What’s the Value of an Annual “Checkup”?

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on hot topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

Are annual checkups all they’re cracked up to be?

Remember Cigna’s “Doctors of America” ads?

“We are the TV Doctors of America,” says McDreamy.

“And we’re partnering with Cigna to help save lives,” says Dr. John Carter.

“By getting you to a real doctor for a checkup,” chimes in Cuddy.

But to put our “Devil’s Advocates of America” hats on: what if this annual checkup business isn’t all it’s cracked up to be?

It is reasonable to hold any potential medical test or treatment to one of three standards:

1. It makes the patient feel better. This includes hundreds of treatments, like using medications and physical therapy for pain, prescribing inhalers for asthma, giving antidepressants and therapy for depression, and replacing knees, for starters. It could even apply to things like bone mineral density screening, sometimes referred to as “DXA,” which linked with osteoporosis treatment may make no difference in the risk of death, but clearly prevents hip, wrist, and spine fractures.

2. If it does not make the patient feel better, the test or treatment should make the patient live longer. This applies to everyday things like checking and treating high blood pressure and high cholesterol (neither one of which make most patients feel any better or worse today) to surgery and chemotherapy for cancers (most of which make patients feel much, much worse at least in the short-term, but prolong many lives).

3. Finally, if a treatment makes no difference in how the patient feels and makes no difference in how long the patient lives, it should at the very least save money. The best example of this may be diabetes screening. As far as we can tell, screening for diabetes does not prolong life, at least not in the two or three trials that have specifically addressed the question. But diabetes screening linked to preventive measures like the Diabetes Prevention Program clearly saves money [disclaimer: the KBGH is closely linked to Health ICT through the Medical Society of Sedgwick County, which receives CDC funding to promote things like blood pressure control, cholesterol management, and diabetes prevention].

Many of the tests and treatments medicine offers do not live up to that rubric. This may be why the Cochrane Review, which many consider the highest level of evidence in medicine, published a review in 2018 stating that “Systematic offers of health checks are unlikely to be beneficial and may lead to unnecessary tests and treatments.” So when the TV Doctors of America say you need an annual checkup, what they surely mean is not that you need an old-fashioned sit-down with your doctor where, at the end of the visit, she gives you a “clean bill of health.” No. What I hope they mean is that you need to have access to a primary care provider. Investigators in 2019 found that every 10 additional primary care physicians per 100,000 people was associated with a 51-day increase in life expectancy, which doesn’t sound like much, but is pretty big by medical standards. Some estimate that a doctor practicing at the top of his license adds about 4.5 net years to the average patient’s life. Not too shabby.

“Systematic offers of health checks are unlikely to be beneficial and may lead to unnecessary tests and treatments.”

What actually improves or extends someone’s life?

What the TV Doctors of America really mean is that you should have certain preventive services like immunizations and periodic screenings for health conditions that, if left untreated, can profoundly shorten your life. Most of these aren’t sexy. Probably the most effective preventive medical intervention, for example, is a simple periodic blood pressure check with medications if your blood pressure is too high. Sexier things like cancer screenings tend to have a “disease-specific” benefit, meaning they prevent you from dying of colon, prostate, cervical, breast, or lung cancers specifically, but they may not make people live longer as a whole.

If there is doubt in your company about what services you should be providing, a good place to start is with the United States Preventive Services Task Force (USPSTF), a rotating group of doctors that follows very specific rules to evaluate the risks and benefits of specific screening. Their opinion holds a lot of weight because any test given a “B” or better rating is mandated to be covered by your insurance. Examples of “A” rated services are things like tobacco use counseling and interventions, blood pressure screening in adults, and screening for cervical and colon cancers, which are all strategies that easily conform to our rubric. Cholesterol testing in people without diabetes or heart disease gets a “B.” Screening for prostate cancer in men aged 55-69 with a prostate specific antigen (PSA) test is a good example of a “C” rated service, since it has no overall mortality benefit and its disease-specific mortality benefit is largely offset by the harms that screening can cause (prostate biopsies and surgeries can cause bladder leakage and erectile dysfunction, among other things). PSA screening for prostate cancer in men aged 70 or older gets a “D” rating because it appears, in the hive mind of the USPSTF, to cause more harm than it prevents; that is, it violates rules #2 and 3.

What does this mean for employers?

How do you apply this to your workforce? Start by being an informed shopper for any workplace wellness services being offered to your company. Whenever a wellness provider tries to charge you a lot of money for offering annual “wellness checks” or “health risk assessments,” check their recommendations against the opinion of the USPSTF (or have us at KBGH check them for you). If the amount of testing they’re charging far exceeds what the experts recommend, ask them why.

Second, work on the health literacy of your employees (we can help with this). It’s hard as a patient to turn down testing or treatment your doctor offers if you don’t have the background to know what works and what doesn’t. I’m a doctor myself, and even I’ve felt vulnerable being squeezed through the gears of the medical-industrial complex.

The lower-ranked your doctor's medical school, the more likely he'll write you a narcotic prescription

You read that headline right: investigators in an NBER paper found that docs who went to a lower US News-ranked school are more likely to write narcotic prescriptions, and the ones who write narcotic prescriptions are likely to write for more drugs, depending on the ranking of their school. And lordy, those osteopathic schools:

US News publishes several rankings, in topics from research to primary care to women's health. For this paper, the investigators used the "research" ranking, which is difficult to translate into medical student bedside education. After all, some of my best teachers in med school hadn't published a paper in a decade.

Several other take-home points from this. First, at first glance general practitioners write a ton of narcotic prescriptions; their rate on the y-axis is roughly double the overall physician population's. But when you consider that primary care docs perform well over half of all the visits delivered, that number of narc prescriptions looks less impressive.

Second, the effect size, if you're willing to take a leap and go straight to the idea that the quality of research at your medical school somehow has a causative effect on how many hydrocodone prescriptions you write, is huge. Using Harvard as the index school, the schools in the eighties and nineties have graduating docs writing three times as many prescriptions.

My first thought when I read this was that docs who went to lower-ranked schools may end up on places where they're more compelled to write narcotic prescriptions: places with high poverty, or a large blue-collar workforce, for instance. But the investigators accounted for that, and found that the relationship persisted even within the same county:

I can't help but try to apply this research to myself, even though I'm an endocrinologist and therefore mostly shielded from the narcotic game, and even though I see relatively few patients nowadays. But here we go. I attended the University of Kansas, which is comfortably ensconced in a tie at number 65 on the research list:

Oof. Medical school got a lot more expensive in the last couple decades.

So where would I live in the narc prescribing graph?

Riiiiiiiiight about there. It's a wonder I'm not a bonafide narcotic prescribing machine. 

What's unsaid in this list is that KU has three campuses (two at the time of my training). And it further goes without saying that the training in Wichita, Salina, or Kansas City may have subtle differences that would lead to slightly different physician performance or behavior. Furthermore, it would be interesting to see the research repeated with residency or fellowship training as the independent variable, since those are the years when trainees really fall into a groove of prescribing habits. If I were held to the standard of my internship with a University of Washington program, I'd be compared to the folks at the skinny end of the graph:

Go dawgs.

But if my fellowship training at UNC-Chapel Hill were the standard, I'd be in a nice, comfortable happy medium between the narc-crazed sixties and the narc-stingy pre-teens:

The take-home from this isn't that we should all check our doctors' CVs before we go see them, in fear of them hooking us on oxycodone. It's just that schools who inhabit the lower tiers of medical research need to do a better job of teaching narcotic prescribing. 

And obviously, the take-home for patients is to be very, very careful about requesting narcotics for pain. They don't work as well as we think they do, and the potential for harm is huge. 

I found this link, fwiw, via marginalrevolution.com