|Value of the periodic health evaluation
|Boulware L E, Barnes G J, Wilson R F, Phillips K, Maynor K, Hwang C, Marinopoulos S, Merenstein D, Richardson-McKenzie P, Bass E B, Powe N R, Daumit G L
This review compared periodic health examinations (PHEs; regular appointments involving only history taking, risk assessment and a tailored physical examination) with usual care. The authors concluded that the PHE improves delivery of some recommended preventive services and may reduce patient worry. The authors' conclusions are likely to be reliable for interventions meeting their definition of a PHE.
To assess the benefits and harms of periodic health evaluations (PHEs).
Studies with quality scores falling within the top 33% of
all study quality scores were deemed to have “high” scores, studies with quality scores falling
within the middle 33% of all study quality scores were deemed to have “medium” scores, and
studies with quality scores falling within the lowest 33% of all scores were deemed to have
“low” scores.The authors searched MEDLINE, the Cochrane Library and CINAHL, and handsearched 24 journals and reference lists of relevant articles. The searches were performed in May 2005 and updated in February and September 2006. The search strategies were reported in an appendix, available electronically. The search was limited to English language studies.
Study designs of evaluations included in the review
Randomised controlled trials (RCTs), non-randomised trials and observational studies were eligible for the review.
Specific interventions included in the review
Studies of PHEs compared with usual care were eligible for the review. A PHE was defined as a visit to a health care provider with the primary purpose of assessing overall health and risk factors for disease that may be prevented by early intervention. The PHE consisted only of history taking, risk assessment and a tailored physical examination. Clinical interventions delivered at the time of the PHE or later were considered as outcomes of the PHE. Studies of system-based interventions designed to improve receipt or delivery of the PHE were also eligible.
Participants included in the review
Studies that focused on adults were eligible for the review; studies that included only participants aged less than 18 years were excluded. The participants in the majority of studies were patients, but studies of health care providers were also included.
Outcomes assessed in the review
Studies were eligible if they assessed the effects of the PHE on any of a wide range of outcomes, including the delivery of clinical preventive services, patient attitudes, health-related behaviour, clinical outcomes, resource use and costs, and overall public health. The majority of the included studies assessed delivery of preventive clinical services, short-term clinical outcomes and longer-term clinical and economic outcomes. Uptake of the PHE itself was the outcome for system-based interventions.
How were decisions on the relevance of primary studies made?
Two reviewers independently assessed the studies for relevance. Any disagreements were resolved by consensus.
Assessment of study quality
Two reviewers independently assessed validity using a 15-item checklist. Based on the results of the checklist, the studies were given a total quality score ranging from 0 (worst quality) to 100 (best quality).
One reviewer extracted the data, and a second checked the extraction. For RCTs, data on the differences in means or proportions between groups were used to calculate a standardised mean difference (Cohen's d effect size) and its associated 95% confidence interval.
Methods of synthesis
How were the studies combined?
The studies were combined in a narrative by type of outcome.
How were differences between studies investigated?
Differences between the studies were discussed in the text.
Results of the review
Thirty-six studies were included: 11 RCTs, 1 non-randomised trial, 7 cohort studies, 14 cross-sectional studies and 3 before-and-after studies. The total number of participants was not reported.
Based on 1 RCT, 1 non-randomised trial and 3 observational studies, there was evidence of medium strength that offering a scheduled PHE (compared with an unscheduled open invitation) and offering a free PHE (compared with making a small charge) had a medium to large positive effect on uptake of the PHE.
Delivery of preventive clinical services.
Based on 4 RCTs and 10 observational studies, PHEs had a positive association with the receipt of gynaecological examinations or Pap smears, cholesterol screening and faecal occult blood testing. PHEs had mixed effects on the receipt of other preventive services such as counselling, immunisation and mammography.
Short-term clinical outcomes.
Six RCTs and 1 observational study assessed the effect of the PHE on outcomes including disease detection, patient health habits, attitudes and clinical measures (including blood-pressure, serum cholesterol and body mass index). The PHE had a beneficial effect on reducing patient worry in 1 RCT; associations between the PHE and other outcomes were mixed.
Longer-term clinical outcomes.
Evidence from RCTs indicated that receipt of a PHE had mixed effects on disability, hospitalisation and mortality.
Five RCTs and 4 observational studies investigated the association between receiving a PHE and health care costs. These studies evaluated a range of different outcomes and found that the effects of the PHE were mixed. In the 4 largest RCTs, the PHE decreased costs in one study, increased costs in another and had no effect in the remaining two.
The PHE improves delivery of some recommended preventive services and may reduce patient worry.
The inclusion criteria for this review were clear but broad (except for the strictly defined intervention). The authors searched a range of sources, although the search was limited to English language publications so relevant studies could have been missed. Unpublished studies were not sought and publication bias was not assessed, so the review might be at risk of publication bias. Validity was assessed using standard methods and the results were taken into account in the narrative synthesis. Appropriate methods were used to reduce error and bias in the study selection, validity assessment and data extraction processes. The use of a narrative synthesis was appropriate in view of the wide range of participants, outcomes and study designs included. The authors' conclusions are in line with the evidence presented and are likely to be reliable for interventions meeting their definition of a PHE.
Implications of the review for practice and research
Practice: The authors stated that there is sufficient evidence to justify implementation of the PHE in clinical practice.
Research: The authors stated that further research is needed to evaluate the long-term benefits, harms and costs of receiving the PHE.
Agency for Healthcare Research and Quality, contract number 290-02-0018.
Boulware L E, Barnes G J, Wilson R F, Phillips K, Maynor K, Hwang C, Marinopoulos S, Merenstein D, Richardson-McKenzie P, Bass E B, Powe N R, Daumit G L. Value of the periodic health evaluation. Rockville, MD, USA: Agency for Healthcare Research and Quality. Evidence Report/Technology Assessment; 136. 2006
Other publications of related interest
Boulware LE, Marinopoulos S, Phillips KA, Hwang CW, Maynor K, Merenstein D, et al. Systematic review: the value of the periodic health evaluation. Ann Intern Med 2007;146:289-300.
Subject indexing assigned by CRD
Ambulatory Care; Appointments and Schedules; Health Surveys; Occupational Medicine; Physical Examination; Physician-Patient Relations; Physician's Practice Patterns; Preventive Health Services /organization & administration; Questionnaires
Date bibliographic record published
Date abstract record published
This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.