Background
Methods
Procedure
Health conditions: selection, incidence and progression
Health condition | Included/ excluded | Rationale |
---|---|---|
Arthritis | Excluded | Despite a high prevalence, the expected impact on costs and outcomes was likely to be low or medium due to uncertainties around optimal identification and management; in addition there was no consistent evidence of whether AHC would improve the identification or management of arthritis. |
High blood pressure (hypertension) | Included | The expected impact on costs and outcomes was high; robust (cost-) effectiveness evidence for blood pressure management was available; evidence was also available that showed that AHC led to improved identification and management of high blood pressure. |
Body mass index, weight, cholesterol | Excluded | Overall, there was only limited evidence that AHC was able to influence those health promotion outcomes. |
Bowel cancer screening | Included | The expected impact on costs and outcomes was high because of a high prevalence of the condition, the availability of a national screening programme, and the availability of (cost-) effective treatment; although uptake has not been considered in the evaluations of AHCs there is evidence that additional information provided by general practitioners increases uptake. |
Breast cancer (screening via mammogram) | Included | The expected impact on costs and outcomes was high because of the high prevalence of the condition, the availability of a national screening programme, and of cost-effective treatment; although uptake has not been considered in the evaluations of AHCs there is evidence that additional information provided by general practitioners increases uptake. |
Cataract | Included | The expected impact on costs and outcomes was high because of the high prevalence, availability of (cost-) effective treatment, and strong evidence that AHCs led to an increase in eye tests. |
Cervical cancer screening | Excluded | The expected impact on costs and outcomes was low because of the low prevalence in this population. |
COPD and asthma | Excluded | Evidence was insufficient: the prevalence of asthma was not well established for this population; there was no evidence that AHC would lead to changes in the identification or management of COPD or asthma. |
Dementia | Excluded | Evidence was insufficient; in particular it was not clear whether dementia was currently checked in AHCs, and whether AHCs led to better identification. |
Epilepsy | Excluded | Evidence was insufficient; in particular there was not enough robust evidence of cost-effective treatment. |
Heart disease | Included (indirectly) | Heart disease was modelled as a consequence of hypertension and diabetes, which were strong predictors of heart disease. Heart disease was not modelled separately to avoid double of counting economic consequences. |
Hearing impairment | Included | The expected impact on costs and outcomes was high due to the high prevalence and high impact for this population. There was robust evidence that AHC led to an increase in hearing tests; (cost-) effective treatment was available. |
Glaucoma | Included | The expected impact on costs and outcomes was high; the impairment linked to glaucoma was and there was strong evidence that AHC led to more eye tests being carried out; (cost-) effective treatment was available. |
Hip fracture | Included (indirectly) | This was modelled as a consequence of osteoporosis, which was a strong predictor fracture. Hip fracture was not modelled separately to avoid double counting of economic consequences. |
Immunisation status | Excluded | The expected impact on costs and outcomes was low; checking for immunisation status is part of another incentivised scheme in primary care. This suggested a more limited role of AHCs in further improving uptake. |
Lung cancer/ smoking | Excluded | The expected impact on costs and outcomes was low due to lack of evidence of cost-effective treatment options that would be influenced by an earlier identification; also lack of robust evidence whether identification improved through AHC. |
Mental health | Excluded | Evidence was insufficient; whilst prevalence data were available, there was no evidence about whether AHC led to a better identification of mental health problems; there was also a lack of evidence regarding (cost-) effective treatment options for this population. |
Osteoporosis (screening) | Included | The expected impact on costs and outcomes was high due the high prevalence and the availability of screening tools that led to an increase in the identification of osteoporosis and reduction in (costly) fractures. Screening for osteoporosis is covered by the new AHC tool in England. |
Prostate cancer | Excluded | Evidence was insufficient; prevalence data were not available and there was no robust evidence about (cost-) effective treatment options and whether AHCs led to increase in identification or improved management of the condition. |
Stroke | Included (indirectly) | This was modelled as a consequence of hypertension and diabetes, which were strong predictors of stroke. Stroke was not modelled separately to avoid double counting economic consequences. |
Thyroid problems | Excluded | There is an overall lack of evidence suggesting that expected impact of identification or monitoring through annual health checks is likely to have a large impact on costs or health outcomes. |
Data | Source and details | |
---|---|---|
Yearly probabilities for developing health conditions | ||
Hypertension, diabetes excluded | ||
40 to 49 years | 0·35 to 1·14% | Derived from 3 years incidence data from IDS-TILDA by McCarron and colleagues [17] |
50 to 64 years | 1·56 to 2·28% | As above |
65 years+ | 2·39 to 4·76% | As above |
Stroke | ||
40 to 49 years | 0 to 1·11% | As above |
50 to 64 years | 0·23 to 1·13% | As above |
65 years+ | 0·44 to 2·85% | As above |
Coronary heart disease (CHD) | ||
40 to 49 years | 0 | As above |
50 to 64 years | 0·07 to 0·91% | As above |
65 years+ | 0·44 to 2·82% | As above |
Diabetes | ||
40 to 49 years | 0 to 1·11% | As above |
50 to 64 years | 0·03 to 1·32% | As above |
65 years + | 0·07 to 1·83% | As above |
Obesity | ||
Proportion with obesity (all ages) | 33·5% | As above |
Bowel cancer | ||
50 to 64 years | 0·24 to 1.28% | |
65 years+ | 0·3 to 2·49% | As above |
Breast cancer | ||
50 to 64 years | 0 to 0·16% | |
65 years + | 0·04 to 0·19% | As above |
Osteoporosis | ||
50 to 64 years | 2·8 to 5·9% | Derived from 3 years incidence data from IDS-TILDA by McCarron and colleagues [17] |
65 years + | 4·8 to 11·2% | As above |
HIP fracture | ||
50 to 64 years | 0·07 to 0.55% | As above |
65 years + | 0·08 to 1·11% | As above |
Cataract | ||
40 to 49 years | 0·9 to 3% | As above |
50 to 64 years | 1·32 to 3·2% | As above |
65 years + | 1·04 to 4·09% | As above |
Glaucoma | ||
40 to 49 years | 0 to 1.2% | As above |
50 to 64 years | 0·14 to 1·1% | As above |
65 years + | 0 to 0·15% | As above |
Hearing problems | ||
All ages | 2 to 13·4% | |
Cohort starting ages (if different from 40 years), years | ||
Bowel cancer | 60 | Starting age of national screening programme |
Breast cancer | 50 | As above |
Osteoporosis | 50 | Age when prevalence strongly increases according to data from IDS-TILDA by McCarron and colleagues [17] |
Populations: starting ages, gender and mortality
Uncertainty
Costs of the scheme
Data | Source and details | |
Cost inputs for annual health checks | ||
General practice doctor | £72 | PSSRU [36]; refers to 20 min of general practice doctor time with unit cost per hour of face-to-face time of £216 (includes all administrative, preparation and follow-up costs, cost of home visits) |
General practice nurse | £43 | PSSRU [36]; refers to 1 h of general practice nurse time with unit cost per hour of £43 |
Support worker | £136 | Expert view; refers to 8 h of support worker time with unit cost per hour of face-to-face time of £17 |
Social worker | £7 | PSSRU [36]; refers to 5 min of social worker time with unit cost per hour of client-related time of £79 |
Cost inputs for modelling hypertension | ||
Diagnosis | £29 to £89 | Lovibond and colleagues [37] |
Hypertension management | £34 to £102 | As above |
Treating stroke (initially) | £5633 to £16,901 | As above |
Subsequent treatment of stroke | £619 to £1856 | As above |
Treating coronary heart disease (initially) | £1854 to £5561 | As above; includes costs of heart failure (£2929), angina (£3273), heart attack = myocardial infarction, MI (£5455); weighted by their prevalence proportions from IDS-TILA by McCarron and colleagues [17] in relation to all coronary heart disease conditions: heart failure (51%), angina (21%), MI (28%) |
Subsequent treatment of coronary heart disease | £143 to £428 | As above; includes costs of heart failure (£311), angina (£187), heart attack = myocardial infarction, MI (£312); weighted by their prevalence proportions from IDS-TILA by McCarron and colleagues [17] in relation to all coronary heart disease conditions: heart failure (51%), angina (21%), MI (28%) |
Cost inputs for modelling diabetes | ||
∆ Controlled vs. uncontrolled glucose, non-overweight patients | -£618 to £2877 | Clarke and colleagues [38]; refers to present of total lifetimes costs; for non-overweight patients treated with insulin |
∆ Controlled vs. uncontrolled glucose, overweight patients | -£5486 to £2875 | As above; refers to present of total lifetimes costs; for overweight patients treated with metformin |
Cost inputs for modelling bowel cancer (screening) | ||
FOBT tests | £16 to £19 | Tappenden and colleagues [39]; refers to 2 FOBT tests (in case first is not returned) |
Colonoscopy | £469 to £573 | National Schedule for Reference Costs 2015–16; refers to diagnostic colonoscopy [40] |
Removing adenoma | £122 to £149 | As above |
Admittance for bleeding | £712 to £870 | As above |
Bowel cancer treatment detected through screening | £5971 to £7298 | Cancer Research UK [30] |
Bowel cancer treatment clinically detected | £7782 to £9511 | As above |
Cost inputs for modelling breast cancer (screening) | ||
Mammogram per woman invited for screening | £14 to £36 | Pharoa and colleagues [31] |
Treating over-diagnosis | £2047 to £2501 | As above |
∆ Treatment, early vs. late stage cancer, under 65 years (lifetime) | -£11,739 to -£14,347 | Laudicella and colleagues [41] |
∆ Treatment, early vs. late stage cancer, over 65 years (lifetime) | -£6404 to -£7827 | As above |
Cost inputs for modelling osteoporosis | ||
DAX scan and General Practitioner (GP) consultation | £113 to £137 | |
Anti-osteoporotic medication (per year) | £54 to £334 | |
Treating hip replacement (HIP) fracture, 1st year | £14,481 to £14,800 | Leal and colleagues [44] |
Treating HIP fracture, 2nd year | £2160 to £2272 | As above |
Cost inputs for modelling cataract | ||
Initial optometrist test | £21 | DH [45] |
Optometrist diagnosis test | £92 to £472 | Burr and colleagues [46] |
Cataract surgery (lifetime) | £1218 to £9211 | Frampton and colleagues [47] |
Cost inputs for modelling glaucoma | ||
Initial optometrist test | £21 | DH [45] |
Optometrist diagnosis test | £92 to £472 | Burr and colleagues [46] |
Treating mild glaucoma (per year) | £259 to £777 | As above |
Treating moderate glaucoma (per year) | £325 to £875 | As above |
Treating severe glaucoma (per year) | £232 to £695 | As above |
Treating visual impairment (per year) | £721 to £927 | As above |
Cost inputs for modelling hearing problems | ||
Ear wax removal | £36 to £44 | Clegg and colleagues [48]; refers to primary care |
Hearing specialist assessment | £46 to £68 | NHS National Tariff 2017 to 2019 [49] |
Hearing aid assessment | £48 to £58 | As above |
Hearing aid, initial | £268 to £370 | As above |
Hearing aid, follow on care | £23 to £28 | As above |
Cost consequences
Effectiveness
Data | Source and details | |
---|---|---|
Effectiveness of annual health checks in terms of: identification; uptake of national screening; management of conditions (in probabilities, annual health check vs. standard care group) | ||
Hypertension identified and managed | 85 to 95·3% vs. 71·4 to 87·8% | Buszewicz and colleagues [23] |
Participation in bowel cancer screening (FOBT), difference between AHC and standard care, in percentage points | 4·1 to 7·8% | Hewitson and colleagues [52] and expert views |
Participation in breast cancer screening (mammogram) | 54·3 to 59·3% vs. 47 to 52% | |
Diabetes managed (identification found similar in both groups) | 69·9% (SD 34·2) vs. 56.8% (SD 29·4) | Cooper and colleagues [16]; refers to proportion of people whose health monitoring needs are met |
Osteoporosis investigated | 85 to 95% vs. 66·2 to 86·8% | Derived from Lennox and colleagues [49] and expert views |
Person with eye problem (cataract or glaucoma) is referred to eye exam | 90% vs. 58.9% (SD 0·24) | Derived from Buszewicz and colleagues [23] and expert views |
Person with hearing problems is referred to hearing assessment | 90% vs. 27·6 to 33% | As above |
Effectiveness of: identification; uptake of national screening; management of conditions | ||
Relative Risk (RR) in stroke, CHD and death, managed versus unmanaged hypertension | ||
Stroke | ||
40 to 59 years | 0·61 to 0·65 | Moran and colleagues [52] |
60 years + | 0·66 to 0·71 | As above |
CHD | ||
40 to 59 years | 0·72 to 0·74 | As above |
60 years + | 0·74 to 0·78 | As above |
Death | ||
40 to 59 years+ | 0·83 to 0·89 | As above |
60 years + | 0·91 to 0·92 | As above |
Increased risk of stroke in people with hypertension | 3 to 5 | Straus and colleagues [55] |
Increased risk of CHD in people with hypertension | 2 to 3 | Padwal and colleagues [54] |
Absolute risk reductions (in percentage points) in death for people participating in bowel screening | 1·01% | Scholefield and colleagues [57] |
Progression probabilities for glaucoma, treatment vs. not in treatment | ||
Progression from mild to moderate | 22% vs. 25% | Burr and colleagues [44] |
Progression from moderate to severe | 7% vs. 11% | As above |
Progression from severe to visual impairment | 6% vs. 10% | As above |
Relative risk reduction of death from breast cancer for women invited for mammography | 0·73 to 0·89 | Pharoah and colleagues [31] |
Probabilities for further investigations and treatment (after screening or diagnosis) | ||
Hypertension | ||
Adherence to management | 75% (in one-way SA: 50%) | Moran and colleagues [54] |
Bowel cancer | ||
Screening positive and requiring further investigation | 1·84 to 2·1% | Raine and colleagues [58] |
Visit at specialist clinic for further investigation if screening was positive | 74·7 to 91·3% | Logan and colleagues [59] |
Bowel cancer if screening was positive | 9·09 to 11·11% | As above |
Pre-cancer polyps if screening was positive | 24·48 to 29·92% | As above |
Admission for bleeding due to further investigation | 0·39 to 0·48% | Tappenden and colleagues [37] |
Osteoporosis | ||
Prescription of drugs to person identified with osteoporosis | 99·6% | Presentation by Shepstone at National Osteoporosis Conference 2016; [58] refers to findings from SCOOP study |
Cataract | ||
Corrected with glasses if referred to eye exam | 50 to 67% | Lennox and colleagues [51] |
Surgery if referred to eye exam | 5 to 9% | Expert view |
Glaucoma | ||
Adherence to treatment | 63·9 to 78·1% | Okeke and colleagues [61]; mean of 71%, value range +/− 10% |
Hearing problems | ||
Hearing problem due to blocked ear wax (i.e. no referral required) | 15·7 to 50% | |
Hearing problem not due to blocked ear wax and referral made to specialist | 50 to 84·7% | Derived as residual from above |
Person referred to specialist assessment attends it | 80 to 90% | Expert view |
Person assessed by specialist as requiring hearing aid | 42·2 to 51·6% | Lennox and colleagues [50] |
Person requiring hearing aid accepts and starts using it | 36·8 to 86% | Morris and colleauges [59] |
Breast cancer | ||
Breast cancer identified through mammogram | 73·3 to 93·8% | Sinclair and colleagues [63] |
Relative risk of over-diagnosis for women invited to mammography | 1·19 | As above |
Quality of life weights
Data | Source and details | |
---|---|---|
Health utilities (including ∆) and QALYs | ||
Stroke | 0·31 to 0·94 | Lovibond and colleagues [37] |
Coronary heart disease | 0·55 to 0·79 | |
Hypertension (without cardiovascular event) | 0·704 to 0·909 | Lovibond and colleagues [37]; refers to general population health utilities from Health Survey England data |
Bowel cancer | 0·697 (+/−10%) | Whyte and colleagues [65] |
Bowel cancer stages Duke’s A, B, C,D | 0·74; 0·70; 0·5; 0·25 (+/− 10%) | Tappenden and colleagues [66] |
Breast cancer | 0·627 to 0·767 | Whyte and colleagues [65] |
HIP fracture, 1st year | 0·64 to 0·77 | |
Without HIP fracture, 50 to 60 years | 0·6 to 0·85 | As above |
Without HIP fracture, 60 years + | 0·55 to 0·82 | As above |
Glaucoma, mild | 0·72 to 0·88 | Burr and colleagues [46] |
Glaucoma, moderate | 0·67 to 0·82 | As above |
Glaucoma, severe | 0·64 to 0·78 | As above |
Health utility gain (∆) from removed ear wax | 0·0054 to 0·0066 | Morris and colleagues [62] |
Health utility gain (∆) from hearing aid | 0·035 to 0·105 | NICE [41] |
QALYs (∆), controlled vs. uncontrolled diabetes in non-overweight patients | −0·07 to 0·22 | Clarke and colleagues [38]; refers to present value of QALYs gained for intensive vs. standard management |
QALYs (∆), controlled vs. uncontrolled diabetes in overweight patients | −0·04 to 0·48 | As above |
QALY gain linked to cataract surgery | 0·084 to 0·963 | Frampton and colleagues [47] |
Results
Incremental costs | Incremental QALYs | Incremental cost-effectiveness ratio (ICER) | |
---|---|---|---|
Mean | £4787.24 | 0·0743 | £85,631.95 |
Standard deviation | £230.05 | 0·0456 | £46,312.30 |
95% Confidence interval | £4772.98 to £5017.29 | 0·0715 to 0·119 | £82,761.49.90 to £131,944.25 |
Cost of the intervention | Mean ICER (95% CI) | Probability of cost-effectiveness at cost per QALY threshold of £20,000 (£30,000) |
---|---|---|
£50 | £17,760 (£17,180 to £27,110) | 70.1% (88.6%) |
£75 | £25,861 (£24,967 to £40,274) | 37.1% (66.1%) |
£100 | £34,959 (£33,818 to £53,363) | 25.5.9% (49.5%) |
£150 | £48,237 (£46,746 to £72,281) | 7.1% (22.2%) |
Discussion
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AHCs should be followed by prompt referrals to specialist services as needed; information on follow-on actions should be recorded;
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Practitioners carrying out AHCs should inform people about available health services including national screening programmes;
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Support people’s communication needs and information preferences; this might include: extending appointment times; contacting persons before appointments; reminding people of appointments; providing written information in an accessible format; using visual aids when explaining procedures or results; supporting the presence of an advocate or someone the person trusts at appointments;
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Increase peoples’ awareness of changing health needs due to ageing; this might include providing training for people and their family members in recognising and managing ageing related changes.