Preventive Health Examinations Offer Few Preventive Services

PITTSBURGH, Sept. 24 -- Preventive care services such as mammography and cholesterol screening are much more likely to be delivered outside the realm of the annual well-patient checkup than as part of it, found researchers here.

Only about 20% of such recommended preventive services occurred during annual preventive health visits, according to an analysis of data from more than 8,400 checkups.

Moreover, the annual cost for those 8,400 visits was about .8 billion, which was almost as much as the .1 billion the nation spent for all breast cancer care in 2004, reported Ateev Mehrotra, M.D., M.P.H., of the University of Pittsburgh, and colleagues, in the Sept. 24 issue of Archives of Internal Medicine.

The findings, support the concept, advocated by some, that preventive care services outside annual checkups or routine gynecologic examinations should be emphasized, they wrote.

The data do not provide any evidence that preventive examinations "detect subclinical illness and improve physician-patient relations," although many physicians believe those are two primary reasons for annual check-ups, the authors said.

More than half the patients (52.9%) received at least one of eight recommended preventive services during the preventive health examination, but only 22.9% of recommended mammograms were ordered during preventive health examinations. Not surprisingly, the rate was higher for preventive gynecologic exams when mammograms were ordered for 44.7% of women ages 40 and older.

Uninsured patients were about half as likely to get annual checkups compared with insured patients. There were also regional variations with those living in the northeast 58% more likely to have an annual preventive health examination than patients who live in the west (relative risk 1.58; 95% CI 1.17-2.14).

Dr. Mehrotra and colleagues searched two databases-the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Care survey-and selected records of 8,413 ambulatory visits from Jan. 1, 2002 through Dec.31, 2004 for analysis.

Visits were identified as preventive health examinations if the major reason for the visit was listed as "general medical examination" or if the diagnostic code was V70.0 or V70.9 (general medical examination). Visits were identified as preventive gynecologic examination if the major reason for the visit was for a gynecologic examination or if the diagnostic code was V72.3.

The records were analyzed to determine how many of these eight preventive services were ordered or performed during the visit:

• Mammograms for women age 40 or older.
• Prostate-specific antigen testing for men ages 50 to 70.
• Pap testing for women 18 to 65.
• Cholesterol testing for women 45 and older and men 35 and older.
• Smoking cessation counseling for smokers.
• Weight loss counseling for obese patients.
• Exercise counseling.
• Nutrition counseling.

They also examined the use of four tests-complete blood cell count, serum electrolytes, urinalysis, and electrocardiogram-that are "not routinely recommended as screening tools and, thus, may be overused in private visits."

Among the findings:

• About 8% of the estimated 792.1 million ambulatory visits during the three years studied were preventive examinations.
• The average preventive health examination lasted just over 23 minutes and the average preventive gynecologic examination took about 21 minutes, versus an average of about 18 minutes for other ambulatory visits.
• Most preventive health examinations were done by three physician specialties. FPs and GPs did 37.1%, general internists did 35.9%, and obstetrician-gynecologists performed 8.2%.
• Ob-gyns performed almost all preventive gynecologic examinations (81.5%), followed by FPs (13.1%) and general internists (4.9%).
• Only 5.4% of men younger than 25 had annual checkups versus 45% of men who were ages 75 and older.
• About 75% of adults who had preventive health examinations and 57.4% of women who preventive gynecologic examinations had at least one other clinic visit in the previous 12 months.

There was not, however, evidence to suggest widespread overuse of the four screening tests. One or more those tests (CBC, serum electrolytes, urinalysis, and ECG) was ordered during just 11% of preventive health examinations and 0.1% of preventive gynecologic examinations.

Future recommendations about preventive medical visits should include consideration of practical workforce issues, they wrote. If every adult were to have an annual checkup that would add 145 million ambulatory visits every year, and each of those visits takes longer than a standard office visit.

Given the available physician supply and the average time spent on ambulatory visits each week, adding 145 million office visits would "account for 41% of all direct patient time for primary care physicians," the investigators wrote.

The authors said the study had a number of limitations, including the possibility that they underestimated the true rate of annual preventive health examinations because the surveys they used did not include data from the Department of Veterans Affairs.

Likewise, "we do not know how many women received both a preventive health examinations and preventive gynecologic examinations in a given year, and our cross-sectional data sets do not allow us to determine how many patients receive examinations in consecutive years."

Finally, the findings "depend on the accurate completion by physicians or their staff "of the encounter forms used by the two national surveys. The authors wrote that a direct comparison with survey data found that physicians and staff tended to be more accurate when recording information about diagnostic tests than counseling services.