General health checks in adults for reducing morbidity and mortality from disease Lasse T Krogsbøll*, Karsten Juhl Jørgensen, Christian Grønhøj Larsen, Peter C Gøtzsche Editorial Group: Cochrane Effective Practice and Organisation of Care Group Published Online: 17 OCT 2012 Assessed as up-to-date: 4 JUL 2012 DOI: 10.1002/14651858.CD009009.pub2 Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

Abstract

Background

General health checks are common elements of health care in some countries. These aim to detect disease and risk factors for disease with the purpose of reducing morbidity and mortality. Most of the commonly used screening tests offered in general health checks have been incompletely studied. Also, screening leads to increased use of diagnostic and therapeutic interventions, which can be harmful as well as beneficial. It is, therefore, important to assess whether general health checks do more good than harm.

Objectives

We aimed to quantify the benefits and harms of general health checks with an emphasis on patient-relevant outcomes such as morbidity and mortality rather than on surrogate outcomes such as blood pressure and serum cholesterol levels.

Search methods

We searched The Cochrane Library, the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Effective Practice and Organisation of Care (EPOC) Trials Register, MEDLINE, EMBASE, Healthstar, CINAHL, ClinicalTrials.gov and WHO International Clinical Trials Registry Platform (ICTRP) to July 2012. Two authors screened titles and abstracts, assessed papers for eligibility and read reference lists. One author used citation tracking (Web of Knowledge) and asked trialists about additional studies.

Selection criteria

We included randomised trials comparing health checks with no health checks in adults unselected for disease or risk factors. We did not include geriatric trials. We defined health checks as screening general populations for more than one disease or risk factor in more than one organ system.

Data collection and analysis

Two authors independently extracted data and assessed the risk of bias in the trials. We contacted authors for additional outcomes or trial details when necessary. For mortality outcomes we analysed the results with random-effects model meta-analysis, and for other outcomes we did a qualitative synthesis as meta-analysis was not feasible.

Main results

We included 16 trials, 14 of which had available outcome data (182,880 participants). Nine trials provided data on total mortality (155,899 participants, 11,940 deaths), median follow-up time nine years, giving a risk ratio of 0.99 (95% confidence interval (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 on cancer mortality (139,290 participants, 3663 deaths), risk ratio 1.01 (95% CI 0.92 to 1.12). Subgroup and sensitivity analyses did not alter these findings.

We did not find an effect on clinical events or other measures of morbidity but one trial found an increased occurrence of hypertension and hypercholesterolaemia with screening and one trial found an increased occurence of self-reported chronic disease. One trial found a 20% increase in the total number of new diagnoses per participant over six years compared to the control group. No trials compared the total number of prescriptions, but two out of four trials found an increased number of people using antihypertensive drugs. Two out of four trials found small beneficial effects on self-reported health, but this could be due to reporting bias as the trials were not blinded. We did not find an effect on admission to hospital, disability, worry, additional visits to the physician, or absence from work, but most of these outcomes were poorly studied. We did not find useful results on the number of referrals to specialists, the number of follow-up tests after positive screening results, or the amount of surgery.

Authors' conclusions

General health checks did not reduce morbidity or mortality, neither overall nor for cardiovascular or cancer causes, although the number of new diagnoses was increased. Important harmful outcomes, such as the number of follow-up diagnostic procedures or short term psychological effects, were often not studied or reported and many trials had methodological problems. With the large number of participants and deaths included, the long follow-up periods used, and considering that cardiovascular and cancer mortality were not reduced, general health checks are unlikely to be beneficial.

 

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Plain language summary

General health checks for reducing illness and mortality

General health checks involve multiple tests in a person who does not feel ill with the purpose of finding disease early, preventing disease from developing, or providing reassurance. Health checks are a common element of health care in some countries. To many people health checks intuitively make sense, but experience from screening programmes for individual diseases have shown that the benefits may be smaller than expected and the harms greater. One possible harm from health checks is the diagnosis and treatment of conditions that were not destined to cause symptoms or death. Their diagnosis will, therefore, be superfluous and carry the risk of unnecessary treatment.

We identified 16 randomised trials which had compared a group of adults offered general health checks to a group not offered health checks. Results were available from 14 trials, including 182,880 participants. Nine trials studied the risk of death and included 155,899 participants and 11,940 deaths. There was no effect on the risk of death, or on the risk of death due to cardiovascular diseases or cancer. We did not find an effect on the risk of illness but one trial found an increased number of people identified with high blood pressure and high cholesterol, and one trial found an increased number with chronic diseases. One trial reported the total number of new diagnoses per participant and found a 20% increase over six years compared to the control group. No trials compared the total number of new prescriptions but two out of four trials found an increased number of people using drugs for high blood pressure. Two out of four trials found that health checks made people feel somewhat healthier, but this result is not reliable. We did not find that health checks had an effect on the number of admissions to hospital, disability, worry, the number of referrals to specialists, additional visits to the physician, or absence from work, but most of these outcomes were poorly studied. None of the trials reported on the number of follow-up tests after positive screening results, or the amount of surgery used.

One reason for the apparent lack of effect may be that primary care physicians already identify and intervene when they suspect a patient to be at high risk of developing disease when they see them for other reasons. Also, those at high risk of developing disease may not attend general health checks when invited. Most of the trials were old, which makes the results less applicable to today's settings because the treatments used for conditions and risk factors have changed.

With the large number of participants and deaths included, the long follow-up periods used in the trials, and considering that death from cardiovascular diseases and cancer were not reduced, general health checks are unlikely to be beneficial.

Annual Screening Mammography Produces Overdiagnoses, No Mortality Benefit

Annual Screening Mammography Produces Overdiagnoses, No Mortality Benefit

By Joe Elia

Annual mammography screening in women under age 60 does not confer a breast cancer mortality advantage, and it results in more than 20% overdiagnosis among the lesions found, according to a follow-up of the Canadian National Breast Screening Study.

As reported in BMJ, between 1980 and 1985, some 90,000 women aged 40 to 59 were randomized to 5 years of annual mammography or no mammography (women aged 40-49 in the mammography group and all women aged 50-59 received annual physical breast examinations).

After up to 25 years' follow-up, there was no discernible difference between groups in breast cancer mortality. Of the screen-detected tumors, 22% were overdiagnoses — one for every 424 women in the mammography arm.

Andrew Kaunitz, an OB/GYN with NEJM Journal Watch, comments: "This important Canadian report documents the failure of screening mammography to impact mortality from breast cancer, as well as breast cancer overdiagnosis. Based on these and other recently published data, clinicians and women should move away from starting screens among women in their 40s and from screening annually. While we reevaluate the practice of screening mammography, adopting the U.S. Preventive Services Task Force 2009 recommendations (beginning screening in average-risk women at age 50 and screening biennially) would appear prudent."

PSA testing

    " It is difficult to get someone to understand something when their pay depends on them not understanding it. " Upton Sinclair
     Eg. The United States Preventative Services Task Force (USPSTF) made a final recommendation on May 21, 2012 which aligned consistently with the draft recommendation publicly announced on October 7, 2011.

The recommendation is against prostate-specific antigen (PSA) based screening for healthy men, asserting that there is “moderate or high certainty that the service has no benefit or that the harms outweigh the benefits,” 

VS -The American Urological Association, on the other hand, says the decision to undergo PSA testing should be individualized. Last year, the group criticized the USPSTF for doing "a great disservice by disparaging what is now the only widely available test for prostate cancer."

PSA Testing in Older Men Continues Unabated Despite USPSTF Recommendation

The rate of screening for prostate cancer with PSA testing has remained unchanged in elderly men despite a 2008 U.S. Preventive Services Task Force recommendation against such testing, according to a research letter in JAMA.
Using data from the National Health Interview Survey, investigators compared PSA screening rates in 2005 and 2010. (In 2008, the USPSTF recommended against screening in men aged 75 and older.) In all age groups — including the elderly — screening rates remained unchanged in the two periods.
The authors say the discrepancy between the recommendation and the observed practice pattern "may reflect lack of guideline awareness, financial incentives, or patient or physician confidence in PSA screening."

Cochrane Review Stirs Controversy Over Statins in Primary Prevention Sue Hughes

January 21, 2011 (London, United Kingdom) — A new Cochrane review has provoked controversy by concluding that there is not enough evidence to recommend the widespread use of statins in the primary prevention of heart disease [1]. The authors of the new Cochrane meta-analysis, led by Dr Fiona Taylor (London School of Hygiene and Tropical Medicine, UK), issued a press release questioning the benefit of statins in primary prevention and suggesting that the previous data showing benefit may have been biased by industry-funded studies. This has led to headlines in many UK newspapers saying that the drugs are being overused and that millions of people are needlessly exposing themselves to potential side effects. This has angered researchers who have conducted other large statin meta-analyses, who say the drugs are beneficial, even in the lowest-risk individuals, and their risk of side effects is negligible. They maintain that the Cochrane reviewers have misrepresented the data, which they say could have serious negative consequences for many patients currently taking these agents. The Cochrane authors reviewed data from 14 trials involving 34 272 patients. Outcomes in patients given statins were compared with outcomes in patients given placebos or usual care. Although results suggested that deaths were reduced on statins, the researchers say the effect is not large enough to justify the cost/effort and risk of adverse effects. Senior author Dr Shah Ebrahim (South Asia Network for Chronic Disease, New Delhi, India) told heartwire that their review differed from others done in primary prevention in that it looked at just those at low risk, limiting the studies included to just those with populations where <10% had a previous history of CVD. It is probably a real effect but it means a lot of people have to be treated to gain this small benefit. Ebrahim commented to heartwire : "If you look at the hard end points of all deaths and coronary deaths, the effects are consistent with both benefit and with the play of chance. But importantly, the absolute benefits are really rather small--1000 people have to be treated for one year to prevent one death. It is probably a real effect, but it means a lot of people have to be treated to gain this small benefit. As we don't know the harms, it seems wrong-minded to me to treat everyone with a statin. In these circumstances, lifestyle changes and stopping smoking would be far preferable." I object to the conclusions they have drawn from their review. But Dr Colin Baigent (Clinical Trials Service Unit, Oxford, UK) commented to heartwire : "I object to the conclusions they have drawn from their review. They say there is not good evidence of benefit, but their own data show significant reductions in deaths and cardiac events." And Baigent further objects to the Cochrane authors' suggestion that harms are not known with statins. "They didn't show any increase in adverse events in their review, but they then say the benefit is not worth the risk. That doesn't make sense." Cochrane Results The Cochrane review showed that in the eight trials that reported on total mortality, none of the individual trials showed strong evidence of a reduction in total mortality, but when the data were pooled, a relative risk reduction of 17% was observed with statin treatment. On combined fatal and nonfatal CHD events, nine trials reported on this end point, with four trials showing evidence of a reduction in this combined outcome, which was maintained in the pooled analysis, with a 28% relative reduction. Seven trials reported on fatal and nonfatal stroke, and on pooled analysis, statin treatment was associated with a 22% relative reduction. Cochrane Review: Risk Ratio of Major Events With Statins in Lower-Risk Primary-Prevention Patients Outcome Risk ratio (95% CI) Total mortality 0.83 (0.73–0.95) Fatal and nonfatal CHD events 0.72 (0.65–0.79) Fatal and nonfatal stroke 0.78 (0.65–0.94) No excess in combined adverse events, cancers, or specific biochemical markers were found. The authors conclude: "This current systematic review highlights the shortcomings in the published trials of statins for primary prevention. Selective reporting and inclusion of people with cardiovascular disease in many of the trials . . . in previous reviews of [statins'] role in primary prevention make the evidence impossible to disentangle without individual patient data." They say that in people at high risk of cardiovascular events (>20% 10-year risk), "it is likely that the benefits of statins are greater than potential short-term harms, although long-term effects (over decades) remain unknown." They conclude: "Any decision to use statins for primary prevention should be made cautiously and in the light of an assessment of the patient's overall cardiovascular risk profile. Widespread use of statins in people at low risk of cardiovascular events--below a 1% annual all-cause mortality risk or an annual CVD event rate of below 2% observed in the control groups in the trials considered here--is not supported by the existing evidence." Latest Oxford Meta-Analysis Not Included The Cochrane review did not include the recent meta-analysis from the Oxford group, published late last year, which showed a clear reduction in events with statin therapy in primary-prevention patients. Baigent noted that this meta-analysis was more reliable than the Cochrane review, as the Oxford researchers used individual patient data from all the trials. "Our 2010 meta-analysis in primary prevention is substantially more complete than the Cochrane review and provides direct and overwhelmingly statistically convincing evidence of a clear reduction in events in all patient groups, right down to those at the lowest risk." On the possible hazards of taking these drugs, Baigent says: "Statin therapy is very safe. The most serious hazard, rhabdomyolysis, is very rare, and most often seen at high doses. There is a possibility that reducing LDL cholesterol might increase the risk of hemorrhagic stroke, but even in primary prevention these hazards would be much smaller than the benefits, and there is no reliable evidence for other hazards mentioned by the Cochrane authors, such as depression and cognitive impairment." It All Comes Down to Economics Baigent says the only argument against using statins in low-risk people is economic. "The absolute benefits of statin therapy become very small when used among people at low absolute risk, so it is important that the costs of such treatment are considered when weighing how widely statins should be used. That is a government decision." In the UK, the National Institute for Clinical Excellence [NICE] currently recommends that statins not be used for people with a CHD risk below 20% over 10 years. Ebrahim says the Cochrane conclusions are in line with this. But Baigent argues that the benefits of statins are clear at levels far below this threshold. "Whether or not it is economic to use them in the lowest-risk individuals is not for me to say, but generic statins are now very cheap, and there is clear evidence of benefit and safety based on substantial numbers of individuals studied in large-scale trials. So, when all the relevant randomized evidence is considered, there does not seem to me to be any justification at all for the Cochrane authors' claim that the evidence is unclear on this issue." Educational Programs Also of Little Benefit In a separate Cochrane review [2], the same group looked at the use of "healthy heart programs" that use counseling and educational methods to encourage people to reduce their risks for developing heart disease. These risk factors include high cholesterol, excessive salt intake, high blood pressure, excess weight, a high-fat diet, smoking, diabetes, and a sedentary lifestyle. They reviewed 55 trials that aimed to reduce more than one risk factor in people without evidence of cardiovascular disease. Results showed that after a median duration of 12 months of follow-up, multiple risk-factor intervention was associated with small reductions in risk factors, including blood pressure, cholesterol, and smoking, but had little or no impact on the risk of coronary heart disease mortality or morbidity. They conclude: "The methods of attempting behavior change in the general population are limited and do not appear to be effective. Different approaches to behavior change are needed and should be tested empirically before being widely promoted, particularly in developing countries where cardiovascular disease rates are rising." In an accompanying editorial [3], Dr Carl Heneghan (University of Oxford, UK) suggests an alternative approach for policy is to focus on populationwide prevention. He reports that "legislating for smoke-free public spaces, redesigning public spaces to improve exercise, or reducing daily dietary salt intake prove generally effective and can be cost-saving interventions. Given the scale of the worldwide CVD problem, large-scale commissioned studies of multiple risk-factor interventions are urgently required." References Taylor F, Ward K, Moore THM, et al. Statins for the primary prevention of cardiovascular disease.Cochrane Database Syst Rev 2011; 1 (CD004816). Ebrahim S, Taylor F, Ward K et al. Multiple risk factor interventions for primary prevention of coronary heart disease. Cochrane Database Syst Rev 2011; 1 (CD001561). Heneghan C. Considerable uncertainty remains in the evidence for primary prevention of cardiovascular disease [editorial].Cochrane Libr2011 (January 19, 2011). Available here. Heartwire © 2011 Medscape, LLC

Red-Wine Researcher Charged With 'Photoshop' Fraud Robert Lowes

January 13, 2012 — A University of Connecticut researcher known for touting the health benefits of red wine is guilty of 145 counts of fabricating and falsifying data with image-editing software, according to a 3-year university investigation made public Wednesday. The researcher, Dipak K. Das, PhD, is a director of the university's Cardiovascular Research Center (CRC) and a professor in the Department of Surgery. The university stated in a press release that it has frozen all externally funded research in Dr. Das's lab and turned down $890,000 in federal research grants awarded to him. The process to dismiss Dr. Das from the university is already underway, the university added. Dr. Dipak K. Das A university special review board (SRB) found evidence of research fraud in 2 dozen published papers dating back to 2002 as well as 3 grant applications. The university said it has notified 11 journals that published the studies of its findings. The publications include The American Journal of Physiology — Heart and Circulatory Physiology and the Journal of Molecular and Cellular Cardiology. Some of the studies asserted that a substance in red wine called resveratrol promoted heart health. "We have a responsibility to correct the scientific record and inform peer researchers across the country," said Philip Austin, interim vice president of health affairs at the University of Connecticut. The review board findings "point to a pervasive attitude of disregard within the CRC for commonly accepted scientific practices in the publication and reporting of research data," its report stated. "Given the large number of irregularities discovered in this investigation...the SRB can only conclude that they were the result of intentional acts of data falsification and fabrication, designed to deceive." The review board report stated that the US Office of Research Integrity (ORI) tipped off the university in 2008 about alleged fraud involving a 2007 article in Free Radical Biology and Medicine coauthored by Dr. Das titled "Redox regulation of resveratrol-mediated switching of death signal into survival signal." The ORI is now conducting its own investigation of Dr. Das, according to the university. Other members of the CRC played a part in the research fraud, and they are under investigation as well. "No Resemblance to Any Legitimate Experiment" The exact nature of the alleged fraud involves images of "blots" obtained through gel electrophoresis that were featured in article figures. Most of the figures presented Western blots, designed for studying proteins. Using Photoshop software as a forensic tool, the review board determined that dozens of images bore evidence of inappropriate manipulation by "photo imaging software." The most egregious examples were pasted-up "artificial blots" that "bear no resemblance to any legitimate experiment" and represent total fabrications. The board also found examples of background erasure, image duplication, and images having been spliced together. The board noted that splicing various blot images together can serve a legitimate purpose but that researchers must precisely describe the manipulation that they perform. Such explanations were lacking in articles coming out of Dr. Das's laboratory. The review board report stated that as head of the lab and senior author of all but one of the tainted articles, Dr. Das "bears principal responsibility for the fabrication and/or falsification that occurred." Furthermore, the evidence "strongly suggests" that Dr. Das was directly involved in faking images for publication. Some of that evidence was pulled from his personal computer. Accused Researcher Cites "Racial Hatred" The report quoted Dr. Das as saying he does not know who prepared the figures that appeared in the journal articles. It stated that he has provided "no substantive information" that could explain the research irregularities. An exhibit in the report contains what the board called Dr. Das's response to the investigation. In a document dated July 30, 2010, Dr. Das said the accusations against him are part of a campaign to rid the university health center of the "Indian community." "I became the Devil for the Health Center, and so did all the Indians working for me," he wrote. "The evidence for conspiracy and racial hatred is overwhelming." He also alleged that the stress of battling the university administration led to a brain hemorrhage and stroke. Medscape Medical News did not receive a reply to an email sent to Dr. Das at his university email address. A company called Resveratrol Partners, which markets a resveratrol-based dietary supplement called Longevinex, said yesterday in a press release that "Dr. Das is attending a scientific conference in India and has not been able to respond to the allegations." The Web site of Resveratrol Partners highlights some of Dr. Das's studies on the cardio benefits of resveratrol. In yesterday's press release, Resveratrol Partners managing partner Bill Sardi said that Dr. Das does not have any business relationship with the company and that other researchers have confirmed the value of Longevinex. Medscape Medical News © 2012 WebMD, LLC Send comments and news tips to news@medscape.net.

Relenza and Tamiflu Questioned

Patients may ask about a widely reported call from the Cochrane Collaboration for full disclosure of information about clinical studies leading to the approval of the neuraminidase inhibitors oseltamivir (Tamiflu) and zanamivir (Relenza) used to treat influenza.

The reviewers point out that data on oseltamivir from 8 trials of a 10-trial meta-analysis remain unpublished and were not available either from the studies' authors or the manufacturer. That meta-analysis "has been the sole publication" cited by the CDC in support of its treatment guidelines.

On the basis of drug company data submitted to government agencies, the reviewers estimate that 60% of patient data from oseltamivir's phase III trials "have never been published." Using such "regulatory information" rather than published journal studies, the reviewers estimate that oseltamivir showed "no evidence of effect" on hospitalization rates; there was not enough information available to assess the drug's effects on complications or viral transmission.