Better Value Health Checks

A Practical Guide

Nick Summerton

• Publisher: CRC Press
• Year: 2018
• eBook ISBN: 9781351615150
• Topic: Business
• Subtopic: Service Industry
• Index: Business

This book explores the practical aspects of setting up and assessing the quality of health checks. It is the first book to support clinicians and managers in enhancing the value of health checks in improving health outcomes, an increasingly essential goal for health services. The book will help maximise outcomes for individuals, families and employers by addressing each element within a health check from primary prevention, risk factor reduction and screening to early diagnosis and tertiary prevention. These are considered in relation to their ability to lead to subsequent improvements in individual health outcomes.

1

Introduction

Individual health checks – incorporating multiple components – have proved to be much more popular with the general public than with healthcare professionals or those responsible for government-funded national screening programmes. Many employers and organisations also struggled to decide if they are a good benefit to offer to workers and members.

In the private sector the emphasis seems to have been on providing packages incorporating as many tests as possible, with only minimal consideration being given to the impacts of such testing on health. As a GP I have often been faced with an anxious patient grasping a sheet of mildly abnormal blood results derived from such a health check. Even more concerning some private tests being offered are of doubtful validity, reliability or utility with the potential for significant harm.

Public-sector initiatives – such as the National Health Service (NHS) Health Check Programme focusing on cardiovascular disease prevention – have been equally disappointing. Here the testing being promoted has been determined primarily by considerations of cost. Having been personally involved in some of the preliminary discussions during the planning of the NHS Health Check Programme, I am aware of at least two key omissions from the portfolio: a screening electrocardiogram (ECG) for atrial fibrillation and ankle-brachial blood pressure index measurement to refine cardiovascular risk. Subsequent evaluations have found only minimal evidence for any beneficial effects of the programme.

However, there is a wealth of good research supporting the impacts of a range of preventative and earlier disease recognition initiatives on health. But it often seems that those designing or developing health checks cast only a cursory glance at such evidence before continuing with their search for new gimmicks or cheaper options. There is an urgent requirement for a fresh approach.

Within many health systems there is now a growing interest in ‘value’ as a more appropriate mechanism to design and deliver care. Value is defined as health outcomes achieved relative to the costs of care. Therefore, value increases when better outcomes are achieved at comparable (or lower) cost, or when equivalent outcomes are achieved at lower cost.

Carefully designed health checks – incorporating preventative activities, risk stratification, screening, early diagnosis and the mitigation of health problems due to ongoing heath conditions – ought to represent high-value care with improved outcomes and reductions in costs. For example, detecting early stage bowel cancer is associated with improvements in survival plus reduced levels of subsequent physical and psychological disability. Direct healthcare costs are also lower (because of less complex/invasive treatments), with less financial burden on individuals, families and employers due to faster recovery and less time off work.

By focusing on better value health checks, the emphasis moves away from cost-oriented or operational discussions about the process of health checks to the actual health benefits – or outcomes – achieved. Designing a better value health check should be about thinking backwards from the desired outcomes as opposed to just focusing on tests and dubious assessments of ‘customer satisfaction’. For example, in relation to ovarian cancer, investing in annual CA-125 monitoring is a much better value option than having a face-to-face consultation with a private doctor to discuss symptoms and undertake an internal examination. It is always ‘nice’ to have some time off work to chat for an hour with a doctor, but is this really delivering the value that individuals, employers and insurance companies are seeking?

Various public health data sets certainly highlight that there is a considerable burden of premature death and disability that better value health checks could potentially help to address. Only around 15% of individuals with atrial fibrillation or alcohol problems are currently detected as well as less than 50% of individuals at raised cardiovascular risk due to increased blood pressure, lipid disorders or impaired glucose regulation.

Focusing on value might also highlight some less positive effects from ill-considered testing. For example, investigations such as ‘total body imaging’ can easily lead on to adverse outcomes due to the identification of incidental findings that, although of no pathological significance, generate considerable anxiety and, not infrequently, require some exploratory surgery to put an individual’s mind at ease. Some low-cost imaging tests – such as the chest X-ray – are used inappropriately to reassure individuals that they have been ‘screened’ for lung cancer. They have not.

Taking time off work to see an NHS GP after a health check to run over results that have been inadequately explained is also not good value for money. A focus on value therefore ensures that we do not ignore the possible adverse consequences of health checks and that we design packages to ensure that the likely benefits outweigh any potential harms.

Above all, health checks need to be viewed as just one step in a process of care and might produce a variety of outputs. Outcomes are therefore about much more than what happens at the health check. For some individuals, the health check identifies nothing of significance, and they may just need a further checkup in the future. For others it highlights specific risk factors and they will need research-based guidance and support as to how to lower these risks with a view to preventing subsequent problems such as diabetes or cardiovascular disease. Another group will have an abnormal result that requires further investigations, and a few individuals might need some specific treatment or a surgical intervention.

This book focuses on the issues to be considered by organisations or individuals wishing to design and deliver better value health checks for adults in addition to those wanting to purchase or procure a package that will actually make a difference to health and wellbeing. The target audience is anyone with an interest in health checks within both the developed and the developing world.

Chapter 2 builds on this introduction and examines, in detail, some of the key challenges that need to be taken into account as well as highlighting the opportunities. Chapter 3 sets out a definition of a better value health check plus the six key architectural features in addition to some of the detailed operational issues that must be considered in seeking to enhance value.

Based on a careful review of good quality primary research evidence, systematic reviews and guidelines, Chapters 4–15 cover some specific diseases or disorders that might be considered for a better value health check focused on adults and appropriate for particular population groups. However, these chapters are offered up as a basis for an informed discussion between designers and developers and those undergoing, purchasing or procuring health checks as opposed to a proscriptive list.

Finally, there is a growing recognition that employers have both an interest in better value health checks (e.g. in relation to organisational outcomes such as productivity) as well as a key role in facilitating health improvements after a health check. Therefore, Chapter 16 specifically focuses on delivering better value for organisations.

2

Health checks: Challenges and opportunities

2.1What are the issues with health checks?

Health checks – also termed multiphasic screenings, health assessments, periodic health examinations or evaluations and preventative health reviews – have a long pedigree.

As far back as 1861 the British physician Horace Dobell put forward an argument for the regular assessment of apparently well individuals in order to identify developing health problems. Subsequently, in the United States, Gould suggested that everyone should undergo a regular – or periodic – health examination. The rationale behind both of these initiatives was that spotting diseases and disorders in their earliest stages would improve the effectiveness of treatment and, therefore, survival (1).

During the first half of the twentieth century health checks were enthusiastically embraced by the medical profession, life insurance organisations and companies. The annual comprehensive physical examination was endorsed by the American Medical Association in the 1920s and rapidly became a standard element of primary care in the United States. Those selling life insurance also began using health checks as a mechanism to assess the financial risk posed by applicants, with gradually increasing comprehensiveness and complexity over time. In addition, private industries and organisations viewed health checks as a way to comply with legislation in addition to enhancing productivity and efficiency. Moreover, within some companies, this interest evolved into a particular focus on senior executives as it was felt that the wellbeing of such individuals was especially important for the success of a company. For example, by the 1950s, the Greenbrier Clinic in the United States was running 3-day health checks for key clients and, in Japan, top executives were admitted to hospital for 5 days of health checks, known as the ‘Human Dry Dock’ (2).

Both Dobell and Gould advocated health checks for everyone but, for a time, their ideas were largely ignored. The first health checks were actually targeted at specific groups such as schoolchildren, military recruits and immigrants. Some were also directed at ...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Contents
• Preface
• Author
• Acknowledgements
• List of abbreviations
• 1. Introduction
• 2. Health checks: Challenges and opportunities
• 3. Better value health checks: Key elements
• 4. Cardiovascular health
• 5. Lung health
• 6. Musculoskeletal health
• 7. Gastrointestinal health
• 8. Liver health
• 9. Endocrine and metabolic health
• 10. Epithelial health
• 11. Mental health
• 12. Men’s health
• 13. Women’s health
• 14. Sexual health
• 15. Older people’s health
• 16. Organisational health
• 17. Conclusion
• Appendix: Quality criteria
• Glossary
• Index