All Risk, No Reward

Pearls:

• Aisha and Neda discuss the pro’s and con’s of the annual physical.

• Pros: improve screening rates, build rapport with patients.

• Cons: time, cost, incidental findings, evidence of efficacy lacking.

• Alternatives: period preventive health checks, engage your patients through technology or workshops or group classes.

• Pros:

• Screenings depending on age, sex, gender, etc.

• Evidence that the annual physical does have a beneficial effect on the delivery of some specific, preventive services.

• Prochazka AV et. al. Support of evidence-based guidelines for the annual physical examination: a survey of primary care providers. Arch Intern Med. 2005 Jun 27;165(12):1347-52. PMID: 15983282.

• Chance to maintain a relationship with a patient

• Reorient towards preventative care as opposed to episodic acute care

• Some evidence to support a mental health aspect of the importance of laying hands on a patient to build a therapeutic relationship

• Improvement in health metrics> Meta-analysis of six different randomized control trials found that annual physicals were associated with statistically significant improvements in metrics like cholesterol, blood pressure and BMI. The differences were small (ie: decrease in BMI was only 0.45).

• Si S et. al. Effectiveness of general practice-based health checks: a systematic review and meta-analysis. Br J Gen Pract. 2014 Jan;64(618):e47-53. PMID: 24567582.

• It is a nice visit for providers!

• Cons:

• There is no consensus on what exactly comprises an annual physical:

• Does it include labs work?

• Does it include a full physical exam?

• Does it include imaging?

• There is no consensus of what patients want:

• A survey of 1200 adults in big cities in the US found that 66% thought an annual physical was necessary and 80-90% wanted different things in the annual physical (ie: physical exam, lab work). When asked if they wanted it knowing they would be charged, only 33% wanted it.

• Oboler SK et. al. Public expectations and attitudes for annual physical examinations and testing. Ann Intern Med. 2002 May 7;136(9):652-9. PMID: 11992300.

• Guidelines about the annual physical are inconsistent:

• The USPSTF does not have any recommendations for an annual physical

• Canadian guidelines have recommended AGAINST an annual physical

• The Province of British Columbia does not even cover annual physicals as a benefit

• The Choosing Wisely Canada states, “Don't do annual physical exams in asymptomatic adults with no significant risk factors”

• The College of Family Physicians of Canada recommends instead of doing an annual physical, do a periodic preventive health check instead

• Harms of incidental findings

• May require repeat testing to patients or lead to unnecessary work-up

• Anxiety provoking for patients

• Cost: one study in 2007 cited an annual cost of physicals of $10 billion in the US

• False reassurance that a head to toe physical exam is going to pick everything up

• Time: general practitioners are spending about 10% of their time on the physical, which does not include the time spent following up incidental findings. This time could be spent increasing clinic access in other ways.

• Mehrotra A et. al. Improving Value in Health Care--Against the Annual Physical. N Engl J Med. 2015 Oct 15;373(16):1485-7. PMID: 26465981.

• Evidence for their benefit is lacking. Large Cochrane review in 2012 that included 183,000 people over 9 years found no benefit to health checks on a variety of factors including morbidity, mortality, hospitalizations or patient worry.

• Krogsbøll LT et. al. General health checks in adults for reducing morbidity and mortality from disease: Cochrane systematic review and meta-analysis. BMJ. 2012 Nov 20;345:e7191. PMID: 23169868.

• Alternatives:

• Preventive health check or the periodic health check

• De-emphasize the check needing to be annual

• De-emphasize a full physical exam

• Keep in touch with patients in other ways

• Technology

• Group education classes or workshops

• Maximize acute care visits to include components of preventative care visits