NHS Health Checks Keep Heart Risk in Check Long-term

Liam Davenport

July 31, 2019

Middle aged and older individuals who completed a national programme aimed at preventing cardiovascular disease have a more favourable body mass index (BMI), blood pressure and smoking status than controls, even 6 years later, suggests a large scale database study.

NHS Health Checks were introduced in 2009 and the programme is available to all individuals in England aged 40–74 years who have not been diagnosed with ischaemic heart disease, stroke or diabetes, and are not already taking statins or antihypertensives.

Health Checklist

The checks estimate an individual’s risk of heart disease, stroke, type 2 diabetes, chronic kidney diseases and some forms of dementia, with personalised risk management interventions provided to those at high risk.

Now, Samah Alageel, PhD, Community Health Sciences Department, King Saud University, Riyadh, Saudi Arabia, and Dr Martin Gulliford, School of Population Health Sciences, King’s College London, looked at outcomes following the checks over a 6-year period.

They studied almost 128,000 individuals who had completed the health check and nearly 323,000 matched controls from the same general practices.

The research, published by PLoS Medicine on July 30th, showed that individuals who underwent health checks were slightly healthier than controls, with lower BMI and blood pressure, and were less likely to be smokers.

Compared with controls, individuals who had health checks were five times more likely to receive weight management advice, three times more likely to receive anti-smoking advice, and 24% more likely to be prescribed statins.

After 6 years, individuals in the health checks group had greater reductions in BMI, and systolic blood pressure and, most notably, were significantly less likely to be smokers than controls.

'Public Health Importance'

The authors acknowledge that the study has several limitations, including the lack of randomisation, raising the possibility of residual confounding, as well as differences in risk factor recording between the two groups and the high frequency of missing values in the records.

Nevertheless, they say that the sustained reductions in cardiovascular risk factors seen with the health checks "could be of public health importance across the population at risk".

In a news release, Samah Alageel said, however, "the programme could benefit from and should be supported with population-wide interventions to improve its outcomes".

Dr Gulliford added that their results suggest that "people who take up a health check may be healthier than controls but are more likely to receive risk factor interventions".

He underlined that these benefits need to be "shared by those most at risk", and that, although the reductions were relatively small, their "cumulative impact" could be "of public health importance".

'Encouraging Results'

Approached for comment, Metin Avkiran, PhD, associate medical director at the British Heart Foundation, told Medscape News UK that the results are "encouraging".

He added: "Further research is needed to confirm that the study's findings do not simply reflect better health and greater health awareness among those who undergo the Health Check, and to determine its impact in preventing devastating conditions such as heart attacks and strokes."

Noting that more than seven million people in the UK live with heart and circulatory diseases and "millions more" have risk factors, Metin Avkiran underlined that awareness and management of risk, and medical treatment where necessary, are "key to preventing risk from becoming reality".

"The NHS Health Check can facilitate that process."

Benefits & Costs

The NHS Health Checks were introduced on the basis that the programme could prevent 1600 heart attacks and strokes per year, as well as at least 650 deaths and 4000 incident cases of diabetes.

It was estimated that this could be brought to patients at a cost per quality adjusted life year of approximately £3000.

However, the programme has been controversial, with critics saying that similar interventions have increased costs with little evidence of benefit.

It was also said that the health checks were not standardised, the focus was solely on risk factor detection, and that there was no link to evidence-based intervention strategies.

Moreover, uptake of the programme has been low, at less than 50% in most areas, and with the most deprived populations and smokers less likely to take part than others.

Against this backdrop, the researchers set out to examine the longer-term impact of the health checks on risk management and outcomes versus standard care.

They obtained records from the Clinical Practice Research Datalink, which includes prospectively collected, anonymised medical records from more than 700 general practices in the UK from 1990.

This equates to approximately 7% of the UK population and is considered to be representative in terms of patient age, sex, and geographical distribution.

As the health checks are conducted only in England, the researchers gathered data on all participants in the database aged 40–74 years who had a health check record between April 2010 and December 2013.

These were compared with a control cohort of individuals registered at the same general practices as those in the health check cohort, with the same exclusion criteria applied as those used for the health checks.

Selecting four controls for each health check individual, the team identified 127,891 health check participants and 322,910 age- and sex-matched controls.

The largest proportion of patients in both study groups were aged 45–54 years, accounting for 41.2% of patients in the health check group, and 45.1% in the control group, with 49.4% and 52.9% respectively being male.

Health check individuals had a slightly lower mean body mass index at baseline than controls, as well as lower systolic and lower diastolic blood pressure.

They were also more likely to be smokers at baseline than controls, at 21% versus 27%.

Analysis revealed that participants who had undergone a health check were more likely to receive weight management advice than controls, at an adjusted hazard ratio of 5.03 (p<0.001).

They were also more likely to receive smoking cession interventions, at an adjusted hazard ratio of 3.20 (p<0.0001), and to be treated with statins, at a hazard ratio of 1.24 (p<0.001).

Over 6 years of follow-up, health check participants had significant net reductions in risk factor values versus controls, including a significant reduction in BMI of 0.30 kg/m2 (p<0.001).

Health check participants also recorded a significantly greater reduction in systolic blood pressure, at an average of 1.43 mmHg (p<0.001).

Smoking rates decreased more among individuals who underwent health checks, down to 17% versus 25% among controls after 6 years, at an odds ratio of 0.90 (p<0.001).

Sensitivity analyses indicated that there were only small differences between male and female participants, with women showing slightly greater reductions in blood pressure after 6 years.

The results were also unaffected by comparing each health check case with only one control.

The study was funded by the National Institute for Health Research Biomedical Research Centre at Guy’s and St Thomas’ NHS Foundation Trust and King’s College London. The research project was supported by a grant from the "Research Center of the Female Scientific and Medical Colleges", Deanship of Scientific Research, King Saud University.

No conflicts of interest declared.

PLoS Med 16 (7): e1002863. 10.1371/journal.pmed.1002863

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