We conducted a retrospective chart review to determine the diagnostic yield of the first episode of a comprehensive prevention-focused PHE. We demonstrated that even in healthy, employed patients, numerous conditions can be identified, some of which may be serious or require additional evaluation and treatment (e.g., pituitary adenoma that may be functional or aortic aneurysm that requires serial monitoring or treatment). This study provides the prevalence estimates of various conditions including malignancies, endocrinopathies, cardiovascular, renal, gastrointestinal, neurologic, and ophthalmologic diseases encountered in this setting. Men and those with multiple complaints at presentation were more likely to receive a clinically relevant diagnosis at the conclusion of the visit. Age was not a predictor in this cohort.
More than half of the clinically significant diagnoses in our study may have been missed without a comprehensive screening strategy, as these had been neither patient prompted nor discoverable by typical USPSTF screening strategies.
Nicotine dependence and alcohol abuse, when diagnosed, had only been self-identified as a problem by some, but not all affected patients. This underscores the importance of proactively addressing these habits with the patient to support healthy lifestyle change, potentially avoiding long-term health consequences. The same is true of obesity, as 90% of those with class III obesity (BMI greater than 40) similarly did not identify weight as a significant health problem.
Our results are consistent with a trial by Fletcher et al. [12] in which the authors tested an approach of active multiphasic screening and case finding examinations that consisted of history, examination, urinalysis, basic chemistry, complete blood count, chest x-ray, electrocardiogram, pulmonary function testing, and audiometry. The case finding group had significantly more diagnoses than a control group (77 new diagnoses in 36 patients or 2.14 diagnoses per participant, of which, 25 were considered important (0.69 diagnosis per participant). Follow up one year later, demonstrated that intervention or change in medical care was required for 40% of these new diagnoses. Fletcher et al. argues that their study refutes the claim that if physicians were truly providing comprehensive care in their practice, there would be no need for additional multiphasic screening [12].
In addition to increased delivery of preventive services [8], PHEs can be associated with improvements in several other patient-important outcomes. Friedman et al. [13] conducted a randomized controlled trial in which annual examinations were provided to 5,156 men and women age 35–54 (average of 6.8 exams over 16 years) and compared their outcomes to a control group. The study group had a 30% reduction in mortality due to pre-specified potentially preventable or treatable conditions (mainly colorectal cancer and hypertension). Patrick et al. [9] compared the outcomes of usual care to a preventive services benefit package that included a health risk assessment, a health promotion visit, a disease prevention visit, and a follow up visit. They demonstrated that Medicare beneficiaries randomized to the intervention group completed more advance directives, participated in more exercise, consumed less dietary fat, and reported higher satisfaction with health, less decline in self-rated health status, and fewer depressive symptoms.
The findings of this descriptive study may not be generalizable to other practice models or patient populations. It is likely that we underestimated the prevalence of multiple conditions because our population is likely to have higher socioeconomic and educational status, and to be gainfully employed with better access to health care. Thus, a higher yield of diagnoses would be anticipated in more diverse populations with fewer resources or contact with the health care system. We did not evaluate patients’ prior experiences with care they received in primary care settings elsewhere. Such care may dictate the frequency of more detailed evaluations like the one we presented in this cohort. In a previous study, a 6889 patient sample from the same cohort [11], we demonstrated fair, although variable, adherence to preventive recommendations (ranging 62%-91%).
Further, it is unclear whether the early diagnosis of many conditions identified in this cohort is cost effective or associated with improved survival and quality of life. It is also important to recognize that the evidence supporting benefits of PHEs is hampered by the heterogeneity of the interventions (i.e., the components and variability of the health evaluations) and with the mixed results reported in the areas of costs, disability prevention, and hospitalization [8]. The results of this report should not be interpreted as evidence against the USPSTF recommendations nor does it suggest more aggressive screening strategies. Rather, these findings support a more comprehensive evaluation. The PHE is a valuable service which facilitates implementing USPSTF recommendations and increases the diagnostic yield of other underlying conditions. This study is not comparative. Therefore, we do not claim superior diagnostic ability over alternative strategies. This study does not evaluate the relative efficacy of the components of the comprehensive evaluation as these can vary according to the unique disease entity. This report also draws attention to the lack of reliable scales, rating systems, and taxonomy that aids in categorizing the importance of diagnoses encountered in outpatient settings. In the medical literature various descriptions of diagnoses exist, such as “patient-important,” “clinically-important,” “requiring medical attention,” “requiring follow up,” and many others. We believe that the establishment of a scale or rating system will inform the design of outpatient practices and the development of clinical practice guidelines.
In summary, this study demonstrates that a comprehensive medical evaluation identifies numerous clinically important conditions that may affect the way patients feel, live and survive, that would not have been diagnosed otherwise. While our findings may not be compelling for policymakers to recommend such an intervention for all individuals, those with values and preferences consistent with the desire for early detection and intervention will likely opt to have a comprehensive PHE. Patients who schedule periodic, often annual, evaluations with their health care provider or present to executive health programs are likely self-selected for such inherent values and preferences. Therefore, providing these individuals with the option of a periodic comprehensive examination would be consistent with their values and with the second principle of evidence-based medicine (Evidence alone is never sufficient to make a clinical decision. Patients’ values and preferences should always be considered) [14]. Additionally, when patient fears and anxieties are adequately addressed, unnecessary testing and excessive utilization of the health care system may be avoided. Data from this study may help with the planning and design of outpatient practices, in addition to shaping both patient and provider expectations of these types of medical encounters.
