July 9, 2019 Read Advisory Board's take: Should you move to less frequent checkups?

Annual checkups were originally designed to detect early signs of disease, but recent research has clinicians debating whether annual medical exams are worth it, Rita Rubin, a senior writer at JAMA writes in a medical news and perspectives article.

The purpose of the checkup

The American Medical Association (AMA) first endorsed the concept of the checkup almost a century ago, Rubin notes. The purpose of these examinations, the chair of AMA's Committee on Health and Public Instruction wrote in JAMA in 1922, was "to detect the early evidence of disorder before discomfort, inconvenience, interference with work, or anxiety [had] driven [apparently healthy people] to seek medical advice for the treatment of established disease."

Research raises questions about the value of a checkup

But while the checkup might've made sense in 1922, "physicians and other interested parties have debated the value of checkups for decades," Rubin writes.

And there's research to back up some of the checkup naysayers, Rubin writes. According to Rubin, randomized trials have found that patients who received periodic health checkups were no less likely to die from any cause or from cardiovascular disease or cancer than those who did not get annual checkups.

With these findings in mind, Rubin notes that the Society of General Internal Medicine has said that "'the evidence base is definitely insufficient to support routine use of annual general health checks for asymptomatic adults without a specific concern, chronic condition, or evidence-based prevention strategy.'"

Similarly, a recent Cochrane Review of 17 randomized trials found "high-certainty evidence" that checkups are "unlikely to benefit patients and might lead to unnecessary tests and treatments," Rubin writes.

Checkup proponents say research only examines one facet of checkups

Despite the evidence calling the value of checkups into question, plenty of physicians still support them. Checkup advocates say the visits today are more than a "disease screening or risk factor," as they were defined in the Cochrane Review, according to Rubin.

Allan Goroll, a professor of medicine at Harvard Medical School and a primary care general internist at Massachusetts General Hospital and supporter of the checkup, explained that the evidence in the studies that have been critical of checkups "strictly looks at the measurable." In turn, checkup doubters "forget that there are other things people get out of an annual visit, and they're not looking at those things," Goroll said.

The purpose of annual checkups, according to Goroll, is "the development and sustaining of a trusting healing relationship" between the patient and the clinician. "A problem with our society is that relationships have become scarcer and undervalued," he said.

To make his point, Goroll points to his experience with a patient who had severe coronary artery disease and was only able to quit smoking because of the work Goroll and the patient did together.

Instead of moving away from checkups, physicians should look to reframe them so that they are designed to develop and maintain a plan for patient health for the long term, according to Goroll. The visits don't even have to be annual, he said, and can be adapted to patients' needs.

"There is no question that the stripped-down, check-the-boxes excuse for an annual visit has no value, and shame on us for offering that to patients," Goroll said. "What we need are high-value visits that are personal, that focus on building trusting relationships, that focus on key concerns of patients" (Rubin, JAMA, 6/19).

Advisory Board's take

Should you move to less frequent checkups?

For years, academic studies have questioned the clinical necessity of the annual visit. Perhaps the most compelling was a longitudinal 2012 British Medical Journal study that found no impact from annual visits on patients' long-term mortality, morbidity, or number of hospitalizations compared to a control group.

Combine that with the difficulties primary care practices face today in achieving scale and you can see why some leading organizations have started to rethink the practice of annual checkups. Especially as primary care is becoming increasingly segmented based on the type of patient, providers are scrutinizing practices that may cause resources to be devoted to patients who don't necessarily need them. And some are making broad changes. For instance, in our 2013 research study, Playbook for Population Health, we reported that Kaiser Permanente Northwest moved towards biannual checkups for healthy adolescents (but they still send annual visit reminders for adolescents with chronic illnesses).

I want to urge caution when moving in this direction

However, I want to urge caution when moving in this direction. The point Dr. Goroll's makes about the role that annual checkups play in developing and sustaining trusted relationships between patients and providers is an important one. A lack of trust is often a root cause of poor primary care utilization and annual checkups are one important way to build trusting relationships. Not to mention, checkups are also an ideal time to understand patients' social determinants of health. As more providers begin embedding social determinants screenings in primary care waiting rooms, they may lose an opportunity to track these important metrics. Therefore, providers need to keep in mind the patient population they serve and how activated they are before moving away from an annual checkup model. My biggest concern is that we may inadvertently disrupt primary care relationships for patients who already have poor access to primary care, where we should actually be ensuring good access for them.

But I do agree that biannual visits can bring efficiency to practices if they prioritize patients that are healthy, well-managed, already activated, and have no psychosocial risk factors. If providers move to this model, they need to ensure that they continue to:

  • Power their patient portals or CRM systems to engage these patients between primary care visits;
  • Arm patients with information on what to do in the face of acute care flare ups;
  • Remind patients about preventive care steps (e.g., flu shots and medication for seasonal allergies);
  • Track key care gap information; and
  • Make themselves easily accessible for when patients have questions.

Some providers use wellness platforms to accomplish these goals, but they are not the only way to achieve them. To learn more about how to achieve these goals, and operate an efficient primary care practice, download our research report on the 10 Imperatives for Primary Care Today.

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