The Growing Mandate for Clinical Preventive Medicine
Am Fam Physician. 2003 Dec 15;68(12):2348-2351.
The potential to save lives and improve the quality of life for millions of Americans through clinical preventive medicine is tremendous. In their classic paper, McGinnis and Foege1 linked one half of the mortality in the United States from the 10 leading causes of death to lifestyle-related behaviors.
One of the key strategies of the U.S. Department of Health and Human Services to improve the health of Americans is to focus on improving five of the lifestyle factors identified. They are tobacco use, overweight/obesity, lack of physical activity, substance abuse, and irresponsible sexual behavior. With their broad responsibilities for people across the entire lifespan, family physicians are ideally poised to lead the national effort in promoting clinical preventive medicine.
According to the Guide to Clinical Preventive Services,2 clinical preventive medicine interventions can be divided into the areas of screening, counseling, immunizations, and chemoprophylaxis. To assimilate the large body of evidence about prevention, the Partnership for Prevention and other groups analyzed the 283 clinical interventions discussed in that guide based on the burden of disease prevented and the cost-effectiveness of the interventions.3 The highest ranked services with the lowest delivery rates (50 percent, nationally) are providing tobacco cessation counseling to adults, screening older adults for undetected vision impairment, offering adolescents an antitobacco message or advice to quit, counseling adolescents on alcohol and drug abstinence, screening adults for colorectal cancer, screening young women for chlamydial infection, screening adults for problem drinking, and vaccinating older adults against pneumococcal disease.
Probably the best tools for learning and implementing clinical preventive medicine are in A Step-by-Step Guide to Delivering Clinical Preventive Services: A Systems Approach4 and the Guide to Clinical Preventive Services, Third Edition: Periodic Updates.5 These user-friendly packages of material (some of which have been published in this journal) come from the third U.S. Preventive Services Task Force (USPSTF); they have been organized by the Agency for Healthcare Research and Quality and are released incrementally. The reports also can be accessed easily online at http://www.ahrq.gov/clinic/uspstFix.htm.
The USPSTF clearly states the evidence on which their recommendations for intervention are based. They grade their recommendations from “A” to “D” based on the strength of the supporting evidence. When the evidence is insufficient to recommend for or against an intervention or service, the grade of “I” is given.
Many medical specialty societies and disease-oriented organizations (e.g., the American Heart Association and the American Cancer Society) have developed their own recommendations for screening and prevention. Unfortunately, the various recommendations sometimes are in conflict. Family physicians and other physicians frequently are asked to use clinical judgment in the context of the physician-patient relationship to sort through conflicting recommendations. For example, the USPSTF has given a grade “I” recommendation for screening for prostate cancer with prostate-specific antigen (PSA) testing or digital rectal examination.6 At the same time, other organizations recommend PSA screening,7,8 and some 27 states have passed laws requiring that insurance cover such screening.9
In these cases, physicians can inform or educate their patients in a “shared decision-making process.” Even though the evidence is far from conclusive for this intervention, many patients still may wish to have the testing done.
The practicalities of organizing the physician's staff and practice to systematically implement clinical preventive services are discussed in A Step-by-Step Guide to Delivering Clinical Preventive Services: A Systems Approach.4 In this guide, physicians are shown how staff can implement the program. Patient flow sheets that can be added to a patient's medical record help tremendously. In my own practice, I have used computerized histories and health-risk appraisals. I have been able to use the printouts for patient education and to start or complete a prevention flow sheet.
A particular challenge for physicians is to redesign practice systems to more cost-effectively carry out clinical preventive medicine. For instance, having special times, personnel, and routines to help groups of patients address issues of diet and weight loss are probably more cost-effective than dealing with each patient, one-on-one, at every visit.
Another major issue is trying to reach all potentially affected patients in a practice or community. Although most people consult their primary care physician every year, we do not have adequate systems to address prevention during every visit with every patient. In addition, many patients do not consult physicians frequently or are not compliant with medical recommendations. The growing evidence that some preventive interventions, such as those for diabetes management, can save insurance companies money is generating incentives to seek out all patients who can potentially benefit from the interventions.10
Time and reimbursement for prevention remain major issues. The good news is that delivery of clinical preventive services such as immunizations, mammograms, and cholesterol screening has risen steadily during the past two decades. Roughly 90 percent of employers now include well-child visits, childhood immunizations, screening tests, and adult physical examinations among covered health benefits, compared with less than one half of employers in 1988.11
The ideal situation would be for physicians and their local communities to work together to link personal/clinical preventive medicine, with community/population-based prevention. These interventions should be linked to state and local health policy. The Centers for Disease Control and Prevention is beginning to report the findings of the U.S. Community Preventive Services Task Force. The future looks promising for community-wide prevention.
1. McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA. 1993;270:2207–12.
2. U.S. Preventive Services Task Force. Guide to clinical preventive services. 2d ed. Alexandria, Virginia. International Medical Publishing, Inc. 1996.
3. Coffield AB, Maciosek MV, McGinnis JM, et al. Priorities among recommended clinical preventive services. Am J Prev Med. 2001;21:1–9.
4. A step-by-step guide to delivering clinical preventive services: a systems approach. Accessed November 12, 2003, at: http://www.ahrq.gov/ppip/manual.
5. U.S. Preventive Services Task Force. Guide to delivering clinical preventive services, 3d ed: periodic updates. Accessed November 12, 2003, at: http://www.preventiveservices.ahrq.gov.
6. U.S. Preventive Services Task Force. . Screening for prostate cancer: recommendation and rationale. Ann Intern Med. 2002;137:915–6.
7. Smith RA, von Eshenbach AC, Wender R, et al. American Cancer Society guidelines for the early detection of cancer: update of early lung cancer detection.. CA: Cancer J. Clin. 2001;51:007–38.
8. Mandelson MT, Wagner EH, Thompson RS. PSA Screening: a public health dilemma. Ann Rev Public Health. 1995;16:283–306.
9. State Cancer Legislative Database Program (SCLD). National Cancer Institute. Accessed November 12, 2003, at: http://www.scld-nci.net.
10. Rubin RJ, Dietrich KA, Hawk AD. Clinical and economic impact of implementing a comprehensive diabetes management program in managed care.. J Clin Endocrinal Metab. 1998;83:2635–42.
11. Woolf SH, Atkins D. The evolving role of prevention in health care: contributions of the U.S. Preventive Services Task Force. Am J Prev Med. 2001;20(suppl3)
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