© 2015 American College of Physicians
The information contained herein should never be used as a substitute for clinical judgment.

Should patients see their doctors for regular check-ups?
Medicine Grand Rounds
September 17, 2015
Discussants
Ateev Mehrotra,
MD, MPH
Series Assistant Editor Moderator
Eileen Reynolds, MD Howard Libman, MD
James Heffernan,
MD, MPH
The Series Editors have no conflicts of interest to disclose.

The speakers have no financial relationships with a commercial entity producing healthcare-related products and/or services.
Dr. Reynolds is President-Elect of SGIM but did not participate in the creation or approval of this guideline.
Eileen Reynolds, MD
Ateev Mehrotra, MD, MPH
James Heffernan, MD, MPH
Howard Libman, MD

Medical History
• Healthy 70 year old woman
• Sees her PCP once a year for a check-up

Past Medical and Surgical History
• Mild atypical neuropathy
• Osteoarthritis s/p hip replacement
• Elevated risk of breast cancer due to strong family history
• In the past 5 years, has been seen 6 times in
PCP’s office
– 5 check ups
– 1 visit for self limited abdominal pain

Year
2011
2012
2013
Interval
2014
2015
Exam/Test
Pap/HPV
Pneumovax
BMD
Sx: varicose vein pain
Referred to genetic counseling for breast cancer risk
Results
Normal
Osteopenia
Referred to vascular
Gail Model: 8% 5 year risk
Atypical skin finding Referred to derm
Abnormal mammogram and MRI
Again discussed breast cancer risk in light of bx and re-referred
Hepatitis C and lipids checked
Ordered repeat BMD
Given PCV13 pneumococcal vaccine
Fall, cognition, depression screens negative
Bx: benign
Gail Model risk now
10.2%
Tests normal/negative
Osteopenia stable
Outcome
Had procedure
Deferred medication; plan annual MRI and mammo
Cryotherapy for 8 lesions
Routine follow up; all handled by phone
Started exemastane 25 mg qd; annual follow up planned
6

• Annual check-ups / Periodic Health Exams
(PHE) are covered by private insurance
• Affordable Care Act (ACA) provides for
Wellness Exams under Medicare (2011)
• Costs are high
• Benefits not convincingly shown
• 2 attempts at comprehensive review

• Systematic review for AHRQ (2007)
• Reviewed 7039 articles; included 50 publications from 33 studies
– 10 RCTs, 23 observational studies
• “Overall the strength and consistency of the evidence varied widely among outcomes, as did the magnitude and direction of the results”
*Boulware LE, Marinopoulos S, Phillips KA, Hwang CW, Maynor K, Merenstein D, et al. Systematic review: the value of the periodic health evaluation. Ann Intern Med. 2007;146:289-300.

• Findings:
– PHE has beneficial effect on receipt of cervical cancer, pap, colon cancer screening
– PHE reduces patient worry
– No effects found on cost, clinical outcomes, mortality
• Authors of AHRQ review concluded:
– Findings “provide health care providers and payors with justification for the continued implementation of the
PHE”
*Boulware LE, Marinopoulos S, Phillips KA, Hwang CW, Maynor K, Merenstein D, et al. Systematic review: the value of the periodic health evaluation. Ann Intern Med. 2007;146:289-300.

• Cochrane review and meta analysis (2012)
– Evaluate benefit to morbidity/mortality reduction
– 14 RCTs included; total 182,880 subjects
• Primary endpoints: total and disease specific mortality
• Secondary endpoints: morbidity; cost + utilization (admissions, disability,referrals, tests/procedures, work absence)
– No benefit of PHE found in any outcome
– No heterogeneity in mortality results across 9 best trials
*Krogsbøll LT, Jørgensen KJ, Grønhøj Larsen C, Gøtzsche PC. General health checks in adults for reducing morbidity and mortality from disease: Cochrane systematic review and meta-analysis. BMJ. 2012;345:e7191.

Forest plot showing effect of general health checks on total mortality
*Krogsbøll LT, Jørgensen KJ, Grønhøj Larsen C, Gøtzsche PC. General health checks in adults for reducing morbidity and mortality from disease: Cochrane systematic review and meta-analysis. BMJ. 2012;345:e7191.

• Cochrane review weaknesses
– Age of the studies
• 10 of 14 RCTs published before 1973
– Outcomes other than mortality often not reported
– Concern about bias in study populations

ABIM Foundation and SGIM: 2013
• “Choosing Wisely” campaign
– “Things Providers and Patients Should Question”
– Aims to raise awareness about high cost, low benefit interventions
• “Don’t perform routine general health checks for asymptomatic adult patients”
– Joins USPSTF (1985) and
– Canadian Task Force (1979) suggesting targeted approaches
*www.choosingwisely.org

To help us decide how to apply this recommendation to our patient’s case we asked our discussants the following questions:
• What are the potential benefits of the periodic health exam?
• What are the potential costs of the periodic health exam?
• What patients should have a periodic health exam?
• What do you recommend for Ms. M?

Howard Libman, MD (Moderator)
Director, HIV Program, Healthcare Associates, BIDMC
Chief, Education Section, Division of General Medicine & Primary Care, BIDMC
Professor of Medicine, Harvard Medical School
Ateev Mehrotra, MD, MPH
Associate Professor of Health Care Policy, Harvard Medical School
Associate Professor of Medicine, Division of General Medicine & Primary Care, BIDMC
James Heffernan, MD, MPH
Primary Care Section Chief, Division of General Medicine & Primary Care, BIDMC
Associate Professor of Medicine, Harvard Medical School

Benefits Harms
& Costs

• Hormone-replacement therapy
• Antibiotics for bronchitis
• Anti-arrythmics after a myocardial infarction
• CABG superior to medical therapy
• Ulcers as an infectious disease

• Targeted evidence-based preventive services
• Targeted counseling for smoking, weight-loss
• Health coaching and care coordination for chronic and complex conditions
• Visits with new symptoms
• Having patients who have not seen their doctor for several years come in for a visit to initiate or maintain a relationship

• A specialized visit at some periodic basis focused on nonspecific screening for illness or risk factors

• Mortality – no benefit
• Morbidity – no benefit
• Surrogate outcomes - ?

• “We also chose not to focus on surrogate outcomes such as changes in risk factors or delivery of preventive services, as these may be misleading because an improvement does not necessarily benefit the participant and because they do not measure harms.”
*Krogsbøll LT, Jørgensen KJ, Grønhøj Larsen C, Gøtzsche PC. General health checks in adults for reducing morbidity and mortality from disease: Cochrane systematic review and meta-analysis. BMJ. 2012;345:e7191.

• Decreasing patient worry
– Evidence mixed and placebo effect
• Increase delivery of preventive care
– PHE inefficient method of delivering preventive care
– Need for active outreach
*Boulware LE, Marinopoulos S, Phillips KA, Hwang CW, Maynor K, Merenstein D, et al. Systematic review: the value of the periodic health evaluation. Ann Intern Med. 2007;146:289-300.

“…we know that all medical interventions can lead to harm.
Possible harms from health checks are overdiagnosis, overtreatment, distress or injury from invasive follow-up tests, distress due to false positive test results, false reassurance due to false negative test results.”
*Krogsbøll LT, Jørgensen KJ, Grønhøj Larsen C, Gøtzsche PC. General health checks in adults for reducing morbidity and mortality from disease: Cochrane systematic review and meta-analysis. BMJ. 2012;345:e7191.

• #1 reason an adult sees a physician
• $10 billion in direct medical costs & $3 billion in patient time
• PCP time is a scare national resource
– ~10% of PCP visits for PHE
– In Massachusetts: ~50 day wait time for an appointment
*Mehrotra A, Zaslavsky AM, Ayanian JZ. Preventive health examinations and preventive gynecological examinations in the United States. Arch Intern Med. 2007;167:1876-83.
*Ray KN, Chari AV, Engberg J, Bertolet M, Mehrotra A. Opportunity costs of ambulatory medical care in the United States. Am J Manag Care. 2015;21:567-74.

• Criticisms
– Prior research looked at wrong outcomes
– Prior research is too old & PHEs are different now
• Response
– Correct next step is a new trial, not continuing to encourage PHE
• Rescue bias
– “Discounts data by selectively finding faults in the experiment.”
– “Suspicious of evidence that is inconsistent with apparently wellconfirmed principles.”
*Kaptchuk TJ. Effect of interpretive bias on research evidence. BMJ. 2003;326:1453-1455.

% PCPs who strongly agree or agree with the following views on the annual physical examination
• 94% believe:
• 94% believe:
• 74% believe:
• 66% believe:
• 63% believe:
• 55% disagree: improves relationship provides valuable time for counseling improves detection of subclinical illness covered by insurance has proven value not recommended
*Prochazka AV, Lundahl K, Pearson W, Oboler SK, Anderson RJ. Support of Evidence-Based Guidelines for the
Annual Physical Examination: A Survey of Primary Care Providers. Arch Intern Med. 2005;165:1347-1352.

Benefits
Mortality
Morbidity
Preventive care
Relationships
Harms &
Costs
Overdiagnosis
Spending
PCP time

• Eliminate PHEs
• Create “Primary care maintenance” visits
– Limited to those with no PCP visits for several years
– Focus on relationships and not on screening/testing
• Focus on better methods of delivering preventive care
• Use savings for primary care interventions that have been shown to been effective such as health coaching
• To Ms. M.
– Come in when she feels ill

*Cameron WB. Informal Sociology: a Casual Introduction to Sociological Thinking. Random House.
1963, p.13.

So what ’s wrong with the evidence cited by SGIM, especially the Cochrane review?
• The “health checks” were NOT primary care visits
– Screening took place in a usual care site in only 4/14 studies
•
The Bottom Line -- What was counted in the
• than half the studies limited to one check
Cochrane review is largely irrelevant in the context
Most studies were initiated in the 1960s and 70s, and none
• Boulware et al. actually endorsed implementation
• Geriatric trials were not included
• Loss to follow up not well described
*Krogsbøll LT, Jørgensen KJ, Grønhøj Larsen C, Gøtzsche PC. General health checks in adults for reducing morbidity and mortality from disease: Cochrane systematic review and meta-analysis. BMJ. 2012;345:e7191.

Convenience survey, academic primary care faculty members 8/2015
• Continuity relationship
• Screening/counseling
• Identification of new clinical issues
• Care coordination
• Education around emerging health information
• Opportunity to focus attention on family and social issues, and goals of care
• Provide a haven for patients to discuss sensitive issues, embarrassing concerns and, most importantly, matters of safety

• Ms. M. has received outstanding care
• Age-appropriate preventive measures over time, based on evolving evidence/recommendations
– PCV and pharmacological breast cancer risk reduction
• Interventions for actinic skin lesions, varicose veins
• Referral for abdominal pain when it arose
• Evolution of an abiding and trusting relationship with her PCP

Continuity of care is an iterative and cumulative process, a point missed entirely in SGIMs admonition against the PHE and not addressed by the studies cited

Study Evidence…
• 51 of 81 separate care outcomes were significantly improved with significantly lower cost and utilization for 35 of 41 cost variables in association with interpersonal continuity
• In review of preventable admissions, increase in continuity metric of 0.1 associated with 2% reduction of preventable hospitalization
• 0.1 increase in COC score  7% overall reduction in “overused procedures”
*Saultz JW, Lochner J. Interpersonal continuity of care and care outcomes: a critical review. Ann Fam
Med. 2005;3:159-166.
*Nyweide DJ, Anthony DL, Bynum JP, Strawderman RL, Weeks WB, Casalino LP, et al. Continuity of care and the risk of preventable hospitalization in older adults. JAMA Intern Med. 2013;173:1879-1885.
*Romano MJ, Segal JB, Pollack CE. The Association Between Continuity of Care and the Overuse of
Medical Procedures. JAMA Intern Med. 2015;175:1148-1154.

…and more study evidence…
• Retrospective cohort review of hospitalizations, ED visits, complications and costs of care associated with the Bice-
Boxerman continuity-of-care (COC) index
– Based on claims data of Medicare beneficiaries experiencing a 12-month episode of care for CHF, COPD or DM
• Higher levels of continuity associated with lower odds of inpatient hospitalization, ED visits, complications and total costs for CHF, COPD and DM
* Hussey PS, Schneider EC, Rudin RS, Fox DS, Lai J, Pollack CE. Continuity and the Costs of Care for Chronic Disease. JAMA Intern Med. 2014:174:742-748.

OR for Hospitalizations, ED Visits, and
Complications with 0.1 Increase in COC Index
Inpatient Hospitalization
CHF
0.94
ED Visits 0.92
Complications Related to CHF/COPD/DM, Comorbidities, &
Patient Safety
Percentage Change in Costs with 0.1 Increase in
COC Index
Total Costs
Inpatient Hospitalization
ED Visits
Complications Related to CHF/COPD/DM, Comorbidities, &
Patient Safety
Odds ratios for incidence, all P < .0001
Cost reductions, all P < .01
*Hussey PS, Schneider EC, Rudin RS, Fox DS, Lai J, Pollack CE. Continuity and the Costs of Care for Chronic Disease. JAMA Intern Med. 2014:174:742-748.
COPD
0.95
0.93
0.92-0.96
4.7 – 6.3% lower
4.6 - 6.1% lower
5.8 - 6.2% lower
4.1 - 9.8% lower
DM
0.95
0.94

• Continuity of care and the PHE are not strictly synonymous, but the PHE remains the anchor of the continuity relationship
• Studies of the value of continuity are far better evidence of the worth of the PHE than the outdated and off-point studies cited by SGIM

• There are 55 USPSTF Grade A and B recommendations for screening
• Many of the screens do not require a visit, but where better to oversee, discuss and counsel than through the PHE?
• “There is always something…”
– Nevus  malignant melanoma
– Low anterior cervical lymph node  Hodgkins disease
– Patient who feels comfortable enough to share history of childhood abuse only after 3 years of care
• Personal bond benefiting both the patient and the PCP
*U.S. Preventive Services Task Force. A and B Recommendations. Available from: http://www.uspreventiveservicestaskforce.org/Page/Name/uspstf-a-and-b-recommendations/
*Wong CJ, Gaster B, Dugdale DC. Choosing Wisely: In defense of the preventive health visit. Am J Prev Med.
2014;47:653-655.

Direct and indirect costs of the PHE itself
• Cost of an individual PHE is modest, but the aggregate annual cost of PHEs exceeds $10 billion
• Indirect costs: time off from work, parking, etc.
But, compared to what?
• Total US health expenditures in 2013  $2.9 trillion
– Hospital care: $936 billion 5% reduction = $46.8 billion
– Physician and clinical services: $586.7 billion (PHE = 1.7%)
• Impressive growing evidence of cost savings related to COC…
*Centers for Medicare & Medicaid Services. National Health Expenditure Data - Historical 2014. Available from: https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-
Reports/NationalHealthExpendData/NationalHealthAccountsHistorical.html.

Direct and indirect costs of the PHE itself
More, compared to what?
• What is the value, and what are the costs of…?
– Six month in-office “OCP checks” by a gynecologist for a
26 year old woman
– Radiographs/MRI before a patient is seen in an orthopedic office, before assessment of the clinical issue
– Annual follow up with an oncologist 7 years after surgical cure of a low-grade malignancy
– Annual follow up with a cardiologist (likely with an echocardiogram) for low grade aortic stenosis

• Non-evidence based testing does occur…
• These costs appear to be more than offset by the reduction in more expensive procedures when there is higher continuity of care
• The “crowding out phenomenon”
• Providing access to timely care is far better addressed in global redesign into modern care models such as the PCMH

The Workload of Primary Care in the
Traditional (Pre -PCMH) Model
• 7.4 hr/day to do prevention
• 10.6 hr/day to do chronic disease management
• 5.6 hr/day to manage acute issues…
*Yarnall KS, Pollak KI, Østbye T, Krause KM, Michener JL. Primary care: is there enough time for prevention? Am J Public Health. 2003;93:635-641.
*Østbye T, Yarnall KS, Krause KM, Pollak KI, Gradison M, Michener JL. Is there time for management of patients with chronic diseases in primary care? Ann Fam Med. 2005;3:209-214.

Practice Transformation to Modern Care Models, e.g., PCMH
1. Team-based care
2. Proactive population management
• Preventive and wellness services for all patients
• Chronic disease management
• Increased use of technology
3. Care management of our sickest patients
4. Patient engagement
5. Aggressive panel/roster/schedule mgt.
6. Continuing important role for the PHE

• Mature PCMH, arguably most successful in the US
• Strong commitment to proactive population and chronic disease management
• Innovative use of and reimbursement for non-office based care – email, phone, etc.
• Better access, longer visits, fewer patients/session
• Improved physician retention
• The PHE – “Well-Care Visit” -- is a cornerstone of the care package offered and delivered

Recommended Interval for Well-Care Visits (years)
Age Women Men
18-21
22-49
50-64
65+
2
1
1
4
2
1
1
4
*GroupHealth. Adult Well-Care Visits, Screenings, and Immunizations 2014 . Available from: http://www.ghc.org/healthAndWellness/index.jhtml?item=/common/healthAndWellness/tests/recommended
Tests/adultTests.html

Everyone should have an initial health evaluation with a primary care provider and then follow up PHEs at intervals determined by the patient’s evolving risk profile, needs and wishes.

Ms. M. has received outstanding care and has a wonderful partnership with her primary care physician. Happily, she has no chronic conditions for which she needs to be routinely seen. I would encourage her to continue PHEs on a schedule that works for her and for her PCP.

• SGIM’s admonition against the PHE is celebrated more in the breach than in the performance
• Patients and PCPs continue to value and benefit in a multifaceted way from the PHE
• The PHE has not been shown to be of low value, high risk or high cost and should not have been singled out for abandonment; rather, the PHE should continue to serve as a high-level capstone activity in evolving models of primary care
• Cutting this core activity out of primary care will not materially improve access and will poison the well for existing PCPs and for trainees interested in primary care

We would like to thank…
Our Patient, Ms. M
Ateev Mehrotra, MD, MPH & James Heffernan, MD, MPH
Risa Burns, MD, MPH
Deborah Cotton, MD, MPH
Howard Libman, MD
Eileen Reynolds, MD
Gerald Smetana, MD
Last Minute Productions
BIDMC Media Services
Lizzie Williamson

© 2015 American College of Physicians
The information contained herein should never be used as a substitute for clinical judgment.