General health checks in adults for reducing morbidity and mortality from disease

Lasse T Krogsbøll; Karsten Juhl Jørgensen; Peter C Gøtzsche

doi:10.1002/14651858.CD009009.pub3

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Figure 1

Study flow diagram

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Figure 2

'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study

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Figure 3

'Risk of bias; graph: review authors' judgements about each risk of bias item presented as percentages across all included trials

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Figure 4

Funnel plot of comparison 1. Health checks versus control, outcome: 1.1 Total mortality.

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Analysis 1.1

Comparison 1 Health checks versus control, Outcome 1 Total mortality.

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Analysis 1.2

Comparison 1 Health checks versus control, Outcome 2 Total mortality ‐ sensitivity analyses.

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Analysis 1.3

Comparison 1 Health checks versus control, Outcome 3 Total mortality ‐ no. of health checks.

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Analysis 1.4

Comparison 1 Health checks versus control, Outcome 4 Total mortality ‐ lifestyle intervention.

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Analysis 1.5

Comparison 1 Health checks versus control, Outcome 5 Total mortality ‐ length of follow‐up.

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Analysis 1.6

Comparison 1 Health checks versus control, Outcome 6 Total mortality ‐ age of trial.

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Analysis 1.7

Comparison 1 Health checks versus control, Outcome 7 Total mortality ‐ geographical location.

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Analysis 1.8

Comparison 1 Health checks versus control, Outcome 8 Total mortality ‐ examination by physician.

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Analysis 1.9

Comparison 1 Health checks versus control, Outcome 9 Total mortality ‐ selection bias.

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Analysis 1.10

Comparison 1 Health checks versus control, Outcome 10 Total mortality ‐ performance bias.

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Analysis 1.11

Comparison 1 Health checks versus control, Outcome 11 Total mortality ‐ detection bias.

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Analysis 1.12

Comparison 1 Health checks versus control, Outcome 12 Total mortality ‐ incomplete outcome data.

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Analysis 1.13

Comparison 1 Health checks versus control, Outcome 13 Total mortality ‐ contamination.

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Analysis 1.14

Comparison 1 Health checks versus control, Outcome 14 Cancer mortality.

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Analysis 1.15

Comparison 1 Health checks versus control, Outcome 15 Cancer mortality ‐ sensitivity analyses.

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Analysis 1.16

Comparison 1 Health checks versus control, Outcome 16 Cancer mortality ‐ no. of health checks.

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Analysis 1.17

Comparison 1 Health checks versus control, Outcome 17 Cancer mortality lifestyle intervention.

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Analysis 1.18

Comparison 1 Health checks versus control, Outcome 18 Cancer mortality ‐ length of follow‐up.

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Analysis 1.19

Comparison 1 Health checks versus control, Outcome 19 Cancer mortality ‐ age of trial.

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Analysis 1.20

Comparison 1 Health checks versus control, Outcome 20 Cancer mortality ‐ geographical location.

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Analysis 1.21

Comparison 1 Health checks versus control, Outcome 21 Cancer mortality ‐ examination by physician.

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Analysis 1.22

Comparison 1 Health checks versus control, Outcome 22 Cancer mortality ‐ selection bias.

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Analysis 1.23

Comparison 1 Health checks versus control, Outcome 23 Cancer mortality ‐ performance bias.

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Analysis 1.24

Comparison 1 Health checks versus control, Outcome 24 Cancer mortality ‐ detection bias.

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Analysis 1.25

Comparison 1 Health checks versus control, Outcome 25 Cancer mortality ‐ incomplete outcome data.

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Analysis 1.26

Comparison 1 Health checks versus control, Outcome 26 Cancer mortality ‐ contamination.

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Analysis 1.27

Comparison 1 Health checks versus control, Outcome 27 Cardiovascular mortality.

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Analysis 1.28

Comparison 1 Health checks versus control, Outcome 28 Cardiovascular mortality ‐ sensitivity analyses.

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Analysis 1.29

Comparison 1 Health checks versus control, Outcome 29 Cardiovascular mortality ‐ no. of health checks.

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Analysis 1.30

Comparison 1 Health checks versus control, Outcome 30 Cardiovascular mortality lifestyle intervention.

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Analysis 1.31

Comparison 1 Health checks versus control, Outcome 31 Cardiovascular mortality ‐ length of follow‐up.

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Analysis 1.32

Comparison 1 Health checks versus control, Outcome 32 Cardiovascular mortality ‐ age of trial.

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Analysis 1.33

Comparison 1 Health checks versus control, Outcome 33 Cardiovascular mortality ‐ geographical location.

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Analysis 1.34

Comparison 1 Health checks versus control, Outcome 34 Cardiovascular mortality ‐ examination by physician.

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Analysis 1.35

Comparison 1 Health checks versus control, Outcome 35 Cardiovascular mortality ‐ selection bias.

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Analysis 1.36

Comparison 1 Health checks versus control, Outcome 36 Cardiovascular mortality ‐ performance bias.

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Analysis 1.37

Comparison 1 Health checks versus control, Outcome 37 Cardiovascular mortality ‐ detection bias.

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Analysis 1.38

Comparison 1 Health checks versus control, Outcome 38 Cardiovascular mortality ‐ incomplete outcome data.

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Analysis 1.39

Comparison 1 Health checks versus control, Outcome 39 Cardiovascular mortality ‐ contamination.

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Analysis 1.40

Comparison 1 Health checks versus control, Outcome 40 Fatal and non‐fatal ischaemic heart disease.

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Analysis 1.41

Comparison 1 Health checks versus control, Outcome 41 Fatal and non‐fatal stroke.

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Summary of findings for the main comparison. General health checks versus usual care

General health checks for reducing morbidity and mortality from disease
Patient or population: general adult populations (geriatric trials not included) Setting: general practice or medical/research centre (Europe and USA) Intervention: one or more general health checks (screening by any healthcare provider for more than one disease or risk factor in more than one organ system using more than one test) Comparison: no health checks
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of participants (studies)	Certainty of the evidence (GRADE)
	Assumed risk^a	Corresponding risk
	Without health checks	With health checks
Total mortality Follow‐up: 4‐30 years	68 per 1000	68 per 1000 (66 to 70)	RR 1.00 (0.97 to 1.03)	233,298 (11)	⊕⊕⊕⊕ high
Cancer mortality Follow‐up: 4‐22 years	26 per 1000	26 per 1000 (24 to 29)	RR 1.01 (0.92 to 1.12)	139,290 (8)	⊕⊕⊕⊕ high
Cardiovascular mortality Follow‐up: 4‐30 years	32 per 1000	34 per 1000 (30 to 37)	RR 1.05 (0.94 to 1.16)	170,227 (9)	⊕⊕⊕⊝^b moderate
Fatal and non‐fatal ischaemic heart disease Follow‐up: 4‐30 years	66 per 1000	65 per 1000 (62 to 68)	RR 0.98 (0.94 to 1.03)	164,881 (4)	⊕⊕⊕⊕ high
Fatal and non‐fatal stroke Follow‐up: 4‐30 years	29 per 1000	30 per 1000 (28 to 34)	RR 1.05 (0.95 to 1.17)	107,421 (3)	⊕⊕⊕⊝^c moderate
The basis for the assumed risk* is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; RR: risk ratio
GRADE Working Group grades of evidence High certainty: we are very confident that the true effect lies close to that of the estimate of the effect. Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect. Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.
^aSome trials used skewed randomisation in age and sex strata, giving unbalanced baselines (accounted for in the analysis estimates used). For this reason, control‐group event rates are somewhat misleading. The risk without the intervention is based on the median event rate in intervention and control groups combined. The corresponding risk with the intervention (and the 95% confidence interval for the difference), is based on the overall relative effect (and its 95% confidence interval). ^bDowngraded due to serious inconsistency. Substantial unexplained heterogeneity in results (I² = 65%) ^cDowngraded due to serious inconsistency. Substantial heterogeneity in results (I² = 53%)

Summary of findings for the main comparison. General health checks versus usual care

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Table 1. Overview of tests used in the trials

Blood pressure

Cholesterol

Height and weight

Risk score

Electrocardiogram

Biochemistry panel

History

Spirometry

Urine analyses

Diabetes

Clinical examination

Vision and/or hearing

Cancer screening

Göteborg 1963

Current symptoms, personal and family history

Fasting blood sugar

Chest X‐ray

Kaiser Permanente 1965

Probably

Current symptoms, personal and family history

Chest X‐ray, mammography, pelvic exam, sigmoidoscopy

South‐East London 1967

Probably

Current symptoms, personal history

Chest X‐ray, faecal occult blood

Malmö 1969

Haematocrit, triglycerides, cholesterol

Interview and questionnaire, not specified

Chest X‐ray

Northumberland 1969

Current symptoms

Stockholm 1969

Probably

Current symptoms, personal history

Göteborg 1970

Family history

WHO 1971

Current symptoms

Salt Lake City 1972

Chest X‐ray, mammography, cervical smear

DanMONICA 1982

Current symptoms, personal and family history

Peak flow

Not explicit, but abdominal ultrasound done

Mankato 1982

OXCHECK 1989

Personal and family history

Family Heart 1990

Dundee

Personal and family history

Random capillary glucose

Ebeltoft 1992

Anggaard

Non‐fasting blood glucose

Inter99 1999

PRECARD

Oral glucose tolerance test

Not all screening tests used are shown; see Characteristics of included studies for full details. The Kaiser Permanente 1965, South‐East London 1967, and Stockholm 1969 trials did not specify the contents of their biochemical screening. It seems unlikely that cholesterol was not included.

Table 1. Overview of tests used in the trials

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Table 2. Overview of mortality

	Deaths in intervention group	Participants in intervention group	Deaths in control group	Participants in control group
Total mortality
Göteborg 1963	146	1010	306	1956
Kaiser Permanente 1965	585	5138	643	5536
South‐East London 1967	196	3292	169	3132
Stockholm 1969^a	492	3064	2503	29122
Malmö 1969	49	809	60	804
Göteborg 1970	1293	10004	2636	20018
WHO 1971^b	1325	30489	1186	26971
OXCHECK 1989	205	8307	54	2783
Ebeltoft 1992	49	2030	43	1434
Inter99 1999^c	595	11629	2568	47987
DanMONICA 1982^d	2033	4789	4399	12994
Cancer mortality
Göteborg 1963	35	1010	73	1956
Kaiser Permanente 1965	173	5138	190	5536
South‐East London 1967	50	3292	47	3132
Stockholm 1969^a	144	3064	757	29122
Malmö 1969	17	809	9	804
Göteborg 1970	315	10004	728	20018
WHO 1971	564	23358	456	20957
OXCHECK 1989	82	8307	23	2783
Cardiovascular mortality
Göteborg 1963	74	1010	132	1956
Kaiser Permanente 1965	240	5138	256	5536
South‐East London 1967	84	3292	52	3132
Stockholm 1969^a	206	3064	947	29122
Malmö 1969	14	809	33	804
Göteborg 1970	526	10004	1077	20018
WHO 1971^b	428	30489	398	26971
OXCHECK 1989	83	8307	17	2783
DanMONICA 1982^d	583	4798	1087	12994
^aSkewed randomisation in age and needs strata, giving unbalanced baselines. ^bWe used a published effect estimate that took the matched pair cluster randomisation into account ^cSkewed randomisation in age and gender strata, giving unbalanced baselines. ^dSkewed randomisation in age and gender strata, giving unbalanced baselines.

Table 2. Overview of mortality

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Comparison 1. Health checks versus control

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Total mortality Show forest plot	11		Risk Ratio (Random, 95% CI)	1.00 [0.97, 1.03]

2 Total mortality ‐ sensitivity analyses Show forest plot	8		Risk Ratio (Random, 95% CI)	1.00 [0.97, 1.03]

2.1 Excluding cluster trials	8		Risk Ratio (Random, 95% CI)	1.00 [0.97, 1.03]
3 Total mortality ‐ no. of health checks Show forest plot	11		Risk Ratio (Random, 95% CI)	1.00 [0.98, 1.03]

3.1 One health check	3		Risk Ratio (Random, 95% CI)	1.00 [0.94, 1.06]
3.2 More than one health check	8		Risk Ratio (Random, 95% CI)	1.01 [0.97, 1.04]
4 Total mortality ‐ lifestyle intervention Show forest plot	11		Risk Ratio (Random, 95% CI)	1.00 [0.98, 1.03]

4.1 Major lifestyle intervention	5		Risk Ratio (Random, 95% CI)	0.99 [0.95, 1.03]
4.2 No major lifestyle intervention	6		Risk Ratio (Random, 95% CI)	1.02 [0.98, 1.06]
5 Total mortality ‐ length of follow‐up Show forest plot	11		Risk Ratio (Random, 95% CI)	1.00 [0.98, 1.03]

5.1 Up to five years	2		Risk Ratio (Random, 95% CI)	1.03 [0.66, 1.60]
5.2 More than 5 years	9		Risk Ratio (Random, 95% CI)	1.00 [0.97, 1.03]
6 Total mortality ‐ age of trial Show forest plot	11		Risk Ratio (Random, 95% CI)	1.00 [0.98, 1.03]

6.1 Trial started before 1980	7		Risk Ratio (Random, 95% CI)	0.99 [0.95, 1.03]
6.2 Trial started after 1980	4		Risk Ratio (Random, 95% CI)	1.02 [0.96, 1.09]
7 Total mortality ‐ geographical location Show forest plot	11		Risk Ratio (Random, 95% CI)	1.00 [0.98, 1.03]

7.1 USA	1		Risk Ratio (Random, 95% CI)	0.98 [0.88, 1.09]
7.2 Europe	10		Risk Ratio (Random, 95% CI)	1.01 [0.98, 1.04]
8 Total mortality ‐ examination by physician Show forest plot	11		Risk Ratio (Random, 95% CI)	1.00 [0.98, 1.03]

8.1 Examination by physician	5		Risk Ratio (Random, 95% CI)	1.00 [0.94, 1.06]
8.2 No examination by physician	6		Risk Ratio (Random, 95% CI)	1.00 [0.97, 1.04]
9 Total mortality ‐ selection bias Show forest plot	11		Risk Ratio (Random, 95% CI)	1.00 [0.98, 1.03]

9.1 Low risk of selection bias	9		Risk Ratio (Random, 95% CI)	1.00 [0.97, 1.04]
9.2 Unclear risk of selection bias	2		Risk Ratio (Random, 95% CI)	1.00 [0.93, 1.08]
9.3 High risk of selection bias	0		Risk Ratio (Random, 95% CI)	0.0 [0.0, 0.0]
10 Total mortality ‐ performance bias Show forest plot	11		Risk Ratio (Random, 95% CI)	1.00 [0.98, 1.03]

10.1 Low risk	7		Risk Ratio (Random, 95% CI)	1.00 [0.97, 1.03]
10.2 Unclear risk	1		Risk Ratio (Random, 95% CI)	1.02 [0.94, 1.11]
10.3 High risk	3		Risk Ratio (Random, 95% CI)	1.08 [0.87, 1.33]
11 Total mortality ‐ detection bias Show forest plot	11		Risk Ratio (Random, 95% CI)	1.00 [0.98, 1.03]

11.1 Low risk	8		Risk Ratio (Random, 95% CI)	1.01 [0.97, 1.04]
11.2 Unclear risk	2		Risk Ratio (Random, 95% CI)	1.00 [0.93, 1.08]
11.3 High risk	1		Risk Ratio (Random, 95% CI)	0.92 [0.77, 1.10]
12 Total mortality ‐ incomplete outcome data Show forest plot	11		Risk Ratio (Random, 95% CI)	1.00 [0.98, 1.03]

12.1 Low risk	10		Risk Ratio (Random, 95% CI)	1.01 [0.98, 1.04]
12.2 Unclear risk	1		Risk Ratio (Random, 95% CI)	0.98 [0.88, 1.09]
12.3 High risk	0		Risk Ratio (Random, 95% CI)	0.0 [0.0, 0.0]
13 Total mortality ‐ contamination Show forest plot	11		Risk Ratio (Random, 95% CI)	1.00 [0.98, 1.03]

13.1 Low risk	7		Risk Ratio (Random, 95% CI)	1.00 [0.97, 1.03]
13.2 Unclear risk	1		Risk Ratio (Random, 95% CI)	1.27 [0.95, 1.70]
13.3 High risk	3		Risk Ratio (Random, 95% CI)	0.99 [0.90, 1.10]
14 Cancer mortality Show forest plot	8		Risk Ratio (Random, 95% CI)	1.01 [0.92, 1.12]

15 Cancer mortality ‐ sensitivity analyses Show forest plot	5		Risk Ratio (Random, 95% CI)	0.97 [0.85, 1.09]

15.1 Excluding cluster trials	5		Risk Ratio (Random, 95% CI)	0.97 [0.85, 1.09]
16 Cancer mortality ‐ no. of health checks Show forest plot	8		Risk Ratio (Random, 95% CI)	1.01 [0.92, 1.12]

16.1 Only one health check	3		Risk Ratio (Random, 95% CI)	1.10 [1.00, 1.21]
16.2 More than one health check	5		Risk Ratio (Random, 95% CI)	0.92 [0.83, 1.02]
17 Cancer mortality lifestyle intervention Show forest plot	8		Risk Ratio (Random, 95% CI)	1.01 [0.92, 1.12]

17.1 Major lifestyle intervention	3		Risk Ratio (Random, 95% CI)	1.01 [0.82, 1.24]
17.2 No major lifestyle intervention	5		Risk Ratio (Random, 95% CI)	1.02 [0.91, 1.15]
18 Cancer mortality ‐ length of follow‐up Show forest plot	8		Risk Ratio (Random, 95% CI)	1.01 [0.92, 1.12]

18.1 Up to five years	2		Risk Ratio (Random, 95% CI)	1.33 [0.89, 1.99]
18.2 More than five years	6		Risk Ratio (Random, 95% CI)	1.00 [0.90, 1.10]
19 Cancer mortality ‐ age of trial Show forest plot	8		Risk Ratio (Random, 95% CI)	1.01 [0.92, 1.12]

19.1 Trial started before 1980	7		Risk Ratio (Random, 95% CI)	1.01 [0.91, 1.12]
19.2 Trial started after 1980	1		Risk Ratio (Random, 95% CI)	1.19 [0.75, 1.89]
20 Cancer mortality ‐ geographical location Show forest plot	8		Risk Ratio (Random, 95% CI)	1.01 [0.92, 1.12]

20.1 Europe	7		Risk Ratio (Random, 95% CI)	1.02 [0.91, 1.15]
20.2 USA	1		Risk Ratio (Random, 95% CI)	0.98 [0.80, 1.20]
21 Cancer mortality ‐ examination by physician Show forest plot	8		Risk Ratio (Random, 95% CI)	1.01 [0.92, 1.12]

21.1 Examination by physician	5		Risk Ratio (Random, 95% CI)	1.02 [0.91, 1.15]
21.2 No examination by physician	3		Risk Ratio (Random, 95% CI)	1.01 [0.82, 1.24]
22 Cancer mortality ‐ selection bias Show forest plot	8		Risk Ratio (Random, 95% CI)	1.01 [0.92, 1.12]

22.1 Low risk	6		Risk Ratio (Random, 95% CI)	0.98 [0.87, 1.10]
22.2 Unclear risk	2		Risk Ratio (Random, 95% CI)	1.10 [0.98, 1.24]
22.3 High risk	0		Risk Ratio (Random, 95% CI)	0.0 [0.0, 0.0]
23 Cancer mortality ‐ performance bias Show forest plot	8		Risk Ratio (Random, 95% CI)	1.01 [0.92, 1.12]

23.1 Low risk	5		Risk Ratio (Random, 95% CI)	1.00 [0.86, 1.16]
23.2 Unclear risk	1		Risk Ratio (Random, 95% CI)	1.05 [0.88, 1.25]
23.3 High risk	2		Risk Ratio (Random, 95% CI)	1.08 [0.80, 1.46]
24 Cancer mortality ‐ detection bias Show forest plot	8		Risk Ratio (Random, 95% CI)	1.01 [0.92, 1.12]

24.1 Low risk	5		Risk Ratio (Random, 95% CI)	0.99 [0.86, 1.13]
24.2 Unclear risk	2		Risk Ratio (Random, 95% CI)	1.10 [0.98, 1.24]
24.3 High risk	1		Risk Ratio (Random, 95% CI)	0.93 [0.63, 1.38]
25 Cancer mortality ‐ incomplete outcome data Show forest plot	8		Risk Ratio (Random, 95% CI)	1.01 [0.92, 1.12]

25.1 Low risk	6		Risk Ratio (Random, 95% CI)	0.98 [0.86, 1.12]
25.2 Unclear risk	2		Risk Ratio (Random, 95% CI)	1.07 [0.96, 1.20]
25.3 High risk	0		Risk Ratio (Random, 95% CI)	0.0 [0.0, 0.0]
26 Cancer mortality ‐ contamination Show forest plot	8		Risk Ratio (Random, 95% CI)	1.01 [0.92, 1.12]

26.1 Low risk	5		Risk Ratio (Random, 95% CI)	1.01 [0.88, 1.17]
26.2 Unclear risk	1		Risk Ratio (Random, 95% CI)	1.19 [0.75, 1.89]
26.3 High risk	2		Risk Ratio (Random, 95% CI)	0.99 [0.82, 1.18]
27 Cardiovascular mortality Show forest plot	9		Risk Ratio (Random, 95% CI)	1.05 [0.94, 1.16]

28 Cardiovascular mortality ‐ sensitivity analyses Show forest plot	6		Risk Ratio (Random, 95% CI)	1.02 [0.92, 1.13]

28.1 Excluding cluster trials	6		Risk Ratio (Random, 95% CI)	1.02 [0.92, 1.13]
29 Cardiovascular mortality ‐ no. of health checks Show forest plot	9		Risk Ratio (Random, 95% CI)	1.05 [0.94, 1.16]

29.1 Only one health check	3		Risk Ratio (Random, 95% CI)	0.89 [0.69, 1.14]
29.2 More than one health check	6		Risk Ratio (Random, 95% CI)	1.10 [0.98, 1.23]
30 Cardiovascular mortality lifestyle intervention Show forest plot	9		Risk Ratio (Random, 95% CI)	1.05 [0.94, 1.16]

30.1 Major lifestyle intervention	3		Risk Ratio (Random, 95% CI)	0.99 [0.86, 1.15]
30.2 No major lifestyle intervention	6		Risk Ratio (Random, 95% CI)	1.07 [0.93, 1.23]
31 Cardiovascular mortality ‐ length of follow‐up Show forest plot	9		Risk Ratio (Random, 95% CI)	1.05 [0.94, 1.16]

31.1 Up to five years	2		Risk Ratio (Random, 95% CI)	0.84 [0.22, 3.18]
31.2 More than five years	7		Risk Ratio (Random, 95% CI)	1.05 [0.97, 1.13]
32 Cardiovascular mortality ‐ age of trial Show forest plot	9		Risk Ratio (Random, 95% CI)	1.05 [0.94, 1.16]

32.1 Trial started before 1980	7		Risk Ratio (Random, 95% CI)	1.01 [0.90, 1.13]
32.2 Trial started after 1980	2		Risk Ratio (Random, 95% CI)	1.24 [0.89, 1.72]
33 Cardiovascular mortality ‐ geographical location Show forest plot	9		Risk Ratio (Random, 95% CI)	1.05 [0.94, 1.16]

33.1 Europe	8		Risk Ratio (Random, 95% CI)	1.05 [0.93, 1.18]
33.2 USA	1		Risk Ratio (Random, 95% CI)	1.01 [0.85, 1.20]
34 Cardiovascular mortality ‐ examination by physician Show forest plot	9		Risk Ratio (Random, 95% CI)	1.05 [0.94, 1.16]

34.1 Examination by physician	5		Risk Ratio (Random, 95% CI)	1.03 [0.84, 1.27]
34.2 No examination by physician	4		Risk Ratio (Random, 95% CI)	1.04 [0.92, 1.17]
35 Cardiovascular mortality ‐ selection bias Show forest plot	9		Risk Ratio (Random, 95% CI)	1.05 [0.94, 1.16]

35.1 Low risk	7		Risk Ratio (Random, 95% CI)	1.04 [0.93, 1.16]
35.2 Unclear risk	2		Risk Ratio (Random, 95% CI)	1.17 [0.71, 1.91]
35.3 High risk	0		Risk Ratio (Random, 95% CI)	0.0 [0.0, 0.0]
36 Cardiovascular mortality ‐ performance bias Show forest plot	9		Risk Ratio (Random, 95% CI)	1.05 [0.94, 1.16]

36.1 Low risk	6		Risk Ratio (Random, 95% CI)	0.99 [0.89, 1.11]
36.2 Unclear risk	1		Risk Ratio (Random, 95% CI)	1.05 [0.91, 1.21]
36.3 High risk	2		Risk Ratio (Random, 95% CI)	1.57 [1.18, 2.09]
37 Cardiovascular mortality ‐ detection bias Show forest plot	9		Risk Ratio (Random, 95% CI)	1.05 [0.94, 1.16]

37.1 Low risk	6		Risk Ratio (Random, 95% CI)	1.03 [0.91, 1.16]
37.2 Unclear risk	2		Risk Ratio (Random, 95% CI)	1.17 [0.71, 1.91]
37.3 High risk	1		Risk Ratio (Random, 95% CI)	1.09 [0.83, 1.43]
38 Cardiovascular mortality ‐ incomplete outcome data Show forest plot	9		Risk Ratio (Random, 95% CI)	1.05 [0.94, 1.16]

38.1 Low risk	8		Risk Ratio (Random, 95% CI)	1.05 [0.93, 1.18]
38.2 Unclear risk	1		Risk Ratio (Random, 95% CI)	1.01 [0.85, 1.20]
38.3 High risk	0		Risk Ratio (Random, 95% CI)	0.0 [0.0, 0.0]
39 Cardiovascular mortality ‐ contamination Show forest plot	9		Risk Ratio (Random, 95% CI)	1.05 [0.94, 1.16]

39.1 Low risk	6		Risk Ratio (Random, 95% CI)	1.00 [0.90, 1.12]
39.2 Unclear risk	1		Risk Ratio (Random, 95% CI)	1.64 [0.97, 2.76]
39.3 High risk	2		Risk Ratio (Random, 95% CI)	1.21 [0.81, 1.83]
40 Fatal and non‐fatal ischaemic heart disease Show forest plot	4		Risk Ratio (Random, 95% CI)	0.98 [0.94, 1.03]

41 Fatal and non‐fatal stroke Show forest plot	3		Risk Ratio (Random, 95% CI)	1.05 [0.95, 1.17]

Comparison 1. Health checks versus control

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