I was
recently interviewed for an Australian Doctor item on health assessments, after
I’d been involved in a Twitter discussion. I thought I’d set out
my thinking and links to the evidence I’m using. I do need to point out that
these are my personal views, and don’t represent the policy of any of the
organisations I work for.
In
Australia, GPs are paid by Medicare for doing health assessments. Health
Assessments in Aboriginal and Torres Strait Islander people are particularly
encouraged, being used as a KPI for many services, and essentially as a proxy
measure for activity in Aboriginal and Torres Strait Islander Health.(See for example, p10 of this PDF, the main evaluation report of the government's program) With this
pressure and expenditure, of course you’d expect it to work.
The
evidence is not as strong as you might think. First up was this study which
caused some ripples in the UK, though not really in Australia. It’s a
systematic review done by the Cochrane Collaboration, so is pretty much gold
standard in the expertise of performing this sort of research. And this sort of
research – that is, a systematic review - is the most reliable in giving
trustworthy answers. They hunted down all the studies ever done to answer this
question, and discovered that doing health checks didn’t help people live
longer, and didn’t reduce people’s diseases. In fact, they were diagnosed
earlier, and so lived more of their life with a diagnosis, without getting
benefit from this. It also looked like people had just as many
admissions to hospital, disabilities, as much worry, the same number of visits
to the physician, and no fewer absences from work, though these findings were
less clear.
Shortly after this, another study from Australia came along.
They wondered if the outcomes of health checks were better for those performed
in General Practice. They used the same systematic review methodology, where
they tried to find all the research that had been done on this. They found that
there were improvements in total cholesterol, body mass index and systolic and
diastolic (that is the top and bottom) blood pressure figures. However, these
improvements were very small – the authors say that they were statistically
significant, which means that these results are probably not a chance finding.
However, it is likely that a change of 0.13mmol/L in cholesterol, and 0.45kg.m2
does not make a difference in real life. This result has been reported asreassuring us GPs that it is worth us doing health assessments after all. I’m
not so sure. There is no evidence of making people live longer in these
studies, and there is even a suggestion that doing a health assessment
increases your likelihood of dying of cardiovascular disease – another
statistically significant result.
At face value, the evidence would indicate that we are
certainly not saving any lives by doing health assessments, we may be labelling
people with pathology for more of their lives, without any attendant benefits,
and this may even be an intervention that gives people heart attacks or strokes
earlier!
There is an argument to be made that in a population that
have a higher risk of cardiovascular disease, such as Aboriginal and Torres
Strait Islander people (though not only that group), there will be more benefit
from doing health assessments. That may well be true, but there is no evidence
at all either way at the moment – the best we have is what I have described
above. This means by making this argument, we are entering a completely
evidence-free zone. We may well be doing harm without realising it. Usually in
medicine we are cautious about using an intervention widely if there is no
evidence that it is beneficial. This would not be the first time that a
combination of optimism and “common sense” that something ought to work has
trumped the lack of evidence.
I’m not a complete nihilist, though, and I do think there is
a way forward.
First, let’s note that health checks don’t appeal to
everybody. This systematic review shows that those who are least likely to
attend health checks are men, people without much money, people who aren’t
white, and less well educated. In other words, those who most need them. It may
be that in the field of Aboriginal and Torres Strait Islander Health we have
come up with a mechanism that intuitively appeals to those developing the
system but not to those using it.
What would those using it want? We know from this research
that the way to break down cultural barriers for Aboriginal and Torres Strait
Islander people using health services is to have a relationship with someone in
the service. Unless used in a very nuanced way, a health assessment is a very
transactional approach, making a consultation a data gathering exercise, not a relationship developing exercise. It’s quite possible that this effort is
alienating to people. Certainly, examples where health checks have been well
received have been when they are promoted as part of service activities that promote relationships.
The alternative approach is to build on the strengths of
General Practice and Primary Care. 85% of people in Australia have seen their
GP in the previous year, and the average number of visits is 5 or 6 each year.
Julian Tudor Hart described anticipatory care, where the relationship developed
and the series of visits over time meant that preventative activities could be
performed in this context. He was the first GP in the world to know the blood
pressure of every one of his patients. The two approaches, health checks and
anticipatory care, were compared in Scotland. This is not an outcomes study, but
we do know the outcomes for general health checks (see above) and we also know
the outcomes for many of the individual preventive activities. The ones
recommended are documented in the RACGP Red Book, and for Aboriginal and Torres
Strait Islander people in the National Guide to a Preventive Health Assessment
by RACGP and NACCHO. (Declaration – I was
on the editorial panel of this guideline and wrote the mental health chapter).
The solution, I think, is to promote the completion of
individual evidence based preventive activities in the context of a long term
therapeutic relationship. The Kanyini Vascular collaboration audit showed that this is already happening - cardiovascular disease preventive activity was occurring at the same level as in non-Indigenous people, but the number of health assessments billed was very low. Behaviour changes and referrals are more
likely to be performed, as the GP and Primary Care team can keep on following
up. Ideally, Medicare would pay at the completion of the recommended
activities, whether this was in a single consultation or over many. (The Diabetes PIP Cycle of care is already paid in this way (PDF)). Granted, the evidence
for this approach is limited. But the best evidence we have for the alternative
shows that it might be harmful. Clinicians are being asked to perform money-raising interventions, which services are measured on, and potentially doing harm in the process.
