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Tuesday Apr 12, 2016

Does Prevention Save Money? That's the Wrong Question

Ben Franklin's proverb that "an ounce of prevention is worth a pound of cure" makes sense to all of us, especially in medicine. Why wouldn't you want to prevent lung cancer by helping someone quit smoking?

Preventive health care is something family physicians excel at. We use evidence-based medicine to focus on how to best prevent heart attacks, to find cancer early and to prevent infectious diseases through immunization. But are we targeting the right individuals and populations in our specific preventive efforts? Are we aware of the most impactful preventive strategies?

A 6-month-old girl receives a vaccination. According to CDC estimates, vaccinations among children born from 1994 to 2013 will prevent 322 million illnesses, 21 million hospitalizations, and 732,000 deaths and save the health care system $295 billion.

Many economists say that prevention isn't cost-effective, and that focusing too much on prevention instead of treatment can actually make things worse for our health care system(www.academyhealth.org). So which is it, and what should family physicians do to best help our patients?

There are actually three types of prevention, a nuance that most policymakers and economists miss.

Primary prevention is preventing a disease or problem in the first place, such as exercising to avoid obesity. This tends to be a combined effort of public health and medical professionals.

Secondary prevention is typically performed in medical settings and has to do with preventing progression or impact of an existing disease, such as establishing an appropriate diet to control blood sugar for someone with diabetes mellitus.

Tertiary prevention is about "softening" the impact a disease may have on a person's life, such as routine eye exams for people with diabetes mellitus to detect and treat early diabetic retinopathy.

Misunderstanding or misidentifying the differences between these types often causes confusion. Assessments of the costs and benefits of preventive efforts typically look at the cost for primary prevention of a disease vs. the cost of treating the disease, which sometimes includes secondary and tertiary preventive measures. If it's a bigger effort and cost to prevent the disease than treat it, is it worth our time and resources?

Many studies have found that the majority of primary and secondary preventive efforts don't save our health care system money(www.nejm.org). However, almost 40 percent of deaths in the United States could be averted through better primary prevention, such as by decreasing tobacco use.(www.ncbi.nlm.nih.gov) Relatively simple public health interventions, such as including seat belts in cars and immunizing infants and toddlers, can save thousands of lives at minimal cost. But what if efforts are spent on those at low risk for a behavior or disease? For example, I don't smoke and have no intention of starting, so anti-tobacco efforts aimed at me won't be of any benefit. But providing me assistance in losing weight, particularly in the setting of my family history of coronary artery disease, could yield significant cost and quality of life results.

Many economists will point to things such as colonoscopies (secondary prevention), citing the extreme increase in cost if every individual 50 years and older is screened. Some have even argued against such practices on the grounds that increasing life expectancy just means that we have to spend more money in the future(goo.gl). But colonoscopies are not "true" (i.e. primary) prevention. There is likely no way to eradicate colon cancer 100 percent before it occurs, which then causes confusion among the general public. Should we be getting colonoscopies or not? We should in order to save lives, but we need to educate that this is early detection, not prevention.

Mammography is another good example of early detection rather than primary prevention. The U.S. Preventive Services Task Force (USPSTF) has been criticized by many for changing the recommendations on when and how often mammography should be done(www.npr.org). The USPSTF's charge is to look at the evidence of what is effective and create guidelines based on that information. It does not take cost into account, but many in the public are upset and confused, as if the system is trying to ration their care by restricting something that instinctively seems appropriate.

So what does this all mean?

It means that we need to understand what is meant by prevention.

It means that as family physicians, we need to be able to educate our patients on what prevention means and what works, and then help them apply it to themselves.

It means that we should be part of the system-wide efforts to focus on what is most effective. This includes ensuring that the preventive quality measures on which we are monitored are based on medical evidence of what truly adds to positive patient outcomes. As Johns Hopkins Bloomberg School of Public Health professor Ron Goetzel, Ph.D., has said, "Instead of debating whether prevention or treatment saves money, we should determine the most cost-effective ways to improve population health(content.healthaffairs.org)."

In the end, preventing disease and its complications is what we do. Whether or not it saves money, it saves lives and improves quality of life; what could be more humane than that?

Kyle Jones, M.D., is a faculty member at the University of Utah Family Medicine Residency Program in Salt Lake City. He is the director of primary care at the Neurobehavior HOME Program, a patient-centered medical home for those with developmental disabilities. You can follow him on Twitter @kbjones11(twitter.com).

Posted at 12:27PM Apr 12, 2016 by Kyle Jones, M.D.

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