AcademyHealth Blog — Advancing Research, Policy and Practice

How Much ‘Research’ is on the Annual Research Meeting Agenda Anyway?

by Communications on January 10, 2013 · 0 comments

The call for abstracts for AcademyHealth’s 2013 Annual Research Meeting (ARM) is open until next week. For the last 30 years, the meeting has been the premier forum for those working in health services research, with a significant portion of the agenda determined through the call for abstracts process.

But how much “research” is actually on the ARM agenda? Turns out, it’s even more than we thought – and more cutting edge.

The agenda is divided between “research” and “research-related topics,” which include sessions to identify evidence gaps (policy roundtables, funding updates) and improve the research process (methods training and professional development). When we talk about “research” in this case, we mean presentations of scientific findings. What we found was that 60 percent of the conference agenda is dedicated to presentation and discussion of the latest evidence. And 80 percent of those presentations are selected through the abstract peer-review process (all invited sessions are chosen by the ARM Planning Committee and/or Method Council, two multidisciplinary groups of volunteers).

It’s clear that research makes up the bulk of the agenda, so we wanted to find out more about the stages of those findings. In a survey to presenters from the 2012 ARM, we found that much of the work presented is new, unpublished research, making the ARM the best place to hear the latest findings from the field. Sixty-three percent of survey respondents who presented at the podium said that they were currently seeking or planning to seek publication for their findings in a peer-reviewed journal, and 62 percent of respondents who presented a poster responded similarly.

Of course, it’s important to put all that research into context and apply it to policy and practice. The roundtable sessions on the other side of the graph are consistently some of the most popular among attendees, which illustrates the importance they place on understanding where findings can be applied and what impact they can have in improving health and health care. The expert panelists in the roundtable sessions are research users who can identify emerging needs for evidence-based solutions. They’re also researchers who can share lessons learned from their own translation experiences. Together, those two parts of the agenda create a rich conference experience for health services researchers, policymakers, and practitioners alike.

We’re looking forward to seeing abstract submissions for this year’s meeting, with conference themes that cover consumer choice and behavior, health IT, improving quality and value, payment delivery system innovations, and patient-centered outcomes research. We are also happy to continue our partnership with the Journal of the American Medical Association (JAMA) and Health Services Research (HSR) to select abstracts for full manuscript submission consideration.

The abstract submission deadline is January 17 at 5:00 p.m. EST.

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Retail clinics and continuity of care

by The Incidental Economist on January 7, 2013 · 1 comment

There are so many reasons the health care system and health reform are complex. Among them is the fact that very few changes are unambiguously for the better. Trade-offs are hard, if not impossible, to avoid. This might be called the first (stylized) rule of health reform: you can’t make the system a little better in one dimension without harming it a bit in another. That’s another way of saying there’s no free lunch, and that fact is among the reasons the status quo is hard to change.

With that in mind, what do we make of the recent boom in retail clinics? A recent HCFO-funded paper by RAND researchers in the Journal of General Internal Medicine highlights a trade-off: retail clinics seem to enhance access to preventive care but they also seem to disrupt relationships between patients and primary care physicians practicing in more traditional settings.

From the abstract, here’s what the investigators did:

OBJECTIVE: To assess the association between retail clinic use and receipt of key primary care functions.

DESIGN: We performed a retrospective cohort analysis using commercial insurance claims from 2007 to 2009.

PATIENTS: We identified patients who had a visit for a simple acute condition in 2008, the “index visit”. We divided these 127,358 patients into two cohorts according to the location of that index visit: primary care provider (PCP) versus retail clinic.

MAIN MEASURES: We evaluated three functions of primary care: (1) where patients first sought care for subsequent simple acute conditions; (2) continuity of care using the Bice–Boxerman index; and (3) preventive care and diabetes management. Using a difference-in-differences approach, we compared care received in the 365 days following the index visit to care received in the 365 days prior, using propensity score weights to account for selection bias.

Comparing the experience before and after an acute condition visit for patients who had that visit at a retail clinic vs. with a PCP, the researchers found that retail clinic patients experienced reductions in continuity of care and in contact with PCPs for acute care. That might be a bad thing. On the other hand, they found no association between retail clinic visits and a host of preventive care including screenings for breast, cervical, and colon cancer, as well as diabetes management.

This being one observational study and with acknowledgement of the limitations of its methods (propensity score weighting and a difference-in-differences design), it’s hard to draw strong conclusions about these findings. As the authors put it,

Some might contend that continuity is the cornerstone of primary care and, therefore, retail clinics’ negative impact on continuity is critical. Others might argue that continuity and first-contact care are less important than preventative care, especially for a healthy patient population [such as that more likely to visit a retail clinic]. In this light, retail clinics’ impact on primary care may not be as great as feared.

Of course, as the authors point out, there is a sense in which it is possible to reap preventative care benefits of retail clinics without experiencing all of the potential consequences to decreased continuity. Improved coordination between retail clinics and PCPs might be fostered through better use of inter-operable electronic medical records, for example.

Then again, returning to the first rule of health reform, health IT has its drawbacks too.

–Austin

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Fiscal Cliff Avoided…For Now.

by Communications on January 2, 2013 · 0 comments

Amid last-minute, high-stakes dramatics, the 112th Congress passed a bill to avert the fiscal cliff – a series of expiring tax breaks and looming spending cuts known as “sequestration” that the Congressional Budget Office and other experts predicted would plunge our nation back into recession.

The bipartisan, American Taxpayer Relief Act of 2012 (H.R. 8) passed the Senate in the early hours of January 1 by a vote of 89 – 8, and passed the House later that evening by a vote of 257-167.

The bill—headed to the president for his signature today—permanently extends the 2001 and 2003 tax rates for ordinary income, capital gains and dividends for individuals with annual incomes below $400,000 and couples with incomes below $450,000. It preserves the current estate tax exemption, permanently fixes the alternative minimum tax, and continues unemployment insurance.

The measure also blocks the scheduled 30 percent cut in Medicare physician reimbursements for one year and delays sequestration until March 1.

The deal comes at a price. The “doc fix” is paid for through $25 billion in adjustments to other provider payments, including coding, End Stage Renal Disease, radiology, multiple procedures, advanced imaging. The bill also repeals the Community Living Assistance Services and Supports (CLASS) program established by the Affordable Care Act (ACA) and eliminates funding for ACA co-ops.

The bill provides a brief reprieve for the research and public health communities, by postponing the sequester’s scheduled 8.2 percent across-the-board cut to discretionary programs. (See the Washington Post’s summary of health policy impacts here.) To pay for the $24 billion cost of delayed sequestration, the bill relies on $12 billion in new revenue and $12 billion in spending cuts to discretionary programs in FY 2013 and FY 2014, which are divided equally between “security” and “nonsecurity” spending. According to the White House, “this will give Congress time to work on a balanced plan to end the sequester permanently through a combination of additional revenue and spending cuts in a balanced manner.”

So we are left to face another fiscal cliff in March—the delayed sequester, the FY 2013 continuing resolution, and the debt ceiling. Advocates for research and public health must remain vigilant in these critical months and continue to urge policymakers to avoid more cuts to research. We need more of this research, not less, if we are to solve the problems facing our health system and stabilize the debt.

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Carotid endarterectomy vs. medical management: the time is ripe for re-examination

by The Incidental Economist on December 19, 2012 · 1 comment

Carotid atherosclerosis results in narrowing of the carotid arteries as plaque builds up along artery walls and at the carotid bifurcation. This narrowing (stenosis) is associated with increased risk of stroke when it progresses into the 50% to 99% range. Carotid endarterectomy (CEA) is a surgical procedure frequently used to reduce the risk of stroke by opening carotid arteries. The procedure is not without risk, however: a small but substantial minority of CEA patients suffer a perioperative stroke. This begs the question whether CEA outcomes are better or worse than medical management. For reasons explained below, this question is ripe for comparative effectiveness research.

By way of full disclosure, I am a co-investigator on an observational study of CEA vs. medical management funded by the Department of Veterans Affairs’ Health Services Research & Dissemination service. My co-investigators are Steven Pizer (PI), Scott Kinlay, Graeme Fincke, Michael McWilliams, and Bruce Landon. Though based on the work of the group, what follows are my views and does not necessarily reflect the position or policy of the Department of Veterans Affairs, my co-investigators, or the other institutions with which they or I am affiliated.

As an alternative to CEA, carotid artery stenting (CAS) is a less invasive alternative that involves inserting a catheter, inflating a balloon to open the artery, and placing a stainless steel stent to keep the artery open. The Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy (SAPPHIRE) trial demonstrated that CAS is not inferior to CEA for patients with coexisting conditions that potentially increase the risk of CEA and who had either symptomatic stenosis of greater than 50% or asymptomatic stenosis greater than 80%. In this trial the probability of stroke or death from neurological causes at 1 year post randomization was not significantly different between CEA and CAS. The lack of evidence demonstrating superiority for CAS combined with a much longer history for CEA probably contribute to much larger volumes of CEA than CAS. A tabulation of the Nationwide Inpatient Sample from 2003 counted 131,565 cases of CEA and only 7,518 cases of CAS. Given the historical infrequency of CAS procedures, an observational study to compare CEA to CAS probably would be difficult.

The body of randomized trial research that demonstrates benefits and risks of CEA is also relatively old. Results from the North American Symptomatic Carotid Endarterectomy Trial (NASCET), published in 1991, demonstrated clear benefits from CEA relative to medical therapy with aspirin for patients with hemispheric or retinal transient ischemic attack or a nondisabling stroke within 120 days prior to randomization and stenosis between 70% and 99% in the symptomatic artery. The European Carotid Surgery Trial (ECST) confirmed these results, demonstrating also that the risks of CEA outweighed the benefits for those with mild stenosis (0% to 29%), and that men derived greater benefit from CEA than women. Further analysis of NASCET data indicated that symptomatic patients with stenosis between 50% and 69% also derived a moderate benefit from CEA.

The efficacy of CEA for treatment of asymptomatic high-grade carotid stenosis has been established by the Asymptomatic Carotid Atherosclerosis Study (ACAS) and the Asymptomatic Carotid Surgery Trial (ACST). The ACAS trial randomized patients with 60% to 99% stenosis to either CEA and aspirin or aspirin alone. After an average of 2.7 years of follow-up this study showed that the incidence of ipsilateral stroke and any perioperative stroke or death was significantly lower in the surgery group than the aspirin only group. However, when outcomes were limited to major ipsilateral stroke, major perioperative stroke, and perioperative death the difference between groups was no longer statistically significant. The ACST trial randomly assigned patients with greater than 60% stenosis to immediate CEA or deferral of CEA until a definite indication occurred. After an average of 3.4 years of follow-up this study found that immediate CEA reduced the 5-year risk of fatal or disabling stroke from 6.1% to 3.5%, but the immediate CEA group had a perioperative risk of stroke or death of 3.1% so they had worse event-free survival until about 2 years following surgery.

Since the ACST ceased randomization in 2003, medical management of asymptomatic carotid stenosis has changed substantially. It is, therefore, possible that aggressive medical control of hypertension, glucose, and lipids combined with antiplatelet therapy and smoking cessation might reduce the risk of stroke sufficiently to make the risks of CEA outweigh the benefits, particularly for those with less advanced stenosis. In fact, a recent review found that rates of ipsilateral and any-territory stroke, with medical intervention alone, have fallen significantly since the mid-1980s, with recent estimates overlapping those of surgical patients in randomized trials. Furthermore, rates for surgical patients from trials may underestimate actual rates because trials are conducted at high volume centers with low perioperative complication rates.

The clinical trial-based evidence on CEA was collected at a time when the comparative medical therapy consisted largely of aspirin alone. More recent advances in medical management include lipid lowering therapy, angiotensin converting enzyme (ACE) inhibitors, and clopidogrel. In clinical trials that include patients with asymptomatic carotid stenosis, medical regimens that include these newer agents reduce the risk of stroke by 50% or more, compared to older medical regimens. As a result, many investigators and clinicians are raising serious doubts about the continued efficacy of CEA for this population.

Consequently, the time is ripe for more comparative effectiveness research on CEA vs. medical management. The latter may now offer better outcomes at lower risks than prior studies could demonstrate.

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HSR Examines Costs and Quality in Latest Issue, Seeks HIT Papers

by Communications on December 18, 2012 · 0 comments

The December 2012 issue of Health Services Research (HSR) looks at use and costs, quality of care, post-acute care, and health plan and physician availability.

The issue opens with two articles that came out of AcademyHealth’s 2012 Annual Research Meeting (ARM). The articles published in this section were selected from the work submitted to the ARM call for abstracts. AcademyHealth staff and the HSR editorial team evaluated work from each of the conference themes and invited authors to submit full manuscripts to be considered for publication. The journal anticipates publishing a set of articles annually based on abstracts submitted to the ARM and selected to be outstanding by both reviewers from the ARM themes and HSR’s own editorial staff and reviewers. The call for abstracts for the 2013 meeting closes January 17.

There is significant focus on costs and quality within this issue of the journal, with examinations of EMR-based decision support systems, the patient-centered medical home, and satisfaction among patients with chronic illnesses.

In partnership with the Office of the National Coordinator for Health Information Technology, HSR is also currently seeking papers for a special issue on health IT. The aim of the special issue is to show progress made under the Healthcare Information Technology for Economic and Clinical Health (HITECH) Act of 2009 and to highlight research on health IT to inform future policymaking. Manuscripts must be submitted by December 28 to be considered for publication. Read the full call for papers here.

The following AcademyHealth members had their work featured in this month’s issue of HSR: [click to continue…]

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Federally Qualified Health Centers

by The Incidental Economist on December 14, 2012 · 1 comment

I’m often asked by people concerned about the impending increase in individuals who may demand health care, “where are all these all of them going to go?” I have no crystal ball, and obviously the answer will vary by population, but the short answer is that many of them will seek care in federally qualified health centers:

A federally qualified health center (FQHC) is a type of provider defined by the Medicare and Medicaid statutes. FQHCs include all organizations receiving grants under Section 330 of the Public Health Service Act, certain tribal organizations, and FQHC Look-Alikes. Requirements for Indian Health Service funded FQHCs may differ from the requirements for FQHCs receiving Section 330 grants and for FQHC Look-Alikes.

There are lots of benefits to being a FQHC. These include:

For new starts, funding up to $650,000 can be requested. Other benefits include:

Cost-based reimbursement for services provided under Medicare
Reimbursement under the Prospective Payment System (PPS) or other State-approved Alternative Payment Methodology (APM) for services provided under Medicaid
Medical malpractice coverage through the Federal Tort Claims Act
Eligibility to purchase prescription and non-prescription medications for outpatients at reduced cost through the 340B Drug Pricing Program
Access to National Health Service Corps
Access to the Vaccine for Children Program
Eligibility for various other federal grants and programs

These centers were mostly established back in 1991 under the first President Bush. The second, and more recent of the Bush Presidents, significantly expanded their use, as did President Obama under the Affordable care Act. It’s thought that 30 million or so Americans might be receiving health care through organizations such as these in the future. They’re much more common than you might think:

After I explain this to people, there inevitably follows some sort of frown and a reply to the sense that we must be forcing all of these millions of people into some sort of second-class system. After all, the private sector always provides better quality than anything the government touches, right?

A recent study published in the American Journal of Preventive Medicine asked and answered that question. “Federally Qualified Health Centers and Private Practice Performance on Ambulatory Care Measures”:

Background: The 2010 Affordable Care Act relies on Federally Qualified Health Centers (FQHCs) and FQHC look-alikes (look-alikes) to provide care for newly insured patients, but ties increased funding to demonstrated quality and efficiency.

Purpose: To compare FQHC and look-alike physician performance with private practice primary care physicians (PCPs) on ambulatory care quality measures.

Methods: The study was a cross-sectional analysis of visits in the 2006–2008 National Ambulatory Medical Care Survey. Performance of FQHCs and look-alikes on 18 quality measures was compared with private practice PCPs. Data analysis was completed in 2011.

Basically, this study looked at national-level data to compare how FQHC’s compared to private practices with respect to 18 different quality measures. What did they find? On eleven of the measures, there was no difference between the two groups; FQHC’s were equal to their private practice counterparts. On one (diet counseling for at-risk adolescents), they did slightly worse. But on the remaining six, they outperformed private practices.

FQHC’s were superior at using ACE inhibitors for congestive heart failure. They were better at using aspirin for coronary heart disease. They were also better at using beta-blockers for coronary artery disease, at not using benzodiazepines for depression, at screening for blood pressure, and at not using screening EKGs in low-risk populations.

But that was the unadjusted analysis. Once the researchers adjusted for patient characteristics, private practices no longer were better than FQHCs on any metrics at all.

I know this will surprise many who are inclined to believe that the government is bad at everything. But in this case, the research indicates that’s just not true. It’s also not true with respect to VA medical centers, which often do better than the private sector in terms of quality. But that’s for another blog post.

FQHC’s are likely going to expand in the coming years. They will often be asked to pick up the slack in terms of seeing the newly insured, especially those who are getting Medicaid through the expansion of the program. That’s not a bad thing.

-Aaron

Dr. Aaron E. Carroll is an associate professor and vice chair of health policy and outcomes research in the department of pediatrics at the Indiana University School of Medicine. He blogs about health policy at The Incidental Economist and tweets at @aaronecarroll.

As part of our ongoing effort to raise awareness of health services research and increase its application in policy and practice, AcademyHealth has partnered with Austin Frakt, Ph.D., and Aaron Carroll, M.D., M.S., to contribute posts on the subjects of health care costs, delivery system transformation, and public and population health – areas AcademyHealth has identified as a priority in the current policy environment. As regular contributors, they’ll be discussing current events with an eye toward how new and existing research informs the issues

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Why we still need prostate cancer comparative effectiveness research

by The Incidental Economist on December 12, 2012 · 1 comment

There have already been many studies of outcomes of prostate cancer treatment. And yet, more of both randomized controlled trials and observational studies are warranted. In this post, I will make the case for the latter by summarizing some of the body of work to date and pointing out the key limitations. By way of full disclosure, I am the principal investigator on observational study of prostate cancer treatment funded by the Department of Veterans Affairs’ Health Services Research & Dissemination service. My co-investigators are Steven Pizer, Price Kerfoot, Graeme Fincke, Michael McWilliams, and Bruce Landon. Though based on the work of the group, what follows are my views and does not necessarily reflect the position or policy of the Department of Veterans Affairs, my co-investigators, or the other institutions with which they or I am affiliated.

In a year 2007 review of the literature the American Urological Association (PDF) identified 27 prostate cancer treatment studies based on randomized controlled trials. However, very few directly compared two different major treatment modalities; most focused on differences in variations within a particular modality. Thus, as of 2007, high quality comparative effectiveness evidence upon which to base decisions across main modalities was lacking. Three separate trials led by Bill-Alexson, Iversen, and Paulson that compared treatment modalities were insufficiently powered to address disease-specific (as opposed to all-cause) mortality or risk of metastatic spread. Moreover, the trials were conducted in an era prior to PSA testing, which is now common.

The PIVOT study has compared all-cause mortality and prostate cancer mortality based on a sample of 731 American men randomized to radical prostatectomy (removal of the prostate) versus watchful waiting (monitoring without definitive treatment). For men with PSA scores below 10 ng/mL, the investigators found no statistically different effects on all-cause or prostate cancer mortality between the two groups. However, with less than 15% of eligible individuals agreeing to participate, non-random selection into the trial may threaten generalizability and the study has been critiqued for being underpowered. Wilt and colleagues note differences between PIVOT enrollees and non-enrollees in age, race, degree of differentiation of prostate cancer, and self-reported health status, suggesting non-random selection may be an issue. Recruitment challenges such as those found on the PIVOT trial are a significant threat to cancer trials in general and prostate cancer ones in particular. This is one advantage observational studies have over trials.

Variations in prostate cancer treatment practice patterns offer opportunities to compare outcomes through observational studies. Though such studies have limitations, they do not face the same challenges of recruitment and generalizability as randomized trials. The results of observational studies could be useful in guiding treatment decisions while awaiting additional results from ongoing or planned, long term clinical trials. Variation in application of radiation or surgical treatment has been documented for at least two decades. Using 1995-1999 National Cancer Institute SEER data, Krupski, et al. documented variation across ten states or metropolitan regions in the likelihood of surgical or radiation therapy. Variation is large (odds ratio range from 0.44 to 2.01) and significant even after controlling for age, ethnicity, income, education, and histologic grade. Similar patterns of variation were found in the Veterans Health Administration, even after adjusting for diagnosing (as opposed to treating) institution, age, grade, stage, race, ethnicity, insurance type, and marital status.

Existing observational studies suffer limitations that can be overcome. In a review of 473 observational studies of prostate cancer treatment outcomes conducted prior to September 2007, Wilt, et al. found wide variation in effectiveness estimates, outcome reporting, and use of controls or risk adjustment. More importantly,

Investigators rarely stratified outcomes according to patient and tumor characteristics. Many [observational] studies included patients with locally advanced disease but did not analyze outcomes on the basis of tumor stage.

Consequently, a consensus on the relative effectiveness of treatment options does not emerge from the body of observational research. The vast majority of observational studies focus on emerging technologies, harms, and quality of life outcomes. Among observational studies that have compared primary treatments ”[o]verall and disease-specific mortality were infrequently reported.”

Within the Veterans Health Administration and in other settings, there is ample data and sample to conduct observational, comparative effectiveness studies of prostate cancer treatment. Crucially, practice pattern variation exists and can be exploited as a source of quasi-randomness. This leads to an “instrumental variables” design, which has its own set of limitations. However, radnomized trials, though valuable, are also limited in ways that observational studies are not, as described above. We need more of both and prostate cancer treatment is just one area in which they can be put to good use. In a subsequent post I will describe another.

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Health Affairs: Good News for Medicare Advantage

by Communications on December 10, 2012 · 0 comments

The December 2012 issue of Health Affairs looks at Medicare Advantage, public health, and system weaknesses. Editor-in-Chief Susan Dentzer notes in her opening remarks that “this month’s Health Affairs contains fodder for pessimists, optimists, and everyone in between. Happily, for this year-end issue, much of the balance is geared toward optimists.”

The most “optimistic” of the articles come from the section on Medicare Advantage plans, with in-depth analysis of risk adjustment measures and emergency department visits by enrollees. The issue moves on to examine positive results of pay-for-performance measures and strategies to reduce rehospitalizations.

The following members had their work published in this month’s issue:

Analysis Of Medicare Advantage HMOs Compared With Traditional Medicare Shows Lower Use Of Many Services During 2003–09
Bruce E. Landon, Robert C. Saunders, L. Gregory Pawlson, Joseph P. Newhouse, and John Z. Ayanian

Steps To Reduce Favorable Risk Selection In Medicare Advantage Largely Succeeded, Boding Well For Health Insurance Exchanges
Joseph P. Newhouse, and J. Michael McWilliams

New Risk-Adjustment System Was Associated With Reduced Favorable Selection In Medicare Advantage
J. Michael McWilliams and Joseph P. Newhouse

In Consumer-Directed Health Plans, A Majority Of Patients Were Unaware Of Free Or Low-Cost Preventive Care
Mary E. Reed, Vicki Fung, and Joseph P. Newhouse

Hospital Pay-For-Performance Programs In Maryland Produced Strong Results, Including Reduced Hospital-Acquired Conditions
Sule Calikoglu, and Robert Murray

Low-Cost Transitional Care With Nurse Managers Making Mostly Phone Contact With Patients Cut Rehospitalization At A VA Hospital
Maureen A. Smith

Disclosure-And-Resolution Programs That Include Generous Compensation Offers May Prompt A Complex Patient Response
Michelle M. Mello

THE CARE SPAN: Hospices’ Enrollment Policies May Contribute To Underuse Of Hospice Care In The United States
Colleen L. Barry and Elizabeth H. Bradley

Simulation Of Quitting Smoking In The Military Shows Higher Lifetime Medical Spending More Than Offset By Productivity Gains
Timothy M. Dall

Reducing Racial And Ethnic Disparities In Colorectal Cancer Screening Is Likely To Require More Than Access To Care
Jim P. Stimpson, José A. Pagán and Li-Wu Chen

Bioterrorism And Biological Threats Dominate Federal Health Security Research; Other Priorities Get Scant Attention
Arthur L. Kellermann

China’s Rapidly Aging Population Creates Policy Challenges In Shaping A Viable Long-Term Care System
Zhanlian Feng, Chang Liu, and Vincent Mor

YOUNG LEADERS: Employing Behavioral Economics And Decision Science In Crucial Choices At End Of Life
Scott D. Halpern

Survey Of Primary Care Doctors In Ten Countries Shows Progress In Use Of Health Information Technology, Less In Other Areas
Cathy Schoen and Michelle Doty

Health Affairs is an official journal of AcademyHealth.

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How general health checks are like angioplasty

by The Incidental Economist on November 26, 2012 · 2 comments

It turns out, periodic, general health checks that involve routine screenings are a lot more like high-tech angioplasty than you might think. This was revealed by a Cochrane Library review published in October that evaluated the effect of general health checks on mortality and morbidity. An accompanying editorial succinctly summarized the findings, placing them in the context of prior studies.

The results of [the Cochrane review by Krogsbøll et al] are consistent with a previous systematic review by Boulware et al that also evaluated the benefits and harms of general health checks.[13] [...] The authors of both reviews reported that general health checks had no effect on mortality, disability and hospitalizations compared with usual care. [...]

How should practitioners use the findings of Krogsbøll et al? Although available trials have limitations, there is no convincing evidence that general health checks are beneficial. Since patients who seek or are willing to undergo routine screening are generally healthier than those who are not [3] (indicating that general health checks are least likely to reach those who could benefit the most), and because most people do not receive interventions that are known to be beneficial, [14] general health checks do not appear to be a wise use of scarce healthcare resources. Heeding the Canadian recommendations (made more than 30 years ago) to abandon routine health checks would save money that could be better used by population-level interventions supported by effective health policy, such as the campaigns to reduce dietary sodium in Finland and the United Kingdom. [15,16]

Placing greater emphasis on preventative care is among the common recommendations for health system reform. Abandoning routine health checks would seem to be the antithesis. How can one prevent what one does not see coming? The key word here is “routine,” as in “providing in an untargetted way.” What the Cochrane review is telling us is that some, but not all, screenings are of value. Yet even those that are, are not so for everyone.

[T]his important review should not be interpreted as nihilistic; it focuses on the screening of asymptomatic people and does not apply to interventions prompted by clinical judgment or patient concern. For all studies in the review, diagnostic testing and treatments were undoubtedly offered to participants in the control groups for these reasons, and probably improved outcomes while reducing the apparent effect of the intervention. Practitioners should continue to investigate and treat patients with symptoms or clinical clues to underlying disease or its risk factors.

In other words, general health checks are a category II technology, cost-effective for some patients and low benefit for others who still may seek or receive them. Broad application is wasteful and costly, just like angioplasty (aka, percutaneous coronary intervention or PCI). Once again, here’s the key chart, though in this case interpret “PCI” as “general heath checks”:

There is a population for whom the screenings (or some of them) of general health checks are highly valuable. That’s where the red line is high in the chart. There is also a large population for which they are of low value. Routine application mixes the two and dilutes the observed effect on mortality and morbidity. The important message is not to abandon all preventative screenings, but to apply them more wisely.

References

3. van Walraven C, Goel V, Austin P. Why are investigations not recommended by practice guidelines ordered at the periodic health examination? Journal of Evaluation in Clinical Practice 2000;6(2):215?24. DOI:10.1046/j.1365-2753.2000.00245.x

13. Boulware LE, Marinopoulos S, Phillips KA, et al. Systematic review: the value of the periodic health evaluation. Annals of Internal Medicine 2007;146(4):289?300.

14. McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. New England Journal of Medicine 2003;348(26):2635?45. DOI:10.1056/NEJMsa022615

15. He FJ, MacGregor GA. A comprehensive review on salt and health and current experience of worldwide salt reduction programmes. Journal of Human Hypertension 2009;23(6):363?84. DOI:10.1038/jhh.2008.144

16. Holland W. Periodic health examination: a brief history and critical assessment. Eurohealth 2009;15(4):16?20. Available at http://www.euro.who.int/__data/assets/pdf_file/0011/83990/Eurohealth15_4.pdf (accessed 15 October 2012).

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Student Chapter Spotlight: University of North Texas Health Science Center

by Communications on November 20, 2012 · 0 comments

AcademyHealth supports the formation of student chapters to enhance the learning and professional development experience for students in health services research and health policy. While AcademyHealth suggests that each chapter perform several key functions, each chapter is encouraged to develop additional programs and projects of interest to its members.

As part of their chapter activities, the University of North Texas Health Science Center (UNTHSC) Student Chapter recently organized a visit with Baylor Health Care System leaders.

“Some takeaways and outcomes we gained from participating in the tour were exceptional career advice, as well as how to become a more marketable candidate for available positions. The Baylor Health Care System emphasized vital credentials such as critical thinking, writing skills, ability to do literature reviews, project management, research implementation, and time and data management,” said Chapter President Debra Tan.

Read more about this event here. To start a student chapter or learn more about possible chapter activities, visit our website.