Should we abandon the periodic health examination?

In 2009, IMS Health published a statistical snapshot of the top 10 reasons patients in Canada visit family physicians and other specialists.¹ Second only to visits for hypertension was “general medical exam” at 10.5 million visits per year. Assuming fee-for-service remuneration, and considering that on average a routine medical examination (also known as an annual physical or a periodic health examination [PHE]) takes up double the time of a regular appointment, this represents approximately 21.4 million appointments a year at an expense of $2 billion in consultation costs alone. Add to this the expense of all the unnecessary testing, investigations, and recalls, and I would estimate the total cost to be much greater. I believe that the Canadian Medicare system can no longer sustain this resource-intensive, non–evidence-based practice.

Outdated

Historically, the annual physical is a generalized head-to-toe examination, accompanied by comprehensive multiphasic investigation and laboratory screening. The roots of the annual physical date back to 1861, with economics being the prime motivating force for its continuance.² In the 1970s and 1980s, both the Canadian Task Force on the Periodic Health Examination and the United States Preventive Services Task Force recommended abandoning the comprehensive systemic examination in favour of case-finding maneuvers during regular visits. Scheduling appropriate evidence-based preventive care during regular visits is achievable, particularly with the increasing computerization of practices.

Efforts to streamline complete health assessments³ and to focus on evidence-based interventions of known efficacy, while improving delivery of some recommended services, have failed to halt annual, non–evidence-based, head-to-toe examinations and multiphasic testing. Essentially, there is no difference between an annual physical and a PHE, except in the terminology. Patients and physicians alike still refer to it as an annual physical, and two-thirds of both physicians and patients still believe that it involves a head-to-toe examination and multiphasic testing.^4,5 I commonly see nonrecommended tests, such as complete blood count, liver function, thyroid-stimulating hormone, vitamin B12, and even international normalized ratio and troponin testing being routinely ordered for healthy individuals.

Better use of resources

Of particular importance is that patients who already regularly visit family physicians, and even patients who already have 4 extended chronic-disease visits per year, are also those most likely to schedule dedicated PHEs. There is no convincing evidence that having a dedicated appointment for a PHE, in place of case-finding maneuvers during regular visits, leads to better health outcomes, or that those who undergo this annual ritual are healthier or have decreased morbidity and mortality compared with those who do not. In fact, there is sufficient evidence to show that many of the investigations conducted during the PHE might be harmful and not in the best interests of the patient.⁶ Advocating for patients includes not subjecting them to unnecessary medical interventions, and both the CMA Code of Ethics⁷ and the College of Family Physicians of Canada’s 4 principles of family medicine⁸ make mention of a responsibility for the judicious use of health care resources.

A disturbing emerging trend is that of practices offering improved access and services for an annual user fee. One of the cornerstones of the “improved care” offered by these practices is a “comprehensive health assessment,” which claims to be evidence-based. These assessments can take anywhere from 3 hours to 3 days and include non–evidence-based investigations, such as whole-body computed tomography scanning, and might in fact be more harmful than beneficial.⁹

One of the main arguments in favour of a PHE is that preventive care services are more likely to take place during a dedicated visit.¹⁰ With the computerization of medical practices, it should not be difficult to schedule necessary preventive care at appropriate intervals and during regular visits. A substantial proportion of taxpayers’ money is being spent on electronic medical records, and already the public is demanding a return on their investment. In essence, every acute care visit should also include a component of preventive care.

While physicians are spending a substantial amount of their time conducting PHEs, provincial governments are having to rely more on nurse practitioners, pharmacists, and other health professionals to provide acute care to those in need. Emergency departments are filled with patients who would be better served by family physicians, and most of these patients do not receive any preventive care.

Provincial funding agencies need to discontinue paying for dedicated PHEs and redirect those fees to primary care practices that are absorbing new patients, providing patients with medical homes, and using their electronic medical records to schedule evidence-based preventive care at appropriate intervals and within the framework of regular acute care visits. An additional 21.4 million appointments a year would contribute substantially to providing all Canadians with family physicians and medical homes, and would reduce some of the pressure on emergency departments.

CLOSING ARGUMENTS

• There is no convincing evidence that having a dedicated appointment for a periodic health examination (PHE), in place of case-finding maneuvers during regular visits, leads to better health outcomes.

• The 10.5 million PHEs that take place each year in Canada are costing the health system in excess of $2 billion dollars a year.

• With the implementation of electronic medical records in most practices, it should not be difficult to schedule necessary preventive care at appropriate intervals and during acute care visits.

• The appointment time freed up by eliminating the PHE would allow more Canadians to access family physicians and reduce the pressure on emergency departments.