Dr Alan Begg considers some current evidence about cardiovascular health screening and how newer drugs and risk assessment tools might help to improve outcomes

An editorial in the British Medical Journal (BMJ) in June this year headlined that general health checks do not work and called for current programmes like the one in the UK to be abandoned.1 The editorial stated that screening programmes for healthy people are justifiable only if randomised trials clearly show that their benefit outweighs harm, and that physicians are already targeting people felt to be at high risk when they see them for other reasons.

Inter99 trial

This BMJ editorial coincided with the publication in the same issue of the Inter99 trial into the effect of screening and lifestyle counselling on the incidence of ischaemic heart disease (IHD) in the general population.2

In the trial, nearly 60,000 people aged between 30 and 60 years in Copenhagen were randomised into an intervention or control group and followed up for 10 years. People in the intervention group were invited for screening, risk assessment, and lifestyle counselling up to four times over a 5-year period. Those with an unhealthy lifestyle had individual lifestyle counselling, and if they were considered to be at high risk of IHD they were offered six sessions of group-based lifestyle counselling on smoking cessation, diet, and physical activity. If medical treatment was required, they were referred to their GP.

Significant changes in lifestyle were noted in participants after 5 years, but there was no effect on the development of IHD, stroke, or death after a period of 10 years (see Box 1).2

Box 1: Results of Inter99 randomised trial2

Primary outcome measure

Incidence of IHD in intervention group (n=11,629) compared with control group (n=47,987)

Hazard ratio 1.03 (95% CI 0.94 to 1.13).

Secondary outcome measures

Stroke: Hazard ratio 0.98 (95% CI 0.87 to 1.11)

Combined events (IHD, stroke or both): Hazard ratio 1.01 (95% CI 0.93 to 1.09)

Total mortality: Hazard ratio 1.00 (95% CI 0.91 to 1.09).

  • IHD=ischaemic heart disease; CI=confidence interval

Benefit of cardiovascular screening

The inability to demonstrate an outcome benefit from this cardiovascular screening is disappointing. The number of events was sufficient to show a possible effect and all staff were committed, trained, and supervised in their behavioural change and lifestyle counselling approach. The intervention was primarily counselling-based, with medical treatment left to general practice,2 but perhaps with modern effective therapeutic interventions, such as statins and blood pressure lowering drugs, both counselling and therapeutic interventions need to be combined, ideally within general practice. This study also raises the question once again of whether risk screening tools are suitable for identifying people at highest risk and whether the tools are validated in the population in which they are being used.

Cochrane review

Other studies have also failed to show a benefit for general health checks. A Cochrane review by the same authors of the BMJ editorial1 and published in the BMJ in 2012 analysed 14 trials.3 No beneficial effects were seen on morbidity, hospitalisation, disability, worry, additional physician visits, or absence from work.3 For the nine trials that provided data on total mortality, the risk ratio was 0.99 (95% CI 0.95 to 1.03) and for the eight reporting cardiovascular mortality, the risk ratio was 1.03 (95% CI 0.91 to 1.17). It is important to note, however, that all these trials were performed well before the widespread use of statins to reduce cardiovascular risk.

UK NHS Health Check

When the plans for universal screening for the early signs of heart disease, stroke, and kidney disease were announced by the then UK Prime Minister, Gordon Brown, in January 2008, Nick Clegg (now Deputy Prime Minister) was quoted as saying that evidence was required ‘that this was more than just another expensive political gimmick from this government’.4 The current NHS Health Check in England, for adults aged between 40 and 74 years, aims to prevent heart disease, stroke, diabetes, kidney disease and some forms of dementia, and to detect potential problems before damage is done.5 Every year, the NHS Health Check is expected to help to:5

  • save 650 lives
  • prevent 1600 heart attacks and strokes
  • prevent 4000 people from developing diabetes
  • detect at least 20,000 cases of diabetes or kidney disease earlier.

Local authority involvement

Responsibility for the 5-yearly health checks passed to local authorities in April 2013 although, while in opposition, the present government implied that the checks would be scrapped or redesigned to ensure that they were of more use to people with unhealthy lifestyles.6,7 In the year ending April 2014, a total of 2,824,726 people were offered a health check and 1,382,864 of the 5-year-eligible population received one, an increase of nearly 10% on the previous year.8 Public Health England considers that programme modelling reveals the health checks to be cost effective, with a cost of around £3000 per quality-adjusted life year gained.9 In February this year, NICE published a briefing to encourage people to have a health check, while acknowledging the debate on their effectiveness.10 One of their key messages was that where the risk assessment is conducted outside the person’s GP practice, then information from the check should be passed to the person’s GP.

Criteria for screening

Public Health England has published an approach to the evidence for the NHS Health Check; it feels that there should be benefit in bringing together into one programme the NICE evidence-based guidance for specific risk factors.9 Public Health England accepts that the programme is being implemented in the absence of direct randomised controlled evidence to guide it, although it rightly points out that the Cochrane review3 looked at trials conducted many years ago, and that the notion of a health check is not clearly defined.

The Principles and practice of screening for disease, published by the World Health Organization in 1968, defined screening as the ‘presumptive identification of unrecognized disease or defect’, including pre-symptomatic disease.11 The National Screening Committee uses appraisal criteria before recommending screening for a particular condition,12 as well as looking at the best available evidence, but the question remains whether health checks meet those criteria.13

Screening for disease or risk

The Best practice guidance for the NHS Health Check recommends a measurement of cardiovascular risk, but screening for specific disease categories is not universal.14 As part of the check, exclusion of diabetes depends on the level of blood pressure and body mass index, and chronic kidney disease is only investigated if the blood pressure is raised. Alcohol advice was introduced in 2013 for those with raised blood pressure and high alcohol intake, as was raising awareness of dementia symptoms and memory clinics for those aged 65–74.15 By offering this ‘bundle’ of tests with low pre-test probability, showing overall benefit is always going to be difficult.

Everyone having an NHS Health Check will be provided with individually tailored advice that will help motivate them and support the necessary lifestyle changes to manage their risk.14 These lifestyle interventions are highlighted in Box 2.

Box 2: NHS Health Check lifestyle interventions 14

  • Stop smoking services referral
  • Physical activity interventions
  • Weight management
  • Alcohol use interventions.

The role of general practice

In their day-to-day practice, GPs identify patients with individual risk factors, people who are at high risk of cardiovascular disease, as well as people with specific associated disease categories, such as diabetes. Any abnormality identified in a health check needs to be acted on, so it is essential that this information is passed on. It has been said that it is the ‘worried well’ who respond to an invitation for a health check.13 These people tend to be of higher than average socio-economic status, with fewer health risks, less morbidity, and higher life expectancy. In recent years, the quality and outcomes framework16 has encouraged regular blood pressure checks and the recording of smoking status, as well as targeting of specific patient groups (e.g. those with severe mental illness). Targeting these high priority groups deemed to be at higher risk (see Box 3) may be more beneficial than providing a universal population based screening approach.

Box 3: High priority groups for assessment of cardiovascular disease risk

People who are:

  • living in deprived circumstances, beginning with the most deprived
  • regular smokers
  • first-degree relatives of individuals with a history of premature cardiovascular disease
  • obese (body mass index greater than 30 kg/m2)
  • relatives of patients with familial hypercholesterolaemia
  • from ethnic minorities (South Asian, black, and Afro-Caribbean).

People who have:

  • confirmed hypertension
  • serious and enduring mental health problems
  • a learning disability.

Next steps

The JBS3 report, published recently, is felt to be pertinent to the NHS Health Check programme, and Public Health England’s Expert Scientific and Clinical Advisory Panel will be carefully considering its relevance to the programme over the coming months.17 They feel that this new guideline provides an opportunity to consider the effectiveness of the different approaches to communicating risk and how behavioural and physiological risk-reduction interventions are prioritised. In addition, the debate in the BMJ and other publications on whether there is benefit in offering statin drugs to those patients at much lower cardiovascular risk continues.18 If NICE does recommend such an approach, then the burden will fall on an overstretched general practice.

  1. Gøtzsche P, Jørgensen K, Krogsbøll L. General health checks don’t work. BMJ 2014; 348: g3680.
  2. Jørgensen T, Jacobsen R, Toft U et al. Effect of screening and lifestyle counselling on incidence of ischaemic heart disease in general population: Inter99 randomised trial. BMJ 2014; 348: g3617.
  3. Krogsbøll L, Jørgensen K, Grønhøj Larsen C, Gøtzsche P. General health checks in adults for reducing morbidity and mortality from disease: Cochrane systematic review and meta-analysis. BMJ 2012; 345: e7191.
  4. BBC news website. Health screening plans unveiled. news.bbc.co.uk/1/hi/uk_politics/7174340.stm (accessed 7 July 2014).
  5. NHS Choices website. Your NHS Health Check guide. www.nhs.uk/Conditions/nhs-health-check/Pages/What-is-an-NHS-Health-Check.aspx (accessed 7 July 2014).
  6. NHS Health Check website. Foreword from Celia Ingham Clark MBE, director for reducing premature mortality, NHS England. NHS Health Check e-bulletin May 2014 edition. www.nhshealthcheck.nhs.uk/?iid=35 (accessed 7 July 2014).
  7. Torjesen I. Government prioritises health checks for 15 million adults despite pre-election promise to scrap them. BMJ 2013; 346: f2941
  8. NHS Health Check website. Quarter-four data. www.nhshealthcheck.nhs.uk/default.aspx?aID=190 (accessed 8 July 2014).
  9. Public Health England. NHS Health Check: our approach to the evidence. PHE, July 2013. Available at: www.healthcheck.nhs.uk/commissioners_and_healthcare_professionals/national_guidance/
  10. NICE website. NICE local government briefings 15. Encouraging people to have NHS Health Checks and supporting them to reduce risk factors. www.nice.org.uk/advice/LGB15/chapter/introduction (accessed 8 July 2014).
  11. World Health Organization. Principles and practice of screening for disease. Public health papers no 34. WHO, 1968. Available at: whqlibdoc.who.int/php/WHO_PHP_34.pdf
  12. Public Health England. UK National Screening Committee. UK screening portal. Programme appraisal criteria. www.screening.nhs.uk/criteria (accessed 9 July 2014).
  13. Goodyear-Smith F. Government’s plans for universal health checks for people aged 40–75. BMJ 2013; 347: f4788.
  14. Department of Health. Public Health England. NHS Health Check programme. Best practice guidance. DH, September 2013. Available at: www.healthcheck.nhs.uk/commissioners_and_healthcare_professionals/national_guidance/
  15. NHS Health Check website. NHS Health Check—changes to content from 2013–14. NHS Health Check e-bulletin March 2012 edition. www.nhshealthcheck.nhs.uk/default.aspx?aID=31 (accessed 7 July 2014).
  16. NHS Employers website. Quality and outcomes framework. www.nhsemployers.org/your-workforce/primary-care-contacts/general-medical-services/quality-and-outcomes-framework (accessed 7 July 2014).
  17. NHS Health Check website. JBS3 report and risk calculator launched. www.healthcheck.nhs.uk/news/jbs3_tool_launched/ (accessed 8 July 2014)
  18. Brown C. Statin-use debate creates furor at BMJ. CMAJ 2014; pii: cmaj.109-4825. [Epub ahead of print.] G