Dr Howard-Tripp raises a very important issue concerning our need to promote cost-effective use of health resources in our health care system. However, ensuring appropriate patients have periodic preventive health examinations is essential to better managing health care costs in our aging society. For example, in 2001 the economic burden of physical inactivity and obesity in Canada was $5.3 billion and $4.3 billion, respectively.1 More efforts to prevent these conditions and their associated chronic diseases are essential, and the periodic health examination (PHE) provides an opportunity to make such efforts.
Dr Howard-Tripp argues that 21.4 million appointments a year and $2 billion in consultation costs could be saved and put to better use if we abolished the PHE. This is an oversimplification of the situation. It assumes that the millions of PHEs performed yearly in Canada are worthless. As mentioned previously, relationship-building and prevention are the focus of these visits. Physicians are often attending to chronic disease and multiple health issues during these appointments as well. They are not empty, test-burdened visits.
I must disagree with the premise that efforts to improve the PHE and make it more evidence-based have failed. The articles quoted as evidence used American data and were published 6 to 8 years ago. For more than 10 years, family medicine residents have been trained to perform age- and sex-specific assessments in lieu of a generalized head-to-toe examination. Frequent articles and continuing education presentations address this issue. I have presented at several continuing medical education conferences where family physicians were very interested to learn that they did not need to do certain tests during the PHE, which can save time. Many family physicians in Ottawa and across the country use the preventive care checklist of the College of Family Physicians of Canada2 or other methods to deliver an appropriate periodic health assessment. Research would help us delineate what proportion of family physicians have not made the switch to more evidence-based practices and why.
What I do think need to change are the billing requirements. This will ensure that physicians adjust their practices. A preventive care assessment should be defined as the recommended preventive maneuvers by age and sex, including a brief lifestyle and psychosocial assessment as necessary, as screening for depression is a recommendation. These longer visits should not have to include functional inquiry or “examination of all body parts” as stated, for example, in the Ontario schedule of benefits,3 as these are not evidence-based practices.
One size does not fit all. If the PHE does not work for some, then other methods to deliver preventive care can be used. But an updated periodic preventive health assessment does address an important need in health care. With proper billing incentives this could be an even more powerful tool.
Footnotes
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References
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