US Health checks can result in large bills for no gain
General health checks, called ‘annual physicals’ in the United States, are sold to the public under false pretences with claims that aren’t true
This also applies to targeted health checks, and mammography screening is a good example.
Women have been told for 40 years in invitations to screening that by detecting breast cancers early, screening saves lives and leads to less invasive surgery.
The truth is that breast screening detects cancers very late, it doesn’t save lives, and more women lose a breast.1
Mammography screening is harmful and general health checks are also harmful. Like breast screening, they detect many things that should not have been treated because they are either insignificant or will disappear again. In contrast to cars, our body has a remarkable capacity for self-healing.
Our review of general health checks
Health checks can result in large bills for no gain just like car checks can. I never send my car to the annual car check, which has saved me an enormous amount of money. I only see a mechanic when there is something wrong with my car or for simple issues such as changing oil.
I have the same relationship with my doctor.
Once, when I was on holiday on Maui, I passed a booth where people could have their blood pressure checked. Just for the fun of it, I stretched my arm out. “What is your usual blood pressure,” a woman asked. “I have no idea,” I replied, which made her laugh in disbelief.
I was 58 years old and fit, and the few times in my life that someone had taken my blood pressure during a hospital admission, it had been low, so why should I bother about that? I couldn’t help provoking her a little and therefore told her I had no idea either of what my cholesterol was.
At that point, she asked me which country I came from!
In Denmark, the doctors were sceptical towards general health checks, but in 2007, the Danish Association of the Pharmaceutical Industry convinced the politicians to introduce them, even though an industry spokesperson admitted that their goal was to sell more drugs.2
Nothing happened, however. But in 2011, our new government wanted to introduce general health checks. I asked to have a meeting with the Minister of Health, Astrid Krag, because our review of the randomised trials, which we had just completed but not yet published, had found no effect on mortality.
I brought a colleague to the meeting who had just finished a large trial in Denmark, which had also failed to find an effect.
We told Krag that health checks are probably harmful, leading to more diagnoses, more drugs, and psychological problems because people are told they are less healthy than they think. She aborted her plans on the spot and said it was the first time the new government had broken a pre-election promise in an evidence-based manner.
We had included 14 trials in adults unselected for diseases or risk factors. We published our review in 20123 and updated it in 2019.4 There was no reduction in total mortality (risk ratio 1.00), cardiovascular mortality (risk ratio 1.05), or cancer mortality (risk ratio 1.01), and with 21,535 deaths, our results were very convincing.
There were no benefits either for clinical events, hospital admissions, or other measures of morbidity, but there were harms. More people got a disease label and more became treated with antihypertensive drugs.
We concluded cautiously that general health checks are unlikely to be beneficial, but in fact they are harmful.
We had also studied 56 Danish websites selling health checks and found that 17 of the 21 most used tests were unjustified or there was evidence against using them for screening purposes.5 None of the websites mentioned any harms of health checks and they presented a median of only one of the 15 information items recommended by the WHO and the Danish Board of Health when screening healthy people.
Thus, there was no informed consent.
Our review saved billions of crowns for Danish taxpayers. Amusingly, statistician Bjørn Lomborg arranged the 2011 Copenhagen Consensus Conference where three health economists concluded that health checks would give the most health for the investment, 26 crowns for every crown invested.6
Quite an impressive gain for something that doesn’t work. We explained what was wrong with the methods.7 The estimate was based on the smallest trial we had included in our review, the Danish Ebeltoft study, which contributed only 0.4 percent of the weight in our updated meta-analysis of mortality.4
It is very bad science to cherry-pick a single, tiny trial. Moreover, the economists calculated life years gained based on an extrapolation from changes in risk factors, which was wishful thinking. In fact, a review of 55 trials with interventions against elevated risk factors in healthy people had not found less morbidity or mortality.8
The UK “Yes, Minister” farce
In the UK, the reactions to our review were so laughable that they could have been an episode in the BBC’s “Yes, Minister” satire series.
The predicament was that the National Health Service already offered universal health checks for people between 40 and 74 years of age who were tested for cardiovascular disease, diabetes, and chronic kidney disease.
A slide show claimed that annual health checks would prevent at least 9,500 heart attacks and strokes, 2,000 deaths and 4,000 people from developing diabetes. A slide with a graveyard ensured that no one would miss what would happen if they didn’t attend health checks:
Once something has been introduced as a national priority, it is very difficult to stop it. When our review came out, a Department of Health representative told the BBC that the NHS Health Check programme was based on “expert guidance.”
This was even better magic than what Lomborg’s health economists had invented in Denmark. The programme was based on evidence until our review showed it didn’t work. Then, all of a sudden, it was based on “expert guidance” instead.
A year later, we had had enough of all the tricks and published a letter in The Times, with the funny title, “Health check check,”9 which resulted in a front-page interview next to a large photo of Prince William, his wife and child, and a royal dog.
Ministers now insisted that 650 lives a year could be saved10 – a sharp retreat from the previous claim of 2,000. But the chief executive of Diabetes UK, Barbara Young, continued undeterred. She said that routine checks could uncover 850,000 people with undiagnosed type 2 diabetes.
However, labelling almost a million healthy people as diseased has no value in itself, and we had found that screening for diabetes is not helpful.
After repeated calls from politicians for the programme to be scrapped, Public Health England needed to do something. They announced that an expert panel would be established to review the effectiveness and value-for-money of NHS Health Checks.11
The attempts at finding a fig leaf and continue with the programme were now so bizarre that I came to think of Monty Python’s Ministry of Silly Walks.12 I decided to add to the amusement in the BMJ, with a quote from the “Yes, Minister” series as my title:
“I don’t want the truth, I want something I can tell Parliament!”:13
Public Health England will establish an expert panel to review the effectiveness and value for money of NHS Health Checks, and it will refresh the economic modelling behind the programme.
We are furthermore told that “although we recognise that the programme is not supported by direct randomised controlled trial evidence, there is nonetheless an urgent need to tackle the growing burden of disease which is associated with lifestyle behaviours and choices.”
The truth, that health checks don’t work and are likely harmful, is too much to bear for Public Health England, it seems. An expert panel is the modern version of the Oracle in Delphi, and statistical modelling is like whispering in a wizard’s ear which result you would like to hear.
Saying that there is an urgent need to tackle the growing burden of disease as an excuse for going against clear evidence from randomised trials reminds me of another episode of Yes, Minister where it was skilfully argued why a huge number of administrators were needed for a hospital that had no patients … Like health checks, mammography screening is harmful, but such trifles don’t affect the leaders of the NHS or the UK Government.
There was also censorship.14 The website for the NHS Health Check programme published a criticism of our review, which appeared to be serious but was unfounded and highly misleading.15
We asked for our reply to be published on the website, which was declined with the argument that the government had already decided that health checks was a national priority and that the website was not a forum for debating their merits.
This was hypocritical because the NHS had done exactly that but denied us the opportunity to respond. It would have been appropriate for the NHS programme to publish its criticism in the BMJ, where we had published our review,3 so we could respond to it.
The NHS preferred censorship for an enriching debate, which they knew they would lose.
The absolute low point was yet to come, however. In 2014, the National Institute for Health and Care Excellence (NICE), supposedly an independent institution, behaved as the lapdog for the NHS and the drug industry in a press release:16
“Helping local authorities to encourage people to attend NHS Health Checks and support them in making changes needed to improve their health, is the focus of a new NICE briefing … providing the best value for money … A report from Public Health England found that checking blood pressure, cholesterol, weight and lifestyle of people in this age group could identify problems earlier and prevent 650 deaths, 1600 heart attacks and 4000 diagnoses of diabetes a year … The NHS Health Check programme is currently part of the health delivery infrastructure in England, so NICE seeks to support its effective delivery.”
Prevent 4000 diagnoses of diabetes a year? Diabetes UK had claimed that routine checks could uncover an estimated 850,000 people with undiagnosed type 2 diabetes. Are we supposed to find 850,000 or avoid finding 4000?
One of my UK colleagues talked about “Stalinism in the NHS” because members of Parliament were highly critical and had noted that health professionals had been pressured to refrain from criticising the project in public.17
Only about 50 percent attended health checks and Public Health England said its aim was to drive the acceptance rate up to 70-75 percent. That would not be possible without deceiving the public even more than before.
Despite all the “Yes, Minister” manoeuvres, people paid attention to our review and the media interest was phenomenal. Many websites, also in the United States, where overdiagnosis, overtreatment and waste of money is far greater than anywhere else, questioned health checks.
The Danish farce
Denmark was a great contributor to the farce and, like in the UK, it was not intended by those who made themselves laughable.
One of the poorest tricks I have been exposed to when my systematic reviews showed that something doesn’t work, e.g. also in relation to mammography screening,18 is to criticise the included trials or the methods of the review, as if this would by some magic render a negative result positive. This was also the case for health checks.19
The key spokesperson for the tiny Ebeltoft study, Torsten Lauritzen, wouldn’t give up. He was amazingly stubborn, but all his arguments were false, e.g. that our screening tests and treatments were outdated and that the trials were old (we included all trials, also the newest ones).20
He referred to a meta-analysis of surrogate outcomes, to retrospective non-randomised comparisons, and to modelling studies, which are the standard “rescues” when results from randomised trials are too painful to accept.
Lauritzen carried on with his wishful thinking that health checks reduce mortality using modelling based on risk factors.21 He mentioned a systematic review of trials in general practice showing an effect of screening on risk factors for cardiovascular disease but failed to note that it also showed that 30 percent more people died from cardiovascular disease in the screened group than in the control group.
As this difference was statistically significant, Lauritzen was scientifically dishonest.
Lauritzen continued propagating misinformation about our research and published a “State-of-the-Art” article in our medical journal, which was cherry-picking in the extreme.22
He only mentioned his own study and an irrelevant diabetes trial that was not about health checks.
Torturing your data in secrecy till they confess
Lauritzen had a contender to the Fool’s Prize in this area, our new Minister of Health, Nick Hækkerup, who had replaced Astrid Krag and had different ideas to hers.
He admitted to a speaker on health in Parliament that our review had not found any effect of health checks but added that the Board of Health had stated that this did not rule out that other forms of health checks could have an effect.
I referred to philosopher Bertrand Russell who had pointed out how meaningless such statements are.23 He said we cannot rule out that there is a porcelain tea set in orbit circulating around the Earth.
Scientifically, we cannot rule out that something might exist. But is it likely that there are UFOs or Martians, or a tea set in orbit?
This is taken from a long document. Read the rest here substack
Header image: The Mirror
Bold emphasis added