Family physicians' days are choked with required administrative tasks and other distractions that pull time and attention away from serving patients.
To help physicians maximize their patient care efforts in this environment, the National Commission on Prevention Priorities (NCPP) recently released its updated ranking of clinical preventive services(www.annfammed.org), which were published in the January/February issue of Annals of Family Medicine.
Specifically, the NCPP, a panel of clinicians, health insurance plan leaders, employers, government representatives and academics, re-examined its 2006 rankings for 28 clinical preventive services the U.S. Preventive Services Task Force (USPSTF) and the Advisory Committee on Immunization Practices said were based on strong evidence of effectiveness. HealthPartners Institute conducted the analytical work for the ranking.
- The National Commission on Prevention Priorities (NCPP) has updated its clinical preventive services rankings and published them in the January/February issue of Annals of Family Medicine.
- The NCPP, a panel of health care clinicians, health insurance plan leaders, employers, government representatives and academics, examined rankings for 28 clinical preventive services experts consider to be based on strong evidence of effectiveness.
- The three highest-ranking clinical preventive services are immunizing children, counseling to prevent tobacco initiation among youth, and tobacco-use screening and brief intervention to encourage cessation among adults.
The NCPP assessed the potential impact of the evidence-based clinical preventive services in terms of their cost-effectiveness and clinically preventable burden, as measured by quality-adjusted life years saved. Each service received a score of 1 to 5 points on each of the two measures for a total score ranging from 2 to 10. New microsimulation models were used to provide updated estimates for 12 of these services.
Co-author Michael Maciosek, Ph.D., of Minneapolis-based HealthPartners Institute, told AAFP News that since the NCPP's 2006 ranking, nine new evidence-based services have been added, six recommendations were retired, and others were substantially changed based on new technologies and evidence.
"The rankings provide guidance to clinicians, medical groups and health plans in choosing what to emphasize with patients and in quality improvement efforts, while recognizing that clinician time with patients is limited and clinicians face increasing demands on their time," said Maciosek. "They can also guide patients on what to expect regarding preventive services in an office visit."
Top Three Clinical Preventive Services
In-depth analyses found the three highest-ranking clinical preventive services, each with a total score of 10, are immunizing children, counseling to prevent tobacco initiation among youth, and tobacco-use screening and brief intervention to encourage cessation among adults.
Maciosek said childhood immunizations have been long recognized as a high-value service when the evidence of benefits and harms are carefully examined. "It's important to keep immunization rates high so we can enjoy the large population health gains and cost-savings provided by the childhood immunization series," he noted.
And although it may seem to physicians that their influence on patient smoking behavior is limited during typically brief office visits, Maciosek said the evidence indicated that physicians who are effective in preventing tobacco use among a small portion of their patients can produce large health gains and reduce health care costs.
Maciosek said the NCPP's ranking might be most helpful as physicians move past these top three clinical services.
"If the office visit is with an adult nonsmoker or advice and assistance with quitting has been provided (to a smoker), then physicians should look at the next set of high-ranking services and choose what to focus on, depending on the age and sex of the patient and other patient characteristics," he explained.
Other High-ranking Clinical Preventive Services
The next tier of high-ranking clinical preventive services, with NCPP scores of 6 and above, includes
- alcohol misuse screening with brief intervention (8),
- discussing aspirin use with high-risk adults (8),
- colorectal cancer screening (8),
- cervical cancer screening (8),
- chlamydia and gonorrhea screening (7),
- cholesterol screening (7),
- hypertension screening (7),
- obesity screening (6),
- healthy diet counseling for those at increased risk of cardiovascular disease (6),
- abdominal aortic aneurysm screening in high-risk men (6),
- HIV screening (6),
- HPV immunization (6),
- seasonal influenza immunization (6),
- syphilis screening (6), and
- vision screening for children (6).
Maciosek said, for example, clinical services that target dietary counseling and obesity screening with referral can have substantial population health benefits.
"This is true even when we account for the fact that few patients will follow up with referrals to intensive diet and physical activity counseling, and that only half of those who do will complete," he noted, "and further, that maintenance of behavior change will be short-lived in some who do complete an intensive program."
Maciosek added that brief counseling to prevent alcohol misuse, such as binge drinking or drinking during recreational activities, can have surprisingly large health and financial benefits, as well.
Takeaways for Family Physicians
According to Maciosek, there is no one-size-fits-all approach to patient care using these ranked clinical preventive recommendations. However, prioritizing and following the guidance on childhood immunizations and tobacco counseling appears to be a "no-brainer."
"Beyond those, understanding the difference in the relative value of services while making preventive care decisions with individual patients can help family physicians use their time most effectively," he said. "In making those decisions, some care -- or better yet, a standardized health risk assessment -- is needed to avoid assumptions about which patients are at risk for harmful behaviors and preventable infectious and chronic diseases."
Maciosek suggested that family physicians set up their office systems to keep these ranked recommendations at their fingertips to help them quickly make the best preventive services choices for individual patients while still managing patients' acute and chronic disease care needs.
"Ideally, all of the services on the list would be provided, and there are still other services recommended by the USPSTF for individuals with specific risk factors that physicians should be mindful of," he said. "The list of evidence-based preventive services is not as daunting when you consider that not all services apply to all patients based on age, sex and risk factors."
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