Year : 2020 | Volume
: 8 | Issue : 2 | Page : 51--55
Are periodic health checkups useful or necessary?
Vasantha Kamath, Shreyashi Ganguly
Department of Internal Medicine, MVJ MC and RH, Bengaluru, Karnataka, India
Dr. Vasantha Kamath
MVJ MC and RH, Bengaluru, Karnataka
Much has been debated about routine periodic health screening in recent years. Those in favor of such screening of laboratory investigations point to the economic and social advantages of early detection and better diagnosis of disease to an individual and the community. The opponents of this type of blanket screening point to the dubious diagnostic value of many of the abnormal results found and the impracticability of making laboratory screening generally available even if it was shown to be of definite value. Despite contrary evidence, most primary care providers believe that an annual physical examination detects subclinical illness. This is partly driven and shaped by factors such as apparent perception of benefit, patient expectation, employer requirement, and insurance industry protocols. Healthcare institutions in India often offer structured health checkup “packages” for routine screening of common diseases. Some tests included within their ambit are in keeping with international and Indian recommendations; however, many are entirely unwarranted. Unnecessary and inappropriate screening tests cause financial and resource burden. Furthermore, there may be overdiagnosis and overtreatment, psychological distress due to false-positive test results, harm from invasive follow-up tests, and false reassurance due to false-negative test results. Evidence suggests that only certain diseases are amenable for screening in an asymptomatic adult. It is recommended that physicians should abandon recommending these general panels in favor of a more selective approach to prevent health problems individualized to every unique patient.
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Kamath V, Ganguly S. Are periodic health checkups useful or necessary?.APIK J Int Med 2020;8:51-55
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Kamath V, Ganguly S. Are periodic health checkups useful or necessary?. APIK J Int Med [serial online] 2020 [cited 2020 Jul 13 ];8:51-55
Available from: http://www.ajim.in/text.asp?2020/8/2/51/282851
An annual health examination or evaluation (AHE) is an exercise in preventive medicine. It has become ubiquitous in modern medicine. An ideal AHE is the opportunity for an otherwise asymptomatic adult to undergo periodic health checkups with a primary care physician. It comprises a general physical examination akin to the “wellness” check of pediatric age group and the use of “routine” biochemical and pathological assessment of their body fluids (blood and urine). It may also include optometric and audiometric evaluation, electrocardiogram (ECG), chest X-ray, and/or ultrasound abdomen. It is in the hope that this maximalist net would be able to detect and screen people for diseases that would otherwise go unnoticed and unchecked. AHE is thought to be part of the adage, prevention is better than cure.
History of Annual Health Examination or Evaluation
The origin of the periodic health examination (PHE) can be traced to 1861 with Horace Dobell, a British Physician. However, that an annual physical examination can serve as an important tool to screen for asymptomatic disease, and predisposition to disease only grew into prominence due to the efforts of oculist Dr. Gould of America and other like-minded physicians.
Early proponents of the examination noted that public health measures had greatly reduced the incidence of communicable diseases. They felt that the concept of preventive medicine should be broadened to include not only sanitation and control of communicable diseases but also control of chronic diseases.
Heart disease, renal disorders, and cancer were the leading causes of death among adults even at that time. These physicians believed that control of these ailments could be achieved by PHEs. Although there were no data to substantiate the claim, the identification of patients at risk was equated with elimination of the disease itself.
Doctors affiliated with life insurance companies were the first group of physicians to develop and carry out a program of AHE in adults. Dr. E. L. Fisk was the leader of this group. He created the Life Extension Institute where policy holders of major insurance companies were examined. By 1909, Dr. Fisk had convinced life insurance companies that the prolonged life expectancy of their policy holders, achieved by the AHE, would result in significant financial savings.
During the subsequent century and a half, numerous influences resulted in promotion of the concept of an annual physical examination, often accompanied by laboratory testing, as an important mass screening technique in asymptomatic adults.
The contents and legitimacy of PHE has changed markedly over time according to the objectives. There were various objectives of the PHE according to the early advocates: reduction of morbidity and mortality, scientific knowledge, economic savings, professional empowerment, the patient–physician relationship, satisfaction of patient demand, and efficient administration.
Therefore, in systems of healthcare with third-party payment systems (employee, insurance), these AHE protocols became synonymous with cost-effective and justified healthcare delivery.
Modern Annual Health Examination or Evaluation Practice in India
The public health expenditure in India (total of center and state governments) has remained constant at approximately 1.3% of the gross domestic product (GDP) between 2008 and 2015 and increased marginally to 1.4% in 2016–2017. This is less than the world average of 6%. The National Health Policy, 2017 proposes to increase this to 2.5% of GDP by 2025. Including the private sector, the total health expenditure as a percentage of GDP is estimated at 3.8%. Government spends 30.6% in covering the cost. Private and social security covers an additional 4.2% and 6.3% of the total costs, respectively.
Most Indians do not enjoy healthcare coverage. Eighty-six percent of rural population and 82% of urban population are not covered under any scheme of health expenditure support. India is often touted as the country with the highest out-of-pocket expense (60.6%). Due to this devastating cost to individuals, about 6%–8% population is pushed below the poverty threshold every year.
Following in at the heels of developed countries, as more and more of the healthcare deliveries got privatized in India, AHE became popular.
Due to the skewed doctor-to-patient ratio in this country, more and more of these preventive services became akin to packages of health checkup. The cost and the kind of services offered by these generalized tests vary from as low as B9;1500 to B9;45,000.
The most common categories were general tests (i.e., complete blood counts, erythrocyte sedimentation rate, blood group), tests for diabetes, tests for lipid profile, and tests for cardiac function. The more comprehensive packages included tests such anti-nuclear antibody, HLA-B27, ultrasound abdomen and pelvis, whole-body magnetic resonance imaging, glucose-6-phosphosphate dehydrogenase, acid phosphatase, and numerous others, none of which are recommended by any guideline.
A review of existing evidence and guidelines affirms that screening for individual ailments in a highly selected population may be beneficial in reducing morbidity and mortality, but subjecting asymptomatic individuals to all these investigations without any index of suspicion may lead to more harm than benefit and hence is not justified.
Thus, fancy catch-it-all general wellness checks serve only the urban, well-heeled population who are more likely to avail medical services anyway.
The Pros and Cons of Annual Health Examination or Evaluation
Organized medicine has played a major role in the development of the PHE. As early as 1922, American Medical Association endorsed AHE based on several objectives. The basic premises underlying the AHE are as follows:
Asymptomatic adults can harbor organic diseasesAHE can detect disease at the “early” stageRecognition of adverse environmental factors and living habitsPromotion of vigor, physical, and mental fitnessThe discovery of disease can lead to its arrest, reversal, or cureThereby, it can reduce morbidity and mortality.
In a way, by bringing the community clinician to the role of prominence of providing healthcare, the idea of AHE took root to mean a more robust health system. Technological optimism, spurred by scientific innovations in medicines, allowed easier screening of more complex diseases early.
The positive predictive value of any abnormal test result is directly proportional to the pretest probability of the disease, which in turn depends on the population chosen. Thus, positive results from tests are more meaningful when undertaken in a carefully selected population, which is at high risk for that illness, rather than in a nonspecific population.
In addition, the use of any diagnostic test should be guided by certain principles. (a) Whether the test is a good diagnostic tool in terms of sensitivity, specificity, simplicity, cost, safety, and acceptability. (b) Whether the burden of the suffering caused by a particular disease in terms of morbidity and mortality warrants early detection and diagnosis. (c) Finally, before undertaking any screening, the physician should consider if the disease diagnosed by said test has a good guideline for therapy.
The major error in early research on AHE was that it failed to address the most important premise: How does detection and early treatment of a disease alters its outcome. This is a crucial flaw.
Data suggest that cardiovascular disease (CVD) burden in India, especially in urban regions, may be aligned with the European and American guidelines. There is substantial evidence of the benefit in assessing each individual's absolute risk of having a CVD event. The Framingham score recommends aggressive intervention to reduce risk factors among patients at high risk of CVD (>20% risk in 10 years). The current guidelines for prevention of CVD generally aim to be comprehensive in listing all risk assessment tests and grading their utility. However, clinical decisions should be based on regional specificities and resource settings. Several tests to assess the risk of CVD such as highly-sensitive C-reactive protein, ankle–brachial index, presence of periodontal disease, carotid artery intima–media thickness, electron beam computed tomography scan, and homocysteine level have a low diagnostic value in asymptomatic individuals. Despite this, many of these tests are included in annual health checkup packages, resulting in unnecessary and frequent testing of healthy individuals.
Chronic obstructive pulmonary disease
It is tempting to undertake mass screening on all smokers to detect chronic obstructive pulmonary disease (COPD). While this approach can pick up more COPD cases, this early detection does not translate into better end points such as exacerbations, hospitalizations, and mortality.
Current COPD guidelines, such as the GOLD guidelines, use a fixed forced expiratory volume in 1 s (FEV1)/forced vital capacity value (0.70) to define airway obstruction, and FEV1% predicted to classify COPD severity. This approach leads over-estimation of the burden of mild and moderate COPD. FEV1 is expressed as a percentage of a predicted value. This can introduce a bias, especially in small people, elderly people, and especially small elderly. Even though these people may be in good respiratory health, the test will be incorrectly identified as having an abnormally low FEV1. Other conditions can potentially lead to a reduced ratio, such as cystic fibrosis or other pulmonary conditions, and certain population may not be able to perform the test adequately (mental retardation and myasthenia gravis). This emphasizes the need for a clinical perspective in addition to spirometry.
The American Cancer Society (ACS) guidelines comprehensively summarize the current screening guidelines for breast, cervical, colorectal, endometrial, lung, prostate, and skin cancers. Of these, the early detection tests for breast, cervical, and prostate cancers are commonly included in routine checkups.
The ACS guidelines recommend periodic clinical breast examination for women aged 20–40 years, preferably at least every 3 years. For women aged >40 years, it is recommended annually. The objective of a mammogram is to detect nonpalpable breast cancers that are smaller than clinically palpable ones. This is since in general small breast cancers confer a better prognosis than larger ones.
Survival in the context of a screening program using mammography is not predictive of reduced mortality because of several key biases. These biases include:
Lead-time bias: Survival time for cancer found through screening mammogram includes the time between detection and the time when cancer would have been detected because of clinical symptomsLength bias: Screening detects cancer while it is preclinical and preclinical durations vary. Cancers with longer preclinical durations present more opportunities for discovery and therefore are more likely to be detected by screening; these cancers tend to be slow-growing and to have better prognoses, irrespective of screening.
Mammography is plagued with other problems of false positives, false negatives, and exposure to radiation.
The WHO guidelines recommend an age of 30 years to start screening because of a higher risk of cervical cancer. Priority should be given to screening women aged 30–49 years, rather than maximizing the number of screening tests in a woman's lifetime. Screening even once in a lifetime would be beneficial. Screening intervals may depend on financial, infrastructural, and other resources. Common screening tests are for human papillomavirus, cytology (Pap test), and unaided visual inspection with acetic acid (VIA).
Studies show that 80% of cervical cancers can be prevented by well-organized, regular Pap smear screening programs, and mortality can be reduced by 90%.,
The ACS guidelines recommend that men who have at least a 10-year life expectancy should have an opportunity to make a decision with their doctor about whether to be screened for prostate cancer by digital rectal examination or prostate-specific antigen (PSA) test, after receiving information about the benefits, risks, and uncertainties associated with prostate cancer screening.
Mass screening for prostate cancer is an obsolete concept. The use of PSA as a screening test is also on the decline.
“Over-diagnosis bias” is an extreme form of length bias; screening may find cancers that are very slow-growing and would never clinically manifest in one's lifetime. Many cancers detected by routine PSA testing are so indolent that many of these patients would have died due to some other cause such as CVD.
Current Suggested Recommendations
Evidence suggests that health checkups should be for at-risk groups based on age, gender, and occupation. It should not be dictated by availability, desires, external pressures, or affordability. Health checkups should fulfill minimum quality assurance standards at a reasonable cost.
Certain diseases such as anemia in women in the reproductive age, hypertension, and diabetes are amenable to uniform screening protocols that can be used at the grass-root level.
All adults who visit a doctor should be screened for hypertension. Routine screening may be discouraged for people >70 years of age.
Routine screening of all men/women aged >35/45 years, respectively, for dyslipidemia may be discouraged; however, the information for a healthy whole-food plant-based diet and lifestyle, and prevention for atherosclerosis should be disseminated.
ECG may be included in the screening of such patients found at risk, especially women who do not manifest the typical coronary artery disease symptoms.
It is reasonable to test for diabetes or prediabetes in all adults over 30 years age, body mass index (BMI) >25 kg/m2, and multiple risk factors for CVD. Either glycosylated hemoglobin, fasting plasma glucose, or 2-h oral glucose tolerance test is appropriate for testing. If the tests are normal, the patient should be retested after 3 years.
Women should be educated about breast self-examination. For women aged 20–40 years, clinical breast examination should be done every 3 years. For older women, it should be done annually. Mammography should be reserved for women > 40 years with risk factors such as family history of breast cancer, early menopause, and absence of breastfeeding.
Nationwide VIA-based screening can be instituted as this would be most economical. However, for health checkups, Pap smear is a better test. In the general population, this may be conducted among women above 30 years of age. Women aged 30–49 years should be prioritized. Routine screening may stop by 60 years of age. Screening even once in a lifetime would be beneficial. Screening intervals may depend on financial, infrastructural, and other resources and may vary from 5 to 10 years. Women who have undergone total hysterectomy for benign disease should discontinue screening for cervical cancer.
Population education on hygienic sexual practices is crucial in preventing cancer of the cervix. This cancer has been found to be much less common in communities that practice male circumcision.
PSA for every elderly male is the most overused and least helpful screening modality. Routine screening by PSA should be stopped. At-risk groups (e.g., strong family history) may undergo transrectal ultrasound or systematic biopsies after counseling for pros and cons of such invasive tests and the indolent course of cancer even without treatment.
Chronic obstructive pulmonary disease
Smoking cessation is the most important secondary prevention intervention for patients found to have COPD. It leads to a sustained small improvement in the level of FEV1 in smokers. Pharmaceutical intervention is only of limited benefit in severe airway disease. It does not affect the progression of disease to a relevant extent. Smoking cessation is all about the motivation of the individual patient. If you feel that a motivation can be related to identifying a currently unrecognized condition in the patient, it might still be appropriate to “screen” the patient in front of you. This can be done without advocating population screening.
The public has a high expectation for a comprehensive annual physical examination and extensive routine testing. The insurance and healthcare industry over-sells this concept due to obvious profit motivation. It thus falls on an individual practitioner to educate the public about the value of PHEs and current recommendations for specific preventive health services and its inherent shortcomings.
PHE has a beneficial effect on the delivery of some clinical preventive services and may have a beneficial effect on patient worry, providing justification for its continued implementation in clinical practice. Nevertheless, routine health checkups as practiced in urban India are counterproductive within the framework of community healthcare. Apart from the tests discussed above, there is no rationale for performing other tests such as Vitamin D, Vitamin B12, thyroid-stimulating hormone, electrolytes, and pulmonary function tests (PFTs) as part of “health checkup” for the general population.
In conclusion, the key PHE recommendations that may be adopted are the following: All adults who visit a doctor should be screened for hypertension. Routine screening for dyslipidemia may be discouraged. Adults over 30 years age, BMI >25 kg/m2, and/or with multiple risk factors for CVD should be tested for diabetes. An ECG may be included in the screening of patients found at risk of CVD. Women should be educated about breast self-examination. Clinical breast examination should be done every 1–3 years depending on age group. Mammograms should be reserved for at risk patients. Pap smear is a good test for cervical cancer screening and may be conducted among women above 30 years of age. Women aged 30–49 years should be prioritized. Routine screening may stop by 60 years of age. Routine screening by PSA should be stopped. At-risk groups may undergo transrectal ultrasound or systematic biopsies if appropriate. The physician at his or her discretion may use PFTs to demonstrate effects of smoking to a patient. Routine screening with PFTs is discouraged for COPD detection.
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Conflicts of interest
There are no conflicts of interest.
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