New study likely to fuel debate over annual physical exams

While most patients and physicians believe it's important for adults to have an annual physical exam, there's growing debate about this conventional wisdom.

A new study published in the Sept. 24 issue of the Archives of Internal Medicine raises serious questions about the hefty costs and uneven content of these already controversial examinations.

In the first study to systematically quantify the number, cost and content of preventive health and preventive gynecological exams, the study's authors found that an estimated 44.4 million adults a year in the United States, or nearly 21 percent, receive a preventive physical exam, while about 19.4 million women, or 18 percent, receive a preventive gynecological exam. The total costs of these exams and associated preventive services are approximately $5.2 billion and $2.6 billion a year respectively, the researchers calculated ¯ nearly equal to the $8.1 billion spent on all breast cancer care in 2004.

“Although annual exams are not recommended by any major North American clinical organization, our health system is clearly devoting a great deal of time, money and resources to them,” noted Ateev Mehrotra, M.D., M.P.H., lead author of the study, assistant professor at the University of Pittsburgh School of Medicine and a policy analyst at RAND Corp. “Most patients believe they should see a doctor every year for a physical in which the doctor will examine them from head to toe and order lots of tests. There are many doctors who disagree. Physicians need to reach greater consensus on what we should advise patients to do,” he added.

The researchers examined data on ambulatory visits from Jan. 1, 2002 to Dec. 31, 2004, obtained from the National Ambulatory Medical Care Survey and the outpatient component of the National Hospital Ambulatory Medical Care Survey. Their analysis of this nationally representative data showed that preventive health and gynecological exams account for one in 12 adult ambulatory visits. Together, they exceed the number of annual visits for either acute respiratory infections or hypertension. The average physical lasted 23 minutes and cost $116, including related laboratory and radiology services.

Given the lack of official guidelines on these visits, researchers were not surprised to find significant variations across the country in who gets a physical and in the type of care and testing performed during these exams. For instance, a person who lived in the Northeast was 60 percent more likely to get a physical than someone in the West. This might be due to differences in clinical practice patterns or patient beliefs in different regions, Dr. Mehrotra speculated.

Many of the preventive health exams in the study included laboratory tests, such as complete blood cell counts or urinalyses, that do not clearly improve patient outcomes. “More than a third of annual physicals include potentially unnecessary testing at a cost of more than $350 million a year,” Dr. Mehrotra estimated. “That's nearly the amount of money that the state of Massachusetts is spending annually to provide insurance to the uninsured.”

At the same time, the researchers found that 80 percent of preventive care occurs outside of physical exams, and most patients were seen by physicians for another reason during the same year. “This finding supports the idea advocated by some that we should use other visits as an opportunity to deliver preventive care,” Dr. Mehrotra said. But he notes that there are important exceptions. In concurrence with previous studies, the researchers found that preventive physicals and preventive gynecological exams were the most common venue for evidence-based preventive services like mammograms and Pap smears.

Dr. Mehrotra and his colleagues hope that their findings will inform future recommendations about the frequency of preventive exams and the feasibility of providing one to all adults in the United States on an annual basis. If every adult were to receive a preventive physical exam annually, the U.S. health care system would need to provide up to 145 million more visits every year, the researchers estimated. That would account for an impractical 41 percent of all time spent on direct patient care by primary care physicians. “This underlines the need to find other means of delivering preventive care beyond annual physicals or to advise some patients they can come in much less frequently,” said Dr. Mehrotra.