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Health Checks -

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Norman Swan: Hello and welcome to the Health Report with me Norman Swan.

Today, cranberries and your bladder—it's juice versus capsules at 50 paces; new uses for mouthwashes—now don't think about that one too hard—a popular theory about asthma maybe biting the dust, and research which suggests Australia might be wasting significant sums of money on health checks.

We probably spend around $100 million a year through Medicare on health checks of one kind or other. One of the programs Medicare pays for is the 45-year-old health check on people who are supposed to have at least one risk factor for chronic problems like heart disease—which probably fits most of us.

But a review of the world's scientific literature on health checks for people at average risk, published by the Cochrane Collaboration, has found no benefit.

Dr Lasse Krogsboll is the lead author. He's a physician and researcher at the Nordic Cochrane Centre in Copenhagen.

Lasse Krogsboll: In Denmark there's been for the past ten years a debate about whether to implement a national offer of health checks or not. We felt that there was a need for a good systematic review with a focus on clinical outcomes rather than surrogate outcomes to inform this debate.

Norman Swan: In other words, do health checks save lives, to be blunt, or prevent you getting a heart attack or a stroke?

Lasse Krogsboll: Yes, those are the outcomes we want. We didn't want surrogate outcomes like blood pressure or cholesterol or delivery of preventive services, because it can be difficult to determine what an improvement in those outcomes means to people in terms of reduced morbidity and mortality. For example, they do not capture information on possible harms of treatment or the consequences of screening.

Norman Swan: There are health checks and health checks. How did you define a health check in this study, because what you did in this study is you reviewed the world literature to find out what studies there were for the benefits of doing a health check. But I mean there are health checks and health checks. You come in to see your general practitioner and they say 'how are you', that could be a health check, or going for a stress ECG or a full-body CT scan could be a health check.

Lasse Krogsboll: Well we wanted to make a broad review, so we tried to define it in a simple and pragmatic way. So we defined health checks as screening general populations for more than one disease risk factor in more than one organ system. And we did not include trials where the participants were selected for having one or another condition like people with hypertension or heart disease.

Norman Swan: So these were people off the street coming in to be checked by a doctor or nurse...or what?

Lasse Krogsboll: Any kind of health professional.

Norman Swan: But a face-to-face assessment of their risks of heart disease or cancer or what have you and fed back to them.

Lasse Krogsboll: Yes, exactly. They were recruited from the community, the general population in many trials, and some trials also from general practice patient lists.

Norman Swan: But not preselected for being at risk.

Lasse Krogsboll: No. And there was also one trial where they identified people from workplaces.

Norman Swan: It doesn't strike me as an area where you're dealing with good raw material in terms of the research that's been done—or am I wrong? Did you find good trials that have been conducted in this space?

Lasse Krogsboll: Yes, we found some good trials. We also found some less good trials of course. But in terms of the randomisation of making comparable groups, we judged many of the trials to be of low risk of bias for that, because most of them randomised people before they contacted them at all.

Norman Swan: And just to explain what we're talking about here, the randomised trial is what you're looking at is one group getting the intervention, one group not. And it's got to be truly randomly allocated with no bias towards one group or another, and that's one of the first things you look at in the quality of a study.

Lasse Krogsboll: Yes, they have to be comparable. And most of these trials had the advantage that they randomised people before they even contacted them, to either receive an invitation or not receive an invitation. And so you bypass some potential sources of bias in the generation of groups.

Norman Swan: And what did you find?

Lasse Krogsboll: We found 16 trials which met our inclusion criteria, and two of those we were not able to find any results on those. One of them was cancelled but we couldn't find any preliminary results. And so we had 14 trials we could analyse and nine of those trials had results on our primary outcomes, which were total mortality and core specific mortality.

For total mortality we had nearly 12,000 deaths in these trials, and the length of follow-up ranged between four years and 22 years, with the median being nine years. And when doing a meta-analysis on that, we could not see any signs of effect, neither beneficial nor harmful. And the same was the case with cardiovascular mortality and cancer mortality.

Norman Swan: So when you split it up to the two commonest causes of death, you couldn't see it in any shape or form. Did you look for non-fatal heart attacks and strokes?

Lasse Krogsboll: Yes. We found two trials reporting on that, and they could not document effects from that either. They were pretty big trials and of reasonable quality. Only two trials reported on that.

Norman Swan: How different was the method for doing the health screen and the sort of tests that the doctor or nurse might have done?

Lasse Krogsboll: They were quite different. Some were very broad and used many tests, and some were more focused on cardiovascular risk factors. But all of them had cardiovascular risk factor assessment. Then there were quite a lot of trials that also questioned people on any possible symptoms or family history. And a lot of trials also used ECT (electrocardiogram) or lung function tests and various blood tests.

Norman Swan: And were any of the trials positive?

Lasse Krogsboll: That depends on what you mean by positive.

Norman Swan: They saved lives...

Lasse Krogsboll: No. There was not any one who found that they saved their lives in terms of total mortality. There was one trial that found that they saved lives in terms of colorectal cancer and hypertension, but that was the only result that found that. And we also included ischemic heart disease and there was no effect.

Norman Swan: What we're not seeing here is that traditional screening campaigns like faecal occult blood don't work. What we're saying here is if you add on a general health screen where you come in and get examined and have tests done to you independent of that, that's not making a difference.

Lasse Krogsboll: Exactly. And we have to also consider what the comparator is, because the control groups in these trials were probably not completely untouched by any kind of prevention or screening. General practitioners often do assess the patients and often do know their patients quite well for many years, and they might be performing many of these preventive activities adequately so that the systematic screening effort, the systematic health check effort does not seem to add anything.

Norman Swan: So you're not really comparing it against nothing.

Lasse Krogsboll: No.

Norman Swan: So what you're saying here is that against the background of what you would normally have in Scandinavia or Australia, adding on a specific health check's not going to add anything.

Lasse Krogsboll: Yes, that's what our results indicate. Of course it's almost by definition not possible to prove that an intervention does not work, but we did have so much evidence that we believe it's unlikely that they reduce mortality and morbidity.

Norman Swan: Now, there is a possibility of harm here, because you could find stuff you were never meant to find. Somebody goes on and has further tests which cost them money, and they might have unnecessary operations or procedures which could do them harm. Did any of these trials measure harm?

Lasse Krogsboll: We had included several outcomes that would reflect harm—for example, a number of new diagnoses. Of course that could be both, beneficial or harmful, but in the absence of real benefit in morbidity or mortality, then more diagnosis would…we think it should be viewed as a harm. We looked at that and we also looked at drug treatments and surgery and a number of follow-up investigations. And most of these were very infrequently reported.

Norman Swan: So you don't know about harms.

Lasse Krogsboll: We don't know very much about harms because they were not studied very much. But we did find some suggestions that more diagnoses were being made. We didn't find anything about surgery in our follow-up investigations, so that's completely unknown.

And we also looked at worry, and there are two trials that investigated whether health checks cause or reduce worry, and they did not find any effects. But it should be noted that those results were long term results. We found no short term results on measures of worry. You might imagine that it might cause worry in the short term but that which would go away.

Norman Swan: So is Denmark going to start health checks, then?

Lasse Krogsboll: Denmark? No. It doesn't seem like it at the moment.

Norman Swan: They're going to save their money.

Lasse Krogsboll: [Laughs] Well I think our results suggest that it would be a good idea to spend the money on something else. That's my opinion.

Norman Swan: And that analysis did not include the elderly, although there isn't much to support health checks for them either, apart from maybe reducing nursing home admissions. The systematic review also didn't cover children's health checks, a bone of contention recently in Australia.

Dr Lasse Krogsboll is a physician and research at the Nordic Cochrane Centre in Copenhagen.