Health Equity in Preventive Services: The Role of Primary Care
Am Fam Physician. 2020 Sep 1;102(5):264-265.
Despite continued improvements in survival from preventable diseases, significant disparities remain. Black men have a 25% higher mortality rate from heart disease than non-Hispanic White men and a 20% higher mortality rate from cancer.1 Women have similar disparities: Black women are just as likely as non-Hispanic White women to receive a diagnosis of breast or cervical cancer, but they are 20% more likely to die from breast cancer and twice as likely to die from cervical cancer.1 Furthermore, breast and cervical cancers are often diagnosed at more advanced stages in Black women.2 There are many causes, but lack of screening is an important factor.
The National Institutes of Health reviewed rates of screening for cardiovascular disease, diabetes mellitus, and cancer in disadvantaged populations.3,4 Although the primary purpose was to stimulate future research, some of their recommendations are applicable to primary care.
Groups that are least likely to receive preventive screening or to have timely, high-quality follow-up include those with limited or no health insurance, limited education and literacy, and no regular source of care, as well as those who are subject to discrimination based on racial, ethnic, or sexual identity. The magnitude of these barriers can be significant: lack of insurance, lack of regular care, and racial minority status each decrease colorectal cancer screening rates by 15%.5 Despite coverage of clinical preventive services under the Affordable Care Act and Medicaid expansion, the lower financial burden has not been sufficient to overcome these disparities.
A team approach is one of the most effective ways to pursue prevention efforts, allowing physicians to focus on patients' social and cultural situations to more effectively tailor care. This approach can also help patients navigate the health care system to obtain the clinical preventive services they need.6 For example, community health center–based patient navigators increase colorectal cancer screening rates by identifying and helping patients overcome barriers to care (e.g., resolving transportation problems).7
Patient tracking is necessary to target outreach to those most likely to benefit from prevention efforts. Electronic health records (EHRs) vary in their ability to track patients, but many offer this feature. Office staff can facilitate scheduling, screening completion, and appropriate follow-up.
Reducing Time Burdens
Minimizing the number of office visits and improving off-hours access facilitate the delivery of preventive care. Lost time from work is especially challenging for disadvantaged patients, so offering access to care after regular work hours and integrating multiple services into a single visit are important. Colon cancer screening programs that offer fecal immunochemical testing by mail are particularly well-suited for these patients.8
Electronic Health Records
Reminder systems may help increase delivery of preventive services. However, many clinicians have “reminder fatigue.” EHRs should be programmed to send reminders for high-yield services recommended by the U.S. Preventive Services Task Force to the care team member who can best implement them. In addition, patients' social and environmental histories should be maintained in the EHR so that social determinants of health can be addressed at the point of care.9,10
Because prevention efforts must extend outside the clinic, community resources are an important element of prevention. The American Academy of Family Physicians' EveryONE Project provides an index of local resources to address social determinants of health (https://navigator.aafp.org).11 Physicians must work with payers and professional societies to improve compensation for outreach efforts.
First-dollar coverage of preventive services under the Affordable Care Act was a great stride forward. However, more must be done to address disparities that affect our most vulnerable patients. We trust that family physicians will continue striving to achieve health equity, which will always start with prevention.
Editor's Notes: Health equity is critical in caring for our patients and their families. American Family Physician is committed to including more content on similar topics for our readers so that we can address systemic racism and strive toward health equity together. —Sumi Sexton, MD, Editor-in-Chief
Dr. Teutsch served as a member of and Dr. Carey chaired the panel for the National Institutes of Health Pathways to Prevention Workshop “Achieving Health Equity in Preventive Services.”4
Referencesshow all references
1. American Cancer Society. Cancer facts and figures for African Americans, 2019–2021. Accessed February 9, 2020. http://bit.ly/32XF8iV...
2. Gray TF, et al. Disparities in cancer screening practices among minority and underrepresented populations. Semin Oncol Nurs. 2017;33(2):184–198.
3. Nelson HD, et al. Achieving health equity in preventive services. Comparative effectiveness review no. 222. Accessed March 6, 2020. http://bit.ly/2IqkC0X
4. Carey TS, et al. National Institutes of Health Pathways to Prevention Workshop: achieving health equity in preventive services. Ann Intern Med. 2020;172(4):272–278.
5. White A, et al. Cancer screening test use - United States, 2015. MMWR Morb Mortal Wkly Rep. 2017;66(8):201–206.
6. Jerzak J. Using empowered CMAs and nursing staff to improve team-based care. Fam Pract Manag. 2019;26(1):17–22. Accessed March 6, 2020. https://www.aafp.org/fpm/2019/0100/p17.html
7. Reuland DS, et al. Effect of combined patient decision aid and patient navigation vs usual care for colorectal cancer screening in a vulnerable patient population: a randomized clinical trial [published correction in JAMA Intern Med. 2017; 177(7):1062]. JAMA Intern Med. 2017;177(7):967–974.
8. Jager M, et al. Mailed outreach is superior to usual care alone for colorectal cancer screening in the USA: a systematic review and meta-analysis. Dig Dis Sci. 2019;64(9):2489–2496.
9. Krist AH, et al. What evidence do we need before recommending routine screening for social determinants of health? [editorial]. Am Fam Physician. 2019;99(10):602–605. Accessed March 6, 2020. https://www.aafp.org/afp/2019/0515/p602.html
10. National Academies of Sciences, Engineering, and Medicine. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. National Academies Press; 2019.
11. American Academy of Family Physicians. The EveryONE Project: education and practice-based resources. Accessed March 6, 2020. https://bit.ly/31G2hI8
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