Routine Physicals Not Entirely Superfluous in Primary Care?

General health checks were not associated with better clinical outcomes for patients, but the data were not a complete wash for proponents of these checkups.

Wellness visits in adult primary care were generally not associated with decreased mortality, cardiovascular events, and cardiovascular disease incidence, reported David Liss, PhD, and colleagues, all of Northwestern University Feinberg School of Medicine in Chicago, in a 32-study review.

However, as shown in the analysis published online in JAMA, these health checks were associated with improved:

• Detection of chronic diseases (e.g., depression and hypertension)

• Risk factor control (e.g., blood pressure and cholesterol)

• Clinical preventive service uptake (e.g., colorectal and cervical cancer screening)

• Patient-reported outcomes (e.g., quality of life and self-rated health)

Yet the potential downsides of health checks may be increased risk of stroke and mortality (the latter due to increased completion of advance directives), the team suggested.

They added that patients participating in routine physicals tended to have better health behaviors in terms of physical activity and diet.

“Primary care teams may reasonably offer general health checks, especially for groups at high risk of overdue preventive services, uncontrolled risk factors, low self-rated health, or poor connection or inadequate access to primary care,” the authors wrote.

Except for the new finding of improved patient-reported outcomes with wellness visits, results of the review are generally in line with previous analyses.

Given the lack of mortality benefit to these checkups, some had previously argued that they should not be done at all. In 2019, Cochrane reviewers concluded that “general health checks are unlikely to be beneficial and may lead to unnecessary tests and treatments.”

“Good healthcare is not just about reducing mortality,” argued Paul Hyman, MD, of Mid Coast Medical Group in Brunswick, Maine, who was not involved with the study. “It is also about improving the quality of life of individual patients and communities.”

Not every patient needs a general health check, but for people who don’t regularly see physicians for chronic health problems, these checkups “are often the best opportunity for physicians and patients to develop a relationship and for physicians to better understand a patient’s health and wellness goals,” Hyman told MedPage Today.

“While the frequency of the comprehensive health review need not be annual for all persons, it needs to be a central part of healthcare delivery at all stages of life to ensure access and personalized care,” said Allan Goroll, MD, of Massachusetts General Hospital and Harvard Medical School in Boston, who was also not involved with the study.

“When performed as a comprehensive review of a person’s life and health status rather than just as a perfunctory exam and a checking of boxes on a computer, the periodic health review adds great value as shown by these data,” Goroll continued. “No, it does not prolong survival, but it establishes and sustains a trusted, healing relationship, so important to patients and to the success of a healthcare delivery system — as underscored during the current pandemic.”

Hyman surmised that the pause in non-COVID healthcare during the pandemic will lead to a rise in morbidity and mortality. “Some of my colleagues and I already see this anecdotally. Patients are returning to the office with more complicated disease presentations. Many of these patients did not have COVID.”

“It may be hard to parse apart how much of this increase is due to pausing on general health checks and what part is due to overall care avoidance by patients and by the disruption that occurred in the healthcare delivery system. So far, my guess is it is more of the latter two, but as time goes by this may change,” he told MedPage Today.

Those who believe routine checkups to have value for some people will still find there is no evidence-based “blueprint” for how to implement them in practice, according to Liss and co-authors.

They cited following U.S. Preventive Services Task Force A and B recommendations, recommended immunizations, and ongoing risk factor control in diagnosed chronic illness as one strategy.

“The appropriate response to the controversy over general medical checkups is not an inflexible, one-size-fits-all approach. Rather, primary care physicians and their patients should have latitude, agreeing on a long-term relationship plan that accommodates the patient’s preferences, albeit within the bounds of reasonable practice standards,” Allan Brett, MD, of the University of Colorado School of Medicine in Aurora, wrote in an accompanying editorial.

The literature review encompassed 19 randomized trials and 13 observational studies evaluating general health checks at various frequencies. Compared with similar analyses in the past, it included more studies from the U.S.

Liss and colleagues cautioned that this was not a meta-analysis, and that the included studies were characterized as having low frequency and intensity of checkups and short follow-up durations.

In general, there is limited recent high-quality evidence on health checks: the majority of trials in the review were conducted at least 20 years ago, and most large studies took place before the introduction of statins, the authors noted.

Yet Brett questioned if any additional randomized trials would really resolve the question of whether general health checks improve hard clinical outcomes: any model will likely become obsolete over follow-up because of factors such as a rapidly changing healthcare system and advances in medical science, he said.

For now, the present review is the best critical look to date at the literature surrounding the annual physical, Goroll commented.

“I hope, though, that we will be able to use the time of the pandemic to learn more about what part of healthcare does provide value and what we can do away with,” Hyman said. “The general health check, I suspect, has utility, but not for everyone all the time.”