What Prevention Actions Should Practices Prioritize for their Limited Resources?

Steven P. Dehmer, PhD

 

In an analysis by Yarnall and colleagues, it was estimated that it would take a physician with a patient panel of 2,500 patients 7.4 hours per working day to deliver all of the evidence-based preventive services recommended by the U.S. Preventive Services Taskforce (USPSTF).1 When patients often arrive with their own “to-do” list of acute needs, the gap between all the good things that could be done and those which can be done is recipe for frustration.

 

Priorities clearly need to be set, but the ability to quickly compare the relative value of an immunization to a cancer screening or a conversation about tobacco cessation — amongst many other beneficial preventive services for a given patient — may not be a natural skill for many well-trained and well-meaning providers. Twenty years ago, the National Commission on Prevention Priorities (NCPP), a panel of public health officials, clinicians, medical directors, and consumer advocates, was convened to help shed light on this issue by developing a consistent and valid methodology for comparing clinical preventive services on the basis of their relative value.2

 

In January, we published a second update to the NCPP’s relative value ranking (Maciosek and colleagues).3 The updated ranking compares 28 effective clinical preventive services on the basis of both health impact (that is, preventable disease burden and mortality) and cost-effectiveness (that is, “bang for the buck”). Consistent with prior rankings, the childhood immunization series and tobacco use screening and counseling (for children and adults) remain the highest value preventive services due to their substantial potential for preventing disease — and even saving money — over time.

 

In a companion paper (Dehmer and colleagues), we reported on the health benefits and cost-effectiveness of aspirin, blood pressure, and cholesterol services for the primary prevention of CVD.4 We found that the hypertension and cholesterol screening and treatment had the greatest opportunity for population health impact, but also that patients taking aspirin according to USPSTF guidelines can expect to save money due to prevented medical costs exceeding the cost of taking aspirin. Moreover, in a first for these rankings, we compared the relative value of the CVD preventive services for subgroups defined by sex and race-ethnicity and by outcomes that may have more meaning to typical patients than overall health impact or cost-effectiveness (e.g., most potential to prevent heart attacks or strokes).

 

Examples of differential priority ranking of the ABCs according to their potential health impact are shown at right. While screening and treatment for hypertension has the most potential for preventing disease burden in the population overall, this result is driven by the large benefits for women; whereas for men, cholesterol screening and treatment ranks highest for CVD prevention. However, for any patient most concerned about (or motivated by) preventing stroke, managing elevated blood pressure should be a top objective. In this way, with increasing personalization of care, we see a future in which patients help their clinicians prioritize prevention according their own values in shared decision-making.

 

The message is this: prevention is worth doing, but it is best done when prioritized by the value it generates for patients.

 


 

  1.  Yarnall KS, Pollak KI, Ostbye T, Krause KM, Michener JL. Primary care: is there enough time for prevention? Am J Public Health. 2003;93(4):635-641.
  2. Coffield AB, Maciosek MV, McGinnis JM, et al. Priorities among recommended clinical preventive services. Am J Prev Med. 2001;21(1):1-9.
  3.  Maciosek MV, LaFrance AB, Dehmer SP, et al. Updated Priorities Among Effective Clinical Preventive Services. Ann Fam Med. 2017;15(1):14-22.
  4.  Dehmer SP, Maciosek MV, LaFrance AB, Flottemesch TJ. Health Benefits and Cost-Effectiveness of Asymptomatic Screening for Hypertension and High Cholesterol and Aspirin Counseling for Primary Prevention. Ann Fam Med. 2017;15(1):23-36.