Clinician Time Spent on Preventive Health Examinations May Outweigh Benefit to Patients

Laurie Barclay, MD

September 25, 2007 — The amount of time spent by both general practitioners (GPs) and obstetricians/gynecologists (OB/Gyns) on preventive health examinations (PHEs) and preventive gynecological examinations (PGEs) may far outweigh the benefits derived from them by patients, according to the results of a retrospective analysis reported in the September 24 issue of the Archives of Internal Medicine. However, a "significant fraction" of preventive tests such as Papanicolaou (Pap) tests and mammograms are conducted during annual PGEs.
Findings of this study suggest that between 2002 and 2004, PHEs accounted for about 1 in 12 outpatient visits for adults in the United States, which translates to approximately 63.5 million US adults having an annual preventive health or gynecological examination, costing a total of about $7.8 billion per year.
"This emphasizes the key role annual physical exams play in our healthcare system, despite the lack of an evidence base or guidelines to support their use," lead author Ateev Mehrotra, MD, MPH, an assistant professor at the University of Pittsburgh School of Medicine in Pennsylvania and a policy analyst at RAND Health, told Medscape Internal Medicine. "Some primary care physicians see annual physicals as the only time that they can focus on preventive care with their patients. Though I don't deny the great time pressures physicians face, this finding emphasizes that most preventive care is already happening outside annual physicals and supports the campaign to 'Take a Minute for Prevention' in our other visits."
Although two thirds of patients and physicians believe in the importance of an annual physical examination, most North American clinical societies do not endorse strictly preventive general health or gynecological examinations.
Using the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical
Care Survey, the investigators analyzed 8413 adult outpatient visits from January 1, 2002, to December 31, 2004, for PHEs and PGEs. Randomly selected physicians completed a 1-page survey describing their visits with each of 30 randomly selected patients during an assigned reporting week.
The Current Population Survey was used to obtain population estimates. Outcome measures were estimated rates of PHEs and PGEs based on demographic characteristics, frequency of 8 preventive services performed during these visits, and total costs of PHEs and PGEs, assuming Medicare reimbursement rates.
"There is evidence that shows that patients are more likely to receive preventive services if they go specifically for their physical exam than if they visit their clinician for an acute illness," says Amir Qaseem, MD, PhD, MHA, senior medical associate, Department of Clinical Programs and Quality of Care of the American College of Physicians in Philadelphia, Pennsylvania. Dr. Qaseem was not involved with this study but was asked by Medscape Internal Medicine to provide independent commentary. "This is because there is not enough time during an acute illness visit to do preventive care and counseling."
Of 181,173 outpatient visits occurring during the 3 years of the survey, 5387 were PHEs, and 3026 were PGEs. On the basis of these figures, the estimated annual number of PHEs nationwide was 44.4 million (20.9%; 95% confidence interval [CI], 18.2% – 23.6%), and that for PGEs was 19.4 million (17.7% of adult women; 95% CI, 14.9% – 20.4%). Taken together, PHEs and PGEs accounted for 8.0% of all ambulatory visits, with total annual costs of approximately $7.8 billion.
Rates of PHEs were lower among young adults. Analysis of regional variation of PHE rates showed that the relative risk for Northeast vs West was 1.58 (95% CI, 1.17 – 2.14). For patients without private insurance or Medicare compared with those who had such coverage, the relative risk was 0.51 (95% CI, 0.40 – 0.65).
Although preventive services such as mammograms, cholesterol screening, and smoking cessation counseling were provided at 52.9% of PHEs (95% CI, 48.8% – 57.0%) and at 83.5% of PGEs (95% CI, 80.7% – 86.3%), only 19.9% of 8 preventive services occurred at a PHE or PGE (95% CI, 18.4% – 21.5%).
"This study shows the high costs associated with providing some of the preventive services," Dr. Qaseem said. "However, although we are aware of the value of some of the preventive services, and it is well established for some such as screening for colon cancer, Pap smear, cholesterol screening, etcetera, there is still no evidence for what are the components of PHE and its role in improving short- and long-term clinical outcomes. Until we have a consensus, it is important to provide evidence-based services to a patient but avoid unnecessary services."
Mammograms ordered at PHEs and at PGEs accounted for 22.9% and 44.7% of all mammograms, respectively, whereas of all visits in which patients were counseled to lose weight, only 8.8% were PHEs and 1.1% were PGEs.
"There are both benefits and downsides in encouraging PHEs. The benefits include some increased preventive testing, and at least we believe a strengthened physician–patient relationship; the downsides include the physician and patient time devoted to these visits, the costs, and the unnecessary testing," Dr. Mehrotra said. "We also must consider the fact [that] the quality of preventive care in the [United States] is still low despite the widespread use of these exams."
The estimated combined annual US total of 63.5 million PHEs and PGEs exceeds the number of annual visits for either acute respiratory infections (30 million) or hypertension, and the estimated annual cost of $7.8 billion nearly approximates the $8.1 billion spent on all breast cancer care in 2004.
Issues meriting further study, according to Dr. Qaseem, include high-quality cost-effectiveness analysis of the amount of physician and staff time and healthcare dollars spent on PHEs vs the benefits derived from these examinations, and a better definition of the PHE and PGE and their recommended components.
For example, even though tobacco counseling may have a much greater health effect than weight reduction counseling, the latter occurred more frequently than the former during preventive visits. Many of the PHEs in this study included routinely performed complete blood cell counts, urinalyses, or other tests that may be unnecessary and do not clearly improve patient outcomes.
"There is a need to study the impact on patient satisfaction as well as on the physician–patient relationship," Dr. Qaseem said. "We need high-quality evidence to show that patients who receive PHE are healthier than those who do not, and finally, cost-effectiveness analysis to prove the benefits of PHE in reducing health care costs."
Although another large-scale, randomized controlled trial could offer additional evidence, Dr. Mehrotra believes that such a trial is not practical, given the largely negative results of previous trials.
"My hope is that this study prompts organizations such as the US Preventive Task Force and specialty societies such as the [American College of Physicians, American Academy of Family Physicians, and American College of Obstetricians and Gynecologists] to weigh these benefits and downsides and come to some consensus on whether we should encourage patients to come in annually (or some other interval) for physicals, and what should be the content of these visits," Dr. Mehrotra concluded. "I think our findings emphasize the real need for some guidance."
Dr. Mehrotra's salary was supported by a National Research Service Award from the Health Resources and Services Administration. Dr. Qaseem reports no relevant financial relationships.
Arch Intern Med. 2007;167(17):1876–1883