hooper, P. Chohan, M. Caley* Public Health Warwickshire, Warwickshire County Council, Warwick, UK
article info Article history: Received 19 September 2013 Received in revised form 28 January 2014 Accepted 28 January 2014 Available online 22 May 2014
In April 2009 the Department of Health (DH) in England introduced ‘NHS Health Checks.’ This is a systematic case finding and vascular risk assessment programme offered to those between the ages of 40e74 years without a prior diagnosis of cardiovascular disease or other risk factors. The aim of NHS Health Checks is to identify and treat patients at high risk of developing cardiovascular disease and identify undiagnosed cardiovascular disease, diabetes, hypertension and chronic kidney disease. This is anticipated to result in early detection and intervention to reduce the risk of future disease and is modelled to reduce future healthcare costs.1 Many of the interventions provided within NHS Health Checks and the early detection and intervention of certain conditions are well supported by evidence to improve outcomes for individual patients. However, NHS Health Checks as a programme was implemented by DH with little direct evaluation of the benefit of the programme as a vehicle to offer these interventions to the general public. There has been a good deal of debate about the relative worth of Health Checks and, although DH has commissioned some research to evaluate the impact of the programme,2 at present little published evidence exists on the actual outcomes of the programme. To
date, no research has been published that estimates the rate of case detection of different conditions by the NHS Health Check programme, nor have there been comparisons made comparing this rate of case detection with usual medical care. This study used the data collected by the NHS Health Checks programme in Warwickshire, a mixed urban and rural county in England, to estimate the rate of case detection of five health conditions by the programme. 40 GP practices offered Health Checks over a three-year period between April 2010 and March 2013. Data collected included the number of Health Checks offered (coverage), the number of Health Checks completed (uptake) and the number of cases of five separate conditions diagnosed as a direct result of the Health Check: hypertension, diabetes, chronic kidney disease (CKD), coronary heart disease (CHD) and atrial fibrillation (AF). Warwickshire is relatively unique in its ability to present case detection figures since it is one of the few areas in England that is collecting this information from its providers of NHS Health Checks. The population eligible for Health Checks was calculated as 87,551 using the standard method recommended by the NHS Health Checks programme.2 The level of coverage and uptake of Health Checks was significantly lower than predicted by modelling carried out in 2011 by the National Institute for Health and Care Excellence (NICE) on the potential effectiveness of the programme.3 37,236 Health Checks were offered, equivalent to 42.53% (95%CI: 42.20%e42.86%) of the eligible population (vs a modelled estimated coverage of 60% over three years). 16,669 Health Checks were completed which is equivalent to 19.04% of the eligible population and 44.77% (95%CI: 44.26%e45.27%) of those offered a Health Check (versus a modelled estimated uptake of 75%).
* Corresponding author. E-mail address: [email protected] (M. Caley). 0033-3506/$ e see front matter ª 2014 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.puhe.2014.01.013
476
p u b l i c h e a l t h 1 2 8 ( 2 0 1 4 ) 4 7 5 e4 7 7
Overall NHS Health Checks detected 1142 case of previously undiagnosed disease. The number of cases of conditions detected and the case detection rate for the five conditions are shown in Table 1. The actual case detection rate is similar to the lowest overall modelled case detection rates for hypertension and CKD and significantly lower for diabetes. The rate of case detection for AF and CHD were not included in the modelled estimates. Linear regression analysis showed no strong or significant association between uptake and practice deprivation score (R2 ¼ 0.08, P ¼ 0.65), practice list size (R2 ¼ 0.08, P ¼ 0.22). The case detection rate for all five conditions showed there was no strong or significant correlation between any of the variables. The findings of this study show that NHS Health Checks has been effective in the detection of previously undiagnosed disease at a local level and are the first published results showing the rate of case detection by the programme. However, figures for coverage, uptake and case detection are all lower than predicted from modelled estimates of performance. This casts some doubt on the quoted modelled benefits of NHS Health Checks both in terms of clinical and cost effectiveness. It has been suggested that the model requires reconsideration with more realistic figures in order to more accurately quantify the potential benefits and costs of the NHS Health Checks programme. The population of the study were more affluent and had a longer life expectancy than the England average. Therefore the authors might expect that the findings of this study overestimate the true national average of uptake but underestimate the true average case detection rates since more affluent populations are generally more likely to accept offers of screening and have a lower prevalence of chronic disease than more deprived populations. There is relatively little published research on NHS Health Checks. The findings on uptake are consistent with earlier evaluations of UK based CVD risk assessment programmes which showed a range of 29e66% uptake4,5 and specifically for NHS Health Checks ranging from 20% to 44.8%.6e8 Three papers have tried to analyse the backgrounds of those that took up Health Checks. In the period 2008-09, Dalton et al. were able to analyse the difference in uptake depending on practice list size which showed smaller
practices having a higher uptake 61.6% for 6000 patients.8 This finding was also supported by the work of Cochrane et al.6 However, in this study the authors found no correlation between the size of the practice and uptake. Cochrane also found that those from less affluent areas were less likely to attend for NHS Health Checks6, again in contrast to this study where there was no correlation with deprivation. A systemic review and meta-analysis that included 14 trials found no effect on total or cause specific mortality from general population health checks on an eligible population.9 However, a more recent meta-analysis showed a significant improvement in some surrogate outcomes including diastolic blood pressure, total cholesterol and BMI and a non-significant improvement in systolic blood pressure and smoking status but also showed a significant increase in CVD mortality.10 Neither of these metaanalyses included research or outcomes from the NHS Health Checks programme specifically. Whilst many of the interventions provided within NHS Health Checks including the early detection and treatment of disease have been proven to be beneficial to individual patients, the evidence of effectiveness and cost effectiveness of NHS Health Checks as a vehicle to deliver these interventions remains in some doubt. It has been shown that NHS Health Checks does detect latent disease in the general population albeit at a lower than predicted. However, a direct comparison of the performance of NHS Health Checks to usual care is lacking and must be the major focus for further research.
Author statements Acknowledgements The authors would like to thank Dr Kathryn Millard and Nicola Wright in the Warwickshire Public Health department for their support with this paper. It would not have been possible without the help of Chris Buyer from Arden Commissioning Support Services who provided the data.
Ethical approval None sought.
Table 1 e Number of cases diagnosed and case detection rate for five conditions.
Funding
Condition
None declared.
Number of cases detected
Diabetes
210
Hypertension
635
CKD
198
CHD
43
AF
56
Total
1142
Actual case detection rate (95% CI) 1.26% (1.01%e1.43%) 3.81% (3.52%e4.10%) 1.19% (1.02%e1.35%) 0.26% (0.18%e0.34%) 0.34% (0.25%e0.42%) 6.85%
Modelled estimated case detection rate 1.45% 4.05%e34.33%
Competing interests None declared.
references
1.32%e12.77% e e e
1. About NHS Health Checks. The NHS Health Check website. Available at: http://www.nhs.uk/Planners/NHSHealthCheck (accessed 13 March 2013). 2. NHS Health Checks Research. The NHS Health Checks website. Available at: http://www.nhshealthcheck.nhs.uk/default.
p u b l i c h e a l t h 1 2 8 ( 2 0 1 4 ) 4 7 5 e4 7 7
3.
4.
5.
6.
aspx?iID¼22&aID¼115&st¼research (accessed 13 March 2013). The NHS Health Check Reckoner. The NHS Health Check website. Available at: http://www.healthcheck.nhs.uk/national_ resources/ready_reckoner_tools/ (accessed 13 March 2013). Waller D, Agass M, Mant D, Coulter A, Fuller A, Jones L. Health checks in general practice: another example of inverse care? British Medical Journal 1990;300:1115. Richardson F, van Woerden H, Morgan L, Edwards R, Harries M, Hancock E, Sroczynsk S, Bowley M. Healthy hearts a community-based primary prevention programme to reduce coronary heart disease. BMC Cardiovascular Disorders 2008;8:118. Cochrane T, Gidlow C, Kumar J, Mawby Y, Iqbal Z, Chambers R. Cross-sectional review of the response and treatment uptake from the NHS Health Checks programme in Stoke on Trent. Journal of Public Health 26 October 2012;35(1):92e8.
477
7. Artac M, Dalton A, Majeed A, Car J, Huckvale K, Millett C. Uptake of the NHS Health Check programme in an urban setting. Family Practice 1 Feb 2013;30(4):426e35. http:// dx.doi.org/10.1093/fampra/cmt002. 8. Dalton A, Bottle A, Okoro C, Majeed A, Millett C. Uptake of the NHS Health Checks programme in a deprived culturally diverse setting: cross-sectional study. Journal of Public Health 5 May 2011;33(3):422e9. 9. Krogsbøll L, Jørgensen K, Larsen C, Gøtzsche P. General Health Checks in adults for reducing morbidity and mortality from disease: Cochrane systematic review and meta-analysis. British Medical Journal 2012;345:e7191. http://dx.doi.org/ 10.1136/bmj.e7191. 10. Si S, Moss JR, Sullivan TR, Newton SS, Stocks N. Effectiveness of general practice-based health checks: a systematic review and meta-analysis. British Journal of General Practice 2014;64. 618 e47ee53.
