The Establishment of National Standards for Health Checks In China and a Comparison with American EHE Standards

Introduction

The health check is a thorough check-up of a patient physical con¬dition through a variety of tests. The check will cover most of the basic systems of the body, including the heart system, lung system, gut system, nerve system, and genitourinary system. It can tell us whether we are at higher risk of getting certain health problems, such as heart disease, cancer, diabetes, stroke, etc. Regular health check can help to find problems before they start. They can also help to find problems early, when your chances for treatment and cure are better. A health check generally involves a medical histo¬ry, a brief or complete physical examination, and laboratory tests. More advanced tests include ultrasound and mammography. Gen¬erally, the routine health checks are not meant to include newborn checks, pap smears (screens for cervical cancer), or regular fol¬low-ups for chronic medical disorders [1].

As society develops and standards of living increase, the concept of health in the population is rapidly changing. According to popu-lation statistics, 5 million health checks per year have been record- ed in Beijing Metropolitan area [2]. The institutes available for health checks, including general hospitals, public health institutes, privately operated medical institutes, disease control institutes, and sanatoria, have recently reached over 5000 [2].

At the meantime, China government is transiting the medical care mode from centering on the treatments of disease to centering on the promotions of health. The health check systems have devel¬oped rapidly in China; thus, different institutes have developed their own distinct items and standards. No national guideline for “health check” standards has been released by now.

We found that the American Executive Health Exam, founded in 1913, has been devoted to developing and establishing the health check paradigm. The EHE has pioneered the fields of employee health and lifestyle management, and is thoroughly devoted to safeguarding future health by disease prevention. The EHE’s mis¬sion is to protect the health of company employees. It also en¬deavors to manage health costs by establishing early detection of preventable diseases and by managing risk factors and lifestyle behaviors that drive diseases [3].

In summary, it is the top priority to set up unified health check standards in China by analyzing the health items within Mainland China by comparison with the American EHE standards

Methods

We collected the health items used in health checks in 60 top hos¬pitals within Mainland China. Then, we calculated the occurrence rate of every item. We excluded items that occurred in less than 80%. The selected items were collected in a list to form China’s health check standards. Finally, we compared these standards with the American EHE standards.

Results

The items used in health checks in China’s top hospitals included a basic physical examination, non-infectious disease screening, malignancy screening, laboratory tests, and imaging examinations. The basic physical examination items are shown in Table 1. In the questionnaire section, the American EHE standards included only a personal history; in contrast, China’s health checks questionnaire included personal history, family history, life style, surgical histo¬ry, medication history, menstruation history (for female), and mar¬riage history. In the ordinary examination section, China’s health checks included the pulse pressure difference, waist hip ratio, and vital capacity; the American EHE standards included the vital ca¬pacity, ABO blood type, and tetanus status.

                              Table 1: Comparison of basic physical examination items used in China and America

Abbreviations

SBP: systolic blood pressure;

DBP: diastolic blood pressure;

BMI: body mass index

Totally, compared with the American EHE standards, China’s basic physical examination was more detailed than America EHE stan¬dards. However, all identified standard items were inexpensive to perform. Therefore, for this part of the basic physical examination, China’s standards were superior to the American EHE standards.

Non-infectious diseases include some common diseases, such as cardiovascular diseases and diabetes. A comparison of non-infec-tious screening items used in China and America is shown in Table 2. Compared with China’s health check, American EHE standards included only the latent risk factors for cardiovascular diseases and diabetes.

                                   Table 2: Comparison of non-infectious disease screening items used in China and America

Abbreviations:

LDL-C: low density lipoprotein cholesterol;

HDL-C: high density lipoprotein cholesterol;

HsCRP: hypersensitive C-reactive protein

The most frequently occurring malignancies include lung cancer, breast cancer, cervical cancer, prostatic cancer, and colon cancer.

A comparison of malignancy screening items used in China and America is shown in Table 3. The malignancy screening items in¬cluded common risk factors and specific risk factors. The Ameri¬can EHE standards included fewer screening items for the specific risk factors compared with China’s health check.

                                                              Table 3: Comparison of malignancy screening items used in China and America

Abbreviations: CEA: carcinoembryonic antigen; CA15-3: cancer antigen 15-3; CA125: cancer antigen 125; NSE: neuron specific enolase. Laboratory screening tests consisted of a routine laboratory test and a laboratory biochemical test. The routine laboratory test in-cluded routine blood, urine, and stool analysis. The laboratory bio-chemical test included analyses of liver function, renal function, blood lipids, and blood sugar. The American EHE standards in-cluded a general blood biochemistry test, a routine urine analysis, blood cholesterol, a cardiovascular blood profile, homocysteine, and glycosylated hemoglobin. A comparison of laboratory screening tests used in China and America is shown in Table 4. In this section, China’s health check included much more items than those used in the American EHE standards. Imaging examinations included ultrasonography, X-ray, mammograms, etc. Both China’s health check and the American EHE standards included a resting ECG and a chest X-ray. China’s health check also included the transabdominal ultrasound, breast ultrasound, and prostate ultrasound. The American EHE standards included a carotid artery ultrasound and a mammogram. A com¬parison of imaging examinations used in China and America is shown in Table 5.

                                                         Table 4: Comparison of laboratory screening items used in China and America

Abbreviations:

TC: total cholesterol;

LDL-C: low density lipoprotein cholesterol;

HDL-C: high density lipoprotein cholesterol

                                                         Table 5: Comparison of image examination used in China and America

Discussion

The health check is a common form of preventive medicine per-formed during regular visits to medical professionals. In general, individuals should obtain health checks yearly or even less fre-quently. It is not entirely clear when health checks were initiated, but they have been advocated since the 1920s [4]. Some authors called for initiatives from the 19th and early 20th century for the early detection of diseases, like tuberculosis, and for period¬ic health checks in schools [5]. The health check is considered a screening that comprises medical tests for the early detection of diseases and occult risk factors for chronic diseases, includ¬ing lung diseases, cardiovascular diseases, metabolic syndrome, and malignancies [6-12]. Due to the large number of institutes that utilize different terminologies and standards in performing these screens, we urgently need to establish a standardized health check. Here, we analyzed the health items used in 60 top hospitals in Mainland China, by excluding items that occurred in less than 80%. The selected items were collected to form a list of China’s health check standards, which were compared with the American EHE standards.

Compared with the American EHE standards, we found that Chi-na’s health check items included more comprehensive, more ex¬pensive, and more advanced techniques, even after we excluded items that occurred in less than 80%. In the basic examination, China’s questionnaire was finely elaborated, and all the items could be determined inexpensively. For the basic physical examination, China’s standards were better than the American EHE standards because it has more detailed questionnaires, which was reported to be very useful in predicting or screening for diseases [13-18].

In screening for non-infectious diseases, China’s health items in-cluded 17 laboratory items, American EHE standards included only 4 basic items. However, China’s health standards missed one of the most important items: the hypersensitive C reactive protein.

In screening for malignancies, the American EHE standards fo-cused on the questionnaire, a breast X-ray examination, a cervical scraping smear, and the prostatic specific antigen (PSA), for de¬tecting early tumor formation. In comparison, China’s health stan¬dards tested more items, which provided more reliable screenings.

In the laboratory analyses, compared with China’s health check, the American EHE standards was more refined. The analyses in-cluded in China’s health check were highly complex and expen-sive.

In the imaging examinations, items used in China’s health check are similar to those used in the America EHE standards

Conclusion

The purpose of health management is to provide early detection and early diagnosis of serious diseases. However, in the absence of standards, medical institutes may aim to make profit in the name of early detection by providing essentially all-inclusive examina¬tions. By referring to the American EHE standards, we found that China’s health check could be simplified, except for the items used in the basic physical examination and malignancy screening.

Abbreviations

SBP: systolic blood pressure;

DBP: diastolic blood pressure;

BMI: body mass index;

LDL-C: low density lipoprotein cholesterol;

HDL-C: high density lipoprotein cholesterol;

HsCRP: hypersensitive C-reactive protein;

CEA: carcinoembryonic antigen;

CA15-3: cancer antigen 15-3;

CA125: cancer antigen 125;

NSE: neuron specific enolase;

TC: total cholesterol;

LDL-C: low density lipoprotein cholesterol;

HDL-C: high density lipoprotein cholesterol.

Authors Contribution

YZ was involved in drafting and revising this manuscript for im¬portant intellectual content. JL were involved in the design plan¬ning of this project. All authors read and approved the final man¬uscript.

Authors Information

Dr. Yanhui Zhu is a clinician scientist, with expertise in clinical informatics. Dr. Jianbo Lei is a clinician scientist and computer expert

Funding

This study was supported by the “Surface Program” of the Nation¬al Natural Science Foundation of China (Grant # 81471756 and 81771937).

Availability of Data and Materials

The datasets used during the current study are available from the corresponding author on reasonable request.

Ethics Approval and Consent to Participate

The study meets the Ethics Standard of Peking University. Data was collected as part of routine management processes. No per¬sonal identifying information is revealed.

References

1. Boulware, L. E., Marinopoulos, S., Phillips, K. A., Hwang,C. W., Maynor, K., Merenstein, D., & Daumit, G. L. (2007). Systematic review: the value of the periodic health evaluation. Annals of internal medicine, 146(4), 289-300.
2. Health check education panel of China health management association. (2012). Identification of common diseases during health check in Chinese population. Chinese Journal of Health Management, 6 (1):9-12.
3. Boulware, L. E., Barnes, G. J., Wilson, R. F., Phillips, K., Maynor, K., Hwang, C., & Daumit, G. L. (2006). Value of the periodic health evaluation. Evidence report/technology assessment, (136), 1-134.
4. Emerson, H. (1923). Periodic medical examinations of appar­ently healthy persons. Journal of the American Medical Asso­ciation, 80(19), 1376-1381.
5. Han, P. K. (1997). Historical changes in the objectives of the periodic health examination. Annals of internal medicine, 127(10), 910-917.
6. Ishida, Y., Ichikawa, Y. E., Fukakusa, M., Kawatsu, A., & Ma-suda, K. (2015). Novel equations better predict lung age: a retrospective analysis using two cohorts of participants with medical check-up examinations in Japan. NPJ primary care respiratory medicine, 25(1), 1-6.
7. Xu, G., Chen, Z., Cao, X., Wang, Y., & Yang, P. (2015). Anal­ysis of pulmonary function test results in a health check-up population. Journal of Thoracic Disease, 7(9), 1624.
8. Hanashiro, S., Takazawa, T., Kawase, Y., & Ikeda, K. (2015). Prevalence and clinical hallmarks of primary exercise head­ache in middle-aged Japanese on health check-up. Internal Medicine, 54(20), 2577-2581.
9. Hwang, G. Y., Cho, Y. J., Chung, R. H., & Kim, S. H. (2014).The relationship between smoking level and metabolic syn­drome in male health check-up examinees over 40 years of age. Korean Journal of Family Medicine, 35(5), 219.
10. Iglar, K., Katyal, S., Matthew, R., & Dubey, V. (2008). Com­plete health checkup for adults: Update on the Preventive Care Checklist Form©. Canadian Family Physician, 54(1), 84-88.
11. Fenton, J. J., Cai, Y., Weiss, N. S., Elmore, J. G., Pardee, R. E., Reid, R. J., & Baldwin, L. M. (2007). Delivery of cancer screening: how important is the preventive health examina­tion?. Archives of internal medicine, 167(6), 580-585.
12. Wen, Y. H., Chang, P. Y., Hsu, C. M., Wang, H. Y., Chiu, C. T.,& Lu, J. J. (2015). Cancer screening through a multi-analyte serum biomarker panel during health check-up examinations: Results from a 12-year experience. Clinica chimica acta, 450, 273-276.
13. Song, W. J., Lee, S. H., Kang, M. G., Kim, J. Y., Kim, M. Y.,Jo, E. J., ... & Cho, S. H. (2015). Validation of the Korean ver­sion of the European Community Respiratory Health Survey screening questionnaire for use in epidemiologic studies for adult asthma. Asia Pacific Allergy, 5(1), 25-31.
14. Wang, R., Lu, X., Hu, Y., & You, T. (2015). Prevalence of pre-hypertension and associated risk factors among health check­up population in Guangzhou, China. International Journal of Clinical and Experimental Medicine, 8(9), 16424.
15. Klatsky, A. L., Friedman, G. D., Siegelaub, A. B., & Gérard,M. J. (1977). Alcohol consumption and blood pressure: Kai-ser-Permanente multiphasic health examination data. New England Journal of Medicine, 296(21), 1194-1200.
16. Kojima, S., Ito, H., Takashimizu, S., Mizukami, H., Nagata, J., Ichikawa, H., & Watanabe, N. (2015). The Influence of Drinking Based on Data from Health Check-up. Nihon Aru-koru Yakubutsu Igakkai Zasshi= Japanese Journal of Alcohol Studies & Drug Dependence, 50(3), 144-157.
17. Allen, K., & Farah, C. S. (2015). Screening and referral of oral mucosal pathology: a check�up of Australian dentists. Australian dental journal, 60(1), 52-58.
18. Drygas, W., Niklas, A. A., PiwoÅ?ska, A., Piotrowski, W., FlotyÅ?ska, A., KwaÅ?niewska, M., & Zdrojewski, T. (2016). Multi-centre National Population Health Examination Survey (WOBASZ II study): assumptions, methods, and implemen­tation. Kardiologia Polska (Polish Heart Journal), 74(7), 681-690.