Putting healthcare dollars into the 'right' prevention services

Although an "ounce of prevention" has always been better than a "pound of cure," it has been difficult to marshal the health care establishment to make the investment in preventive services, or to concentrate their attention on those areas where the most benefit is gained for each dollar invested.

A series of articles and commentaries in the July issue of the American Journal of Preventive Medicine address the need to channel resources into those areas of preventive care which will benefit the most people for each dollar spent.

Former Surgeon General of the United States David Satcher, MD, chaired the National Commission on Prevention Priorities, which guided the approach used to rank these services. He writes, "Our intent was to identify preventive services that produce the greatest population health benefit and cost effectiveness in order to help inform decision makers at multiple levels about which preventive services are most valuable." Dr. Satcher emphasizes that the evidence-based studies in this issue "provide fascinating insights on the most valuable clinical preventive services."

Continuing the theme, Samuel R. Nussbaum, MD, of WellPoint, Inc., a major healthcare benefits company, writes, "One of the most effective approaches we can take in both the public and private sectors is to direct more attention and more resources to preventive health services. The challenge, however, for providers, payers, and policymakers, is determining the most beneficial preventive services in a resource-constrained environment. The reality is that some health services are emphasized at the expense of others, and decisions are often based on practice experience versus evidence-based science and rigorous comparative analyses. Too often, medical services of unproven value usurp the resources that could be used to provide preventive services."

Steven H. Woolf, MD, MPH, addresses this issue in more detail. He writes, "Under conditions of limited time and resources, the issue is not whether prioritization occurs…but how it occurs. In most settings, the process, whether it is called rationing or prioritizing, is neither systematic nor rational…The consequences of these misplaced priorities are hardly esoteric.…For example, the primary prevention of disease would save more lives than treating diseases after symptoms develop, but the vast resources of the healthcare system are spent largely on the latter. Failure to realign priorities sacrifices both lives and resources. Health could be markedly improved, with far less expenditure, if our healthcare system prioritized services based on their effectiveness and value (the cost of services per unit of health improvement)."

In the first two of five articles by Michael V. Maciosek, PhD, and coauthors Leif I. Solberg, MD, Nichol M. Edwards, MS, Hema S. Khanchandani, MPH, Michael J. Goodman, PhD, Ashley B. Coffield, MPA, Thomas J. Flottemesch, PhD, and Winnie W. Nelson, PharmD, at HealthPartners Research Foundation, Minneapolis, Minnesota and Partnership for Prevention, Washington, DC, the methodology for evaluating the cost-effectiveness of various preventive services is explained. Starting with the original data and rankings of 2001 from the Partnership for Prevention, and guided by the National Commission on Prevention Priorities (NCPP), the authors show that first, it is possible to calculate an objective measure of the health benefits of a specific preventive service and second, that a relative ranking of these services can provide clear guidance to public health officials and medical providers on where healthcare dollars can be directed for the most benefit.

The next two articles from the same group examine in detail two specific preventive services that were ranked highly, influenza vaccines for the elderly and colorectal cancer screening. In the study of flu vaccination, the methodology shows that over 275,000 years of life can be saved by offering vaccine to everyone over 50 years of age. For those over 65, the cost is only $970 per year of life saved.

In the study of colorectal cancer screening, the authors find even more years of life would be saved and deaths prevented, but that only 50% of the population actually takes advantage of the service. They write, "Colorectal cancer screening continues to be a high-impact, cost-effective service utilized by fewer than half of the group aged 50 and older. It remains an important missed opportunity for improving health at a reasonable cost. Ten thousand additional deaths would be prevented each year if screening were offered to the entire target population, and an additional 12,000 would be prevented if all individuals accepted screening."

In the last of the five articles, Leif I. Solberg, MD and coworkers look at the effectiveness of counseling smokers to quit. Noting that over 18% of all deaths in the United States in 2000 were due to smoking-related disease, they show that even a limited intervention by health care providers would be cost-effective and result in an estimated 2.5 million years of life saved. Dr. Solberg writes, "Even if there is need for caution in taking these estimates literally, or if there is disagreement on the appropriateness of including cost savings from prevented smoking-attributable illness, there is no conceivable scenario in which smoking-cessation assistance that is consistently delivered in clinical practice settings would not be one of the most important preventive services. The challenge for this service is different--it is to find ways to ensure that it is delivered at rates and in ways that achieve the extraordinary potential benefits."

Addressing that challenge, C. Tracy Orleans, PhD, and colleagues describe the health systems changes and continued leadership required to support primary care providers in delivering brief primary care quit smoking advice and intervention (counseling and medication) routinely. Applauding the great progress that has been made in health plans and practices across the country, they emphasize that individual clinicians, especially those in small practices, need help: "although clinicians can do much to improve cessation counseling, creating a system to help smokers obtain the quitting assistance that they need is an undertaking best implemented at the level of policymakers: leaders of health systems, employers, payers, and state tobacco control leaders.…the NCPP findings demonstrate that healthcare decision makers, purchasers, and policymakers stand to achieve extraordinary returns-- in extended lives and cost savings--by getting serious about helping smokers to quit."

The articles from this issue are:

Effective Clinical Preventive Services
A Commentary
David Satcher, MD, PhD

Prevention
The Cornerstone of Quality Health Care
Samuel R. Nussbaum, MD

A Sense of Priorities for the Healthcare Commons
Steven H. Woolf, MD, MPH, Kurt C. Stange, MD, PhD

Influenza Vaccination
Health Impact and Cost Effectiveness Among Adults Aged 50 to 64 and 65 and Older
Michael V. Maciosek, PhD, Leif I. Solberg, MD, Ashley B. Coffield, MPA, Nichol M. Edwards, MS, Michael J. Goodman, PhD

The Health Impact and Cost Effectiveness of Colorectal Cancer Screening
Michael V. Maciosek, PhD, Leif I. Solberg, MD, Ashley B. Coffield, MPA, Nichol M. Edwards, MS, Michael J. Goodman, PhD

Priorities Among Effective Clinical Preventive Services - Methods
Michael V. Maciosek, PhD, Nichol M. Edwards, MS, Ashley B. Coffield, MPA, Thomas J. Flottemesch, PhD, Winnie W. Nelson, PharmD, Michael J. Goodman, PhD, Leif I. Solberg, MD

Priorities Among Effective Clinical Preventive Services
Results of a Systematic Review and Analysis
Michael V. Maciosek, PhD, Ashley B. Coffield, MPA, Nichol M. Edwards, MS, Thomas J. Flottemesch, PhD, Michael J. Goodman, PhD, Leif I. Solberg, MD

Repeated Tobacco-Use Screening and Intervention in Clinical Practice
Health Impact and Cost Effectiveness
Leif I. Solberg, MD, Michael V. Maciosek, PhD, Nichol M. Edwards, MS, Hema S. Khanchandani, MPH, Michael J. Goodman, PhD

The Top Priority
Building a Better System for Tobacco-Cessation Counseling
C. Tracy Orleans, PhD, Steven H. Woolf, MD, MPH, Stephen F. Rothemich, MD, MS, James S. Marks, MD, MPH, George J. Isham, MD, MS

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These appear in the American Journal of Preventive Medicine, Volume 31, Issue 1 (July 2006) published by Elsevier). Additional information, including study-related materials and data for the articles by Maciosek et al can be found at www.prevent.org/ncpp.


Last reviewed: By John M. Grohol, Psy.D. on 21 Feb 2009
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