Delivering an ounce (or more) of prevention in your office

According to researchers at the Centers for Disease Control and Prevention, about half of all deaths in the United States are caused by a few largely preventable behaviors and exposures.

Tobacco use, poor diet and physical inactivity, and alcohol abuse were the leading "actual" causes of death in 2000, responsible for 435,000, 365,000 and 85,000 deaths, respectively. Total mortality from those four unhealthy behaviors (885,000 deaths) accounted for 37% of the 2.4 million deaths that year, according to an article in the March 10, 2004, and a letter in the Jan. 19, 2005, issues of the Journal of the American Medical Association.

Physicians and other health care professionals can play a key role in improving patients' health behaviors through the delivery of clinical preventive services. The U.S. Preventive Services Task Force, which is supported by the Agency for Healthcare Research and Quality, has issued evidence-based guidelines for more than 90 preventive services divided into four categories -- screening, counseling, immunization and preventive medication (link).

Kimberly Yarnall, MD, and colleagues at Duke University Medical Center estimated in an April 1, 2003, American Journal of Public Health article that primary care physicians would need to spend, on average, 7.4 hours per working day to deliver all of the USPSTF-recommended services to a panel of 2,500 patients with an age and sex distribution similar to that of the U.S. population. Obviously, asking physicians to allocate 7.4 hours of each workday to prevention alone is unrealistic, and that's one reason why a National Commission on Prevention Priorities was established, with support from the CDC and the AHRQ.

In a July 2006 American Journal of Preventive Medicine article, the NCPP ranked the importance of clinical preventive services according to two factors:

• The clinically preventable burden, defined as the total quality-adjusted years of life -- QALYs -- that could be gained if the clinical preventive service were delivered at recommended intervals to a U.S. birth cohort of 4 million people over the years of life for which the service was recommended.
• The cost-effectiveness of the service (average net cost per QALY gained in typical practice by offering the clinical preventive service at recommended intervals to a U.S. birth cohort over the recommended age range).

The NCPP gave a maximum of five points for each of these two factors for each of 21 services recommended by the USPSTF and three adult immunizations recommended by the CDC's Advisory Committee on Immunization Practices.

The services identified as the highest priorities for quality improvement efforts were those receiving the highest score (a maximum of 10) and being delivered to less than half of the U.S. population eligible to receive the services.

The services meeting those criteria included two with a score of 10 (aspirin chemoprophylaxis for the prevention of cardiovascular events, and tobacco-use screening and brief intervention), four with a score of 8 (colorectal cancer screening, pneumococcal immunization, screening and brief intervention for problem drinking, and vision screening in adults), and one with a score of 6 (Chlamydia screening in sexually active women younger than 25).

In August, the coalition Partnership for Prevention released an NCPP report indicating that increasing the delivery of just five preventive services to 90% of targeted adults would save more than 100,000 lives each year in the United States (link). The two services with the potential to provide the greatest gains were aspirin chemoprophylaxis (45,000 lives saved) and advice and assistance in quitting smoking (42,000 lives saved).

The high ranking for aspirin chemoprophylaxis, now being used by about 40% of targeted adults, was surprising to many individuals in the preventive medicine community.

The American Heart Assn. has recommended low-dose aspirin for persons at high risk of coronary heart disease, especially for those with a 10-year risk of having a heart attack or dying of coronary heart disease of 10% or higher.

The heart association has, on its Web site, a 17-question tool based on the Framingham Heart Study to estimate a person's 10-year risk of coronary heart disease (link). The Mayo Clinic has a similar but shorter (eight-question) tool on its Web site (link).

With these practice guidelines and priorities in hand for clinical preventive services, three more ingredients are needed to maximize their administration:

• Training and tools.
• Fair payment for delivery of preventive services.
• Incorporation of prevention into performance measurement systems and quality improvement activities.

AHRQ has developed extensive tools to support the delivery of clinical preventive services through its Put Prevention into Practice initiative (link). The AMA and many other medical societies have developed similar tools (link).

Health insurance was designed originally to cover care for catastrophic illness, and thus third-party payment for preventive services is spotty. Medicare coverage policy, which sets a standard followed by many other payers, is a case in point.

Medicare covers a small number of USPSTF-recommended services, including influenza and pneumococcal immunization, screening for osteoporosis and breast and colorectal cancer, and tobacco-cessation counseling. A specific act of Congress was required to allow Medicare to pay for most of those services.

To help level the playing field between prevention and treatment, Congress should give the Centers for Medicare & Medicaid Services clear authority to cover preventive services.

That could be accomplished by adding one word -- prevention -- to the Medicare law, to allow the program to cover items or services that are "reasonable and necessary for the prevention, diagnosis, or treatment of illness or injury."

AMA policy supports Medicare payment for preventive services and the extension of Medicare coverage to evidence-based clinical preventive services without having to change federal law for each preventive service to be covered.

Insurance coverage, however, will not guarantee optimal utilization of services. The Government Accountability Office, in a September 2003 report (03-958), showed that relatively few Medicare beneficiaries receive the full range of preventive services covered by the program (link).

A key strategy to increase the utilization of preventive services that are covered is to add them to performance measurement systems and quality improvement activities.

In an editorial in the March 21, 2006, Annals of Internal Medicine, I reviewed the tobacco measures that have been developed for health plans, hospitals and physicians. Performance measures for all of the high-priority preventive services need to be developed and used throughout our health care system.

Prevention gets a lot of lip service from politicians and other decision-makers. But in many respects, our nation suffers from a prevention deficit disorder. Taking the steps outlined above would go a long way toward mitigating that malady.