General health checks may not reduce morbidity or mortality but do increase the number of new diagnoses
- 1Department of Primary Care and Public Health, Imperial College London, London, UK
- 2Department of Public Health, NHS Brent, London, UK
- Correspondence to: Professor Azeem Majeed
Department of Primary Care and Public Health, Imperial College London, Reynolds Building, London W6 8RP, UK;
Commentary on: Google Scholar
Implications for practice and research
General health checks aim to detect risk factors and diseases in healthy people, with the aim of either preventing a disease from developing, or treating a disease earlier in its course.
A systematic review of randomised controlled trials (RCTs) of general health checks found that they did not reduce morbidity or mortality, but did increase the number of new diagnoses.
The burden of non-communicable disease such as cardiovascular disease, type 2 diabetes and kidney disease is increasing worldwide.1 These diseases all share risk factors that include smoking, hypertension, obesity, physical inactivity and hyperglycaemia. Their prevention, early identification and effective management could have major public health and economic benefits, and this has led to renewed interest in and an expansion of health check programmes in many countries.2 However, the long-term benefits of such programmes, including their impact on mortality, morbidity, the detection of previously undiagnosed diseases and risk factor reduction, and any harms caused by the programmes are uncertain.
Krogsbøll and colleagues aimed to quantify the benefits and harms of general health checks on outcomes such as morbidity and mortality. They carried out a systematic review of RCTs comparing health checks with no health checks in adults unselected for disease or risk factors. They used standard Cochrane collaboration methods to carry out their review. RCTs of older people were not included. Health checks were defined 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 each of the included RCTs. Authors of the original trials were contacted for additional outcomes or trial details if needed. A random-effects model meta-analysis was used to examine the impact on mortality, and a qualitative synthesis for other outcomes.
Krogsbøll and colleagues identified 14 trials with suitable outcome data (182 880 participants); 9 trials provided data on total mortality (155 899 participants, 11 940 deaths). The risk ratio for death was 0.99 (95% CI 0.95 to 1.03). Eight trials provided data on cardiovascular mortality (152 435 participants, 4567 deaths, risk ratio 1.03, 95% CI 0.91 to 1.17); and eight trials provided data on cancer mortality (139 290 participants, 3663 deaths, risk ratio 1.01, 95% CI 0.92 to 1.12). They found limited benefits for the other areas examined, such as clinical events, but some trials did report an increase in the diagnosis of conditions such as hypertension and hypercholesterolaemia.
Although Krogsbøll and colleagues concluded that general health checks did not reduce morbidity or mortality, their review has a number of limitations. The trials included differed markedly in their definition of what constituted a ‘general health check’ and in the disease they were aiming to address. They also differed in how any newly identified risk factors or disease would be managed. In many studies, the only intervention offered was brief lifestyle advice. Some of the trials were also old, dating from the 1960s. Many of the currently available risk reduction interventions (such as the widespread use of electronic patient records for targeting specific patient groups, tools for measuring individual cardiovascular risk, and low-cost statins for primary prevention) were unavailable at the time most of these trials were carried out.3
The National Health Service (NHS) Health Check Programme in England has been designed to target a related set of cardiovascular conditions, followed by the implementation of a range of evidence-based risk-reduction measures derived from National Institute of Health and Clinical Excellence guidelines.4 The programme is currently undergoing evaluation and the results will provide evidence on the costs and benefits of more modern health check programmes. The conclusions of the review, therefore, have limited relevance to the NHS Health Check Programme in England, and programmes such as the Million Hearts Initiative in the USA. The review does, though, reinforce the need for a robust evaluation of such prevention and disease detection programmes, including the assessment of both their clinical and cost effectiveness, and any harm that might arise from psychological distress or overtreatment of risk factors that would not progress to significant disease. Evaluation of health check programmes and confirmation of their benefits is particularly important in an era when the NHS in England and health systems in many other European countries are operating under severe financial constraints.5
Competing interests AM has received funding from the Department of Health's Policy Research Programme to carry out a national evaluation of the NHS Health Check Programme.